The Healthcare Policy of Pain Management

Rationale for Pain Management Being a Healthcare Policy Priority

Chronic pain is a major cause of suffering, disability, lost productivity, and diminished quality of life across the entire life span and around the world. The global burden of chronic pain is increasing in parallel with the aging worldwide population and the greater prevalence of pain-associated medical conditions like diabetes and obesity.

In its seminal report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” the Institute of Medicine (IOM) observed that more Americans suffer from chronic pain than the combined prevalence of heart disease, cancer, and diabetes.

According to the United States Centers for Disease Control and Prevention, based upon 2016 National Health Interview Survey data, an estimated 20.4% (50.0 million) of adults in the United States have chronic pain, and 8.0% (19.6 million) of adults in the United States have high-impact chronic pain. Similarly, 27% of the European adult population are affected annually by a chronic pain condition.

The individual and societal costs of chronic pain are multifaceted and extensive. It is essential that well-informed healthcare providers and health policymakers are fully cognizant of these costs ( Table 5.1 ). ^, Notably, chronic pain-related costs borne by individual patients and their families—such as uninsured treatments, informal care, and intangibles related to loss of quality of life—are unquestionably substantial but difficult to measure, and hence often under recognized and underappreciated. ^,

The societal impact of nearly 30% of American adults having a chronic pain condition includes associated (1) annual direct medical costs of US$261–$300 billion and (2) lost productivity costs of US$297-$336 billion—totaling upwards of $US635 billion dollars per year. ^{, ,}

The estimated direct and indirect healthcare costs for chronic pain disorders in the European Member States vary between 2% to 3% of gross domestic product across the European Union. For 2016, this estimate would correspond up to 441 billion Euros.

Even in a country like Canada, with its more constrained, government-controlled, universal health insurance, the most recently estimated mean total yearly expenditure of CDN$5177 per adult with chronic pain equates to an estimated total annual economic burden of chronic pain of CDN$7.2 billion for all of Canada.

Based upon a series of focus groups of key stakeholders from across the United States, the Pain Action Initiative: A National Strategy (PAINS) originally identified six major themes regarding chronic pain ( Table 5.2 ) ¹² —all of which speak to interconnected ethical, economic, and healthcare policy aspects of chronic pain.

Subsequently, the Pain Management Best Practices Inter-Agency Task Force was convened by the United States Department of Health and Human Services in conjunction with the United States Department of Defense and the United States Department of Veterans Affairs, along with the Office of National Drug Control Policy, to address acute and chronic pain, especially in light of the ongoing opioid crisis. This Task Force was mandated both (a) to identify gaps, inconsistencies, and barriers and (b) to make updated recommendations for current best practices in managing chronic pain ( Table 5.3 ).

A greater prevalence of chronic pain in the United States has been reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents. Furthermore, such vulnerable groups of patients—specifically, children, the elderly, the indigent and uninsured, certain racial minorities, and those with major chronic comorbidities (including mental health disorders)—are also at higher risk of inadequate pain management. ^,

By many accounts, patients with chronic pain in the United States and around the world continue to face a major burden, and often an attendant health crisis, because of persistent major challenges in obtaining adequate care—resulting in profound physical, emotional, and societal costs. ^{, ,} Pain management thus has a myriad of major healthcare policy factors and implications, some of which will be discussed further in this chapter.

Corporatization of American Pain Medicine: Its Implications for Widening Pain Care Disparities

In his January 1961 farewell address to the country, United States President Dwight D. Eisenhower warned the nation of the widely unrecognized threat to American democracy from the emerging military-industrial complex. In a similar vein, Arnold Relman, the former editor of The New England Journal of Medicine , opined in 1980, the emergence of what he labeled as the “medical-industrial complex” and presciently observed:

This new “medical-industrial complex” may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and “cream-skimming,” and it may also exercise undue influence on national health policy. Closer attention from the public and the profession, and careful study are necessary to ensure that the “medical-industrial complex” puts the interests of the public before those of its stockholders.

The subsequent inexorable rise of this medical-industrial complex has resulted in an immense for-profit American healthcare industry—ranging from proprietary hospital systems, skilled nursing facilities, and nursing homes to diagnostic services, medical devices, hemodialysis, pharmaceutical industry (“Big Pharma”), the insurance industry, home health care, and many other related brand-named activities.

The well-established phenomena of corporatization, consolidation, and commoditization are based on the fundamental business principle of maximizing profitability, primarily through improved economies of scale, greater efficiency, and cost containment. These phenomena can apply to the overall healthcare sector through its individual healthcare companies and medical professional practices ( Table 5.4 ).

Over the past 40 to 50 years, there has been a widespread corporate transformation in American healthcare. ^{, ,} The original motivating ideology for the corporatization and proprietization of healthcare was a commitment to excellence of care. However, this impetus has been replaced by cost containment and profitability. ^, With the concomitant concentration and centralization of healthcare delivery in the United States, the pursuit of profit has become central.

The primary goal of health corporations has become to earn profits, with their justifying mantras of “no margin—no mission” or “no income—no outcome.” However, ironically, their corporate product is health care, for which the poor and vulnerable populations have an equal or greater need but often limited or no access. Thus the corporatization of medicine presents a complex moral dynamic across the variables of access, cost, efficiency, and quality of care.

As the corporatization of health care has become more pronounced in the US, it has paradoxically been in part responsible for not only the high cost but also the inconsistency and fragmentation of the medical care and services that Americans receive. Health care in the United States has thus become dominated by a business philosophy whose primary concern is increasing shareholder value rather than providing optimal care and experience for patients. Furthermore, vulnerable groups become more vulnerable when profit becomes the driving force in conceptualizing, organizing, and delivering health care.

The writ large corporate systematization and commodification of medicine has had a knock-on effect on pain medicine. ^, Scientific progress continues to increase the understanding of pain mechanisms and availability of effective pain therapeutics. However, the administrative and economic infrastructure that supports—or just as often denies—providing indicated medical services leaves clinicians ever more disempowered to use this knowledge to effectively care for all individuals who are experiencing chronic pain—thus threatening the moral obligation to treat all pain patients safely, effectively, and equally.

There has been an accompanying transformation (devolution) of the “profession” of pain medicine into the “business” of pain medicine, which has been marked by:

• physician complicity in the transformation of pain medicine from a profession to a business;

• the refusal by the health insurance industry to cover multi-disciplinary/interdisciplinary pain management programs;

• the increase in pain management spending without any evidence of improved patient outcomes;

• the overutilization of interventional procedures and spine surgery by physicians who have questionable relationships with industry;

• the innate, continued conflict of interest relating to industry and its impact on pain education; and

• the corporatization of American pain management and the resulting benefits to certain special interests and concomitant increases in disparities in pain care.

Ideally, pain medicine depends upon patients having ready access to freestanding or hospital-based clinics, interdisciplinary care teams with diverse providers and specialty services, diagnostics, interventions, medical products and devices, as well as pharmaceuticals—but each vital component poses layers of bureaucratic, financial, and non-access related barriers.

The biopsychosocial model of pain has been well-recognized as an optimal approach to the assessment, treatment, and prevention of pain. This comprehensive, multidimensional approach to chronic pain equally considers the multiple biologic, psychological, and social factors frequently associated with chronic pain ( Table 5.5 ).

However, a narrow-minded vision of pain treatment in the United States—once again, more driven mainly by market forces than evidence—has resulted in a decreasing number of multi-disciplinary pain management programs. The practice of pain care that focuses predominantly on pharmaceutical agents and biomedical interventions is inaccurately redefining pain as a nociceptive phenomenon—thus undermining the perceived importance of its psychosocial dimensions, which are direct determinants of the tremendous direct and indirect costs of pain to the individual and society. Therefore many pain medicine practices in the United States have become nothing more than profit-driven, “block shops” and “pill-mills” that are staffed and owned by entrepreneurial “needle jockeys” and “pill-pushers” who enjoy very large profit margins and high professional incomes.

While the corporatization, consolidation, and commoditization of pain medicine have implications for many populations, three groups are the most vulnerable to its effects: the poor, minorities, uninsured, and underinsured. The corporatization of pain medicine in the United States has had major implications, especially in widening the disparities in pain care ( Fig. 5.1 ). Specifically, the highly profit-oriented mindset and culture within the current practice of pain medicine has resulted in the amplification of the already-existing disparities in care by driving up its costs and limiting options, thereby making comprehensive pain treatment inaccessible to more Americans.

Although the corporatization of American medicine may originally have been well-intended—ostensibly, to promote competition, and thereby to drive down healthcare costs—the actual consequence of this widespread phenomenon has been an increase in human pain and attendant suffering.

Pain Management as a Global Public Health Priority and a Human Right

The initial 2013 Global Burden of Disease Study, and its subsequent updates undertaken in 2015, 2016, and 2017, have provided valid, consistent, and striking evidence of the substantial, global morbidity and disability burden of pain, and diseases associated with pain, in both the developed and developing countries.

Quite importantly, although some infectious diseases have decreased in prevalence since 1990, the burdens associated with chronic pain are overall increasing. This is partly because of dominant demographic forces like the aging of populations across the developed countries and similarly increased survival into middle and old age in the developing countries—resulting in not only a growing population size but also a mounting prevalence of chronic diseases.

Humans are thus living longer, but with more chronic disease and disability. An unprecedented transition is occurring from a world with predominantly communicable diseases to one with chronic disease and disability, with implications for the welfare of people worldwide. However, health systems and economies are not prepared for this transition. Instead, the discordance between health system responses and the changing population needs is worsening, as are health inequalities.

Not surprisingly, the World Health Organization (WHO) and the United Nations (UN) have estimated (1) that over 75% to 80% of the world’s population receives inadequate treatment for moderate to severe pain and (2) that at least 5 billion people live in countries with minimal to no appropriate access to governmental controlled analgesics like opioids and psychotropics.

Given this enormous worldwide burden, pain should presumably represent a continued major global public health concern. ^, Yet until only recently, pain management has been relatively neglected by national governmental agencies and international non-governmental organizations (NGOs).

Acute, chronic, and cancer pain collectively represent the often unreported and hence silent dimension of many of the worldwide causes of adult and pediatric morbidity and mortality. ^, Although acute pain may reasonably be considered a symptom of disease, illness, or injury, chronic and recurrent pain is a specific healthcare problem—a disease in its own right. ^, It has been persuasively posited that this pervasive view of chronic pain as a symptom of disease, rather than a disease state in itself, has contributed to the paucity of public health and health policy attention and funding that chronic pain has historically received. ^,

Consequently, the WHO, the International Association for the Study of Pain (IASP), and the European Federation of the IASP Chapters jointly declared in 2004 that such widespread, inadequately treated chronic pain must not be tolerated and that the relief of pain should be a universal human right. ^, In 2010, the IASP issued its “Declaration that Access to Pain Management is a Fundamental Human Right” (“Declaration of Montreal”) ( Table 5.6 ), which in addition to emphasizing that chronic pain is a disease entity, reaffirmed the basic human right to access effective pain management and the obligation of governments and healthcare institutions to establish laws, policies, and processes that help promote—not inhibit—access to pain management. ^,

Fortunately, the concept of access to pain management as a human right has recently gained increasing currency. Beginning as individual-level advocacy (“cries in the dark”), this concept was embraced by the disciplines of pain medicine and palliative care and by mainstream human rights organizations (e.g., Human Rights Watch). By 2019, the UN and regional human rights bodies had accepted the concept and incorporated it into their key human rights reports, reviews, and standards.

The two ultimate aims of this sustained global pain initiative have been (1) to inform international, regional, and national health policymakers about the personal burden and the economic costs of chronic pain and (2) to educate physicians and allied healthcare professionals about pain assessment and treatment to promote higher standards of care worldwide. ^, Similar attention has been focused on receiving effective palliative care being a universal, international human right. ^, Lastly, the denial of adequate pain treatment, when used as a form of punishment or torture, is a grossly egregious human rights violation.