With all the debates and foot-dragging on the order of Richard III as to where health care needs to go, I get the unmistakable impression that much of the true conscience of American medicine lies within recent reports from the Institute of Medicine.

Just a decade after having released its groundbreaking and eloquent treatise arguing for the reconstruction of the American health care system from the ground up, with an emphasis upon prevention,¹ the IOM has struck again with a new and important conceptualization of chronic pain.

For far too long there has been hand-wringing over the fact that a minimum of 116 million Americans experience chronic pain every year, with a national cost ranging between $560 billion and $635 billion.² This turns out to be a conservative estimate because children and military personnel have not been included. Prevention and pain treatment are thwarted by inadequate treatment, delay or outright inaccessibility of health care.

Chiropractors, are you listening? There are five basic concepts in the IOM report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, that relate to the chiropractic profession directly:²

• Chronic pain can be its own disease: Because neuroplastic adaptations to an initial episode of pain occur,^3-5 chronic pain turns out to have a distinct pathology unto itself. It causes distinct changes in the nervous system that often worsen over time and has significant psychological and cognitive correlates as well.
• Comprehensive treatment with an interdisciplinary approach is often needed for prevention and management.
• There are distinct roles for both patients and clinicians: The effectiveness of pain treatments depends greatly upon the clinician-patient relationship, never upon the clinician alone.
• Chronic pain requires a public-health and community-based approach: Large numbers of people are affected with disparities in occurrence, treatment, and prevention, all of which clearly make chronic pain a public health issue.
• There are transformations in pain perception: This is experienced by both those suffering from it and those treating it.

From these principles evolved a number of directives from the Institute of Medicine, including the following:²

• A population-level prevention and management strategy is needed: Specifically, Health and Human Services should develop a comprehensive plan with specific goals, actions, and timeframes. Better data are needed to help shape these efforts, especially for groups of people currently underdiagnosed and undertreated. To address this issue, federal and state agencies as well as private organizations need to accelerate their data collection on pain incidence, prevalence, and treatments.
• There must be an awareness that pain varies from patient to patient: This means health care providers should tailor pain care to each person's experience, an element that more and more is being recognized as being an integral part of the evidence in evidence-based medicine.⁶
• Federal agencies and other stakeholders should redesign education programs to address gaps in knowledge: Implicit in this directive is the need for interdisciplinary recognition, cooperation and respect.
• Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

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