Why We Do What We Do

The Institute for Chronic Pain has a new content page on our website entitled: Why Healthcare Providers Deliver Ineffective Care. As is our custom, we announce such additions to the website on our blog and provide a little introduction to it. The content on this new page of the website is particularly important to me because providing content like it is one of the reasons why I founded the Institute. It’s not too far of a stretch to say that it’s why we do what we do. By way of introduction, then, I’d like to explain.

I founded the Institute for Chronic Pain for a number of reasons, but one of them continues to this day. Indeed, I am reminded of it most everyday.

The reason is others and mine persistent frustration over what seems like an almost endless delivery of ineffective healthcare within the field of chronic pain management. At the time of the Institute’s formation, in late 2012, the previous decade had seen an exponential increase in the delivery of procedures and therapies for chronic pain, most notably, spinal injections, spinal surgeries, and the long-term use of opioids. The use of these procedures and therapies had far surpassed the field’s traditional and empirically-supported treatment – the interdisciplinary chronic pain rehabilitation program, which had been the mainstay of treatment for twenty or thirty years by the end of the last century. For all those previous years, patients had benefited from such programs and with each decade the field had published more studies and meta-analyses demonstrating their effectiveness. In the mid-1990’s to the early 2000’s, the field began to change and change rapidly. The use of spinal injections, spinal surgeries, and opioid medications became prolific, far exceeding the use of interdisciplinary chronic pain rehabilitation programs. As a result, interdisciplinary chronic pain rehabilitation programs began to close their doors in great numbers for lack of patients.

One might consider such a sea change within the field of chronic pain management a natural progression of the field: due to scientific advances and discoveries, one set of therapies came to predominate over an older form of therapy. However, it wouldn’t be accurate.

The older form of therapy, interdisciplinary chronic pain rehabilitation programs, remained (and still remains today) the more empirically-supported treatment. In other words, such programs remain the more effective treatment and yet, as a field, we routinely deliver care that is not as effective as we could deliver – we routinely provide spinal injections, surgeries and opioid medications to patients with chronic pain, and tend to forego recommending the more effective option of interdisciplinary chronic pain rehabilitation programs. While recognition of this problem is growing and gaining momentum, this state of affairs continues to this day.

Typical responses by the healthcare system: empirical-based healthcare

Many in the field, who recognize this problem, attempt to resolve it by focusing on changing the practice patterns of providers – encouraging them to recommend less orthopedic-related care, such as spinal injections, spinal surgeries, and opioid medications, and instead recommend more nervous system-related care, such as interdisciplinary chronic pain rehabilitation.

Specifically, leaders in the field attempt to educate and persuade healthcare providers to make recommendations based on what the available scientific research tells us is most effective. This ideal for guiding the practice of healthcare is called ‘empirically-based healthcare.’ The word ‘empirical’ in this context means scientific and phrases such as ‘empirically-based’ or ‘empirically-supported’ when used in the context of treatments means that the scientific evidence supports the effectiveness of the given treatment.

This goal to have the scientific evidence for or against treatments guide our recommendations is important. It should lead the field to make more recommendations for those treatments that science tells us are effective and lead us to make less recommendations for treatments that have been shown to be less effective. Indeed, who wouldn’t argue that we should be focusing our care and resources on treatments that are the most effective?

Health insurance companies and professional provider organizations

Typically, health insurance companies or different types of provider organizations lead the drive to change provider practice patterns within the field of chronic pain management. Insurance companies periodically institute policy changes that encourage the use of empirically-supported treatments and various professional organizations develop guidelines for what constitutes appropriate care for different chronic pain conditions. In my geographical area, for instance, local insurance companies have twice attempted to mandate that patients receive non-surgical second opinions, such as psychological evaluations for rehabilitation care, before obtaining spine surgery. I personally have also served on two different guideline development committees for the management of back pain.

While admirable, these attempts never succeed in producing a significant change in the practice patterns of healthcare providers. They fight a steep uphill battle. Many of the forces for maintaining the status quo of providing ineffective healthcare on a widespread basis remain powerful and complicated. They are difficult to resolve. We discuss many of these problems in the new content page of our website.

Despite these problems, the actions of insurance companies and professional organizations are necessary. For after all, providers are an important part of the healthcare equation. They are the ones who make the recommendations and deliver the care. It’s obviously important therefore that they become convinced to recommend care that science has shown to be most effective.

While necessary, a sole focus on changing provider practice patterns is not sufficient to bring about widespread change in the field. Such a focus leaves out the role of patients who, in large measure, have a say in the care they receive. Any change to the field of chronic pain management must also focus on changing societal beliefs about chronic pain and how to best treat it.

The role of the Institute for Chronic Pain

To meet this need, we developed the Institute for Chronic Pain. While insurance companies and professional organizations play a necessary role in attempting to change the ‘supply’ side of care (i.e., what tends to get recommended by healthcare providers), the Institute for Chronic Pain focuses on changing the ‘demand’ side of care (i.e., what patients and their families expect and want when seeking chronic pain management).

Why is the latter important?

Through much of my career I have worked within interdisciplinary chronic pain rehabilitation programs. I have evaluated countless patients for such programs and a common experience upon evaluation and subsequent recommendation of the treatment is that patients refuse it.

Now there often are many reasons why people can’t or won’t pursue such a recommendation, but a common one is that the recommendation to participate in an interdisciplinary chronic pain rehabilitation program simply doesn’t make sense to them. It’s understandable given our societal belief systems about the nature of chronic pain. Many in our society understand chronic pain as something that is the result of a long-lasting orthopedic injury and as such they think that the most effective approach is to pursue orthopedic-related interventions, such as injections or surgery, that treat the spine or other joint that is the site of pain. As a result, given these societal beliefs, patients can come to refuse to participate in an interdisciplinary chronic pain rehabilitation program, in favor of seeking less effective orthopedic-related care – spinal injections, spinal surgery, and use of opioid pain medications.

To this problem, we have been actively attempting to produce content that explains how chronic pain is typically a nervous system-related condition, not an orthopedic condition, and so therefore should be mostly treated through interdisciplinary chronic pain rehabilitation. We have reviewed how the field is in the process of a paradigm shift, a change in how experts in the field understands the nature of chronic pain and what the field considers to be the most effective treatments for it. We have reviewed the contrasting ways of understanding chronic pain and have reviewed how basic science indicates that chronic pain is the result of a nervous system condition called central sensitization. We have reviewed and clarified the relationships between chronic pain and a number of the most common complicating conditions, such as anxiety, depression, trauma, insomnia, fear-avoidance, and catastrophizing; in so doing, we have explained that these conditions commonly complicate the course of chronic pain because they too are nervous system-related conditions. We have reviewed how interdisciplinary chronic pain rehabilitation focuses on reducing central sensitization and thereby such programs reduce the typical cause of pain and suffering. On our social media sites, such as Facebook, Twitter, and Linkedin, among others, we post (on an almost daily basis) news reports on published studies of the relationship between chronic pain and the nervous system, particularly the brain. In all, the Institute for Chronic Pain devotes much of its resources to changing our societal beliefs about the nature of chronic pain and how best to treat it. Our aim is to bring our common societal understandings into line with the consistent findings of the basic and applied science of pain.

In short, as our mission states, we aim to change the culture of how chronic pain is managed.

In response to these efforts to change our societal understanding of the nature of chronic pain, there remains a common reaction to which we, as the Institute for Chronic Pain, have not yet responded, at least not until now. Within the public at large, but also within the clinic when reviewing the above information with individual patients, there remains doubt that orthopedic-related care, such as spinal injections, surgeries and use of opioids, are less effective than interdisciplinary chronic pain rehabilitation. The doubt continues due to the following reason: people don’t believe it simply because orthopedic-related therapies are so much more commonly performed than interdisciplinary chronic pain rehabilitation therapies. If what we say is true – that science tells us that orthopedic-related therapies are less effective, then it would mean that the field of chronic pain management has gotten it absurdly wrong. But this conclusion, for many, seems too hard to believe. In other words, the difference between how many in the field actually practice and how science informs us that we should practice seems too incongruous to be believable.

Understandably, then, the question thus remains: ‘How could the healthcare system have gotten it so wrong? These therapies (spinal injections, spine surgeries, opioid medications) just simply have to be the most effective treatments or healthcare providers wouldn’t recommend them as often as they do.’

To this question, we put together and published the new webpage, entitled: Why Healthcare Providers Deliver Ineffective Care.

Author: Murray J. McAllister, PsyD

Date of last modification: 1-20-2015

A Webpage Worth the Read

Those of you who are connected to one of our social media sites know that we tend to post daily on the latest news and research in the field of chronic pain management. We recently came across a description of cognitive behavioral therapy for chronic pain on the web, which we initially thought we’d send out on one of our daily posts. After finding myself reading it for a second time, however, I thought that it was too good to simply send out on social media without more comment than the usual line or two of introduction that we tend to provide.

The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.

As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.

He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.

All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn’t discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don’t do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.

Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn’t fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.

While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do — any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.

Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.

Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage here.

Incidentally, if you aren’t already connected to us through social media, please check them out and connect with us. It is one of the most important ways you can support the work of the Institute for Chronic Pain. Being socially connected can also provide you with daily information, news and research that are useful, accurate, and up-to-date. To do so, just click on one of the following links and hit the follow or like button: Facebook, Linkedin, Google+, or Pinterest. Thank you for supporting the ICP.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-4-2014

Is Degenerative Disc Disease Inevitably Degenerative?

It’s common to be upset when you’ve been told that you have degenerative disc disease. It’s an awful sounding diagnosis. It sounds like you have a disease that is deteriorating your spine. And on top of it all, it doesn’t sound like there’s much you can do about it. The spine, it seems, is inevitably degenerating.

Patients commonly express the belief that their chronic back or neck pain is a progressive condition that will unavoidably lead to greater and greater pain and disability. They’ve been told that they have degenerative disc disease and that it is the cause of their pain. It was found on their MRI scan of the spine. Since the cause of their pain is called ‘degenerative,’ they understandably believe that it’s inevitable that they are going to get worse. Their future, it seems, holds nothing but increasing pain and impairment.

Sometimes, healthcare providers believe that degenerative disc disease is inevitably degenerative too. Commonly, patients tell me that they’ve been told by their healthcare provider that they will end up in a wheelchair someday or that the provider is surprised the patient can walk upright given the extent of the findings of degenerative disc disease that’s evident on the MRI scan. Such comments by healthcare providers seem to indicate that they too believe that degenerative disc disease is inevitably degenerative, progressively leading to a worsening of pain and disability.

What is the natural course of degenerative disc disease?

How confident should we be in this belief that degenerative disc disease is inevitably degenerative? What does science tell us about what happens to so-called degenerative changes of the spine over time? In healthcare, studies of what happens to health conditions over time when left untreated are called ‘natural history’ studies. Such studies simply track a condition over time to see what its natural trajectory is– whether the condition tends to get better or worse. It would be helpful to look at natural history studies of the conditions that fall under the category of degenerative disc disease. We’d then know what the natural trajectory is for such conditions.

Degenerative disc disease is a catchall phrase for a number of conditions of the spine. These conditions are typically evident on CT and MRI scans. They are a loss of disc height, disc bulges and herniations, annular tears, endplate changes, osteophyte complexes, neuroforaminal stenosis, and central canal stenosis, among others.

Let’s look at what happens to these conditions over time. Many chronic back or neck pain patients have such degenerative changes in their spine as evidenced by MRI or CT scans and it will be helpful to know something about what typically happens to them if you have them. Contrary to popular belief, we will find that the changes to the spine that we call degenerative disc disease are not inevitably degenerative.

When I review this research with patients, they are a little surprised. They have long thought of their condition as inevitably progressive and it can take a little bit of time to get used to the idea that their condition is not as degenerative as they had thought it to be. Moreover, they are frequently a little skeptical. One of the most common exceptions to the review of this research goes something like, ‘Well, Doc, I’ve been told that my degenerative disc disease is very severe… Severe or advanced degenerative disc disease is going to get worse. How could it not?’ That is to say, a common belief about degenerative disc disease is not only that it is inevitably degenerative, but that the more advanced it is the more progressive it will be. Another way to put it is the belief that the worst or most advanced stages of degenerative disc disease will always tend to lead to the most severe pain and disability. So, let’s review what science tells us about what happens to the most advanced or worst degenerative changes over time too.

Specifically, with our review of natural history studies of degenerative disc disease, we want to determine the answers to two questions:

  • Do degenerative changes to the spine inevitably worsen?
  • What happens to the most severe degenerative changes?

 Natural history studies of degenerative disc disease

Symmons, et al., (1991) were some of the first investigators to look at these questions. They took X-rays of 742 women aged 45 or older and then repeated the X-rays 8 to 11 years later. They broke women into two groups, those with back pain and those without back pain. They found degenerative changes in both groups. They also found that degenerative disc disease progressed most often in those with back pain. Over the study period, they found that almost 60% of women with back pain had a progression of their degenerative disc disease; whereas, a little more than 30% of women without back pain had a progression of their degenerative disc disease. Notice, however, that progression of degenerative disc disease is not inevitable. The remaining 40% of those with back pain had degenerative disc disease that did not get worse. The remaining 70% of the women without back pain had degenerative disc disease that did not get worse.

This study relied on X-rays, rather than more accurate CT or MRI scans. Is there evidence of the same findings with CT or MRI scans?

Using MRI scans on a repeated basis, Matsubara, et al., (1995) followed 32 patients with herniated discs in their lumbar spine over the course of a year. They found that 62% of the disc herniations spontaneously reduced in size and the remaining 38% of herniations did not get worse. In this study, we see a significant degenerative disc problem – herniations – tending to get better the majority of the time. Even when disc herniations failed to get better, they did not tend to get worse. Here, we find that the disc herniations are not inevitably degenerative.

These researchers also found data that pertains to the severity of disc herniations. Contrary to the popular belief that the worst problems tend to become more problematic, they found that the larger the disc herniation, the more it reduced.

Another spinal condition that falls under the category of degenerative disc disease are endplate changes. Hutton, et al., (2011) reviewed two groups of patients with lumbar-related endplate changes who had had MRI’s repeated over time. The first group was 36 patients with a minimal level of endplate changes. The second group was 22 patients with a more advanced stage of such changes. Of the first group with less significant endplate changes, half remained the same; a little less than half got worse; and two patients reversed back to normal. Of the second group with the more advanced changes, most remained the same; some got better and none got worse.

Here again, we see two important facts about this specific type of degenerative change. First, in its least advanced stage, sometime it does get worse, but only less than half the time. Thus, we really can’t say it is inevitable that it gets worse. Second, contrary to the notion that the more severe spine problems always lead to more severe consequences, we see that the advanced stages of endplate changes generally stay the same. Sometimes it gets better, but they don’t tend to get worse.

Park, et al., (2013) found in a sample of 27 cervical spondylolisthesis patients that only three had a progressive worsening of their condition over a 2-7 year follow-up period. None of the three experienced any significant neurological injury or an increase in their symptoms as a result.

Humphreys, et al., (1998) looked at still other conditions of the spine, which are associated with degenerative disc disease. They found that foraminal stenosis did in fact narrow with age but found no progression of disc height, lordosis, or central canal stenosis. So, here again, we find that degenerative changes of the spine are far from inevitably degenerative.

Regarding the latter, Karadimas, et al., (2013) reviewed the literature on cervical spondyltic myelopathy, or a degenerative narrowing of the spinal cord in the area of the neck, and found that the condition naturally worsened in 20-60% of the cases. Again, we see a significant degenerative condition can get worse, but does not always get worse. Indeed, depending on the study, 40-80% of the time it does not get worse.

Some might counter with a subtle variation of the second question we have been attempting to review, namely that the most advanced degenerative disc disease tends to be more degenerative. They might acknowledge that degenerative disc disease itself may not inevitably become worse. They might even acknowledge that the most advanced stages of such changes don’t tend to inevitably get worse. However, they might argue that the most severe degenerative changes to the spine do in fact lead to greater pain and/or a greater decline in functioning. In other words, those with the most severe degenerative disc disease will inevitably experience the greatest pain and disability.

A recent study by Berg, et al., (2013) inadvertently sheds light on this point. They were interested in looking at whether degenerative disc disease correlates with pain and disability in a sample of 170 low back pain patients who had been recommended for disc replacement surgery at either of the two lowest disc levels of the lumbar spine (i.e., L4-5 & L5-S1). Presumably, the degenerative disc disease evident at these two levels was severe enough to have the surgery recommended to them. Interestingly, they found no significant correlation at all between degenerative disc disease and either pain or disability. Even among a subgroup of people with the most severe degenerative changes (the severest of the severe), they still found no correlation. They subsequently added findings of facet arthropathy, another degenerative condition, and with the combination of degenerative disc and facet changes they still found no correlation between such changes and either pain or disability. In other words, neither more severe findings of degenerative disc disease nor a greater amount of such degenerative conditions lead to a worsening of pain or impairment. (This study highlights another interesting question to which we tend to all assume we know the answer – to what extent does degenerative disc disease explain chronic back or neck pain. This question will be taken up in our next blog post).

Concluding remarks

To summarize, we set out to determine the truth of certain common beliefs that patients have about degenerative disc disease. These beliefs are that degenerative disc disease is inevitably going to worsen, or at the very least the most severe degenerative changes are always going to get worse. By reviewing what the science tells us about degenerative disc disease, we see that neither of these beliefs are true. While degenerative changes do sometimes get worse, they very often either remain the same or get better. Also, we see evidence that the worse the degenerative condition is, the more it tends to either stay the same or get better.

Has your healthcare provider ever told you or implied that degenerative disc disease was inevitably going to get worse? Why do you think that this belief continues to be common when the scientific literature doesn’t support it?

References

Berg, L., Hellum, C., Gjertsen, O., Neckelmann, G., Johnsen, L. G., Storheim, K., Brox, J. I., Eide, G. E., & Espeland, A. (2013). Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis. Skeletal Radiology, 42(11), 1593-1602.

Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23, 2180-2184.

Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.

Karadimas, S. K., Erwin, W. M., Ely, C. G., Dettori, J. R., & Fehlings, M. G. (2013). Pathophysiology and natural history of cervical spondyltic myelopathy. Spine, 38(22S), S21-S36. doi: 10.1097/BRS.0b013e318a7f2c3

Matsubara, Y., Kato, F., Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.

Park, M. S., Moon, S. H. Lee. H. M., Kim, S. W., Kim, T. H., Suh, B. K., & Riew, K. D. (2013). The natural history of degenerative spondylolisthesis of the cervical spine with 2-7year follow-up. Spine, 38(4), E205-E210. doi: 10.1097/BRS.0b013e1827de4fd

Symmons, D. P., van Hemert, A. M., Vandenbroucke, J. P., & Valkenburg, H. A. (1991). A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings. Annals of the Rheumatic Diseases, 50, 162-166.

Author: Murray J. McAllister, PsyD

Date of last modification: 3-10-2014

Reducing Overtreatment & the Profit-Motive in Healthcare

It might be easy to conclude that anyone who wants to reduce the role of the profit-motive in healthcare must be either an extremist or a fool. Upon reflection, however, it becomes clear that we are experiencing an era of overtreatment in healthcare (see, for example, Dr. H. Gilbert Welch’s piece here) and one area where it is particularly apparent is in the management of chronic pain. While there are likely many causes of overtreatment, one of them surely is the profit-motive that occurs within a fee-for-service model of reimbursement.

In the last few posts (dated 12-22-13 & 12-29-13), we have been exploring the role that the profit-motive plays in the generation of recommendations for treatment. We have seen that in a fee-for-service model of reimbursement the treatment of chronic pain can constitute a ‘perfect storm’ for overtreatment (i.e., providing an overabundance of care that has a low likelihood of effectiveness). Let’s review how it might play out.

How overtreatment occurs in chronic pain management

Patients with chronic pain are commonly distressed. This distress can lead to a willingness to try any number of medications and procedures, sometimes even repeating previously failed treatments over the years. Their healthcare providers lack any incentive to discourage such an overabundance of care, even if therapies have little chance for success. Rather, because of the fee-for-service system of reimbursement, they are in fact incentivized to make the recommendations. Indeed, the more care they recommend, the more they are likely to provide, and the more care they provide the more money they make.

It’s not that such providers are making recommendations solely on the basis of what’s in their financial best interests. As healthcare providers, they are charged to work in the best interests of the patient as well. They make recommendations and provide care in the ways they do because it is possible that such care might be helpful. If asked, they’d say that they see patients helped everyday by the medications or interventions or surgeries they provide. And it would be true.

Most any therapy can be helpful. Any clinician can point to patients for whom any numbers of the common available therapies have been helpful. For most patients and providers, this justification is good enough. If a particular therapy has been helpful in the past for Mr. Smith, why not try it for Ms. Jones? Besides, Ms. Jones has chronic pain, likely for years, and is in distress and seeking care, wanting to try something. Ms. Jones’ provider can thus recommend the therapy with a clean conscience. It’s what the patient wants and it’s possible that it will be effective.

 

Notice that the bar to justify a treatment recommendation gets set pretty low. A recommendation for a particular therapy seems reasonable if there’s a possibility of success. Both the patient and the provider seem satisfied to move forward with it, as long as it’s possible that it will be helpful. No one in this interaction seems to require a higher degree of justification, such as some degree of probability that a therapy will be effective. The possibility of effectiveness, rather than then probability of effectiveness, is good enough.

This all-too-common justification for treatment recommendations leads to overtreatment because it masks the profit-motive that underlies it. As we saw in our initial post, the justification only seems reasonable when it occurs within the context of a fee-for-service reimbursement system. In other words, providers would require a higher level of justification, if they themselves were the payer of the fee for the therapy, rather than the receiver of the fee. In a capitated system, for example, where providers stand to lose money rather than gain money when providing care, they might inquire more fully into how likely a given treatment will be effective before proceeding, rather than simply asking whether it might be effective. In contrast, in a fee-for-service system of reimbursement, there is no incentive to have a higher criterion for the care we deliver.

This state of affairs leads to scenarios like those of patients I see everyday. Working in chronic pain rehabilitation, we tend to evaluate patients after they have exhausted countless pharmacological, interventional, and surgical options – no matter how remotely likely they were to have been effective. The typical patient we see is in their forties or fifties and has had chronic pain for more than five years. They have been managed on opioids for most of these years. As a consequence, by the time they get referred to us, our patients have trialed a number of opioids and have become tolerant to even very high doses. They typically have been to two or more interventional pain clinics, where over the years they have had ten to twenty spinal injections and have had three or four repeated radiofrequency neuroablations. They commonly have had three or more spine surgeries.

I am not exaggerating.

They often tell me that I am the first person who has ever told them that they have chronic pain. I sometimes find it difficult to believe. I think what they must mean is that I was the first person to tell them in a way that they really understood – that “chronic” really means chronic, i.e., incurable. What they tell me, though, is that all other providers have tended to leave them with the impression that, while their pain has been long-lasting, it’s only a matter of finding the right procedure and they can be cured. When I ask, they tell me that no provider has ever sat them down and had a serious discussion of exactly how unlikely such a cure really is. Instead, what appears to happen is that they have undergone countless procedures and therapies over the years with very little chance of serious success. What it appears is that they have been overtreated.

Overtreatment in chronic pain management is exceptionally common. It is not just my impression. It’s been shown in systematic ways that the rates of use of opioids, interventional procedures, and spine surgeries have grown exponentially over the last few decades (Deyo, et al., 2009; Manchikanti, Pampati, et al., 2010).

What can healthcare providers do?

The first thing any provider can do is to decide whether this state of affairs is a problem or not.

I suspect that some providers in chronic pain management won’t think it is problematic at all. Spine surgeons and interventional pain providers profit greatly from the current fee-for-service practice patterns (Medical Group Management Association, 2011). Recurrent studies over the years show that their routine care for pain disorders persistently fail to follow established guidelines for common conditions, such as back pain. Instead of obtaining care that professional organizations agree is the most effective, patients continue to obtain MRI or CT scans, interventional procedures, and spine surgeries at increasingly high rates (Deyo & Mirza, 2006; Deyo, et al., 2009; Hrudey, 1991; Ivanova, et al., 2011; Mafi, et al., 2013; Pham, et al., 2009). Such less than optimal tests and procedures constitute some of the most over-utilized assessments and treatments in our healthcare system.

Thought leaders in the field of interventional pain management advocate against policy changes that encourage the use of empirically supported treatments (Manchikanti, Falco, et al., 2010). Organizations of both spine surgeons and interventional pain providers have also advocated against the Affordable Care Act and its provisions to encourage the use of empirically effective treatments (see, for example, Branch & Rao, 2009; Manchikanti, et al., 2011).

Many of us, however, in chronic pain management consider overtreatment unacceptable and are committed to delivering healthcare based on what’s most effective. Indeed, it is a moral obligation. Whether done out of a business practice or ignorance or both, it is simply wrong to withhold the most effective therapy from patients or to recommend tests and procedures that lie outside of treatment guidelines, assuming that guideline based treatments have not already been tried.

If your patient had cancer, you wouldn’t want him or her to pursue less effective treatments before pursuing more effective treatments. But, this is exactly the scenario of care that most chronic pain patients get recommended today in our field.

These points bring us to the next thing that providers can do to reduce profit-motive and overtreatment in chronic pain management.

Learn about established treatment guidelines

The American Pain Society has developed and published a number of treatment guidelines. A brief list of them can be found here.

As a profession, we are called to first provide the most effective care to our patients. To do so, we first need to know what these therapies are. We are therefore obligated to know these therapies and to provide them or refer accordingly.

Take the time to teach patients about what therapies are most effective

It takes time to teach patients why orthopedic treatments for chronic pain, such as spine surgeries and interventional procedures, are commonly ineffective. The prevailing zeitgeist remains that chronic pain is an orthopedic condition. Initially, it often doesn’t make sense to patients why rehabilitation therapies are more effective.

A common complaint among providers is that it takes too much time to explain it to patients and so often ‘the path of least resistance’ is to refer them to orthopedic care that lies outside the treatment guidelines (see, for example, this problem as discussed by DeNoon in the Harvard Health Blog).

Another version of the profit-motive, however, underlies this complaint. It only takes too much time to explain to patients important aspects of their care if you are attempting to see as many patients as possible as a means to increase productivity reimbursement.

If, however, we take our calling as a profession as the primary value, and place business as a secondary value, then the practice of taking time to explain to patients the nature of their condition and the reasons why they should pursue guideline based care becomes our moral obligation. It’s not inefficient. It is not a nuisance or an inconvenience. It’s our job.

We have the opportunity everyday – often multiple times daily – to do our job and explain to patients the following: chronic pain syndromes are a nervous system problem and not an orthopedic problem; and chronic pain syndromes are most effectively treated with chronic pain rehabilitation programs, not narcotics, spine surgeries, and interventional procedures.

To help in these discussions, refer patients and their families to the Institute for Chronic Pain and other resources. Indeed, keep a list of reputable websites and blogs to provide to patients so they can continue to educate themselves.

Support policies and organizations that encourage effective care over profitable care

Support organizations such as the following:

If you find important information, pass it on to all of those in your network. (Indeed, please pass this blog post on to all in your network.)

Also, if you are an American healthcare provider, support policies and laws, such as the Affordable Care Act (ACA), that encourage experimentation with getting away from the fee-for-service reimbursement system. For example, in some minimal ways, the ACA contains policies that experiment with moving away from paying provider organizations based solely on the quantity of patients they see and quantity of tests and procedures they perform; instead, it begins to experiment with paying provider organizations based on the quality of their performance in keeping people well. The jury remains out, of course, whether such projects will prove fruitful, but their intention is an admirable attempt to reduce the profit-motive in healthcare and subsequently reduce overtreatment.

Suggested reading: Unnecessary care: Are doctors in denial and is the profit motive to blame?

References

Branch, C. & Rao, R. (July 28, 2009). Letter to Honorable Speaker Pelosi. Retrieved from http://www.spine.org/Documents/NASSHealthCareReformLetterPelosi.pdf

DeNoon, D. (July 31, 2013). Back pain often overdiagnosed and overtreated. Harvard Health Blog. Retrieved from http://www.health.harvard.edu/blog/back-pain-often-overdiagnosed-and-overtreated-201307316546

Deyo, R. A. & Mirza, S. K. (2006). Trends and variations in the use of spine surgery. Clinical Orthopedics 433, 139-146.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Hrudey, W. P. (1991). Overdiagnosis and overtreatment in low back pain. Journal of Occupational Rehabilitation, 1(4), 303-312.

Ivanova, J. I., Birnbaum, H. G., Schiller, M., Kantor, E., Johnstone, B. M., & Swindle, R. (2011). Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine Journal, 11(7), 622-632.

Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581. doi: 10/1001/jamainternmed.2013.8992

Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the healthcare reform for the new decade. Pain Physician, 14, E35-E67. Want to do away with the measures that change fee-for-service to reimbursement systems that pay for effectiveness

Manchikanti, L., Falco, F., Parr, A. T., Boswell, B., & Hirsch, J. A. (2010). Facts, fallacies, and politics of comparative effectiveness research: Part I: Basic considerations. Pain Physician, 10, E23-E54.

Manchikanti, L., Pampati, V., Singh, V., Boswell, B., Smith, H. S., & Hirsch, J. A. (2010). Explosive growth of facet joint injections in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. BMC Health Services Research, 10, 84. doi: 10.1186/1472-6963-10-84

Medical Group Management Association. (2011). Physician Compensation and Production Survey 2011 Report Based on 2010 Data. Washington DC: Medical Group Management Association.

Pham, H. H., Landon, B. E., Reschovsky, J. D., Wu, B., Schrag, D. (2009). Rapidity and modality of imaging in acute low back pain in elderly patients. Archives of Internal Medicine, 169(10), 972-981. doi: 10.1001/jamainternmed.2009.78

Author: Murray J. McAllister, PsyD

Date of last modification: 1-5-2014

How Money Influences Healthcare Recommendations

One of the more common sentiments that patients express to me is that they have come to the conclusion that money influences healthcare recommendations. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried multiple times, they have concluded that the business side of healthcare played too much of a role in their own care. They are now disappointed, angry, and jaded about how much they trust healthcare providers.

Sometimes, the sentiment comes when they first accept that their chronic pain is really chronic. They wonder why no one ever sat them down and talked with them about how their pain is actually chronic. What they got instead, they say, were healthcare providers who kept recommending procedure after procedure that were all vain attempts to cure something that they should have acknowledged was a chronic condition. It must have been for the money, they conclude.

Sometimes, the sentiment comes after patients learn how ineffective common surgical and interventional procedures are. They subsequently wonder why, if it’s not for the money, healthcare providers recommend treatments that well-designed studies have shown to be ineffective.

Sometimes, too, they come to wonder about the role of money once they have participated in a chronic pain rehabilitation program. After being on opioid medications for many years, they go through a program and come to learn how to self-manage pain without the medications. Once they get over their initial shock that they really can manage pain without opioids, they begin to wonder, “Why didn’t anyone ever refer me to a program like this before?” Then, they start wondering about the role that money might have played in continuing them on opioids for many years without ever referring them to a program that could have shown them how to live well without the medications.

However the sentiment arises, patients with chronic pain express it fairly often: money influences healthcare recommendations.

So, is it true that money can play a role in the recommendations that healthcare providers make? I think that most healthcare providers would quietly acknowledge that it is true. A number of commentators in the field also acknowledge it (see, e.g., Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

Like most things in life, though, it’s complicated. The question doesn’t lend itself very well to a simple ‘yes or no’ response. Let’s look at some of these complications so that we can appreciate how complicated the issue really is. It’s important to have an accurate understanding and appreciation for the issue, because, after all, it’s not true that all healthcare is bad even if things like the profit-motive sneak into it and influences it. We need healthcare. It’s too simple and likely not good for any of us to get so mad at its imperfections that we become jaded and forego it. We shouldn’t throw the baby out with the bath water, as the old saying goes. Rather, we can acknowledge its imperfections and take them into account in order to make clear-headed decisions about the recommendations that our healthcare providers make. By having a sophisticated understanding and appreciation for how healthcare works, we can make better and more informed decisions about the recommendations that we receive – whether to pursue them or not.

The following is the first of a three-part series on the role of the profit-motive in healthcare, particularly as it relates to the management of chronic pain. This first blog post focuses on how money influences healthcare recommendations. The two following posts will be about 1) what you, as a patient, can do about it, and 2) what healthcare providers can do about it.

Fee-for-service reimbursement influences healthcare recommendations

In countries where healthcare delivery is a for-profit industry, financial incentives can influence recommendations. To see how, we need to provide a quick review of how financial reimbursement works in a for-profit health care industry.

In the U. S., for example, most hospitals, clinics, and individual providers get paid a set amount of money every time they see a patient or perform a procedure or order a test. This system of reimbursement is called ‘fee-for-service.’ Individual providers are commonly akin to independent contractors with their practice being their business and their livelihood dependent on how many patients they see and how many procedures and tests they provide. In addition, administrators of hospitals and clinics track and evaluate providers’ performance based on ‘productivity’ (i.e., how many patients that are seen and how many procedures and tests that are provided).

Notice the subtle value system at work. Healthcare providers make more money when they see more patients and perform more procedures and tests. Their administrators will subsequently see those providers with the highest productivity as most favorable. Administrators promote or lay off healthcare providers in part based on productivity or lack of it. In all these ways, fee-for-service reimbursement creates incentives to provide more rather than less care.

Now, we all know that incentives influence behavior. It’s true in all walks of life and it is similarly true in for-profit healthcare. Fee-for-service incentives influence the type and amount of recommendations that patients receive from their providers, clinics and hospitals. It stands to reason that such influence occurs. Sales people are rarely salaried employees. Rather, they are paid on commission because it influences them to be more productive in the amount of sales they produce – the more they sell, the more they are paid and the more their positions remain safe from being laid off. It’s the same with most healthcare providers – the more patients they see and the more procedures and tests they recommend and convince patients to have, the more they get paid and the more their administrators value their position.

There are actual studies that demonstrate the influence of incentives on productivity in healthcare. For example, Hickson, Altmeier, and Perrin (1987) compared salaried physicians to fee-for-service physicians. Both groups involved the same type of physician and saw the same types of patients. The fee-for-service physicians saw more patients than the salaried physicians.

Likewise, Strope, et al. (2009) studied a recent trend for providers to build their own ambulatory surgery centers and subsequently change the site where they perform procedures, from the hospital or clinic, to the ambulatory surgery center that they own. The advantage of performing procedures at an ambulatory care center that the provider owns is that the provider will make more money. Specifically, they get to bill at a higher rate than in the clinic, even if it is for the same procedure, and they get to keep the money that ordinarily would have gone to the hospital for the use of the hospital facilities. So, what did Strope, et al., find in their study of this recent trend? Once providers could bill at higher rates of reimbursement and subsequently collect more money, the rate of procedures significantly increased, including the most profitable procedures. It’s hard to argue, in such circumstances, that need for such procedures dramatically changed once providers came to own the surgery centers.

Similarly, providers who own their own imaging devices (e.g., X-ray, CT or MRI scans) are upwards of eight times more likely to order scans than those who don’t own their own imaging devices, even when the latter providers are from the same specialty and are seeing the same type of patients with the same types of health problems (Kouri, Parsons, and Alpert, 2002). Again, it’s hard to argue that those providers who own their own imaging devices have somehow tapped into an unmet need of patients (see, for example, Fisher & Welch, 1999).

Rather, it stands to reason that such incentives lead to healthcare providers seeing more patients and providing more recommendations to undergo procedures and tests. As such, incentives to make more money can influence what and what doesn’t get recommended.

The concern is that money influences healthcare recommendations in such a way that it leads to unnecessary and/or ineffective care. As seen above, healthcare providers who own their own facilities or equipment have dramatically higher rates of procedures and tests than the same type of healthcare providers who don’t own their own facilities or equipment. Are the dramatically higher numbers of procedures and tests necessary? If they are unnecessary, they likely do not add value to the diagnosis or treatment of the condition of the particular patient. In other words, under these circumstances, they are ineffective for the particular need of the patient.

The pressure of a fee-for-service system of healthcare can similarly lead to unnecessary and therefore ineffective treatments and tests in the management of chronic pain. It’s common to see patients who have a history of obtaining multiple series of the same surgical or interventional procedures at different clinics, even though the first series turned out to be ineffective for their particular pain condition. Why did the subsequent providers think that repeating the same series of interventional procedures or re-doing the spine surgery was a good idea when previously the procedures were ineffective?

How money influences clinical decision-making

To be fair, there are likely many factors at work that go into a decision to make a recommendation for a particular treatment and not just the fact that the provider will personally profit from delivering the treatment.

Imagine, for example, that you are the provider in the following scenario. You have a patient who has chronic pain and is in some degree of distress about it. You’ve learned that the patient has already had a series of interventional procedures, say, and they were not helpful in reducing pain. However, you are an interventional pain provider and interventional procedures are what you do. The patient is there, at your clinic, and wants you to do something. Might you not reason to yourself, ‘well, there’s a chance that it might work, even if it’s unlikely to work, and the patient wants me to try something; rather than sending the patient away without doing anything and making him or her dissatisfied, let’s give it a try.’ We could call this type of clinical decision-making the ‘we might as well give it a try’ decision.

At first blush, it doesn’t seem like the fact that you will personally profit from the procedure has anything to do with the decision. Indeed, the decision seems to be able to stand on its own, as it were. The patient is in pain and is upset about it. The patient wants you to do something. It just so happens that what you do is something that has already been tried and failed in the past. However, there’s still a chance that it might now work. If it works, the patient will be happy. If it doesn’t work, you can say that at least you tried. If you don’t do anything and send the patient away, they’ll likely be more upset than they are now. So, you ‘might as well give it a try.’ The argument seems to stand on its own without needing to reference the fact that you will personally profit from the procedure. This last statement might be true at least until we change the scenario a little by changing the reimbursement system.

Suppose, for instance, that, rather than a fee-for-service system where you profit directly from delivering the care, you work within a capitated system of reimbursement where the profit lies in providing the least and most effective care possible. In a capitated system, providers are not given a fee each time they see a patient or perform a procedure. Instead, they are given a set amount of money for the entire care of a patient for a certain time frame, such as a year. The set amount of money will cover all the care that the patient needs for the given time frame. The incentive in a capitated system is to keep people healthy and out of the doctor’s office so that they don’t use up the set amount of money with frequent visits, procedures, and tests. It also incentivizes providing the care that’s most likely to be effective, and minimizing any ineffective or unnecessary care – again, for the same reason, so that the patients don’t use up the set amount of money that was previously given for their care over the year. Capitated systems of reimbursement are not very common these days, though they were the heart of the HMO system back in the 1970-80’s in America.

Nonetheless, suppose that, as the interventional provider in our scenario, you are now working under such a system of reimbursement. Under this system, would you be as inclined to come to the same decision to repeat a series of interventions that had previously failed– the ‘we might as well give it a try’ decision. Providing the interventional procedures are going to hurt, rather than help, your bottom line. You are still charged to care for the patient who is in pain and distress, but would you use up the set amount of money that you were given by performing procedures that have already been done and were ineffective? Might it not be the case that you would reason against it now? In this scenario, the fact that the series of interventions has already been tried and failed seems to take on greater importance. You would weigh the previously failed treatment more heavily in your decision-making process. In your clinical decision-making process, you might reason, ‘well, why repeat a failed treatment?’

At first blush, it seems like a perfectly reasonable decision. If your car wouldn’t start and you had already paid one mechanic to fix it and the repair didn’t work, you wouldn’t take it to another mechanic and pay for the exact same repair. Rather, you’d want to pursue a different approach. Similarly, as the interventional provider, your decision to refrain from pursuing the same procedure that previously had not worked seems sound.

But, let’s step back for a second, and take stock of our two different, albeit reasonable, decisions.

It’s the same patient with the same condition, but you’ve come to two contradictory treatment recommendations. The only difference that accounts for the different treatment recommendations is how you will get reimbursed. Notice how subtly money influences your decision-making.

It’s an uncomfortable fact that the system of reimbursement in healthcare can influence clinical decision-making.

In the posts to follow, we’ll review what you, the patient, can do to minimize the role that money has in the recommendations that you receive and decide to pursue. Then, we’ll review what us healthcare providers can do to reduce the role that money has on our recommendations.

References

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Fisher, E. S. & Welch, H. G. (1999). Avoiding the unintended consequences of growth in medical care: How might more be worse? Journal of the American Medical Association, 281(5), 446-453.

Hickson, G. B., Altmeier, W. A., & Perrin, J. M. (1987) Physicians reimbursement by salary or fee-for-service: Effect on physician practice behavior in a randomized prospective study. Pediatrics, 80(3), 344-350.

Kouri, B. E., Parsons, R. G, & Alpert, H. R. (2002). Physician self-referral for diagnostic imaging: Review of the empiric literature. American Journal of Roentgenology, 179(4), 843-850.

Perret, D. & Rosen, C. (2011). A physician driven solution – The association for medical ethics, the physician payment sunshine act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

Strope, S. A., Daignault, S., Hollingsworth, J. M., Ze. Z., Wei, J. T., & Hollenbeck, B. T. (2009) Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the state of Florida. Medical Care, 47(4), 403-410.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 12-22-2013

Institute for Chronic Pain – One Year Anniversary

The Institute for Chronic Pain celebrates this month its one-year anniversary of going live with our website and blog.  The Institute for Chronic Pain is an educational and public policy ‘think tank’ devoted to changing the culture of how chronic pain is managed. We imagine a day when the management of chronic pain is guided by the principles of empirical-based healthcare (i.e., pursuing only those treatments that research has shown to be effective). Our public face is our website and blog, where we provide academic-quality information that is accessible to patients, their families, as well as providers and third-party payers.

In this last year, our main goal was to establish the website as a leading source of information on chronic pain and its treatments, particularly chronic pain rehabilitation.

In this next year, our main goal is to grow our stakeholder community. We want to be a trusted source of high quality information to patients and their families. We also want to increase our presence among the provider and third party payer communities. We expect to provide content by an increasing diversity of experts in healthcare and from academia. Outreach to third party payers will also be essential, providing information on empirically-based treatments for chronic pain.

To these ends, we ask you to become a stakeholder with us in the future of a more effective and cost-effective healthcare system for the management of chronic pain syndromes. Please like us or follow us on:

The more we learn together, the more effective our care will be as providers and consumers of chronic pain management.

In closing this celebration announcement, I’d like to re-post our first introductory blog post (in a slightly edited fashion). Originally published on October 7, 2012, it remains a fresh statement of our guiding vision. Thank you for being a stakeholder in this future.

_________________________________________________________________________

Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.

 Changing the culture of how chronic pain is managed

Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.

Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.

It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.

  • As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
  • As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
  • We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
  • As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured; we tend to recognize the chronicity of  other chronic conditions, such as diabetes or heart disease, but tend to forget it when it comes to chronic pain.
  • Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
  • As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
  • As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
  • As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
  • As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures, which are largely ineffective

The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.

To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.

In short, we need to change the paradigm that underlies chronic pain management.

Analogy to the change in our cultural understanding of cigarette smoking

Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago.  In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.

A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. Providers began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.

Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked, and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.

It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.

On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from what they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.

On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.

All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking.  They have been largely effective in making a profound and beneficial impact on our health.

The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.

It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.

The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:

  • We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
  • Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
  • Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
  • We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
  • We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.

The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.

Goals of the Institute for Chronic Pain

The Institute has set out a number of methods for achieving the resolution of these goals.

  • We provide a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
  • We provide this blog through our website.
  • We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
  • We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
  • We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
  • We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
  • We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
  • We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.

Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.

We hope that you will join us in this endeavor. Join our community and be part of this change.

____________________________________________________________________

Author: Murray J. McAllister, PsyD

Date of last modification: 10/7/2013

Why See a Psychologist for Pain? (Part 2)


In the last post, we addressed the question, “Why see a psychologist for pain?” The answer is that psychologists are the experts in teaching patients how to self-manage and cope with chronic pain. Patients who see psychologists for chronic pain can learn how to self-manage and cope with pain so well that they can largely come to live a normal life despite having chronic pain.

 

Another way to respond to the question of “Why see a psychologist for pain?” is to look at the role of the nervous system in chronic pain and how psychologists are experts in the treatment of health problems related to the nervous system. Let’s attempt to unpack this statement.

Nervous system & chronic pain

People commonly think of chronic pain as if it is a long-lasting symptom of an injury or illness that has failed to heal. This viewpoint is mistaken. Take, for example, the notion of degenerative disc disease. It is common to think that degenerative changes of the spine are the cause of chronic back pain. However, we know that degenerative changes of the spine are only minimally correlated with pain, which means that most of what makes up the experience of pain cannot be attributed to degenerative changes of the spine (Endean, Palmer, & Coggon, 2011). Such changes of the spine are a minor ingredient, if you will, in the pie that’s chronic pain.

A more accurate understanding of chronic pain is that it is a disorder of the nervous system called “central sensitization.” An orthopedic injury, for example, might have initially caused a case of back pain, but now, after many months or years, the whole nervous system is involved, including the brain and spinal cord. Changes to the whole nervous system have now made the nerves at the original site of the injury highly sensitive and reactive. They are stuck, as it were, in a “hair trigger” mode that makes any little movement painful.

In the notion of central sensitization, we also see one of the central tenets of chronic pain rehabilitation: that when it comes to chronic pain, what initially caused the pain is not now the only thing that maintains pain on a chronic course. The notion captures the complexity of causal factors in chronic pain, as opposed to acute pain, which may have one cause – an injury or illness. Biological, psychological, and environmental factors are known to influence the development of central sensitization (please see the Institute’s content page on central sensitization for more details). The notion of central sensitization also explains other psychosocial aspects of chronic pain – chronic fatigue, insomnia, limited cognitive deficits such as poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007)

For many years, psychologists have successfully treated patients with health conditions related to the nervous system: depression, the various anxiety disorders, insomnia, irritable bowel syndrome, as well as chronic pain.

Psychological therapies for chronic pain

The Society for Clinical Psychology, which is a division of the American Psychological Association, developed task forces to compile a list of treatments that have been determined to be effective for a variety of disorders. They defined “effectiveness” as having multiple clinical trials from different researchers showing the effectiveness of a specific treatment. Not surprisingly, they have identified as effective multiple psychological treatments for mental health disorders such as depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, and general anxiety. However, they have also identified as effective multiple psychological therapies for health conditions. There is strong empirical support for cognitive behavioral treatments for chronic low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, headache, and chronic pain syndromes in general. They have also identified effective psychological therapies for primary insomnia and irritable bowel syndrome. You can find information on these treatments here and here.

These therapies are effective likely because of their impact on the nervous system. Just as cognitive behavioral therapies reduce the reactivity of the nervous system in persons with post-traumatic stress disorder or panic disorder, in terms of their heightened startle response or susceptibility to panic, respectively, cognitive behavioral therapies for chronic pain disorders are likely to reduce the reactivity of the nervous system. By reducing the reactivity of the nervous system, patients come to have less pain and increased abilities to cope with the pain that remains.

References

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Published date: 7-29-2013

Date of last modification: 7-29-2013

Author: Murray J. McAllister, PsyD

Values & Chronic Pain Management

I recently came across this blog post in my reading and thought that it would be a good conversation starter. In the post, Mark MacLeod, MD, raises the point that we need to have an on-going discussion about values in healthcare. Dr. MacLeod is on to something here. In his piece, Dr. MacLeod is writing within and about the Canadian healthcare system. However, his point is applicable to any country’s healthcare system. We need to engage in a communal dialogue about our values when it comes to what we should (or should not) do with our healthcare systems.

In such a discussion, values play at least three important functions. First, they serve as guides for our behavior when actively engaged in an activity. In this sense, we might ask whether our behavior is in accordance with certain rules or norms we live by. Second, values serve as goals when engaged in an activity. They show us what we should be shooting for. In this sense, we might ask about the goals that we are trying to bring about when engaged in some activity. Third, values serve as a means to judge how good of a job we did, once we engaged in some activity. They allow us to compare what it is we completed with what it was we were trying to complete. This comparison is the distinction between what is (i.e., what we did) and what should be (i.e., what we were aiming for).

As we go about making our healthcare system(s) better, what values do you think should guide our behavior? What values should we try to attain when making our healthcare system(s) better? What values should we use when taking stock of our healthcare system(s) – i.e., how we are doing right now or into the future?

Taking these questions closer to home, what values should guide our behavior when managing chronic pain? What values should guide us when trying to make the quality of chronic pain management better? What values should we use to judge how well we manage chronic pain?

It would be interesting to hear from you. How might you answer these questions? It would be interesting and helpful to engage in a dialogue about your values when it comes to chronic pain management, and how they might be similar or dissimilar based on your personal or professional experiences, and what country you might be from. Of course, I would also ask that the values of civility, politeness and respect guide our conversation.  🙂

Here are mine.

Professionalism

Call me ‘old school’ but I think healthcare providers should do what they do because primarily they want to help people. Loosely, the definition of a profession is a vocation that involves providing a humanitarian service to others. The primary focus of a profession is that it is a job that helps people: a job that aims to make sick or injured people well (a healthcare provider); a job that teaches people (an educator); a job that protects people and their property (police officers & firefighters); and so on. While a sense of professionalism has remained strong in the professions of education and first responding, professionalism seems to be waning in healthcare, especially over the last thirty years in the U.S. Indeed, in certain circles, talk about how we should be in it to help people can sound quaint.

In the U.S., hospitals, clinics, and provider groups have become corporatized (if I can make up a word). Over the last thirty years, many such groups have become actual corporations. They have shareholders and CEO’s who are not healthcare providers, but rather individuals with significant business experience and training. Of course, some hospitals, clinics, or provider groups have maintained their non-profit status,  but even most of these have become corporatized in their behavior. The bottom line is as important (and sometimes more important) as the health and well-being of those they serve.

The values of corporations and the language of production has permeated our healthcare system in the last thirty years in the U.S. Hospital, clinic, and provider groups, — even individual providers – are measured not by how well their patients are, but by how productive they are. Monthly quotas and productivity reports are now standard fare for healthcare providers.

Now, don’t get me wrong. There is nothing wrong with corporations. They serve a great function and their primary function is to make money. Again, there is nothing wrong with making money. It’s a great thing.

It’s a matter, however, of what is most valued. As healthcare providers, are we primarily in the field to help people or are we primarily in the field to make money? Are we primarily a profession or are we primarily a business? In the last thirty years in the U.S., we have become primarily a business.

I think we should primarily be a profession.

What difference does it make?

On a societal level, it matters because when healthcare providers are structured and therefore act as a business it leads to a lot of healthcare spending that we all end up paying for in our premiums. Hospital, clinics, and provider groups – even most individual providers – get paid based on productivity. The more healthcare providers treat and test, the more they get paid. Subsequently, the more healthcare providers treat and get paid for it, the more we, as a society, have to pay for it through our insuranace premiums. By incentivizing treatment and testing, we as a society foster an expensive healthcare system.

On the individual level, it matters because it creates a certain tension between you and your healthcare provider. As a patient, you expect your healthcare provider to be a professional – to act in your best interest. However, the healthcare system incentivizes your healthcare provider to act in his or her best interest. Therein lies the tension.

Patients feel it everyday. I hardly have a day go by when I don’t hear from a patient about his or her resentment towards healthcare providers, particularly chronic pain management specialists. They tell an all-too-common story: they have been treated over the years with countless procedures, surgeries, and tests, and have never gotten considerably better; they continue with intolerable levels of chronic pain and disability; subsequently, it has dawned on them that maybe it wasn’t their best interests that were served in this long history of care.

Providers too feel it, at least some of us. They remain concerned about the administrative focus on the bottom line. It’s not uncommon to talk among ourselves and question, “Didn’t we get into the field to help people?’

Truth be told, though, not all of us resent it. As you can see in the news most everyday, many hospital, clinic, and provider groups fight tooth and nail to maintain this system of incentivizing treatment and testing. They would have a lot to lose if it were given up.

One simple step towards solving this tension that patients can make is to demand to see healthcare providers who are salaried. It might take some looking around, but some of the most prestigious healthcare institutions in the U. S. pay their providers on salary, rather than production.

With some notable exceptions (including healthcare providers), most professions are salaried. Teachers don’t get paid based on how many students they teach. Police officers don’t get paid based on how many people they pull over. Fire fighters don’t get paid based on how many fires they put out. Why? It’s because we, as a society, want them to maintain a focus on the good of others. We don’t want to put them in a position of having to choose between their own self-interest (i.e. their livelihood) and the interests of those they serve.  We want assurance, for instance, that the police officer pulls someone over because it was the right thing to do, not because the police officer would stand to financially profit from it.

When you think about it, professions are jobs that have a certain amount of power in society: healthcare providers, teachers, police officers, fire fighters, and so on, have been given power to influence people – hopefully for the good. With this power, we want them to exercise it for our well-being, not their own. We don’t want their self-interest to corrupt the power that society has given them. We need them to primarily serve society’s interests, not primarily their own. As such, society reimburses them through a salary system that keeps their focus on us.

Similarly, you could demand to see healthcare providers who are reimbursed through a salary and, as such, are not incentivized to treat and test you. You will have greater assurance that your healthcare providers are making recommendations based on what they think are in your best interest, not theirs. In other words, you will have a greater assurance that your healthcare providers are primarily acting out of their profession (and not primarily acting as a business).

Evidence-based healthcare

As we attempt to make chronic pain management more helpful, I think we should have as a goal to make it more effective.

How would we do that? A lot of healthcare is done out of tradition (it’s how we were taught) or because it is profitable. But don’t we deserve a higher bar? Indeed, healthcare providers should make recommendations based on what is most effective – not on what they have always done in the past or what will make them the most money.

If you had cancer, you would want the most effective treatment, right? And if the first treatment didn’t work, you would go on to the next most effective treatment, right? Shouldn’t we do that with all health conditions?

The practice of engaging in the most effective treatments first is called evidence-based healthcare, or empirical based healthcare.

How do we determine what is most effective? Well, we need a way that is rigorous – we wouldn’t, for instance, want to decide by just flipping a coin. We would want to put it to a more rigorous test. The testing process would have to involve more than one patient or even a few patients.  Why? It’s because most any treatment works for some small percentage of people. It’s called the placebo effect. So, we need to see what works for most people. In our society, we do this with the scientific method and specifically employing a method of testing called the ‘clinical trial.’ The most rigorous testing occurs when we put together a large number of clinical trials into what’s called ‘a meta-analysis,’ which gets the overall average outcomes of all the clinical trials. The results of clinical trials and meta-analyses are thought of as the most valid and reliable information about the effectiveness of a particular therapy.

So, what difference does empirical-based healthcare make?

On the individual patient level, if you value what science tells us is most effective, then you are more apt to pursue those treatments and therapies that are most effective. Educate yourself as to what is most effective in chronic pain management. The ICP attempts to provide this information on many of its content pages. Ask your healthcare providers whether they know of the clinical trials and meta-analyses that support their recommendations. Don’t be satisfied if they respond with something to the effect of either, “This is how we have always done it” (i.e. tradition) or “We’ve had some good luck with this procedure” and then telling a story about how someone got better with it (i.e., not rigorous enough testing).

On the societal level, when we use the value of empirical-based healthcare, we make chronic pain management more effective for most patients. Patients would be less apt to get recommended procedures that are known to be ineffective (as defined by the afore-mentioned scientific methods). It might also lower society’s health insurance costs (in the form of premiums) because insurance companies would be less apt to pay for procedures and therapies that are known to be ineffective. Less costs to insurance companies means less cost to us, those who are insured.

Integrity

I think integrity is also a value that should guide us as we attempt to change how chronic pain is managed (or change the healthcare system for the better, more generally).  As a society, we need our healthcare providers to walk the walk, not just talk the talk.

Few hospital, clinic, or provider groups would disagree with my three values. Nonetheless, many would fight (and do fight) the consequences of them if these values were really used to guide how we managed chronic pain. There is big money involved, at least in the U. S. Any change in a system, of course, leads to some winners and some losers. If we changed how chronic pain is managed by focusing it on only treatments that have empirical evidence supporting their effectiveness, certain hospitals, clinics, and provider groups would stand to lose a lot of money. Right now, some of the most profitable procedures in chronic pain management are also the most ineffective (as defined by the afore-mentioned scientific methods). Moreover, many individual providers in chronic pain management are paid based on production. A change to a salary system would almost surely reduce an individual provider’s income.

However, it would also necessitate a return to our profession. Healthcare providers would have to be in it, seeing patients day after day, because they primarily want to help people. It is why most of us got into the field in the first place. Our practice, then, would be true to our values. That wouldn’t be such a bad thing in my book.

What are the values that you think should guide chronic pain management now, and how do you think we might change it for the better in the future?

Author: Murray J. McAllister, PsyD

Date of last modification: 5-20-2013

Effectiveness of chronic pain rehabilitation programs

It often comes as a surprise to patients that chronic pain rehabilitation programs are typically the most effective form of treatment for patients with chronic (non-cancer) pain syndromes. As a society, we tend to assume that medications, procedures and surgeries are not only effective, but are the most effective treatments for chronic pain. But, it’s not the case.

Criteria for Effectiveness

In the field of chronic pain management, we tend to use certain criteria by which to measure the effectiveness of treatments. These criteria are the following:

  • Pain reduction
  • Improvement in functioning (such as, return to work rate)
  • Reduction in the need for opioid, or narcotic, pain medications
  • Reduction in the use of healthcare services for pain, more generally

These standard criteria make sense. A treatment is judged effective to the extent that it reduces pain, helps people return to work, helps them to need less narcotic pain medications, and helps patients to not have to see their healthcare providers as much.

chronic pain rehabilitation program

Pool therapy in a chronic pain rehabilitation program.

Let’s review each of these criteria one at a time, comparing how chronic pain rehabilitation programs do with other standard medical care (which might include narcotic and non-narcotic pain medications, procedures and surgeries) for chronic pain.

Pain Reduction

  • 20-40% average reduction in pain following participation in chronic pain rehabilitation programs (Gatchel & Okifuji, 2006; Turk, 2002)
  • 30% average reduction in pain with standard medical care (Gatchel & Okifuji, 2006)

Return to Work Rates

  • 60% rate of return to work following participation in chronic pain rehabilitation programs (Flor, Frydrich, Turk, 1992; Gatchel & Okifuji, 2006)
  • 27% rate of return to work with standard medical care (Gatchel & Okifuji, 2006)

Reductions in Opioid, or Narcotic, Pain Medication Use

  • More than 60% of patients are able to taper from opioid pain medication use following participation in chronic pain rehabilitations (Tollison, Kriegel, & Downie, 1985; Tollison, Hinnant, & Kriegel, 1991; Turk, 2002)
  • Less than 10% of patients are able to taper from opioid pain medications with standard medical care (Tollison, Kriegel, & Downie, 1985; Tollison, Hinnant, & Kriegel, 1991)

Reductions in Healthcare Utilization

  • 68% reduction in overall medical costs following participation in chronic pain rehabilitation programs (Gatchel & Okifuji, 2006)
  • Generally not reported in efficacy studies of medication management, interventional procedures, or surgeries, though 15-20% of those receiving spinal surgery will require re-operation (Gatchel & Okifuji, 2006; Turk, 2002)

Chronic pain rehabilitation programs are powerful interventions. They have significantly higher rates of return to work, significantly greater reductions in opioid, or narcotic, medications use, and significantly greater reductions in the need to seek on-going healthcare for chronic pain.  The comparable statistics between such programs and standard medical care for the criteria of pain reduction is remarkable when considering that over half of patients in chronic pain rehabilitation programs are also tapering opioid, or narcotic, medications.

In all, such outcomes are what make most experts in chronic pain management conclude that chronic pain rehabilitation programs are the most effective treatment approach for patients with chronic pain syndromes.

References

Flor, H., Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analysis. Pain, 49, 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Tollison, C. D., Hinnant, D. W., & Kriegel, M. L. (Eds.). (1991). Psychological concepts in pain. Philadelphia, PA: Lea & Febiger.

Tollison, C. D., Kriegel, M. L., & Downie, G. W. (1985). Chronic low back pain: Results of treatment at the pain therapy center. Southern Medical Journal, 78, 1291-1295.

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Author: Murray J. McAllister, PsyD

Date of last modification: 12/6/2012