Realizing the “Promise” of Pain Management and Palliative Care
Professional Responsibility of Pain Care
Technological advancements within science and medicine have enabled prolongation of the lifespan for those patients with incurable diseases. Yet, at the same time, such relative successes have fostered an increased prevalence of chronic illness and subjective suffering—including intractable pain—due, in part, to the inability to completely eradicate symptoms and to the progressive use and sometimes exhaustion of therapeutic and economic resources available to the patient. This has compelled an increased impetus for medicine to develop those dimensions of practice that seek to heal what cannot be cured. To a significant extent, pain medicine and palliative care have arisen from, and seek to meet, this need.
The obligation to treat pain and suffering, while inherent to all of medicine, is by definition most fundamental to the profession of pain medicine and palliative care.1 Clearly, pain management can be, and often is, necessary albeit not sufficient for rendering sound, palliative care. But technically effective pain care must also be rendered in ways that uphold the moral affirmations of medicine and, while certain ethical (and legal) frameworks exist to guide the tenor, scope and limits of the profession, the actual implementation of care is reliant upon the physician. In this way, the physician is both a therapeutic and moral agent given that any (if not all) clinical decisions affect the vulnerability of the patient, reflect the asymmetries of knowledge and power between physician and patient, and impact trust within the medical relationship.
The complexity of pain and pain care is such that a simple “one-size fits all” approach to management is not practical—and probably not ethically justifiable.2 An integrative use of interventional, pharmacologic, physiatric, and psychiatric pain management may represent a viable option—both early in and throughout the care of long term and terminal pain patients. In this context, interventional techniques may be especially useful because of their capacity to effectively reduce pain, make patients more amenable to other therapeutics, and enhance patients’ quality of life.
Practical and Ethical Claims of Integrative Pain Medicine
If the past ten years’ congressionally-declared “Decade of Pain Control and Research” in the United States has done nothing else, it has certainly instigated 1) a more internationalized interest in the problem of pain and the difficulties and responsibilities of pain care, and 2) a more well-defined need—and thus goal—for biomedical research to facilitate improved translational applications and models.3 Despite such progress, interventional management techniques still tend to be under-utilized within palliative care—particularly that which is provided in a paradigm of long-term (i.e., not end-of-life) treatment.
A number of long-held beliefs may contribute to under-utilization. Integrative pain medicine and palliative care may not appear to be inexpensive or cost-effective from the perspective of hospital operators and insurance companies. The problem chiefly lies in an inability to calculate the cost of pain and palliative care given the relative uncertainties of matching objective medical treatment(s) to subjectively defined states (i.e., pain and suffering) and ends (e.g., palliation). Long-term pain care can be viewed as cost-intensive by insurance providers and hospital operators, with perceived high expense(s) evoked by the requirements for both medical staff and equipment/ facility resource utilization.
From a perspective of hospital economics, prima facie it might not seem to be “worthwhile” to care for chronic pain patients, given costs incurred relative to payment schedules established according to existing diagnosis-related group (DRG) treatment classification system(s). The development and expansion of in-patient and/or out-patient pain and palliative care networks are not generally facilitated by current DRG systems. This is because DRGs are not designed to reflect 1) the wide pathological variance of chronic pain patients, and 2) the finances required to support services necessary to effectively and ethically treat chronic pain conditions.4 Thus, if the goal of providing high quality pain medicine and palliative care is to be achieved in light of the noted achievements of technology in medicine —and the explicit call to use such advancements to address the increasing incidence and prevalence of chronic pain—then special provisions for adequate funding of both in-patient and out-patient approaches must be developed and implemented.5,6
However, to safely, effectively, and ethically deal with the often complex pathologies of chronic pain patients, it is necessary to maintain multi-disciplinary and integrative treatment provided by professions focal to pain and palliative care (e.g., specialized physicians, social workers, physiotherapists, psychologists, clergy and secular spiritual counsellors, et al). In this way, treatment would constitute a service of ongoing assessment and interventions that are rendered by a multi-professional, closely-knit team on a regular basis and as appropriate to both the changing status and needs of each specific patient.7
It is difficult to categorize chronic pain patients in a homogeneous cost group within current DRG systems and so inter-disciplinary pain/palliative care could be seen as impossible to finance because of its requisite utilization of diverse resources. The lack of a more encompassing integrative pain/palliative care paradigm reflects the inchoate nature of the profession of “pain medicine.” This has given rise to misconceptions that interventional pain management is a “standalone” approach and has led to the opinion that its ongoing, collaborative use with other disciplines (e.g., primary care, physiatry and psychiatry/ psychology) would incur unnecessarily high costs that would be difficult to advocate.
But is this latter opinion correct? Previous studies have shown that the employment of collaborative interventional techniques within an inter-disciplinary pain/palliative care paradigm can be both cost- and time-effective.8 For example, when compared with long-term use of systemically-administered primary and adjunctive/adjuvant analgesics, interventional techniques reveal a very favorable cost-to-benefit ratio when compared to solely systemic analgesia. Even in those cases in which analgesia is less than complete but meaningful pain relief is nonetheless achieved, the cost and time savings incurred by reducing the amount of systemic drugs used, and the time needed to obtain stable effects might well balance and justify the initial expenses of interventional procedures.9 Clearly, how-ever, the use of nerve blocks and (rather than “or”) pharmacological, physical medicine and psychiatric/psychological approaches within a methodologically- conjoined treatment protocol affords considerable complementary attributes.