Ever since John Bonica began espousing the concept of a multidisciplinary program to address pain symptoms in the early 1950s, a whole movement for treating pain has developed. Today, there are more than 3,300 pain treatment facilities and solo practitioners who identify themselves as pain specialists in the United States.1 In my opinion, the birth of these centers has been one of the most important medical developments in recent years. By bringing together multidisciplinary team members working in synergy with one another, pain clinics have heightened our capacity to address the decades-old problem of providing relief for chronic pain syndromes.
Despite the considerable track record of these programs' documented success in dealing with patients who cannot be successfully addressed by any other means,2 they have many critics. They do not reduce pain, they are only palliative; they are too costly; they require considerable time to participate; there are high drop out rates. These criticisms have spurred clinics to individualize treatments, making them more accessible to a wider range of patients and more cost effective.
“Chronic pain syndrome” has been used to describe persistent pain conditions for which there is a discrepancy between the degree of identifiable disease and the severity of the illness. The pain itself becomes a source of significant distress, which, in turn, can aggravate the experience of the pain. In order to combat pain, we have to address three different levels of the patient's experience: the motivational/affective system which can augment or diminish the pain through contributing emotions, the cognitive/evaluative system which can distort the pain by misinterpreting its meaning, and the sensory discriminative system which often overreacts to a painful stimulus.
Multidisciplinary teams are effective, in part, because they address these different levels of understanding of the patient's experience with the different team members automatically focusing on different ‘levels of meaning’ of the patient’s pain. For example, the psychologist often focuses on the cognitive/evaluative element of the pain, thereby helping the patient to put his or her pain into a helpful perspective. The physical therapist/ occupational therapist fundamentally addresses the sensory discriminative system, allowing the patient to recognize that that his or her discrimination of fatigue and pain in muscle movement is faulty. The physician primarily addresses the motivational/affective area by encouraging the patient and providing him or her with helpful medical information and interventions. Also, programs emphasize different components of the regimen depending on the needs of individual patients. For example, some patients require greater emphasis on motivation and encouragement, others on physical therapy and so on. I believe that programs need to further develop the collaboration between these disciplines so that the patient truly feels that he or she has a team that understands him or her and is not treating him or her as one of a group of patients.
Another advance was the shift from inpatient to outpatient programs3 in order to utilize the patient’s own social environment as support rather than removing the patient from it. These outpatient programs offer a substantial cost savings.
In studying the large drop out rates for pain programs, Biller4 has provided evidence that the program’s success may be substantially related to the patient’s readiness to change. Patients who are ‘precontemplators’ (according to Prochaska’s5 readiness to change treatment model) are not ready to seriously consider treatment. These patients are not as likely to change as those in an ‘active’ stage, i.e., actively trying to master their pain problem. Based upon this model, pain programs whose admission criterion assesses patients' readiness to change are then able to prepare precontemplators for change. Keefe6 has suggested that these patients should be introduced to the benefits of better managing their lives and assist in establishing a relationship with a fellow sufferer or a health care professional who can inspire him or her. Modern pain clinics that develop programs for those who are not ready to change widen the net of patients who can benefit from the program.
Other programs helpful in further individualizing treatments have been added to pain management treatments. According to Turk and Rudy,7 chronic pain patients cannot be treated as a homogeneous group. They use different coping strategies and have different support networks, emotional states, and pain conditions. This fact is being recognized as pain programs emphasize marital treatment6 for some, while others have emphasized community support treatments,8 specific exercise programs for specific diseases,9 and home interventions.10 I believe that many more patients require individualized exercise programs and greater degrees of supportive services in their own communities than they currently receive. The greater our ability to provide specialized services, unique to each individual, and to sustain the treatments most critical to that individual for sufficient time periods for effectiveness to occur, the greater the range of patients who can benefit from them.
It is especially important to realize that the trends toward individuality of treatments and cost-effectiveness must advance by further dividing the patient group into subpopulations and designing treatments critical for success of each. Gone are the days when you can lump all patients together, assuming they all have the same problem. We are merely beginning to address patients' concerns by practicing tailor-made programs that take all aspects of a patient's life into account.