Dr. Michael J. O’Connell, PainCare, New Hampshire, commented that many pain managers across the nation claim to provide “comprehensive” chronic pain management, yet this term has not been defined by any of the pain societies. This is unfortunate since the pain patient should know before accessing services, or wasting a good deal of money on one type of ineffective treatment, and other potentially successful types not mentioned or offered. Even the dictionary definition of “comprehensive” is uncertain, alluding to the inclusion of “many” or “all.” Which is it? Such vagueness is not helpful.
So it would seem that “comprehensive pain management” should include most, if not all services generally considered as useful treatment for pain. Enter another problem…how is “useful” or “effective” measured or characterized? Dr. O’Connell notes that historically this problem has been addressed by research, and scientific study. Pain management as a discipline in itself, and is historically very “new” compared with other specialties such as general surgery, cardiology or neurology. Hence, chronic pain management has not been subjected to rigorous study, and therefore its underpinnings are fragile if not precarious.
For example, the use of opioids in chronic conditions has been advocated by icons in pain management such as Lyn Webster, MD, former president of the American Academy of Pain Medicine, and Russ Portenoy, MD of New York’s Beth Israel Medical Center and former president of the American Pain Society. Both of these renowned figures have been tarnished if not disgraced by accepting immense pharmaceutical funding to advocate for opioids, and with precious little clinical support for effective long term outcomes. Webster has come under scrutiny by the DEA for over 20 ODs among his patients and has left clinical practice (despite having developed an assessment tool to root out abusers, both men named in a recent suit brought by the city of Chicago and several counties of California against the pharma that funded these men in promoting opioid use for chronic pain).
Another tool of the chronic pain manager, targeted steroid and anesthetic injections, has been subjected to a huge volume of studies by Lax Maschikanti, MD of Kentucky. While he professes to be heavily involved with face to face treatment of patients in his private practice, he apparently had enough time to produce more than 100 studies over the past few years, looking at the effectiveness and safety of such injections, many printed in peer reviewed journals. In addition, Dr. Maschikanti is reportedly heavily involved with the politics of pain and health care, the primary motivator behind a PAC advocating for the field of pain management. All these activities makes one question whether he sleeps, and the quality and reliability of his innumerable research articles.
Other tools of the chronic pain manager include behavioral medicine, psychotherapy, non opioid medications, physiotherapy, neurostimulation, chiropractic and alternative care with massage therapy, herbs, etc. Not one of these modalities has been subjected to rigorous scientific analysis of efficacy, not just short term, but long term. Not one randomized controlled study with significant numbers of patients has been produced on any.
So you can see that to answer the question, what is comprehensive pain management?, is to question the answer. Until questionable research can address the efficacy of each modality, the definition of comprehensive care cannot be entirely articulated.