Leading Figure Describes Current State of Pain Management

December 16, 2009 | Filed Under: General Information | Comments(0)

John Loeser, M.D., and J.J. Bonica, M.D., are two of the leading figures of chronic non-cancer pain (CNCP) management in the US. Dr. Loeser has been writing, treating, teaching and researching chronic non-cancer pain for the half a century that the field has been trying to make chronic non-cancer pain management better grounded in its own science and, thereby, make it more relevant, accessible, effective, safer and less expensive for patients. The citation is as follows: Loeser, John (2007). “Foreward” in Schatman, Michael E. and Alexandra Campbell, Eds. Chronic pain management: guidelines for multidisciplinary program development. NY/London: Informa Healthcare, p. iii-iv (Pain Management Series, 3)

The idea that chronic pain is a medical problem was born with the pioneering work of John J. Bonica, M.D., at the end of World War II. Chronic pain entered the world of academic medicine when Dr. Bonica was appointed the founding Chairman of Anesthesiology at the University of Washington in 1960. The term, multidisciplinary pain clinic (MPC), was invented by Dr. Bonica, originally to describe an approach to the diagnosis and treatment of chronic pain patients by a group of physicians who interacted with each other as well as with the patients. In the 1960’s, also at the University of Washington, Wilbert Fordyce, a psychologist in the Department of Rehabilitation Medicine, recognized that a behavioral approach to the treatment of chronic pain patients could be more successful than injections, pills or surgery. He started a behavioral pain management service in Rehabilitation Medicine and brought his principles of pain management into the multidisciplinary pain clinic. Other psychologist broadened the Fordyce approach to include cognitive-behavioral strategies and increased its effectiveness. In 1983, Dr. Fordyce and I started a 20-bed inpatient and outpatient multidisciplinary pain clinic that was independent of any single academic department. This served as the prototype for multidisciplinary pain clinics throughout the world, in part because of our active teaching programs and openness to visitors. Physicians of many specialties, psychologists, nurses, physical and occupational therapists and vocational counselors were all integral members of our team.

Many other health care providers also played important roles in the development multidisciplinary pain management; the Commission on Accreditation of Rehabilitation Facilities (CARF) adopted our model as the accreditation standard for multidisciplinary pain clinics. Multidisciplinary pain clinics were developed throughout the world, often with varying content and emphasis to fit the needs of the patients they treated and the providers they had available. In countries with rational health care systems, this form of patient diagnosis and treatment seems to have prospered, as it has been recognized as more effective, less hazardous, and less costly than traditional approaches to treating chronic pain patients. Based squarely upon a biopsychosocial model rather than the prevalent biomedical model, multidisciplinary pain management has been seen as a threat to biomedicine and the industry’s imperative to consume expensive health resources.

In the United States, with a non-system of health care and the dramatic introduction of economic factors into health care decisions, MPCs have not fared as well and the number of programs has decreased steeply in the past ten years. There are many factors that have contributed to the relative demise of MPCs.

First, a labeling issue: Any group of two or more health care providers can call themselves a multidisciplinary pain clinic and is capable of deceiving the public as to what they offer insofar as diagnostic and treatment options. This is a common occurrence and has brought considerable disrepute to bona fide MPCs.

Second, decisions about what forms of health care are to be offered are not made uniquely by doctors and their patients. Instead, insurance companies and large hospitals and academic medical centers ignore both the moral imperatives to treat chronic pain and the available outcomes data on treatment efficacy and often will not fund MPCs. For large, American hospitals, especially those associated with a medical school, revenue generation is the major determinant of what services the institution will offer. MPC is not seen as a value compared to cosmetic surgery.

Third, payment to providers is skewed in favor of procedures and surgeries, putting great economic pressures on those who provide a personal service without a procedural intervention.

Fourth, proceduralists have done a much better job lobbying funding agencies and the public as to the utility of their interventions than have those who run MPCs.

Fifthly, there is no single optimal plan for how to run an MPC and what its content, duration of treatment and team members should be. This has made it difficult for funding agencies to evaluate programs and compare costs and efficacy.

Finally, organized medicine has never accepted the validity of multidisciplinary pain management and there are many impediments to its implementation in the medical community.

This book is designed to combat many of the problems that confront multidisciplinary pain management in the United States today. A stellar group of contributors has addressed the problems of building and maintaining a multidisciplinary pain clinic. The emphasis is upon outcomes, not personal anecdotes. Multidisciplinary pain care is the best treatment we now have for the rehabilitation and relief of suffering of chronic pain patients. Chronic pain patients always have psychosocial factors that influence their disability and suffering; pills and surgery do not address these at all. This volume will be an important tool in the restoration and continued development of multidisciplinary pain management in the United States and the remainder of the developed world.

John D. Loeser, M.D.

Professor of Neurology and Anesthesiology

University of Washington Medical School

Seattle, Washington, U.S.A.