March 24, 2023

Health and Global Policy Institute (HGPI) Project for Chronic Pain Measures
Achieving Equity in Multidisciplinary Pain Treatment and Support Systems for PainManagement
Introduction
It has been reported that chronic pain affects 22.5% of the adult population in Japan, which is approximately 23.15 million
people. While pain has not attracted much attention as a factor that contributes directly to mortality, it is a major cause of
productivity losses among the working population and a common reason people are certified as requiring long-term care or
support. As Japan continues to experience a declining birthrate and population aging, building effective and efficient pain
treatment and support systems for pain management are also urgent issues from the perspective of ensuring thesustainability of the social security system as well as our entire society.
Rapid progress has been made in pain research in recent years. The International Association for the Study of Pain (IASP)
revised its definition of pain in 2020. Then, in 2021, a Japanese term was assigned to “nociplastic pain,” the third mechanistic
pain descriptor which emphasizes that pain can correspond to psychosocial factors in addition to structural or medical factors.
To provide treatment and support that takes this mechanism into account, we must recognize the limitations of theconventional biomedical model as well as the need to implement the biopsychosocial (BPS) model. We must then take rapid
steps to develop systems and policies that will provide the foundation for the BPS model.
Based on the knowledge we obtained from hearings with a broad range of stakeholders involved in pain treatment andsupport, desk studies, and other efforts, this report outlines current circumstances and issues for pain treatment and support
systems for pain management and compiles methods of addressing those issues in the future. After summarizing current
issues, this report offers the four recommendations described in the following chart regarding the direction of next steps andfuture discussion points for resolving those issues.

March 24, 2023
Because pain can become a problem for all diseases, it will be necessary to address it with treatment and support that utilizes
a collaborative approach spanning multiple fields of specialty. Furthermore, collaboration that surpasses the boundaries
among fields of specialty, institutions, and the health, long-term care, and welfare systems as well as the private healthcare
service sector will be necessary to achieve equity in multidisciplinary pain treatment and support systems for pain
management. This presents a complex political challenge that involves a broad range of stakeholders. HGPI will continue toactively pursue equity in multidisciplinary treatment and support systems by encouraging multi-stakeholder discussions thatencompass the perspectives of those most affected and examine future discussion points to address these needs.

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Current issues facing pain treatment and support systems for pain management
1

Systems for guiding people living with highly individualized pain to suitable treatment and support
1.1 Systems that can provide comprehensive treatment and consultation support
Pain can originate from a number of organic diseases and chronic pain can be influenced by psychosocial stress inaddition to organic tissue damage. This means treating chronic pain requires comprehensive diagnostic techniques
to determine if an organic disease is present as well as advanced medical techniques based on the biopsychosocial(BPS) model. To support the provision of this type of comprehensive medicine, a new certification for generalpractitioners was established as part of the new specialty system that came into effect in 2018, and the FY2022
revision of the Model Core Curriculum for Medical Education added “Willingness to see patients and citizens in acomprehensive manner” among the necessary qualities of physicians. At the same time, our existing healthcare
system is based on the principle of free access, in which patients can select which department to seek a medical
consultation from, and with each department providing healthcare independently. This means that selecting themost suitable department or healthcare service is difficult for people living with chronic pain that is the result ofcomplex interactions among various underlying factors. As a matter of fact, some people have become what are
known as “pain refugees” because they cannot receive suitable treatments or support for their conditions and end
up visiting various medical departments or trying various folk remedies to find a treatment or form of support that isright for them.
1.2

Understanding toward pain among healthcare providers and service providers in the healthcare sector
It has been reported that people living with chronic pain use various healthcare facilities and services. In the Pain
Associated Cross-sectional Epidemiological (PACE) Survey 2009, a 2011 survey that examined which facilities orservices were used by people living with chronic pain, 55.9% of respondents used some variety of healthcare service.
Among them, 46.3% used clinics, 40.9% were receiving care at hospitals, and 27.3% were visiting osteopathic clinics.
In addition, 35.6% reported using other healthcare services or alternative medicine. Among respondents who werebeing treated at hospitals and clinics, 45.2% said they were dissatisfied with treatment. As these findings show us, inaddition to healthcare institutions, people living with chronic pain are also visiting osteopathic clinics and using
alternative medicines, and they report being dissatisfied with treatment at healthcare institutions. Given thesecircumstances, both health professionals and healthcare service providers should be provided with education that isbased on the latest science on pain, but at the moment, such education has only been included in pre-graduation
curricula for some healthcare providers, like physicians.

1.3

Understanding among citizens regarding the concept of pain and how to utilize healthcare and other forms of
support for pain management
Culture is known to be a factor that influences how people perceive pain. According to a 2017 online survey amongpeople living with chronic pain, 66.6% of respondents said they thought people should tolerate pain and 32.8% said
they had never visited a healthcare institution for pain. This suggests that people in Japan have a strong tendency
toward tolerating pain and refrain from seeking medical attention even when pain becomes chronic. There is also astrong tendency for people to perceive pain in terms of what is known as “nociceptive pain,” or pain at the affectedarea that is caused by illness or injury. In other words, the concept of pain that is influenced by psychosocial factors
which was elucidated recently has not yet taken root. In Japan’s current healthcare system, people have the freedom
to choose which healthcare institution to visit, so they must decide for themselves the best place to seek treatment.
As long as pain and pain treatments are not understood properly, it will be difficult to provide suitable pain
treatments at early stages.

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2

Systems for providing specialized healthcare for pain
2.1 Incentives for collaboration among departments, professions, and institutions are insufficient for establishing an
infrastructure for multidisciplinary treatment and support
Holding multidisciplinary conferences to provide diagnoses and treatment plans that are based on evaluations
conducted from multiple angles can be effective for certain types of chronic pain. Non-pharmacological therapies like
exercise therapy, psychotherapy, and pain management education have also been recommended for treating
chronic pain. In addition, there are times it may be necessary to coordinate with employment support and otherforms of support related to welfare as part of treatment. Many of the aforementioned multifaceted evaluations,multidisciplinary conferences, and various forms of treatment are not included in the current medical service feeschedule, so such treatments and services must be provided without reimbursement. There is also no
reimbursement provided for the workload of coordinating multiple facilities when they collaborate on providing
multidisciplinary care. As long as initiatives to provide effective treatments and support according to guidelines are
not covered in the medical service fee schedule, the ability of healthcare institutions providing multidisciplinary
treatment and support to operate in a sustainable manner is at risk.
2.2

Human resources for providing specialized chronic pain treatment and support for chronic pain management are
insufficient
Healthcare providers who possess a broad range of specialized knowledge and skills based on the BPS model arenecessary for providing suitable treatment and support for chronic pain, and they are central in providing treatment
and support at facilities called multidisciplinary pain centers. Currently, there are 30 of these facilities in Japan.
However, education to develop personnel with the high levels of expertise needed to treat chronic pain has yet to beinstitutionalized. In other words, healthcare professionals that are currently active in this area acquired the necessary
knowledge and skills on their own through their experiences in clinical settings and research after graduation. Thismeans one challenge facing multidisciplinary pain centers is a shortage of specialist healthcare providers who canprovide sustainable treatments for chronic pain. Efforts to establish a training program focusing on chronic pain werebeing advanced under the Ministry of Education, Culture, Sports, Science and Technology’s (MEXT) Problem-Solving
Training Program for Advanced Medical Personnel, but that program has yet to be institutionalized. It is urgent thatJapan establish a system to train the necessary specialists.
In addition to education in the field of medicine, such issues also affect education in the fields of dentistry andnursing, as well as training for therapists including psychologists. For example, a form of chronic pain in the area ofdentistry called orofacial pain is not recognized as a field of specialty for dentists, and there are many issues thatmust be addressed before equity in treatment and support systems can be achieved in this area. In one country,
orofacial pain is considered a field of specialty within dentistry and efforts are being made to institutionalize
education specializing in that field. A small number of dentists who have trained and been certified in countries thatare leading the way in this area have established an academic society for orofacial pain in Japan. While they are
currently advancing efforts for recognition of this field in Japan, it has yet to be officially recognized as a field ofspecialty. As long as it goes unrecognized, an educational system cannot be built and a system for treating orofacial
pain by dentists specializing in this area cannot be established.

2.3

Evaluation systems for assessing specialized medical treatments for pain
Effective treatment methods have been established for some forms of chronic pain and include pharmacotherapy
and interventional therapy (such as nerve blocks or minimally-invasive surgery). However, the points assigned tothese treatments in the medical service fee schedule result in less reimbursement than they are given in otherMarch 24, 2023
countries. This is, in part, due to the fact that reimbursements are not provided for the pharmaceuticals used inproviding nerve blocks or for the costs of medical supplies used to provide these treatments. Furthermore, certain
interventional therapies carry the risk of serious complications, which in turn carry a high risk of litigation. This makes
it difficult to disseminate them in clinical settings, even for medical treatments that can be counted on to have acertain degree of effectiveness.
3

Creating a foundation for providing integrated pain treatment and support for pain management in communities
3.1 Collaboration among insured medical services and various treatment and support providers
Systems must be established so people can continue receiving the medical care and support they need in theircommunities after undergoing specialized treatments at multidisciplinary pain centers, which are often located atuniversity hospitals. In the current system, most outpatient treatments are provided by individual departments, andthere is no system for providing treatment across multiple departments based on the BPS model. In particular, theabsence of a collaborative system that coordinates health facilities providing treatments covered by insurance andcommunity resources providing a wide range of evidence-based interventions such as psychotherapy, exercise
therapy, integrative medicine, and employment support is making it difficult to provide a wide range ofevidence-based interventions in communities.
3.2

4

Ensuring equality among various professionals to create a foundation for adopting the BPS model
Providing comprehensive treatment and support in communities based on the BPS model will require further steps
to promote cooperation. For that multidisciplinary cooperation to take place, equal relationships must be establishedamong professions. This will require addressing a number of issues. The scope of medical specialists’ duties isregulated by the Medical Practitioners’ Act, which provides physicians a monopoly over the professional practice of
medicine that is relaxed on a limited basis to allow other health professionals to engage in certain medical practices.
Such restrictions are in place to protect the public from medical practices performed by anyone who does notpossess sufficient training. However, advances in medicine that were made after the enactment of the Medical
Practitioners’ Act have resulted in the development of practices (like rehabilitation conducted using the BPS model)that do not fall under that Act’s intended meaning of “medical practice” (which is defined as “an act, out of acts
belonging to the realm of medical care or health guidance, that could be hazardous to health or hygiene unless theact is conducted by a medical practitioner”). This means physicians now have a monopoly over those practices
outside of the intended meaning. This may lead to excessive burdens being placed on physicians or result inhierarchies forming among professions based on the scope of practices they are allowed to perform or the
reimbursements provided by the medical service fee system.

Establishing evidence and research and development systems
4.1 Establishing research systems to study pain for each disease and department
As pointed out in Clinical Practice Guidelines for the Management of Chronic Pain, there is not much high-quality
research on chronic pain treatment being conducted in Japan. Most of the pain research conducted in Japan falls
into specific disease areas and examines pain associated with diseases, with many studies focusing on peripheral
tissues to clarify the pathology of each disease. However, what people living with chronic pain experience isemotional, so research undertaken from the perspectives of neurology and psychology that does not focus on
peripheral tissues must be conducted at the same time. Conducting studies on pain treatments that take acomprehensive view of pain will require multidisciplinary and interdisciplinary perspectives. However, researchsystems for conducting such studies are only in place at certain research institutions in Japan, so they must be
expanded in the future.

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4.2

Research and evidence evaluation systems for non-pharmacological treatment methods
Many of the non-pharmacological treatments recommended by the Clinical Practice Guidelines for the Managementof Chronic Pain lack evidence in Japan, are not included in the medical service fee schedule, or are provided as
non-medical healthcare services, such as chiropractic adjustment. Given the current situation, ensuring
evidence-based non-pharmacological treatments are granted public health insurance coverage will require firstestablishing domestic evidence and evaluating it. However, only a few research institutions conduct research on the
medical effects of treatments that are not considered medical practice, and the processes for conducting scientificevaluation on evidence for human treatment methods and obtaining insurance coverage are unclear. Looking at
psychotherapy as an example, we see that efforts to establish scientific evidence in Japan are lagging behind, anddiscussions regarding the creation of a national license system for certified psychotherapists or their utilization in
medical practice tend to focus on political aspects rather than scientific evaluation. Integrative medicine provides
another example. Evidence compiled at the Evidence-based Japanese Integrative Medicine (eJIM) site operated by
the Ministry of Health, Labour and Welfare (MHLW) is mainly from the U.S. with little evidence from Japan. In
addition, political interventions aimed at establishing an evidence-based integrative medicine provision system arelacking. Given these circumstances, it is difficult to establish domestic evidence for non-pharmacological treatmentswith established evidence overseas or to provide new non-pharmacological treatments as forms of medical practiceor in collaboration with medical practice.

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Next Steps and Future Discussion Points for Achieving Equity in Multidisciplinary Pain
Treatment and Support Systems for Pain Management1

Reinforcing education and awareness raising to foster public understanding toward concepts related to pain
1.1 Introduce education and training programs before and after graduation for all disciplines in health, medicine, andwelfare as well as for healthcare-related private sector services
Pain can be a problem in various disease areas and people living with chronic pain utilize services other than those
provided at healthcare institutions, including integrative medicine. A system is needed to ensure people receive or
can be referred to appropriate treatment and support regardless of which services they use. Achieving this will
require all professionals serving in health, medicine, and welfare as well as those in related private sector healthcare
services to have an accurate understanding of the concept of pain, so rapid steps must be taken to provide educationand training. When providing that education, the concept of pain should be introduced as part of pre-graduate
education for all professions while promoting training programs for those who have already graduated. Whilereferring to items like curricula for health, medical, and welfare professionals provided by the IASP, items that havealready been incorporated in pre-graduate occupational curricula in Japan, and the “Japan Pain Foundation’s Basic
Workshop” from the Japan Pain Foundation, prompt action must be taken to promote education and raiseawareness.
1.2

2

Reinforce education and awareness raising efforts that foster an appropriate understanding of pain among the
public
It has been pointed out that in Japan, people have a deep-rooted cultural perception of pain as something that must
be endured, people tend not to use healthcare or other services when experiencing pain, and that sufficientunderstanding toward people living with pain has not been fostered. There is also insufficient understanding toward
the fact that pain can be a mental issue that is affected by psychosocial stress in addition to being something that
affects the body. In addition to hindering efforts to provide appropriate early interventions, these national
characteristics dampen initiative among people living with chronic pain, which is something that is necessary whentreating chronic pain. It will be necessary to promote the efficient provision of appropriate treatment and support byencouraging education on pain as part of compulsory education and by improving the public’s understanding of pain
and its treatments through nationwide campaigns to build awareness.

Building systems that deliver specialized treatment and integrated care
2.1 Reinforce secondary care by creating independent departments that specialize in pain medicine, establishing a
specialist certification, and training personnel to lead specialized treatment
Pain is a problem that may be experienced by people living with various diseases that span multiple areas of
discipline. Responding to intractable pain that accompanies various diseases will require establishing independent
departments that cooperate with the corresponding department for each disease to provide specialized pain
treatments. In China, some institutions have established systems in which people whose pain does not improve withtreatment from their department are referred to independent pain departments that collaborate to provide
specialized treatment and support. A number of initiatives to reinforce specialized secondary care for pain haveadvanced in Japan, including the establishment of Japan’s first pain clinic department in 1962 and the establishmentof pain clinic departments in 2008. However, specialized treatments for pain are not adequately evaluated in the
medical service fee schedule, making it difficult to continue operating such clinics in a sustainable manner. To
reinforce secondary care for pain, independent pain departments that collaborate with other departments must beMarch 24, 2023
established and proper evaluations for specialized pain treatments in the medical service fee schedule must be
considered.
Healthcare providers who have multidisciplinary knowledge and skills are also required to provide secondary care forpain. A specialist certification and curriculum has not been institutionalized to foster such human resources in Japan,
so a specialized occupation has not been established. In addition to knowledge regarding anesthesiology andpsychiatry, treating pain requires physicians to possess knowledge on pain from fields related to various parts of thebody, starting with orthopedics and dermatology. They must also possess knowledge and various skills from theperspectives of general practice and occupational medicine. Knowledge in multiple areas and a variety of skills arealso required to provide proper treatment for orofacial pain, which is a problem in the field of dentistry. In addition to
the general knowledge provided by the dental curriculum, they must be able to conduct differential diagnosis on
orofacial pain as well as have knowledge of pain science and various pain interventions. As treating pain requires abroad range of knowledge and skills, it will be necessary to establish a systematized specialist training process andcreate a system to certify them.
2.2

Strengthen primary care through which parties most affected receive the integrated treatment and support theyrequire by linking comprehensive care and consultation services with various community resources
There are limits as to how accurately people living with pain can understand the concept of pain and be able toselect the forms of treatment and services that are ideal for them, so a system is necessary that provides
comprehensive and appropriate treatments and consultations regardless of pain mechanism. Providing integrated
primary care has been a topic of discussion for many years, and the institutionalization of family doctor services was
included in the “Proposed Amendment to the Health Insurance Act to Establish a Sustainable Social Security System
for All Generations” approved by Cabinet Decision in February 2023. While taking future policy developments into
account, a primary care system that is easy for people living with pain to understand must be established to ensure
access to appropriate and timely treatment and support.
Establishing such a system will require creating comprehensive consultation services on treatment and fostering a
climate in which such services can be fully utilized. When providing treatment and support for chronic pain in
communities, it will be particularly important to establish a collaborative system that links medical consultation
services with community resources that can provide various interventions as well as to ensure collaborating,non-medical community resources are of sufficient quality. A joint initiative between the “Project for Developing an
R&D Infrastructure for Implementing Prevention and Health Promotion in Society” from the Ministry of Economy,
Trade and Industry (METI) and the Japan Council for Quality Health Care that aims to formulate and disseminate
evidence-based guidelines for ensuring quality in the healthcare service sector are now advancing. While referring tosuch innovative initiatives, steps must be taken to ensure that the healthcare services involved in chronic pain
treatment and support are of sufficient quality while working to reinforce collaboration between those services andhealthcare.

2.3

Establish systems for collaboration across specialties, departments, facilities, and systems to provide a foundation
for multidisciplinary treatment and support
Liaison services that span multiple disciplines and departments to provide medical examinations from various angles,
formulate treatment and support plans through conferences, and provide treatment have been shown to beeffective at providing appropriate treatment and support for chronic pain. Efforts to establish systems for providing
liaison services at multidisciplinary pain centers are currently advancing under the Model Project for Chronic Pain

March 24, 2023
Treatment Systems, and granting insurance coverage to disseminate liaison services is an item that requires urgent
consideration. In addition, healthcare facilities must collaborate to provide multidisciplinary treatment in regions thatlack healthcare institutions providing multidisciplinary treatment. Hachinohe City in Aomori Prefecture provides one
example of such efforts. To provide multidisciplinary treatment and support in Hachinohe City, case conferences
known as “pain meetings” are regularly held by various specialists with the goal of reinforcing collaboration acrossmultiple specialties and departments and at multiple facilities. Expectations are high for frameworks that encourage
collaboration among multiple facilities in communities to be disseminated to other cities throughout Japan.
Various interventions that are considered outside the scope of medical practice like employment support or otherforms of welfare support and integrative medicine have also been shown to be effective for treating chronic pain.
Japan requires a framework for collaboration between providers of medical and non-medical interventions. Efforts toconsider the integrated provision of welfare and other community resources and healthcare as integrated care areadvancing, and Japan has legislated integrated care as part of the Integrated Community Care System, particularly inthe field of welfare for older adults. Within the Integrated Community Care System, efforts are being made toreinforce integrated care provision through community care meetings, which are conferences held by various
specialists in the region. While referring to this and similar efforts in other fields, it will be necessary to constructtreatment and support systems for chronic pain that reflect each community’s resources and unique forms of
demand with the objective of enabling people living with chronic pain to access integrated care anywhere in Japan.
3

Establishing a system that builds evidence for a broad variety interventions and rapidly disseminates them
3.1 Reinforce multidisciplinary research systems that conduct specialized research related to pain
Conducting research on pain itself rather than how it manifests as a symptom for each disease will require a
multidisciplinary research system that gathers specialists from various fields. Overseas, pain research is being
advanced by people serving in fields like neurology, psychology, rehabilitation, sociology, linguistics, and engineeringin addition to specialists in medicine and pharmaceutics. In Japan, efforts to establish research systems for chronic
pain have advanced since chronic pain was named an issue facing society in the Plan for Promotion of Medical
Research and Development, but steps must be taken to further expand multidisciplinary research systems thatinvolve specialists in various fields related to pain.
3.2

Establish a data infrastructure to facilitate efforts to verify effectiveness for various interventions
Coordinating healthcare and non-medical community resources such as welfare and integrative medicine in an
effective and efficient manner will require promoting efforts to verify the effectiveness of interventions provided
through non-medical services. In the U.K., which has established a general practice (GP) registration system,
information on referrals to various community resources is stored in a database of medical information obtained
through general practice called the Clinical Practice Research Datalink (CPRD), which provides a foundation forresearch on various interventions. Japan is currently advancing steps to institutionalize family doctor services and it
will be necessary to establish a similar data infrastructure to reinforce evidence-based family doctor services andadvance research on primary care for chronic pain.

3.3

Clarify methods of evaluating new human technologies as well as for completing processes like obtaining
insurance coverage
One problem for various non-pharmacological treatments recommended by the latest revision of the Clinical
Practice Guidelines for the Management of Chronic Pain is that sufficient evidence on their therapeutic effectivenesshas not been established in Japan. Factors that have resulted in this lack of evidence from Japan include the fact that

March 24, 2023
certain non-pharmacological therapies are being provided through non-medical healthcare services and that there isno system in place for verifying their therapeutic effects. In an initiative called the Research Project for Improving
Quality in Healthcare and Collecting Scientific Evidence on Integrative Medicine, the Japan Agency for Medical
Research and Development (AMED) is working to establish evidence on the effects of non-medical services andother interventions. While referring to such efforts, research on non-medical services for chronic pain must be
reinforced, on-site systems for collecting data from healthcare services must be established, and systems forscientifically verifying the effectiveness of those services based on the data collected must be created. Furthermore,
to rapidly develop systems that will enable people living with chronic pain to access evidence-based non-medical
treatments, it will be necessary to train providers of non-medical treatments for which evidence has been
established through scientific evaluations of human technology, to create new qualifications, and to clarify theprocesses by which such treatments can be utilized at healthcare institutions with health insurance coverage.
4

Formulating policy guidelines that are based on the perspectives of those most affected to achieve equity whenproviding a broad range of evidence-based interventions
4.1 Adopt the eleventh revision of the International Classification of Diseases (ICD-11) in a timely manner and build afoundation for reinforcing treatment and support systems that address pain as a disease
Although Japan’s first pain clinic was established in 1962 and multidisciplinary pain centers are currently being
established throughout Japan, pain treatment is not yet sufficiently evaluated and reimbursed in the medical service
fee schedule. This makes it difficult to provide specialized pain treatment and support in a stable manner. One reason
specialized pain treatment has not received sufficient evaluation is because pain has been considered a symptom
rather than recognized as a disease. The International Classification of Diseases 11th Revision (ICD-11) presented by
the World Health Organization (WHO) in 2022 adopted a new classification of chronic pain developed by the IASP.
While pain was previously recognized as a symptom, it has now received its own systematic classification as anindependent disease. Many guidelines have adopted this new classification, including Clinical Practice Guidelines for
the Management of Chronic Pain from Japan, and it has become the basis for evidence-based treatment systems.
Adopting the ICD-11 in Japan will create a foundation for a system for providing people living with chronic pain withaccess to specialized treatments that are based on the latest science as well as for reinforcing the R&D infrastructure,so urgent action must be taken.
4.2

Reconsider the definition of “medical practice” and the scope of benefits offered by public health insurance andestablish systems that will serve as a foundation for implementing a biopsychosocial model that supports people
living with chronic pain
Many of the treatments and evaluations that people living with chronic pain need and that are based on the BPS
model are not recognized as “medical practice,” so each treatment or evaluation must be examined to determine
which ones can be recognized as “medical practice” to promote the BPS model. The definitions of “medical practice”
and who can engage in “medical practice” in a professional capacity were discussed when the current Medical
Practitioners’ Act was enacted. Those discussions pointed out the need to reconsider what constitutes a disease or atreatment in accordance with progress in medicine, and that it is difficult to assign a straightforward definition to“medical practice” or “medical care.” It will be necessary to consider the establishment of a system for examining
each form of treatment required by people living with chronic pain to determine which ones constitute “medical
practice” based on to the latest evidence, to define the scope of duties for each profession or type of institution(for-profit or non-profit), and to facilitate smooth collaboration among specialties and those providing medical andnon-medical care. The current system requires physicians to possess a wide range of knowledge and skills necessary
for providing suitable treatment and support and is placing an excessive burden on physicians. To provide various

March 24, 2023
treatments needed by people living with chronic pain in a sustainable manner, it will be essential to make further
progress in task shifting and task sharing. This will require multi-stakeholder discussions on the definition of “medical
practice,” the scope of duties each profession is allowed to handle, and the ideal structure of collaboration among
medical and for-profit corporations.
Building a system that provides equal access to forms of treatment and support based on the BPS model to people
living with chronic pain will require reconsidering the scope of benefits provided by public health insurance. The
Japanese public has enjoyed good health due to the support from the public health insurance system, which has
continuously provided appropriate medical care when it is needed. In 2018, an independent research project fromthe Institute for Health Economics and Policy (IHEP) called the Study Group on Reviewing of the Scope of Benefits of
Public Health Insurance released a report that points out the need to reflect on advances that have been made in
medicine and science and reexamine medical practices covered by public health insurance and who is eligible fortreatment. To expand options available to patients and reinforce sustainability of public health insurance, that report
recommends expanding the system for patient-selected extra medical services to allow combined treatment for
specified services. As pain is a subjective emotion, some are concerned that providing treatment and support withinpublic health insurance for all people living with pain will cause runaway growth in demand. Multi-stakeholder
discussions must be held on the scope of benefits covered by public health insurance and the option of partiallyrelaxing restrictions on combined treatments in order to expand treatment options available to people living with
pain.
4.3

Hold multi-stakeholder discussions and formulate a Basic Act on Chronic Pain that is based on the needs of people
living with chronic pain
From the establishment of the National Health Insurance system in 1961 to today, Japan has continuously
maintained a world-class healthcare system that has allowed all citizens to enjoy access to necessary and appropriate
healthcare. However, Japan’s current health, medical, and welfare systems make it difficult to provide suitable
treatment and support for chronic pain due to gaps among the healthcare and welfare systems, medical
departments, and fields of specialty. Current systems also make it difficult to incentivize the provision of suitable
treatment and support. Addressing these issues will require discussions on various topics to be held over the
medium- to long-term. These topics include the concepts of medical treatment, medical practice, and the medical
profession; the scope of benefits covered by public health insurance; issues related to combined treatments and thesystem for patient-selected extra medical services; and various characteristics that form the foundation of thehealthcare system in Japan, including the system for specialist physicians and access to healthcare institutions. Whileadvancing those medium- to long-term discussions, steps must be taken to rapidly establish a system providing
people living with chronic pain the pain treatment and support for pain management they require. While holding
careful discussions on maintaining consistency with the existing healthcare system, this will require formulating a“Basic Act on Chronic Pain” (tentative name) to provide a foundation for comprehensive action frommulti-stakeholders so treatment and support provision systems based on the perspectives of those most affected
can be established without undermining the benefits of existing systems.

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Acknowledgements
HGPI held hearings with the experts listed below during the creation of these recommendations. We express our deepest
gratitude for their valuable input. These recommendations were compiled by HGPI in its capacity as an independent healthpolicy think-tank based on those hearings and are not meant to represent, in any capacity, the opinions of any related partyor organization to which those parties are affiliated.
Hearing participants (titles omitted; in Japanese syllabary order)
Mariko Asaeda
Vice-Representative Director, the Goodbye Pain Patient Support Organization for Intractable
Neuropathic Pain
Masako Ikawa
Dental Surgeon, Department of Oral Surgery, Shizuoka City Shimizu Hospital
Masako Iseki
Professor, Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine
Takahiro Ushida
Director and Professor, Multidisciplinary Pain Center and Institute of Physical Fitness, Sports Medicine
and Rehabilitation, Aichi Medical University
Fusao Kato
Director, Jikei Center for Neuroscience of Pain, The Jikei University School of Medicine
Masaki Kitahara
Clinical Professor, Pain Clinic, Yokohama City University Medical Center
Hironori Kuga
Director, National Center for Cognitive Behavior Therapy and Research, National Center of Neurology
and Psychiatry
Eriko Satomi
Chief, Department of Palliative Medicine, National Cancer Center Hospital
Yumika Shirase
Professor, Graduate School of Social Sciences, Hitotsubashi University
Takuya Numasawa Director, Department of Orthopedic Surgery, Hachinohe City Hospital
Sei Fukui
Clinical Professor, Pain Management Clinic, Shiga University of Medical Science Hospital
Takako Matsubara Professor, Graduate School of Rehabilitation, Kobe Gakuin University
Koji Mori
Professor, Department of Occupational Health Practice and Management, University of Occupational
and Environmental Health, Japan
Shoji Yabuki
Professor, Endowed Chair, Department of Pain Medicine, Fukushima Medical University
Kazuro Wakazono Representative Director, the Goodbye Pain Patient Support Organization for Intractable
Neuropathic Pain

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About Health and Global Policy InstituteHealth and Global Policy Institute (HGPI) is a Tokyo-based independent and non-profit health policy think tank, established in
2004. Since our establishment, HGPI has been working to help citizens shape health policy by generating policy options andbringing together stakeholders as a non-partisan think-tank. Our mission is to enhance the civic mind along with individuals’
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28, 2021, by the Think Tanks and Civil Societies Program (TTCSP) of the Lauder Institute at the University of Pennsylvania.
Author: The Health and Global Policy Institute (HGPI) Mental Health Policy Project Team
Takahiro Sakauchi Senior Associate, HGPIShunki Shimizu
Intern, HGPIRyoji Noritake
CEO, Board Member, HGPIThis report is copyright 2023 Health and Global Policy Institute.

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Global Business Hub Tokyo
1-9-2, Otemachi, Chiyoda-ku, Tokyo
100-0004 JAPANTEL: +81-3-4243-7156 FAX: +81-3-4243-7378
E-mail: info@hgpi.org