There is evidence that all types of pain are inadequately managed in the United States and that this was true long before the advent of managed care.37, 39, 42 This situation is likely due to a number of social factors, including the following:
Public interest in the problem of pain is mounting. Several states have developed Pain Commissions or investigative and advisory task forces to study the issues 1, 31 and recommend legislation. Intractable pain treatment laws or regulations have emerged.2, 23 Despite efforts such as these, the plight of many chronic pain patients remains quite real. Patients are, for the most part, often poorly understood; seriously undertreated or overtreated; and sometimes seen as social outcasts by friends, family, and other support systems. Underscoring these kinds of issues is the undeniable fact that Americans have been unwilling to pay for some basic level of health care for all of its citizens. The elderly and chronically ill, who are more likely to suffer with problems of pain, are therefore likely to be among those who are disenfranchised by the system. Without a national health plan, Americans are left with an unregulated health care delivery system driven by multiple and often, conflicting interests.
Conceptually, barriers to health care in general can be classified as extrinsic and intrinsic to the health care system. Extrinsic barriers include administrative, regulatory, and socioeconomic roadblocks. Intrinsic barriers include issues of competence and availability of care. Pain Medicine, an emerging medical specialty with a well-defined body of knowledge and circumscribed scope of medical practice, has its own set of roadblock issues. This article discusses both the general roadblocks and those that in addition, are specific to Pain Medicine, and to the special population of patients that it serves.
Many physicians, beleaguered by loss of autonomy, decreasing revenue, and threats of professional liability, focus on extrinsic barriers. Patients confronted with denial of access to specific practitioners or treatment modalities by managed care organizations, understandably also focus on such extrinsic roadblocks. This perception gives rise to the increasingly loud chorus denouncing managed care and its associated administrative and regulatory tools of enforcement. It is equally important, however, to recognize that there are several intrinsic barriers to effective health care, roadblocks that are inherent to the medical profession. Among the general extrinsic barriers are; (1) inadequate financial resources (millions of Americans remain uninsured or underinsured, and the numbers grow daily); (2) professional liability threats that create tension between the overutilization associated with practicing defensive medicine and the utilization management that ratchets down access to care; (3) regulatory barriers associated with government-sponsored programs; (4) managed care techniques, and; (5) chaos within the business community as the financing of health care continues its rollercoaster ride. Intrinsic barriers include; (1) medical workforce issues, such as maldistribution of medical specialists; (2) clustering of high competency specialists and high technologic resources within a few regional and academic institutions; (3) decreasing financial resources for adequate medical training, research and maintenance of existing health care facilities; and (4) lack of quality of care at the physician-patient encounter level characterized by underuse, overuse or misuse of services.6
Roadblocks to effective pain treatment are encompassed by the extrinsic and intrinsic barriers to general medical care previously discussed. Pain Medicine is a unique specialty that experiences some additional discrete barriers to effective pain treatment. Inadequate financial resources create a major barrier. Prolonged management of complex persistent pain problems is expensive. In the event that health care insurance is nonexistent or pain treatment is not a covered benefit, patients generally have inadequate financial resources to assume personal responsibility for their care. Health care insurance, even when providing coverage, is often inadequate or depleted. Some of this relates to diagnostic and therapeutic coding problems. There are no distinct ICD-9 codes, which clearly identify persistent pain problems, particularly those that do not have a recognizable disease entity defined by histopathologic considerations.30 The CPT codes used to identify medical services and surgical procedures tend to be inappropriate for the specialty of pain medicine. Evaluation and management codes particularly do not encompass the work, as defined by time and complexity, necessary to evaluate properly a patient with complex pain problems.40 Many of the medical services and diagnostic and surgical procedures relevant to pain medicine are not adequately valued to recognize the work involved.
Many of the extrinsic barriers to effective pain management are the result of an identity problem. Although Pain Medicine is a distinct specialty and is recognized as such by the American Medical Association and many other specialty organizations, it still lacks credibility and true identity from the viewpoint of many administrative and regulatory agencies and third-party payers. Often the specialty of Pain Medicine is confused with subspecialties in pain management, representing components of other primary specialties. Even more devastating is the confusion of Pain Medicine with unorthodox modalities of treatment that are elements of the health care community. Understandably, in the face of such rank confusion, third-party payers, managed care organizations, regulatory agencies, and even other medical specialists are reluctant to acknowledge the legitimacy of pain medicine or to provide benefit coverage for pain problems. To remedy this situation, it is imperative for the specialty of Pain Medicine to achieve a clear identity as a legitimate and credible specialty.
Restrictions imposed on prescribing controlled substances, particularly opioids, represent a unique barrier to effective pain management. Oversight of controlled substances is within the purview of the Federal Drug Enforcement Agency (DEA) and state medical licensing boards. There is a widespread perception that these agencies have exercised surveillance and control over physicians with excessive and misdirected zeal. Many of the existing statutes and regulations are antiquated. Pain organizations (American Academy of Pain Medicine and American Pain Society) have done an excellent job of educating regulators at the federal and state levels and achieving more enlightened regulations and policies.2, 43
Expectations of patients suffering from persistent pain problems are often unrealistic, albeit for understandable reasons. Many patients with persistent pain problems have had prolonged, ineffective and unpleasant relationships with physicians and other health care providers. Such patients are confused, angry, conflicted, depressed, impoverished and alienated. They expect complete and immediate relief of pain and suffering at minimal expense. Not only are such expectations unrealistic, but also the effective management of complex pain disorders is at best prolonged, expensive and incomplete.
Perhaps the single greatest intrinsic barrier to effective pain management is the lack of a clear identity for the specialty of Pain Medicine. This transcends the lack of recognition and credibility by outside providers and organizations. It includes physicians who are dedicated to treating pain disorders, many of whom fail to recognize or acknowledge the difference between a subspecialty of pain management and a specialty of Pain Medicine. Even physicians who classify themselves as specialists in the field of Pain Medicine may not appreciate the body of knowledge and scope of practice of this particular field.17, 35, 36
Research in the treatment of pain disorders lags behind other fields of medicine. There is a paucity of evidence-based methodology in Pain Medicine. There is a dearth of data concerning pain management based on sound scientific studies using outcome criteria. The cost-effectiveness of much of pain management today cannot be adequately supported. In the face of such deficiencies, coverage and reimbursement for the management of pain disorders is often difficult to obtain.
Education in pain management is virtually nonexistent at the graduate and postgraduate levels. A survey of medical schools in several states indicates that few hours beyond the basic courses in pharmacology are devoted to the recognition, evaluation and management of pain disorders. Residency training programs, particularly those in primary care, frequently do not provide adequate education in the area of pain management. There is some indication that certain specialty fields do require training in pain management as part of the special requirements imposed by the American College of Graduate Medical Education.21 More education is necessary at all levels, however, including medical school, residency training, fellowship training, and continuing medical education. It is imperative that the specialty of Pain Medicine work with educators in these areas to achieve a broader, more comprehensive educational opportunity for physicians.
It is widely recognized within and outside the medical profession that physicians in general have not performed credibly in the alleviation and management of pain disorders.7, 8, 39 Patients still suffer needless pain postoperatively. Pain associated with malignant disease is not effectively managed in many instances. Persistent benign pain problems, including those falling into the diagnosis of Pain Disorder (as listed in the Diagnostic and Statistical Manual of Mental Disorders [DSM IV]), are subjects of confusion and mismanagement. The focus of Pain Medicine is pain, not so much as a symptomatic manifestation of a nociceptive stimulus but rather as a distinct multifactorial illness with biopsychosocial components.36 To appreciate the specialty of Pain Medicine, it is necessary to differentiate between category I pain, frequently referred to as acute or subacute pain, and category II pain, frequently but erroneously referred to as chronic pain. For the sake of clarity, category I pain has been designated as endynia and category II pain as maldynia. Although these concepts have been articulated and have been accepted by the leadership of organized Pain Medicine, much work needs to be done to educate the medical profession and the public. It is particularly imperative that orthodox palliative medicine recognizes the validity of maldynia as an entity consistent with the biomedical model on the basis of cellular and molecular pathology. The problems in clinical practice are those of underuse, overuse and misuse of services, and frequently misguided efforts to relieve the suffering of these patients.39 Many of these problems relate to the poor education of physicians with respect to recognition and management of a wide spectrum of pain disorders. The alleviation of this particular barrier is multifactorial. Clearly, education of the medical profession is in the forefront. Education of the public, third-party payers, managed care organizations and regulatory agencies is also necessary to remove the extrinsic barriers. Efforts must be mounted to correct the present undersupply of physicians who are adequately trained in Pain Medicine and are committed to the evaluation of care of patients with pain disorders. Quality assurance and peer review mechanisms must be established to detect and eliminate marginal practices that prey on an unsuspecting public.
Dr. Richard Stieg is board certified in Neurology, Pain Medicine, and Addiction Medicine. He is a founding member and tenth President of the American Academy of Pain Medicine. He has also served the American Pain Society in various board capacities and as co-founder of their journal, Pain Forum.
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