CLEVELAND, Ohio -- High costs and the alarmingly high number of accidental deaths linked to prescription pain pills have made pain treatment a central issue in health care across Ohio and the nation.

A recent report by the Institute of Medicine underlined the urgency of developing better pain-management strategies in the United States, where chronic pain affects more than 116 million people and costs as much as $650 billion yearly in direct medical treatment and lost productivity.

"Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity," the report stated. "Given the burden of pain in human lives, dollars and social consequences, relieving pain should be a national priority."

Americans make up 4.6 percent of the world population and consume 80 percent of the global opiate supply, including nearly all of the hydrocodone supply, according to the American Society of Interventional Pain Physicians.

Body of pain

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In Ohio, deaths from unintentional prescription drug overdoses have increased more than 350 percent between 1999 and 2008, making it the leading cause of accidental death in the state since 2007.

In August, an Ohio law went into effect requiring special licensing for pain clinics and doctors with 50 percent or more of patients being treated with controlled substances for chronic pain. The law tightly regulates record keeping on patients and mandates subspecialty certification and continuing education in pain management for physicians. The law also limits how many pills doctors can dispense and establishes a system for collecting unused narcotics.

With the tightening of regulations, learning the best way to prescribe painkillers, including narcotics, is critical for doctors.

The Institute of Medicine report said more research is needed so that physicians have better data to guide them when treating patients -- especially children and the elderly who sometimes cannot express their needs.

"Pain is something that the U.S. health care system doesn't deal with well," said Dr. Alan Hull, associate dean for curricular affairs in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. "We need to work on recognizing and treating pain appropriately."

Given the restraints on doctors' time during standard appointments, he said, "there certainly is a science and art to being able to read patients and develop a relationship with them."

The Institute of Medicine report recommended that medical education programs expand curriculum about pain.

Limited instruction for medical students



A separate study released last month by researchers from Johns Hopkins School of Medicine found that medical school curriculum addressing pain is limited and often fragmented.

"Health care has undergone dramatic changes in the last 25 years," stated the study published in the American Pain Society's Journal of Pain , "but inadequate treatment of pain has persisted." The study stated that the areas of cancer, pediatric and geriatric pain treatment are unaddressed by the vast majority of medical schools.

Dr. Jennifer Kriegler, associate professor of medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, said unlike when she was receiving her training, schools have been doing a much better job of teaching medical students and residents about pain -- especially chronic pain.

Medical schools throughout Ohio are devoting more time to classroom curriculum on chronic pain -- often linked to cases of drug abuse -- and to student observation of patients.

"Treating pain is much more than giving somebody medication," Kriegler said. "That's what students need to know. It takes a multifaceted approach."

Dr. David Ryan, who runs the pain management program at MetroHealth Medical Center, said doctors have to look at the whole patient. "The best pain physicians take time to listen to the patient and understand their problems, taking into consideration both the physical and emotional complexities," he said.

"Because pain is so complicated, it covers almost the entire spectrum of medical training," Ryan said, "as doctors learn the intricacies of how pain works."

'Not all pain is the same pain'



Research shows that pain tolerance varies from person to person, according to the Institute of Medicine report, which recommended that pain management be tailored to each patient's experience.

Dr. Salim Hayek, division chief of pain medicine at University Hospitals Case Medical Center, said patients -- even those with the same injury or illnesses -- perceive twinging, throbbing, aching or soreness very differently.

Pain is important, he said, because it's the body's signal that something is wrong. And, Hayek said, "Not all pain is the same pain." Acute pain from surgery, for example, eventually goes away, but chronic pain in the lower back may linger for months.

Yet, even if levels of discomfort are similar among people, Hayek added: "The drugs don't work on 100 percent of the patients or 100 percent of the pain." Everyone builds up a tolerance to a pain drug, he explained, but this occurs more quickly with younger patients. Doctors need to keep this and other factors in mind when considering a course of action.

The Institute of Medicine report said that managing pain is a challenge, and more research needs to be done to better understand treating pain.

Research already is revealing the negative effects of underdiagnosing and undertreating pain and that the "wait to see if it goes away" approach could have consequences.

Recent studies show that acute pain -- such as that accompanying burns or kidney stones -- should be treated immediately. Otherwise, there can be changes in the central nervous system and spinal cord that cause the pain to become worse. These changes can result in severe pain that lingers long after the original injury or disease is resolved.

Dependence after an acute condition



Physicians strive to find the balance of keeping patients comfortable and avoiding dependency on these powerful drugs.

"If someone has an acute condition, such as a broken ankle, by all means pain drugs can be safely prescribed for a short period of time -- two to five days," Hayek said.

Doctors said that the vast majority of the patients who need pain medications don't abuse them.

Medical students, Kriegler said, learn to start with where the pain begins and then move to family history and what's going on in the patient's life. "You can't get away from the brain being both an emotional and physiological organ," she said.

Dependence on drugs can occur for many reasons.

"A lot of times people take medication for an acute problem," she said, "but then what happens is, when the pain is gone, they realize the medication helped them in terms of something else -- such as easing their anxiety."

In cases where the injury has healed, other physiological sources have been ruled out and the pain continues, Kriegler said, "we need to treat the problem in the brain because that's where the change has occurred."

Even if there is no obvious source, the pain is very real to the patients. So doctors in training are being taught to find additional means to help patients get some relief.

"If a person says they cannot go to work because of pain," Kriegler said, "then maybe what they need is physical therapy." For other patients, regular exercise may help them begin to feel better, and that's a subject worth discussing.

Counseling could be in order for a patient who, for example, has suffered past abuse or has a fear of illnesses recurring because of family history, she said. "Medical students need to understand that if they cannot help patients, they need to get them to the right specialist who can."

Kathy Cole-Kelly, professor of family medicine at Case Western Reserve School of Medicine, said putting the patient in the center of treatment is key.

Cole-Kelly, who teaches communication skills at the medical school, said students are trained to look at the situation from the patient's perspective. That involves asking questions about a patient's life and listening. A patient with headaches may be worried because his uncle died of a brain tumor.

Family beliefs based on different cultures or heritages could be at the center of a patient's complaints about pain, she said. A patient is more likely to understand his situation if the doctor talks through the beliefs with the patient rather than just dismissing him, she said.

Cole-Kelly said medical students can learn these communication skills just as they learn to recognize physical ailments.

Once medical students get to the hospital floors, Kriegler said, they soon realize how emotional the pain can be for patients and their families.

"If you don't deal with the emotional aspects, you are not going to be a good doctor," Kriegler said.