Challenges and Issues in Pain Management and Anesthesiology

Pain management is about three decades old, and while significant strides have been made in understanding pain mechanisms, implementing new pain therapies and effectively treating more patients, there are still many obstacles to overcome and various nuances to navigate in order to become the mature medical discipline that it is destined to be.

As a founding member of most of the established national and international pain organizations, I was privileged to witness the birth and continuing development of pain medicine and pain management. Anesthesiologists have always been in the forefront of pain medicine, and the legendary works of John Bonica, considered to be the ‘father of pain medicine’, and many others, including Harold Carron, Terry Murphy, Alon Winnie, Steven Brena and Prithvi Raj, have served to provide a meaningful and secure place for pain medicine among medical disciplines.

At the onset, it was realized that credentialing was critical to the survival of the specialty and the American College of Pain Medicine and subsequently the American Board of Pain Medicine were developed to serve as the legitimate credentialing bodies for pain clinicians in the US. There were and still are several bodies offering credentialing pathways with varying degrees of legitimacy and authenticity. In this country, the gold standard for credentialing of medical specialties is the American Board of Medical Specialties (ABMS).

The need for centralization

It was the goal of the American Board of Pain Medicine to be officially recognized by the ABMS, but this endeavor was unfortunately not supported by the then leadership of the American Board of Anesthesiology (circa 1992). It is important to note that approximately 85% of the members of the American Board of Pain Medicine were anesthesiologists. This lack of support served to foment polarization and fragmentation and ultimately weakened the specialty.

In spite of this, the American Board of Pain Medicine continues to flourish and it is recognized as equivalent to ABMS certification in California, Texas and Florida. It is hoped that the other 47 states will follow soon and that pain credentialing in the US would be centralized and would serve as a model for the rest of the world.

Opioid use

Prior to Ron Melzack’s publication of his 1987 article in Scientific American on the ‘Needless Tragedy of Pain’, the use of opioids was limited almost exclusively to post-operative pain, and in those circumstances too, opioids were inappropriately prescribed. The average physician (general practitioner and specialist alike) avoided using opioids, either from a lack of understanding and knowledge of these drugs or from an influence of the various myths surrounding opioids and their use.

There were also some physicians and other healthcare providers who justifiably avoided using opioids because of legitimate concerns from the actions of federal and state officials regulating the use of these drugs. Fortunately, that situation has changed here in the US and Europe, and is changing rapidly in other countries. Multiple pain symposia, pain publications and other educational activities have helped to enhance the knowledge base of physicians and this has translated into more widespread prescription of opioids for acute and chronic pain patients.

A minor but significant negative effect on that knowledge enhancement is that many patients with post-operative pain, post-traumatic pain or post inflammatory pain are kept on opioisd long after surgery, trauma or inflammation have subsided and phenomena like dependency, tolerance, addiction or withdrawal phenomena may develop. There currently exists in this country a problem, typified by the alleged Rush Limbaugh affair, in which patients obtain opioids and narcotics from non-legitimate sources (including at street corners) and various socio-cultural-legal complications may develop.

The swinging of the opioid pendulum from a period of under-use to inappropriate use is occurring and the concept of drug diversion is now a reality. This situation has produced unpleasant interphases between providers and patients who occasionally make inappropriate and aggressive demands for opioids. While this unfortunate development should in no way hinder the effective use of opioids for acute and chronic pain, the prescribing physician has to remain vigilant and perceptive to those nuances that are associated with opioid prescribing and their clinical implications.

In short, the assessment and effective management of pain is a patient right that should be preserved but the support of illicit drug use for whatever purpose should not be facilitated under the guise of pain management. There are a handful of naïve, and an even smaller number of corrupt, physicians who have paid dearly for not recognizing that difference. Like most issues in medicine, there are several grey areas and it is hoped that with adequate clinical experience, sound educational knowledge and good common sense, most of these pitfalls may be avoided most of the time.

Increasing knowledge

When comparing pain research publications that are released today with those of 30 years ago, it is just astounding to appreciate the dramatic increase. Basic science has been prolific in the output of good quality scientific material on pain mechanisms and pain pathophysiology. There now has to be a shift to making that research more clinically relevant and applicable to the treating physician at the patient’s bedside. The formal trend towards translational research should be developed and enhanced at the university level in which formal interactions between basic scientists and pain clinicians should be developed, nurtured and expanded to provide high quality, clinically relevant innovations, techniques and therapies that would be beneficial to the chronic pain patient.

In spite of the tremendous proliferation of scientific publications, many current therapies are still considered either anecdotal, investigational or experimental. There are very few well-designed, randomized, placebo-controlled studies on pain-related therapies. Obviously, this situation exists because it is extremely difficult to implement in the typical pain clinic setting. Fundamental issues like pain measurement and pain assessment are still quite primitive.

The VAS, with all the shortcomings, still remains the gold standard of pain assessment. With redoubled efforts, it is hoped that this situation will change and that more objective and reliable measures would emerge; that would require a joint effort between basic scientist, pain clinician, government and industry. The role of industry in that arena is diminishing for a variety of reasons not the least is economics.

In the meantime, and while we wait for the outcomes of translational research activities, practice guidelines and outcome metrics should be disseminated not only for publication value but also for the initiation of relevant discussion on interesting and controversial topics. These initiatives may help develop a reasonable standard of care for the future practice of pain medicine.

Reducing funds

The Balanced Budget Act of 1997 (BBA’97) produced a significant decrease in Federal reimbursement for healthcare in general and pain management, in particular here in the US. Those budgetary cuts came at a time when Managed Care was flourishing and the alphabet soup (HMO, PPO, DRG, etc.) was on the menu of most hospitals, clinics and health care providers. The ultimate effect was reallocation of funding (some may call that strategy rationing) and many pain services were under-valued, under-funded and under-reimbursed.

In an attempt to remain economically viable, many university-based pain clinics lost money and some were closed; many private enterprises made up for this situation by increasing patient volume and by definition is cases, quality may have been compromised. Sadly, by the year 2000, the federal government had amassed a surplus or over a trillion dollars, but no attempt to replenish the budget cuts of 1997 was implemented. Pain clinicians have been forced to become good businessmen and women (which is not all bad) and develop creative and effective but reasonable techniques to care for the chronic pain patient.

At the same time, third party payors have become quite sophisticated at denying claims, citing procedures as ‘investigational and experimental’. In general, a full re-assessment of the relationship between providers and payors should be undertaken and, notwithstanding infrequent abuse on both sides, a productive relationship may be established so that the chronic pain patient would be the ultimate beneficiary.

The growth and development of pain medicine should be nurtured at universities and academic centers. While industry has a meaningful role to play, the task remains with the academic centers, where bright, independent-thinking minds will initiate, develop and process new ideas that may ultimately benefit patients and mankind in general. The recent cases where conflicts of interest have developed remain numerically small, but the implications for a loss of trust, independence and integrity have been somewhat.

The notion that a major pharmaceutical company would pay physicians to append their name to publications that they did not participate in is naïve at best and reprehensible at worst. It is imperative for society and the general public to have sound confidence in the integrity of medical researchers. Whereas it is not inappropriate to be funded and supported by industry, the results of that work should be unbiased and full disclosure of the relationship should be made so as to preserve transparency.

As the American economy turns sour, ripples affect all segments of society. The medical profession, and pain management in particular, are not immune from this economic downturn. As revenues decline, there is a tendency for people to become creative and that is a good thing. Nevertheless, innovation and creativity should never compromise professional standards at any time.

Specifically, there appears to be a developing trend in some major universities where various departments hire their own ‘pain specialists’ in an attempt to keep their business in-house and to generate revenue. There is nothing wrong with this principle from an economic standpoint. However, when these pain specialists are not well-trained, fully credentialed or adequately supervised, professional standards are compromised at the peril of the sanctioning institution. These cannibalistic attitudes may be good economics, but are definitely bad medicine and less than optimal professionalism.

Essential service

Acute pain management is one of those disciplines that is always given high marks by patients who have surgery at most hospitals. Patients usually state in hospital surveys that the highpoint of their hospital stay for surgery is the excellent pain relief by the various modalities administered by the acute pain service. Unfortunately, reimbursement for these services is far from satisfactory. In order to continue to provide this important service, especially to patients who can least afford them, creative methods should be developed to support the departments, providing that invaluable acute pain service in much the same manner as that in which emergency service in a hospital is supported.

The specialty of anesthesiology is over 160 years old and has faced its challenges quite well. The fact that peri-operative mortality and morbidity have significantly decreased not only in the US but also in the developing world is directly related to the significant strides made in the field as far as training, research and professionalism are concerned. Patients almost always expect a good outcome from the anesthetic experience even in high-risk clinical situations.

The relationship between anesthesiologists (physicians) and nurse-anesthetists (CRNAs, or nurses) is improving, and in most medical centers, residents and CRNAs work side by side, under the supervision of attending or consultant anesthesiologists, to provide good care for their patients.

An alarming situation that did occur in the 1980s was the relatively cool reception given to anesthesiologists who were interested in pain medicine and pain management. This unfortunate attitude by the then leadership of American Board of Anesthesiology produced the secession of many pain physicians from the anesthesia umbrella. As a result, multiple pain organizations were formed; some were legitimate while others were not. Fortunately, the current anesthesia leadership has recognized this schism and active and bold steps are being undertaken to correct political misstep. They should be commended for this action.

Attempts to alter the strategies for anesthesia training and education are currently being implemented, not only for knowledge enhancement but also as a tool to encourage anesthesia trainees to remain in academic centers as junior faculty after training. This approach is critical, because the professors of anesthesia of tomorrow will come from the current group of trainees and the future of the specialty and its outcome will depend on the quality of the training that these current trainees receive.

Creative programs are being designed to permit incoming residents to incorporate research projects into their anesthesia training programs so that the academic stimulus is introduced to them very early in their careers. Scholarly programs like these would serve to enrich the base on which the future of anesthesiology may develop and flourish.