In Virginia, like the rest of the country, pain is one of the most common causes of medical consultation. Pain can be either acute or chronic. Acute pain is the sudden onset of pain sensation triggered by the nervous system secondary to specific events like accident injuries, surgical site pain, child labor and delivery, etc. Acute pain usually resolves following adequate management of the underlying cause. Chronic pain is different. It is the persistence of pain beyond six months that usually results from a combination of biologic, psychologic and social factors.
Why is adequate pain management important? Several studies have linked chronic pain to reduced mobility, limitations in daily activities, opioid dependence, numerous psychiatric conditions and reduced quality of life (2). In 2016, an estimated 20.4% of U.S. adults had chronic pain and 8.0% of U.S. adults had high-impact chronic pain. Both were more prevalent among adults living in poverty, adults with less than a high school education, and adults with public health insurance (2). These socio-economic conditions are more prevalent in certain areas within the State and identifying populations at risk is necessary to advise efforts to advancing and targeting quality pain services.
Chronic pain contributes to an estimated $560 billion each year in direct medical costs, lost productivity, and disability programs (2). One study estimated that approximately 3 percent of patients in the primary care setting were receiving chronic opioid therapy for pain (defined as daily use of medically prescribed opioids for at least 90 days) (4). Although there is wide variation in patient and disease factors that determine the best mode of pain management for each individual, there is a wide belief that interventional pain management, when compared to chronic opioid therapy, is safer and more efficient, long-term. Hence, this article focuses on access to adequate pain management but not necessarily access to prescription analgesics.
Who is at risk for chronic pain and why does this matter in Virginia? Veterans are more likely to experience chronic pain than the general population. Joint and back pain and other musculoskeletal ailments are the most common diagnoses among Iraq and Afghanistan Veterans. In a 2017 report, the National Institutes of Health (NIH) estimated that 65.6% of American Veterans reported having pain in the three months before they were surveyed, with 9.1% classified as having severe pain. Severe pain was 40% greater in Veterans than non-Veterans, especially among those who served in recent conflicts.
With that said, the demand for adequate pain management is especially high in Virginia. Of all the 116 Congressional Districts (CD) in the nation, the Commonwealth of Virginia’s CD2 and CD3 has the 2nd and 3rd highest number of veterans after Florida’s CD1. Virginia’s CD2 includes the cities of Virginia Beach, Williamsburg, parts of Norfolk and Hampton, and counties of Accomack, Northampton and York. Virginia’s CD3 includes Isle of Wight county, and the cities of Franklin, Newport News, Portsmouth, and parts of Chesapeake, Hampton, Norfolk and Suffolk.
How well is demand for adequate pain management being met in the Commonwealth? Based on Physician Profile Data from the Virginia Department of Health Professions, physician response rate to “Specific Specialty of Practice” survey is 76%. According to the survey, only 20 health facilities, excluding the major academic hospitals, self-reported as “Pain Medicine” facility (Of note, this data only represents Anesthesiologist, Physical Medicine and Rehabilitation Physicians, and Neurologists who self-reported as non-hospital based Pain Specialists to Virginia Department of Health Professions (Table 2) though response to specific specialty question was not required).
If this response rate applies to Pain Medicine, then we can estimate that there are less than 30 self-recognized Pain Management facilities in Virginia. This suggests the need for better data on the number, and distribution, of licensed Interventional Pain Specialists to better estimate the status of adequate pain service in the State. Nonetheless, the available data suggests significant deficit in supply of Pain Specialists in all Congressional Districts (CD) of the Commonwealth of Virginia; more pronounced in CDs’ 2 and 3 where both the veteran and general population (Table 1) are skewed towards their constituent cities.
Table 1: Most populated cities in VA. Source: United States Census Bureau. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2019. U.S. Census Bureau, Population Division. Web. May 2020. http://www.census.gov/.
Table 2: Non-hospital based, Government-recognized Pain Specialists in Virginia. Source: Virginia Department of Health Professions. http://www.dhp.virginia.gov/downloads/profiledata.asp
Figure 1. Number of drug overdose deaths involving opioids in Virginia, by opioid category. Drug categories presented are not mutually exclusive, and deaths may have involved more than one substance.
Source: CDC WONDER.
Future predictions are not quite encouraging either. While the Virginia Physician Supply Demand Model (VPSDM) predicts that Virginia will add physicians steadily, the rate of projected growth steadily declines. The VPSDM projects Virginia will add 3,500 patient care physicians from 2010 to 2020. From 2020 to 2030, Virginia is only projected to gain an additional 3,200 patient care physicians. Since new graduate assumptions in the model are constant, the decline in the projected growth rate is due to increases in projected retirements and mortality as the baby-boomers reach retirement age.
Virginia’s full time employed patient care physician workforce will begin to decline by 2030 if the Commonwealth continues to capture only 500 new physicians annually. If Virginia manages to capture 700 new physicians each year, the VPSDM projects that supply will begin to approach demand, suggesting that Virginia may need to capture just over 700 new physicians annually to meet projected demand.
- Boudreau D, Von Korff M, Rutter CM, Saunders K, Ray GT, Sullivan MD, Campbell CI, Merrill JO, Silverberg MJ, Banta-Green C, Weisner C. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18(12):1166.
- Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018; 67:1001–1006. DOI: http://dx.doi.org/10.15585/mmwr.mm6736a2external icon.
- Frank JW, Bohnert ASB, Sandbrink F, McGuire M, Drexler K. Implementation and Policy Recommendations from the VHA State-of-the-Art Conference on Strategies to Improve Opioid Safety [published online ahead of print, 2020 Nov 3]. J Gen Intern Med. 2020;1-5. doi:10.1007/s11606-020-06295-y
- Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press; 2011.
- Sandra H. Sacks, MD, MEd, Perry G. Fine, MD, Shane Brogan, MB, BCh, Jill E. Sindt, MD. Anesthesiologists and Palliative Care – Integrating Interventional Pain Expertise into Palliative Care Teams.
ASA Monitor. November 2020; 841127–28 DOI: https://doi.org/10.1097/01.ASM.0000722136.86024.16
- United States Department of Veteran Affairs. https://www.va.gov/vetdata/veteran_population.asp
- United States Census Bureau. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2019. U.S. Census Bureau, Population Division. Web. May 2020. http://www.census.gov/.
- Virginia Department of Health Professions. http://www.dhp.virginia.gov/downloads/profiledata.asp