After All, Pain Is a Complex Sensory and Emotional Experience (IASP, 1994). Clinical Economics and the Treatment of Persistent Pain

Abstract

Persistent pain is a clinical and economic problem at all levels of the healthcare system. Although epidemiologicandeconomicestimatesareoftensensitive to variations in definitions, methods of data collection, and other assumptions used in these studies, even conservative estimates indicate that many millions of individuals worldwide experience persistent pain and that associated costs are not only in the tens to hundreds of billions of U.S. dollars a year, but that indirect costs— mainly lost productivity—account for the bulk of these expenditures. As a result, Drs. Gatchel and Okifuji suggest that persistent pain is better viewed as a disease of functioning rather than simply one of pain. 5 Cost-Effectiveness Given the importance of functioning in understanding the effects of persistent pain on society, it makes sense to examine the evidence of cost-effectiveness of treatments for persistent pain. The results of formal cost-effectiveness analysesareexpressedintermsofcostperoutcome,suchas dollars per life saved. 3 Thus, one important question has to do with the choice of outcome. In some conditions, such as asthma, the symptom-free day is used, and a variation on this theme may be useful in assessing the cost-effectiveness of treatment for persistent pain. 9 Looking more closely at the calculation presented in this review, lifetime costs attributedtotreatmentinacomprehensiveprogramaresubtracted from costs associated with conventional treatment. No outcome is explicitly defined, suggesting that there is no difference in effectiveness between conventional care and multidisciplinary treatment, an assumption that is contrary to the evidence presented in this review. In fact, when considered side by side, the lower estimated lifetime costs of at least $357,000 per person treated in comprehensive pain programs, including disability costs, and evidence of clinical efficacy suggest that treating persons with persistent pain in comprehensive pain programs may dominate conventional care. Yet, there are some potentially important limitations of these estimates. First, concluding dominance in cost-effectiveness requires that an intervention be both less expensive and more effective (not just efficacious under tightly controlled conditions) than the comparator strategy. 3 Most healthcare interventions are purchased with a tradeoff of cost and effectiveness. We may gain effectiveness at a higher price or be willing to accept lower effectiveness to obtain a lower price. Second, the authors