SRIDHAR VASUDEVAN, MD
MARCH 3, 2015
Over 100 million Americans suffer from chronic pain such as spinal disorders (lower back pain, disc disease, pinched nerves and neck pain), complex regional pain syndrome, fibromyalgia and headaches. The cost of chronic pain in human suffering, lost worker productivity and in health care dollars is counted in the billions.
Yet despite newer, expensive and invasive treatments like spinal fusions and disc surgery, spinal cord stimulators, steroid and painkiller injections, nerve “burning” and of course the excessive use of opioid drugs, chronic pain is becoming worse in the U.S. adult population not better!
How does contemporary pain treatment make it worse? Through its blind allegiance to a controversial medical procedure called the “wallet biopsy,” a term coined by Otis Webb Brawly, MD, chief medical officer of the American Cancer Society and author of How We Do Harm. If the wallet biopsy comes back “positive” and reveals money to spend (covered by insurance or a desperate, out-of-pocket paying patient), the patient will get a lot more treatment and not necessarily the right kind, says Dr. Brawley.
In the last 20 years, the “wallet biopsy” has elevated to wide use chronic pain treatments that are uncoordinated, expensive and have disappointing outcomes. For example, almost nine million Americans got pain injections such as corticosteroids in 2010. The injections draw lucrative reimbursements but have limited if any long-term benefit according to the medical literature.
Spinal cord stimulators can sometimes be effective write the pain specialists Drs. Chou and Loeser but their risk/benefit ratio raises questions: 26 to 32 percent of patients receiving spine stimulators “experienced a complication following spinal cord stimulator implantation, including electrode migration, infection or wound breakdown, generator pocket-related complications, and lead problems.” They are also extremely expensive.
Surgery, of course, is a common treatment for pain, but many back surgeries have shockingly low success rates that patients would probably not risk if they were choices offered in traffic — or at the casino. Second operations on the lumbar spine are disturbingly common and most result from new or recurrent pain, device failures and complications following the first operation — in other words “failures.”
In fact, “failed back syndrome,” a term frequently heard in the U.S. is an ailment that “does not exist in most of the world,” writes Peter Abaci, MD, in his book Take Charge of Your Chronic Pain because “Most other countries don’t perform spine surgeries at the high rate that we do in the United States.”
The common and often excessive use of imaging technology like X-rays and MRIs is also not helping people who are suffering from chronic pain. Seldom is the “pain generator” — the cause of a patient’s pain — revealed in diagnostic imagery. Conversely, abnormalities that would never have used the patient pain often are revealed, leading to unnecessary care.
As almost everyone living in America knows, opioids became popular for use in individuals with chronic pain (and even people with minor conditions) in the 1990’s with unfortunate outcomes. Opioid drugs, also called narcotics, have exerted disastrous consequences in dependence, overdoses, diversion, and misuse. Thanks to wider use, prescription opioid deaths doubled in a decade, to 16,000 in 2012.
Opioids are taking a huge toll on the workplace, too. An average worker compensation claim without opioids is $13,000 but when short-acting opioids like Percocet are added it leaps to $39,000. Add long-acting opioids like OxyContin and the figure skyrockets to $117,000. Recently, two definitive papers in the Annals of Internal Medicine revealed that almost no data exist supporting their opioid use in chronic beyond six weeks.
Yet there is an answer to chronic pain that many physicians and pain specialists have agreed upon for years: multidisciplinary treatment. The “team” consists of a physician who uses a biopsychosocial approach to chronic pain and a multidisciplinary team approach, physiatrist (a physician specialized in physical medicine and rehabilitation), a physical therapist, a health psychologist and other allied professionals like an occupational therapist, rehabilitation nurse, social worker or vocational therapist. Multidisciplinary treatment was used effectively for chronic pain until health care reimbursement patterns began to favor the “wallet biopsy.”
The irony is that multidisciplinary treatment is actually more cost effective in the long run. “In the short run, treating a patient with an opioid like OxyContin, which costs about $6,000 a year, is less expensive than putting a patient through a pain treatment program that emphasizes physical therapy and behavior modification,” writes Barry Meier, author of A World of Hurt. Over time, however, such programs “might yield far lower costs.”
Sridhar Vasudevan is a clinical professor of physical medicine and rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin.