Chronic Pain Surgery: Too Risky, Too Costly

With high costs, risks of adverse events, and scant evidence of effectiveness, surgery for chronic pain is a prime example of overutilization of healthcare services.

There is inadequate evidence to justify surgical procedures to treat chronic pain, recent research shows.

"Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain," researchers reported this month in the journal Pain Medicine.

Chronic pain is a widespread and costly condition in the United States, affecting more than 100 million people and costing as much as $635 billion annually.

The Pain Medicine research features a review of 25 clinical trials involving 2,000 patients with conditions including lower back pain, arthritis, angina, abdominal pain, and endometriosis.

The researchers compared outcomes for invasive procedures and sham procedures. In a sham procedure, the patient goes through the rituals of a surgical procedure such as preparations and set up, anesthesia if needed, and tissue penetration. However, the tissue is not manipulated in a way that is thought to correct the underlying problem, and the patient is closed up or the instrument withdrawn.

For adverse events, there was a significantly higher risk for invasive procedures (12%) than sham procedures (4%).

The risks associated with surgery for chronic pain are too high and more clinical trials should be conducted, the researchers wrote.

"The risks of surgical and invasive procedures are not minor and appear to be higher with real compared with sham procedures. Risks in both groups include anesthesia, permanent injury to the body, psychologic stress, and time, cost, and productivity losses. Without more rigorous examination, large numbers of patients are exposed to risky and possibly unnecessary procedures."

The lead author of the research, Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, says physicians and chronic pain patients should consider surgery carefully.

"Right now, the scientific evidence does not justify doing these procedures for chronic pain. However, patients and circumstances vary, and physicians and patients need to decide individually what's appropriate for any particular patient. Taking this evidence and discussing it with the patient in shared decision-making is the best approach," Jonas told HealthLeaders last week.

Alternatives to surgery
 

Surgery for chronic pain is a prime example of overutilization of healthcare services and poor care coordination, Jonas says.

"It takes a multidisciplinary team of healthcare professionals at its center to help manage chronic pain. Yet one of the things the U.S. healthcare system as a whole systematically fails at is fostering coordinated care. Most care is piecemeal with little communication among providers. So, people with chronic pain are left to jump from provider to provider, often undergoing unnecessary, costly, duplicative procedures, and taking ineffective drugs—with ultimately little relief."

There are several options for treating chronic pain that do not involve invasive procedures or addictive medications such as opioids, he says.

"The American College of Physicians, the Centers for Disease Control and Prevention, the National Institutes of Health, and many other national bodies have recommended nonpharmacological approaches for the treatment of chronic pain. These include acupuncture, yoga, massage, and other such approaches. In addition, behavioral medicine has been demonstrated for many decades to be effective for chronic pain."