Dr. Danielle Perret and Dr. Charles Rosen have published an article in this months Pain Medicine that is worth the time it takes to read it. It is almost 10 pages long and it adresses nicely issues such as “frequent application of interventional techniques “ , the Charite Disc, the fact that the US uses 99% of the worlds hydrocodone supply, ultrashort acting fentanyl, and most importantly, conflicts of interest in pain education and research in the context of industry support. They also make a case for a potential solution. Dr. Rosen is one of the founders of the Association for Medical Ethics (AME).
AME is an organization:
“intended to promote full financial disclosure in the practice of medicine and research. Namely, the association recognizes that the patient and the practicing physician have a right to realize if a drug or device manufacturer paid the authors of a positive study; the amount and nature of finacial compensation should also be transparent.”
The authors state that the AME is the only organiaztion – as well as Website – that lacks industry funding. They descibe the obvious advantages of such an organization. I had never heard of this organization before but the concept seems quite appealing. Their Website is rather brief but worth a visit. It costs nothing to join except declaring that you will not accept money from any industry source. They do evidence reviews on their site similar to Cochrane reviews that were fun to read- especially the IDET material.
In discusssing interventionalist’s they underscore the need for competency assessment of many poorly trained interventionalists who are out there practicing, the paucity of evidence in this field, and the incentive for physicians to overuse potentially lucrataive procedures. I completely agree. I am sure many of us have been horrified by the abuse we witness in our field. I recently saw an elderly man who relocated to New Hampshire (where I practice) from Florida who wanted me to provide him the epidural injections that were so useful to him in Florida. I obtained a copy of his procedure notes and could not believe that the “interventionalist” was performing four transforaminal injections at a time for this gentleman with a nonoperated and otherwise normal back. A single interlaminer injection would be the indicated procedure at probably one fifth the cost and with only a fraction of the risk!
I have momentarily wondered why pharmaceutical companies came out with Onsolis (fentanyl buccal soluble film) and Fentora (fentanyl effervescent buccal tablets) when Actiq (fentanyl buccal lozenges) was already available. Since as far as I can tell there is no clinical advantage of one over the other, the answer can only be money. I have seen patients presenting in my office with chronic pain using these incredibly expensive drugs for no good reason. I have used Actiq twice that I can recall in nonterminal patients- but both times with good reasons. Of course, the data supporting the use of these drugs comes from pharmaceutical manufacturers. Does breakthrough pain even occur in patients with chronic pain? Is ultrashort acting fentanyl more or less safe then other oral opioids? Are there side-effects unique to these drugs that we are as yet unaware of? Is there an unbiased individual who can answer these questions? We know from reviewing the Infuse (my last post) data that pharmaceutical company funded data is biased; anybody that accepts funds from device or drug manufacturers is biased; and there can be no doubt about that (unless you are a choirboy- see my last post).
In their conclusion, these authors state:
“Medicine should return to being independant, unbiased, and guided only by what is best for the patient, not necessarily what the patient or the medical manufacturers want”.
We will not quibble with the fact the the device and drug manufacturers are responsible to ther shareholders for profit as their primary motivator. I believe that in general they are interested in patient well-being and safety as well but this concern can easily be subjugated by an overwhelming and severely biased assessment of the value of their product. I also believe that millions or billions of dollars is incentive enough to create criminals out of doctors or device and drug manufacturers. The stakes are so enormous that lying and deceiving for dollars becomes a very real option. To read about the Cumbria Worlds Biggest Liar competition select the following link.