Patients typically receive 8 to 10 sessions of CBT, with each session covering a topic such as sleep hygiene, assertiveness training, anger management, or controlling automatic thoughts that lead to catastrophization or fear of the pain getting worse.
At our center we spend an hour educating patients about pain medications, explaining how they work and why some pose risks. Patients undergo 6 to 8 sessions of physical therapy and graded exercise, starting slow and gradually building to a level that does not aggravate their pain. Teaching them correct posture and how to lift objects also is important.
Planning for long-term success
Pain management takes place on numerous levels that incorporate self care, primary care, specialty care, and the multimodal care of interdisciplinary pain centers. To avoid relapse after patients have been treated at an interdisciplinary pain center, it is important that they have a clear idea of how to proceed with their individualized programs in a self-directed manner. Those who do well in the program and return to work or the home environment may be vulnerable to stressors that can lead to relapse.
Patients who fear they cannot control the pain or that they may do something to worsen it are at risk of becoming depressed, dependent, or guarded in their activities.12 Our program is developing a system to monitor patients more closely after they finish their program to identify those who may be spiraling downward. Patients are invited to return at any time for “booster” sessions.
Primary care involvement can strengthen patient resolve
“Also, primary care physicians—who handle most front-line pain care—should collaborate with pain specialists in cases where pain persists.”1
The degree to which primary care physicians (PCPs) want to be involved with chronic pain management varies, of course. Interdisciplinary programs should explore the comfort level of individual providers and work with them accordingly—at the very least communicating with and including the PCP in the patient’s process so that he or she understands what the patient has encountered and achieved.13 This collaborative approach enables PCPs to motivate patients to continue the progress they’ve made, reinforce the biopsychosocial model for treating pain, and communicate with the interdisciplinary team about patients who may be relapsing.
Barriers to interdisciplinary care
“System and organizational barriers, many of them driven by current reimbursement policies, obstruct patient-centered care.”1
The IOM has estimated the direct and indirect costs of pain in America to be over a half a trillion dollars per year. The potential for interdisciplinary pain care to contribute to national deficit reduction is real and is not limited to chronic pain. In fact, the application of interdisciplinary evaluations and treatment to acute and subacute pain may be more important to reduce costs related to preventing high-risk patients from becoming chronic.
A cost-utility analysis of 994 patients in pain clinics with acute back pain at high risk of becoming chronic who were provided early intervention with an interdisciplinary approach resulted in fewer health care visits and fewer missed days of work compared with patients who received usual care.14
Additional cost savings could be realized by routinely applying the biopsychosocial model to acute and subacute pain. Through well-developed evaluation systems, we could identify patients at high risk of progressing to chronicity. Screening for risk stratification is key to reducing the large number of chronic pain patients who are overmedicated, disabled, and depressed. Just as it makes sense to reduce individuals’ cardiac risk factors and not wait until they are in heart failure to act, employing a comprehensive interdisciplinary program for acute pain would be less expensive than waiting to treat pain that has become chronic.
However, only some insurers cover use of interdisciplinary pain programs, often to a limited extent, and may employ carve outs for specific therapies. Medicare does not reimburse well for interdisciplinary treatment. Consequently, many programs are paid through worker’s compensation. It is therefore challenging for interdisciplinary programs to remain viable.
Further benefits to the wider community
Our current health care system in the United States is not financially sustainable. To help curtail overutilization of health care resources in this country, we have to acknowledge psychosocial issues and embrace interdisciplinary pain programs when treating patients with pain. But it will take time and a huge cultural change for this to happen.
The future may require a combination of interdisciplinary treatment with a strong component of analgesic treatments rather than an “all or none” approach in which patients receive either “behavioral” treatment or “medical” treatment only. By definition, interdisciplinary pain treatment requires medicine as a discipline to reduce pain using everything medicine has to offer to accomplish this end.
Helpful information for you and your patients
The American Academy of Pain Management (AAPM) offers professional credentialing in pain management and accredits pain management clinics in the United States. You may be able to locate a specialist or clinic in your area at the academy’s Web site: https://members.aapainmanage.org/aapmssa/censsacustlkup.query_page.
Disclosures
Carl Noe, MD, has served as a consultant to Palladian Partners, Inc., a health communications and services company.
Charles F. Williams has no conflicts of interest to disclose.