Last updated: Tue, Jan 14, 2025
Suppose that you were offered two different treatments for your painful condition. Suppose that the benefits and the drawbacks of the two treatments were quite different. Perhaps one takes much longer, one costs less, one has “side effects,” and that they differ in many other ways. Suppose that you were told in accurate detail all of the vicissitudes of both treatments, good and bad. How would you decide?
Functionaries in the medical system are faced with this problem whenever two treatments are compared. For treatments involving drugs and medical devices, the FDA is involved. In other situations, it may be decided by any of a number of groups. If one of the treatments is better in every way than the other, there is no problem, and it is said that the better treatment dominates the other. However, in general each treatment will have its good and its bad points. What then?
The issue of how to evaluate pain-related treatments has received attention from groups with special interests in the outcomes. In 2002, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) went to work on this with financing provided through unrestricted educational grants from pharmaceutical companies.
1 The study group contains members from academia, government, pharmaceutical companies, and pain advocacy groups.
I have noted that chronic pain brings with it a constellation of effects in addtion to pain levels, including mood abnormalities (such as depression), reduced social function, and reduced activity of many types or reduced activity globally. The pain research literature has been interpreted as defining three “relatively independent” factors that seem to determine the experience of pain patients:
Each of these can be measured using self-report or other techniques, many of which are reasonably well-established. The IMMPACT group identified several other aspects of pain experience that may also be important and suggested that they too might be included in evaluation of pain treatment trials:
A very broad measure of quality of treatment is what is called health-related quality of life, or HRQoL, which is a summary number made up by combining scores for factors such as pain intensity, physical function, and so forth. HRQoL is a name given to techniques for combining multiple measurements into a single score. There is no standard HRQoL procedure. Among the several HRQoLs that have been published, there are generic ones (good for any illness) and ones that are specific to a disease or a disease group. A simple HRQoL procedure might assign a score between 0 and 33 to pain intensity, another score of the same range to physical function, and another to emotional function. The result would be a number from 0 to 99 for each subject or patient that would purportedly measure his/her quality of life. An HRQoL measure always contains implicit judgments in the decisions about what factors to include and what weight to give to each.
One technique for deriving a score from multiple component measurements uses what are called “utilities.”2 Scores of pain intensity, say, are converted into utility scores. A group of healthy patients may have been asked what weight they would assign to being pain-free versus higher pain levels, and these weights are used to combine pain intensity measurements that make up the HRQoL. The result is a utility number from 0 to 1, where 0 means “no life” and 1 means “perfect health.” After these computations are made, each subject has a utility number for their condition before treatment and another for their condition afterward. The utility can also be multiplied by the duration over which the effects are expected to endure. This results in what are called quality-adjusted life years, which can be added and subtracted and compared to make statements about the overall value of a treatment.
I think that several observations about these processes are worthwhile:
Is this important? Clearly I think that it is. The process which determines what treatments will be discussed by your doctor is coming increasingly under the control of the economic watchdogs of the system. These groups have essentially no liability for withholding useful treatments. They have increasingly adopted tactics (like the IMMPACT effort) that operate early in the process, out of the public eye, and certainly well outside the ability of most sick people to participate in it. This and related issues are covered in more detail in The Pain Institutions, which outlines the overall process that establishes what kind of care is delivered in your doctor's office.