Chief

The Institute of Medicine (IOM) published a consensus report in June 2011 on the “national challenge” of chronic pain.¹ Below the heading “Underlying Principles,” the report states,

“Given chronic pain’s diverse effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems.” ¹

Yet much of the medical community tends to treat pain as a physical problem with pharmacologic solutions, effectively dismissing the value of interdisciplinary pain management and the biopsychosocial model underlying this approach, even though its interrelated factors are clearly linked to improved physical symptoms and decreased use of costly medical resources.^2,3 However, over the past 2 decades an undeniable body of evidence favoring an interdisciplinary approach has been growing.

Rationale and research

Success with a multimodal approach to pain management has been demonstrated for a number of pain conditions, perhaps most clearly in studies of chronic low back pain (LBP). In one study, 108 patients (63% with LBP) underwent multiple sessions of individual cognitive behavioral therapy (CBT), physical therapy, aquatic physical therapy, occupational therapy, group education, and group relaxation.⁴ At program enrollment, program completion, and long-term follow-up, researchers gathered data on changes in pain severity, emotional stress, interference of pain on functioning, perceived control of pain, helpfulness of treatment, and hours resting. At 6 months and 1 year following completion of the study, all 6 measures showed statistically significant improvement over baseline, with 95% confidence intervals in 5 of the 6 showing no overlap between pre-program and follow-up measures. [TABLE 1]

TABLE 1:   Variance of outcomes of a comprehensive pain management program with 1-year follow-up (n=46) 

* No overlap in confidence interval between pretreatment and either posttreatment or 1-year scores

**n=40

Source: Adapted with permission from Oslund S, et al. Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Proc (Bayl Univ Med Cent). 2009;22(3)211-214.

In a systematic review of 10 randomized controlled trials encompassing 1964 patients with disabling LBP, researchers found strong evidence that intensive multidisciplinary biopsychosocial rehabilitation improves function when compared with inpatient or outpatient treatments. The review also found moderate evidence of pain reduction with multidisciplinary care compared with non-multidisciplinary care.⁵

Studies of musculoskeletal pain also have reported good results with interdisciplinary care. In a study of interdisciplinary pain management for chronic musculoskeletal pain, military personnel were to receive either interdisciplinary care with physical therapy, occupational therapy, and psychosocial intervention, or standard anesthesia treatment alone.⁶ At 6 months and 1 year, data collected on pain, disability, functional status, and fitness for return to duty showed that interdisciplinary care was far superior to standard care.

A systematic review of randomized controlled trials found strong evidence that multidisciplinary care is more effective for nonmalignant chronic pain diagnoses (chronic LBP, back pain, fibromyalgia, and mixed chronic pain) than standard medical treatment, and moderate evidence for its effectiveness compared with other nonmultidisciplinary treatments.⁷ According to the study authors, the data support, at minimum, offering a range of treatments—including individual exercising, training in relaxation techniques, group therapy with a clinical psychologist, patient education, physiotherapy, and medical training therapy—and providing neurophysiology information. They also point out that no particular combination or duration of therapy has proved superior to others in clinical outcomes.

Risks of interdisciplinary care versus standard care

Therapies employed in interdisciplinary pain management are relatively low-risk compared with other interventions, such as opioid use or surgery. A 2010 Cochrane review of opioid use for chronic non-cancer pain found that concerns about long-term use of opioids can present a potential barrier to treatment. Opioids often lead to adverse effects (gastrointestinal effects such as constipation and nausea; headache; fatigue; urinary complications) severe enough to warrant discontinuation.8 This review found the rate of opioid addiction in these study populations was extremely low, however, and concluded that potential iatrogenic opioid addiction should not be a barrier for well-selected and well-supervised patients. As this study indicates, patients who gain pain relief from prescribed opioids might become drug dependent, but will not become addicted.

Also, although opioids are widely used,their ability to control pain varies. A study from the Mayo Comprehensive Rehabilitation Center of 233 consecutively enrolled patients with chronic nonmalignant pain found 48% were using opioids daily at baseline, at a cost of $23.13 per day or $8326.90 per year (average wholesale price) per patient.⁹ Patients who completed a 3-week multidisciplinary intervention significantly reduced their medication use at 6-month follow-up, for an estimated annual savings of $2404.80 per patient.

Two studies comparing interdisciplinary care with spine fusion surgery for chronic back pain found interdisciplinary care to be a reasonable alternative for many patients. In a study of patients with chronic LBP who had previous surgery for disc herniation, spinal fusion showed no benefit over cognitive intervention and exercise after 1 year.¹⁰ [TABLE 2] A multicenter trial comparing surgical stabilization of the lumbar spine with an intensive rehabilitation program based on CBT found no clear evidence that spinal fusion provided greater benefit.¹¹

TABLE 2 : Primary and secondary outcomes comparing spinal
fusion with CBT and exercise

*Oswestry Disability Questionnaire in which the sum of response scores ranges from 0 to 100,where 100 represents the worst possible pain and disability.

**Based on a vertical visual analog scale ranging from 0 to 100, where 100 reflected the worst pain imaginable.

Source: Adapted from Brox JI, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study. Pain. 2006;122(1):145-155. This table has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The table

may not be reproduced for any other purpose without permission.

What interdisciplinary pain management looks like

Key disciplines of an interdisciplinary pain management program are medicine, psychology, and rehabilitation. However, programs vary in available services and professional disciplines, setting, and duration. A fully integrated pain treatment center offers a range of therapies that may include transcutaneous electrical nerve stimulation, CBT, biofeedback, physical therapy, psychoeducational group treatment, and medications such as nonnarcotic analgesics and nerve blocks. Additional disciplines may include outcome database managers, vocational specialists, nutrition, case management, nursing, chaplaincy, and other disciplines an individual patient may need.

Patients should be evaluated by a pain medicine specialist and a behavioral medicine specialist. Treatment recommendations should include a structured curriculum including education, CBT, and physical therapy to address fear avoidance behavior, medication use, disability, affective distress, health care overutilization, quality of life, activities of daily living, and other patient-centric goals of rehabilitation. The interdisciplinary treatment team should be housed in the same facility and meet at least once per week to discuss new and existing patients and monitor progress toward outcome goals.

At our clinic, the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center in Dallas, each patient undergoes consecutive evaluations by a pain physician, psychologist, physical therapist, and perhaps a psychiatrist. A case manager helps patients navigate through the evaluation and treatment process. At weekly case conferences, the team meets to discuss new patients, review the progress of current patients, and reinforce or modify treatment plans.

Individualizing goals

“Among steps to improving care, health-care providers should increasingly aim at tailoring pain care to each person’s experience and self-management of pain should be promoted.”¹

Pain influences and inhibits numerous areas of a patient’s life. For many chronic pain patients, duration of pain brings with it the belief that “hurt equals harm.” As a result, they decrease physical activities, become socially isolated, and often feel unable to effectively manage, control, and conquer their pain. The longer chronic pain endures, the more deleterious the psychosocial consequences, even if pain and dysfunction do not worsen.

Chronic pain causes patients to feel a domino effect of psychological and cognitive disturbances including anxiety, depression, anger, and sleep disturbance. Disability caused by pain may bring on economic and domestic difficulties. Relationships can suffer, in part because it is hard for others to understand the impact of pain, especially when there is no obvious pathology.

Part of the evaluation process is to assess these possibilities and to address them in a concerted way. We encourage patients to focus on making progress toward their treatment goals rather than hoping to find a definitive cure for a pain generator that may or may not be identifiable. Therefore, in addition to the standard outcomes we aim for with each patient (eg, improvement in physical and psychological function measures), we establish individual treatment goals based on the initial interviews and the patient’s desire to return to work, get into vocational retraining or education, or achieve other productivity or recreational outcomes.

Patients typically receive 8 to 10 sessions of CBT, with each session covering a topic such as sleep hygiene, assertiveness training, anger management, or controlling automatic thoughts that lead to catastrophization or fear of the pain getting worse.

At our center we spend an hour educating patients about pain medications, explaining how they work and why some pose risks. Patients undergo 6 to 8 sessions of physical therapy and graded exercise, starting slow and gradually building to a level that does not aggravate their pain. Teaching them correct posture and how to lift objects also is important.

Planning for long-term success

Pain management takes place on numerous levels that incorporate self care, primary care, specialty care, and the multimodal care of interdisciplinary pain centers. To avoid relapse after patients have been treated at an interdisciplinary pain center, it is important that they have a clear idea of how to proceed with their individualized programs in a self-directed manner. Those who do well in the program and return to work or the home environment may be vulnerable to stressors that can lead to relapse.

Patients who fear they cannot control the pain or that they may do something to worsen it are at risk of becoming depressed, dependent, or guarded in their activities.¹² Our program is developing a system to monitor patients more closely after they finish their program to identify those who may be spiraling downward. Patients are invited to return at any time for “booster” sessions.

Primary care involvement can strengthen patient resolve

“Also, primary care physicians—who handle most front-line pain care—should collaborate with pain specialists in cases where pain persists.”¹

The degree to which primary care physicians (PCPs) want to be involved with chronic pain management varies, of course. Interdisciplinary programs should explore the comfort level of individual providers and work with them accordingly—at the very least communicating with and including the PCP in the patient’s process so that he or she understands what the patient has encountered and achieved.¹³ This collaborative approach enables PCPs to motivate patients to continue the progress they’ve made, reinforce the biopsychosocial model for treating pain, and communicate with the interdisciplinary team about patients who may be relapsing.

Barriers to interdisciplinary care

“System and organizational barriers, many of them driven by current reimbursement policies, obstruct patient-centered care.”¹

The IOM has estimated the direct and indirect costs of pain in America to be over a half a trillion dollars per year. The potential for interdisciplinary pain care to contribute to national deficit reduction is real and is not limited to chronic pain. In fact, the application of interdisciplinary evaluations and treatment to acute and subacute pain may be more important to reduce costs related to preventing high-risk patients from becoming chronic.

A cost-utility analysis of 994 patients in pain clinics with acute back pain at high risk of becoming chronic who were provided early intervention with an interdisciplinary approach resulted in fewer health care visits and fewer missed days of work compared with patients who received usual care.¹⁴

Additional cost savings could be realized by routinely applying the biopsychosocial model to acute and subacute pain. Through well-developed evaluation systems, we could identify patients at high risk of progressing to chronicity. Screening for risk stratification is key to reducing the large number of chronic pain patients who are overmedicated, disabled, and depressed. Just as it makes sense to reduce individuals’ cardiac risk factors and not wait until they are in heart failure to act, employing a comprehensive interdisciplinary program for acute pain would be less expensive than waiting to treat pain that has become chronic.

However, only some insurers cover use of interdisciplinary pain programs, often to a limited extent, and may employ carve outs for specific therapies. Medicare does not reimburse well for interdisciplinary treatment. Consequently, many programs are paid through worker’s compensation. It is therefore challenging for interdisciplinary programs to remain viable.

Further benefits to the wider community

Our current health care system in the United States is not financially sustainable. To help curtail overutilization of health care resources in this country, we have to acknowledge psychosocial issues and embrace interdisciplinary pain programs when treating patients with pain. But it will take time and a huge cultural change for this to happen.

The future may require a combination of interdisciplinary treatment with a strong component of analgesic treatments rather than an “all or none” approach in which patients receive either “behavioral” treatment or “medical” treatment only. By definition, interdisciplinary pain treatment requires medicine as a discipline to reduce pain using everything medicine has to offer to accomplish this end.

Helpful information for you and your patients

The American Academy of Pain Management (AAPM) offers professional credentialing in pain management and accredits pain management clinics in the United States. You may be able to locate a specialist or clinic in your area at the academy’s Web site: https://members.aapainmanage.org/aapmssa/censsacustlkup.query_page.

Disclosures

Carl Noe, MD, has served as a consultant to Palladian Partners, Inc., a health communications and services company.

Charles F. Williams has no conflicts of interest to disclose.

The Institute of Medicine (IOM) published a consensus report in June 2011 on the “national challenge” of chronic pain.¹ Below the heading “Underlying Principles,” the report states,

“Given chronic pain’s diverse effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems.” ¹

Yet much of the medical community tends to treat pain as a physical problem with pharmacologic solutions, effectively dismissing the value of interdisciplinary pain management and the biopsychosocial model underlying this approach, even though its interrelated factors are clearly linked to improved physical symptoms and decreased use of costly medical resources.^2,3 However, over the past 2 decades an undeniable body of evidence favoring an interdisciplinary approach has been growing.

Rationale and research

Success with a multimodal approach to pain management has been demonstrated for a number of pain conditions, perhaps most clearly in studies of chronic low back pain (LBP). In one study, 108 patients (63% with LBP) underwent multiple sessions of individual cognitive behavioral therapy (CBT), physical therapy, aquatic physical therapy, occupational therapy, group education, and group relaxation.⁴ At program enrollment, program completion, and long-term follow-up, researchers gathered data on changes in pain severity, emotional stress, interference of pain on functioning, perceived control of pain, helpfulness of treatment, and hours resting. At 6 months and 1 year following completion of the study, all 6 measures showed statistically significant improvement over baseline, with 95% confidence intervals in 5 of the 6 showing no overlap between pre-program and follow-up measures. [TABLE 1]

TABLE 1:   Variance of outcomes of a comprehensive pain management program with 1-year follow-up (n=46) 

* No overlap in confidence interval between pretreatment and either posttreatment or 1-year scores

**n=40

Source: Adapted with permission from Oslund S, et al. Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Proc (Bayl Univ Med Cent). 2009;22(3)211-214.

In a systematic review of 10 randomized controlled trials encompassing 1964 patients with disabling LBP, researchers found strong evidence that intensive multidisciplinary biopsychosocial rehabilitation improves function when compared with inpatient or outpatient treatments. The review also found moderate evidence of pain reduction with multidisciplinary care compared with non-multidisciplinary care.⁵

Studies of musculoskeletal pain also have reported good results with interdisciplinary care. In a study of interdisciplinary pain management for chronic musculoskeletal pain, military personnel were to receive either interdisciplinary care with physical therapy, occupational therapy, and psychosocial intervention, or standard anesthesia treatment alone.⁶ At 6 months and 1 year, data collected on pain, disability, functional status, and fitness for return to duty showed that interdisciplinary care was far superior to standard care.

A systematic review of randomized controlled trials found strong evidence that multidisciplinary care is more effective for nonmalignant chronic pain diagnoses (chronic LBP, back pain, fibromyalgia, and mixed chronic pain) than standard medical treatment, and moderate evidence for its effectiveness compared with other nonmultidisciplinary treatments.⁷ According to the study authors, the data support, at minimum, offering a range of treatments—including individual exercising, training in relaxation techniques, group therapy with a clinical psychologist, patient education, physiotherapy, and medical training therapy—and providing neurophysiology information. They also point out that no particular combination or duration of therapy has proved superior to others in clinical outcomes.

Risks of interdisciplinary care versus standard care

Therapies employed in interdisciplinary pain management are relatively low-risk compared with other interventions, such as opioid use or surgery. A 2010 Cochrane review of opioid use for chronic non-cancer pain found that concerns about long-term use of opioids can present a potential barrier to treatment. Opioids often lead to adverse effects (gastrointestinal effects such as constipation and nausea; headache; fatigue; urinary complications) severe enough to warrant discontinuation.8 This review found the rate of opioid addiction in these study populations was extremely low, however, and concluded that potential iatrogenic opioid addiction should not be a barrier for well-selected and well-supervised patients. As this study indicates, patients who gain pain relief from prescribed opioids might become drug dependent, but will not become addicted.

Also, although opioids are widely used,their ability to control pain varies. A study from the Mayo Comprehensive Rehabilitation Center of 233 consecutively enrolled patients with chronic nonmalignant pain found 48% were using opioids daily at baseline, at a cost of $23.13 per day or $8326.90 per year (average wholesale price) per patient.⁹ Patients who completed a 3-week multidisciplinary intervention significantly reduced their medication use at 6-month follow-up, for an estimated annual savings of $2404.80 per patient.

Two studies comparing interdisciplinary care with spine fusion surgery for chronic back pain found interdisciplinary care to be a reasonable alternative for many patients. In a study of patients with chronic LBP who had previous surgery for disc herniation, spinal fusion showed no benefit over cognitive intervention and exercise after 1 year.¹⁰ [TABLE 2] A multicenter trial comparing surgical stabilization of the lumbar spine with an intensive rehabilitation program based on CBT found no clear evidence that spinal fusion provided greater benefit.¹¹

TABLE 2 : Primary and secondary outcomes comparing spinal
fusion with CBT and exercise

*Oswestry Disability Questionnaire in which the sum of response scores ranges from 0 to 100,where 100 represents the worst possible pain and disability.

**Based on a vertical visual analog scale ranging from 0 to 100, where 100 reflected the worst pain imaginable.

Source: Adapted from Brox JI, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study. Pain. 2006;122(1):145-155. This table has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The table

may not be reproduced for any other purpose without permission.

What interdisciplinary pain management looks like

Key disciplines of an interdisciplinary pain management program are medicine, psychology, and rehabilitation. However, programs vary in available services and professional disciplines, setting, and duration. A fully integrated pain treatment center offers a range of therapies that may include transcutaneous electrical nerve stimulation, CBT, biofeedback, physical therapy, psychoeducational group treatment, and medications such as nonnarcotic analgesics and nerve blocks. Additional disciplines may include outcome database managers, vocational specialists, nutrition, case management, nursing, chaplaincy, and other disciplines an individual patient may need.

Patients should be evaluated by a pain medicine specialist and a behavioral medicine specialist. Treatment recommendations should include a structured curriculum including education, CBT, and physical therapy to address fear avoidance behavior, medication use, disability, affective distress, health care overutilization, quality of life, activities of daily living, and other patient-centric goals of rehabilitation. The interdisciplinary treatment team should be housed in the same facility and meet at least once per week to discuss new and existing patients and monitor progress toward outcome goals.

At our clinic, the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center in Dallas, each patient undergoes consecutive evaluations by a pain physician, psychologist, physical therapist, and perhaps a psychiatrist. A case manager helps patients navigate through the evaluation and treatment process. At weekly case conferences, the team meets to discuss new patients, review the progress of current patients, and reinforce or modify treatment plans.

Individualizing goals

“Among steps to improving care, health-care providers should increasingly aim at tailoring pain care to each person’s experience and self-management of pain should be promoted.”¹

Pain influences and inhibits numerous areas of a patient’s life. For many chronic pain patients, duration of pain brings with it the belief that “hurt equals harm.” As a result, they decrease physical activities, become socially isolated, and often feel unable to effectively manage, control, and conquer their pain. The longer chronic pain endures, the more deleterious the psychosocial consequences, even if pain and dysfunction do not worsen.

Chronic pain causes patients to feel a domino effect of psychological and cognitive disturbances including anxiety, depression, anger, and sleep disturbance. Disability caused by pain may bring on economic and domestic difficulties. Relationships can suffer, in part because it is hard for others to understand the impact of pain, especially when there is no obvious pathology.

Part of the evaluation process is to assess these possibilities and to address them in a concerted way. We encourage patients to focus on making progress toward their treatment goals rather than hoping to find a definitive cure for a pain generator that may or may not be identifiable. Therefore, in addition to the standard outcomes we aim for with each patient (eg, improvement in physical and psychological function measures), we establish individual treatment goals based on the initial interviews and the patient’s desire to return to work, get into vocational retraining or education, or achieve other productivity or recreational outcomes.

Patients typically receive 8 to 10 sessions of CBT, with each session covering a topic such as sleep hygiene, assertiveness training, anger management, or controlling automatic thoughts that lead to catastrophization or fear of the pain getting worse.

At our center we spend an hour educating patients about pain medications, explaining how they work and why some pose risks. Patients undergo 6 to 8 sessions of physical therapy and graded exercise, starting slow and gradually building to a level that does not aggravate their pain. Teaching them correct posture and how to lift objects also is important.

Planning for long-term success

Pain management takes place on numerous levels that incorporate self care, primary care, specialty care, and the multimodal care of interdisciplinary pain centers. To avoid relapse after patients have been treated at an interdisciplinary pain center, it is important that they have a clear idea of how to proceed with their individualized programs in a self-directed manner. Those who do well in the program and return to work or the home environment may be vulnerable to stressors that can lead to relapse.

Patients who fear they cannot control the pain or that they may do something to worsen it are at risk of becoming depressed, dependent, or guarded in their activities.¹² Our program is developing a system to monitor patients more closely after they finish their program to identify those who may be spiraling downward. Patients are invited to return at any time for “booster” sessions.

Primary care involvement can strengthen patient resolve

“Also, primary care physicians—who handle most front-line pain care—should collaborate with pain specialists in cases where pain persists.”¹

The degree to which primary care physicians (PCPs) want to be involved with chronic pain management varies, of course. Interdisciplinary programs should explore the comfort level of individual providers and work with them accordingly—at the very least communicating with and including the PCP in the patient’s process so that he or she understands what the patient has encountered and achieved.¹³ This collaborative approach enables PCPs to motivate patients to continue the progress they’ve made, reinforce the biopsychosocial model for treating pain, and communicate with the interdisciplinary team about patients who may be relapsing.

Barriers to interdisciplinary care

“System and organizational barriers, many of them driven by current reimbursement policies, obstruct patient-centered care.”¹

The IOM has estimated the direct and indirect costs of pain in America to be over a half a trillion dollars per year. The potential for interdisciplinary pain care to contribute to national deficit reduction is real and is not limited to chronic pain. In fact, the application of interdisciplinary evaluations and treatment to acute and subacute pain may be more important to reduce costs related to preventing high-risk patients from becoming chronic.

A cost-utility analysis of 994 patients in pain clinics with acute back pain at high risk of becoming chronic who were provided early intervention with an interdisciplinary approach resulted in fewer health care visits and fewer missed days of work compared with patients who received usual care.¹⁴

Additional cost savings could be realized by routinely applying the biopsychosocial model to acute and subacute pain. Through well-developed evaluation systems, we could identify patients at high risk of progressing to chronicity. Screening for risk stratification is key to reducing the large number of chronic pain patients who are overmedicated, disabled, and depressed. Just as it makes sense to reduce individuals’ cardiac risk factors and not wait until they are in heart failure to act, employing a comprehensive interdisciplinary program for acute pain would be less expensive than waiting to treat pain that has become chronic.

However, only some insurers cover use of interdisciplinary pain programs, often to a limited extent, and may employ carve outs for specific therapies. Medicare does not reimburse well for interdisciplinary treatment. Consequently, many programs are paid through worker’s compensation. It is therefore challenging for interdisciplinary programs to remain viable.

Further benefits to the wider community

Our current health care system in the United States is not financially sustainable. To help curtail overutilization of health care resources in this country, we have to acknowledge psychosocial issues and embrace interdisciplinary pain programs when treating patients with pain. But it will take time and a huge cultural change for this to happen.

The future may require a combination of interdisciplinary treatment with a strong component of analgesic treatments rather than an “all or none” approach in which patients receive either “behavioral” treatment or “medical” treatment only. By definition, interdisciplinary pain treatment requires medicine as a discipline to reduce pain using everything medicine has to offer to accomplish this end.

Helpful information for you and your patients

The American Academy of Pain Management (AAPM) offers professional credentialing in pain management and accredits pain management clinics in the United States. You may be able to locate a specialist or clinic in your area at the academy’s Web site: https://members.aapainmanage.org/aapmssa/censsacustlkup.query_page.

Disclosures

Carl Noe, MD, has served as a consultant to Palladian Partners, Inc., a health communications and services company.

Charles F. Williams has no conflicts of interest to disclose.

The Institute of Medicine (IOM) published a consensus report in June 2011 on the “national challenge” of chronic pain.¹ Below the heading “Underlying Principles,” the report states,

“Given chronic pain’s diverse effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems.” ¹

Yet much of the medical community tends to treat pain as a physical problem with pharmacologic solutions, effectively dismissing the value of interdisciplinary pain management and the biopsychosocial model underlying this approach, even though its interrelated factors are clearly linked to improved physical symptoms and decreased use of costly medical resources.^2,3 However, over the past 2 decades an undeniable body of evidence favoring an interdisciplinary approach has been growing.

Rationale and research

Success with a multimodal approach to pain management has been demonstrated for a number of pain conditions, perhaps most clearly in studies of chronic low back pain (LBP). In one study, 108 patients (63% with LBP) underwent multiple sessions of individual cognitive behavioral therapy (CBT), physical therapy, aquatic physical therapy, occupational therapy, group education, and group relaxation.⁴ At program enrollment, program completion, and long-term follow-up, researchers gathered data on changes in pain severity, emotional stress, interference of pain on functioning, perceived control of pain, helpfulness of treatment, and hours resting. At 6 months and 1 year following completion of the study, all 6 measures showed statistically significant improvement over baseline, with 95% confidence intervals in 5 of the 6 showing no overlap between pre-program and follow-up measures. [TABLE 1]

TABLE 1:   Variance of outcomes of a comprehensive pain management program with 1-year follow-up (n=46) 

* No overlap in confidence interval between pretreatment and either posttreatment or 1-year scores

**n=40

Source: Adapted with permission from Oslund S, et al. Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Proc (Bayl Univ Med Cent). 2009;22(3)211-214.

In a systematic review of 10 randomized controlled trials encompassing 1964 patients with disabling LBP, researchers found strong evidence that intensive multidisciplinary biopsychosocial rehabilitation improves function when compared with inpatient or outpatient treatments. The review also found moderate evidence of pain reduction with multidisciplinary care compared with non-multidisciplinary care.⁵

Studies of musculoskeletal pain also have reported good results with interdisciplinary care. In a study of interdisciplinary pain management for chronic musculoskeletal pain, military personnel were to receive either interdisciplinary care with physical therapy, occupational therapy, and psychosocial intervention, or standard anesthesia treatment alone.⁶ At 6 months and 1 year, data collected on pain, disability, functional status, and fitness for return to duty showed that interdisciplinary care was far superior to standard care.

A systematic review of randomized controlled trials found strong evidence that multidisciplinary care is more effective for nonmalignant chronic pain diagnoses (chronic LBP, back pain, fibromyalgia, and mixed chronic pain) than standard medical treatment, and moderate evidence for its effectiveness compared with other nonmultidisciplinary treatments.⁷ According to the study authors, the data support, at minimum, offering a range of treatments—including individual exercising, training in relaxation techniques, group therapy with a clinical psychologist, patient education, physiotherapy, and medical training therapy—and providing neurophysiology information. They also point out that no particular combination or duration of therapy has proved superior to others in clinical outcomes.

Risks of interdisciplinary care versus standard care

Therapies employed in interdisciplinary pain management are relatively low-risk compared with other interventions, such as opioid use or surgery. A 2010 Cochrane review of opioid use for chronic non-cancer pain found that concerns about long-term use of opioids can present a potential barrier to treatment. Opioids often lead to adverse effects (gastrointestinal effects such as constipation and nausea; headache; fatigue; urinary complications) severe enough to warrant discontinuation.8 This review found the rate of opioid addiction in these study populations was extremely low, however, and concluded that potential iatrogenic opioid addiction should not be a barrier for well-selected and well-supervised patients. As this study indicates, patients who gain pain relief from prescribed opioids might become drug dependent, but will not become addicted.

Also, although opioids are widely used,their ability to control pain varies. A study from the Mayo Comprehensive Rehabilitation Center of 233 consecutively enrolled patients with chronic nonmalignant pain found 48% were using opioids daily at baseline, at a cost of $23.13 per day or $8326.90 per year (average wholesale price) per patient.⁹ Patients who completed a 3-week multidisciplinary intervention significantly reduced their medication use at 6-month follow-up, for an estimated annual savings of $2404.80 per patient.

Two studies comparing interdisciplinary care with spine fusion surgery for chronic back pain found interdisciplinary care to be a reasonable alternative for many patients. In a study of patients with chronic LBP who had previous surgery for disc herniation, spinal fusion showed no benefit over cognitive intervention and exercise after 1 year.¹⁰ [TABLE 2] A multicenter trial comparing surgical stabilization of the lumbar spine with an intensive rehabilitation program based on CBT found no clear evidence that spinal fusion provided greater benefit.¹¹

TABLE 2 : Primary and secondary outcomes comparing spinal
fusion with CBT and exercise

*Oswestry Disability Questionnaire in which the sum of response scores ranges from 0 to 100,where 100 represents the worst possible pain and disability.

**Based on a vertical visual analog scale ranging from 0 to 100, where 100 reflected the worst pain imaginable.

Source: Adapted from Brox JI, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study. Pain. 2006;122(1):145-155. This table has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The table

may not be reproduced for any other purpose without permission.

What interdisciplinary pain management looks like

Key disciplines of an interdisciplinary pain management program are medicine, psychology, and rehabilitation. However, programs vary in available services and professional disciplines, setting, and duration. A fully integrated pain treatment center offers a range of therapies that may include transcutaneous electrical nerve stimulation, CBT, biofeedback, physical therapy, psychoeducational group treatment, and medications such as nonnarcotic analgesics and nerve blocks. Additional disciplines may include outcome database managers, vocational specialists, nutrition, case management, nursing, chaplaincy, and other disciplines an individual patient may need.

Patients should be evaluated by a pain medicine specialist and a behavioral medicine specialist. Treatment recommendations should include a structured curriculum including education, CBT, and physical therapy to address fear avoidance behavior, medication use, disability, affective distress, health care overutilization, quality of life, activities of daily living, and other patient-centric goals of rehabilitation. The interdisciplinary treatment team should be housed in the same facility and meet at least once per week to discuss new and existing patients and monitor progress toward outcome goals.

At our clinic, the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center in Dallas, each patient undergoes consecutive evaluations by a pain physician, psychologist, physical therapist, and perhaps a psychiatrist. A case manager helps patients navigate through the evaluation and treatment process. At weekly case conferences, the team meets to discuss new patients, review the progress of current patients, and reinforce or modify treatment plans.

Individualizing goals

“Among steps to improving care, health-care providers should increasingly aim at tailoring pain care to each person’s experience and self-management of pain should be promoted.”¹

Pain influences and inhibits numerous areas of a patient’s life. For many chronic pain patients, duration of pain brings with it the belief that “hurt equals harm.” As a result, they decrease physical activities, become socially isolated, and often feel unable to effectively manage, control, and conquer their pain. The longer chronic pain endures, the more deleterious the psychosocial consequences, even if pain and dysfunction do not worsen.

Chronic pain causes patients to feel a domino effect of psychological and cognitive disturbances including anxiety, depression, anger, and sleep disturbance. Disability caused by pain may bring on economic and domestic difficulties. Relationships can suffer, in part because it is hard for others to understand the impact of pain, especially when there is no obvious pathology.

Part of the evaluation process is to assess these possibilities and to address them in a concerted way. We encourage patients to focus on making progress toward their treatment goals rather than hoping to find a definitive cure for a pain generator that may or may not be identifiable. Therefore, in addition to the standard outcomes we aim for with each patient (eg, improvement in physical and psychological function measures), we establish individual treatment goals based on the initial interviews and the patient’s desire to return to work, get into vocational retraining or education, or achieve other productivity or recreational outcomes.

Patients typically receive 8 to 10 sessions of CBT, with each session covering a topic such as sleep hygiene, assertiveness training, anger management, or controlling automatic thoughts that lead to catastrophization or fear of the pain getting worse.

At our center we spend an hour educating patients about pain medications, explaining how they work and why some pose risks. Patients undergo 6 to 8 sessions of physical therapy and graded exercise, starting slow and gradually building to a level that does not aggravate their pain. Teaching them correct posture and how to lift objects also is important.

Planning for long-term success

Pain management takes place on numerous levels that incorporate self care, primary care, specialty care, and the multimodal care of interdisciplinary pain centers. To avoid relapse after patients have been treated at an interdisciplinary pain center, it is important that they have a clear idea of how to proceed with their individualized programs in a self-directed manner. Those who do well in the program and return to work or the home environment may be vulnerable to stressors that can lead to relapse.

Patients who fear they cannot control the pain or that they may do something to worsen it are at risk of becoming depressed, dependent, or guarded in their activities.¹² Our program is developing a system to monitor patients more closely after they finish their program to identify those who may be spiraling downward. Patients are invited to return at any time for “booster” sessions.

Primary care involvement can strengthen patient resolve

“Also, primary care physicians—who handle most front-line pain care—should collaborate with pain specialists in cases where pain persists.”¹

The degree to which primary care physicians (PCPs) want to be involved with chronic pain management varies, of course. Interdisciplinary programs should explore the comfort level of individual providers and work with them accordingly—at the very least communicating with and including the PCP in the patient’s process so that he or she understands what the patient has encountered and achieved.¹³ This collaborative approach enables PCPs to motivate patients to continue the progress they’ve made, reinforce the biopsychosocial model for treating pain, and communicate with the interdisciplinary team about patients who may be relapsing.

Barriers to interdisciplinary care

“System and organizational barriers, many of them driven by current reimbursement policies, obstruct patient-centered care.”¹

The IOM has estimated the direct and indirect costs of pain in America to be over a half a trillion dollars per year. The potential for interdisciplinary pain care to contribute to national deficit reduction is real and is not limited to chronic pain. In fact, the application of interdisciplinary evaluations and treatment to acute and subacute pain may be more important to reduce costs related to preventing high-risk patients from becoming chronic.

A cost-utility analysis of 994 patients in pain clinics with acute back pain at high risk of becoming chronic who were provided early intervention with an interdisciplinary approach resulted in fewer health care visits and fewer missed days of work compared with patients who received usual care.¹⁴

Additional cost savings could be realized by routinely applying the biopsychosocial model to acute and subacute pain. Through well-developed evaluation systems, we could identify patients at high risk of progressing to chronicity. Screening for risk stratification is key to reducing the large number of chronic pain patients who are overmedicated, disabled, and depressed. Just as it makes sense to reduce individuals’ cardiac risk factors and not wait until they are in heart failure to act, employing a comprehensive interdisciplinary program for acute pain would be less expensive than waiting to treat pain that has become chronic.

However, only some insurers cover use of interdisciplinary pain programs, often to a limited extent, and may employ carve outs for specific therapies. Medicare does not reimburse well for interdisciplinary treatment. Consequently, many programs are paid through worker’s compensation. It is therefore challenging for interdisciplinary programs to remain viable.

Further benefits to the wider community

Our current health care system in the United States is not financially sustainable. To help curtail overutilization of health care resources in this country, we have to acknowledge psychosocial issues and embrace interdisciplinary pain programs when treating patients with pain. But it will take time and a huge cultural change for this to happen.

The future may require a combination of interdisciplinary treatment with a strong component of analgesic treatments rather than an “all or none” approach in which patients receive either “behavioral” treatment or “medical” treatment only. By definition, interdisciplinary pain treatment requires medicine as a discipline to reduce pain using everything medicine has to offer to accomplish this end.

Helpful information for you and your patients

The American Academy of Pain Management (AAPM) offers professional credentialing in pain management and accredits pain management clinics in the United States. You may be able to locate a specialist or clinic in your area at the academy’s Web site: https://members.aapainmanage.org/aapmssa/censsacustlkup.query_page.

Disclosures

Carl Noe, MD, has served as a consultant to Palladian Partners, Inc., a health communications and services company.

Charles F. Williams has no conflicts of interest to disclose.