November - 20219From the perspective of non-interventional tools addressing the behavioral aspect of pain, pain education, and treatment of traumatic life events, advances continue to be made in the realm of computer-based education, but the technology has not yet reached the point where it can be implemented into practice without significant hurdles. The one exception to this may be the increase in virtual/telehealth usage which has allowed group education and behavior change-focused groups to come together virtually, arguably decreasing barriers to attendance. The single biggest problem remains getting reimbursed for appropriate care for patients suffering from pain. I think the reason for this is a simple fact that the patient population is not homogenous. Some patients have uncomplicated pain from a pinched nerve in their low back who will respond very well to physical therapy and an epidural injection. In these patients, the pain is still predominantly maintained by peripheral nerves. However, others may present with similar symptoms, but, upon closer examination, also have depression, anxiety, sleeplessness, a history of horrible childhood trauma, food, and housing instability, and other challenges. In these patients, the pain is not going to respond to treatments targeting the peripheral nervous system because their pain is at the level of the central nervous system. Reimbursement models do not take this into account. For instance, the latter patient described above is placed in the same category as the former "simple" patient when one reviews the outcome data on epidural injections and other interventions. Because it is well known that an injection will not help with pain from the central nervous system, some of the data would appear to imply that injections are not helpful as a whole. As a result, some insurers have concluded that injections are not helpful for anyone in pain and have stopped paying for them largely because the studies evaluating their efficacy do not consider the psychological and psychosocial variety within the pain population. Instead, they largely focus on anatomical variations. Conversely, some providers have taken advantage of the fact that higher reimbursement is realized by focusing predominantly on patients who can receive injections. I do not pretend that this relationship is novel to Pain Management, but rather is the tug of war that plagues all of medicine. Perhaps a more tangible challenge would be the training of pain specialists. Many of the fellowships for pain specialists tend to focus on the safe administration of injections and only provide minimal teaching about the treatment of more complex, what we call centralized pain. The multidisciplinary model is mentioned, but little training is given in how to work in a carefully integrated team. Mitigating this challenge would
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