The extreme examples are quite obvious: If a country is so poor that it has no structured health care system and few providers, no pain management is offered. Folk remedies abound in every such culture, but their efficacy is probably not beyond the placebo effect. When some degree of formal health care exists in a country, governmental regulations may dramatically impact pain management. For example, many governments in developing countries did not, until recently, allow any opiates to be prescribed for outpatients or inpatients, instead limiting their availability to operating room use. Those who made such rules clearly valued the attempt to prevent drug abuse more than they cared about needless pain and suffering in those with cancer and other serious diseases. Finally, when strenuous international and local efforts successfully made opiates available in some of these countries, the cheapest and most effective standard drug, morphine, was often not on the list of allowable drugs; heavily marketed, patented, more expensive preparations appeared in the local pharmacopoeia. Economic factors (bribes?) were likely influential.

Another example can be seen in a country like Turkey, which has a centrally controlled health care system. Relatively early in the development of pain management, the government established training centers in pain management, established a credentialing board for physicians and treatment facilities, incorporated pain medicine in the curricula of medical schools, and mandated the distribution of accredited pain specialists in major medical centers. Pain management has flourished in this country. Similar examples of governmentally mandated pain management facilities and personnel can be found in the Scandinavian countries and the United Kingdom. As described in the prior chapter, Australia has recently recognized pain management as a specialty and established a reimbursement schedule that will encourage physicians to enter this discipline. These policies will certainly improve the availability of physicians who are willing to undertake the management of complicated chronic pain patients. Social and economic factors are important in the provision of services to pain patients.

There is some experimental data on the influences of socioeconomic factors on pain patients; however, there is very little empirical evidence about how the provision of health care for such patients is influenced by either economic or other social issues. One well-described socioeconomic factor is the economic status and race of the patient. Studies in the United States have documented the unavailability of opiates in pharmacies in New York City that are located in African American and/or poor neighborhoods (3). Other studies have shown that minority patients do not receive the same assessment or treatment as whites (4). Health care for those who suffer is one of the many activities of any culture or state; it tends to be integrated with the concepts of other forms of social support and is not often the subject of scrutiny. In the United States, social and economic events of the past 35 years have led to significant changes in the provision of health care for those who have pain, both chronic and acute. Most of my comments on socioeconomic effects on pain management in this country are based upon first-hand observation (5).

At the dawn of the Pain Movement in the 1960s, there were almost no physicians or psychologists who considered themselves pain specialists. There were few pain clinics, a handful of monographs, no standard texts, no pain journals, few continuing medical education courses, and no professional societies devoted to pain. Pain was usually considered the by-product of a disease and was expected to disappear if the disease was successfully treated. As observed from time immemorial, there certainly were patients suffering with chronic pain, both due to cancer and noncancer diseases, but there were few pain specialists and no guidelines for pain management. Opiates were not widely used, and dosing was minimal when they were. Things evolved in a helter-skelter fashion. Opiate prescriptions increased, and large numbers of patients were referred to the early pain clinics with multiple opiates prescribed by multiple physicians unknown to each other. These patients complained vigorously about their pain despite their heavy medication intake. Pain clinics quickly learned that tapering such painful people off of their opiates, along with physical activation, education, treatment of depression, and focused return-to-work programs reduced their pain and functional disabilities. From these observations arose the dogma that chronic pain patients should not be treated with opiates. The experiences of pain clinics were generalized to the population at large in the absence of any data to indicate that those who came to pain clinics were typical of all who suffered from pain.

Pain clinics proliferated, often with different conceptual underpinnings. The message about inappropriate use of opiates was widely disseminated. Problem patients with high opiate intake became less common. Then the cancer pain movement began, and it was learned that patients with pain due to cancer often required very large doses of opiates to get relief, inexorable dose escalation due to tolerance was not a major problem, and that, with stable disease status, doses of opiates were typically stable. Furthermore, when treatment other than opiates was implemented that alleviated the cause of the pain, such patients rapidly reduced or discontinued their use of opiates without manifesting an abstinence syndrome. With little evidence to support generalization of the experience with cancer pain to noncancer pain, it was loudly advocated by a small number of physicians that every patient should be given whatever dose of opiate was required to obtain pain relief. The physician’s life was easier: Just prescribe an opiate in whatever dose the patient wanted and get the patient out of the office. Poor prescribing habits eventually led to inappropriate usage, a rapid increase in emergency room visits and deaths related to prescription opiates, and little reduction in pain and disability in the overall population of patients with chronic pain (6). Public outcry about excessive opiate prescribing and efforts by state and federal officials to discourage opiate usage for medicinal purposes now have made it difficult for appropriately selected patients to obtain chronic opiate prescriptions.

We have seen two revolutions of the opiate-prescribing cycle in the United States. What has been lacking is reliable evidence to support the position of either side in this dispute. Care for patients with chronic pain has fluctuated widely, but certainly not on the basis of scientific evidence. Fortunately, most opiates are inexpensive, and agencies designed to control costs (often labeled as “managed care”) have not focused upon their use.

Another example of socioeconomic changes in the provision of care for pain patients is the rapid expansion of pain specialists among anesthesiologists that occurred in the past 20 years both in the United States and in other countries. In the United States, federal agencies determine the charges for services by an arcane process that is not immune to lobbying. Procedures such as epidural steroids, facet blocks, and nerve blocks are reimbursed far more handsomely than consultation time with the patient. It is no accident, therefore, that proceduralists rapidly increased in number (even in the absence of outcomes-based evidence for efficacy) whereas multidisciplinary pain clinics have rapidly decreased in number, since they do not generate sufficient revenue to satisfy practitioners or hospital administrators. The number of providers is directly related to economic factors such as remuneration for services. This phenomenon is part of the irrational U.S. health care system, and is not seen in countries that have a systematic plan for specialist numbers and distribution.

The advent of managed care in the United States was an attempt to contain costs and in some cases to establish profitable business franchises, disguised as an effort to improve patient management. Although some large managed care organizations persist, this method has not been very successful at either improving management or containing costs. Managed care has dramatically reduced the time that a physician has available to spend with each patient, although successful management of a chronic pain patient requires listening to and understanding the patient’s narrative. This cannot occur in a 7-minute visit. Furthermore, managed care organizations often limit access to specialists, tests, drugs, procedures, and surgery; these constraints, too, can be damaging to patients with pain. Chronic pain is often not considered a “real” disease, and sufferers are considered less than deserving of care (7).

As is true for almost every aspect of medical practice, there are wide variations in rates of surgery for low back pain (1,8,9,10,11). Economic factors are certainly one of the reasons for this finding. Small area analysis of surgery for low back pain has shown wide variations in the rates of surgery in different states in the United States. These variations are clearly not due to a higher prevalence of patients with defective backs who reside in each high-rate area. Although no satisfactory explanation for all of the variance has been forthcoming, clearly, physician practice style, which is influenced by both peer group pressures and economics, plays a role. Both factors do so in a largely unexamined fashion and lead to increased patient management costs.

When surgeons make a much more handsome living than medical practitioners, it should not surprise anyone that more young doctors choose to go into surgery. The rate of surgery for low back pain is directly proportional to the number of orthopedic and neurologic surgeons in a country, not to the population at risk (10). Within the neurosurgical and orthopedic specialties, it is widely recognized that the most lucrative practice involves spinal fusions using hardware. Hence, the type of care offered to patients with low back pain is largely determined by the availability of providers, which is partially determined by economic factors.

In his fascinating book, Occupation and Disease, Dembe documents the socioeconomic factors that have changed the way the Western world looks at low back pain (12). What started out in the 18th and early 19th centuries as a form of rheumatism, whose pathogenesis lay completely within the sufferer, evolved over a 100-year period to be an occupational disorder secondary to trauma. The development of orthopedics as a specialty facilitated this transition and led to increasing surgery to contend with low back pain. The idea that the workplace was the cause of low back pain and that illnesses originating in the workplace should be paid for by the employer completed the change in thinking about how to manage low back pain. Social and economic factors, and not the failure of the working man’s back or wrist, are thus responsible for the huge increase in health care costs and disability compensation
for conditions such as low back pain and carpal tunnel syndrome.

Despite the remarkable preclinical advances described by Baron, Basbaum, Cousins, Dickenson, Yaksh, and others in this volume, health care is, and always has been determined much more by socioeconomic factors than medical science. Contemporary pain management has not been shaped by evidence of treatment efficacy. If it were, multidisciplinary pain clinics would be flourishing, instead of waning (13).