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10 Articles in Volume 10, Issue #1
An Overview of CRPS
Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care
Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
Dextrose Prolotherapy Injections for Chronic Ankle Pain
Genetic Influences on Pain Perception and Treatment
Headache in Children and Adolescents
Hormone Replacements and Treatments in Chronic Pain: Update 2010
Opioid Treatment 10-year Longevity Survey Final Report
Therapeutic Laser in the Treatment of Herpes Zoster
Use and Effectiveness of Spinal Cord Stimulation

Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care

The task ahead is to integrate a moral vision and ethical roadmap into the development of unifying guidelines and policies that acknowledge and preserve particular values of stakeholders, adapt and mobilize market structures in the service of medicine and, in so doing, strive to uphold the integrity of pain care as a patient-centered endeavor.

A New Year: Facing Durable Challenges and Tasks

In this issue of Practical Pain Management, Prof. Peter Moskovitz addresses the complexities, issues, and problems that arise in, and from, the diagnosis and treatment of complex regional pain syndrome (CRPS).1 As Prof. Moskovitz astutely notes, the “problem of CRPS” is in many ways representative of the more generalized problems in pain research and treatment. To be sure, these are multifold and multifocal, and questions of diagnostic accuracy, if not nosological validity, often reflect differing types and lines of evidence. Evidence, and/or evidence-hierarchies simply cannot—nor should not—be viewed as a “one-size-fits-all” construct.2 Heterogeneous bio-psychosocial variables inherent to each patient must be taken into account when examining what type and extent of evidence is right, and how any such evidence can, and should, be regarded and utilized to maximize the “good” of both the patient and the profession and practice of pain medicine.

The Obama healthcare plan proposes evidence-based analyses to guide diagnosis, treatments and outcomes.3 However, evidence-based medicine (EBM) like any other technique, has certain strengths, limits, and weaknesses. Such limitations do not refute EBM as concept but, instead, reveal EBM to exist within a milieu of new information, knowledge and practices. This mandates commitment to revise methods of research, as well as clinical evaluation, care and results. Any attempt at EBM (and its use in medical decision-making) must strive to remain progressive in this way, given the pace of scientific, technological and even socio-economic change. Thus, the goal of EBM is to utilize various levels of information to answer the prudential questions of “what can be done,” and most importantly, “what should be done to treat a given patient.”4

Evidence, Efficacy and the Environment of Pain Medicine

The relationship between “evidence” and therapeutic efficacy is neither trivial nor static. It obtains a multi-step process of: 1) critical appraisal of any evidence for its validity, 2) integration of this appraisal with a given patient’s specific biological condition and life circumstances, and 3) evaluating whether the evidence matches the variables of a particular case with sufficient alignment so as to justify use. In light of this, we have opined that EBM and therapeutic agency are both casuistic processes that are reliant—to a large degree—upon the practical wisdom of the physician.5 As Moskovitz rightly claims, the limitations of research to generate valid evidence, and of EBM to guide diagnosis and care, reflect the core constraints of much of pain care, if not medicine in general. These most certainly include a paucity of economic support for research, practice, and sustained patient care.

Rather than a “cooperative” that integrates the interests of involved parties (e.g., biomedical research, clinicians, patients, healthcare administrators, in-surers, et al.), the field tends to denigrate into tensions, if not frank conflicts, based upon seemingly dis-parate values of camps that Moskovitz appropriately refers to as ”stakeholders.” Undeniably, this has had a negative impact upon the scope, purpose(s), and moral and practical obligations of pain management.6 Such constraints both reflect and contribute to an economic turn away from collaboration and complementarity in pain care.7 These economic barriers are also an intimidating portent of the future that we believe should compel and guide reformation of guidelines and new policies—both in the United States and on a global scale—to sustain healthcare that more effectively conjoins multiple stakeholder views and values to focus upon: 1) advancing the research enterprise to generate new knowledge; 2) enabling comprehensive clinical care that employs this knowledge; and 3) empowering the patient to access and afford treatment and in this way lessen the personal and social impact of pain.8 Recent calls for government agencies, as well as insurance companies, to establish programs of long-term pain care reflect these concerns and prompts.

But, as we have claimed: “…the good of medicine does not exist in a socio-economic vacuum and, if these therapeutic and ethical goods are to be appropriately rendered to those in pain, systems utilized toward these ends must be practically enacted.”9 It therefore becomes vital to recognize how the relative interests of practitioners, healthcare and insurance communities, public, economic infrastructure, and body politic affect any realistic expression of costs and benefits in the provision of care. The needs and values of each of the involved stakeholder groups must be acknowledged and considered, not in isolation, but in concert within the paradigm of a healthcare system as it 1) actually exists and 2) would be proposed and/or planned to maximize specific outcome benefits. This may entail a two-step process of “forward and reverse gaming” tentative systems to determine those configurations of stakeholder interactions that are most effective toward the desired end-goals. It is also important to employ a strategy of rapprochement to reconcile the tensions that exist among these groups so as to facilitate collaborative discourse necessary to develop policies that incorporate “…structure and function that engages ethical systems and approaches in ways that support and sustain the good to be provided on individual and public levels.”10

Stakeholders, Values, Ethics, and Policy

But the question remains as to how such amelioration of stakeholder values might be accomplished in the real-world circumstances of medical practice. To complicate this question further, it is important to recall that these values are embedded within a larger value-edifice of the healthcare, socio-economic, and political systems in which patient care occurs. I have argued that the physician is both a therapeutic and moral agent, given that any, if not all, clinical decisions affect the existential “being” of the patient and impact the covenant of trust that undergirds the medical relationship.11,12 Yet, clinical and moral expertise are not monolithic entities. Each reflects particular values that may dictate physicians’ predispositions toward certain clinical approaches, types of care (perhaps even patients!), and all affect decisional process.13 Moreover, values and predispositions are reliant, to some extent, upon the overall “milieu” in which the practice occurs. So while we have called for the physician to be a prescient arbiter of clinical and moral good, the interaction of values cannot be ignored but, rather, should be openly acknowledged, identified, and figured into the calculus of relative attractors and constraints that could affect the trajectory of various decision moves within the medico-social system.

It is probable, if not likely, that tensions and conflicts will occur within the ‘players’ or ‘nodes’ of this system (to use the relevant terminology) and, as Moskovitz explains, a large part of the clinician’s responsibility therefore is to act as a “mediator” to identify and resolve con-flict(s) between the various stakeholders. He alludes to a “three-way conflict” that is “universal and fraught with danger.” This conflict might be reducible to discord within and between the biological, psychological and/or social domains oper-ating in the various stakeholder nodes.14This triangulation reflects the relationship(s) of patients, the environment(s) in which they are nested, and medicine as a force—but not the only force—within the environment. To be sure, numerous factors, goods and values impinge upon the clinical relationship and, in so doing, establish relational patterns of their own (e.g., that involve the patient, clinician, healthcare administrators, insurers, et al.). Simply put, persons, pain (as a disease and illness), medicine and society all exist as components of a complex dynamical system.15

Moskovitz’s claim that the role of the clinician-mediator is to “…help the patient navigate” within this system is accurate. Yet, despite best intentions, the very nature of the system itself dictates that clinicians cannot work or function in isolation, but must be part of a larger network of stakeholders. In light of this, it is important to align the values and activities of the various stakeholders to create a positive, participatory system that works toward a specific goal, objective and/or end.

Obviously, a first goal of any healthcare system is to define patient benefit. This cannot be presented in esoteric terms, but rather must be explicated in ways that are operational and tenable within each of the stakeholder camps. The moral precepts that underline the treatment of pain are critical to this definition, and translating morality into ethics can be useful to bespeak the values (and/or values’ desiderata) of stakeholders. But, as Moskovitz cautions: “…no stakeholder…in pain management is ever free…of conflicts.” Thus, it may well be that an ethics of pain care, while necessary to establish methods to elucidate, analyze and approach conflicts, is most assuredly not sufficient to resolve these problems within a healthcare plan. However, as Moskovitz advises, “…being mindful” of different stakeholder values, while adhering to a vision of morally sound pain care, “…is the least we can do” (italics added). Perhaps ethics can achieve this.


For any pain medicine to succeed and be meaningful and authentic within a healthcare plan, the real task ahead is to integrate this moral vision and ethical roadmap into the development of unifying guidelines and policies that acknowledge and preserve particular values of stakeholders, adapt and mobilize market structures in the service of medicine and, in so doing, strive to uphold the integrity of pain care as a patient-centered endeavor. Without doubt, the task is arduous, laden with conflicts, and “fraught with danger” of both deepening existing rifts and possible failure; but the benefits achieved by success are far-reaching and make ongoing efforts toward this end evermore worthwhile.

Last updated on: January 6, 2012
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