A Physician-Driven Solution—The Association for Medical Ethics, The Physician Payment Sunshine Act, and Ethical Challenges in Pain Medicine

Abstract

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

A glimmer of hope in American pain medicine?

“…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.…”

Editorial: The Suppression of Evidence-Basis in Pain Medicine and the Physician-Driven Quest to Re-establish It

“…In this issue, Drs. Danielle Perret and Chuck Rosen [25] not only elucidate the scope of the problem of practicing pain medicine without respect to the evidence‐bases, but offer a physician‐driven solution to this unfortunate trend. The authors begin their article by expressing their concerns regarding the status of interventional pain medicine, suggesting that it may not be as reliant upon an evidence‐basis as would be optimal.…”

“…The authors begin their article by expressing their concerns regarding the status of interventional pain medicine, suggesting that it may not be as reliant upon an evidence‐basis as would be optimal. Concerns regarding an absence of a widely accepted standard of care in interventional pain medicine have certainly been expressed over recent years [26,27], although Perret and Rosen [25] address issues of profit motive more aggressively than has been done in the past. Despite the fact that the second author (CR) is an orthopedist, the authors are comfortable moving to an examination of the lack of evidence for the efficacy of many routinely performed orthopedic procedures, noting that the technophilic approaches that have become standard are extremely expensive given their lack of an adequate evidence‐basis.…”

“…Although the need to balance technology and practical wisdom in other disciplines in pain management has been discussed previously [28], the authors' willingness to acknowledge this shortcoming within their own craft is commendable. Perret and Rosen [25] dedicate a formidable portion of their article to pain physicians' overreliance upon opioid analgesics as a primary treatment, irrespective of chronic opioid therapy's lack of a sufficient evidence‐basis. The authors are inclusive in their succinct discussion of chronic opioid therapy, addressing issues including the history of trends in the prescription of opioids, side effects, and the growing body of literature on problems of potential safety and iatrogenesis—both to the individual and to society as a whole.…”

“…Given its current challenges, merely criticizing the “business” of pain medicine is facile, and has not been established as a vehicle for changing the manner in which it is practiced or improving outcomes. What sets Perret and Rosen's [25] article apart from other analyses of the problems that plague our field of practice is that they describe physician‐driven efforts that have been made to solve many of the challenges with which our discipline is faced. The authors discuss the Physician Payment Sunshine Act, which will hopefully result in financial transparency through requiring public disclosure of all payments to physicians by industry when it is implemented in 2013.…”