To Overcome Chronic Pain, First Use “Evidence-Based Thinking”

January 31, 2008 | Filed Under: Tips | Comments(0)

Dr. Henry Adams, Dipl. in Pain Management, AAPM, Member/Medical Staff Coalinga State Hospital

Healthcare, it is said, is going through a revolution called “Evidence-based medicine,” which is defined as follows:

Evidence-based medicine (EBM) aims to apply evidence gained from the scientific method to certain parts of medical practice. It seeks to assess the quality of evidence supporting specific treatments (or lack thereof). According to the Centre for Evidence-Based Medicine, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” EBM seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best control possible of outcomes in medical treatment, even as debate about which outcomes are desirable continue. (Wikipedia)

What this means is that, after hundreds of years of medicine being “an art” in which every physician’s personal opinion was equally valid, the complexity of technology and the complexity and cost of treating the chronic diseases currently going around the world, governments and Courts have decided, requires far stricter standardization. That standardization, experts decided, could best be achieved by basing clinical decisions on on something on which everyone can agree, namely that the quantitative bases of the scientific method allow for the establishment of reliability and validity standards that effectively reduce risk in our clinical decisions. Put simply, EBM is simply “good science,” the practical effect of which is that by doing “good science,” one significantly reduces “error” in our decisions which, in turn, decreases risk while increasing the likelihood of positive outcomes for the end-recipient of all these efforts, the patient. What that means in chronic non-cancer pain is that you the patient now have the means of increasing the likelihood of selecting clinicians with a high likelihood of increasing your functional capacity, your ability to return to work and control your pain while decreasing your dependence on costly medical services. Now, clearly, whenever we can make decisions this way, we wind up making much more risk-free decisions, which increases the likelihood of restoring functionality, return to work, decreased pain and decreased costs of – if the “evidence” doesn’t support their use – unnecessary physicians and medical services.

Therefore, what EMB does is to give patients – especially those with complex disorders like chronic non-cancer pain where the risk of error, because of the multiple mechanisms and systems involved, is exponentially greater – with a means of determining when risk is greater or less depending on key elements that clinicians “bring to the party” and weeding out as much “error” as possible in the treatment process.

Below is an example of “good science” that helped our pain patients get optimal care:

1. The management of chronic non-cancer pain is like any other sub-specialty. Sub-specialty education, training, experience, certification and a successful track record is needed to be able to provide “evidence” that can “stand up in Court.” E.g., if we have heart symptoms that seriously disrupt our ability to function, work and enjoy our usual lifestyle, the wise decision is to go to a clinician with the sub-specialty education, training, experience, certification and positive track record of returning heart patients to functionality, work and decreased dependence on cardiologists than when they started. This, clearly then, is a clinician who can take their opinion, behavior and track record to Court and be accepted by a judge as an “expert” capable of providing “expert opinion” and evidence that a gate-keeping judge would allow to be put before the jury. Patients who were able to apply this way of thinking were able to eliminate:

Non-specialty physicians lacking documentable expertise in pain management and CNCP

Non-specialty clinicians working in chronic pain programs lacking documentable expertise in pain management and CNCP

Single modality (drugs only) treatments lacking randomized controlled trials (RCTs) to support them

All treatments not supported by RCTs as being effective for 5+ pain

All non-certified clinicians lacking extensive experience with the full range of CNCP disorders.

What remains is what wise patients try to achieve locally when they screen clinicians:

A physician Board Certified in pain management or pain medicine, experienced in prescribing the full range of pain drugs, including opioids, with a minimum of 5 years experience in CNCP, and who has worked as a member of a team in a functionality restoration program

A psychologist certified in pain management, experienced in the full range of CNCP disorders and approaches, with education, training, experience and a positive track record of restoring functional capacity using operant behavioral modification of habits and lifestyle and responsible for coordinating a team of credentialed clinicians in an integrated functionality restoration program

There are numerous other steps that we will periodically post. In the meantime, this step alone got most of our CNCP patients into treatments that had a high likelihood of restoring their functional capacity, helping them get back to work, and decreasing their pain and their dependence on costly medical services.

Dr. Henry Adams