Chronic Pain Management: Guidelines for Multidisciplinary Program Development PDF

Preface

Chronic pain of benign origin results in staggering costs, to society as a whole as well as to the individual sufferer. Although it is impossible to accurately determine the total economic cost of chronic pain to society, its combined direct and indirect annual cost in the United States was estimated in 2001 to be almost $300 billion (1). A huge proportion of the economic cost associated with chronic pain consists of fees for treatments which have not been found to be particularly efficacious. These were estimated in 2001 to be about $125 billion annually (2). It should be noted that both of these figures are conservative, as neither has been adjusted for inflation.

Of greater moral importance, however, is the overwhelming non-economic cost of chronic pain to the people that it afflicts. Those affected include not only the person who experiences the pain directly, but loved ones as well. Losses experienced by patients with chronic pain include not only the physical, but vocational, financial, social, sexual, recreational, emotional, and spiritual. A recent qualitative study found that in addition to socioeconomic losses and financial hardships, people with chronic pain experienced decreases in self-worth, positive expectations for the future, and hope (3). Other studies (4)-(8) have identified increases in feelings of despair, loss of meaning of life, losses of freedom/independence, threat to integrity, role loss, and disorganization of the patient's "being in the world" as the worst consequences of chronic pain conditions. Chronic pain is clearly a disease of the person, not simply of the body.

Despite the fact that traditional medical approaches to treating chronic pain such as surgery, medications and other invasive interventions, do little, if anything, to restore the chronic pain sufferer's overall quality of life, these traditional approaches continue to be considered the first line of offense against chronic pain. This is particularly disheartening given the lack of empirical support for the clinical efficacy of these approaches in terms of long-term pain relief, much less for their ability to impact the myriad indirect negative effects of the chronic pain experience. The good news is that for many years, pain practitioners have possessed a treatment model that can help people with chronic pain restore their lives. The bad news is that the health insurance industry, as a whole, is becoming progressively less willing to fund this treatment approach. As is discussed throughout this textbook, comprehensive multidisciplinary chronic pain management has been empirically demonstrated, beyond a doubt, to be a clinically effective and cost-efficient approach to the treatment of chronic pain of benign origin. The ethical failure of the insurance industry, however, has led to a dramatic decrease in the availability of such programs over the past decade (9), (10).

We appreciate the inspiration of the American Academy of Pain Management in our decision to produce this book which we hope will serve two purposes. The first is to arm the multidisciplinary pain practitioner with a concise resource that powerfully presents overwhelming evidence regarding the efficacy and cost-efficiency of multidisciplinary chronic pain management, particularly in comparison to the traditional and ineffective approaches that continue to be overutilized in the treatment of chronic pain. We have enlisted the participation of leading authorities in the world of multidisciplinary chronic pain management to contribute chapters on this topic. Our second purpose is to provide a "how-to" manual for multidisciplinary chronic pain management program development. We have been fortunate to obtain the participation of chronic pain clinicians/academicians who are certainly experts in this area.

Chronic Pain Management: Guidelines for Multidisciplinary Program Development is divided into 5 sections. Following a Foreword by John Loeser, one of the eminent pioneers in the field, the first section covers the history and empirical support of multidisciplinary chronic pain management. This section includes a chapter on the history of the multidisciplinary approach to chronic pain (Marcia Meldrum), an in depth analysis of the clinical efficacy and cost-efficiency of the multidisciplinary approach in comparison to "traditional" approaches (Dennis Turk and Kimberly Swanson), and a presentation of the literature on problems associated with "carving out" specific services from programs that need to be offered as coherent wholes (Robert Gatchel, Nancy Kishino, and Carl Noe). For those of us who have practiced pain management from a multidisciplinary approach and have seen the problems associated with efforts that treat the "pain" but not the "person," the superiority of the multidisciplinary approach is very obvious. For those whose understanding of chronic pain is more limited, however, the chapters in this section serve to erase any doubt regarding the efficacy of the more "person-centered" approach to chronic pain treatment.

The second section of this text covers the need for multidisciplinary chronic pain management given the countless problems associated with other approaches. This section includes a chapter on multidisciplinary treatment as an alternative to chronic opioid therapy (Jane Ballantyne) and spinal surgery (Richard Guyer and Andy Block), both of which have been heavily criticized as overutilized and of questionable efficacy. This section also includes chapters on the use of approaches that have been empirically demonstrated to be of limited efficacy when provided in a unimodal fashion, but which can be valuable components of a comprehensive chronic pain management program. Chapters are provided on complementary and alternative medicine (CAM) (Gabriel Tan and Mark Jensen) and on interventional approaches (Mike Hatzakis and Michael Schatman).

The next section of the book focuses on people who are actually treated through multidisciplinary chronic pain management programs, as well as on those who are sometimes not treated at all. We were fortunate to have a patient (Debra Benner) who experienced first-hand the benefits of being treated in a program that was developed by the book's first editor (MES) and whose training and work as a hospital chaplain provide unique insights into pain management that few are fortunate enough to experience. Additionally, a chapter in this section by one of the great champions of vulnerable populations (Ray Tait) allows the reader to consider issues of distributive justice in the field of chronic pain management.

The fourth section of the textbook looks at clinical elements of a comprehensive pain management program that make it truly "multidisciplinary." The section includes a broad chapter on the "nuts and bolts" of putting together a comprehensive interdisciplinary/multidisciplinary treatment team, delineating the functions of all of the members (Steven Stanos). This chapter is of great importance, as it outlines the need for communication and cooperation between various types of healthcare professionals whose training may not necessarily be based on the same underlying assumptions about illness and disease. The other chapter in this section discusses the role of psychological assessment in multidisciplinary chronic pain management (Allen Lebovits). As these programs place a heavy emphasis on the psychological sequelae of chronic pain as well as upon the patient's nociceptive experience, the value of psychologists providing other treatment team members with an understanding of a patient's psychodynamics as they relate to his or her pain is essential if the patient is to achieve success.

The fifth and final section of this book is the longest, dealing with the administrative/ financial aspects of developing a multidisciplinary chronic pain management program. At present, it is not the clinical efficacy of multidisciplinary chronic pain programs that is in question; rather, it is the ability of these programs to remain effective in the rapidly changing economic climate while maintaining financial viability. The first chapter in this section addresses strategies for developing strong policies and procedures, which are likely to contribute to the consistency of treatment that is provided to chronic pain patients (Paula Spoonhour and Michael Schatman). While each multidisciplinary program is likely to have its own unique qualities, internal consistency is essential if referral sources and third party payors are to consider a program seriously. The next chapter addresses the importance of outcomes measurement and data collection in multidisciplinary chronic pain management as a means of documenting and improving the quality of programs (Kevin Vowles, Rick Gross, and Lance McCracken). The third chapter in this section speaks to pain program accreditation (Alexandra Campbell). While any licensed health care professional can claim to provide chronic pain management services, meeting the standards necessary for accreditation can contribute significantly to a program's legitimacy, both in the eyes of the insurance industry and potential referral sources. The next chapter provides strategies for obtaining reimbursement for the provision of multidisciplinary chronic pain management (Ron Kulich and Michael Adolph), the necessity of which is obvious if this treatment model is to continue to be viable. The authors take the perspective that programs need to be run like businesses if they are to survive in a health care industry climate that considers cost-containment and profitability to be more important than the welfare of those who suffer from chronic pain. The final chapter in the book discusses the very successful model for multidisciplinary chronic pain management that has been developed and nurtured in one of the nation's largest and best known health maintenance organizations, Kaiser Permanente (Bill McCarberg).

We are highly appreciative of all of the authors who contributed their time and effort to write chapters for what we believe to be an important and timely volume. A wide variety of healthcare professionals are represented among the authors but they share the common thread of believing in multidisciplinary chronic pain management, and have dedicated their professional lives to practicing and/or furthering the field. In a presentation at the Eighth World Congress of the International Association for the Study of Pain, John Bonica was referred to as the "world champion of pain" (11). All of the authors who contributed to this textbook were influenced by Dr. Bonica, and all of them embody his spirit in continuing to serve as "champions of pain" through their efforts to practice and promote multidisciplinary chronic pain management.