Roadblocks to effective pain treatment.

Despite the endless rhetoric about the need to demonstrate value in health care delivery and the debatable sophistry that health care purchasers are truly becoming value oriented, the fact remains that in the United States health care increasingly involves cost-controlled methods of delivery. Many individuals believe they have or wish they had a right to totally unrestricted and unlimited access to health care, no matter how redundant, ineffective, or costly it may be. Such a concept cannot be sustained by an appeal to logic or medical ethics. Individuals do have a rational expectation of reasonable access to efficacious and cost-effective medical care, including pain treatment. Unlimited medical needs and escalating high-cost technologic advances, in the face of national resources, creates a need for resource allocation. In a utilitarian society, resource allocation becomes an acceptable and perhaps even a desirable method of apportionment. In such an environment, however, patients using the most resources would seem to be at the greatest risk to facing roadblocks to effective care. Complex or chronically ill patients represent populations that might be particularly vulnerable to being underserved, but that is only part of the story. The title of this article implies that the new stewards of American health care (the payers, government, managed care organizations, and countless other intermediaries) have created administrative barriers that affect access to care for pain patients and beleaguer physicians who try to care for them. Although such roadblocks exist, the reasons for inadequate care of pain patients are far more complex. Therefore creating a laundry list of abuses within a kaleidoscopic ever-changing health care environment serves no useful purpose and would be outdated by the time this article comes to print. The reader who seeks to find simple solutions to everyday practice problems or to justify any sense he or she may have of victimization in the current environment will be disappointed. Rather the authors discuss the broad range of social and political issues that create roadblocks, including organized medicine's failure to meet the needs of people in pain. The symptom pain, which leads more patients to seek medical attention than any other, is so often misunderstood and mismanaged. There is evidence that all types of pain are inadequately managed in the United States and that this was true long before the advent of managed care. 37,39,42 This situation is likely due to a number of social factors, including the following: 1Inadequate training of medical, nursing, and related health care providers in techniques of pain management, including the appropriate use of opioids 2Inadequate public and professional knowledge about the pathophysiology and psychosocial aspects of pain and inadequate resources available for appropriate management. 3Fear of punitive action against practitioners who use opioids 4Charlatanism in the area of pain treatment 5Paucity of treatment guidelines and best practice standards, which, in part, is secondary to the difficulty in collecting and analyzing uniform treatment outcome measures in this large and heterogeneous patient population 6Roadblocks to access of care by experienced pain medicine practitioners for a variety of reasons Public interest in the problem of pain is mounting. Several states have developed Pain Commissions or investigative and advisory task forces to study the issues 1,31 and recommend legislation. Intractable pain treatment laws or regulations have emerged. 2,23 Despite efforts such as these, the plight of many chronic pain patients remains quite real. Patients are, for the most part, often poorly understood; seriously undertreated or overtreated; and sometimes seen as social outcasts by friends, family, and other support systems. Underscoring these kinds of issues is the undeniable fact that Americans have been unwilling to pay for some basic level of health care for all of its citizens. The elderly and chronically ill, who are more likely to suffer with problems of pain, are therefore likely to be among those who are disenfranchised by the system. Without a national health plan, Americans are left with an unregulated health care delivery system driven by multiple and often conflicting interests.