Norman Marcus, MD - How can we know what pain treatments make sense?
Guidelines for care of specific conditions, produced by professional medical organizations, should be based on a rigorous analysis of all existing literature about the treatment of the condition. Guidelines for Low Back Pain were published by the American Pain Society advising that many pain treatments were not clearly effective. Another organization not liking these guidelines offered two systematic critiques (1), (2). The APS responded addressing the need for unbiased assessments of treatments offered by healthcare providers. If you make your living doing a procedure, it may be difficult to admitt that what you do doesn't work well. The results for treatment of low back pain in the US (and elsewhere) are generally not good.
An article in JAMA in 2009 pointed out that even though the expenditures on neck and back pain increased 65% ($34 billion), from 1997 to 2005, the percentage of persons disabled with neck and/or back pain rose from 20 to 25%. We continue to spend more than any other country in the world and yet we have increasing numbers of patients unable to function. What we are doing is obviously not working well. The APS article asks for integrity from professionals providing these costly treatments for pain. An honest reassessment of our standards of care can help eliminate ineffective procedures. Clearly some procedures do work for some people, but the indiscriminate use of costly interventions leads to unnecessary and often ineffective care. This will affect the bottom line as it should. Incentivizing for the performance of a procedure rather than for its outcome can never produce an efficient health care system. Common sense would tell us that exercise and diet would be the most cost-effective way to improve many common pain complaints. How often has your doctor spent time on these interventions?
I held a German medical license for a year in 1998. I spent time with an orthopedic surgeon in Regensburg seeing patients in his office and discussing their non-surgical treatment options. I asked him how he had the time to do this and not be in the operating room doing surgery. His answer was that he made the same amount of money in the office or doing surgery. That would be one way to dramatically change the medical cost of care in the US. Pay more for non-invasive treatment, and less for invasive treatments such as surgery, nerve blocks and spinal cord stimulators. Encourage pain patients to see physicians that provide comprehensive treatment before they are seen by doctors who only do invasive procedures.
Use of ineffective or marginally effective drugs also adds to our run- away cost of care for common pain complaints. A recent review of Botox for neck pain found that this very expensive treatment was not effective. Some years ago a prominent medical web site for physicians stated that Botox was the only good treatment of muscle/soft tissue pain. The editor of that section received fees as a speaker for the company promoting Botulinum Toxin. We need federal funding to do non-biased head to head comparisons of drugs so that the claims of new expensive drugs can be assessed to see if they are any better than what is available and less expensive.