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The American chronic pain crisis and the media: about time to get it right?

On November 23, 2015, the venerable Wall Street Journal published an article entitled “New Help for Back Pain”.1 In this article, the author wrote of “an innovative approach to help patients cope and heal called functional restoration”, suggesting that it helps avoid costly diagnostic tests, surgery and other expensive treatments, and the risks of problems potentially associated with opioid analgesics. While the author’s claims regarding interdisciplinary chronic pain management’s potential benefits are accurate, as is so often the case, the media’s inability to comprehend the “big picture” of the American crisis in pain medicine has resulted in yet another much-read yet highly biased and misinformative article that ultimately serves to exacerbate the difficulties with which our patients, and the system that they attempt to navigate, are faced. 
 
The author, Ms Landro, refers to interdisciplinary programs as “innovative”. This is inaccurate and befuddling, as interdisciplinary chronic pain management programs have been in existence for over half a century.2 In the 1970s, such programs were described as “medicine’s new growth industry”,3 with an estimated 1,000 such programs in the US around the turn of the millennium.4 Through empirical investigations and meta-analyses, these programs were found to not only be clinically effective in terms of functional restoration and relief of psychological symptoms, but cost-effective as well.5 On an anecdotal level, I witnessed the “miracles” that these programs performed, as I developed and ran an interdisciplinary pain program for 16 years. 
 
Tragically, the profit-driven American health care insurance industry decided that these programs were “too expensive”, irrespective of their aforementioned empirically-established cost-efficiency. At first, insurers attempted to reduce their costs by “carving out” services from programs. A typical interdisciplinary program would include physician management, psychological services, nursing, physical and occupational therapy, biofeedback, and vocational counseling.6 Despite the great success of these treatment programs, the insurance industry arbitrarily began to exclude payment for certain services, clearly without an empirical basis for doing so. For example, the program described in the recent Wall Street Journal article,1 according to the author, involves a “staff including a doctor, occupational and physical therapists, and a nurse practitioner”, with other crucial services not provided. Research by Gatchel et al7 has indicated that these “carve-out” programs obtain results significantly inferior to those obtained by comprehensive interdisciplinary programs. Thus, when the author reports that the cost of such a program is approximately US$17,000, she is reporting on the cost of a truncated “carve-out” rather than a considerably more expensive and effective full comprehensive program. Interestingly, most of the research supporting the cost-efficiency of interdisciplinary chronic pain management was conducted prior to the days of “carve-outs”.8 Reducing costs by bastardizing services was not sufficient for the health insurance industry, however. In the early years of this millennium, insurers began to simply refuse to cover these programs altogether,9–13 choosing to follow the “business ethic” of cost-containment and profitability while denying any fiduciary obligation to their enrollees. Although the main “culprit” in the demise of interdisciplinary pain management in the US was the insurance industry, it has also been noted that the hospital industry should shoulder some of the blame; hospitals shut down their pain clinics not necessarily because they were losing money, but rather because they were generating insufficient profits.14 
 
The tone of Ms Landro’s Wall Street Journal article1 suggests that interdisciplinary programs are an “option” for patients with chronic back pain, when, in fact, access in most states is not a possibility. In a 2012 study on international perspectives on interdisciplinary chronic pain management,15 I noted that from over 1,000 programs in the US in 1999, the number of programs had dropped to approximately 90 (outside of the military and the Veterans’ Administration). Not surprisingly, results of the study indicated that while the number of interdisciplinary programs in the US has been decreasing precipitously, the number of treatment facilities in industrialized nations with National Health Services had increased dramatically during the prior decade. The same was true of the Veterans’ Administration and the military in the US, as these entities (like National Health Services) “own” their enrollees pain care for life and accordingly have chosen to follow the evidence basis and provide the most effective, cost-efficient, and compassionate possible treatment. 
 
Unfortunately, Ms Landro’s article is not the only example of the American print media’s misinformation potentially causing harm to the already vulnerable population of patients with chronic pain. In a recent article in the Journal of Pain Research,16 my colleagues and I elucidated the detrimental impact of the media in our society’s “war on opioids” – which has essentially represented an attack on those who manufacture, prescribe, or rely upon opioid analgesics in order to manage their chronic pain. Our expression of concern regarding the deleterious impact of the media’s often biased and disingenuous behavior was certainly not the only one of its type expressed.17–20 Although negative stories regarding opioids in the print media have been empirically determined to affect physicians’ prescribing patterns,21 there is no evidence that negative print media characterizationshave had any impact on the real problem around opioids – ie, a lack of adequate risk mitigation practices among physicians. The media has happily published myriad stories regarding prescription opioid-related abuse, diversion, overdose, and deaths, yet is seemingly unwilling to write stories regarding the millions of Americans with chronic pain whose qualities of life are actually enhanced through their appropriate utilization of opioid analgesics. “If it bleeds, it leads” has clearly become media’s mantra regarding pain management, resulting in the desire to sell print trumping its broader societal responsibility to disseminate accurate, unbiased, and balanced information. 
 
I grew up in the era of Woodward and Bernstein, when the media was composed of individuals who we considered heroes – ie, journalists willing to take personal risks to disseminate accurate and unbiased information that the American people deserved to understand. During the days of the Watergate scandal, the US was clearly facing great crisis. Today, with the Institute of Medicine report22 indicating that approximately 100 million Americans suffer from chronic pain, we are experiencing another type of crisis. Given the moral deterioration of pain medicine in our country,11,23,24 this crisis has only become amplified. Accordingly, is it not time for the media to step up to the plate, and consider writing legitimate stories that may actually help patients with pain – and assist those of us who are trying our best to aid them?

On November 23, 2015, the venerable Wall Street Journal published an article entitled "New Help for Back Pain". 1 In this article, the author wrote of "an innovative approach to help patients cope and heal called functional restoration", suggesting that it helps avoid costly diagnostic tests, surgery and other expensive treatments, and the risks of problems potentially associated with opioid analgesics. While the author's claims regarding interdisciplinary chronic pain management's potential benefits are accurate, as is so often the case, the media's inability to comprehend the "big picture" of the American crisis in pain medicine has resulted in yet another much-read yet highly biased and misinformative article that ultimately serves to exacerbate the difficulties with which our patients, and the system that they attempt to navigate, are faced.
The author, Ms Landro, refers to interdisciplinary programs as "innovative". This is inaccurate and befuddling, as interdisciplinary chronic pain management programs have been in existence for over half a century. 2 In the 1970s, such programs were described as "medicine's new growth industry", 3 with an estimated 1,000 such programs in the US around the turn of the millennium. 4 Through empirical investigations and meta-analyses, these programs were found to not only be clinically effective in terms of functional restoration and relief of psychological symptoms, but cost-effective as well. 5 On an anecdotal level, I witnessed the "miracles" that these programs performed, as I developed and ran an interdisciplinary pain program for 16 years.
Tragically, the profit-driven American health care insurance industry decided that these programs were "too expensive", irrespective of their aforementioned empiricallyestablished cost-efficiency. At first, insurers attempted to reduce their costs by "carving out" services from programs. A typical interdisciplinary program would include physician management, psychological services, nursing, physical and occupational therapy, biofeedback, and vocational counseling. 6 Despite the great success of these treatment programs, the insurance industry arbitrarily began to exclude payment for certain services, clearly without an empirical basis for doing so. For example, the program described in the recent Wall Street Journal article, 1 according to the author, involves a "staff including a doctor, occupational and physical therapists, and a nurse practitioner", with other crucial services not provided. Research by Gatchel et al 7 has indicated that these "carve-out" programs obtain results significantly inferior to those obtained by comprehensive interdisciplinary programs. Thus, when the author reports that the cost of such a program is approximately US$17,000, she is reporting on the cost of a truncated "carve-out" rather than a considerably more expensive and effec-

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Schatman tive full comprehensive program. Interestingly, most of the research supporting the cost-efficiency of interdisciplinary chronic pain management was conducted prior to the days of "carve-outs". 8 Reducing costs by bastardizing services was not sufficient for the health insurance industry, however. In the early years of this millennium, insurers began to simply refuse to cover these programs altogether, [9][10][11][12][13] choosing to follow the "business ethic" of cost-containment and profitability while denying any fiduciary obligation to their enrollees. Although the main "culprit" in the demise of interdisciplinary pain management in the US was the insurance industry, it has also been noted that the hospital industry should shoulder some of the blame; hospitals shut down their pain clinics not necessarily because they were losing money, but rather because they were generating insufficient profits. 14 The tone of Ms Landro's Wall Street Journal article 1 suggests that interdisciplinary programs are an "option" for patients with chronic back pain, when, in fact, access in most states is not a possibility. In a 2012 study on international perspectives on interdisciplinary chronic pain management, 15 I noted that from over 1,000 programs in the US in 1999, the number of programs had dropped to approximately 90 (outside of the military and the Veterans' Administration). Not surprisingly, results of the study indicated that while the number of interdisciplinary programs in the US has been decreasing precipitously, the number of treatment facilities in industrialized nations with National Health Services had increased dramatically during the prior decade. The same was true of the Veterans' Administration and the military in the US, as these entities (like National Health Services) "own" their enrollees pain care for life and accordingly have chosen to follow the evidence basis and provide the most effective, cost-efficient, and compassionate possible treatment.
Unfortunately, Ms Landro's article is not the only example of the American print media's misinformation potentially causing harm to the already vulnerable population of patients with chronic pain. In a recent article in the Journal of Pain Research, 16 my colleagues and I elucidated the detrimental impact of the media in our society's "war on opioids" -which has essentially represented an attack on those who manufacture, prescribe, or rely upon opioid analgesics in order to manage their chronic pain. Our expression of concern regarding the deleterious impact of the media's often biased and disingenuous behavior was certainly not the only one of its type expressed. [17][18][19][20] Although negative stories regarding opioids in the print media have been empirically determined to affect physicians' prescribing patterns, 21 there is no evidence that negative print media characterizations have had any impact on the real problem around opioids -ie, a lack of adequate risk mitigation practices among physicians. The media has happily published myriad stories regarding prescription opioid-related abuse, diversion, overdose, and deaths, yet is seemingly unwilling to write stories regarding the millions of Americans with chronic pain whose qualities of life are actually enhanced through their appropriate utilization of opioid analgesics. "If it bleeds, it leads" has clearly become media's mantra regarding pain management, resulting in the desire to sell print trumping its broader societal responsibility to disseminate accurate, unbiased, and balanced information.
I grew up in the era of Woodward and Bernstein, when the media was composed of individuals who we considered heroes -ie, journalists willing to take personal risks to disseminate accurate and unbiased information that the American people deserved to understand. During the days of the Watergate scandal, the US was clearly facing great crisis. Today, with the Institute of Medicine report 22 indicating that approximately 100 million Americans suffer from chronic pain, we are experiencing another type of crisis. Given the moral deterioration of pain medicine in our country, 11,23,24 this crisis has only become amplified. Accordingly, is it not time for the media to step up to the plate, and consider writing legitimate stories that may actually help patients with painand assist those of us who are trying our best to aid them?

Disclosure
The author has no conflicts of interest in this work.