The evidence base for the effectiveness of interventions and management strategies in chronic pain is large,69'70
although questions relating to the quality of studies and their relevance for clinical practice and economic evaluation remain.71 For example, an epidemiological survey of over 10,000 individuals concluded that "opioid treatment of long-term/chronic noncancer pain does not seem to fulfil any of the key outcome opioid treatment goals: pain relief, improved quality of life, and improved functional capacity.''44 The propensity to bolt on economic evaluations to clinical studies and to model the economic impact of interventions following on from randomized controlled trials, without taking into consideration some of the broader issues and factors from the complex environment that impinge on the overall impact of treatments and therapies, has been very noticeable in the last few years, as the focus has switched more to the assessment and appraisal of healthcare technologies. As a result, it may be more appropriate to rename cost-effectiveness studies as cost-efficacy studies and, while valiant efforts are being made to deal with the effect of uncertainty so as to aid the decision-making process, the fact remains that the everyday world of health care is very different from the quasi-laboratory conditions under which clinical studies are undertaken and, irrespective of the number of simulations of the available data, it is impossible to capture all possible scenarios and situations that might arise in the real world of clinical practice. The nature and extent of adverse events associated with some interventions have also resulted in considerable debate and discussion as to what constitutes effectiveness when the issues of efficacy and safety are combined. For example, a systematic review of over 5000 patients confirmed that most patients will experience at least one adverse event resulting from opioid use in chronic nonmalignant pain, and that substantial minorities will experience common adverse events of dry mouth, nausea, and constipation, and will not continue treatment because of intolerable adverse events.72
In relation to strategies for the management of chronic pain patients, the evidence base for their effectiveness is also increasing, although again the issue of what works, where, and when remains inconclusive. For example, a recent meta-analysis of psychological treatments of pain in children claimed that "there is, at present, no evidence for the effectiveness of psychological therapies in attenuating pain in conditions other than headache,''73 while reviews of multidisciplinary pain treatments in adults have been more circumspect due to the quality of studies in low back pain74 or concluded that there is very little evidence for effectiveness in neck and shoulder
The notion of efficiency has been discussed in general terms above, while in terms of pain management, there are three factors to consider in assessing the relative efficiency of interventions and programs, namely:
• maximizing the reduction in pain;
• minimizing the overall cost;
• minimizing the impact of adverse events.
It is essential to realize that the cost of treatment is not simply the costs of drugs or medical and nursing time, but the total costs of providing the treatment.55 As shown above under The economic impact of pain, the costs of dealing with adverse events are not insubstantial, and by merely focusing attention on acquisition costs, decision-makers are only considering the tip of the iceberg and neglecting the "under the water'' costs of dealing with adverse events, medical errors, and negligence claims, in addition to ineffective treatments and complementary medical examinations undertaken.76 Similarly, it has been argued that less emphasis on technological solutions and a shift towards the biopsychosocial model would be an efficient use of limited resources in pain management -"every study published shows that aggressive, multi-disciplinary pain management for the most disabled group of chronic patients will produce significant cost savings, to say nothing of the human suffering that will be alleviated.''77 However, even this claim can be called into question, as a systematic review of the effectiveness of multidisciplinary pain treatment of chronic non-malignant pain patients in terms of economic outcomes, has concluded that "due to serious methodological problems in study designs and outcome measures, it is not possible to draw conclusions on clinical or economical effectiveness.''78
The availability and accessibility of good quality services for all patients is highly desirable and should form part of the decision-making process. It has been argued that, in selected populations, patients managed through multi-disciplinary programs have lower costs, return to work more frequently, and experience greater pain control than those who are managed with more traditional methods.79 However, the availability of such facilities is sketchy and some populations have "no local access to services for patients with long-lasting pain''2 - a situation likely to deteriorate, as demographic factors intensify the demand for chronic pain services for the foreseeable future.80
The patient perspective is extremely important in terms of trying to achieve some degree of equity. Pain management programs were regarded as relatively high priority in a survey of nearly 3500 patients in Scotland, undertaken to assess the feasibility of using patients' perceptions of need for primary healthcare services to develop priorities, although the authors highlighted the fact that the area had received marginal attention in terms of development.81 It has been strongly advocated that society has an obligation to reduce levels of pain and restore normal functioning, based upon both moral principles and economic reality,78 with the ethical dimension18 being a powerful addition to the other three Es discussed earlier in this section.
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Do You Suffer From Chronic Pain? Do You Feel Like You Might Be Addicted to Pain Killers For Life? Are You Trapped on a Merry-Go-Round of Escalating Pain Tolerance That Might Eventually Mean That No Pain Killer Treats Your Condition Anymore? Have you been prescribed pain killers with dangerous side effects?