Also, although opioids are widely used,their ability to control pain varies. A study from the Mayo Comprehensive Rehabilitation Center of 233 consecutively enrolled patients with chronic nonmalignant pain found 48% were using opioids daily at baseline, at a cost of $23.13 per day or $8326.90 per year (average wholesale price) per patient.9 Patients who completed a 3-week multidisciplinary intervention significantly reduced their medication use at 6-month follow-up, for an estimated annual savings of $2404.80 per patient.
Two studies comparing interdisciplinary care with spine fusion surgery for chronic back pain found interdisciplinary care to be a reasonable alternative for many patients. In a study of patients with chronic LBP who had previous surgery for disc herniation, spinal fusion showed no benefit over cognitive intervention and exercise after 1 year.10 [TABLE 2] A multicenter trial comparing surgical stabilization of the lumbar spine with an intensive rehabilitation program based on CBT found no clear evidence that spinal fusion provided greater benefit.11
TABLE 2 : Primary and secondary outcomes comparing spinal
fusion with CBT and exercise
| Outcome | Lumbar fusion (n=28) | CBT/exercises (n=29) |
| Oswestry* Baseline 1-year | 47 38.1 | 45.1 32.3 |
| Back pain** Baseline 1-year | 64.6 50.7 | 64.7 49.5 |
| Leg pain** Baseline 1-year | 52.7 45 | 55.3 47.7 |
| Working | 10% | 40% |
*Oswestry Disability Questionnaire in which the sum of response scores ranges from 0 to 100,where 100 represents the worst possible pain and disability.
**Based on a vertical visual analog scale ranging from 0 to 100, where 100 reflected the worst pain imaginable.
Source: Adapted from Brox JI, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study. Pain. 2006;122(1):145-155. This table has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The table
may not be reproduced for any other purpose without permission.
What interdisciplinary pain management looks like
Key disciplines of an interdisciplinary pain management program are medicine, psychology, and rehabilitation. However, programs vary in available services and professional disciplines, setting, and duration. A fully integrated pain treatment center offers a range of therapies that may include transcutaneous electrical nerve stimulation, CBT, biofeedback, physical therapy, psychoeducational group treatment, and medications such as nonnarcotic analgesics and nerve blocks. Additional disciplines may include outcome database managers, vocational specialists, nutrition, case management, nursing, chaplaincy, and other disciplines an individual patient may need.
Patients should be evaluated by a pain medicine specialist and a behavioral medicine specialist. Treatment recommendations should include a structured curriculum including education, CBT, and physical therapy to address fear avoidance behavior, medication use, disability, affective distress, health care overutilization, quality of life, activities of daily living, and other patient-centric goals of rehabilitation. The interdisciplinary treatment team should be housed in the same facility and meet at least once per week to discuss new and existing patients and monitor progress toward outcome goals.
At our clinic, the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center in Dallas, each patient undergoes consecutive evaluations by a pain physician, psychologist, physical therapist, and perhaps a psychiatrist. A case manager helps patients navigate through the evaluation and treatment process. At weekly case conferences, the team meets to discuss new patients, review the progress of current patients, and reinforce or modify treatment plans.
Individualizing goals
“Among steps to improving care, health-care providers should increasingly aim at tailoring pain care to each person’s experience and self-management of pain should be promoted.”1
Pain influences and inhibits numerous areas of a patient’s life. For many chronic pain patients, duration of pain brings with it the belief that “hurt equals harm.” As a result, they decrease physical activities, become socially isolated, and often feel unable to effectively manage, control, and conquer their pain. The longer chronic pain endures, the more deleterious the psychosocial consequences, even if pain and dysfunction do not worsen.
Chronic pain causes patients to feel a domino effect of psychological and cognitive disturbances including anxiety, depression, anger, and sleep disturbance. Disability caused by pain may bring on economic and domestic difficulties. Relationships can suffer, in part because it is hard for others to understand the impact of pain, especially when there is no obvious pathology.
Part of the evaluation process is to assess these possibilities and to address them in a concerted way. We encourage patients to focus on making progress toward their treatment goals rather than hoping to find a definitive cure for a pain generator that may or may not be identifiable. Therefore, in addition to the standard outcomes we aim for with each patient (eg, improvement in physical and psychological function measures), we establish individual treatment goals based on the initial interviews and the patient’s desire to return to work, get into vocational retraining or education, or achieve other productivity or recreational outcomes.