It’s estimated that just over twenty percent of Americans suffer from chronic pain. I find that to be a frightening number, and I am among them. There is no shortage of theories about why people suffer from chronic pain, and the theories transcend physical ressons. In truth, above the age of fifty most people have pretty rough looking spines on MRI exam, but a chunk of those people don’t have pain while others are in nearly constant pain – and nobody knows what determines which group a person falls into.
Medical interventions for chronic pain are primitive and ineffective. The United States Drug Enforcement Administration (DEA) often seems so preoccupied with finding some drug they can actually effectively interdict that they don’t really care what the impact of their restrictions are on the patients who legitimately need and don’t abuse pain medications. Consider that, having had some success making Opioids harder to get for both legitimate users and illegal abusers, the DEA is now interested in other, non-narcotic pain medications that addicts misuse for their sedating qualities. This means that patients who don’t abuse these medications (which were formerly viewed as “safe” and more effective alternatives to Opioids) have to jump through hoops to get and fill prescriptions. This is not because these medicines are controlled substances, but rather because they might be one day.
If it’s not a medication issue, it is the issue of so-called pain clinics staffed by interventional anesthesiologists. Generally speaking, patients have to go to these clinics to get narcotic pain medication prescriptions written, but the clinics make their real money by doing “procedures” such as epidural steroid injections. These injections used to be administered in a physiatrist’s office on an exam table for little more than the cost of the medication. Now they are administered at your pain clinic’s “operating room,” with x-ray guidance and multiple staff members in the room, as well as a “pre-op” check in area and a post-procedure “recovery” area. As you might imagine, the move from the exam table to the operating room means these are now relatively high ticket outpatient procedures. Unfortunately, to be effective a patient most often needs two or three injections and the injections are temporarily effective treatments rather than cures. Pain clinics are profitable to the extent that they convince patients to get on the procedure treadmill. Some studies have found that simply putting the needle into the affected area provides the same relief even if medication isn’t injected. Of course, insurance companies won’t pay for an injection that isn’t an injection, so patients are often injected needlessly.
There are other dehumanizing elements to pain clinic culture. While it’s understandable that a certain amount of controlling behavior on the part of clinic staff is necessary since some of the medications prescribed are controlled substances, most patients are made to feel like addicts even if they don’t abuse medications. For example, even medications in the same class as aspirin and ibuprofen are prescribed precisely thirty, or ninety, days from the last refill. Since most patients are on multiple medications, this means that the patient has to make multiple trips to the pharmacy each month to refill medications that have no abuse potential at all. If the patient is on a narcotic pain medication, they sign a pain medication contract annually, which is fine, but then at each appointment they are given a form to fill out asking if they are aware they signed a pain contract. We are in pain, not stupid or memory impaired. If these procedures are questioned, there is no opportunity for discussion but plenty of opportunity for suspicion that the patient is trying to get away with something.
There is no question that pain has a profound psychological component. Nearly all pain doctors will tell you that is true, yet most pain clinics do not have any psychological component to their treatment team. Why not? Could it be that the income per square foot of office space for a support group is minuscule compared with the income for an “operating room?” The other, likely unintentional, consequence of not having therapists on staff is that there isn’t a place to process the impact of the controlling environment on the patient, nor is there anyone on staff who is likely to recognize that it could be a problem and raise the issue at staff meetings.
When we have discussions in this country about our healthcare system and the out of control expenses therein, we need to talk about places like pain clinics. They aren’t the only place in American medicine charging exorbitant fees for (at best) temporary relief. Nor are they the only soul crushing places in the medical community that lack psychological or spiritual support systems. The pain treatment industry generates in excess of three hundred billion dollars for itself each year, and these procedure mills are a big part of the problem. Presently there isn’t an alternative, but with that kind of money rolling in there isn’t much incentive to develop one, is there?