Rethinking Algorithms of Pain Care: The Use of the S.A.F.E. Principles

Abstract

In 1996, Krames, trying to make sense out of therapeutic choice for pain management of chronic noncancer-related pain problems wrote that “because there are multiple choices, both interventional and noninterventional for the management of pain, the treating physician should choose one therapy over another in a rational manner …”[1] Because, at the time there was little information to mine for decision-making, the only variables accessible to the treating physician for choosing one therapy over another were levels of invasiveness and “up-front” costs of the therapy. Krames suggested an algorithm of choosing that was based on the time-honored medical principle, the KISS principle, or “Keep It Sweet and Simple.” This algorithm based on the KISS principle listed least invasive and less “up-front” costly therapies first and more invasive and more costly therapies, later in the algorithm. He also suggested that some therapies could be used in series, some in parallel, abandoning those that do not work and trying more invasive therapies and more costly therapies until the algorithm (choices) was exhausted. Based on this algorithm, implantable technologies for pain, stimulation therapies, and implantable drug delivery systems (IDDS) were relegated to last resort therapy. While this approach was appropriate for the time, today, a review of the literature allows us to make more rational choices between pain therapies based on variables other than invasiveness and up-front costs. Today, it may not be in the best interest of a patient, or even the third party payer, to wait until all less costly and less invasive, but not effective, treatment options have failed before initiating more invasive therapies including nerve-blocking procedures, epidural steroid injections, facet injections/neurolysis, or therapies of neuromodulation, such as spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), peripheral subcutaneous field stimulation (PSFS), or intrathecal therapies via IDDS. If a given …