The Challenges of Assessing and Treating Pain

MDNG Pain Management, September 2008, Volume 1, Issue 1

Over the years, the public has fostered something of a love affair with the notion of pain. French philosopher Simone Weil noted that, "Pain is the root of knowledge."

Over the years, the public has fostered something of a love affair with the notion of pain. French philosopher Simone Weil noted that, “Pain is the root of knowledge.” In 1982, singer John Mellencamp proudly sang that it “Hurts so good.” Everywhere, professional and weekend warriors grunt the words, “No pain, no gain,” as they squeeze out one more push-up.

In reality, however, there is nothing smart, good, or macho about pain—especially chronic pain, from which an estimated 50 million Americans suff er every day. A recent report by market research firm Decision Resources, “Novel Approaches to Pain,” indicates that the overall drug market for pain will reach more than $47 billion in 2023 in the US, France, Germany, Italy, Spain, the UK, and Japan. By that same year, novel drug classes will claim more than one-fi fth of total market share.

With so many suff erers and so many treatment options, one might think that the assessment and treatment of chronic pain in the US is under control. Not so, according to Robert Gatchel, PhD, professor and chairman, Department of Psychology, College of Science, University of Texas at Arlington. He describes the healthcare industry’s handling of pain management as “dismal” and adds that “it’s almost bioethically criminal what’s going on.”

Shortage of trained professionals

In June 2008, the AMA issued its opinion on the state of pain management in the US, noting that, “In the past several years, there has been growing recognition on the part of healthcare providers, government regulators, and the public that the under-treatment of pain is a major societal problem. Pain of all types is undertreated in our society.”

Barry Cole, MD, MPA, executive director of the American Society of Pain Educators and the program director of PainWeek 2008, says the problem stems from a shortage of trained professionals. “It’s not about recognition,” says Cole. “It’s that we don’t have anybody who’s ever been trained to do pain management in the US except for a very small sub-group of people. We’re talking less than 10,000 pain professionals in the US.”

Both Cole and Gatchel place the burden of blame squarely on the shoulders of third-party payers and managed care. The 3,000 pain clinics that existed in the US at the end of the 1980s has dwindled down to approximately 300 today, and the interdisciplinary approach to pain management that proved very eff ective has all but been abandoned. “That’s because all the insurers decided that they didn’t want to have to pay for the interdisciplinary approach,” says Cole. “In some kind of Alice-in-Wonderland logic, they’d rather spend $10,000 once for a one-shot approach than look at the evidence.”

That evidence, says Gatchel, is in the form of a “plethora of high-quality studies” demonstrating both the treatment and longterm cost eff ectiveness of interdisciplinary pain management for chronic pain conditions. Th e data from these studies has been replicated in diff erent countries, demonstrating the effi cacy of the interdisciplinary treatment modality. “And what do third-party payors do?” Gatchel asks rhetorically. “Th ey deny those services.”

Divergent approaches

Cole believes that the majority of pain professionals today are interventional in their treatment orientation. That might amount to just three epidural steroids, and done. Or a spinal cord stimulator trial, and done. And insurers, says Cole, are willing to pay thousands of dollars for these “one-shot approaches,” even though, from a workers’ compensation perspective, return to work is in no way assured.

Gatchel explains that with an interdisciplinary approach, a physician—nurse team, a physical therapist, a psychologist–psychiatrist, and an occupational therapist are all working together as a team, taking a coordinated approach for pain assessment and treatment. The treatment, he says, is tailored to the assessment. “

Chronic illnesses are a bio-psycho-social phenomenon,” says Gatchel, explaining that pain management involves more than just easing physical discomfort. “A person who is struggling with a chronic illness may feel helpless, become depressed, and try to selfmedicate. That’s the psychological aspect. These folks cannot socially connect, and they may have difficulty finding a job. You empathize with them for the pain. But more importantly, you evaluate how it’s aff ecting their functioning.”

Bruce Levin, MD, a Pennsylvania-based, board-certified anesthesiologist with a subspecialty in interventional pain, agrees that people often have emotional, psychological, personal, economic, and even legal forces in motion. Those forces will often dictate how the person feels or how they project the way they feel. Those forces also play a role in interventional outcomes.

“If someone has signifi cant depression and anxiety, they will more often than not show failure to therapy,” says Levin. He points to studies indicating that patients who had an abusive parent, an alcoholic parent, a physically violent parent, a sexually abusive parent, or a parent who abandons have a far lower success rate from back surgery than patients who do not come from such backgrounds. “You have to balance a patient’s general nature and history before you can assess.”

Today’s medical system, says Ira Fox, MD, DABPM, FIPP, founder of Anesthesia Pain Care Consultants, is lacking in terms of insight into this issue. Fox, whose practice off ers both interventional and interdisciplinary services, says that an insurance carrier will readily pay as much as $100,000 for someone to have a spine operation. In the same breath, though, they may tell the patient that going through an interdisciplinary pain program, which may be more of what they need in order to deal with various psychological and emotional issues, is a non-covered service. “And the data out there doesn’t even support the evidencebased medicine aspect of whether these surgeries work.”

Echoes Gatchel, “A person with hypertension is prescribed medication, but they are also allowed to see a dietician and enroll in an exercise program. They get more respect because hypertension can kill you. It’s the same with asthma. But pain? No one ever died from pain.”

The measurement challenge

Levin says that pain assessment today is lacking in sophistication and accuracy. The challenge is that pain is subjective. What one patient might categorize as severe pain might not be severe to another patient. “Pain is not something that is easily diagnosable or documented by MRIs or imaging studies. We have to look at pain in a more subjective way and trace each patient longitudinally along the course of various treatments.”

QualityMetric, developers of a wide range of patient-reported outcome surveys, has developed a tool with that approach in mind. The Pain Impact Questionnaire (PIQ-6) —an off spring of the company’s SF-36, which has been used to measure health in 136 countries around the world—is a simple, six-question survey that measures the impact of chronic pain on work and leisure activities, as well as on emotional well-being.

Jim Dewey, company co-founder and chief innovation and research offi cer, explains that the survey developers realized early on that it’s not the health condition of an individual that’s important. Rather, it’s the impact of that health condition on their life. As such, the survey asks questions about things an individual does every day—for example, “During the past four weeks, how much did pain interfere with your normal work?”—and offers a six-point range, from “none” to “severely.”

“One of the most powerful things about the survey is the information that it provides,” Dewey explains. “The survey results show scores against the U.S. average. We’re not just looking at how one person is impacted by pain, but in the context of what other people are experiencing. This way, an individual or a health professional can track the results.”

Eva Stuart, a registered nurse with the Scripps Center for Integrative Medicine in La Jolla, CA, has been using the PIQ-6 along with the SF-36 for the past two years. The questionnaires, she says, have been extremely helpful in the center’s goal to treat the entire patient.

“One of the great things about the SF-36 is that it has a mental as well as a physical summary, and our whole philosophy is integration of mind, body, and spirit,” says Stuart. “The PIQ-6 is very specific, and it has been very useful in getting a quick measurement of an individual’s pain. If what you’re looking for is just pain management, you can use it without the SF-36.”

Dewey says that the PIQ-6 is currently being used by hospitals, disease management companies, and pharmaceutical and biotech fi rms to monitor the eff ectiveness of a treatment or intervention. “If you can’t measure something, how do you know that you did anything, treatment-wise, that was eff ective?” asks Dewey, rhetorically.

The fraud factor

Despite the difficulty in measuring and treating pain, both Medicare and private health plans are looking into assessing the medical necessity of pain management. The main goal, particularly from the Medicare perspective, is to reduce fraud associated with injections of steroids, nutrients, and other non-essential uses. But the problem with that approach, says Gatchel, is that it hinders treatment for people who are truly in need.

“Medicare fee schedules these days are not very high,” says Gatchel. “When health plans won’t cover interdisciplinary care, they say, ‘Well, that’s all the government is allowing.’ But that doesn’t mean you have to benchmark to the government. They’re not decreasing premiums, are they? Until there is some congressional pressure put on them, it’s just unadulterated fl eecing of the public.”

Levin says one aspect of fraud is overutilization. But, he points out, rather than criminalizing doctors, it’s more important to examine what constitutes eff ective treatment. For example, three epidurals a year is considered standard treatment, but what if a patient falls out of that norm? “What if a patient can’t function without the epidural, and the risks of surgery are too great because they’re morbidly obese?” Levin asks. “What is considered reasonable, and what is considered excessive?”

Dewey suggests that if Medicare and health plans are truly interested in cracking down on pain management fraud, they might want to consider using the PIQ-6, which in its computer-adaptive format, calculates a Z score, or the probability score that the individual taking the survey is telling the truth. “In cases like workers’ comp, if you have someone sit down at a computer, they see one question at a time, and based on their answers, the next best question is pulled up,” Dewey explains. “The score is not something someone wrote into a medical record. It’s a test result, and it can be compared to norms.”

Ongoing challenges

Cole says the greatest challenge in pain management today is the lack of access for the majority of people in pain, coupled with a lack of education for the providers who see patients in pain. He explains that the lowest common denominator of pain management is either a family practitioner or internist hoping to treat a complicated, complex patient in seven minutes or less.

“What are you going to do in seven minutes to resolve a 5- or 10-year problem that has now resulted in unemployment, depression, substance use, and all that goes with the chronicity of pain?” asks Cole. “We’ve dumbed down the delivery of pain management services to the lowest common denominator, and we have left primary care quite literally holding the bag.”

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at