A Comprehensive Population Health-Level Strategy for Pain 

National Pain Strategy
1 

Table of Contents

EXECUTIVE SUMMARY .......................................................................................................................... 3

Population Research.................................................................................................................................. 4

Prevention and Care.................................................................................................................................. 4

Disparities................................................................................................................................................. 5

Service Delivery and Payment.................................................................................................................. 5

Professional Education and Training ........................................................................................................ 5

Public Education and Communication...................................................................................................... 6

Next Steps for Implementation ................................................................................................................. 6

THE NATIONAL PAIN STRATEGY: A Vision ........................................................................................ 6

BACKGROUND .......................................................................................................................................... 9

INTRODUCTION ...................................................................................................................................... 13

REPORTS FROM THE WORKING GROUPS..................................................................................... 17

Population Research............................................................................................................................ 17

Prevention and Care............................................................................................................................ 23

Disparities........................................................................................................................................... 29

Service Delivery and Payment............................................................................................................ 34

Professional Education and Training .................................................................................................. 41

Public Education and Communication................................................................................................ 46

APPENDICES ............................................................................................................................................ 51

Appendix A. List of Oversight Panel Members..................................................................................... 52

Appendix B. List of work group members, expert consultants, and staff.............................................. 54

Appendix C. Member nomination process and conflict of interest disclosure ...................................... 64

Appendix D. Chronic pain screener questions....................................................................................... 65

Appendix E. Operational questions for determining high-impact chronic pain .................................... 66

Appendix F. Diagnostic clusters for population pain research .............................................................. 67

Appendix G. Pain treatment indicators: Health care services for pain measurable with electronic health 

care data .................................................................................................................................................. 68

Appendix H. Public and private payer coverage and payment methodologies for pain-related 

treatments................................................................................................................................................ 70

Appendix I. The VA Stepped Care Model of pain care......................................................................... 74

Appendix J. Core competencies for pain education............................................................................... 75

Appendix K. Suggested learning objectives for a public awareness campaign ..................................... 76
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Appendix L. Learning objectives and potential outcome measures for an educational campaign on 

safer use of pain medications.................................................................................................................. 77

Appendix M. Conflicts of Interests/Financial Disclosures..................................................................... 78

BIBLIOGRAPHY ....................................................................................................................................... 81
3 

EXECUTIVE SUMMARY

In 2010, the National Institutes of Health (NIH) contracted with the Institute of Medicine (IOM) 

to undertake a study and make recommendations “to increase the recognition of pain as a significant 

public health problem in the United States.” The resulting 2011 IOM report called for a cultural 

transformation in pain prevention, care, education, and research and recommended development of “a 

comprehensive population health-level strategy” to address these issues.1

 In response to the report, the 

Assistant Secretary for Health, Department of Health and Human Services (HHS) asked the Interagency 

Pain Research Coordinating Committee (IPRCC) to oversee creation of this National Pain Strategy

(NPS). Experts from a broad array of public and private organizations explored areas identified in the 

core IOM recommendations—population research, prevention and care, disparities, service delivery and 

reimbursement, professional education and training, and public awareness and communication. A 

companion effort is underway to address the IOM’s call for further research to support the cultural 

transformation. 

As articulated in the IOM report, efforts to reduce the burden of pain in the United States cannot 

be achieved without an expanded and sustained investment in basic and clinical research on the 

biopsychosocial mechanisms that produce and maintain chronic pain and development of safe and 

effective pain treatments. As a first step to respond to the full set of research recommendations of the 

IOM, the IPRCC and the NIH completed a comprehensive analysis of the existing federal pain research 

portfolio.

i The next step is development of the Federal Pain Research Strategy which will complement the 

NPS. It will identify gaps in our research agenda and recommend directions for new research to guide 

federal entities in their support of essential pain research programs.

Findings and recommendations from the IOM report1 guided the development 

of the National Pain Strategy (NPS). These included: 

• The public at large and people with pain would benefit from a better understanding of pain 

and its treatment in order to encourage timely care, improve medical management, and 

combat stigmatization. 

• Increased scientific knowledge regarding the pathophysiology of pain has led to the 

conclusion that chronic pain can be a disease in itself that requires adequate treatment and a 

research commitment.

• Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and 

interdisciplinary treatment, all components of which should be evidence-based. 

• Data are lacking on the prevalence, onset, course, impact, and outcomes of most common 

chronic pain conditions. The greatest individual and societal benefit would accrue from a 

focus on chronic pain.

• Every effort should be made to prevent illnesses and injuries that lead to pain, the progression 

of acute pain to a chronic condition, and the development of high-impact chronic pain.

• Significant improvements are needed to ensure that pain assessment techniques and practices 

are high-quality and comprehensive.

 

i The Interagency Pain Research Data Base and Summary Report can be found at: 

http://iprcc.nih.gov/portfolio_analysis/portfolio_analysis-index.htm
4 

• Self-management programs can improve quality of life and are an important component of 

acute and chronic pain prevention and management.

• People with chronic pain need treatment approaches that take into account individual 

differences in susceptibility for pain and response to treatment, as well as improved access to 

treatments that take into account their preferences and are in accord with best evidence on 

safety and effectiveness.

• Treatments that are ineffective, whose risks exceed their benefits, or that may cause harm for 

certain subgroups need to be identified and their use curtailed or discontinued. 

• Much of the responsibility for front-line pain care rests with primary care clinicians who are 

not sufficiently trained in pain assessment and comprehensive, evidence-based treatment 

approaches.

• Greater collaboration is needed between primary care clinicians and pain specialists in 

different clinical disciplines and settings, including multispecialty pain clinics.

• Significant barriers to pain care exist, especially for populations disproportionately affected 

by and undertreated for pain2,3, 4 and need to be overcome.

• People with pain are too often stigmatized in the health care system and in society, which can 

lead to delayed diagnosis or misdiagnosis, bias in treatment, and decreased effectiveness of 

care.5

The objectives and action plans developed in this report to address the core 

IOM findings and recommendations are summarized below by work group 

topics and include: 

Population Research

Understanding the significance of health problems in a population is a core public health 

responsibility. To increase the quantity and quality of what is known about chronic pain within the U.S. 

population, the NPS recommends specific steps to increase the precision of information about chronic 

pain prevalence overall, for specific types of pain, and in specific population groups and to track changes 

in pain prevalence, impact, treatment over time, to enable evaluation of population-level interventions and 

identification of emerging needs. It also recommends development of the capacity to gather information 

electronically about pain treatments, their usage, costs, effectiveness, and safety. 

Prevention and Care

Prevention of acute and chronic pain, especially primary prevention strategies, needs greater 

emphasis throughout the health care system, including delivery of long term services and supports, and in 

environments where injuries are likely to occur (e.g. the workplace), and among people at increased risk 

of developing chronic pain. When chronic pain develops, treatment should begin with a comprehensive 

assessment, followed by creation of a care plan that can evolve over time to address the full range of 

biological, psychological, and social effects of pain on the individual. The NPS recommends 

strengthening the evidence base for pain prevention strategies, assessment tools, and outcome measures—

particularly those relevant for primary care—in part through the development of new, rigorously 

researched approaches. It also recommends improvements in pain self-management programs that can 
5 

help affected individuals improve their knowledge, skills, and confidence to prevent, reduce, and cope 

with pain, and minimize treatment risks and adverse effects. 

Disparities

Pain is more prevalent or disabling and/or care is inadequate in certain vulnerable populations 

including people with limited access to health care services, racial and ethnic minorities, people with low 

income or education, children, older adults, and those at increased risk because of where they live or 

work, or because of limited communication skills.2,3 Many of these groups face additional problems of 

stigmatization and bias in pain care.

3,4,5 To eliminate disparities and promote equity in pain assessment 

and treatment, the NPS recommends efforts aimed at increasing understanding of the impact of bias and 

supporting effective strategies to overcome it; increasing access to high-quality pain care for vulnerable 

population groups; and improving communication among patients and health professionals. 

Service Delivery and Payment

Evidence suggests that wide variations in clinical practice, inadequate tailoring of pain therapies 

to individuals, and reliance on relatively ineffective and potentially high risk treatments such as 

inappropriate prescribing of opioid analgesics, or certain surgical interventions, not only contribute to 

poor quality care for people with pain, but also increase health care costs.

1,6,7 The NPS recommends a 

population-based, biopsychosocial approach to pain care that is grounded in scientific evidence, 

integrated, multimodal, and interdisciplinary, while tailored to an individual patient’s needs. Research and 

demonstration efforts are needed that build on current knowledge, develop new knowledge, and support 

further testing and diffusion of model delivery systems.

Professional Education and Training 

Although pain is one of the most common reasons for health care visits, most health profession 

education programs have yet to give it adequate attention.8 The NPS recommends steps to improve 

discipline-specific core competencies, including basic knowledge, assessment, effective team-based care, 

empathy, and cultural competency. It encourages educational program accreditation bodies and 

professional licensure boards to require pain teaching and clinician learning at the undergraduate and 

graduate levels. The NPS also recommends development of a web-based pain education portal that would 

contain up-to-date, comprehensive, and easily accessed educational materials. These training efforts 

should be made in coordination with current HHS efforts to develop tools for providers to recognize the 

risk factors and symptoms of opioid use disorders.ii

 

ii Examples of ongoing government efforts, such as the prescriber training developed as part of opioid 

risk mitigation strategies appropriate prescribing of extended-release and long-acting (ER/LA) opioid 

analgesics is included in the FDA Blueprint for Prescriber Education that is part of the FDA-approved 

Risk Evaluation and Mitigation Strategy for Extended-Release and Long-Acting Opioid Analgesics.

http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163647.htm and the Secretary’s 

Initiative on Opioids: Objectives to improve clinical decision making: http://aspe.hhs.gov/basicreport/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths 
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Public Education and Communication

Key to a cultural transformation in pain care is a greater understanding—among members of the 

public and people with pain alike—of important aspects of chronic pain and its appropriate treatment. The 

National Pain Strategy recommends a national public awareness campaign involving public and private 

partners to address misperceptions and stigma about chronic pain. The learning objectives of the 

campaign would emphasize the impact and seriousness of chronic pain and its status as a disease that 

requires appropriate treatment. In addition, an educational campaign on the safer use of pain medications 

that is targeted to people with pain whose care includes these medications is recommended.

Next Steps for Implementation

Sustained efforts across HHS, working through operating divisions, staff divisions, and also with 

non-governmental partners, will be required in order to implement the public health, clinical, and research 

initiatives described in this Strategy. These efforts will help to prevent pain, improve patient care and 

outcomes, assure appropriate patient and provider education, and advance pain-related applied research. 

The Office of the Assistant Secretary for Health (OASH), in conjunction with HHS operating and staff 

divisions, will consider the recommendations included in the Strategy and develop an implementation and 

evaluation plan based on this process.

THE NATIONAL PAIN STRATEGY: A Vision

The objectives of the National Pain Strategy aim to decrease the prevalence of pain across its 

continuum from acute to high-impact chronic pain and its associated morbidity and disability across the 

lifespan. The intent is to reduce the burden of pain for individuals, their families, and society as a whole. 

The Strategy envisions an environment in which: 

• People experiencing pain would have timely access to patient-centered care that meets their 

biopsychosocial needs and takes into account individual preferences, risks, and social 

contexts, including dependence and addiction.

• People with pain would have access to educational materials and learn effective approaches 

for pain self-management programs to prevent, cope with, and reduce pain and its disability. 

• Patients, including those with low literacy or communication disabilities, would have access 

to information they can understand about the benefits and risks of treatment options, such as 

those associated with prescription opioid analgesics. 

• All people with pain would be assured of receiving needed preventive, assessment, treatment, 

and self-management interventions, regardless of race, color, nationality, ethnicity, religion, 

income, gender, sex, age (neonatal through end of life), mental health and substance use 

disorders, physical or cognitive disability, sexual orientation and gender identification, 

geographic location, education, language proficiency, health literacy, or medical condition. 

All pain-related services would be provided without bias, discrimination, or stigmatization. 
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• Americans would recognize chronic pain as a complex disease and a threat to public health 

and productivity. Individuals who live with chronic pain would be viewed and treated with 

compassion and respect. 

• Clinicians would take active measures to prevent the progression of acute to chronic pain and 

its associated disabilities. 

• Clinicians would undertake comprehensive assessments of patients with chronic pain, leading 

to an integrated, patient-centered plan of coordinated care, managed by an interdisciplinary 

team, when needed. Treatment would involve high-quality, state-of-the-art, multimodal, 

evidence-based practices. While most pain care would be coordinated by primary care 

practitioners, specialists would be involved in the care of patients who have increased comorbidities, complexity, or are at risk for dependence or addiction.

• Clinicians would receive better education and training on biopsychosocial characteristics and 

safe and appropriate management of pain. Clinician’s knowledge would be broadened to 

encompass an understanding of individual variability in pain susceptibility and treatment 

response, the importance of shared (patient-providers) and informed decision-making, ways 

to encourage pain self-management, appropriate prescribing practices, how empathy and 

cultural sensitivity influence the effectiveness of care, and the role of complementary and 

integrative medicine. 

• Payment structures would support population-based care models of proven effectiveness in 

interdisciplinary settings and encourage multimodal care aimed at improving a full range of 

patient outcomes. 

• Electronic data on pain assessment and treatment would be standardized, and health systems 

would maintain pain data registries that include information on the psychosocial/functional 

impact of chronic pain and the costs and effectiveness of pain management interventions. 

These data resources would be used in an ongoing effort to evaluate, compare, and enhance 

health care systems, identify areas for further research, and assess therapies for quality and 

value.

• The evolution toward a public health approach to pain prevention and care would be 

facilitated by epidemiologic, health services, social science, medical informatics, 

implementation, basic, translational, and clinical research, informed by clinician/scientist 

interactions. 

• Data on the health and economic burdens of chronic pain would guide federal and state 

governments and health care organizations in their efforts to work toward these objectives. 

Such data would lay the groundwork for enhancing the effectiveness and safety of pain care 

overall and for specific population groups and would enable monitoring of the effectiveness 

of policy initiatives, public education efforts, and changing treatment patterns.

• A more robust and well trained behavioral health work force would be available to support 

the needs of patients who suffer from chronic pain, including those at risk who need mental 

health care and substance abuse prevention and recovery treatment. 

• The actions in this strategy would be undertaken in the context of the dual crises of pain and 

opioid dependence, overdose, and death in the United States. Actions to improve pain care 

and patient access to and appropriate use of opioid analgesics for pain management would be 

coordinated and balanced with the need to curb inappropriate prescribing and use practices. 

To achieve this balance a broad range of stakeholders including those engaged in pain care 
8 

and pain care policies, as well as those working in substance use prevention, treatment, and 

recovery, would be engaged as the actions of the NPS are undertaken.
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BACKGROUND 

The 2010 Patient Protection and Affordable Care Act (PPACA) Section 4305, required the 

Secretary of HHS to enter into an agreement with the IOM for activities to increase the recognition of 

pain as a significant public health problem, identify and reduce barriers to appropriate care, evaluate the 

adequacy of assessment, diagnosis, treatment, and management of acute and chronic pain across the 

population, and improve pain care research, education and care. As a result, HHS, working through the 

NIH, commissioned an IOM study to assess the state of pain care. The IOM report, issued in June 2011,1

included 16 recommendations for improvements in:

• data collection and reporting

• the availability and effectiveness of pain care 

• public, patient, and professional education about pain

• relevant basic, translational, and clinical research

The IOM’s emphasis on pain as a significant public health challenge, amenable to population 

health-level interventions, placed a large share of responsibility for implementing these recommendations 

on federal health agencies (Institute of Medicine, 2011, p. 5). Specifically, Recommendation 2-2 called 

for creation of “a comprehensive population health-level strategy for pain prevention, treatment, 

management, and research.” 

The following year, HHS created the IPRCCiii to coordinate all pain research efforts within HHS 

and across other Federal Agencies. In October 2012, the Assistant Secretary for Health asked the IPRCC 

to oversee the creation of the comprehensive population health-level strategy envisioned in IOM 

Recommendation 2-2. The IPRCC and NIH established a framework for developing a National Pain 

Strategy, in consultation with the Chair and Vice Chair of the IOM Committee.

iv 

The six key areas addressed in the National Pain Strategy are: 

• population research

• prevention and care

• disparities

• service delivery and payment

• professional education and training

• public education and communication

The IPRCC selected expert working group members to address each of these key areas and 

created an oversight panel (Appendices A and B) to guide and coordinate the working groups’ interrelated 

efforts. Nominations for working group and oversight panel membership were solicited from professional 

 

iii A list of the federal agency, scientific, public, and ex-officio members of the IPRCC can be found at 

http://iprcc.nih.gov/about/committee/committee-roster.htm. 

iv Philip Pizzo, MD, former dean, Stanford University School of Medicine; Noreen Clark, PhD, Director, 

Center for Managing Chronic Disease, University of Michigan (deceased). 
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societies, federal and state agencies, private foundations, advocacy organizations, and through the Federal 

Register (Appendix C). The goal was broad representation from relevant public and private organizations, 

health care providers, insurers, and people with pain and their advocates, as recommended by the IOM 

committee. The body of this report is structured to reflect the results of the work groups’ deliberations. 

Each of the six sections includes a statement of the problem and a set of priority objectives with 

accompanying discrete and achievable deliverables to address the problem. The time frame for 

completion of deliverables is presented as short (approximately one year), medium (two to four years), 

and long term (within five years). Stakeholders best positioned to achieve the deliverables are identified 

and metrics to assess progress are suggested. 

The report is intended to initiate a longer-term effort to create a cultural transformation in how 

pain is perceived, assessed, and treated—a significant step toward the ideal state of pain care. An ensuing 

companion strategy to address the crucial contribution of research to the NPS objectives also is being 

developed by the IPRCC. 
11

Box 1 contains definitions of terms frequently used in this report.

Box 1

Definitions 

Acute pain is an expected physiologic experience to noxious stimuli that can become pathologic, is 

normally sudden in onset, time limited, and motivates behaviors to avoid actual or potential tissue 

injuries. 

Biopsychosocial refers to a medical problem or intervention that combines biological, psychological, and 

social elements or aspects. 

Chronic pain is pain that occurs on at least half the days for six months or more. 

Complementary health approaches are mind and body practices and natural products of non-mainstream 

origin, including chiropractic and osteopathic manipulation, meditation, massage, relaxation, yoga, 

acupuncture, and naturopathic medicine. 

Continuum of pain is the characterization of pain as a temporal process, beginning with an acute stage, 

which may progress to a chronic state of variable duration. 

Disease management refers to a system of integrated, multidisciplinary interventions and 

communications for populations with chronic disorders in which self-care efforts are significant.

Disparities refers to the definition created by Healthy People 2020,

v terming disparities “a particular type 

of health difference that is closely linked with social, economic, and/or environmental disadvantage. 

Health disparities adversely affect groups of people who have systematically experienced greater 

obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; 

mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic 

location; or other characteristics historically linked to discrimination or exclusion.” The work group 

recognizes that this definition is not tailored to the unique nature of pain and, further, that age disparities 

in this report include those faced by children from infancy to adolescence and those in older adulthood. 

High-impact chronic pain is associated with substantial restriction of participation in work, social, and 

self-care activities for six months or more. This term is introduced in the NPS for development of 

research tools that will allow population level data collection on the degree to which pain interferes with 

peoples’ lives.

Integrated care is the systematic coordination of medical, psychological and social aspects of health care 

and includes primary care, mental health care, and, when needed, specialist services. 

 

v http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
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Integrative health care incorporates complementary approaches into mainstream health care to achieve 

health and wellness. 

Interdisciplinary care is provided by a team of health professionals from diverse fields who coordinate 

their skills and resources to meet patient goals. 

Intractable pain is defined as pain that is not relieved by appropriate treatment. 

Levels of care are offered by primary care practitioners, who provide routine screenings and assessment 

and management of common pain conditions due to headache, diabetes, arthritis, and low back pain, for 

example; pain medicine specialists who provide secondary-level consultations, which can include 

multidisciplinary team-based care, including rehabilitation therapy and behavioral health care; and 

interdisciplinary pain centers which provide tertiary care through advanced pain medicine diagnostics 

and interventions. 

Multimodal pain treatment addresses the full range of an individual patient’s biopsychosocial challenges 

by providing a range of multiple and different types of therapies that may include medical, surgical, 

psychological, behavioral, and integrative approaches as needed. 

Opioid Use Disorder occurs when recurrent use of prescription opioid analgesics (opioid based pain 

relievers) and /or illegal opioids such as heroin, causes clinically and functionally significant impairment 

and failure to meet major responsibilities at work, school, or home. Diagnosis is based on inability to 

control or reduce use, social impairment, tolerance and other physiological signs, and pharmacological 

criteria. 

Pain self-management programs address the systematic provision of education and supportive 

interventions by health care providers to strengthen patients’ skills and confidence in medical 

management, role management, and emotional management of their health problems, including regular 

assessment of progress and problems, decision making, goal setting, self-monitoring, and problem 

solving. Specifically for pain self-management, these programs involve acquiring knowledge about pain 

and building skills and confidence to prevent, cope with, and reduce pain. These programs can include a 

broad range of complementary health approaches. These programs can stand alone and be individually 

directed, be integrated into health care settings, or offered by community agencies. 

Prevention as it relates to pain addresses three tiers. Primary prevention includes efforts to reduce injuries 

or diseases that may result in pain. Secondary prevention includes interventions designed to reduce the 

likelihood that acute pain transitions into chronic pain. Tertiary prevention interventions attempt to limit 

the development of disabilities and other complications of chronic pain after it has developed. 
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INTRODUCTION 

Acute pain is an unpleasant, though normal sensory experience in response to a noxious stimulus 

and plays an important protective role by alerting a person to actual or potential physical injury. Painful 

symptoms often can be self-managed while the underlying cause resolves and recovery occurs. Such 

instances generally require little or no professional intervention. Acute pain does not always resolve as 

expected however, especially if it is associated with a serious disease or condition, or begins with an 

injury that does not receive timely or appropriate medical care. When pain persists after the underlying 

cause is resolved, it may signal that pain-initiated changes in the central nervous system have occurred. If 

so, this chronic pain is no longer a symptom of another disorder and has become the disease itself.9

 

The persistence of pain creates a complex biopsychosocial phenomenon that may interfere with 

many aspects of a person’s life—ability to work, social activities, and both physical and mental 

health.

10,11 Secondary psychosocial and physical problems in turn, can worsen pain, posing escalating 

threats to health and well-being12and chronic pain has been linked to premature death.

13 These 

overwhelming challenges of living with chronic pain contribute to a suicide rate that is higher than that of 

the general population.

14,15 Many factors influence the way individual patients perceive and cope with 

pain and the likelihood they will seek and receive care and respond to treatment. Past experiences, 

familial and genetic factors (including race, sex, and gender), comorbidities, cultural background, and 

psychological, economic, and environmental factors all play a role.

16,17 Despite the complexity of pain 

and its care, pain education, research, and treatment historically have focused narrowly on the 

pathophysiological mechanisms involved in chronic pain. This approach inadvertently encourages a 

“magic bullet” approach to treatment, deemphasizing the many other factors that, if overlooked, may 

result in futile treatment and rehabilitation. Other factors affect quality of patient care throughout the 

continuum of pain and are exemplified by wide variations that exist in clinical practices related to pain 

prevention, assessment, and treatment. Care is often fragmented and lacks a comprehensive assessment or 

treatment plan, and patients may encounter difficulty accessing the full range of potential treatments.6

According to the IOM report, most Americans who live with chronic pain do not receive appropriate 

care.1

 

Chronic pain and its treatment can be a lifelong challenge at the individual level and is a 

significant public health problem. Population level surveys indicate that between 11% and 40% of the 

U.S. population report some level of chronic pain, with millions suffering from daily, severe, and 

disabling pain.

18,19,20,21 Some population groups, whether defined by age, sex, gender, race/ethnicity, 

geographic isolation, socioeconomic status, occupation, or other characteristics are differentially affected 

by certain pain conditions, have less access to pain prevention, assessment, and treatment services, and 

experience worse outcomes.3,4 Nationwide, patients face many systemic hurdles to appropriate care, 

including those driven by provider attitudes, biases and stereotyping of patients.5,6 Inadequate provider 

training and payment policies may contribute to unnecessary diagnostic tests and procedures and 

ineffective, risky treatments.6,7 These situations likely contribute to the high health care costs associated 

with chronic pain. High direct medical care costs, as well as costs associated with disability programs, 
14

lost productivity, and family burden all contribute to the IOM annual cost estimate of $560 billion to $635 

billion.

vi,22,23 

More precise assessments of the incidence, prevalence, and disability associated with pain in the 

U.S. population and subpopulations are needed to establish a reliable basis for population-wide 

interventions, and a baseline to assess treatments for the physical, psychological, social, and economic 

burdens of pain, as well as barriers to quality care. Viewing chronic pain from a public health perspective 

allows patients, families, clinicians, and policymakers to benefit from available public health knowledge 

and disease models and adds precision to the concept of pain prevention. This melding of a public health 

mindset and personalized treatment offers the best chance to improve all Americans’ access to highquality and more cost-effective pain care. Public health concerns related to the misuse or diversion of 

prescription opioid pain medications and risk for dependence and overdose with long term opioid 

prescribing add another layer of complexity to the management of chronic pain and need to be considered 

during development of policies and programs related to pain management. As part of a public health 

effort over the past few decades to improve pain management, the broader prescribing of opioids led to a 

significant rise in adverse health consequences, including misuse, addiction, and overdose deaths. 

Prescribing practices, marketing, and misleading information on safety drove a steady and significant 

increase in the number of opioid prescriptions dispensed, rising from 76 million in 1999 to 219 million in 

2011.

24 The amount per prescription, the duration of the supply, and the cumulative dose prescribed also 

increased.25 These dramatic increases paralleled rises in opioid-related substance abuse treatment 

admissions26 and rates of opioid-involved overdose deaths, which reached 28,647 in 2014.

27,28 Certain 

behaviors and risk factors that make people vulnerable to prescription opioid pain medication abuse or 

overdose have been identified.

29 Understanding these factors is important to enable identification of 

populations at highest risk and for development of and improved access to interventions that target these 

high-risk groups. 

Programs to curb inappropriate prescribing practices and prescription opioid abuse must be 

balanced with the use of and access to these drugs for appropriate and quality pain management. Primary 

care physicians treat the majority of chronic pain patients and some primary care physicians report 

reluctance to prescribe opioids for chronic non-cancer pain because of concerns over dependence, 

addiction and abuse behaviors.

30,31,32,33 Pharmacy shortages and regulated dispensing policies34 might 

result in inadequate treatment for those patients where the benefits of opioids outweigh the risks. While 

all patients who are on opioid therapy for chronic pain are at risk for opioid use disorder, limited recent 

studies have shown that most (74-96%) of these patients use their prescriptions without suffering from 

opioid addiction.35,36,37 All people with pain should receive adequate care. 

In some clinical contexts, opioids can help manage pain when other pain medicines have not or 

are not expected to provide enough pain relief. A recent conference to assess the safety and efficacy of 

long-term opioid use for chronic pain found no studies on their long term effects (more than one year) on 

pain, function, or quality of life. While the report states clearly that there are some patients for whom 

opioids are the best treatment for their chronic pain, it concluded that further research is needed to guide 

appropriate patient assessment, opioid selection, dosing strategies, and risk mitigation. However, for 

 

vi These cost estimates were based on the U.S. adult non-institutionalized civilian population and, 

therefore, exclude children, prisoners, people in nursing homes or other institutional settings, and the 

military.
15

many more, there are likely to be more effective approaches.38 The Centers for Disease Control and 

Prevention is developing a guideline for opioid prescribing for chronic pain outside of active cancer 

treatment, palliative care, and end-of-life care. Improving the way opioids are prescribed through clinical 

practice guidelines will help to improve the safety of treatment and reduce risks associated with long-term 

opioid therapy including abuse, dependence, overdose, and death. Providers also need better training in 

safer and more effective prescribing practices, recognizing risks of adverse effects, and approaches to 

proactively facilitate access to addiction treatment for patients at risk. These efforts represent areas in

need of more research and development to ensure that pain management is team based, personalized, 

multidisciplinary, patient-centered, and available to those who need it. 

Access to safe and effective care for people suffering from pain remains a priority that needs to 

be balanced in parallel with efforts to curb inappropriate opioid prescribing and use practices. A 

population with improved pain prevention and care and less pain would mitigate the need for prescription 

opioid analgesics. This need for balance underscores the importance of engaging with a broad range of 

stakeholders, including those engaged in pain care and pain care policies, as well as those working in 

opioid abuse prevention and treatment, as the actions of the NPS are undertaken.

The NPS recognizes that opportunities to prevent the conditions and events that lead to chronic 

pain, such as those associated with the work place and lifestyles must not be missed. Furthermore, 

evidence-based strategies to intervene early to prevent acute pain from becoming a chronic condition and 

the research to develop them are needed. It notes that effective pain care must emphasize shared decisionmaking, informed pain assessment, and integrated, multimodal, and interdisciplinary treatment 

approaches that balance effectiveness with safety. These objectives require a better trained workforce. 

Even though pain is a leading cause of primary care visits, clinicians are generally under-trained in ways 

to assess and effectively manage pain. Improvements in professional education about state-of-the-art care 

for pain, in all its dimensions, including better communication, empathy, cultural sensitivity, and risk 

management will yield significant care improvements. In parallel with provider training, a robust public 

education effort may lend support and knowledge to people with pain, and to the clinicians, researchers, 

and advocates working to prevent and reduce the impact of pain among Americans. This effort will 

improve understanding of chronic pain and its significance among individuals, families, and society and 

increase knowledge about the availability of more effective treatment approaches. 

The U.S. health care system is evolving toward a care model that is patient-centered, evidenceand outcomes-guided yet personalized, and provided through high-performing, interdisciplinary care 

teams. This evolution suggests that development of a National Pain Strategy is timely. Opportunities for 

improvements in care may arise with the increasing emphasis on team-based care and care coordination, 

facilitated by the adoption of health information technology, including electronic health records (EHRs) 

continued health services delivery research, and implementation of better models. More effective delivery 

of services, supported by appropriate health care system features and payment are essential to the 

“cultural transformation” called for in the IOM report. 
16

IOM underlying principles that informed development of this National Pain 

Strategy (Box 2)

Box 2

IOM Committee Underlying Principles*

• A moral imperative. Effective pain management is a moral imperative, a professional responsibility, 

and the duty of people in the healing professions.

• Chronic pain can be a disease in itself. Chronic pain has a distinct pathology, causing changes 

throughout the nervous system that often worsen over time. It has significant psychological and 

cognitive correlates and can constitute a serious, separate disease entity.

• Value of comprehensive treatment. Pain results from a combination of biological, psychological, and 

social factors and often requires comprehensive approaches to prevention and management.

• Need for interdisciplinary approaches. Given chronic pain’s diverse effects, interdisciplinary 

assessment and treatment may produce the best results for people with the most severe and persistent 

pain problems.

• Importance of prevention. Chronic pain can have such severe impacts on all aspects of the lives of 

people who have it that every effort should be made to achieve both primary prevention (e.g., 

workplace ergonomics) and secondary prevention (of the transition from the acute to the chronic 

state) through early intervention.

• Wider use of existing knowledge. While there is much more to be learned about pain and its 

treatment, even existing knowledge is not always used effectively, and thus substantial numbers of 

people suffer unnecessarily.

• The conundrum of opioids. The committee recognizes the serious problem of diversion and abuse of 

opioid drugs, as well as questions about their usefulness long-term, but believes that when opioids are 

used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, 

post-operative, and procedural pain, as well as for patients near the end of life who desire more pain 

relief.

• Roles for patients and clinicians. The effectiveness of pain treatments depends greatly on the 

strength of the clinician-patient relationship; pain treatment is never about the clinician’s intervention 

alone, but about the clinician and patient (and family) working together.

• Value of a public health and community-based approach. Many features of the problem of pain lend 

themselves to public health approaches--a concern about the large number of people affected, 

disparities in occurrence and treatment, and the goal of prevention cited above. Public health 

education can help counter the myths, misunderstandings, stereotypes, and stigmatization that hinder 

better care.

*Institute of Medicine, 2011, op. cit., p. 3.
17

REPORTS FROM THE WORKING GROUPS 

Population Research

The 2011 IOM report led to growing recognition of the impact of pain on the health, productivity, 

and well-being of the U.S. population. Efforts to lower the impact of chronic pain at the individual and 

population levels need to be guided by population-based data. The quality and quantity of information 

being gathered on pain and its treatment needs to be improved in order to collect essential data on the 

prevalence, onset, course, impact, and outcomes for most common chronic pain conditions. These data 

will help guide policies and initiatives of federal and state governments, health care organizations, and 

insurers. 

A core responsibility of public health agencies is assessing the significance of health problems in 

the population. These calculations typically reflect a problem’s incidence, prevalence, and severity 

(morbidity, mortality, and disability) in the population as a whole, across the lifespan, and in relevant 

groups defined by demographic characteristics, geography, or other parameters of interest. For chronic 

pain, better data are needed to understand the scope of the problem and to guide action, including efforts 

to reduce the impact of chronic pain through primary, secondary, and tertiary prevention. Such estimates 

of impact are needed in order to define health care workforce and service delivery needs and priorities for 

insurance benefits, as well as for monitoring the quality, safety, effectiveness, and costs of relevant 

programs and policies. Population research is an essential tool in the implementation of the NPS. 

The World Health Organization’s International Classification of Functioning, Disability and 

Health (ICF) considers determinants of health and disability from the perspective of the biopsychosocial 

model.39 The following ICF concepts are relevant to defining chronic pain:

40,41,42,43

Impairments: Problems with body structure or function

Activities: The execution of a task or action by an individual

Activity limitations: Difficulties an individual may have in executing activities

Participation: Involvement in a life situation 

Participation restrictions: Problems experienced in life situation or social role involvement 

Three inter-related manifestations of chronic pain define its overall individual and societal 

impact: perception, activity limitations, and participation restrictions. Lower to intermediate levels of pain 

severity are less likely to significantly impact social, recreational and vocational functioning, while more 

severe levels are associated with activity limitations and participation restrictions.

25 The IOM report 

emphasized that chronic pain affects to some extent, and estimated that over 100 million adults in the 

U.S.1 It is important to differentiate people with high-impact chronic pain from those who maintain 

normal activities although experiencing chronic pain. Accordingly, the pain assessment tools proposed for 

population research in chronic pain (Appendixes D-F) are designed to identify people in the general 

population who suffer from chronic pain at various levels of severity, including those who have highimpact chronic pain based on the degree to which pain limits their ability to participate in work, social, or 

self-care activities. 
18

The pain assessment tools proposed for population research use the definitions of chronic pain 

and high-impact chronic pain, which are based in part on the widely used definition of chronic pain 

recommended by the International Association for the Study of Pain,44 modified to account for 

intermittent pain. 

The Problem: Population level data on prevalence, onset, course, impact, and outcomes are not adequate 

to guide policies, and practices to improve pain care. Improvements in data methods and measures are 

needed to:

(1) guide efforts to reduce the burden of chronic pain through more accurate estimates of the 

prevalence of chronic pain and high-impact chronic pain in the general population and within population 

groups defined by demographic factors (age, sex, gender, race, ethnicity, education, and socioeconomic 

status) and geographic areas, including identification of risk factors that predispose towards the 

development of chronic pain;

(2) provide standard methods and metrics for the analysis of electronic health care data related 

to pain treatment, which can reveal patterns of health services utilization, including over- and undertreatment, costs, and, most important, quality of care; (analyses should consider the need to gather 

information on use of self-care practices and complementary approaches that are not captured through 

health records);

(3) develop a system of metrics for tracking changes in pain prevalence, impact, treatment and 

barriers to treatment, and costs over time that will enable assessment of progress, evaluation of the 

effectiveness of interventions at the population health level—such as public education or changes in 

public policy, insurance benefits, treatments, and organization of care—and identification of emerging 

needs; (analyses should consider the need to track and account for lack of access to services).

The intent of the Population Research section is to provide methods and metrics to guide 

progress toward achieving improved prevention (primary, secondary, and tertiary) and management of 

pain in the United States.

Objective 1: Estimate the prevalence of chronic pain and “high-impact chronic pain” in the general 

population and in primary care settings, both overall and for anatomically defined pain conditions 

and for various population groups. vii

Short-term (approximately one year) strategies and deliverables: 

• Engage active population researchers to test a set of proposed pain screener questions 

(Appendix D) and brief self-assessment questions about high-impact chronic pain (Appendix 

E) in an existing and representative population sample and among those whose pain treatment 

pattern suggests high-impact chronic pain is likely. 

• Convene key stakeholders to review questions related to pain in current national population 

surveys45 and make recommendations regarding the appropriateness of standardizing, adding, 

or revising questions to bring these surveys in line with the NPS-proposed self-assessment 

questions in Appendixes D and E.

 

vii Stratified by age, sex, gender, race and ethnicity, education, socioeconomic status, health status, and 

indicators of biopsychosocial resiliencies and vulnerabilities
19

• Conduct additional evaluative studies of the NPS-proposed self-assessment questions and any 

alternative questions including cognitive testing and translation into other languages.

• Prepare a manuscript for submission to a peer-reviewed journal reporting the results of the 

tests of the proposed brief pain self-assessment questionnaire.

Medium-term (two to four years) strategies and deliverables: 

• Convene key stakeholders to refine self-assessment questions and measurement strategies and 

to build support for and facilitate implementation of the proposed population-based 

measurement and evaluation components of the National Pain Strategy. 

• Incorporate a brief pain self-assessment questionnaire resulting from this process into at least 

one national morbidity survey, and schedule initial implementation of data collection using 

these items.

Long-term (within five years) strategies and deliverables:

• Use the increasingly refined measures developed to evaluate longitudinal pain outcomes 

including post-acute care evaluations, the Minimum Data Set, and other comparable

population-based tools, from among populations covered through Medicare, Medicaid, and 

then those privately insured.

• Modify the measures as needed to evaluate longitudinal pain outcomes among vulnerable and 

special populations (including workers in high risk occupations, pediatric populations, those 

exposed to early trauma, individuals with physical and cognitive disabilities, and older 

adults).

Federal Stakeholders: 

• Administration for Community Living (ACL), Agency for Healthcare Research Quality 

(AHRQ), Centers for Disease Control and Prevention (CDC), Centers for Medicare & 

Medicaid Services (CMS), Department of Defense (DoD), NIH, National Prevention Council 

(NPC), Veterans Health Administration (VHA) 

Collaborators: 

• public and private health insurers 

• researchers

• health care provider and professional organizations 

• patient advocacy organizations and people with pain

Metrics: The screener tool should be validated through a larger population level study (short-term). The 

progress of the refinement of the assessment tool by expert panels (medium-term) and its 

incorporation into national morbidity surveys and its application to determining longitudinal pain 

outcomes among public and private health care beneficiaries (long-term) should be monitored. 
20

Objective 2: Refine and employ standardized electronic health care data methods to determine the 

extent to which people with common pain conditions, including those from vulnerable groups, 

receive various treatments and services, the costs of these services, and the extent of use of 

treatments that evidence has shown are effective and underused or ineffective and overused. 

Short-term (approximately one year) strategies and deliverables: 

• Carry out proof-of-concept analyses with large public and private health care databases to 

identify patterns of pharmacological and non-pharmacological treatments among people in 

specified diagnostic clustersviii (Appendix F) and their associated costs. This activity would 

provide insights regarding disparities in pain care, as well as how different payment models 

affect both patterns of treatment and costs across a sampling of the general population.

• Prepare a manuscript for submission to a peer-reviewed journal reporting the results of the 

proof-of-concept analyses of health care data on diagnostic clusters and pain treatment 

indicators and related recommendations. 

• Encourage CMS to issue rules to make adequate pain control measures, including clinical 

quality measures, a component of its Medicare and Medicaid incentive programs for 

establishing meaningful use of electronic health record (EHR) technology, an action deemed 

especially helpful in monitoring care for vulnerable populations.

Medium-term (two to four years) strategies and deliverables: 

• Refine the initially proposed diagnostic clusters and treatment indicators, including 

adaptation of the diagnostic clusters to ICD-10 nomenclature. 

• Convene key stakeholders to consider standardization and widespread use of the resulting 

diagnostic clusters and treatment indicators in population research using electronic health 

care data. Ideally, the resulting analyses would be accompanied by evidence-based 

characterization of treatment indicators (Appendix G), including the relative value of specific 

pain treatments, as emphasized in the Service Delivery and Payment section.

Long-term (within five years) strategies: 

• Establish a pain research network to study risk factors for the initiation and maintenance of 

chronic pain and high-impact chronic pain and patterns of pain treatment using the diagnostic 

clusters and pain treatment indicators.ix Use the network to develop data, including EHRs and 

patient reported outcomes, on trends in pain treatment in different population groups

(including vulnerable populations) including and costs of specific pain treatment services and 

to identify opportunities and priorities for primary prevention.

 

viii Diagnostic clusters refer to clinical groups of painful conditions, grouped on the basis of anatomical 

location of the pain rather than diagnostic specificity. They allow analysis of electronic data on use of 

health services for common pain conditions in clinically meaningful groups (e.g., back pain, headache). 

ix Recognizing that these categories are subject to continued refinement based on experience, new 

research findings, and external factors, such as the implementation of ICD-10.
21

Federal Stakeholders: 

• ACL, AHRQ, CDC, CMS, DoD, Indian Health Service (IHS), Office of the National 

Coordinator for Health Information Technology (ONC), NIH, NPC, VHA

Collaborators: 

• evidence-based practice centers in universities

• relevant primary care and specialty professional societies 

• long-term services and supports providers

• public and private sector health care financing and delivery systems that have large patient 

and health maintenance organizations and support research 

• public and private health insurers

• patient advocacy organizations; and people with pain

Metrics: The progress of the refinement of the diagnostic clusters and related treatment indicators, their 

incorporation into ICD-10 nomenclature and their standardization and use in population research should 

be monitored (medium-term). The adoption of diagnostic cluster and pain treatment indicator 

methodology within CMS and outside government-funded programs should be assessed (long-term). The 

development of the research network and its subsequent progress in generating quality data on trends in 

pain treatment in population subgroups, associated costs of specific pain treatment services should be 

evaluated (long-term). 

Objective 3: Develop a system of metrics for tracking changes in pain prevalence, impact, treatment, 

and costs over time to assess progress, evaluate the effectiveness of interventions at the population 

health level—such as public education or changes in public policy, payment, and care—and identify 

emerging needs. Apply these metrics to evaluate the effectiveness of primary, secondary and 

tertiary prevention interventions. 

Short-term (within one year) strategies and deliverables: 

• Set measurable goals for reducing the prevalence of high-impact chronic pain and for 

increasing the value of health care and preventive services for chronic pain to be incorporated 

into Healthy People 2020. 

• Coordinate across the federal agencies that gather data related to primary prevention 

strategies (primarily injury prevention and improved management of certain chronic 

conditions). 

Medium-term (two to four years) strategies and deliverables: 

• Develop approaches to assessing pain’s impact in longitudinal studies that consider pain 

perceptions, activity limitations, and participation restrictions in work, social and self-care 

roles, work productivity, utilization of disability benefits and other services, family effects, 

and utilization and costs of health care services. 

• Evaluate outcomes of Healthy People 2020 chronic pain objectives to inform and guide 

appropriate objectives/questions for a dedicated chronic pain objective to be included in HP 

2030. 

Long-term (within five years) strategies and deliverables:
22

• Encourage health care providers, including long-term services and supports and insurers to

use data developed under these initiatives and the collaborative relationships established to

guide enhancements to health care and preventive services.

• Encourage health care providers and insurers to use data developed under these initiatives and

the collaborative relationships established to evaluate the effectiveness of interventions at the

population health level, such as public policy initiatives, demonstration projects in the

organization or payment for care, or public education efforts.

x

Federal Stakeholders: 

• ACL, AHRQ, CMS, CDC, DoD, IHS, NIH, NPC, VHA

Collaborators: 

• entities that collect data on pain, pain treatment, use of disability programs, and public

benefits

• employer and employee organizations

• public and private sector health care financing and delivery systems that have large patient

and health maintenance organizations and support research

• patient advocacy organizations, and people with pain

Metrics: The extent of adoption of the pain assessment and treatment metrics and their use in assessing 

programmatic interventions should be assessed. The adoption of the proposed measures in the 

Healthy People data tools and reporting system should be monitored and expanded (ongoing). 

The extent of use of diagnostic clusters in program planning, implementation, and evaluation at 

the community, state, and federal levels should be assessed. 

x For example, the Bree Collaborative recently developed strategies to enhance the value of health care for 

low back pain (see http://www.breecollaborative.org/topic-areas/spine) . Washington State’s Bree 

Collaborative provides a model for such collaboration. 
23

Prevention and Care 

Preventable causes of acute and chronic pain should be identified and addressed throughout the 

health care delivery system. When acute pain from injury or disease is present, or when a persistent pain 

state has developed, clinicians should assess and comprehensively manage it using practice guidelines 

based upon best available evidence of effectiveness. Current opportunities to manage the continuity of 

care during transitions across health care settings and to expand real-time access to a carefully selected 

and synthesized body of relevant evidence should be enhanced in order to improve coordination of care 

and optimal use of resources. 

The quality and quantity of evidence needed to guide appropriate and comprehensive clinical 

approaches to the prevention, assessment, and treatment of pain across the lifespan is inadequate, in part 

because of the complex nature of pain. Given that acute pain can progress to chronic pain, which is a 

disease in itself, certain principles are clear:

• Evidence-based care should follow the public health prevention model and address primary, 

secondary, and tertiary prevention.

• Evidence-based pain care should involve an interdisciplinary team approach that includes the 

patient, and family when appropriate, and covers the different levels of pain care—from 

prevention to self-care to acute to chronic pain management—as needed. 

• High-quality pain care should be available to all and in all settings and at all levels of care, 

from primary care to interdisciplinary pain care centers, to functional rehabilitation settings, 

and nursing homes as the intensity of pain management efforts increases.

The Problem: Chronic pain can affect people of any age and may begin with an injury, disease process, 

or procedure that evolves into a persistent painful condition. Often, the cause of its onset is uncertain 

however, and the mechanisms by which it persists are complex. There is a great need to better understand 

the factors that cause pain to become persistent and to develop and apply measures to prevent acute pain 

and its transition to a chronic state. Opportunities to prevent acute to chronic pain progression depend not 

only on the nature of the initial insult and treatment, but also upon various patient-related risk factors. 

While there is much more to learn about chronic pain prevention and treatment, existing knowledge could 

be used more effectively to reduce substantially the numbers of people who suffer unnecessarily. Most 

people who have pain do not receive appropriate assessments or evidence-based care that is coordinated 

across providers and personalized for specific higher-risk situations.

1

 A robust basic, translational, and 

health services research effort is needed to validate the effectiveness of pain prevention and management 

strategies already in use across the spectrum of care settings, and to develop new ones.

The intent of the Prevention and Care section is to advance evidence-based, culturally sensitive and

personalized prevention and care of pain, using the biopsychosocial model and providing value determined 

by accepted, validated, and systematically collected outcomes.

Objective 1: Characterize the benefits and costs of current prevention and treatment approaches. A 

thorough benefit-to-cost analysis of current prevention and treatment approaches, including work place 

injury prevention programs, self-management methods and programs for prevention and care, should be 

performed to identify and create incentives for use of interventions having high benefit-to-cost ratios. 
24

Conversely, approaches and treatments with little absolute benefit or a low benefit-to-risk ratio should be 

identified through clinical studies, and efforts made to dis-incentivize their use. In judging the benefit of 

treatments, clinicians and payers should bear in mind that an individual may belong to a specific 

population group in which the treatment may be either more beneficial (or more risky) than in the 

population at large. Providers and payers should tailor care to address such individual variation in patient 

response.

Short-term (approximately one year) strategies and deliverables:

• Perform a benefit-to-cost analysis of existing methods and programs to prevent and treat pain 

for which the best available evidence suggests benefit (and for which benefits outweigh 

risks). Such an analysis may help guide the choice between therapies that are equally 

efficacious but whose cost differs.

• Prepare a manuscript for submission to a peer-reviewed journal reporting the results of the 

benefit-to-cost analyses of current prevention and treatment approaches and related 

recommendations. 

Medium-term (two to four years) strategies and deliverables:

• Develop a best-estimate synthesis of causes of preventable injuries nationwide, including 

both workplace and non-workplace related injuries and physical trauma by:

o Identifying areas where more evidence is needed (for example, linking work relatedness 

to EHRs, evaluate occupational injuries that may be substantially underreported46). 

o Reviewing existing programs for primary prevention, the evidence for their effectiveness

and the barriers to their implementation.

o Estimating the number of people with chronic pain whose condition is preventable as a 

first step in developing more robust preventive efforts. 

• Begin research efforts geared toward dissemination of existing effective programs and 

development of new prevention and treatment methods likely to have high benefit-to-cost 

ratios. 

Long-term (within five years) strategies and deliverables:

• Incorporate the most clinically effective and cost-efficient treatments into practice guidelines 

and other quality-related efforts, with inclusion of standards-based clinical decision support 

to enable providers and patients to make decisions in line with best practice guidelines. 

Followed by:

• Assessment of insurer practices that either deny payment for clinically effective and costefficient treatments for patients who could benefit from them or insurer practices that 

continue to pay for less effective treatments. 

o Development of a patient-centered framework for measuring treatment outcomes on pain, 

level of disability, and the full range of psychosocial impacts. 

Federal Stakeholders: ACL, AHRQ, CDC, CMS, ONC, National Institute for Occupational Safety and 

Health, Occupational Safety and Health Administration, VHA, and other relevant federal entities 
25

Collaborators: 

• private health insurers

• employers, labor unions and trade associations 

• patient advocacy organizations, and people with pain

Metrics: The level of integration of effective, cost-efficient pain treatments into the health care system 

and the impact on outcomes for people with pain should be assessed at five years, which ideally 

could be compared with baseline data to determine any short-term trends. 

Objective 2: Develop nationwide pain self-management programs.xi Despite evidence to support teambased, self-management programs for pain their implementation has lagged. This is a missed opportunity 

to provide people with pain the appropriate skills, education, and resources to play an active role in 

managing their pain, which includes understanding when clinical consultation is needed. These programs 

should be integrated into the health care systems and other services’ networks to bolster their use and 

prevalence and to guide patients through multiple levels of pain care. Goal setting (action planning), 

problem solving, decision making and psychosocial aspects of care should be included in the programs. 

Team based programs should be multidisciplinary including integrative health professionals, patientcentered, developed with provider input and monitoring, and paralleled with clinical care when needed. 

Short-term (approximately one year) strategies and deliverables: 

• Perform an environmental scan of pain self-management programsxii that: 

o cover the continuum of prevention and pain care; foster skills and integrative health 

self-management approaches to prevent, cope with, and reduce pain; and provide 

people having pain with the practice and confidence to utilize the core selfmanagement skills of goal setting (action planning), problem solving, and decision 

making. 

o are offered in differing health care settings, by community agencies (e.g. aging 

services providers), patient advocacy organizations, or that stand alone.

o are culturally neutral and sensitive, allow for tailoring of the intervention as needed 

for special populations, apply across the lifespan to include children and older adults, 

and are available in multiple languages and formats. 

Medium-term (two to four years) strategies and deliverables:

• Evaluate the efficacy of existing pain self-management programs and support research and 

development of new programs and models, as necessary, to address the continuum of pain. 

 

xi See definitions, Box 1. In addition, to meet people’s various circumstances and learning preferences, 

self-management programs must be offered in multiple models (in groups of varying sizes, electronically 

via smartphone or computer, by mail, or by telephone).

xii Specific programs that warrant an evaluation include the American Chronic Pain Association’s 

program, Stanford Patient Education Research Center Programs, and model falls prevention programs. 

Existing models from integrative healthcare disciplines also should be evaluated.
26

• Leverage existing programs, such as the extensive number of self-management tools for 

patients with chronic disease.

xiii

• Develop new types of patient tools for pain management and provider feedback using, for 

example, mobile applications, that also integrate with EHRs, personal health records/patient

portals, wearable devices, and other technologies.

Long-term (within five years) strategies and deliverables: 

• Implement, evaluate, and disseminate nationally evidence-based pain self-management 

programs that are effective, as documented by high-quality research methods, and that have 

developed materials and a structure enabling them to be transferred to one or more additional 

sites. 

• Encourage the inclusion of evidence-based programs as covered benefits under public and 

private integrated health systems, including Patient Centered Medical Homes and the VHA, 

especially for people with indicators or risk factors for transitioning to chronic pain.

o Disseminate broadly, information on effective pain self-management programs through 

various health information directories, such as http://www.health.gov/ and nongovernmental resources for patients.

o Through various means, direct those with indicators or risk factors for transitioning to 

chronic pain to effective self-management programs.

Federal Stakeholders: ACL, AHRQ, CMS, DoD, IHS, VHA in collaboration with the Health Resources 

and Services Administration (HRSA, as appropriate to their statutory priorities and within their 

authority), and other relevant federal agencies

Collaborators:

• private entities that support health care assessments and outcomes monitoring 

• the Patient-Centered Outcomes Research Institute (PCORI)

• professional organizations, including those representing rehabilitation medicine, athletic 

trainers, and licensed complementary and integrative health fields

• public and private payers

• health care provider organizations, and other potential funders 

• patient advocacy organizations, and people with pain

Metrics: The short-term progress of the programs should be assessed through data on the outcomes for 

people with pain and collected through established tools, such as the NIH and Department of 

Defense’s collaborative Pain Assessment Screening Tool and Outcomes Registry/Patient 

Reported Outcomes Information System PASTOR/PROMIS, the NIH Pain Consortium, Stanford 

University’s Collaborative Health Outcomes Information Registry (CHOIR), and those developed 

by the Joint Commission; and by innovative use of data from EHRs. The level of integration of 

 

xiii Examples of program models include: Stanford’s Patient Education Research Center, Arthritis SelfManagement Program, and Chronic Pain Self-Management Program ; the University of New Mexico’s 

telehealth program, Project ECHO; the A Matter of Balance program developed by Boston University; or 

the National Institute of Disorders and Stroke’s program for pediatric migraine, under development.
27

and payment for effective pain self-management into the health care system should be assessed at 

five years, which ideally could be compared with baseline data (environmental scan). 

Objective 3: Develop standardized, consistent, and comprehensive pain assessments and outcome 

measures across the continuum of pain. Pain assessment should be multifaceted and include self-report, 

as well as clinician examination. Assessment and outcome measures should include relevant pain, 

physical, psychological, emotional, and social domains of functioning that conform to the 

biopsychosocial model of pain, as well as patient-reported outcomes and patient-defined goals. 

Assessments and outcomes should accommodate patient communication challenges (e.g. through 

behavioral symptoms measures), be used for point-of-care decision-making by clinicians, longitudinal 

outcomes monitoring, estimations of value of optional treatment approaches, and practice-based 

effectiveness studies. 

Short-term (approximately one year) strategies and deliverables:

• Develop comprehensive quality assessments and outcome measures for the continuum of pain 

o Establish expert working groups to survey and identify gaps in available assessment and 

outcomes tools for the continuum of pain, including both general assessments and 

condition-specific modules, as well as opportunities to leverage outcome data from 

existing resources such as registries, especially taking into consideration their usefulness 

for primary care providers and for population research.xiv 

o Conduct research and developmental studies to create new assessment tools and identify 

models.

o Integrate appropriate pain self-assessment tools into EHRs, patient portals, and other 

forms of health information technology (health IT) to aid providers and patients in 

clinical decision making. 

o Recommend ways to integrate outcomes measures into existing assessment systems, as 

necessary.

Medium-term (two to four years) strategies and deliverables: 

• Disseminate existing assessment tools and outcome measurement systems that prove most 

effective and are easily managed, and create incentives for using them.

• Conduct pilot studies of new models that emerge from research.

Long-term (within five years) strategies and deliverables: 

• Evaluate the benefits and costs of improved, standardized assessment tools and outcome 

measures. 

• Assess health insurer practices to improve appropriate use of pain treatments, including 

opioid and non-opioid therapies.

Federal Stakeholders: ACL, AHRQ, CDC, CMS, FDA, ONC, NIH, and other relevant federal entities. 

 

xiv The NIH Task Force on Research Standards for Chronic Low Back Pain is an example of such a task 

force.
28

Collaborators:

• public and private health insurers

• PCORI 

• professional organizations (especially primary care) 

• National Committee for Quality Assurance (NCQA) and other relevant health care 

systems accrediting bodies

• pain advocacy organizations, and people with pain

Metrics: The extent of adoption of improved assessment tools and outcome measurement systems into 

existing assessment systems, provider practices, EHRs, patient portals, and other forms of health 

IT should be monitored annually over five years. The costs and benefits of the tools should be 

evaluated at five years.
29

Disparities 

 

Pain care disparities are complex, due to myriad contributing factors within and outside the health 

care sector. Elimination of disparities and equity in care cannot be achieved without increased access to 

high-quality treatment, development of strategies and expectations for equitable assessment and treatment 

of pain, and creation of appropriate supporting programs and services (such as effective patient 

communication strategies, and disability and addiction services as needed) for people with pain. A more 

robust and well trained workforce is needed to address the need for access to quality care for all people 

with pain and especially for those in vulnerable populations. Specific needs include expansion of the 

nation’s behavioral health workforce to support the needs of patients with chronic pain and those at risk 

for substance use and mental health disorders. Also needed is improved communication between service 

providers and people with pain and their families. 

The IOM report, extensive research, and patient reports indicate that substantial disparities in pain 

prevention, occurrence, assessment, treatment, and outcomes are common; U.S. data indicate a greater 

prevalence of pain conditions among specific population groups. The Healthy People 2020 current 

definition of health disparities is included in the Background section of the strategy. 

While many factors affect an individual’s experience of pain and willingness to seek or adhere to 

treatment, and while more comprehensive efforts are needed to prevent pain in higher risk groups, this 

section of the National Pain Strategy focuses on improving the quality of pain care for vulnerable 

populations, especially as it may be affected adversely by provider attitudes and behaviors that result in 

discrimination, bias, or stigmatization, which themselves can lead to or exacerbate pain. When this 

section of the NPS discusses bias, stigmatization, and discrimination, it is referring to all higher-risk 

groups that comprise vulnerable populations. Examples of patient groups and conditions for which bias 

has been reported are diverse and widespread and include: women experiencing pain from chronic fatigue 

syndrome, fibromyalgia, and other conditions; people who are on prescription opioids for intractable 

pain; children—especially infants and others who cannot communicate; older adults—especially those in 

nursing home settings who have limited communication; people with substance use and mental health

disorders; and patients with sickle cell disease or pain associated with human immunodeficiency virus 

(HIV) infection. 

The Problem: A significant problem facing vulnerable populations arises from conscious and 

unconscious biases and negative attitudes, beliefs, perceptions, and misconceptions about higher-risk 

population groups (e.g. sex, gender, age, disability, ethnic, or racial bias) or about pain itself.

6,47,48,49 If 

held by clinicians, social service program administrators, or other decision-makers, these attitudes can 

negatively affect the care and services they provide. For example, inappropriate or inadequate treatment 

may result if clinicians fail to understand or accept that individuals differ in pain sensitivity and treatment 

response due to a wide range of factors. People with pain who encounter these biases can feel stigmatized, 

which may decrease their willingness to report pain in a timely way, participate in decisions about their 

care, adhere to a recommended treatment plan, or follow a self-care protocol. This perception also may 

negatively affect their psychological state.

An additional barrier to eliminating pain disparities is the lack of sufficient knowledge of behavioral and 

biological issues that arise from age (infancy through older adults), genomic variability, pharmacokinetic 

and pharmacodynamics differences, which affect pain onset, chronicity, and management and data to 

understand patterns of pain and its treatment in higher risk and vulnerable populations.
30

The intent of the Disparities section is to improve the quality of pain care and reduce barriers for all 

vulnerable, stigmatized, and underserved populations at risk of pain and pain care disparities. 

Objective 1: Reduce bias (implicit, conscious, and unconscious) and its impact on pain treatment by 

improving understanding of its effects and supporting strategies to overcome it.

Short-term (approximately one year) strategies and deliverables: 

• Document the evidence base of adverse effects of clinician bias on the pain experience for 

use in developing, validating and implementing clinician and public education, policy 

recommendations, and health system reforms:

o Conduct a baseline survey, using quantitative and qualitative research design, of health 

care and social services providers to assess their biases, attitudes, beliefs, knowledge, and 

behavior regarding pain among people from vulnerable populations. 

o Convene an expert group to review evidence on effects of health care, long-term services 

and supports, and social services provider bias in decision-making regarding integrated, 

multimodal, and interdisciplinary pain care, strategies to overcome bias (at the patient, 

clinician, institutional, and health system levels), and to identify gaps in knowledge. 

These gaps should support a research strategy to improve clinician education, pain care, 

and direct pain policy. 

o Convene an expert group to assess the state of the science and promote a better 

understanding of biological variability, including genetic and other influences, affecting 

pain sensitivity and treatment response across diverse populations. 

Medium-term (two to four years) strategies and deliverables:

• Disseminate the proceedings of these groups to health care and social service providers, 

policy makers, and other stakeholders through a manuscript in a relevant journal and other 

appropriate means. 

• Develop pilot projects, designed to reduce bias in pain care at the provider, health care, longterm services and supports, and social service systems levels, using the conclusions of the 

expert groups. 

• Conduct demonstration projects to evaluate bias reduction strategies in health care systems or 

other large population-based service delivery systems, based on the results of the pilot 

projects. 

Longer-term (within five years) strategies and deliverables: 

• Develop, implement, and evaluate policy recommendations and guidelines on bias reduction 

for health care, long-term services and supports, and social service providers, based on 

outcomes of the demonstration projects. 

Federal Stakeholders: ACL, AHRQ, HRSA, Office of Minority Health (OMH), NIH

Collaborators:

• professional medical organizations 
31

• researchers (including social sciences)

• health care, long-term services and supports, and social services providers (including licensed 

practitioners who provide integrative and complementary health approaches)

• state and federal policymakers

• community representatives

• patient advocacy organizations and people with pain 

Metrics: Identified knowledge gaps on effects of provider bias in health care outcomes should be included 

in a long term research strategy. Practices to reduce bias, based on demonstration projects, should 

be incorporated into health care, long-term services and supports, and social service systems. The 

extent of implementation of policy recommendations and guideline adoption should be assessed 

at five years through a follow-up survey to determine changes in health care, long-term services 

and supports, and social service provider biases, attitudes, beliefs, knowledge, and behavior.

Objective 2: Facilitate communication among patients and health professionals.

Short-term (approximately one year) strategies and deliverables:

• Convene an expert group to review and make recommendations on effects of disparities in 

pain care and means to heighten its national awareness.

• Disseminate findings of the review group to the general public, researchers, health care and 

social services providers, and professional organizations. 

Medium-term (two to four years) strategies and deliverables:

• Improve the health literacy of people with pain through promotion and dissemination of the 

National Action Plan for Health Literacy and the National CLAS standards to relevant health 

care providers and health care systems. 

• Perform an environmental scan for existing communication guidelines that are specific to 

pain care and relevant to patients with limited English proficiency or health literacy, 

communications disabilities, or age related communication limitations.

Long-term (within five years): 

• Develop needed communication guidelines in accord with the gaps from the environmental 

scan, that are consistent with the National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care (National CLAS Standards: 

www.thinkculturalhealth.hhs.gov ).xv

 xv Title VI of the Civil Rights Act of 1964 requires federally assisted programs to take reasonable 

steps to provide meaningful access for persons who have limited English proficiency which may include 

the provision of language assistance services at no cost to the person being served. Section 504 of the 

Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990 require that 

recipients ensure that communication with individuals with disabilities is equally effective as 

communication with persons without disabilities. 
32

Federal Stakeholders: ACL, AHRQ, HRSA, OASH: ODPH, OMH, Substance Abuse and Mental Health 

Services Administration (SAMHSA) 

Collaborators:

• health care, long-term services and supports, and social service providers’ credentialing 

agencies (certification standards and guidelines) and accrediting bodies (NCQA and other 

relevant health care systems accrediting bodies)

• health professional training programs and licensing bodies (to promote cultural and linguistic 

competency)

• patient advocacy organizations and people with pain

Metrics: The establishment of payment models for payment of direct translation and interpreters should 

be tracked and linked to the number of staff and quality translation services available in pain care 

settings. 

Objective 3: Improve the quality and availability of data to assess the impact of pain and under or 

overtreatment for vulnerable populations, and the costs of disparities in pain care.

Short-term strategies (approximately one year) and deliverables:

• Develop data standards and definitions to track pain prevalence and treatment across 

vulnerable populations. These standards and definitions could be applied to EHRs, 

population-level surveys, and relevant clinical research

Medium-term (two to four years) strategies and deliverables: 

• Convene an expert group to assess the current costs of pain care disparities, including costs 

that result from health care utilization, lost work or educational opportunities, and use of 

disability and other benefits.

Long-term (within five years): 

• Use current and new data standards as developed above to enable national studies of 

inappropriate, under- and over-treatment among vulnerable populations, and to assess 

progress toward eliminating it. 

Federal Stakeholders: ACL, AHRQ, CDC, HRSA, NIH, ONC

Collaborators:

• private entities (for research using new or existing data sets and data collection standards)

• the pain research community

• patient advocacy organizations and people with pain (for input on data needs, adequacy, and 

usability)

Metrics: The number of studies published using the data standards and definitions developed to assess 

prevalence and treatment outcomes should be monitored. Data mining based on these standards 

and definitions from EHRs, population surveys and clinical studies should be tracked to assess 

effectiveness of dissemination. 
33

Objective 4: Improve access to high-quality pain services for vulnerable population groups. 

Short-term (approximately one year) strategies and deliverables: 

• Conduct an environmental scan of current patient resources that link people with chronic pain 

to appropriate care (e.g., health centers, long-term services and supports, social services, and

behavioral health providers, and clinician specialists).

• Promote awareness of these resources through stakeholder agencies (e.g. websites, social 

media) and professional organizations (e.g. websites, membership). 

• Develop demonstration projects of ways to improve access to current resources (including 

means to determine the potential of patient-centered medical homes to serve people who are 

at risk for disparities in care and aging and disability resource centers. 

Medium-term (two to four years) strategies and deliverables:

• Develop a web-based portal of resources to link patients and families to appropriate care 

(leverage http://healthfinder.gov/, http://eldercare.gov) and self-management tools. 

• Develop demonstration projects to evaluate the web-based portal in improving access to highquality care among vulnerable populations.

• When appropriate, promote and disseminate telehealth for hard-to-reach populations and for 

clinicians who do not practice where multidisciplinary colleagues are available. 

• Coordinate with ongoing efforts to expand the behavioral health workforce capacity for 

psychological needs related to pain care, mental and substance use disorders, through HHS 

sponsored programs to attract new students to the field.

xvi 

Long-term (within five years) strategies and deliverables:

• Promote and disseminate effective models from the demonstration projects (access models, 

web-based tools), and provide incentives to adopt them.

• Develop, test, evaluate, and promote provider-facing clinical decision support tools to 

identify patients who are vulnerable to disparities in care, and to make treatment and referral 

decisions that prevent/reduce disparities. 

Federal Stakeholders: ACL, CMS, DoD, HRSA, IHS, OMH, VHA

Collaborators: 

• private entities to promote awareness of existing programs, develop demonstration projects, 

and evaluate existing tools

• health care, long-term services and supports, and social service systems 

• professional medical organizations

• community representatives

• patient advocacy organizations, and people with pain 

 

xvi Examples can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741399/
34

Metrics: The frequency of access to the information gateway portal and telehealth consultation should be 

tracked annually and outcomes of the demonstrations projects should be used to improve the 

gateway and the effectiveness of the telehealth programs. 

Service Delivery and Payment

A primary objective in enhancing the delivery of quality pain care is to make optimal and 

personalized pain management accessible to all. Wide variation in clinical practice and in patients’ 

responses to therapies, along with inappropriate or repeated use of relatively ineffective and potentially 

risky treatments (e.g. prescription opioids and certain procedural/surgical interventions), has been linked 

to poor quality outcomes and high costs of pain care.1,6 Given that commonly used single-modality 

treatments often fail as first-line therapies for chronic pain, attention among leaders in the field has shifted 

to improving pain assessment and delivery of integrated, multimodal, interdisciplinary care that is 

effective and safe.

1,6 The IOM report reflected this shift by advocating consistent and complete pain 

assessments, payment reform to foster coordinated interdisciplinary care, and greater support for primary 

care clinicians to deliver the most effective, safe, and timely care, including more opportunities for 

consultations with pain specialists. The recommendations of this workgroup support a framework for 

which the advances in prevention and care outlined in the IOM report can be provided to all individuals 

with pain.

Insurance policies have been shown to affect consumer choices of treatments and their adherence 

to treatment regimens. Payment policies also can affect the clinical strategies adopted by health care 

providers. Payment policies for different procedures and products, formulary placement of drugs, and 

managed care arrangements all can affect the choices made by patients and physicians about managing 

chronic pain. The structure of payment and coverage arrangements can therefore exert powerful effects on 

how pain is managed.

Patients suffering from chronic pain may have access to complementary and alternative strategies 

for pain management, but these strategies have diverse economic implications. For example, consider 

acupuncture, cognitive behavioral therapy (CBT) and use of various prescription opioids. Many insurance 

plans do not cover acupuncture, and if they do provide coverage, subject it to strict duration limits. 

Moreover, these treatments are time consuming, must often occur during “work hours” and may require 

substantial cost sharing (e.g., $20 to $50 per visit in the case of CBT). The cost to consumers of 

prescription opioid products varies according to the specific drug and its placement on the prescription 

drug formulary. Some generic products (e.g., methadone) have out- of- pocket costs of as little as $10 

to$15 for a 30-day supply. Brand name drugs may have higher out of pocket costs in the range of $20 to 

$35 for a 30-day supply. Thus, consumers in many insurance plans may gravitate to prescription drugs 

over complementary or alternative treatments, creating risks for subsequent problems with opioid 

dependency.

Providers frequently are very constrained in the time they can spend with individual patients. The 

typical primary care visit is approximately 17 minutes in duration, and fees permitted for brief office 

visits are fixed. Such visits usually involve attending to a number of clinical issues as well as trying to 

develop a rational, individualized pain treatment regimen. Capitation schemes create incentives for 

clinicians to minimize the total resources devoted to addressing complex problems such as pain control. 

In pay-for-performance systems additional payments are earned based on favorable outcomes being 
35

achieved. In pain management, there are no such systems. Providing referrals for acupuncture or CBT 

may require primary care providers or specialists to provide clinical services with which they have little 

experience. Specifically, monitoring such services for referred patients may be difficult, and patient 

outcomes are more uncertain and require more clinician time to assess. These complexities can create 

situations where clinical choices for physicians and patients are weighted towards use of prescription 

drugs. 

Ideally, clinicians might face neutral economic consequences as a result of choosing among 

effective pain control strategies. This could allow reimbursement for longer visits when selecting a 

therapy that involves more clinician time and less prescription opioid use. Exploring coverage and 

payment mechanisms that align consumer and provider interests in choosing cost-effective treatment 

strategies that balance risks and benefits of care for individuals can make an important contribution to 

implementing an HHS pain management strategy.

The National Pain Strategy endorses a population-based, disease managementxvii approach to pain 

care that is delivered by integrated, interdisciplinary, patient-centered teams and is consistent with realworld experience. To succeed, the care model must shift from the current fragmented fee-for-service 

approach to one based on person-centered care, better incentives for prevention (primary, secondary, and 

tertiary) and for collaborative care along the continuum of the pain experience—from acute to chronic 

pain across the lifespan, including at the end of life—at all levels of care and in all settings.

The Problem. Access to high-quality integrated care based on clinical evidence is hindered by many 

challenges. Pain management often is limited to pharmacological treatment offered by a primary care 

practitioner or to procedure-oriented and incentivized specialty care that is neither coordinated nor 

aligned with best available evidence or expected outcomes.

1,7 This situation is especially relevant for 

people with high-impact chronic pain, where integrated care is likely to be most effective. Even when 

interdisciplinary care is provided, creating and executing a care plan is often fragmented, with poor 

communication and collaboration among clinicians and without consideration of patient preferences.

1,7

The clinician or team’s choice of therapy may be based on practice experience or insurance coverage, 

rather than one informed by a comprehensive pain assessment, clinical evidence, or best practices. 

More quality research is needed on the effectiveness of interventions, integrated care, models of 

care delivery, and payment innovations. Also needed are more effective methods to disseminate research 

findings and incentives to incorporate them into clinical practice. Level-I studies (e.g. high-quality 

randomized controlled trials or prospective studies) in pain are limited. Patient-reported outcomes are 

rarely collected outside of clinical trials. Observational data and registry studies sometimes lack detail and 

relevant outcomes. There is a need for research to enhance drug discovery for safer opioids and nonopioid analgesics, to raise the level of evidence for treatment approaches, and to improve evidence for 

clinical guidelines. 

The incongruity between high-quality care and real-world clinical practice is however, only partly 

the result of limited evidence to support existing clinical guidelines. Current payment practices 

complicate use of integrated, interdisciplinary, patient-centered teams. Payers tend to cover mono-therapy 

 

xvii Disease management refers to a system of integrated, multidisciplinary interventions and 

communications for populations with chronic disorders in which self-care efforts are significant. (Disease 

Management Association of America. Disease State Management Definition. Accessed at 

www.dmaa.org/dm_ definition.asp, March 30, 2006.) 
36

and interventional procedures instead of prevention programs and services that conform to the 

biopsychosocial model of care. Payment often is not provided for pain self-management programs, patient 

and family social services support, patient decision making, patient education on the biopsychosocial 

effects of pain, team-based medication management, psychological counseling, cognitive-behavioral 

therapy, physical medicine and rehabilitation, and complementary and integrative health approaches. 

Current payment mechanisms (Appendix H) tied to the fee-for-service payment system generally fail to 

support more value-driven approaches (for example, the stepped model of pain care and other emerging 

models of coordinated care). 

Further hurdles to quality pain care delivery are lack of access to and payment for medications

managed primarily by retail pharmacies and third-party payers. Although analgesics should not be the 

sole intervention for most pain conditions, they may be essential for improved quality of life. Rationing, 

medication shortages, and inadequate payment for medication management and monitoring, and the high 

cost of abuse deterrent formulations decrease patient’s access to medications and cause considerable 

hardship, especially for vulnerable populations.

3,6

The intent of the Service Delivery and Payment section is to create a payment and delivery environment 

that facilitates coordinated care across the continuum of pain and throughout the lifespan in order to 

conform to the biopsychosocial model and provide value, as defined by outcomes of care. 

Objective 1: Define and evaluate integrated, multimodal, and interdisciplinary care for people with 

acute and chronic pain, and end of life pain, which begins with a comprehensive assessment, creates 

an integrated, coordinated, evidence-based care plan in accord with individual needs and 

preferences and patient-centered outcomes, and is supported by appropriate payment incentives. 

Short-term (approximately one year) strategies and deliverables:

• Perform an environmental scan to access quality of care and costs of current treatment 

approaches and identify the existence of more effective models. 

• Convene expert stakeholders to develop strategies to address the shortcomings in quality of 

care and the high costs of current pain treatment approaches, the existence of more effective 

models, and the steps that can be taken toward achieving high quality care and outcomes. 

Medium-term (two to four years) strategies and deliverables:

• Solicit proposals through the Center for Medicare and Medicaid Innovation for evaluating 

emerging and innovative models of integrated care for chronic pain conditions. 

• Conduct rigorous evaluations of these models through independent evaluators, and others that 

have been initiated but not yet evaluated, especially those using the stepped model of pain 

care, the biopsychosocial model, team-based care, pain self-management approaches, and 

care planning based on comprehensive pain assessments based on a biopsychosocial model 

that includes the etiology of pain. 

• Monitor and evaluate outcomes of the models tested.

Long-term (within five years) strategies and deliverables:

• Evaluate optimal models in federal, state, and private provider contexts and implement as 

appropriate.

Federal Stakeholders: ACL, CMS, DoD, HRSA, IHS, VHA
37

Collaborators:

• primary and specialty care clinicians, neuro- and orthopedic surgeons, and licensed 

integrative health care practitioners)

• professional accreditation entities

• integrated health care systems 

• large private third-party payers

• pain advocacy organizations, and people with pain

Metrics: Metrics used to determine positive outcomes from models on measures of physical, 

psychological, and functional improvement for patients, as well as cost savings relative to 

conventional care should be used as a measure of progress. Incorporation of validated, successful 

models into health care systems and clinical practice should be monitored and assessed.

Objective 2: Enhance the evidence base for pain care and integrate it into clinical practice through 

defined incentives and payment strategies, to ensure that the delivery of treatments is based on the 

highest level of evidence, is population-based, and represents real-world experience. 

Short-term (approximately one year) strategies and deliverables: 

• Perform an environmental scan to assess barriers to quality care (e.g. identify outcomes of 

current insurers’ practices of prior authorization, fail first protocols, and caps on treatments, 

and pharmacy benefit managers). 

Medium-term (two to four years) strategies and deliverables:

• Solicit population-based studies designed to develop and implement practices for primary 

care settings, pain self-management programs, and integrative health approaches that are 

cost-effective, represent real-world settings, and include patient representatives to provide 

practical approaches for assessing therapeutic effects. Evidence-based outcomes from these 

studies can be analyzed through available pain data registries, EHRs, population surveys, and 

other appropriate data sources, including the tools recommended in the Population Research 

section.

• Leverage existing pain registries or initiate development of new pain registries to track 

outcomes—including patient-reported outcomes—of the models tested in Objective 1 and 

develop, standardize and integrate process and outcomes measures into EHRs, which may 

then be compiled across networks.

Long-term (within five years) strategies and deliverables:

• Integrate and disseminate study results:

o Compile and integrate outcomes of the population-based studies (above), the models 

tested (Objective 1), and those from the large national databases recommended in the 

Population Research section that are relevant to treatment choices. 

o Inform the design of these research projects and integrate their findings with data 

obtained in the national survey activities described in the Population Research 

section.
38

o Disseminate their results to clinicians, quality improvement initiatives, public-private 

partnerships, patient and advocacy organizations, and others, to encourage 

implementation of more appropriate, evidence-based care. 

• Expand the pilot pain registries to incorporate over time, findings from other studies, 

including randomized controlled trials, pragmatic trials, and other high-quality research 

methods.

• Convene expert stakeholders from appropriate disciplines to consider the outcomes of the 

pilot studies on emerging models of service delivery and payment and to discuss adoption of 

consistent clinical guidelines on pain care across clinical specialties. 

• Use population-based data to inform national policy for opioid use and monitoring, including 

comparative effectiveness of opioids versus other forms of treatment, effectiveness of state 

prescription drug monitoring programs and point-of-care interventions to prevent abuse and 

misuse, and the effects of regulatory and enforcement policies (Food and Drug 

Administration and Drug Enforcement Administration), on abuse, misuse, and access to 

opioid medications. 

• Assess the impact of potential changes in policies on opioid use and opioid use disorder.

Federal Stakeholders: ACL, AHRQ, CDC, DoD, FDA, HRSA, NIH, VHA

Collaborators: 

• private entities that support population-level research, including PCORI, private payers, 

integrated health systems

• private agencies and software experts developing electronic medical records and other 

relevant programs

• health profession organizations

• health, long-term services and supports, and social service provider organizations

• credentialing bodies for primary care and specialty clinicians

• pain advocacy organizations and people with pain

Metrics: The incorporation of validated, successful models and practices from the pilot projects into 

provider practices and health care systems should be assessed. The outcomes of evaluated 

interventions and care, including patient and family assessments and costs, as compared to usual 

treatment should be assessed. The adoption of evidence-based practice guidelines for multiple 

disciplines should be assessed. 

Objective 3: Tailor payment to promote and incentivize high-quality, coordinated pain care through 

an integrated biopsychosocial approach that is cost-effective, value-based, patient-centered, 

comprehensive, and improves outcomes for people with pain.

Short-term (approximately one year) strategies and deliverables: 

• Identify and invest in the development and implementation of models of care that deliver 

high-value pain care that both maximizes patient benefit and minimizes risk and costs and 

accounts for potential need for long term and enduring care. 
39

• Identify alternate strategies to serve those most likely to lack access to these innovative

models and those with unique needs such as patients with or at risk for addiction, those who

have suffered psychological trauma, pediatric populations, and older adults.

• Identify, measure, and recommend means to control variations in pain care and access to pain

care that lead to low-quality or high-cost care.

• Develop new tools to facilitate payment for higher quality pain care.

xviii

• Define, identify, and engage eligible pain care clinicians and health, long-term services and

supports, and social service providers willing to participate in quality and utilization reporting

that includes pain measures, including those participating in existing programs, such as the

Medicare Physician Quality Reporting System, the Advancing Excellence campaignxix and all

of the other quality reporting systems that CMS hosts.

Medium-term (two to four years) strategies and deliverables:

• Develop and test methodologies for defining episodes of care related to pain conditions to

inform payment models and identify where pain should be included as a critical outcome of

existing episode-based payment models.

• Develop clinical quality measures and clinical decision support for pain care.

• Assess their impact on outcomes of care to define further refinement of these tools and then

discontinue support for tools that are not effective in improving safety or quality, while

promoting those that do.

Long term (within five years) strategies and deliverables:

• Develop and support pilot projects to test and rigorously evaluate the impact of payment

innovations on pain care quality measures and cost savings. Include evaluation of adverse

effects of payment innovations on evidence-based invasive interventions, devices and novel

technologies, high cost drugs and access to quality pain care. Develop a plan for assessment

of longer term outcomes of the pilots such as cumulative health care costs and comparison of

long-term disability to productivity.

• Disseminate results of the pilot projects to public and private payers for consideration in

updating their payment policies and practices.

• Make clinical quality measures for pain care and associated decision support part of incentive

programs.

Federal Stakeholders: ACL, AHRQ, CMS, DoD, HRSA, National Library of Medicine (NLM), ONC, VHA

Collaborators:

• accountable care organizations

• state Medicaid programs

xviii An example would be episode groupers, which are software programs that organize claims data into 

clinically coherent episodes based, typically, on diagnosis. As designed for use by the Centers for 

Medicare & Medicaid Services and other payers, they help in identifying high-cost providers and also

could be used for payment purposes, much as diagnosis-related groups have been used in hospital 

payment. xix www.nhqualitycampaign.org
40

• integrated health care systems 

• private agencies and software experts developing electronic medical records and other 

relevant programs 

• health service researchers 

• primary care, licensed integrative health care providers, and specialty clinicians, including 

surgeons 

• long term services and supports and social services providers

• private payers

• professional medical organizations 

• health care quality organizations 

• pain advocacy organizations and people with pain

Metrics: The proportion of payments under the demonstrations that successfully support integrated care 

data should be monitored and assessed. The development of quality measures for integrated pain 

care, outcomes of care, including patient and family assessments, and impact on costs (for the 

demonstrations) should be assessed. The impact of clinical decision support on safety, quality, 

and outcomes of care should be assessed to guide further refinement of effective clinical decision 

support tools and allow for identification and discontinuation of support for tools that are not 

effective in improving safety, quality, or outcomes of care.
41

Professional Education and Training

Pain is one of the most common reasons for health care visits.

1,50 Nonetheless, most health care 

professions’ education programs devote little time to education and training about pain and pain care.

9

Given “strong indications that pain receives insufficient attention in virtually all phases of medical 

education,” the IOM report found “education is a central part of the necessary cultural transformation of 

the approach to pain” and recommended improvement in the curriculum and education for health care 

professionals.

51 

To assure the needed improvement, education and training must allow learners to achieve 

discipline-specific core competencies, which include empathy and cultural sensitivity across a broad 

range of disciplines, and prepare them to provide high quality team-based care for pain. Demonstration of 

competency in pain assessment, safe and effective pain care (including specific training on safe opioid 

prescribing practices), the risks associated with prescription analgesics, communication of these risks to 

patients, and prescriber education should be a requirement for licensure and certification of health

professionals and should be considered in curriculum review for accreditation of health professional 

training programs. 

Efforts to enhance health care provider knowledge and skills for safer prescribing practices and

identification of risks for opioid use disorder should be coordinated with ongoing activities across HHS

including the Secretary’s Initiative on Prescription Opioids, the pending CDC Guideline for Prescribing 

Opioids for Chronic Pain, the FDA approved Risk Evaluation and Mitigation (REMS) for ExtendedRelease and Long-Acting Opioid Analgesic Products, the Office of Disease Prevention and Health

Promotion’s (ODPHP) Pathways to Safer Opioid Use, SAMHSA’s Providers’ Clinical Support System

for Opioid Therapies, and HHS’s Behavioral Health Coordinating Council . 

These training enhancements should be developed in collaboration with relevant accrediting 

bodies and certifying boards to promulgate their use. Sub-specialty training and certification should 

include training in effective team management for patients with the most complex pain conditions. 

The Problem: The high prevalence of pain across the population and its impact on individuals and 

families creates a significant responsibility for health care professionals. Despite the need to address this 

public health problem, many health, long-term services and supports, and social service professionals, 

especially physicians, are not adequately prepared and require greater knowledge and skills to contribute 

to the cultural transformation in the perception and treatment of people with pain.

9 Education and training 

of health, long-term services and supports, and social service professionals in the complex etiology, 

prevention, assessment, safe and effective treatment of pain, and risks associated with poor pain 

management is insufficient, in part because educators lack access to valid information about pain and pain 

care. Core competencies in pain care are not fully developed and generally do not inform undergraduate 

(pre-licensure) curricula in health, long-term services and supports, and social service professions schools 

or graduate training programs, even those in pain medicine. As a result, practitioners may rely primarily 

on procedural or pharmacological approaches that alone are not effective and may have significant 

unintended adverse consequences such as addiction and medication misuse for which many health care 

providers lack skills and knowledge to identify and manage. 
42

Moreover, cultural bias exists in the medical community against people with pain, especially 

those with chronic pain, which can negatively affect patient care and reinforce pain stigmatization.

6,21

This bias and the documented decline in empathy as medical training progresses52 may be interrelated, in 

the case of pain care, and exacerbated by knowledge deficits, frustration with the limited effectiveness of 

usual treatments for chronic pain, and the complex nature of pain and pain care and risks associated with 

treatments.

The intent of the Professional Education and Training section is to anchor an attitudinal transformation 

toward pain and a reorganization of pain management by the health care system across all care settings 

and in the education and training of health professionals. The mission includes grounding the pain-related 

education and training of physicians, nurses, advanced practice nurses, clinical pharmacists, dentists, 

podiatrists, clinical health psychologists, social workers, physician’s assistants, nurse practitioners, 

physical and occupational therapists, behavioral health specialists for mental health and substance use 

disorders, and other health, long-term services and supports, and social service professionals in core 

competencies, and making available easily accessible, evidence-based information for educators to work 

toward this goal.

Objective 1: Develop, review, promulgate, and regularly update core competencies for pain care 

education and licensure and certification at the pre-licensurexx (undergraduate) and post-licensure 

(graduate) levels.

Short-term strategies and deliverables:

• Convene an expert group that includes all relevant pre-licensure health professions to review, 

revise, and promote the set of interdisciplinary core competencies that have been developed 

and widely accepted for pre-licensure education in pain and pain care53 (Appendix J). The 

expert group should develop a set of learning objectives to be achieved by the core 

competencies, devise plans to incorporate the competencies into their programs, beginning 

with selected sites for piloting curricular changes, and evaluate the effects of the core 

competencies. The relevant accrediting, certification, and licensing entities should be 

involved at early planning and subsequent phases of this strategy. 

• Examine current specialist training and certification in pain medicine through the planned 

effort of the Accreditation Council for Graduate Medical Education (ACGME), to assure that 

pain specialists are effectively trained to lead clinical teams in managing the most complex 

and challenging patients with acute and chronic pain and to provide needed support for 

formal and informal clinical medical education. Enhance team management training in 

currently existing ACGME-accredited programs (e.g. ACGME pain medicine residency 

requirements). Extend this examination through the planned effort of discipline-specific 

accrediting and certifying bodies related to nursing, clinical pharmacy, clinical health 

psychology, and other relevant health, long-term services and supports, and social service

professional training schools and programs.

 

xx Pre-licensure (undergraduate) level refers to a health professional currently enrolled in their degree program (e.g. 

bachelor, master, doctorate) and not yet licensed. Post-licensure (graduate/postgraduate) refers to a health 

professional who holds a degree in their discipline, has obtained their license and may be enrolled in a clinical 

residency or training fellowship program (graduate/postgraduate). 
43

• Solicit input from the public, including people with pain, professional organizations, and 

students, to enhance clinical empathy, cultural competency, and expanded patient-centered 

communication for people with pain, based on impact, feasibility, and ease of dissemination. 

Medium-term strategies and deliverables:

• Promulgate interdisciplinary core competencies (include empathy and cultural sensitivity) for 

pre-licensure education, professional licensure examinations and educational accreditation 

standards. 

• Convene an expert group from pain-relevant primary care specialties, including internal 

medicine, family medicine, pediatrics, obstetrics/gynecology, as well as advanced practice 

nursing and physician assistant fields to develop and promote core primary care competencies 

by building on the existing undergraduate (short term) interdisciplinary core competencies 

and to approach ACGME regarding incorporation into relevant ACGME program 

requirements. 

• Convene accrediting (e.g. ACGME, LCME) and certifying entities and related groups 

relevant to health care providers who provide pain management within the scope of their 

practice, to develop consensus and an implementation plan on the depth with which 

competency in pain care is integrated into health professions education, accreditation, and 

certification. 

• Publish and promulgate core competencies in post-licensure fields, including primary care

education and training, through the work group convened for this purpose and in 

collaboration with relevant accrediting bodies.

Long-term (within five years) strategies and deliverables:

• Convene an expert group from pain care specialties to develop and review, promote, and 

publish core competencies in pain care in relevant specialties, replicating the same general 

process used in primary care.

• Commission a baseline evaluation of the use of core competencies in pre-and post-licensure 

primary care and specialty education and training, evaluate them over time to determine 

progress, and regularly update them.

• Evaluate the projects for enhancing empathy to determine their suitability for widespread use, 

and implement them accordingly.

Federal Stakeholders: CDC, FDA, SAMHSA, and VHA, in collaboration with HRSA (as appropriate to 

their statutory priorities and within their authority) 

Collaborators:

• relevant state and federal accreditation, certification, and licensing entities for physicians, 

nursing, dentistry, clinical pharmacy, physical therapy, physician assistants, clinical health 

psychology, long-term services and other relevant health disciplines

• relevant professional organizations for physicians, nursing, dentistry, clinical pharmacy, 

physical therapy, physician assistants, clinical health psychology, long-term services and 

other relevant health disciplines

• pain advocacy organizations and people with pain
44

• addiction and opioid use disorder advocacy organizations

Metrics: The validity and reliability of core competencies should be evaluated through the pilot projects 

based on the learning objectives developed by the expert group. The incorporation of core 

competencies into pre- and post-licensure disciplines should be tracked on an annual basis. 

Objective 2: Develop a pain education portal that leverages current activities and contains a 

comprehensive array of standardized materials to enhance available curricular and competency 

tools to address management across the continuum of pain and across the lifespan. The portal will 

serve as a central, comprehensive source for pain education materials and will be monitored regularly and 

updated as new evidence-based guidelines and resources are available. The need for knowledge and skills 

that address how clinician empathy influences the effectiveness of care should be included in the 

available educational materials. The portal also should support an expanded knowledge base among 

providers to assess, identify, and refer individuals at risk for mental health and substance use disorders to 

behavioral health specialty care when needed.

54

Short-term strategies and deliverables:

• Convene expert stakeholders to survey current resources, link to other relevant electronic

artifact portals, and determine the content for a pain education portal. The portal would

contain evidence-based and/or peer reviewed best practices material about pain assessment

and care for use by educators and learners across all health, long-term services and supports,

and social service settings and for all patients, including vulnerable populations.

• Develop and evaluate a pilot portal that leverages the NIH Pain Consortium Centers of

Excellence in Pain Education and the AHRQ’s U.S. Health Knowledge Information Database.

Medium-term strategies and deliverables:

• Coordinate efforts and existing resources to launch the publically accessible portal and

broadly disseminate and promote its availability and use.

• Reconvene stakeholders to develop an annual survey to measure each school’s progress in

teaching about pain and to develop learning objectives to assess effects of enhanced pain

education. Systematic reviews of studies about pain education would be a starting point in

developing the content of the survey.

• Conduct the initial survey of schools.

Long-term (within five years) strategies and deliverables:

• Monitor and continue to update the portal, which would be fully developed over a five-year

horizon. Conduct an annual online survey to solicit feedback on quality and utility of the

portal.

• Repeat the survey (five year intervals) of schools and otherwise monitor pain education to

assure that core competencies are taught.

Federal Stakeholders: AHRQ, CDC, DoD, FDA, HRSA, NIH, NLM, ONC, SAMHSA, VHA (to develop 

content and architecture and strategies to monitor and promote the portal)

Collaborators: 
45

• professional medical organizations

• educators (to help develop survey and portal content)

• pain advocacy organizations and people with pain

Metrics: Frequency of access to, and downloads from the portal should be monitored and reported 

annually. Feedback from the annual online survey of the portal should be used to update and 

improve its quality and utility. Results of the annual survey of school’s progress should be 

promptly reported. Progress in enhancing educational content on core competencies should be 

linked to achievement of learning objectives.
46

Public Education and Communication

The Institute of Medicine considered education central to a cultural transformation in pain care 

and recommended expanded and redesigned programs aimed at increasing public and patient 

understanding of pain. A national pain awareness campaign could draw on the experience of numerous 

federal agencies that have managed communications campaigns about public health topics as diverse as 

childhood immunizations, tobacco control, HIV/AIDS, depression, and nutrition. 

Such campaigns generally involve numerous public and private partner organizations, each able 

to reach different segments of the population, use multiple media (including entertainment and social 

media), and require careful planning, research on audience segments’ attitudes and beliefs and receptivity

to test messages, and evaluation. A campaign with multiple components, heavy media buys, and other 

activities can be costly, which underscores the importance of focused strategy development. 

The National Pain Strategy envisions a significant effort to increase public awareness about pain 

and recommends two campaigns. The priority campaign is an extensive public awareness campaign about 

pain, to reach all people including patients, their caregivers, and health care, long-term services and 

supports, and social service providers, and the secondary campaign would promote safer medication use 

by patients. Both should use a scientific approach, integrate health literacy principles and cross-cultural 

awareness and be tailored to specific audiences segmented by health status, demographic and cultural 

characteristics, and preferred informational media.

xxi These campaigns should be undertaken in such a 

way that they do not compete.

The Problem: Pervasive stigmatization and misperceptions about pain are a root cause of significant and 

costly barriers to treatment and make it difficult for people with chronic pain to live productively and with 

dignity. Education is key to unlocking a necessary cultural transformation in the understanding of chronic 

pain, its care and treatment and treatment risks. In part, these problems arise because of the lack of highquality, evidence-based communications campaigns that: 

• Increase public awareness and knowledge about the pervasiveness of chronic pain, its complexity, 

and the importance of access to prompt and effective treatments. 

• Change cultural attitudes about chronic pain, debunking stereotypes and myths related to people with 

chronic pain and various pain treatment options and emphasizing the value of pain self-management

programs in enabling people to live better with chronic pain. 

• Foster coalitions involving federal agencies, health care, long-term services and supports, and social 

service professionals and institutions, training and accreditation agencies, insurers, employers, 

foundations, patient advocate organizations, and others to participate in such campaigns and promote 

core messages. 

• Deliver provider, public and patient education on risks and benefits of pain treatments and safer use 

of pain medications, including awareness of the risks for opioid use disorders that are associated with 

these prescription pain medications.

 

xxi In general, the planning and implementation for the campaigns follow the stages outlined in the 

National Cancer Institute’s Making Health Communication Programs Work 

(http://www.cancer.gov/cancertopics/cancerlibrary/pinkbook/page1). 
47

The intent of the Public Education and Communication section is to assure that chronic pain is 

recognized as a serious public health issue in the United States and that people with chronic pain have 

timely access to appropriate, safe pain management.

Objective 1: Develop and implement a national public awareness and information campaign about 

the impact and seriousness of chronic pain, in order to counter stigmatization and correct common 

misperceptions. 

Short-term strategies and deliverables:

• Perform an environmental scan of existing relevant campaigns on chronic conditions and 

assess their impact in order to draw on successes in the design of this campaign.

• Establish a broadly representative advisory panel of stakeholders, to include patients with 

pain and members of their families, advocacy groups, professional societies, policy groups. 

• Define campaign learning objectives (suggested concepts are in Appendix K), intended 

audiences, advisory structure, and budget.

• Develop requests for proposals from strategic communications firms to develop and conduct 

the campaign, review proposals, and select a firm (a separate firm may be engaged to conduct 

the evaluation).

• The selected firm would, as needed:

o review available psychographic information regarding attitudes about pain (in the general 

population, in population subsets of interest, and in key stakeholder groups) and 

commission additional research, including surveys. 

o review available evidence about settings, channels, and activities best suited to reach 

these audiences, and commission additional research. 

o review existing information and educational materials. 

o develop a communications strategy based on behavior change theories for each targeted 

audience.

o work with the advisory board to identify and recruit partner organizations and define their 

roles in the campaign.

• Based on this preliminary work, develop and pretest messages and materials using, wherever 

possible, information developed by other components of the National Pain Strategy. 

Medium-term strategies and deliverables: 

• Implement the program, including partner participation strategies, spokesperson training, and 

program-related services (e.g., pain self-management programs suggested in the Prevention 

and Care section), media (news, entertainment, social) strategies, and promotional materials.

• Monitor audience reach, feedback and partner engagement; adjust strategies as necessary.

Long-term (within five years) strategies and deliverables:

• Conduct an outcome evaluation to assess campaign effectiveness, as measured by changes in 

public opinion related to the campaign’s learning objectives. 

• Prepare a report based on the campaign evaluations for submission to a peer-reviewed 

scientific journal. 
48

• As funds are available, continue to monitor, implement, assess, and adapt campaign 

components, as needed, and report on campaign outcomes in a peer-reviewed journal.

Federal Stakeholders: ACL, CDC, FDA, NPC, OASH (ODPHP, Office of the Surgeon General, Regional 

Health Administrators) 

Collaborators:

• public health organizations

• professional organizations 

• private and public insurers

• human resources professionals

• health care providers

• patient advocacy organizations and people with pain

• employee assistance programs

Metrics: the outcome evaluations would provide data on changes in public (and those of relevant 

demographic or other subgroups) attitudes based on campaign learning objectives, which are to 

be developed by the advisory panel, which ideally could be compared with baseline data to 

determine any short-term trends and refined and updated over time to maintain the campaign 

messaging based on achievements of the learning objectives.

Objective 2: Develop and implement a national educational campaign to promote safer use of all 

medications, especially opioid use, among patients with pain. 

Short-term strategies and deliverables:

• Identify an HHS team and select an advisory board with broad representation, including 

people with pain, as well as experts in health communications and public relations, to 

develop, plan, implement, and evaluate the campaign. The selected team would:

o define the advisory structure and budget. 

o review existing information and educational materials. 

o review available research on attitudes, knowledge, and medication practices of patients 

with chronic pain who take prescription medications, especially opioids. 

o review available evidence about settings, channels, and activities best suited to reach 

these patients, and commission additional research, as needed. 

o develop a communications strategy.

o identify and recruit partner organizations.

• Align campaign messages and approaches with ongoing HHS efforts to promote safer and 

more appropriate use of prescription medications by patients and prescribers, such as:

o promoting appropriate, safer, and effective use of opioids to manage chronic pain through 

the interactive tool Pathways to Safer Opioid Usexxii 

o electronic prescribing of controlled substances (EPCS).

o facilitating use of state prescription drug monitoring programs. 

 

xxii http://health.gov/hcq/trainings/pathways/
49

o promoting clinical prescribing guidelines, such as the pending CDC Guidelines for 

Prescribing Opioids for Chronic Pain and the FDA Medication Guide for ER/LA Opioids 

(REMS xxiii). 

• Cover the learning objectives and outcomes outlined in Appendix L in the campaign. 

• Develop and pretest messages and materials based on preliminary work. 

Medium-term strategies and deliverables:

• Implement the program, including partner participation strategies, spokesperson training, 

program-related services (e.g., a hotline), media (news, entertainment, social) strategies, and 

promotional materials.

• Monitor campaign reach and feedback and partner engagement; adjust strategies as 

necessary.

Long-term (within five years) strategies and deliverables:

• Conduct an outcome evaluation through nationally representative surveys and when 

appropriate through pre- and post-test surveys, using outcome measures tailored to the 

learning objectives to assess campaign effectiveness. 

• Continue to implement, assess, and adapt campaign components as needed. 

• Conduct a five year progress assessment of the issue of safer use of pain medications.

• Prepare reports based on the campaign evaluations for submission to a peer-reviewed 

scientific journal. 

Federal Stakeholders: CDC, FDA, NPC, OASH (ODPHP, Office of the Surgeon General, Regional 

Health Administrators), and SAMHSA 

Collaborators:

• public health organizations

• professional organizations 

• health, long-term services and supports, and social services providers

• public and private insurers

• human resources professionals

• health care providers

• credentialing bodies 

• major retail pharmacy chains

• National Association of Boards of Pharmacy

• professional pharmacy organizations and pharmacists

• pain patient advocacy organizations and people with pain

• addiction and opioid use disorder advocacy organizations

Metrics: the outcome evaluations would provide current data on the medication practices of patients with 

pain based on campaign learning objectives, which ideally could be compared with baseline data 

 

xxiii http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163647.htm 
50

to determine any short-term trends and refined and updated over time to maintain the campaign 

messaging based on achievements of the learning objectives. 
51

APPENDICES 

A. List of oversight panel members 

B. List of working group members, expert consultants, and staff

C. Member nomination process and conflict of interest disclosure

D. Chronic pain screener questions

E. Operational questions for determining high-impact chronic pain

F. Diagnostic clusters for population pain research

G. Pain treatment indicators: Health care services for pain measurable with electronic health care data 

H. Public and private payer coverage and payment methodologies for pain-related treatments

I. The Stepped Care Model of pain care

J. Core competencies for pain education

K. Public education general campaign learning objectives

L. Learning objectives and potential outcome measures for an educational campaign on safe use of pain 

medications 

M. Conflicts of Interests/Financial Disclosures
52

Appendix A. List of Oversight Panel Members

Sean C. Mackey, MD, PhD – Co-Chair

Chief, Division of Pain Medicine

Redlich Professor of Anesthesiology, Perioperative and Pain Medicine; Neurosciences; and Neurology 

(by courtesy)

Stanford University School of Medicine

Linda Porter, PhD – Co-Chair

Policy Advisor for Pain and Director, Office of Pain Policy

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Colonel Chester Buckenmaier III, MD for: 

Major General Richard W. Thomas, MD, DDS, FACS 

Director of Defense and Veterans Center for Integrative Pain Management 

Professor Anesthesiology

Uniformed Services University

Daniel B. Carr, MD, MA

Professor, Public Health and Community Medicine, Anesthesiology and Medicine

Director, Pain Research, Education, and Policy Program

Tufts University School of Medicine

Myra Christopher, BA

Kathleen M. Foley Chair in Pain and Palliative Care

Center for Practical Bioethics

Terrie Cowley, BA

President and Co-Founder

TMJ Association

David W. Dodick, MD

Professor, Neurology

Director, Headache Program and Sport Neurology and Concussion Program Mayo Clinic College of 

Medicine

Carmen R. Green, MD

Associate Vice President and Associate Dean for Health Equity and Inclusion

Professor, Anesthesiology, Obstetrics and Gynecology, and Health Management and Policy

University of Michigan

Charles G. Helmick III, MD

Senior Medical Epidemiologist, Arthritis Program

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention 

Robert D. Kerns, PhD

Special Advisor for Pain Research, and 

Director, Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center 

Veterans Health Administration, Department of Veterans Affairs

Professor, Psychiatry, Neurology, and Psychology, Yale University 
53

Audrey Kusiak, PhD

Portfolio Manager, Rehabilitation Research and Development Service

Office of Research and Development 

Department of Veterans Affairs

Judith Paice, PhD, RN, FAAN

Director, Cancer Pain Program, Division of Hematology-Oncology

Research Professor, Medicine

Northwestern University Feinberg School of Medicine

Gregory Terman, MD, PhD

Professor, Anesthesiology and Pain Medicine

University of Washington

Christin L. Veasley, BSc

Co-Founder

Chronic Pain Research Alliance
54

Appendix B. List of work group members, expert consultants, and staff

Population Research

Ann Scher, PhD – Co-Chair

Associate Professor of Epidemiology 

Uniformed Services University of the Health Sciences

Michael Von Korff, ScD Co-Chair

Senior Investigator, Group Health Research Institute

Group Health Cooperative

Olivia Carter-Pokras, PhD

Associate Professor, Epidemiology 

University of Maryland College Park School of Public Health

David W. Dodick, MD

Professor, Neurology

Program Director, Neurology Residency Program and Headache Medicine Fellowship Program

Mayo Clinic College of Medicine

Joseph L. Goulet, MS, PhD

Director, Statistics and Methodology Core 

Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center 

VA Connecticut Healthcare System

Assistant Professor, Psychiatry 

Yale University

Scott R. Griffith, MD, LTC, MC, USA

Director, NCC Pain Management Fellowship

Walter Reed National Military Medical Center

Robin J. Hamill-Ruth, MD

Associate Professor, Anesthesiology, Critical Care Medicine, and Pain Medicine 

Co-Director, Pain Management Center 

University of Virginia Health System 

John Kusiak, PhD

Director, Molecular and Cellular Neuroscience Program

Center for Integrative Biology and Infectious Diseases 

National Institute of Dental and Craniofacial Research

National Institutes of Health

Linda LeResche, ScD

Professor, Oral Medicine

Adjunct Professor, Oral Health Sciences 

Associate Dean for Research 

University of Washington School of Dentistry

Walter F. Stewart, MPH, PhD

Vice President and Chief Research & Development Officer 

Sutter Health

Raymond C. Tait, PhD
55

Vice President for Research 

Professor, Neurology and Psychiatry 

Saint Louis University

Gregory Terman, MD, PhD

Professor, Anesthesiology and Pain Medicine

University of Washington

Christin Veasley, BSc

Co-Founder

Chronic Pain Research Alliance

Prevention and Care

Daniel B. Carr, MD, MA

Professor, Public Health and Community Medicine, Anesthesiology and Medicine

Director, Pain Research, Education, and Policy Program

Tufts University School of Medicine

Sean C. Mackey, MD, PhD – Co-Chair

Chief, Division of Pain Medicine

Redlich Professor of Anesthesiology, Perioperative and Pain Medicine; Neurosciences; and Neurology 

(by courtesy)

Stanford University School of Medicine

Christine Branche, PhD, FACE

Principal Associate Director

National Institute for Occupational Safety and Health 

Centers for Disease Control and Prevention

Colonel Chester Buckenmaier III, MD for:

Major General Richard W. Thomas, MD, DDS, FACS

Director, Defense and Veterans Center for Integrative Pain Management 

Professor Anesthesiology

Uniformed Services University

Kathleen M. Foley, MD

Attending Neurologist, Pain and Palliative Care Service 

Memorial Sloan-Kettering Cancer Center 

Professor, Neurology, Neuroscience, and Clinical Pharmacology 

Weill Medical College of Cornell University

Sharon Hertz, MD

Deputy Director, Division of Anesthesia, Analgesia, and Addiction Products 

U.S. Food and Drug Administration

Richard Ricciardi, PhD, NP

Health Scientist, Center for Primary Care, Prevention, and Clinical Partnerships 

Agency for Healthcare Research and Quality
56

Jackie Rowles, MBA, MA, CRNA, ANP, FAAPM, DPNAP, FAAN

Certified Registered Nurse Anesthetist and Adult Nurse Practitioner Pain Specialist 

Meridian Pain Group

Cindy Steinberg

National Director of Policy and Advocacy 

U.S. Pain Foundation

Chair, Massachusetts Pain Initiative (MassPI) Policy Council

Disparities

J. Nadine Gracia, MD, MSCE – Co-Chair

Deputy Assistant Secretary for Minority Health 

Director, Office of Minority Health 

U.S. Department of Health and Human Services

Carmen R. Green, MD – Co-Chair 

Associate Vice President and Associate Dean for Health Equity and Inclusion

Professor, Anesthesiology, Obstetrics and Gynecology, and Health Management and Policy

University of Michigan

Diana Burgess, PhD

Associate Professor, Medicine 

University of Minnesota 

Research Scientist, Center for Chronic Disease Outcomes Research

Veterans Affairs Health Services & Development (VA HSR&D) Center of Innovation (COIN).

Vyjeyanthi Periyakoil, MD

Clinical Associate Professor, Medicine 

Director, Stanford Palliative Care Education and Training Program 

Stanford University School of Medicine

Beverly Thorn, PhD, ABPP

Professor and Chair, Psychology 

University of Alabama

Elizabeth Unger, MD, PhD

Chief, Chronic Viral Diseases Branch 

National Center for Emerging and Zoonotic Infectious Diseases 

Centers for Disease Control and Prevention 

Salina Waddy, MD

Program Director, Health Disparities 

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Diana Wilkie, PhD, RN, FAAN

Professor, Biobehavioral Health Science 

Harriet H. Werley Endowed Chair for Nursing Research 

University of Illinois at Chicago College of Nursing
57

Service Delivery and Payment 

Robert D. Kerns, PhD – Co-Chair 

Special Advisor for Pain Research, Pain Management, and 

Director, Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, 

Veterans Health Administration, Department of Veterans Affairs

Professor, Psychiatry, Neurology, and Psychology, Yale University 

Mark Wallace, MD – Co-Chair

Chief, Division of Pain Medicine, Anesthesiology

Director, Division of Clinical Research, UCSD Clinical and Translational Institute

University of California, San Diego

Paul Arnstein, PhD, RN, FAAN

Pain Relief Specialist

Certified Family Nurse Practitioner, Clinical Nurse Specialist and Pain Management Nurse Massachusetts 

General Hospital

Sean Cavanaugh

Deputy Administrator and Director, Centers for Medicare 

Centers for Medicare & Medicaid Services

Jan Favero Chambers

President and Founder 

National Fibromyalgia and Chronic Pain Association (NFMCPA)

Editor-in-Chief

Fibromyalgia & Chronic Pain LIFE magazine

Jack Conway, JD

49th Attorney General 

Commonwealth of Kentucky

Elizabeth B. Gilbertson, MA

Chief of Strategy

Unite Here Health

Karl Lorenz, MD, MSHS

General Internist and Palliative Care Physician 

Director, VA palliative care Quality Improvement Resource Center (QuIRC)

VA Greater Los Angeles 

Associate Professor, Medicine 

University of California, Los Angeles

Professor, RAND 

Brook I. Martin, MPH, PhD

Assistant Professor, Orthopaedic Surgery and The Dartmouth Institute for Health Policy and Clinical 

Practice 

Dartmouth Hitchcock Medical Center

Dartmouth College
58

Judith Paice, PhD, RN, FAAN

Director, Cancer Pain Program, Division of Hematology-Oncology 

Research Professor, Medicine

Northwestern University Feinberg School of Medicine

Patricia Sinnott, PT, MPH, PhD

Health Economist 

VA Health Economics Resource Center (HERC)

Department of Veterans Affairs

Steven P. Stanos, Jr, DO

Director, Corporate Pain Services

Rehabilitation Institute of Chicago (RIC) 

Marianne Udow-Phillips

Director, Center for Healthcare Research & Transformation 

University of Michigan

Catherine H. Underwood, MBS, CAE

Chief Executive Officer

American Pain Society

CAPT Sherri Yoder, PharmD, BCPS

Director, Pharmacy Services 

Crow Service Unit in Crow Agency, Montana

Professional Education and Training

Rollin Gallagher, MD, MPH – Co-Chair

National Program Director, Pain Management 

Veterans Health Administration

Philadelphia Veteran Affairs Medical Center 

Director, Pain Policy Research and Primary Care 

University of Pennsylvania School of Medicine

James Rathmell, MD – Co-Chair 

Professor, Anaesthesia 

Harvard Medical School 

Executive Vice-Chair and Chief, Division of Pain Medicine 

Massachusetts General Hospital

Brian Berman, MD 

Professor, Family and Community Medicine

Director, Center for Integrative Medicine 

University of Maryland School of Medicine

Colonel Chester Buckenmaier III, MD for: 

Major General Richard W. Thomas, MD, DDS, FACS

Director of Defense and Veterans Center for Integrative Pain Management
59

Professor Anesthesiology

Uniformed Services University

Daniel B. Carr, MD, MA

Professor, Public Health and Community Medicine, Anesthesiology and Medicine

Director, Pain Research, Education, and Policy Program

Tufts University School of Medicine

Steven P. Cohen, MD

Professor, Anesthesiology and Critical Care Medicine 

Johns Hopkins School of Medicine and Uniformed Services University of the Health Sciences Director, 

Medical Education and Quality Assurance, Pain Management Division 

Johns Hopkins School of Medicine

Director, Pain Research

Walter Reed National Military Medical Center

Terrie Cowley, BA

President and Co-Founder

TMJ Association

Margaret Faut-Callahan, CRNA, PhD, FNAP, FAAN

Interim Provost, Dean, and Professor, Nursing

Marquette University

Scott M. Fishman, MD

Charles and Patricia Fullerton Endowed Chair of Pain Medicine

Executive Vice Chair and Professor, Anesthesiology and Pain Medicine

Chief, Division of Pain Medicine 

University of California, Davis School of Medicine

Francis Keefe, PhD – Liaison 

Professor, Psychiatry and Behavioral Sciences 

Director, Duke Pain Prevention and Treatment Research Program

Duke University Medical Center 

Bill McCarberg, MD

Founder 

Chronic Pain Management Program for Kaiser Permanente (retired) 

Physician

Neighborhood Healthcare in Escondido California

Brian Schmidt, DDS, MD, PhD

Director, Bluestone Center for Clinical Research 

Professor, Oral and Maxillofacial Surgery and Physiology and Neuroscience

New York University 

Christina Spellman, PhD

Executive Director

The Mayday Fund

David J. Tauben, MD
60

Interim Chief, Division of Pain Medicine

Medical Director, Center for Pain Relief

Director, Medical Student Education in Pain Medicine

Clinical Associate Professor, Medicine and Anesthesia and Pain Medicine

University of Washington 

David Thomas, PhD

Deputy Director, Division of Clinical Neuroscience and Behavioral Research

National Institute of Drug Abuse

National Institute of Health

Mary Willy, MPH, PhD (retired 2015)

Associate Director, Division of Risk Management

Office of Medication Error Prevention and Risk Management 

Center for Drug Evaluation and Research 

Food and Drug Administration

Public Education and Communication

Penney Cowan – Co-Chair

Founder and Chief Executive Officer

American Chronic Pain Association (ACPA)

Linda M. Harris, PhD – Co-Chair

Senior Health Communication and ehealth Advisor to the Deputy Assistant Secretary for Health, Disease 

Prevention and Health Promotion 

Team Lead, Health Communication and ehealth 

Office of Disease Prevention and Health Promotion

Office of the Secretary

Department of Health and Human Services

Humayun J. Chaudhry, D.O., M.S., MACP, FACOI, FAODME

President and CEO 

Federation of State Medical Boards (FSMB) of the United States

Myra Christopher, BA

Kathleen M. Foley Chair in Pain and Palliative Care

Center for Practical Bioethics

Lee Claassen, CAE

Executive Director

Interstitial Cystitis Association (ICA)

Ronald Dubner, DDS, PhD

Professor, Neural and Pain Sciences 

University of Maryland School of Dentistry

Keith Humphreys, PhD

Professor, Psychiatry 

Stanford University School of Medicine 

Career Research Scientist 
61

U.S. Department of Veterans Affairs

Francis Keefe, PhD 

Professor, Psychiatry and Behavioral Sciences 

Director, Duke Pain Prevention and Treatment Research Program

Duke University Medical Center 

Rebecca Kirch, JD

Director, Quality of Life & Survivorship 

American Cancer Society

Julie Madden, MA

Associate Director, Policy for the Human Capital and Resources Management Office 

Centers for Disease Control and Prevention

Susan E. Maier, PhD 

Deputy Director

Office of Research on Women’s Health

Office of the Director

National Institutes of Health

John Piette, PhD

Professor, Health Behavior and Health Education 

Co-Director, Center for Chronic Disease Management

University of Michigan School of Public Health

Tina M. Tockarshewsky, BA

President and Chief Executive Officer 

The Neuropathy Association

Mary Vargas, JD

Founding Partner 

Stein & Vargas, LLP

Lynn Webster, MD, FACPM, FASAM

Vice President, Scientific Affairs

PRA 
62

Support and consulting staff

Jordan Broderick, MA

Office of Disease Prevention and Health Promotion

Office of the Secretary

Department of Health and Human Services

Chazeman Jackson, MA, PhD

Health Science Advisor

Office of Minority Health

Department of Health and Human Services

Nicole Kelly

Board of Directors

American Chronic Pain Association 

Cheryse Sankar, PhD

Health Science Policy Analyst

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Tara A. Schwetz, PhD

Health Science Policy Analyst

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Lindsay R. St. Louis, BS

Candidate, MS in Pain Research, Education and Policy 

Tufts University School of Medicine 

Expert Consultants 

Eugene Hsu, MD, MBA

Pain Medicine Fellow

Oregon Health & Science University

Adjunct Professor

Anesthesiology and Critical Care Medicine

Johns Hopkins University School of Medicine

Timothy Furnish, MD

Assistant Clinical Professor, Anesthesiology

University of California, San Diego

Beth Murinson, MD

Assistant Professor, Department of Neurology

Johns Hopkins School of Medicine
63

Science Writers

Neil E.Weisfeld, JD, MsHyg

Victoria D. Weisfeld, MPH 

Co-Principals

NEW Associates
64

Appendix C. Member nomination process and conflict of interest disclosure

The National Pain Strategy (NPS) is a nationwide plan to address the core recommendations of 

the Institute of Medicine’s (IOM) report, Relieving Pain in America , on pain prevention, treatment, 

management, education, and research. The entity charged by HHS to address the IOM recommendations 

is the Interagency Pain Research Coordinating Committee (IPRCC), which was established under the 

ACA and, as such, is subject to rules and guidelines of the Federal Advisory Committee Act (FACA). 

The IPRCC’s Task Force of experts, established to develop the NPS plan, also falls under the FACA rules 

and guidelines. 

The Task Force is organized into six thematic working groups and an oversight panel and 

comprises approximately 80 members, with broad representation and expertise in accord with the 

recommendations of the IOM committee. Screening and selection of the NPS Task Force members was a 

multi-step process, performed according to FACA's requirements. A call for nominations was made 

through distribution to advocacy groups, professional societies, website notification, and email 

distribution. It was published as a Federal Register Notice as well. Candidates were selected based on 

expertise and knowledge, and the overall Task Force representation fulfilled IOM recommendations. A 

working group of the IPRCC screened and approved the slate of working group members. 

Nominees were informed of the nature of conflicts of interests that would preclude their service 

and were required to disclose any potential conflicts and the nature of the conflicts. They were also 

required to disclose whether they were registered lobbyists, which precludes service under FACA. 

Conflict of interest disclosures were reviewed by the FACA Committee Management Officer and the 

IPRCC’s Designated Federal Officer. If potential conflicts were identified, the nominee’s conflict 

situation was reviewed by the NINDS Deputy Ethics Counselor to determine eligibility for service on the 

working group.

The working groups were advised of the needs and guidelines to protect the confidentiality of 

discussions to develop the NPS. Requests from all outside entities to present or provide unsolicited 

information to the working groups during the process were directed to the IPRCC’s Designated Federal 

Officer. 
65

Appendix D. Chronic pain screener questions 

Definition Item Criteria

Pain on at 

least half the 

days for 6 

months

Over the last six months, on about how many days 

have you had pain?

 I have not had pain

 I have had pain, but on less than half the 

days 

 I have had pain on more than half the 

days, but not every day

 I have had pain every day, but not all the 

time

 I have had pain all day, every day, 

without break

Chronic pain is pain on at least half the 

days over the past six months. 

Chronic pain 

severity 

(mild, 

moderate, 

severe)

In the past 7 days, how would you rate your pain 

on average? 

 0=No pain 10= Worst imaginable pain 

In the past 7 days, how much did pain interfere 

with your day-to-day activities? 

 0=No interference 10=Completely interferes

In the past 7 days, how much did pain interfere 

with your enjoyment of life? 

 0=No interference 10=Completely interferes

Mean or sum of the three 

0-10 pain ratings. 

 Mean Sum

Mild < 4 < 12

Moderate 4 to < 7 12 to 20

Severe 7 to 10 21 to 30

NOTE: If only two pain ratings are 

available, divide by the sum by two and 

multiple by 3 to obtain an estimated 

sum score. 
66

Appendix E. Operational questions for determining high-impact chronic pain 

Among people with chronic pain (as determined by screener questions in Appendix D), high-impact 

chronic pain is operationally defined by enduring participation restrictions because of pain, including: 

Participation 

restrictions 

because 

of pain

• Over the past 6 months because of pain...

I have had trouble doing my usual work (including work 

for pay, work around the home, volunteer work).

 Never Rarely Sometimes Usually Always

• I have had trouble doing my regular social and recreational 

activities (such as visiting friends, going to the movies, 

attending clubs or religious activities).

 Never Rarely Sometimes Usually Always

• I have had trouble taking care of myself (for example 

dressing, bathing, or feeding myself).

 Never Rarely Sometimes Usually Always

At least one item 

rated “usually” or 

“always”
67

Appendix F. Diagnostic clusters for population pain research

1. Back pain 

2. Neck pain

3. Limb/extremity pain, arthritis disorders (including osteoarthritis and joint pain)

4. Fibromyalgia and wide-spread muscle pain

5. Headache

6. Orofacial, ear, and temporomandibular disorder pain

7. Abdominal pain and bowel pain

8. Chest pain

9. Urogenital, pelvic, and menstrual pain

10. Fractures, contusions, sprains and strains

11. Other painful conditions. 

This includes sickle cell disease, Complex Regional Pain Syndrome, systemic lupus 

erythematosus, acquired deformities (excluding spinal disorders), spinal cord injury, 

Lyme disease, Neuropathic pain. Note: Cancer pain is included here, but relevant 

diagnostic codes need to be identified. 
68

Appendix G. Pain treatment indicators: Health care services for pain measurable with electronic health care data 

Type of service Sub-types Notes Identification 

Professional 

services

Primary care visits Provider codes in 

combination with 

Pain specialist visits Differentiate type of specialist (e.g. neurology, Diagnostic Clusters 

orthopedic surgery, rehabilitation medicine, 

anesthesiology, rheumatology) 

Physical therapy visits

Occupational therapy visits

Psychologist visits

Chiropractic visits These may not be routinely available in many 

Alternative/complementary electronic health care databases. 

care visits 

Oral medications Opioids Differentiate short-acting and extended release. 

Chronic use may be defined by 70+ days supply in a 

90 day period, receiving 6+ dispensings in a year, or 

other indication of sustained use. 

National Drug 

Classification (NDC) 

codes) in combination 

with Diagnostic Clusters 

NSAIDS Only available when prescribed, not over-the-counter. when necessary

Sedatives, anti-anxiety 

agents, sleep medications 

and muscle relaxants

Chronic use may be defined by 45+ days supply in a 

90 day period or other indication of sustained, 

frequent use. 

Triptans

Anticonvulsants

Antidepressants SSRI, SNRI, Tricyclic antidepressants and other 

heterocyclic medications may be differentiated. 

Aspirin and 

acetaminophen

These will not be adequately captured by electronic 

health care data because they are generally taken 

over-the-counter.

Procedures Surgery Differentiate anatomical site of surgery (back, hip, 

knee, shoulder, etc.) and type of surgery within 

Procedure codes in 

combination with 
69

anatomical site (e.g. laminectomy, fusion, discectomy 

for back surgery). 

Diagnostic Clusters when 

necessary

Injections, blocks and 

infusions

Differentiate type (e.g., epidural steroid injections, 

selective nerve root blocks, trigger point injections, 

facet point injections, sympathetic nerve root blocks, 

joint injections, peripheral nerve blocks).

TENS, spinal cord 

stimulation, deep brain 

stimulation

Inpatient care Surgical admission Diagnostic codes 

identifying primary 

reason for admission

Non-surgical admission
70

Appendix H. Public and private payer coverage and payment methodologies for pain-related treatments

Public & Private Payer Coverage of Pain-Related Treatments

Payer Pain-related Treatments

Medications

Regional 

Anesthetic 

Interventions

Surgery Psychological 

Therapies

Rehabilitative/Physical 

Therapy

Complementary and 

Alternative Medicine 

(CAM)

Medicaid X No state specific 

data found X X X X5

Medicare X X X X3 X4 X5

Private Insurers

(BCBSM example) X X X X X X

Veterans Health 

Administration 

(VHA)

X X X X X X6

U.S. Department of 

Defense (DoD)/ 

TRICARE1

X X X X X X7

Federal and State

Workers’ 

Compensation 

Programs2

State: X

Federal: X

State: X

Federal: X

State: X

Federal: X

State: No state 

specific data found

Federal: X

State: X

Federal: X

State: No state specific 

data found

Federal: X
71

“X” indicates the payer offers coverage for procedure(s) within the treatment category

1 TRICARE is the health care program of the DoD Military Health System and is administered through managed care support contracts. The program offers service members and their 

families three main health plan options (TRICARE Prime, TRICARE Standard, and TRICARE Extra) that allow them to receive care from private health care providers.

2 The Federal Employees’ Compensation Act (FECA) is the workers’ compensation program for federal employees and provides medical benefits to employees who are injured or 

become ill in the course of their federal employment. FECA covers all medical costs associated with the treatment of the work-related injury or illness. FECA benefits are paid out of 

the congressionally appropriated Federal Employees’ Compensation Fund. In contrast, state workers’ compensation programs are regulated by the state and provided through private 

insurance, state insurance funds, or self-insurance. Policies and programs vary widely among states.

3 In 2014 and 2015, Medicare beneficiaries were responsible for a 20% coinsurance for outpatient psychological counseling services. Before 2014, the coinsurance was 35 to 50 

percent.

4 Most health plans have limitations on physical therapy and occupational therapy services. For 2015, Medicare had a $1,940 combined annual cap for physical therapy and speechlanguage pathology services, and a $1,940 annual cap for occupational therapy services. Many Medicare Advantage plans have chosen not to institute a therapy cap.

5 Medicare and most state Medicaid programs only cover chiropractic services for manual manipulation of the spine to treat a subluxation (when one or more bones in the spine move 

out of position). A few state Medicaid programs, such as Florida and Rhode Island, have covered other CAM services, including acupuncture and massage therapy.

6 Every VHA provider has a specific requirement to make chiropractic services available onsite.

7 While some military medical facilities may offer services like acupuncture and chiropractic care, these are reserved for active duty members only. CAM services are largely excluded 

under TRICARE. 

Sources: Kaiser Family Foundation, State Facts, Medicaid Benefits, 2011; Centers for Medicare & Medicaid Services; BCBSM; TRICARE; VHA; Department of Defense, Report to 

the Congress: Complementary and Alternative Medicine within the Military Health System, 2011; Department of Defense, Report to the Congress: The Implementation of a 

Comprehensive Policy On Pain Management by the Military Health Care System; Congressional Research Service, The Federal Employees’ Compensation Act (FECA): Workers’ 

Compensation for Federal Employees, June 2013.
 

72

Public & Private Payment Methodologies for Pain-Related Treatments

Payer1 Pain-related Treatments

Medications

Regional 

Anesthetic 

Interventions

Surgery Psychological 

Therapies

Rehabilitative/Physical 

Therapy

Complementary 

and Alternative 

Medicines (CAM)

Medicaid2

Pharmacies are reimbursed for the 

acquisition cost of the drug plus a 

dispensing fee, both of which can 

vary by state. 

For states that contract with a 

managed care entity (MCE) to 

provide drug benefits, the MCE 

would negotiate payments. 

No state 

specific data 

found

Varies by state

35 states use feefor-service to pay

for psychologist 

services for 

individuals 

enrolled in adult 

Medicaid.

33 states use fee-for-service to 

pay for occupational therapy 

services for individuals 

enrolled in adult Medicaid. 

35 states and DC use fee-forservice to pay for physical 

therapy services for individuals 

enrolled in adult Medicaid.

26 states use fee-for 

services to pay for 

chiropractic services 

for individuals 

enrolled in adult 

Medicaid.

Medicare

Medicare Part D plans negotiate 

prices with pharmacies and 

manufacturers. The negotiated 

price includes the ingredient cost 

and dispensing fee.

Fee schedule 

and/or 

Prospective 

Payment 

System 

(depending on 

setting)

Fee schedule 

and/or 

Prospective 

Payment System

(depending on 

setting)

Fee schedule 

and/or 

Prospective 

Payment System 

(depending on 

setting)

Fee schedule and/or

Prospective Payment System

(depending on setting)

Fee schedule

Private Insurers

(BCBSM 

example)

Fee-for-Service Fee-forService Fee-for-Service Fee-for-Service Fee-for-Service Fee-for-Service

Veterans Health 

Administration

(VHA)3

VA negotiates pricing and 

purchases directly from 

wholesalers and manufacturers. 

Global Budget Global Budget Global Budget Global Budget Global Budget

U.S. Department 

of Defense 

(DoD)/ 

TRICARE4

DoD negotiates prices with 

pharmacies and manufacturers.

Fee-forService

Fee-for-Service

and Prospective 

Payment System

Fee-for-Service

Fee-for-Service

and

Prospective Payment System

Fee-for-Service

Federal and 

State 

Workers’ 

Compensation 

Programs5

State: Varies by state

Federal: Based on the Average 

Wholesale Price (AWP) for 

prescription drugs plus a 

dispensing fee, or on the Usual 

and Customary charge amount 

(whichever is less).

State: Fee-forService

Federal: Feefor-Service

State: Varies by 

state

Federal: Fee-forService

and Prospective 

Payment System

State: Fee-forService

Federal: Feefor-Service

State: Varies by state

Federal: Fee-for-Service and

Prospective Payment System

State: Fee-forService

Federal: Fee-forService
 73

1 All payers appear to be relying largely on single modality approaches.

2 In July 2011, almost 75% of Medicaid beneficiaries were enrolled in some type of managed care program. Benefits that are not included in a state's managed care contract are often 

provided on a fee-for-service basis or by a non-comprehensive prepaid health plan. 

3 The VHA, within the Department of Veterans Affairs, is appropriated a fixed amount of funds by Congress. Those funds are distributed to 23 regional service networks. The amount 

distributed to each region is determined by the Veterans Equitable Resource Allocation (VERA) system, an allocation method based on the number of patients served in the region 

and the severity of their conditions. VHA facilities do bill third-party payers (e.g., private insurance) for non-service-connected care. The funds generated from third-party payers go 

to the billing VHA facility. The VHA does reimburse for care provided at non-VHA facilities, using fee-for-service, when a veteran is unable to access care at a VHA facility in 

emergencies, if a covered service cannot be provided at a VHA facility, or due to geographic inaccessibility. 

4 Payment rates for TRICARE are generally aligned with Medicare. Health care providers who are employed at military medical facilities are salaried, like the VHA, and do not 

receive payment from TRICARE for the care they provide.

5 Payment rates for the services covered by FECA are determined by the Department of Labor’s Office of Workers’ Compensation Programs fee schedule, which are generally 

aligned with Medicare. Similar to FECA, fee-for-service is the most common payment method among state workers’ compensation programs. Payments made under state programs 

are generally greater than Medicare payments.

Sources: Kaiser Family Foundation, State Facts, Medicaid Benefits, 2011; Centers for Medicare & Medicaid Services; BCBSM; Congressional Research Service, Military Medical 

Care: Questions and Answers, January 2014; Congressional Research Service, Health Care for Veterans: Answers to Frequently Asked Questions, February 2014; Government 

Accountability Office, Access to Civilian Providers under TRICARE Standard and Extra, June 2011; U.S. Department of Labor, OWCP Medical Fee Schedule 2013. 
74

Appendix I. The VA Stepped Care Model of pain care

Routine screening for presence & severity of pain; Assessment and 

management of common pain conditions; Support from MH-PC Integration; 

OEF/OIF, & 

Post-Deployment Teams; Expanded care management ;

Pharmacy Pain Care Clinics; Pain Schools

Multidisciplinary Pain Medicine Specialty Teams; Rehabilitation 

Medicine;

Behavioral Pain Management; Mental Health/SUD Programs

Advanced pain medicine diagnostics & 

interventions;

CARF accredited pain rehabilitation

STEP

2

STEP

3

STEP

4

VA Stepped 

Pain Care

Complexity

Treatment 

Refractory

Comorbidities

RISK

Nutrition/weight management, exercise/conditioning, & sufficient sleep; mindfulness 

meditation/relaxation techniques; engagement in meaningful activities; family & social 

support; safe environment/surroundings 

STEP

1
75

Appendix J. Core competencies for pain education

Core competencies for pain management from an inter-professional consensus summit have been endorsed widely 

and supported by national healthcare organizations across the major health professions.

51 They provide a starting point for 

accrediting and credentialing organizations to help guide educators to develop and revise curriculum that advances care 

for effectively preventing and managing pain. 
76

Appendix K. Suggested learning objectives for a public awareness campaign

To increase public awareness about pain and people with pain, the committee recommends developing a 

campaign that will cover the following learning objectives (listed in order of priority): 

1. Chronic pain is a disease. 

2. Chronic pain is manageable.

3. Chronic pain is more prevalent than cancer, diabetes, and heart disease combined. 

4. Chronic pain is real.

5. Most Americans will experience chronic pain or care for someone with chronic pain. 

6. People in chronic pain deserve respect, compassion, and access to timely treatment. 

7. Many people in chronic pain nevertheless live productive lives. 

8. The goal for chronic pain management is to alleviate pain and restore function. Patients should be aware 

of realistic treatment expectations.

9. Chronic pain may cause depression and depression increases the severity of pain. 

10. Chronic pain may require a spectrum of medical and surgical treatments and/or non-medical interventions, 

including self-management strategies along with the active participation of people with chronic pain in 

their own pain care management.

11. Appropriate chronic pain management may involve prescription medications, which require knowledge of 

risks for adverse effects such as dependency and addiction.

12. Activity level and mood may vary depending on the intensity of chronic pain (good days and bad days). 

13. Awareness of conditions and activities that contribute to injury, especially in the workplace, can prevent 

pain.
77

Appendix L. Learning objectives and potential outcome measures for an educational 

campaign on safer use of pain medications 

Learning Objectives

Increasing the number of people with chronic pain who report that they:

1. Talk with their clinician about their hopes and expectations and share activities of daily living or function that are 

important to them.

2. Work with their clinician to develop a plan of treatment consistent with their goals.

3. Know that analgesic medications can be an appropriate pain management option in selected and monitored 

patients and they are not the only option.

4. Know their prescription medication is only for them and do not share it with others.

5. Store their medicine in a safe place where children or pets cannot reach it.

6. Dispose of unused medication properly.

7. Take medicine only if it has been prescribed or approved by their doctor. 

8. Do not take more medicine or take it more often than instructed. They call their doctor if their pain worsens.

9. Know how to understand and recognize expected and unexpected adverse effects such as dependency and 

addiction and to discuss risks with their doctor.

10. They talk to their doctor before taking prescription medications in combination with other drugs, including 

alcohol, sleeping pills, or anti-anxiety medication.

11. Have discussed with family and friends how to recognize and respond to overdose, including the use of naloxone.

12. Encourage family and friends to utilize Poison Control Centers as a confidential resource and to report possible 

opioid exposure and/or abuse by calling the Poison Help line 24

Potential Outcome Measures

Where possible, existing data sources should be employed to monitor measures such as:*

1. Proportion of patients who 

a. discuss daily activities (quality of life) with their provider

b. discuss expectations about the outcomes of pain treatment and side effects with their provider

c. have a functional contract (defined) with their provider and discuss with their provider other appropriate 

treatments 

2. Number of patients taking opioids who:

a. report storing their medication safely 

b. do not save expired un-wanted, or unused medications (CPDA) 

c. report calling their doctor if pain worsens 

d. dispose of unused medication properly (CPDA) 

e. take opioids not prescribed for them 

f. take higher or more frequent doses than prescribed 

g. report mixing pain medicines with alcohol, sleeping pills, or any illicit substance 

3. Number of overdoses reported in national emergency department data 

4. Number of reports to the National Poison Data System

*A potential data source for some of these research questions is Research America’s National Poll on Chronic Pain and 

Drug Addiction (CPDA).

 

24 Poison Control Hot Line (1-800-222-1222).
78

Appendix M. Conflicts of Interests/Financial Disclosures

The following members reported no conflicts of interest:

Paul Arnstein, PhD, RN, FAAN

Brian Berman, MD 

Christine Branche, PhD, FACE 

Chester Buckenmaier III, Colonel, MD 

Diana Burgess, PhD 

Daniel B. Carr, MD, MA 

Olivia Carter-Pokras, PhD 

Sean Cavanaugh, Ph.D.

Jan Favero Chambers

Humayun J. Chaudhry, D.O., M.S., MACP, FACOI, FAODME 

Lee Claassen, CAE

Steven P. Cohen, MD

Jack Conway, JD

Penney Cowan

Ronald Dubner, DDS, PhD

Margaret Faut-Callahan, CRNA, PhD, FNAP, FAAN 

Kathleen M. Foley, MD

Rollin Gallagher, MD, MPH

J. Nadine Gracia, MD, MSCE - Co-Chair 

Scott R. Griffith, MD, LTC, MC, USA

Joseph L. Goulet, MS, PhD

Robin J. Hamill-Ruth, MD

Linda M. Harris, PhD

Charles G. Helmick III, MD 

Sharon Hertz, MD 

Keith Humphreys, PhD

Francis Keefe, PhD 

Robert D. Kerns, PhD 

Rebecca Kirch, JD

Audrey Kusiak, PhD

John Kusiak, PhD

Linda LeResche, ScD 

Karl Lorenz, MD, MSHS

Sean C. Mackey, MD, PhD 

Julie Madden, MA 

Susan E. Maier, PhD

Brook I. Martin, MPH, PhD

Bill McCarberg, MD 

Judith Paice, PhD, RN, FAAN

Vyjeyanthi Periyakoil, MD 

John Piette, PhD

Linda Porter, PhD
79

James Rathmell, MD

Richard Ricciardi, PhD, NP 

Jackie Rowles, MBA, MA, CRNA, ANP, FAAPM, DPNAP, FAAN 

Ann Scher, PhD 

Brian Schmidt, DDS, MD, PhD 

Patricia Sinnott, PT, MPH, PhD

Christina Spellman, PhD 

Cindy Steinberg 

Walter F. Stewart, MPH, PhD 

Raymond C. Tait, PhD 

David J. Tauben, MD 

Gregory Terman, MD, PhD 

David Thomas, PhD 

Beverly Thorn, PhD, ABPP 

Tina M. Tockarshewsky, BA 

Marianne Udow-Phillips, MHSA 

Elizabeth Unger, MD, PhD 

Mary Vargas, JD 

Michael Von Korff, ScD 

Salina Waddy, MD 

Lynn Webster, MD, FACPM, FASAM 

Diana Wilkie, PhD, RN, FAAN 

Mary Willy, MPH, PhD 

CAPT Sherri Yoder, PharmD, BCPS

The following members reported conflicts of interest as required. Public Disclosures:

Myra Christopher, BA 

Employer: Center for Practical Bioethics

Terrie Cowley, BA 

President: The TMJ Association

Steering Committee Member: Consumers United for Evidence

David W. Dodick, MD 

Advisor/Consultant: Allergan, Inc., Alder Biopharmaceuticals Inc., Pfizer Inc, Merck & Co. Inc., eNeura 

Therapeutics, Boston Scientific, CoLucid Pharmaceuticals Inc., Autonomic Technologies Inc., 

MAP Pharmaceuticals, Inc., Bristol-Meyers Squibb Company, Arteaus Therapeutics, Amgen Inc., 

St. Jude Medical

Received Grants for Clinical Research: St. Jude Medical

Scott M. Fishman, MD 

Past President/Board Member: American Academy of Pain Medicine

Past President/Chair: American Pain Foundation

Chair: Pain Care Coalition 

Elizabeth B. Gilbertson, MA 

Employer: Unite HERE Health

Member, Board of Directors: National Committee for Quality Assurance

Carmen R. Green, MD 
80

Employer: University of Michigan

Advisory Board Member: University of New Mexico

Committee Member: American Pain Society, Mayday Fellowship Advisory Committee

Member: American Cancer Society Council for Extramural Grants

Steven P. Stanos, Jr, DO 

Consultant: Zogenix, Pfizer, myMatrixx, Mallinckrodt

Catherine H. Underwood, MBS, CAE 

Chief Executive Officer: American Pain Society

Christin L. Veasley, BSc 

Employer: National Vulvodynia Association

Mark Wallace, MD

Consultant: Boston Scientific, Jazz Pharmaceutical, Pfizer Advisory Board: Jazz Pharmaceutical, Insys, 

Depomed, Pfizer, Inergetics, Speaker Bureau: Jazz Pharmaceutical
81

BIBLIOGRAPHY

1

 (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 

Washington, DC, Institute of Medicine.

2 Anderson, K. O., C. R. Green and R. Payne (2009). "Racial and ethnic disparities in pain: causes and 

consequences of unequal care." J Pain 10(12): 1187-1204.

3

Tait, R. C. and J. T. Chibnall (2014). "Racial/ethnic disparities in the assessment and treatment of pain: 

psychosocial perspectives." Am Psychol 69(2): 131-141.

4 Mathur, V. A., J. A. Richeson, J. A. Paice, M. Muzyka and J. Y. Chiao (2014). "Racial bias in pain perception 

and response: experimental examination of automatic and deliberate processes." J Pain 15(5): 476-484. 5 Upshur, C. C., G. Bacigalupe, and R. LuckmanCitn. 2010. “They don’t want anything to do with you”: Patient 

views of primary care management of chronic pain. Pain Medicine 11(12):1791-1798. 6 Turk, D. C., H. D. Wilson, and A. Cahana. 2011. Treatment of chronic non-cancer pain. Lancet 377(9784): 

2226-2235

7

 Epstein, N.E. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a 

comprehensive review of the literature. Surg Neurol Int.; 2013: 4(Suppl 2):S74-93. 

8

 Mezei L, Murinson B. Pain education in North American medical schools. J Pain 2011; 12(12): 1199–1208 

9 International Association for the Study of Pain Declaration; http://www.iasppain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/20042005RighttoPainRelief/painasadisease.pdf 

10 Stewart WF, Lipton RB, Simon D, Von Korff M, Liberman J, 1998 Reliability of an illness severity measure 

for headache in a population sample of migraine sufferers. Cephalalgia. 1998;18(1):44-51 

11 Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. 2006 Survey of chronic pain in Europe: 

prevalence, impact on daily life, and treatment. Eur J Pain:10(4):287-333. 

12 Davis LL, Kroenke K, Monahan P, Kean J, Stump TE, 2015 The SPADE Symptom Cluster in Primary Care 

Patients with Chronic Pain. Clin J Pain. 2015 Aug 20 DOI:10.1097/AJP.0000000000000286 Ahead of Print 

13 Jansson, C*

., Mittendorfer-Rutz, E.; Alexanderson, K. 2012 Sickness absence because of musculoskeletal 

diagnoses and risk of all-cause and cause-specific mortality: A nationwide Swedish cohort study. Pain 

153(5), May 2012, p 998–1005. 

14 Tang, N. K., and C. Crane. 2006. Suicidality in chronic pain: A review of the prevalence, risk factors and 

psychological links. Psychological Medicine 36(5):575-586.

15 Fishbain, D. A., Lewis, J. E. and Gao, J. (2014), The Pain Suicidality Association: A Narrative Review. Pain 

Medicine, 15: 1835–1849. doi: 10.1111/pme.12463

16 Newton, B. J., J. L. Southall, J. H. Raphael, R. L. Ashford and K. LeMarchand (2013). "A narrative review of 

the impact of disbelief in chronic pain." Pain Manag Nurs 14(3): 161-171.

17 Narayan, M. C. 2010. Culture’s effects on pain assessment and management. American Journal of Nursing

110(4):38-47.

18 Johannes C, et al. The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based 

Survey. J Pain. 2010 November; 11(11): 1230–1239. 

19 Portenoy RK, et al. Population-based survey of pain in the United States: differences among white, African 

American, and Hispanic subjects. J Pain. 2004 Aug; 5(6): 317-28. 

20 Peter Croft, Fiona M. Blyth, Danielle van der Windt. Chronic Pain Epidemiology: From Aetiology to Public 

Health. 2010. 

 
82

 21 Nahin, R. 2015 Estimates of Pain Prevalence and Severity in Adults: United States 2012. The Journal of 

Pain: 16(8):769-780. 

22 Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug; 13(8): 715-24. 

These cost estimates were based on the U.S. adult non-institutionalized civilian population and, therefore, 

exclude children, prisoners, people in nursing homes or other institutional settings, and the military. 

23 2008 Medical Expenditure Panel Survey, AHRQ 

http://meps.ahrq.gov/mepsweb/data_files/publications/st342/stat342.pdf. 

24 IMS Health, Vector One: National, Years 1991-1996, Data Extracted 201. IMS Health, National Prescription 

Audit, Years 1997-2013, Data Extracted 2014.

25 Kenan K. Mack K, Paulozzi L. Trends in prescriptions for oxycodone and other commonly used opioids in 

the United States, 2000-2010. Open Med.2012;6(2):41–47. http://www.drugabuse.gov/related-topics/trendsstatistics/monitoring-future

26 Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2007: national 

estimates of drug-related emergency department visits.

27 Mack, K.A. Drug-induced deaths - United States, 1999-2010. MMWR Surveill Summ. 2013 Nov 22;62 

Suppl 3:161-3. CDC

28 Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014, 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w

29 http://www.cdc.gov/drugoverdose/epidemic/riskfactors.html.

30 Blake H, et al. Prescribing Opioid Analgesics for Chronic non-Malignant Pain in General Practice- a Survey 

of Attitudes and Practice. Br.J. Pain, 2015 9(4) 225-232. 

31 Jamison RN et al., Beliefs and Attitudes About Opioid Prescribing and Chronic Pain Management: Survey of 

Primary Care providers. J. Opioid Manag. 2014 10(6): 375-82.

32 Breuer B, et al. Pain management by primary care physicians, pain physicians, chiropractors, and 

acupuncturists: a national survey. South Med J. 2010 Aug; 103(8): 738-47. 

33 Nwokeji ED, et al. Influences of attitudes on family physicians' willingness to prescribe long-acting opioid 

analgesics for patients with chronic nonmalignant pain. Clin Ther. 2007; 29 Suppl: 2589-602. 

34 Foreman, Judy. “Backlash Against Walgreen’s New Painkiller Crackdown.” wbur’s Common Health. 2013 

Aug http://commonhealth.wbur.org/2013/08/walgreens-painkiller-crackdown 35 Fishbain DA, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid 

analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based 

review. Pain Med. 2008 May-Jun; 9(4): 444-59. 

36 Fleming MF et al., Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. 

2007. J. Pain 8(7):573-82.

37 Hojsted J et al., Addictive Behaviors Related to Opioid Use for Chronic Pain: A Population-Based Study: 

2013. Pain 154(12): 2677-83. 

38 Pathways to prevention https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-

14.pdf 

39 World Health Organization. International Classification of Functioning, Disability and Health. Geneva, 2001. 

40 Tucker CA, Cieza A, Riley AW, Stucki G, Lai JS, Ustun TB, Kostanjsek N, Riley W, Cella D. Concept 

analysis of the Patient Reported Outcomes Measurement Information system (PROMIS) 

41 Stier-Jarmer M, Cieza A, Borchers M, Stucki G, World Health Organization. How to apply the ICF and ICF 

core sets for low back pain. Clin J Pain 2009; 25:29-38. 

42 Leonardi M, Steiner TJ, Scher AT, Lipton RB. The global burden of migraine: measuring disability in 

headache disorders with WHO’s Classification of Functioning, Disability and Health (ICF). J Headache Pain

2005; 6:429-40. 
83

 43 Stucki G, Ewert T. How to assess the impact of arthritis on the individual patient; the WHO ICF. Ann Rheum 

Dis 2005; 64:664-8. 

44 International Association for the Study of Pain. (1986). Classification of chronic pain. Descriptions of 

chronic pain syndromes and definitions of pain terms. Pain Suppl, 3, S1-226. 

45 Including the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination 

Survey (NHANES), as well as Behavioral Risk Factor Surveillance System surveys, the Health and Retirement 

Survey, the Medicare Current Beneficiary Survey, and other regular and special supplemental population-based 

pain research appropriate for this purpose. 

46 U.S. Government Accountability Office. 2009. Enhancing OSHA’s records audit process could improve the 

accuracy of worker injury and illness data. GAO-10-10, p. 19. See also Figures 12 and 13. Accessed June 27, 

2014, from http://www.gao.gov/assets/300/298510.pdf. 47 Mathur, V. A., J. A. Richeson, J. A. Paice, M. Muzyka and J. Y. Chiao (2014). "Racial bias in pain perception 

and response: experimental examination of automatic and deliberate processes." J Pain 15(5): 476-484.

48 Tait, R. C. and J. T. Chibnall (2014). "Racial/ethnic disparities in the assessment and treatment of pain: 

psychosocial perspectives." Am Psychol 69(2): 131-141.

49 Bekanich, S. J., N. Wanner, S. Junkins, K. Mahoney, K. A. Kahn, C. A. Berry, S. A. Stowell and A. J. 

Gardner (2014). "A multifaceted initiative to improve clinician awareness of pain management disparities." Am 

J Med Qual 29(5): 388-396.

50 Medical Expenditure Panel Survey: 

http://meps.ahrq.gov/mepsweb/data_files/publications/st471/stat471.shtml 

51 IOM, 2011, p. 191, Finding 4-1, and Recommendation 4-2. 

52 Neumann, M., F. Edelhäuser, D. Tauschel, M.R. Fischer, M. Wirtz, C. Woopen, A. Haramati, and C. 

Scheffer. 2011. Empathy decline and its reasons: A systematic review of studies with medical students and 

residents. Acad Med 86(8): 996-1009. 

53 Fishman SM, Young HM, Lucas Arwood E, Chou R, Herr K, Murinson BB, Watt-Watson J, Carr DB, 

Gordon DB, Stevens BJ, Bakerjian D, Ballantyne JC, Courtenay M, Djukic M, Koebner IJ, Mongoven JM, 

Paice JA, Prasad R, Singh N, Sluka KA, St Marie B, Strassels SA. 2013 Core competencies for pain

management: results of an interprofessional consensus summit. Pain Med. 2013 Jul;14(7):971-81. doi: 

10.1111/pme.12107. 

54Polydorou, S., Gunderson, E.W., Levin, F.R., 2008Training Physicians to Treat Substance Use Disorders. Curr 

Psychiatry Rep: 10(5):399-404.