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toward the use of new terms such as “pain associated with human immunodeficiency virus (HIV) infection” or “pain associated with cancer.” (The term “cancer pain” is used in this monograph for the sake of brevity.) Cancer pain includes pain caused by the disease itself (e.g., tumor invasion of tissue, compression or infiltration of nerves or blood vessels, organ obstruction, infection, inflammation) and/or painful diagnostic procedures or treatments (e.g., biopsy, postoperative pain, toxicities from chemotherapy or radiation treatment).102 There are several reasons why some experts feel that cancer pain merits a discrete category. First, its acute and chronic components and multiple etiologies make it difficult to classify based on duration or pathology alone. Second, cancer pain differs from chronic noncancer pain (CNCP) in some significant ways (e.g., time frame, levels of pathology, treatment strategies) (Table 3).99 However, there is little evidence to support a distinction between these pain types based on underlying neural processes. Therefore, many pain experts categorize cancer pain as acute or chronic pain.98 4. Chronic Noncancer Pain A subtype of chronic pain is CNCP, which refers to persistent pain not associated with cancer. In contrast to patients with chronic cancer pain, patients with CNCP often report pain levels that only weakly correspond to identifiable levels of tissue pathology and/or respond poorly to standard treatments.99-100 As CNCP may last for many years, some consider use of the traditional term for such pain, “chronic nonmalignant pain,” inappropriate. Thus, there is movement toward use of alternate terms such as “chronic noncancer pain” and “chronic noncancer-related pain.” Causes of CNCP include acute injury that has proceeded to chronic pain (e.g., whiplash) and various chronic conditions (Table 4). In some cases, there is no discernable cause, and the pain is considered the disease. CNCP can affect virtually any body system or region, and pain severity ranges from mild to excruciating. Some types of CNCP have well-defined characteristics and patterns, whereas others do not. Neuropathic and myofascial CNCP can be particularly hard to diagnose, as they may occur in the absence of a known injury or disease process.100 Because of its chronicity and impact on daily activities, patients with CNCP may experience vocational, interpersonal, and/or psychological problems (Table 3).15 If the symptoms of CNCP consume the attention of and incapacitate the patient, he or she may suffer from a psychosocial disorder known as “chronic pain syndrome” (CPS) (Table 3).100 The pain experienced by these patients is real, and not all patients with CNCP develop this syndrome. Appropriate management of both CNCP and CPS requires an 12 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance Table 4. Examples of Chronic Noncancer Pain • Osteoarthritis • Low back pain • Myofascial pain • Fibromyalgia • Headaches (e.g., migrainea, tension-type, cluster) • “Central pain” (e.g., spinal cord injury, stroke, MS) • Chronic abdominal pain (e.g., chronic pancreatitis, chronic PUD, IBS) • Sickle cell diseasea • CRPS, Types I and II • Phantom limb pain • Peripheral neuropathy • Neuralgia (e.g., post-herpetic, trigeminal) Sources: References 99 and 100. aMigraines and sickle cell disease may be more accurately classified as intermittent pain but are treated as chronic noncancer pain for purposes of this discussion. CRPS: complex regional pain syndrome; IBS: Irritable bowel syndrome; MS: multiple sclerosis; PUD: peptic ulcer. interdisciplinary approach that addresses the complex interaction of physical, psychological, and social factors that contribute to the ongoing pain. D. P REVALENCE , C ONSEQUENCES , AND C OSTS OF PAIN Pain is common, and inadequately managed pain is associated with many adverse consequences. This section of the monograph reviews epidemiological data, evidence that pain is undertreated, and consequences of inadequately managed pain. These consequences affect patients, their families, and society as a whole and can be broadly categorized as physiological, psychosocial (quality of life), and financial. 1. What Is the Size and Scope of Pain As A Health Care Problem? Acute pain is the most common reason why patients seek medical attention.88 Common reasons for visits to health care professionals include acute pain (e.g., musculoskeletal pain, gastrointestinal pain, chest pain, headache) and injuries (e.g., fractures, sprains, lacerations).103 Chronic pain is also a problem of epidemic proportions. About 50 million of the estimated 75 million Americans who live with “serious pain” suffer from chronic pain.104 Many have been living with their pain for more than 5 years and experience pain almost 6 days a week.14 A survey of self-help organization members suggested that back and neck pain, myofascial pain/fibromyalgia, headache, arthritis pain, and neuropathic pain are the most common types of CNCP.105 Low back pain, arthritis, and migraine headache alone account for pain in tens of millions of Americans.88 2. What Evidence Suggests That Pain Is Undertreated? In 1992, the AHCPR developed a CPG for acute pain management, in part due to mounting reports of inadequate postoperative pain control.13 Clinical
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