Angie's List member Jill Biller has suffered from lower back pain for a long time. When she moved to Palm Coast, Fla., from Virginia, she just wanted a refill of the prescription painkiller hydrocodone. Instead, she says, the doctor "treated me like a junkie."
Biller is among the estimated 100 million sufferers of chronic pain in the United States, according to a 2011 report from the Institute of Medicine. Nearly 60 percent of Angie's List members who took a 2011 online poll say they suffer or have suffered chronic pain. Like many of them, Biller finds empathy, much less help, hard to come by.
Health care providers in the pain management category garner negative reviews at twice the average of other Angie's List categories - 20 percent of the 1,900 reviews filed in the past three years have C, D or F grades. Members report their health care provider didn't take their problem with pain seriously, and in an Angie's List online poll, 21 percent of respondents say they haven't found a good approach to managing their pain.
A common, costly ailment
Chronic pain differs from acute pain in that it lingers long after an injury has healed. In some cases, it starts with no definable injury at all. Headaches, lower back pain and joint pain are the most common complaints, according to the Centers for Disease Control and Prevention, with joint pain the only one clearly associated with an underlying disease - osteoarthritis.
The pain can't be seen, felt or heard by anyone other than the patient, but one thing that can be measured is its cost - up to $635 billion a year in medical treatment and lost productivity, according to the study by the IOM.
"Pain is a disease," says Melanie Thernstrom, a chronic pain sufferer in Portland, Ore., author of The Pain Chronicles and a patient representative on the IOM committee. "It causes damage in the nervous system and in the brain over time. It is dangerous not to treat pain."
Treatment can involve medical management; physical, psychological or interventional therapies; and alternative treatments. Yet pain remains untreated - or improperly treated - in many cases, due to a range of factors that include doctors' lack of training and insurance companies' reluctance to pay for the most effective treatment, the IOM reports.
Expertise in pain management
Only 22 percent of 133 accredited U.S. medical schools teach chronic pain management, and even then it's part of a broader course, according to the Association of American Medical Colleges. It adds up to 11 hours of pain education in four years of training. In a 2009 American Medical Association survey, doctors ranked their pain management education 2.65 out of 5.
Board certified anesthesiologists, neurologists, psychiatrists or physchologists can pursue certification in a pain medicine subspecialty by participating in a one-year fellowship in pain management and passing a written exam. About 3,400 of the approximately 130,000 specialists nationwide hold the pain medicine subspecialty certifications recognized by the AMA. Groups, such as the American Board of Pain Medicine and the World Institute of Pain, also offer certification, but lack of certification doesn't prohibit a doctor from specializing in pain management.
Experts say subspecialty certification doesn't guarantee quality care, but it typically indicates more in-depth knowledge. The IOM reports that medical boards in some states, including California and Florida, recognize only the AMA-approved or ABPM subspecialty certification, which allows doctors to receive insurance reimbursement at specialty rates.
Dr. Dan Carr, an anesthesiologist and founding director of the Tufts University School of Medicine's pain research, education and policy program in Boston, says people may complain more frequently about pain management because doctors - even those holding a subspecialty in pain medicine - are trained to focus on objective measures and procedures, yet pain also has social and psychological aspects many doctors don't know how to handle.
Numerous studies, Carr says, show pain sufferers feel better when somebody listens. "There is an enormous social component to pain," he says. "Patients will be more satisfied if they feel they have been cared for. That has more to do with their satisfaction with pain control than the actual intensity of their pain."
Other doctors are quick to prescribe pain medicine, rather than taking time to understand why a patient is suffering, says Dr. Loren Fishman, a highly rated rehabilitative medicine specialist with Manhattan Physical Medicine and Rehabilitation in New York. "In many cases doctors don't know anatomy well enough to find the causes," he says. "I prefer to find the cause and eliminate pain." About 90 percent of the time, he's able to wean his patients off medicine, he says, by using a multidisciplinary approach that could include surgery, yoga therapy and Pilates.