The benefits of interdisciplinary pain management

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

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

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

Rationale and research

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

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

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

**n=40

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

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

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

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

Risks of interdisciplinary care versus standard care

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