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The Integrated Approach to the Management of Pain

National Institutes of Health
Consensus Development Conference Statement
May 19-21, 1986

Conference artwork, stylized figure of a neuron in blue and red against a black background.

This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/.

This statement was originally published as:The Integrated Approach to the Management of Pain. NIH Consens Statement 1986 May 19-21;6(3):1-8.

For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: The Integrated Approach to the Management of Pain. NIH Consens Statement Online 1986 May Online 19-21 [cited year month day];6(3):1-8.

Introduction

We have come a long way in our social and professional attitudes toward the management of pain that have changed and developed during the last half century. A prior consensus statement, published in 1979, stressed the "caring" as well as the "curing" role in the management of pain associated with terminal disease and called for a more humanitarian approach. Since the time of that statement, further progress has been made in understanding and assessing the multidimensional character of pain, advancing the state of pharmacological techniques, and developing a variety of nonpharmacological approaches to the treatment of pain. In addition, recent years have witnessed the advent and growth of multidisciplinary pain clinics employing a range of methods and styles for the treatment of pain. While no single model commands universal acceptance, this new commitment to utilizing multiple modes of treatment and employing the skills of a multidisciplinary team of health professionals has come to be known as the "integrated approach to the management of pain."

Despite these recent scientific advances in the understanding and treatment of pain, it is important to recognize that there is no "magic bullet" or universally accepted treatment for the relief of pain and suffering. Contemporary science and clinical practice cannot assure the full relief of all pain. The data indicate that there remains a proportion of patients whose pain presents difficult, and so far unsolved, problems for successful management.

Yet, over and above these limitations posed by current knowledge and technology, many informed observers, supported by some scientific data, perceive continuing deficiencies in the clinical management of pain. Concerns are focused on reported undermedication of individuals with acute pain and chronic pain associated with malignant diseases as well as reported overmedication of people with chronic pain not associated with malignant disease.

There is reason for concern that the education and training of many health care professionals, for example, in schools of medicine, nursing, dentistry, and physical therapy, do not place adequate emphasis on contemporary methods of pain assessment and management. Furthermore, communications among physicians, dentists, nurses, other health care professionals, and patients regarding pain relief in clinical settings of both inpatient and outpatient types are less than adequate. These perceived deficiencies help to explain the attractiveness of collaborative approaches to pain management that stress joint efforts and enhanced communication among health care professionals. The multidimensional character of pain, the difficulty of assessment, and the multiplicity of possible interventions suggest the complexity of the task and reinforce the arguments favoring collaboration and shared responsibility among health care professionals in the management of pain. There is also an inherent role for the individual with pain, and often the family, in determining the course of treatment and participating in the process of pain management. Well-established ethical and legal principles require that individuals in pain have a significant voice in treatment decisions. It is therefore important that they be informed sufficiently to understand, appreciate, and make intelligent decisions regarding the approach to pain management.

Estimation of the prevalence and incidence of pain as indicators of the magnitude of the problem addressed in this report is of great importance. Clearly, based on self-reports and clinical experience, a large number of persons experience pain. However, reliable and valid estimates cannot be extrapolated from the data presented at this conference. Much of the information presented is based on reports from pain clinics that comprise only a small and nonrepresentative sample of persons with pain. Yet epidemiological, economic, and biostatistical data delineating the magnitude of the problem of pain in this country--to individuals, communities, and health care facilities--are fragmented and inadequate.

The term "integration" within the context of this consensus panel is used to describe an approach to the most effective use of pharmacological and nonpharmacological agents in the management of pain. In an effort to resolve some of the questions surrounding the integration of approaches to pain management, the Warren Grant Magnuson Clinical Center, the National Cancer Institute, the National Institute of Neurological and Communicative Disorders and Stroke, the National Institute of Dental Research, and the Office of Medical Applications of Research, NIH, jointly sponsored a Consensus Development Conference on the Integrated Approach to the Management of Pain. The conference brought together biomedical investigators, physicians, dentists, psychologists, nurses, other health care professionals, and representatives of the public on May 19-21, 1986.

Following a day-and-a-half of presentations by health care experts and discussion by the audience, a consensus panel, drawn from the health care and lay communities, considered the evidence and data presented and agreed on responses to the following questions:

  • How should pain be assessed?
  • How should pharmacological agents be used in an integrated approach to pain management?
  • How should nonpharmacological interventions be used in an integrated approach to pain management?
  • What is the role of the nurse in the integrated approach to pain management?
  • What are the directions for future research in pain management?

How Should Pain Be Assessed?

Pain is a symptom that arises in response to a noxious stimulus or tissue injury. In some instances, pain may persist after the tissue damage has healed or in the absence of evident tissue damage. Clinicians have found it useful to classify pain into three major categories based on etiology: pain following acute injury, disease, or some types of surgery (acute pain); pain associated with cancer or other progressive disorders (chronic malignant pain); or pain in persons whose tissue injury is nonprogressive or healed (chronic nonmalignant pain). An individual may have more than one type of pain.

Pain is a subjective experience that can be perceived directly only by the sufferer. It is a multidimensional phenomenon that can be described by pain location, intensity, temporal aspects, quality, impact, and meaning. Pain does not occur in isolation but in a specific human being in psychosocial, economic, and cultural contexts that influence the meaning, experience, and verbal and nonverbal expression of pain.

Verbal self-reporting and behavior measures have been developed to assess the characteristics of a person's pain. Self-reported pain assessments can range from a simple "yes" or "no" response to questions such as "Are you in pain?" to a complex battery of instruments that measure multiple factors. The McGill-Melzack Pain Questionnaire is a widely used tool that measures sensory, affective, and evaluative dimensions of pain. Other self-report tests consist of verbal descriptions that range from low to high amounts of the dimensions of pain to be measured and visual analog scales which may represent the entire continuum of a dimension of the pain experience. The degree of pain is reported by selecting a verbal descriptor or making a mark on the line to indicate the level of pain.

Pain behaviors can be measured by personal diaries kept by persons in pain to record such things as daily activities, self-reports of time of onset, pain severity, medication consumption, perceived effect of drugs, and reported response to pharmacological and nonpharmacological attempts of relief. In using direct observation, the clinician can document pain behaviors such as guarded movement, rubbing of painful areas, and sighing. Important to observe are the related practices of withdrawal and social isolation, drugs abused, overutilization of the health care system, and inordinate preoccupation with pain. Interpretation based on such observation warrants sensitivity to the patient's individuality, culture, and modes of pain expression.

The assessment of pain in children presents special problems and is a subject of current research interest. Clinical impressions suggest that children in pain may frequently be undertreated. The usual verbal testing techniques are not applicable for younger children, and measures of pain magnitude are imprecise in children at earlier stages of cognitive development. Since children of all ages can and do express their pain, innovations in assessment tools designed expressly for children must be developed. Assessment techniques that require magnitude estimates and cognition are also of limited applicability to special populations, for example, those who are cognitively impaired or faced with language, cultural, or educational barriers. More effective approaches to the assessment of pain in these persons with special needs deserve exploration.

The clinical assessment of the person with pain begins with diagnostic evaluation and clarification of the goals of therapy. These should be appropriate for the type of pain, its cause, and the characteristics of the individual affected. Also, when and how often pain assessments should be made varies. Expectations for improvement differ according to these factors. Repeated clinical measures of acute pain must be relatively short and should focus primarily on sensory description and comparative estimates of magnitude and intensity. At present, few valid and reliable acute pain measures exist. With chronic pain, assessment may be more productively focused on affective and evaluative aspects of the pain experience, as well as on its history and context. Many existing pain assessment measures are based on a chronic pain model. Recent research indicates that an attempt should be made to measure as many dimensions as feasible in all types of pain, although the relative importance of each dimension varies by pain type.

Acute Pain

The single most useful method for evaluating acute pain outside of the research environment is to ask the person how he or she feels. Assessment tools such as the visual analog scale may be adapted to the needs of the bedside and are easy to use. The McGill-Melzack Pain Questionnaire may be useful during the initial evaluation. However it may not be practical on an ongoing basis in the clinical management of the individual experiencing pain. Further testing to establish reliability and validity of several different types of pain-specific self-report and visual analog scales in the clinical setting is indicated.

Chronic Pain Associated With Malignant Disease

Wide variations exist among persons with chronic pain associated with malignant disease. At such times, self-reports, the visual analog scale, and the McGill-Melzack Pain Questionnaire are useful when the person's condition permits. At other times, some individuals are quite ill and may be motionless and silent and only the simplest descriptions of discomfort can be elicited from them. Care givers should review evidence of change in appetite, activity, social interaction, sleep patterns, and the impact of pain on the quality of life.

Chronic Pain Not Associated With Malignant Disease

The primary objective when evaluating individuals with this kind of pain should include the level of function as it may not be possible to achieve complete relief of pain. Both self-report measures and direct observation of motor activity are useful. Measures of psychological function may be important in evaluating the individual's emotional state and coping mechanisms since depression can be an important factor for many persons. Outside the research environment practical measures such as an increase in physical activity or improvement in interpersonal relationships will reflect improvement.

Thus far, the evaluation of treatment effectiveness for pain has relied largely on clinical impressions of outcome. Clinical investigators are presently involved in the development of valid and reliable measures of appropriate short- and long-term outcomes. This includes measures that are useful for longitudinal study of change over time, such as increase in physical activity, as well as measures of absolute endpoints. These include increased activities of daily living, improved patterns of socialization, and return to employment. Effective assessment has related economic effects as well since, in part, it determines eligibility for benefits.
 

How Should Pharmacological Agents Be Used in an Integrated Approach to Pain Management?

Individualization of Drug Therapy

There may be marked individual variation in intensity of effect for any dose of a drug. Variations in dose-response are due to variations in rates of drug absorption, metabolism, and excretion and to variations in cell or organ sensitivity to the drug, presence of disease, and variations in age and body size. Attention should be given to these variations in dose-response in individualizing drug choice and drug dosage for patients with pain.

Acute Pain

Surveys of hospitalized people with acute pain have found that many continue to have moderate or severe pain because their treatment has been with doses of narcotic analgesics that have been too low or given at too long an interval between doses. Reasons for low doses or doses given infrequently include incorrect assessment, insufficient knowledge of the pharmacology of the prescribed drug, and personal attitudes of the caregivers and patients alike about narcotic analgesics. Concern about the problems of addiction and respiratory depression is greater than the actual risk. Approaches to addressing such problems include educating health care professionals about analgesic drugs and making them aware of how their attitudes may affect their use or nonuse of narcotic analgesics effectively. Public education with respect to these issues is also important.

One of the innovative ways that may provide effective individualized analgesia and comfort for these people has been the development of patient-controlled analgesia (PCA). This technique utilizes a device that permits intravenous self-administration of narcotic drugs within limits of dose and frequency established by the physician.

Chronic Malignant Pain

There are many parallels in the inadequate treatment of cancer pain with the inadequate treatment of acute pain. Surveys of people with metastatic cancer have revealed that the majority have moderate or severe pain. Research has shown that narcotic analgesics given on a scheduled basis in adequate doses is an improvement over the former p.r.n. (pro re nata or as occasion arises, according to circumstances, or as is necessary) method of physician-ordered narcotic use and nurse- or pharmacist-interpreted administration of drugs to address these pain problems.

An additional issue of concern in this patient population is the development of tolerance. There is an indication that when dosage requirement increases, the reason can be disease progression and not always increased tolerance. Physical dependence does occur but is not of clinical significance in advanced disease. Some people with metastatic cancer cannot achieve pain control by systemic narcotics. In many situations, dose-limiting side effects are a problem. The addition of other drugs such as steroids or nonsteroidal anti-inflammatory drugs to the regimen may improve pain control without enhancing drug toxicity. In addition, other modalities of therapy such as nerve blocks, neurosurgical procedures, radiation therapy, chemotherapy, and other appropriate interventions, while not considered in detail at this conference, should not be ignored in the care of the individual with cancer pain. An innovative approach to the treatment of cancer pain has been the exploration of new routes or methods of narcotic administration. These include continuous subcutaneous infusion, epidural and intrathecal routes, mucous membrane or transdermal absorption, oral formulations with slow release and absorption, and PCA.

One should be aware that many individuals with pain due to cancer early in the course of their illness can achieve pain control with nonnarcotic analgesics. For this class of drugs as for the narcotics, individualization of dose and of drug is essential.

Chronic Nonmalignant Pain

People with chronic pain of nonmalignant cause are a heterogeneous group with a variety of illnesses. They are treated with a wide variety of medications and other therapies, often with limited success. In an effort to alleviate the pain, drug dosage is often progressively raised to the point at which significant side effects appear. In addition to the established analgesics, tricyclic antidepressants have been tried in some of these conditions with variable results. They are most effective when clinical depression accompanies pain. Phenothiazines may have been used in treating nausea or anxiety accompanying pain, but they are not effective as analgesics or as potentiators of analgesics. Special care should be taken to avoid overtreatment of these individuals, particularly with drugs that have a real risk of side effects or addiction.

Children and Infants

There are special problems in providing adequate analgesia for infants and children. These special problems are due to deficiencies in assessing pain and to the lack of sufficient knowledge about factors influencing drug action in this population. Special attention should be given to solving these problems.

Quality Assurance

We recommend that examination of the adequacy of pain relief for persons in the hospital or receiving services from other health care institutions and agencies should be made a part of existing quality assurance programs.
 

How Should Nonpharmacological Interventions Be Used in an Integrated Approach to Pain Management?

This past decade has witnessed a dramatic increase in laboratory and clinical research on nonpharmacological approaches to pain management. Experienced clinicians report some success with a variety of nonpharmacological modalities, including acupuncture, biofeedback, transcutaneous electrical nerve stimulation (TENS), hypnosis, physical therapy, and behavioral approaches such as coping strategies, desensitization, modeling, operant conditioning, and relaxation. Diagnostic and therapeutic nerveblocks of many parts of the body may be useful in pain management and as predictors of the effect of neurosurgical intervention. Acupuncture and TENS are most commonly used for chronic musculoskeletal disorders. Biofeedback is often used for the treatment of headaches and painful vascular conditions. Investigators agree that now is an appropriate time to evaluate the effectiveness of each of these modalities with specific patient populations through the use of controlled studies.

Behavioral therapies are used for some individuals with chronic pain. Practitioners believe that such therapies are indicated when excessive pain behavior is inconsistent with other clinical findings. They are also used when there is a progressive decline in activity, evidence of abuse in pain medications, or an inordinate dependence on spouse or family members.

Biofeedback involves giving individuals information about physiologic responses and ways to exercise voluntary control over these responses. It is useful in muscle tension headaches and migraine headaches. A variety of relaxation techniques can be used in reducing pain associated with stress or anxiety.

With regard to the nonpharmacological approaches to pain, there must be a willingness on the part of the patient to participate with the clinician in the decision about which modality to use. In addition, it is important that the family members be educated about the proposed modality and their role in its application. Persons uncomfortable with or unwilling to take potent drugs for the relief of pain may be more willing to consider nonpharmacological approaches.

The various modalities, singly or in combination, can be utilized in the management of acute or chronic pain. Some persons may require a simultaneous or sequential combination of multimodal approaches incorporating pharmacological and nonpharmacological approaches in pain management.
 

What Is the Role of the Nurse in the Integrated Approach to Pain Management?

While the consensus panel was asked to investigate particularly the role of the nurse within this framework, it recognizes and supports the significant contributions made by all members of the health care team to the management of the person with pain. The expertise of the members of various specialties of the medical profession is critical to the management of pain.

However, the nurse may be the first health care provider to encounter the person experiencing pain as well as to identify the problem of uncontrolled pain. Thus, many opportunities exist for nurses to enhance the effectiveness of care delivery to individuals with pain. The nurse can be the key link in facilitating communication between the individual and the family and other members of the health care team. In so doing, nurses, along with other health care professionals, can make a significant contribution in facilitating effective patient participation in the decisionmaking process.

The role of the nurse in the assessment and management of pain varies according to the type of patient population being served, the setting in which care is delivered, as well as the educational and professional experience of the individual nurse. In acute care settings, the nurse occupies a central position in assessing the individual with pain, in administering physician-selected therapeutic modalities, and in monitoring the condition of the person in pain.

For those individuals experiencing chronic pain who are being discharged from hospitals or other institutions, nurses are in a pivotal position to assess the congruence between the person's condition, need for care, and the community health, public health, or home health resources available for the management of the individual in the noninstitutional setting.

For individuals managed at home, the nurse is frequently the professional who provides care, maintains ongoing communication with the individual and family, monitors the situation, and serves as the link with other care providers.

The role of the generalist nurse should not be underestimated. Nurses at this level have the most consistent interaction with the individual experiencing pain. Examples of the types of interventions that should be provided by the generalist nurse include:

  • Preoperative patient education to lessen postoperative pain.
  • Nursing care plans that reflect individual medication schedules based on individual preference and activity schedules.
  • Implementation of nonpharmacological methods during acutely painful events such as childbirth, burn wound debridement, and diagnostic tests.

 

The nurse who specializes in the assessment and management of persons with pain may serve as part of an interdisciplinary team or may be individually identified as a resource within a particular setting. The nurse who specializes at this level must also possess increasingly sophisticated skills in the areas of pain assessment, pharmacology, choices of route and timing of drug administration, and participation in nonpharmacological interventions.

Whether or not the nurse practices as a member of an interdisciplinary team, the nurse may be identified as the coordinator of patient care. In this role, the nurse must be able to communicate effectively not only with the person in pain but also with the entire family and health care team.

The role of the nurse with advanced preparation should include:

  • Clinical management responsibilities such as titration of analgesics within a protocol according to the patient's level of analgesia, assessment, and participation in the use of both pharmacological and nonpharmacological modalities.
  • Provision of consultation and educational services to other members of the nursing staff, other providers, and community groups.
  • Active participation in research.

 

To fulfill these roles effectively, nursing curricula must include pain management content. Nurses practicing in nursing service, nursing education, and nursing research settings should be provided with fellowships for further study of pain management.
 

What Are the Directions for Future Research in Pain Management?

Future research should be directed to:

  • Identify the factors that facilitate or hinder the dissemination and implementation of up-to-date information in clinical practice in the treatment of pain.
  • Determine the appropriateness of using existing research measures in clinical settings and to evaluate their validity as adjuncts to clinical judgments in pain assessment. Investigators should consider the special issues related to children in pain that have received less attention in the past.
  • Identify the specific factors associated with outcome within treatment modalities.
  • Assess more fully the potential value of each of the nonpharmacological approaches to pain in acute and chronic pain states through controlled studies in specific populations.
  • Discover and develop more effective analgesic drugs with larger margins of safety. Precise knowledge about the pharmacology of known drugs is important, but the development of medicine with new intrinsic actions and new drug molecules is needed. The basic research needed to improve the pharmacological therapy of pain will have to be performed in humans and many species of animals and should utilize a wide variety of research disciplines and methodologies.
  • Continue research on endorphins, enkephalins, and narcotic receptors that shows promise of producing better analgesic drugs. In addition, this research may contribute to a better understanding of the mechanisms of such nonpharmacological therapy as acupuncture and TENS.
  • Develop and evaluate methods of drug delivery, including PCA, sustained release formulations, epidural administration, and transdermal absorption of narcotic drugs to improve pain management with presently available narcotic drugs.
  • Conduct epidemiological studies of the incidence and prevalence of pain.
  • Study the nature and meaning of pain in a variety of settings and within a broad range of populations as the basis of developing ethnoculturally and contextually appropriate assessment tools.

Conclusions

Pain is an important and complex phenomenon. Accurate pain assessment requires classification by type of pain and includes the establishment of treatment objectives. Different assessment tools are necessary to reflect the problems inherent in the various classifications of pain. Increasing numbers of assessment tools are available for use in research settings. Some of these tools are of clinical value when used with properly selected individuals.

Unfortunately, even when pain is reported and assessed, it may not necessarily be attended, monitored, treated, and satisfactorily managed. An integrated approach to the assessment and management of pain brings greater options to individuals seeking the alleviation of pain.

New methods are available to deliver drugs effectively with less toxicity. Pharmacotherapy may be very effective in treating pain. However, personal attitudes may account for the undertreatment of persons in pain. Insight, education, attitude change, and accountability in the professional practice of health professionals will influence positively the implementation of adequate pain therapy. Nonpharmacological methods are playing an increasing role in the treatment of some types of pain.

Nurses have well-established pivotal roles in the assessment and management of pain that will increase in importance. All members of the multidisciplinary health team urge effective teaching about the nature of pain and recommend that the integrated approach to pain management be included in both formal and continuing education of the various members of the pain team.

Throughout the conference, the theme emerged that no single treatment modality is appropriate for all or even for most individuals suffering from pain. The treatment, and the evaluation of that treatment, should vary with the constellation of factors surrounding that individual.

These considerations should guide future research.
 

Consensus Development Panel

Laurel Archer Copp, Ph.D., F.A.A.N.
Panel Chairperson
Dean and Professor
University of North Carolina School of Nursing
Chapel Hill, North Carolina
The Reverend Dr. Vienna Cobb Anderson, M.F.A., D.Min.
Episcopal Priest in the Community of Hagar
Chaplain
Hospice of Washington, Washington, D.C.
Adjunct Professor
Virginia Theological Seminary, Alexandria, Virginia
Consultant
St. Francis Center
Washington, D.C.
Mark J. Brown, M.D.
Associate Professor of Neurology
Department of Neurology
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Ronald J. Dougherty, M.D.
Medical Director
Pelion, Inc., A Chronic Pain Outpatient Clinic
Administrative Service Chief
Chemical Abuse Recovery Service
Benjamin Rush Center
Syracuse, New York
William Greenfield, D.D.S.
Associate Dean for Hospital and Extramural Affairs
Professor of Oral and Maxillofacial Surgery
New York University College of Dentistry
New York, New York
Catherine M. Hogan, R.N., M.N.
Oncology Clinical Nurse Specialist
Clinical Director
Outpatient Services
Pittsburgh Cancer Institute
Pittsburgh, Pennsylvania
Jean E. Johnson, Ph.D., R.N.
Professor, University of Rochester School of Nursing
Associate Director and Clinical Chief for Nursing Oncology
University of Rochester Cancer Center
Rochester, New York
Donald S. Kornfeld, M.D.
Professor of Clinical Psychiatry
Columbia University College of Physicians and Surgeons
Director
Psychiatric Consultation-Liaison Service
Presbyterian Hospital
New York, New York
E. David Mellits, Sc.D.
Director of Clinical Biostatistics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Marilyn T. Oberst, Ed.D., R.N.
Professor and Associate Dean for Research
University of Wisconsin-Madison School of Nursing
Madison, Wisconsin
Emanuel M. Papper, M.D., F.F.A.R.C.S.
Professor of Anesthesiology
University of Miami School of Medicine
Miami, Florida
Marcus M. Reidenberg, M.D.
Professor of Pharmacology and Medicine
Cornell University Medical College
New York, New York
Jeanne M. Steele, Ph.D., M.S.N.
Associate Professor
Nursing Graduate Program
Indiana University of Pennsylvania
Alan J. Weisbard, J.D.
Assistant Professor of Law
Cardozo Law School
New York, New York
Carolyn A. Williams, Ph.D.
Professor and Dean
College of Nursing
University of Kentucky Medical Center
Lexington, Kentucky

Speakers

Carol Reed Ash, Ed.D., R.N., F.A.A.N.
"Education Approaches for Teaching Pain Management"
Associate Dean
Continuing Education Program
Adelphi University School of Nursing
Garden City, New York
John J. Bonica, M.D., D.Sc., F.F.A.R.C.S.
"Magnitude of the Problem and the Epidemiology of Pain"
Chairman Emeritus and Professor
Department of Anesthesiology
University of Washington School of Medicine
Seattle, Washington
Nessa Coyle, M.S., R.N.
"Routes of Administration of Pharmacologic Agents: Current Trends and Developments"
"Teamwork of Health Professionals in Pain Management: Goals, Approaches, and Role Relationships"
Director
Supportive Care Program, Pain Service
Department of Neurology
Memorial Sloan-Kettering Cancer Center
New York, New York
Marilee I. Donovan, Ph.D., M.N.
"Pain Assessment in the Severely Ill"
Chairperson
Department of Medical Nursing
Rush-Presbyterian-St. Luke's Medical Center
Chicago, Illinois
Joann M. Eland, Ph.D., R.N.
"The Assessment of Pain in Children"
Assistant Professor
University of Iowa College of Nursing
Iowa City, Iowa
Richard H. Gracely, Ph.D.
"Verbal Pain Assessment"
Research Psychologist
Clinical Pain Section
Neurobiology and Anesthesiology Branch
National Institute of Dental Research
National Institutes of Health
Bethesda, Maryland
George Heidrich, M.A., R.N.
"Selection of Scheduling of Pharmacologic Interventions"
Program Coordinator of Analgesic Studies
Coeditor, Journal of Pain and Symptom Management
Department of Anesthesiology
University of Wisconsin at Madison
Madison, Wisconsin
Mary Ellen Jeans, Ph.D.
"Multidisciplinary Teams: Composition and Approach"
Director
School of Nursing
Associate Dean of Nursing
Faculty of Medicine
McGill University School of Nursing
Montreal, Quebec
CANADA
Francis J. Keefe, Ph.D.
"Behavioral Approaches to Pain Management"
"Behavioral and Psychophysiological Aspects of Pain Assessment"
Associate Professor of Medical Psychology
Director
Pain Management Program
Department of Psychiatry
Duke University Medical Center
Durham, North Carolina
James A. Lipton, D.D.S., Ph.D.
"Cultural Aspects of Pain Assessment"
Evaluation Research Specialist
National Institute of Dental Research
National Institute of Health
Bethesda, Maryland
John D. Loeser, M.D.
"Pain and Its Management: An Overview"
Professor
Neurological Surgery
Director
Multidisciplinary Pain Center
Department of Neurological Surgery
University of Washington
Seattle, Washington
Patricia A. McGrath, Ph.D.
"Nonpharmacologic Interventions for Controlling Acute, Chronic, and Recurrent Pain"
Assistant Professor
Department of Pediatrics
Faculty of Medicine
University of Western Ontario
Director
Pain Program
Department of Pediatrics
Faculty of Medicine
Children's Hospital of Western Ontario
London, Ontario
CANADA
Russell K. Portenoy, M.D.
"Assessment of Interventions for the Treatment of Pain and Other Symptoms"
Codirector
Unified Pain Service
Assistant Professor of Neurology
Department of Neurology
Albert Einstein College of Medicine
Bronx, New York
Ann Gill Taylor, Ed.D., R.N., F.A.A.N.
"Patients' Perspective in the Pain Experience"
Professor of Nursing
University of Virginia School of Nursing
Charlottesville, Virginia
Dennis C. Turk, Ph.D.
"Chronic Pain: The Necessity of Interdisciplinary Communication"
Director
Center for Pain Evaluation and Treatment
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

Planning Committee

Margaret R. Dear, R.N., Ph.D. (chairperson)
Senior Nurse Scientist
Nursing Department
Clinical Center
National Institutes of Health
Bethesda, Maryland
Anne R. Bavier, R.N., M.N.
Program Director
Nursing Research
Division of Cancer Prevention and Control
National Cancer Institute
National Institutes of Health
Bethesda, Maryland
Michael J. Bernstein
Director of Communications
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland
Laurel Archer Copp, R.N., Ph.D.
Consensus Conference Panel Chairperson
Dean and Professor
University of North Carolina School of Nursing
Chapel Hill, North Carolina
Ronald Dubner, D.D.S., Ph.D.
Chief
Neurobiology and Anesthesiology Branch
National Institute of Dental Research
National Institutes of Health
Bethesda, Maryland
Jerry M. Elliott
Program Analyst
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland
Mark Hallett, M.D.
Associate Director for Branches
Intramural Research Program
Clinical Director
National Institute of Neurological and
Communicative Disorders and Stroke National
Institutes of Health
Bethesda, Maryland
Colleen Henrichsen
Acting Chief
Office of Clinical Reports and Inquiries
Clinical Center
Ada Jacox, R.N., Ph.D.
Professor and Director
Center for Research
University of Maryland School of Nursing
Baltimore, Maryland
Mitchell B. Max, M.D.
Clinical Coordinator
Pain Research Clinic
National Institute of Dental Research
National Institutes of Health
Bethesda, Maryland
Angela W. Miser, M.D.
Visiting Associate
Pediatric Branch
National Cancer Institute
National Institutes of Health
Bethesda, Maryland

Conference Sponsors

Warren Grant Magnuson Clinical Center
John L. Decker, M.D. Director
National Cancer Institute
Vincent T. DeVita, Jr., M.D. Director
National Institute of Neurological and Communicative Disorders and Stroke
Murray Goldstein, D.O., M.P.H. Director
National Institute of Dental Research
Harald L�, D.D.S., Dr. Odont. Director
Office of Medical Applications of Research
Itzhak Jacoby, Ph.D. Acting Director

Supplemental Information for NIH Consensus Statement on Integrated Approach to the Management of Pain

Since the NIH Consensus Statement on Integrated Approach to the Management of Pain was issued, additional information has become available that supplements the original statement.

A number of individuals and organizations have begun initiatives to improve the treatment of pain. The following two publications provide an introduction to these efforts:

  • Max MB. Improving Outcomes of Analgesic Treatment: Is Education Enough? Ann Int Med, 1990;113(11):885-889.
  • Committee on Quality Assurance Standards, American Pain Society. American Pain Society quality assurance standards for relief of acute pain and cancer pain. Proceedings of the VIth World Congress on Pain. Elsevier Science Publishers, 1991:185-189.

 

Additional useful resources include "Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain," a concise and authoritative pocket-sized review of core material on the use of analgesics, available from the American Pain Society, P.O. Box 186, SKokoie, Illinois 60076-0186 (708-966-0050). This organization and the Oncology Nursing Society (Pittsburgh, PA) are organizing multiple initiatives to improve pain relief, and interested individuals shuld contact them.

The National Cancer Institute's Cancer Information Service offers an excellent booklet for cancer patients and their families: "Questions and Answers About Pain Control," a joint publication with the American Cancer Society. This is available at no charge by calling 1-800-4-CANCER. Also, the U.S. Agency for Health Care Policy and Research has published a clinical practice guideline "Acute Pain Management: Operative or Medical Procedures and Trauma," which can be obtained at no cost by calling 1-800-358-9295

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