Over the past 8 years, I have acquired a degree of notoriety relating to my scathing
criticism of the badly broken American pain care system. In the three-part series
on the crisis in pain care in the United States that I coauthored with Dr Jim Giordano
in 2008,1–3 we performed an ethical analysis of our system, examining the need for
a paradigmatic revision if we were to adequately treat a disease as complex as is
chronic pain, given the system’s economic realities. Due to the insurance and hospital
industries’ adherence to the “business ethic” of cost-containment and profitability
(as opposed to patient well-being), we were witnessing the profound undertreatment
of pain in conjunction with a growing reliance upon technophilism, ie, an emphasis
on technologically driven pain care sorely lacking a reasonable evidence-basis. Early
in the following decade, Dr Alan Lebovits and I guest-edited a special series in Pain
Medicine on the unfortunate devolution of the “profession” of pain medicine to the
“business” of pain medicine.4 This series featured a number of highly critical articles,
including examinations of the health insurance industry’s refusal to cover interdisciplinary
pain management programs,5 the corporatization of American pain management and the
resulting benefits to certain special interests and concomitant increases in disparities
in pain care,6 physician complicity in the transformation of pain medicine from a
profession to a business,7 the increase in pain management spending without any evidence
of improved patient outcomes,8 the overutilization of interventional procedures and
spine surgery by physicians who have “questionable” relationships with industry,9
conflict of interest relating to industry and its impact on pain education,10 and
our failure to adequately address the ethical dilemmas that have been plaguing pain
medicine for centuries.11 Although these articles, written by luminaries in the field,
provided extremely entertaining (yet disturbing) reading, I question whether they
had a significant impact on the ethical imbroglio that was (and still is) American
pain medicine.
Irrespective, in a quixotic fashion, I persisted. Subsequent articles and textbook
chapters included an examination of problems in pain management disparities research,12
the ethical imperative of balancing continuing medical education and conflicts in
pain medicine,13 the role of inadequate workers compensation systems in perpetuating
pain and disability,14 the lack of an evidence basis for mandated use of (expensive)
electronic medical record systems in palliative and hospice medicine,15 an exposé
on medical marijuana dispensaries that make absurd amounts of money without carrying
products that are particularly medical,16 the perpetuation of the American opioid
crisis by the health insurance industry’s concern solely for cost-containment and
profitability,17 automobile insurance carriers’ refusal to pay for psychological injuries
sustained in motor vehicle accidents – thereby perpetuating physical and psychological
suffering,18 and the American media’s desire to “sell print” rather than providing
an unbiased account of the many benefits as well as the obvious potential harms of
opioid analgesics.19
Does anyone recognize a theme here? I have been convinced – and thoroughly so – that
the quality of American pain medicine is severely compromised by the “evils” of capitalism.
Due to the commodification of the American pain care system, patients have become
“fungible”. Physicians treating pain in the United States had become so frustrated
by our system that they had all given up hope and were treating pain medicine like
any other business. Or so I thought.
Last week, I had the opportunity to visit an organization in Massachusetts, Boston
PainCare. A colleague had recommended that I meet with the physician owners of this
pain clinic in order to discuss future possibilities for collaborative research. What
I learned about their organization and commitment to the highest quality pain care
and research frankly amazed me, to the extent that I felt compelled to write this
editorial about what they are doing for their patients, and hopefully for the paradigm
through which pain is treated in the United States. As one of their owners stated,
“Like any business model our clinic needs to be profitable, but our focus is not on
maximizing revenue at the expense of patient care”. Quality of care is clearly the
primary concern of these physicians – which I posit is sadly an anomaly in American
pain medicine.
Boston PainCare was founded in 2007 by six anesthesiologists who had been treating
patients in a hospital setting. Their initial goal remains their goal today, ie, to
treat people suffering from pain from a patient-centric model that embraces functional
and behavioral interventions as the core of its treatment approach. This is of great
importance in the current climate of pain medicine, in which patients have been lost
in “a sea of drugs and procedures”20 for too many years. Since the organization’s
inception, it has grown substantially, as the partners have the wisdom to recognize
that the discipline of anesthesiology – while an important component of pain care
– is not sufficient to meet all of the complex biopsychosocial needs of patients suffering
from the disease of chronic pain. This evolution in thinking is reflected in their
approach to the use of interventional treatments. While Boston PainCare performs procedures
in its own onsite ambulatory surgery center, they strongly reject the American pain
medicine “block-shop” mentality in which too many injections are provided without
adequate empirical evidence.21 Instead, these procedures are viewed as adjunctive
therapies used to facilitate what they see as the central mission of pain treatment,
namely the improvement of a patient’s quality of life through the recovery of meaningful
functioning (independence in self-care, social reengagement, vocational activities)
and the replacement of maladaptive behaviors with adaptive coping strategies.
As the founding partners at Boston PainCare recognized that many of the patients who
were referred to them were suffering from intractable headache pain, they brought
a world-renowned neurologist/headache specialist into their facility to develop a
specialized Headache Institute.
Additionally, given the body of research supporting the reciprocal and bidirectional
relationship between chronic pain and impaired sleep,22 Boston PainCare opened an
in-house Sleep Center in 2009, with that program receiving American Academy of Sleep
Medicine accreditation. To the best of my knowledge, this is the only in-house accredited
sleep center in a pain management facility in the United States. Given the organization’s
emphasis on quality, it is not surprising that the Sleep Center is led by a physician
who is board-certified in Sleep Medicine.
Despite being founded by anesthesiologists, this unique group of clinicians recognizes
that chronic pain needs to be treated not only biopsychosocially, but perhaps even
from a sociopsychobiological model23 that emphasizes functional restoration through
an interdisciplinary pain management program as well as the imperative of evidence-based
behavioral approaches to chronic pain. Accordingly, the treatment team at Boston Pain
Care includes four doctoral-level psychologists, all of whom have availed themselves
of post doctoral training in pain management. Additionally, patients thought to potentially
benefit from complementary and alternative medicine approaches are provided with such,
with a chiropractor also included on the facility’s interdisciplinary team. Nutrition
is also considered an important part of treatment, which is supported by recent literature.24
Boston PainCare’s staff includes four Registered Nurses and three Nurse Practitioners,
who provide a wide range of clinical, educational, and administrative services. Their
interdisciplinary functional restoration program staff, of course, includes a physical
therapist. As is a problem throughout the vast majority of the United States,25 the
insurance reimbursement climate in Massachusetts has made it a challenge to grow their
interdisciplinary pain management program to the degree that the team would find optimal.
Accordingly, the facility attempts to make all treatment that it provides as interdisciplinary
as possible through regularly scheduled team meetings as well as frequent informal
communication between members of the represented disciplines.
Boston PainCare’s stated mission is the creation of a sustainable and scalable interdisciplinary
treatment model capable of providing high quality care to an often poorly served patient
population while reducing the adverse economic and societal consequences associated
with the fractionated, unimodal and non purposeful treatment approaches commonly employed
by the majority of pain care providers.26 Critical to this process is the development
of their customized electronic health record system (NextGen platform), which allows
for the identification and tracking of common treatment goals used by all disciplines
in the development of individualized treatment plans. Individual and aggregated patient
data extracted from their electronic health record system are also used for the monitoring
of progress toward each patient’s treatment goals as well as for the development of
best practice approaches. As important, their use of information technologies allows
them to incorporate cost, safety, and efficacy data into the creation of the clinic’s
treatment guidelines, such as the center’s tiered pharmacy protocol that allows their
clinicians to improve outcomes while reducing overall treatment costs.
Much has been written regarding the deleterious impact of the “war on opioids” on
patients suffering from chronic pain.27–32 Recent prescribing guidelines, disingenuously
identifying themselves as voluntary,33,34 have had a clear “chilling effect”, resulting
in many physicians choosing to exclude opioid analgesics from their pain management
armamentaria.35 The anti-opioid climate in Massachusetts has been particularly pernicious,
with a new bill limiting opioid prescriptions providing evidence of such.36 Irrespective,
the physicians at Boston PainCare prescribe opioids to well-selected patients for
whom there exist no other viable options. This is not to suggest that these providers
are “pro-opioid”; in fact, much of their clinical work and research involves tapering
patients for whom opioids are not appropriate from these medications. More so, they
feel an obligation as pain specialists to not only reduce the adverse consequences
of irresponsible opioid prescriptive habits but to also protect the appropriate access
to these drugs through the practice and promotion of rational opioid treatment, which
certainly involves aggressive risk mitigation. Patients being considered for opioid
therapy undergo extensive psychological and functional evaluations prior to prescription.
This approach was endorsed through a systematic review of guidelines for opioid prescribing
that was conducted when guidelines were evidence-based rather than biased and consensus-based.37
Additionally, the Boston PainCare Medication Management Program is not run in a one
size fits all manner. For example, team members meet on a weekly basis to review all
new patient evaluations to determine the appropriateness of medication treatment.
Patients accepted for enrollment are then placed into one of five care plan tracts
by team decision, each of which offers varying levels of medical and behavioral health
services to best meet the needs of each patient. Prescribing practices are supported
by the presence of a doctoral-level pharmacist who provides chart reviews and pharmacological
consultations for all patients undergoing medication treatment as well as monitoring
of the center’s rational prescribing program. While the rates of urine drug testing
among physicians prescribing opioids in the United States are woefully low, with as
few as 7% of patients receiving chronic opioid therapy determined at baseline measurement
to undergo urine drug testing,38 all patients receiving opioids at Boston PainCare
undergo routine urine drug testing. This process is made seamless by the inclusion
of a medical technologist on staff and an in-house toxicology laboratory that allows
for the review of drug testing data prior to the dispensing of opioid prescriptions.
Indicative of the effectiveness of the overall approach to opioid treatment at Boston
PainCare, the rate of occurrence of reported aberrant urine drug test results at their
center (7.6%)39 is significantly lower than those commonly cited in medical literature
(13%–40%).40 Furthermore, the treatment team at Boston Pain Care is unaware of any
opioid overdose deaths since the facility’s inception 9 years ago.
Finally, the medical staff at Boston Pain Care conducts and publishes scientific research
on what constitutes effective pain management, with six manuscripts accepted over
the past 3 years.39,41–45 Additionally, the center has forged collaborative research
relationships with both Tufts University and Massachusetts General Hospital, and currently
have three manuscripts in preparation involving clinical outcomes data extracted from
the more than 8,000 patients in their customized health records database. This is
extremely important, as the days of the scientist–practitioner model of pain management
seem to have become a thing of the past, with the disconnect between academicians
and clinicians in pain medicine and its implications addressed in the literature.46
In summary, there is much that is wrong with American pain medicine, and I have learned
that writing myriad articles merely exposing these problems does not necessarily remedy
them. My recent visit to Boston PainCare, however, was both elucidating and encouraging.
The interdisciplinary management of chronic pain at this high level was typically
only seen at teaching institutions in the United States; however, as John Loeser noted
almost a decade ago, even in academic institutions, “revenue generation is the major
determinant of what services the institution will offer”.47 Such an attitude is clearly
not the guiding force behind Boston PainCare. This is one of the rare American pain
treatment facilities that does it right, and the owners and their staff are aware
of the excellence that they provide. However, rather than merely resting on their
laurels, the leadership of this organization is dedicated to changing the paradigm
through which chronic pain is treated not only on a local level, but nationally as
well. Given my own burning desire to see a paradigmatic revision in pain care, my
hope is that this brief discussion of the successful Boston PainCare model will serve
to inspire other private and public facilities worldwide to closely examine their
policies, procedures, and motivations, and to become a part of the solution rather
than remaining a contributor to the problem of purely profit-motivated (and consequently
inadequate) pain management.