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American Pain Society
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Glenview, IL 60025
Norman Harden, MD
The following excerpt, written by Norman Harden, MD, outgoing Midwest Pain Society president, appeared in the Midwest Pain Society’s Update newsletter.
Pain management is in extreme flux. Keeping pace with the ever-changing climate clinically, scientifically, and financially has made this “decade of pain” endlessly fascinating so far.
We practice in a time when unproven experimental, invasive, and expensive procedures are often compensated without question. Many of the surgical and interventional techniques used for pain have never been subjected to evidence-based inquiry. Oddly, the FDA approves devices and procedures relatively easily, while making it practically impossible to obtain an indication for a pain medication. In this context, there has been a proliferation of extremely goofy therapies, which are expensive at best, and downright dangerous at worst.
From foramen magnum surgery for fibromyalgia to cortical electrostimulation for CRPS, we proceed without evidence. Doctors seem intent on proving they cannot and will not control costs or insist on good science before proceeding down any trendy new path. The truly baffling part of this equation is payors are apparently prepared to support any glitzy, high-tech intervention doctors can think of. Where it would clearly be in the insurance industry’s best interest to insist on evidence-based medicine, it seems equally caught-up in the headlong rush to instant gratification and technical solutions.
Paradoxically, payors remain obstinately penny-wise and pound foolish about pragmatic, effective, low-tech rehabilitation techniques that are unequivocally proven to work. They will kick and scream about relatively inexpensive interdisciplinary pain management techniques, which have been shown in multiple randomized controlled trials to work for chronic pain, yet will pay for a fourth or fifth ineffective surgery without batting an eye. The payor community seems intent on remaining completely clueless as to concepts of cost effectiveness, risk, benefit, or value.
The United States seems unready to move forward in the acceptance of “chronic disease,” and seems to be entrenched in the obsession with “cure,” “quick fix,” and technical solutions. We seem as a people and a healthcare system to be unwilling to commit to the hard work and sacrifice necessary to definitively manage pain. We are unable to assume responsibility for self-management or embrace improvement in function as often more realistic and attainable than always and immediately living pain free. “Doctor, we can send men to the moon, surely there is some pill or some surgery”
Europe, specifically countries in which healthcare is nationalized, is doing a much better job at investigating pragmatic choices that deliver measurable pain outcomes. As doctors, patients, and payors prove unable to manage cost or effectiveness, fiscal reality has forced other government bureaucracies to do so. All across Europe and in Canada, ponderous systems based on results and savings are evolving. Unfortunately, the scary reality is the United States may also be forced to nationalize if we don’t get our act together very soon. We still have an opportunity to maintain quality, choice, and free enterprise while learning pragmatic lessons from countries that have already been forced into nationalization. In my opinion, this is an important challenge we must take very seriously, and avoid the unseemly posture of the ostrich.
