The Clinical Art of Pain Medicine: Balancing Evidence, Experience, Ethics, and Policy

Abstract

Efficacy, effectiveness, morbidity risks, and costs are four metrics that inform our conscious clinical reasoning about treatment for each patient. These metrics also inform general treatment strategies for different patient groups defined by characteristics such as mechanism, disease, age, comorbidities, and insurance coverage. Physician factors such as bias and values, sometimes unconscious, may also affect clinical reasoning. The Spine Section herein, while arguing best practices for zygapophysial blocks, highlights the importance of carefully considering the source and meaning of our metrics in pain medicine practice. Efficacy tells us about the chances of pain relief and its expected magnitude from any treatment, based on double-blind, placebo-controlled clinical trials in specific clinical populations. Effectiveness , a less precise metric usually derived from extended open label clinical trials and clinical experience, informs us of the performance of a treatment in a practice setting where factors such as convenience, comorbidities, and tolerability influence our decisions. Tricyclic antidepressants for neuropathic pain or depression are a good example––efficacy is established, but effectiveness in the field, which is enhanced by side-effects such as nighttime sedation and by once-a-day dosing convenience, is limited by both side-effect burden and concerns about toxicity and drug–disease interactions (e.g., arrhythmias, hypotension, urinary retention, suicide). Morbidity risks may emerge in early clinical trials, but sometime only after large populations are exposed to a particular drug or procedure in routine clinical practice over years or in large, postapproval multicenter trials. Nonsteroid anti-inflammatory drug (NSAIDS) (gastrointestinal and renal risk), Cox 2 inhibitors (cardiovascular risk), and spinal surgery for nonspecific low back pain (failed back surgery syndrome) are examples of risks that emerged in the public's awareness long after treatments were widely used in the field. Costs may influence practitioners' decisions about what to recommend, and patients' decisions about what prescriptions to fill and what advice …