Multidisciplinary Pain Treatment in the World of Opioid Guidelines
Recent opioid treatment guidelines from the CDC and states further reinforce the implicit message—to much of the public and medical community—that pain treatment equals opioid prescribing.
In reality, treating chronic pain is more nuanced, and the available opportunities for treatment should be deepened. The prescription drug abuse epidemic has taken much of the attention away from the chronic pain pandemic, a more pervasive and costlier disease than the current prescription drug abuse problem. We rarely take a step back and educate the public on what works and what is helpful for chronic pain.
The concepts of multi- and interdisciplinary care for chronic pain have been around for decades, albeit in small pockets and regional centers throughout the United States. These multidisciplinary pain centers have collected compelling evidence of efficacy for over four decades. It makes sense that the pain community should promote these models and decentralize them so they are accessible regionally, affordable, and tailored to individual patients and their cultural/social milieus.
The state of chronic pain fits perfectly within the constructs of the biopsychosocial model for care. This delivery of care requires a team of providers who are individually armed with unique perspectives to gain into a patient’s abilities and disabilities. Many multidisciplinary pain programs incorporate physical and occupational therapy, psychological services, pain education and nutrition counseling, among other services. Programs can run six to eight hours per day for many weeks.
Oftentimes, medical providers are tapering patients off opioids in these “boot camp”–style practices, and the programs work for many patients. They often leave feeling better physically and psychologically, with reduced medication use or completely weaned off opioids.
Some of these programs were born out of states that embraced a “back to work” philosophy as the policy for workers’ compensation. These programs carry a “big stick,” when compensation benefits hinge upon completion of a pain rehabilitation program. While this can be a useful motivational tool, and these models have worked well at saving money in the long run for workers’ compensation programs and reducing health care costs for patients, this care model is not available in all states—and not all chronic pain patients have a work-related injury.
There are effective pain rehabilitation programs available at some hospital centers and academic practices. Again, the evidence is great for these three- to six-week programs, but I also contend that they have a strong population bias. Not all patients have an insurance policy that will cover such a program. Many patients pay out of pocket and find these programs on their own; and the time and money needed often reduces the number of candidates to such programs. Additionally, some programs go through an internal process of “weeding out” candidates who are not likely to finish the program from the beginning.
This is not a criticism of the work these programs do; many are phenomenal. There are, however, limitations to such programs, especially in areas similar to where I practice, where patients cannot or are unable or unwilling to pay due to financial limitations, insurance limitations, time constraints or lack of motivation.
New multidisciplinary models that are financially feasible, readily accessible and applicable to the widest chronic pain population must be developed. They should promote better patient outcomes in ways similar to intensive pain rehabilitation models. The new models should disseminate the message of rehabilitating patients physically and emotionally, and their care should be delivered to as many patients as possible early and throughout their pain management.
Skilled therapists need to address a patient’s negative views on pain early in the treatment process, with an emphasis on physical, social, educational, vocational and psychological function as the end points to treatment, rather than analgesic efficacy of medications or procedures. This needs to be the hallmark message for outcome-driven pain treatment.
Dr. Choo is medical director of Pain Consultants of East Tennessee Surgery Center, in Knoxville. He has worked with state legislators, other medical providers and law enforcement with regard to pain management legislation issues in Tennessee. He served on the Opioid Prescribing Committee for the Tennessee Medical Association in order to help craft legislation aimed at curbing prescription drug abuse while protecting chronic pain patients’ needs.
The 2016 CDC opioid guideline for primary care clinicians has captured the attention of the health care environment. Primary care clinicians will continue caring for patients in pain, particularly as our growing population ages, although there may be reluctance by some to manage the complexity of chronic pain.
Perhaps as health care providers age, there may be an elevated personal awareness and understanding of the presence of pain, and recognition of the need to incorporate, if possible, a multidisciplinary pain treatment approach. This approach may or may not include pharmacologic regimens, but will surely involve integrative therapies.
If distance or access to multidisciplinary treatment programs is present, then we need to identify how to incorporate our ever-changing world of technology and communication into an individualized plan of care.
Another barrier that needs to be diminished is coverage for multidisciplinary services. As Dr. Choo stated, “not all chronic pain patients have a work-related injury.” When our health care coverage and reimbursement model operates to “put the patient first,” then perhaps a multidisciplinary pain treatment approach will become more accessible.
Pain is not a stand-alone entity; it frequently presents with complexities, challenges, and almost always affects quality of life and outcomes. Treating pain may be managed by a sole health care provider, but the multidisciplinary approach and utilization of integrative therapies is generally the best model to maximize optimal patient outcomes and decrease overall costs of care.
—Susan Pendergrass, MSN, MEd, FNP-BC
Published: Pain Medicine News