Friday, September 23, 2011

What’s Gone Wrong with Pain Management?

Pain-Pourri A thought-provoking essay by a long-term pain practitioner presents a controversial indictment of current pain management perspectives and approaches. Of special concern are procedural techniques, or interventions, that may be driven more by economics than better patient care and, in the ongoing turf wars between interventionists and medical practitioners, patients with pain are in danger of becoming collateral damage.

Writing online ahead of print publication in the journal Pain Practice, Gerald M. Aronoff, MD, DABPM, suggests pain management today seems all about the money. He wants practitioners to assess whether they are contributing to the problems of excessive and escalating healthcare costs and declining care for patients with pain [Aronoff 2011].

Aronoff, who has 32 years as a pain practitioner — caring for more than 13,000 patients with chronic pain to date and currently practicing at Carolina Pain Associates in Charlotte, North Carolina — is concerned that many pain management practices are influenced by profit margins. Patients receiving repeated diagnostic tests and unproven treatments that may include unnecessary surgeries, injections, or procedures often do not benefit in terms of pain or function. And, the result of such practices has been escalating healthcare costs and declines in patient overall health. He writes, “I have witnessed the transition from the physician being viewed as a patient advocate to the more recent view that patients frequently need advocates to protect themselves against physicians.”

It is common practice for the initial workup of patients with chronic pain to begin in a primary care physician’s (PCP) office, Aronoff observes, but many PCPs who treat chronic pain feel ill-equipped to do so. In many cases, patients are referred to pain specialists for evaluation and treatment. However, he continues, unless the patient is appropriate for an interventional procedure and agrees to have it done, the patient is often referred right back to the PCP — who is told that the “pain physician” does not provide pharmacological or other non-interventional pain management.

Having not gotten the care for their patients that they felt was needed, many PCPs stop referring to pain specialists. Moreover, Aronoff observes…

“It is astounding that a large percentage of the people I see in evaluation referred for pain management give a history, indicating that the majority of care they received from prior pain practices came from mid-level providers and they frequently were not seen and or evaluated by the pain physician to whom they were referred; some of those patients were only seen by the physician in the context of doing a procedure.”

In that regard, Aronoff describes a practice he finds especially troubling…

“I have gone to some chronic pain practices at which one or more physicians’ names appeared on the office door; however, the practice was run by mid-level providers [eg, PA, NP] without an on-site pain physician and with most of the treatment decisions apparently not discussed with a pain physician. I found this to be very distressing. Many of the patients evaluated required complex decision-making by experienced pain physicians. Should we be surprised that so many pain patients develop prolonged chronic pain syndromes with delayed recovery and often iatrogenic complications including iatrogenic disability? I think not.”

He acknowledges that having treatment rendered by lower-paid professionals is cost-effective from a practice management perspective, but this is often not optimal for patient care. Still, Aronoff does recognize that in many communities pain physicians may not be accessible and patients are fortunate to have experienced nurse practitioners or physician assistants with advanced training in pain management caring for them, and many of these healthcare providers do render good treatment.

Aronoff further comments on another troublesome trend…

“I find that access to interdisciplinary and coordinated multidisciplinary [pain] care has dwindled and is generally now inaccessible for most patients in the United States who could benefit from it.  . . . .  Treatment programs that are geared toward functional restoration emphasizing not only pain treatment but also physical and emotional rehabilitation, and prevention of disability are nonexistent in most communities.  . . . .  This interdisciplinary treatment generally involves various combinations of physicians, physician assistants, psychologists, pharmacists, nurses, nurse practitioners, physical therapists, occupational therapists, dentists, pharmacists, and other healthcare professionals.”

One reason the availability of interdisciplinary pain management has decreased, of course, is because of healthcare costs. However, Aronoff also argues that we live in a “procedure-driven healthcare system in which physician reimbursement is related to doing things to patients.” These “things” range from procedures such as trigger point and facet injections to nerve blocks, implanted spinal cord stimulators, intrathecal pumps, surgical procedures, and others. He warns of the inherent dangers in this…

“While some of these procedures may be appropriate for some patients at certain times, my review of what is occurring (and has occurred for many years) in the field of pain medicine suggests that some practitioners excessively use interventions that often appear to be unfortunately financially motivated and less driven by patient needs. Why have these actions become more prevalent? Is this based on an ethical breakdown motivated by financial gain?”

Rather, Aronoff proposes that in treating chronic pain syndromes “the least invasive treatment capable of bringing about the desired effect is not only the treatment of choice for the patient but also the most cost-effective for society.” Along with that, noninvasive treatments should always be preferred over invasive interventions or procedures; however, since there is inadequate reimbursement for rehabilitation and non-interventional treatments, many patients do not have access to more conservative quality pain care. Consequently, “some patients receive excessive interventional treatment and at times this results in iatrogenic disability,” he writes.

Clearly, in Aronoff’s critique, economics is often the prime force driving patient care for pain. In some cases, patients are referred for non-interventional pain care only after all procedures covered by insurance have been exhausted; in other cases, patients may receive only pharmacologic care — sometimes excessive polypharmacy — because more integrated rehabilitative approaches are uncompensated by insurance. He says, “all chronic pain patients deserve a careful assessment to determine their needs. All patients should receive a plan of care that matches their individual needs, is cost-effective and safe based on evidence-based studies rather than a physician’s profit margin.”

Aronoff concedes that healthcare providers are poorly reimbursed for preventive approaches to health and the inordinate amount of time that patients with chronic pain may require. What does such care entail?

“Other than traditional monitoring of pain, or response to medication or procedures, it should involve discussion about Wellness principles, the need for many patients to make major life style changes, learn improved coping skills, and replace conditioned dysfunctional and maladaptive pain behaviors (and other illness- and disability-seeking behaviors) with more adaptive coping strategies. For many patients, these may be far more efficacious than medication or interventional treatments for treating chronic pain or preventing disability.”

He observes that many patients develop false beliefs about their pain, their need for high doses of medications, their incapacity to move forward with their lives, and their need for work limitations and restrictions. Consequently, they may be channeled into a disability lifestyle, which is inadvertently reinforced by pain-care providers who rely excessively on polypharmacy and/or interventional procedures. Aronoff concludes his essay by saying…

“I believe it is appropriate to eliminate the wasted expense in the healthcare system by de-emphasizing high technology diagnostic or treatment modalities for patients not needing them, for tightening the guidelines for repeat invasive techniques for patients who did not respond to the initial ones, and to have better use of invasive techniques generally adhering to established evidence-based guidelines. We need to return to increased emphasis on use of common sense and good clinical judgment combined with our diagnostic acumen, and in so doing, we will be part of the solution rather than part of the problem and also render improved health care.”

COMMENTARY: Aronoff, who was educated at the New Jersey College of Medicine and at Harvard (psychiatric residency), is a past president of the American Academy of Pain Medicine and has served in leadership positions at many other medical societies and associations during his long career. An interesting aspect of his essay is that the journal in which it appears, Pain Practice, is from the World Institute of Pain [website here], an organization dedicated to supporting the advancement of interventional pain management practices. Hence, he is addressing a readership audience of interventional specialists, while also appearing to criticize an inappropriate over-emphasis on “procedures” performed in their pain practices.

This is reminiscent of the “turf war” of sorts raging for some time between interventionists and medical pain specialists over whose approaches should be first-line treatments for chronic pain conditions. Most healthcare providers and patients are unaware of this battle; although, patients are sometimes torn between the two groups of specialists and end up as collateral damage (which Aronoff’s essay seems to suggest).

This battle was highlighted just last month, August 2011, in an article titled “Guideline Warfare Over Interventional Therapies for Low Back Pain” [Chou et al. 2011]. It appeared in the Journal of Pain, from the American Pain Society (APS), and was authored by Roger Chou and colleagues who had developed the guidelines on interventional therapies in 2009 under APS auspices.

Apparently, leaders of the American Society of Interventional Pain Physicians (ASIPP) were highly critical that the APS guidelines found insufficient evidence to recommend interventional procedures for low back pain. Essentially, they accused the APS panel of improper methodology and unfair bias in the guideline-development process. In rebuttal, Chou et al. claimed that ASIPP’s critiques contained numerous errors and failed to adhere to scientific standards for assessing evidence. And, so, the battle rages on.

Also of interest, through the years, members of ASIPP [website here] have been active in writing articles that are sometimes critical of pharmacologic therapies for chronic pain, primarily opioids, and mainly published in their own bimonthly journal, Pain Physician. The organization also strongly influenced congressional approval of the National All Schedules Prescription Electronic Reporting (NASPER) Act, which authorized a shared reporting system for prescription medications to help control the misuse, diversion, and trafficking of those drugs — essentially, what became Prescription Drug Monitoring Programs. It is curious that an organization whose members largely favor and focus on nonpharmacologic interventions would devote so much time and effort toward initiating monitoring programs that might affect the prescribing of pain medications.

These are just some examples of the jockeying for position occurring in the pain management arena, with their impacts on healthcare costs and patient care. And, of course, it also should be considered that the essay above by Aronoff might have been biased somewhat by his training in psychiatry and specialization in traditional pain medicine practices spanning several decades.

> Aronoff GM. The Evolution of Pain Treatment: Is it all about Money? Pain Practice. 2011(Sep 16), published online ahead of print [
abstract here].
> R Chou, Atlas SJ, Loeser JD, et al. Guideline Warfare Over Interventional Therapies for Low Back Pain: Can We Raise the Level of Discourse? J Pain. 2011;12(8):833-839 [
abstract here].