Publications
APS Bulletin • Volume 15, Number 4, Fall 2005
President's Message
Pain Management: The Need for CPR
Dennis C. Turk, PhD
Editor’s note: This article is adapted with permission from Pain Management in the Decade 2010-2020: Déjà Vu Du Jour, which appeared in Pain Management Today. This article is adapted with permission from Thomson Professional Postgraduate Services.
The quest to control pain dates back to prehistoric times. Ancient skulls display man-made holes that may indicate the earliest known surgery to relieve pain. The first written account of a pain treatment appeared over 6,000 years ago in the Ebers papyrus (2005) in which the goddess Isis prescribes opium to relieve the god Ra’s headache. Acupuncture as part of traditional Chinese medicine has been used to control pain for nearly 5,000 years (The Yellow Emperor’s, 2002). More than 2,400 years ago, Hippocrates (Kinsel & Straus, 2003) recommended the use of extract of willow bark to treat pain. The analgesic effects of electric eels and torpedo fish were described in ancient medical texts where electrical discharge was believed to provide analgesic benefit (Kane & Taub, 1975). In addition, hot springs, sulfur baths, and mud baths have been advocated for their therapeutic properties dating back 6,000 years to the Summerians’ Nippur Tablet (Sumner, 2000).
The current pain management armamentarium relies heavily on the ancient one. Opioids, nonsteroidals, surgery, thermal agents, and physical modalities continue to be the mainstays of pain management. What has changed? There are new routes of administration of pharmacological agents (e.g., intrathecal, transdermal) and electrical current (e.g., spinal cord stimulators) and new classes of pharmacological agents (e.g., antidepressants, anticonvulsants). Despite the long history and advances in knowledge of neuroanatomy, neurophysiology, and neurochemistry, however, not much has changed.
Perhaps advances in pain management began in the 1960s when Bonica (1974) fostered the involvement of multiple disciplines in pain management, Melzack and Wall (1965) articulated the gate control hypothesis, and Fordyce (1976) extended the principles of operant conditioning to chronic pain. These three streams, which provided the impetus for the explosion of knowledge of the complexity of chronic pain and the role of psychosocial and behavioral factors along with physical ones in understanding and treating chronic pain patients, culminated in the creation of multidisciplinary pain centers. Rehabilitation-oriented multidisciplinary pain centers (RMPCs) began to appear in the 1970s (Loeser & Turk, 2000).
There have been a large number of studies (Turk, 2002) and meta-analyses (Flor, Fydrich, & Turk, 1992; Guzman et al., 2001; Morely, Eccleston, & Williams, 1999) supporting the clinical and cost-effectiveness of RMPCs. Paradoxically, despite the fact that there are more published studies substantiating the effectiveness of RMPCs than any other treatment for pain, these programs have difficulty surviving (Loeser & Turk, 2000). Given all the calls for “evidence-based medicine” and the buzz phrase “pay for performance,” it is surprising that third-party payers refuse to reimburse for treatment or attempt to “carve out” parts and thereby dilute treatment effectiveness (Gatchel, et al., 2001). One problem is that despite general descriptions there are no standards regarding what constitutes an RMPC. The result is that third-party payers have little basis for judging whether a facility that labels itself as such is, in fact, an RMPC.
Another contributing factor to the decline of RMPCs is the perception that these programs are expensive. Advanced single modality treatments for pain are expensive. Consideration of the cost factors involved for RMPCs and the alternatives has led some to conclude that RMPCs are substantially more cost-effective than surgery, implantable devices, and neuroaugmentation procedures (Turk, 2002). This message has not been acknowledged by third-party payers and concerns about the availability of such programs have been dwarfed by what I view as the new “opioid wars,” which have garnered so much attention. But that is a subject for a future essay.
The consequence of lack of awareness of outcome studies and erroneous perceptions by third-party payers has resulted in a return to the earliest treatments of chronic pain in which solo practitioners utilize their preferred methods. Examination of the literature on the effectiveness of these approaches leaves much to be desired. For example,
- Although clinically meaningful, the most potent medications reduce pain by only approximately 35% in fewer than 50% of patients.
- A substantial proportion of patients who undergo spinal surgery continue to report considerable pain, functional impairment, and experience complications following treatment.
- Implantable devices are expensive, and even carefully selected patients are not pain free and show only modest improvements in physical and emotional functioning.
- The long-term benefits of any treatment for chronic pain are largely unknown due to the short duration of clinical trials (Turk, 2002).
I asked Bob Gatchel to chair the APS Taskforce on Comprehensive Pain Rehabilitation, aptly known as “CPR.” This taskforce prepared a summary document outlining the published results supporting the clinical and cost-effectiveness of RMPCs. This document will be widely disseminated to third-party payers to alert them to the potential benefits of these programs. An executive summary of the document will be posted on the APS Web site when it becomes available.
What are the implications of my observations? As Niels Bohr acknowledged, “prediction is very difficult, especially about the future.” There are some areas where predictions can be made with some confidence. With advanced knowledge of neurophysiology, neuroanatomy, and neurochemistry, we will see the development of new classes of medications and more sophisticated surgical and other invasive approaches. Understanding of genetics will likely permit the customizing of treatment to individuals based on their genetic codes. There will continue to be multidisciplinary teams involved in pain management. The composition, however, will be different than from the past. Cynically stated, the new multidisciplinary teams will likely consist of one or more healthcare providers along with an accountant! Coverage for rehabilitation programs and psychosocial services will be an uphill battle despite evidence supporting their importance, clinical and cost-effectiveness.
References
Bonica, J. J. (1974). Organization and function of a pain clinic. In J. J. Bonica (Ed.) Advances in neurology (pp. 433-443). New York, NY: Raven Press.Ebers Papyrus. Retrieved August 3, 2005, from http://en.wikipedia.org/wiki/Ebers_papyrus. Accessed August 3, 2005.
Flor, H., Fydrich, T., & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.
Fordyce, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis: Mosby.
Gatchel, R. J., Noe, C. E., Gajraj, N., Vakharia, A.S., Polatin, P.B., Deschner, M., et al. (2001). Treatment carve-out practices: Their effect on managing pain at an interdisciplinary pain center. Journal of Workers’ Compensation, 10, 50-63.
Guzman, J., Esmail, R., Karjalinen, K., Malmivaara, A., Irvin, E., & Bombadier, C. (2001). Multidisciplinary rehabilitation for chronic low back pain: Systematic review. British Medical Journal, 322, 1511-1516.
Kane K., & Taub, A. (1975). A history of local electrical analgesia. Pain, 1, 125-138.
Kinsel, J. F., & Straus, S.E. (2003). Complementary and alternative therapeutics: Rigorous research is needed to support claims. Annual Review of Pharmacology and Toxicology, 43, 463-484.
Loeser, J. D., & Turk, D. C. (2000). Multidisciplinary pain management. In J. D. Loeser, S. D. Butler, C. R. Chapman, & D. C. Turk (Eds.), Bonica’s Management of Pain (3rd ed., pp. 2069-2079). Philadelphia: Lippincott Williams & Wilkins.
Melzack, R., & Wall, P D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.
Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive-behaviour therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.
Sumner, J. (2000). The natural history of medicinal plants. Portland, OR: Timber Press. The Yellow Emperor’s Classic of Internal Medicine (I. Veith, Trans.). (2002). Berkeley, CA: University of California Press. (Original work published 1949.)
Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain, 18, 355-365.