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Pain management must not become “complimentary” medicine
CRITICAL COMMENTARIES Pain Management Must Not Become “Complimentary” Medicine Daniel B. Carr
J
ost’s article should be required reading for all clinicians caring for patients with pain and all researchers who hope their discoveries one day find clinical application. How is it possible that a scholarly article in the current Journal of Pain makes no mention of nociceptive mechanisms, neurobiology, analgesic pharmacology, or clinical pain assessment or treatment, yet still is a “must read” for all American Pain Society (APS) members? The reason is that this piece clearly and eloquently details how the massive public health programs of Medicare and Medicaid are profoundly dysfunctional in their funding of pain management. At the same time, private insurers also are globally trimming payment for medical services in general, requiring greater efficiency from all practitioners and allowing less attention and fewer resources to be devoted to each patient. Nonphysician health care providers who play a crucial role in optimal pain management for patients in and out of the hospital (eg, psychologists, nurses, pharmacists, and social workers) now are struggling to deliver even a minimum level of services in the face of widespread cutbacks and mergers. Had Ginsburg’s poem “Howl” not already been written, it might well have been penned by one of my many distraught colleagues in academic pain management centers, in which pervasive uncertainty and fiscal strains have produced endemic agitated depression. Ironically, the praiseworthy biomedical enterprise of pain control is being eroded just as proper pain management is becoming expected by patients and accreditors. In an earlier, embryonic version of this review published as part of a valuable symposium on legal and regulatory issues in pain management convened by the Mayday Fund, Jost described Medicare and Medicaid as providing “leaky
From the Departments of Anesthesia and Medicine, Tufts University School of Medicine, New England Medical Center, Boston, MA. Address reprint requests to Daniel B. Carr, MD, DABPM, The Departments of Anesthesia and Medicine, Tufts University School of Medicine, New England Medical Center, 750 Washington Street, Boston, MA 02111. © 2000 by the American Pain Society 1526-5900/00/0103-0003$8.00/0 doi:10.1054/jpai.2000.8917
umbrellas and ragged safety nets.”1 For years these programs have fallen short of ensuring effective pain control for their participants, and also mostly have failed to control needless costs incurred by ineffective or misguided therapies. The consequences of this ad hoc and disjointed approach are devastating both for the public and for health care providers involved in pain control. In very real ways, the inappropriate policies that Jost dissects are forcing pain management toward “complimentary” status (ie, given for free). Although preclinical evidence and clinical trials agree upon the merit of early, aggressive pain control (preemptively when possible), both public and private funding policies for funding pain delay, defer, or deny resources to the patient with established pain or at risk to develop pain. Researchers are not immune to the implications of financial constraints on pain-related clinical care. Underpayment for clinical pain therapies has a chilling effect on funding for basic neuroscience and pharmacology to develop innovative approaches for analgesia that might incur short-term costs but prove cost-effective in the long run. Those components of clinical and preclinical research that require a stable medical infrastructure (and enough excess revenue to initiate exploratory studies, sustain unfunded research, and allocate nonclinical time toward academic activities) are jeopardized, if not faltering. Established therapies of proven value, such as multidisciplinary chronic pain treatment programs, now must struggle to reach breakeven levels of reimbursement even for those patients whose insurers do not flatly deny enrollment. Behavioral therapies for routine postoperative pain, proven effective in numerous high-quality trials,2 are offered to few hospitalized surgical patients.3 In large part, institutional inability to offer such valuable nonpharmacological therapies reflects declining global reimbursement for postoperative pain control.4 The vision of current pain management as “the best of times, the worst of times”5 is eloquently expressed in many articles within the APS Bulletin, the APS’s regional pain association
The Journal of Pain, Vol 1, No. 3 (Fall), 2000: pp 195-196
195
196
Pain Management
newsletters, 5 the IASP monograph Pain Treatment Centers at a Crossroads,6 and the forthcoming APS monograph Pain Management in Managed Care.7 On one hand, we appear poised to enter a golden age of pain control, in which advances in neurobiology and related sciences permit us to approach pain as a disease in its own right, with well-defined mechanisms that provide opportunities for targeted, effective therapies. Increasing numbers of these therapies are now evaluated rigorously in well-designed analgesic clinical trials, the results of which are synthesized in meta-analyses and disseminated to patients, families, and health care providers throughout the world via the Internet.8 On the other hand, erosion of financial support for routine clinical pain control has led to a crossroads in which “despite the growing awareness of the need for improved pain management, patients face increasing barriers limiting access to pain treatment.”9 Because poorly controlled pain leads to suffering and impairment, inadequate pain therapy incurs substantial indirect, human costs for patients and their families as well as direct economic costs.10 (Let us not forget, too, that at present 1 in 7 Americans lacks any health insurance.) The Medicare and Medicaid financing shortfalls for pain control are all the more striking given
the recent evolution of medical care towards a patient-centered view in which quality of life is paramount. One senses that underpinning the concern for pain control in contemporary health care (beyond the intrinsic humaneness and physiological benefits of optimal pain control) is that asking about and responding to patients’ pain offers impersonal health care systems a means to show concern for patients’ subjective internal experience.11,12 Patients and their families, in turn, are eager to affirm the importance of their personal experience during health care by drawing providers’ attention to their unrelieved discomfort,13 particularly when the health care system is not yet as well attuned to addressing other dimensions of distress.14 Because pain control is so crucial to quality of life, those in APS, particularly members and officers in the vanguard of policy and governmental issues, should take Jost’s article as a manifesto. By doing so at a time of historic United States budget surpluses, the APS can address our nation’s broad goal of improving quality of life for its citizens, and ally itself with patients and their families. As an advocate for patients with pain, the APS must insist that legislators reform or discard Medicare and Medicaid payment policies. These rules now detract from social, medical, and moral support for the very persons they were intended to sustain.
References
8. Carr DB, Wiffen P, Fairman F, LeMaitre M: The Cochrane Collaboration and its Pain, Palliative and Supportive Care review group, in Max M (ed): Pain 1999—An Updated Review (Refresher Course Syllabus). Seattle, WA, IASP, 1999, pp 399-410
1. Jost TS: Public financing of pain management: Leaky umbrellas and ragged safety nets. J Law Med Ethics 26: 290-307, 1998 2. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R: Psychological influences on surgical recovery: Perspectives from psychoneuroimmunology. Am Psychol 53:1209-1218, 1998 3. Warfield CA, Kahn CH: Acute pain management: Programs in U.S. hospitals and experience and attitudes among U.S. adults. Anesthesiology 83:1090-1094, 1995 4. Carr DB, Miaskowski C, Dedrick SC, Williams GR: Management of perioperative pain in hospitalized patients: A national survey. J Clin Anesth 10:77-85, 1998 5. Stevens DS: Pain management practice: “It was the best of times, it was the worst of times.” N Engl Pain Assoc Newslett 5:14-15, 1999 6. Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996 7. Lande S, Kulich RJ: Pain Management in Managed Care. Glenview, IL, American Pain Society, 2000
9. Burchiel KJ: Social costs of denying access to care, in Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996, pp 215-228 10. Ferrell BR: How patients and families pay the price of pain, in Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996, pp 215-228 11. Chapman CR, Nakamura Y: Pain and consciousness: A constructivist approach. Pain Forum 8:113-123, 1999 12. Morris DB: Illness and Culture in the Postmodern Age. Berkeley, CA, University of California, 1998 13. Gerteis M, Edgman-Levitan S, Daley J, Delbanco T (eds): Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, CA, Jossey-Bass, 1993 14. Field MJ, Cassel CK (eds): Approaching Death: Improving Care at the End of Life. Washington, DC, National Academy, 1997
J
ost’s article should be required reading for all clinicians caring for patients with pain and all researchers who hope their discoveries one day find clinical application. How is it possible that a scholarly article in the current Journal of Pain makes no mention of nociceptive mechanisms, neurobiology, analgesic pharmacology, or clinical pain assessment or treatment, yet still is a “must read” for all American Pain Society (APS) members? The reason is that this piece clearly and eloquently details how the massive public health programs of Medicare and Medicaid are profoundly dysfunctional in their funding of pain management. At the same time, private insurers also are globally trimming payment for medical services in general, requiring greater efficiency from all practitioners and allowing less attention and fewer resources to be devoted to each patient. Nonphysician health care providers who play a crucial role in optimal pain management for patients in and out of the hospital (eg, psychologists, nurses, pharmacists, and social workers) now are struggling to deliver even a minimum level of services in the face of widespread cutbacks and mergers. Had Ginsburg’s poem “Howl” not already been written, it might well have been penned by one of my many distraught colleagues in academic pain management centers, in which pervasive uncertainty and fiscal strains have produced endemic agitated depression. Ironically, the praiseworthy biomedical enterprise of pain control is being eroded just as proper pain management is becoming expected by patients and accreditors. In an earlier, embryonic version of this review published as part of a valuable symposium on legal and regulatory issues in pain management convened by the Mayday Fund, Jost described Medicare and Medicaid as providing “leaky
From the Departments of Anesthesia and Medicine, Tufts University School of Medicine, New England Medical Center, Boston, MA. Address reprint requests to Daniel B. Carr, MD, DABPM, The Departments of Anesthesia and Medicine, Tufts University School of Medicine, New England Medical Center, 750 Washington Street, Boston, MA 02111. © 2000 by the American Pain Society 1526-5900/00/0103-0003$8.00/0 doi:10.1054/jpai.2000.8917
umbrellas and ragged safety nets.”1 For years these programs have fallen short of ensuring effective pain control for their participants, and also mostly have failed to control needless costs incurred by ineffective or misguided therapies. The consequences of this ad hoc and disjointed approach are devastating both for the public and for health care providers involved in pain control. In very real ways, the inappropriate policies that Jost dissects are forcing pain management toward “complimentary” status (ie, given for free). Although preclinical evidence and clinical trials agree upon the merit of early, aggressive pain control (preemptively when possible), both public and private funding policies for funding pain delay, defer, or deny resources to the patient with established pain or at risk to develop pain. Researchers are not immune to the implications of financial constraints on pain-related clinical care. Underpayment for clinical pain therapies has a chilling effect on funding for basic neuroscience and pharmacology to develop innovative approaches for analgesia that might incur short-term costs but prove cost-effective in the long run. Those components of clinical and preclinical research that require a stable medical infrastructure (and enough excess revenue to initiate exploratory studies, sustain unfunded research, and allocate nonclinical time toward academic activities) are jeopardized, if not faltering. Established therapies of proven value, such as multidisciplinary chronic pain treatment programs, now must struggle to reach breakeven levels of reimbursement even for those patients whose insurers do not flatly deny enrollment. Behavioral therapies for routine postoperative pain, proven effective in numerous high-quality trials,2 are offered to few hospitalized surgical patients.3 In large part, institutional inability to offer such valuable nonpharmacological therapies reflects declining global reimbursement for postoperative pain control.4 The vision of current pain management as “the best of times, the worst of times”5 is eloquently expressed in many articles within the APS Bulletin, the APS’s regional pain association
The Journal of Pain, Vol 1, No. 3 (Fall), 2000: pp 195-196
195
196
Pain Management
newsletters, 5 the IASP monograph Pain Treatment Centers at a Crossroads,6 and the forthcoming APS monograph Pain Management in Managed Care.7 On one hand, we appear poised to enter a golden age of pain control, in which advances in neurobiology and related sciences permit us to approach pain as a disease in its own right, with well-defined mechanisms that provide opportunities for targeted, effective therapies. Increasing numbers of these therapies are now evaluated rigorously in well-designed analgesic clinical trials, the results of which are synthesized in meta-analyses and disseminated to patients, families, and health care providers throughout the world via the Internet.8 On the other hand, erosion of financial support for routine clinical pain control has led to a crossroads in which “despite the growing awareness of the need for improved pain management, patients face increasing barriers limiting access to pain treatment.”9 Because poorly controlled pain leads to suffering and impairment, inadequate pain therapy incurs substantial indirect, human costs for patients and their families as well as direct economic costs.10 (Let us not forget, too, that at present 1 in 7 Americans lacks any health insurance.) The Medicare and Medicaid financing shortfalls for pain control are all the more striking given
the recent evolution of medical care towards a patient-centered view in which quality of life is paramount. One senses that underpinning the concern for pain control in contemporary health care (beyond the intrinsic humaneness and physiological benefits of optimal pain control) is that asking about and responding to patients’ pain offers impersonal health care systems a means to show concern for patients’ subjective internal experience.11,12 Patients and their families, in turn, are eager to affirm the importance of their personal experience during health care by drawing providers’ attention to their unrelieved discomfort,13 particularly when the health care system is not yet as well attuned to addressing other dimensions of distress.14 Because pain control is so crucial to quality of life, those in APS, particularly members and officers in the vanguard of policy and governmental issues, should take Jost’s article as a manifesto. By doing so at a time of historic United States budget surpluses, the APS can address our nation’s broad goal of improving quality of life for its citizens, and ally itself with patients and their families. As an advocate for patients with pain, the APS must insist that legislators reform or discard Medicare and Medicaid payment policies. These rules now detract from social, medical, and moral support for the very persons they were intended to sustain.
References
8. Carr DB, Wiffen P, Fairman F, LeMaitre M: The Cochrane Collaboration and its Pain, Palliative and Supportive Care review group, in Max M (ed): Pain 1999—An Updated Review (Refresher Course Syllabus). Seattle, WA, IASP, 1999, pp 399-410
1. Jost TS: Public financing of pain management: Leaky umbrellas and ragged safety nets. J Law Med Ethics 26: 290-307, 1998 2. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R: Psychological influences on surgical recovery: Perspectives from psychoneuroimmunology. Am Psychol 53:1209-1218, 1998 3. Warfield CA, Kahn CH: Acute pain management: Programs in U.S. hospitals and experience and attitudes among U.S. adults. Anesthesiology 83:1090-1094, 1995 4. Carr DB, Miaskowski C, Dedrick SC, Williams GR: Management of perioperative pain in hospitalized patients: A national survey. J Clin Anesth 10:77-85, 1998 5. Stevens DS: Pain management practice: “It was the best of times, it was the worst of times.” N Engl Pain Assoc Newslett 5:14-15, 1999 6. Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996 7. Lande S, Kulich RJ: Pain Management in Managed Care. Glenview, IL, American Pain Society, 2000
9. Burchiel KJ: Social costs of denying access to care, in Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996, pp 215-228 10. Ferrell BR: How patients and families pay the price of pain, in Cohen MJM, Campbell JN (eds): Pain Treatment Centers at a Crossroads. Seattle, WA, IASP, 1996, pp 215-228 11. Chapman CR, Nakamura Y: Pain and consciousness: A constructivist approach. Pain Forum 8:113-123, 1999 12. Morris DB: Illness and Culture in the Postmodern Age. Berkeley, CA, University of California, 1998 13. Gerteis M, Edgman-Levitan S, Daley J, Delbanco T (eds): Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, CA, Jossey-Bass, 1993 14. Field MJ, Cassel CK (eds): Approaching Death: Improving Care at the End of Life. Washington, DC, National Academy, 1997