When More than Science and Compassion Guide Healthcare

Pain care has evolved and changed over the last four decades and there’s no reason to think that it won’t continue to do so. One would like to think that basic and applied pain science guide these changes over time and to some extent such science does. However, we know that economic and social forces also have played a role, sometimes a predominant role, in the evolution of pain care over the last four decades. For instance, the rise and fall of long-term opioid management as the preferred therapy for those with chronic, benign pain syndromes seems to have been driven more by market and social forces than basic and applied science.

When market and other social catalysts to changes in the delivery of healthcare come to light, it’s always disquieting for both clinicians and patients. We have a certain faith in our healthcare delivery system -- that the care we deliver, or receive as patients, is the product of a slow march towards more effective care that is informed and propelled by science. Instances like the rise and fall of opioid management challenge our faith in this regard. It makes us reflect on the extent to which the realities of our healthcare system don’t match our idealistic perceptions of it.

“If these medicines weren’t safe and effective, then my doctor wouldn’t have prescribed them.” I work in an area of chronic pain management called chronic pain rehabilitation. Chronic pain rehabilitation is an interdisciplinary form of care that assists patients in learning to self-manage chronic pain, taper from opioid medications if they are on them, return to work, and reduce their dependency on the healthcare system for the management of their pain. It’s challenging yet rewarding work, seeing patients through a process of learning to empower themselves to take back control of their lives, even though their pain continues on a chronic basis. In the heyday of opioid management, it was even more challenging. I have heard countless patients express the above statement, or something similar to it, when discussing how chronic pain rehabilitation and its concomitant focus on tapering opioids, might be in their best interest.

As we all know, the ethos of the time, up until very recently, was that patients should be on opioids for chronic pain, that the medications were largely safe in terms of addiction, and that the medications were largely the most effective form of pain management available. None of these beliefs, however, were derived from basic or applied science.

Rather, they were largely the result of a pervasive marketing strategy of pharmaceutical companies that convinced even boards of medicine that govern the ethical practice of prescribing. Direct marketing to patients, direct marketing to providers, continuing education, and state professional licensing boards, all became vehicles for the proliferation of the afore-mentioned beliefs. By wittingly or unwittingly proliferating these beliefs, patients, providers and institutions also became vehicles to sell a lot of opioid medications for the pharmaceutical companies.

In working in chronic pain rehabilitation during a time marked by this ethos, it was hard to engage patients in giving up their opioid medications in favor of learning to self-manage pain. Raising concerns about the safety of these medications or their effectiveness relative to the effectiveness of chronic pain rehabilitation tended to yield responses like the one above: “If these medicines weren’t safe and effective, then my doctor wouldn’t have prescribed them.”

Notice the faith in the healthcare system that’s implied in such a statement. The implication is that the healthcare system is a system engaged in a march through time with compassionate altruism and science as its sole guides. Notice too the extent of the disconnect between such a statement and the actual empirical evidence that fails to support it, both at the time of the heyday of opioid management and still to this day.

For in actuality, opioids are not safe. They are not especially effective for the management of chronic, benign pain syndromes. And they really shouldn’t be used for such conditions in light of the fact that science tells us that interdisciplinary chronic pain rehabilitation is a much more effective form of care.

We are currently in a time in which our faith in the system is being challenged. As providers, we must reflect on how our idealism and our realities do not entirely match. As we discern our challenged faith in the system, we should also reflect on the extent to which we should share the need for this discernment with our patients. Do we have an ethical obligation to discuss with patients the forces that can guide us, either knowingly or unknowingly, when making recommendations?

Of course, we tend to be uncomfortable with such talk. We don’t tend to openly discuss how the free-market influences healthcare, preferring to focus on the other influences that act upon us, such as how science and compassion inform and guide our recommendations.

Our tendency to focus on only a portion of these influences, however, fails us and our patients on some occasions. We are living through one of these occasions. Perhaps, we should become more willing to acknowledge that there are many people and organizations making money off our scientifically guided and compassionately informed interactions with patients in the consulting room. Perhaps we have an ethical obligation to ourselves and to our patients to acknowledge that, figuratively, there are other people in the consulting room with us who influence the nature of our interactions. For if we acknowledge these influences in some fashion to our patients, we might just better maintain our integrity and our patients’ trust in us.

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change how chronic pain is managed by creating a demand for empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog. Additionally, Dr. McAllister is the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.