The Demise of Multidisciplinary Pain Management Clinics?
Chronic pain of non-malignant origin poses a severe problem not only to individuals who suffer from pain but to society as a whole. Estimates of the monetary cost of medications and other treatments which provide patients, at best, with temporary relief were estimated at $125 billion annually in 1999.1 A 2003 study on lost productive time and cost due to chronic pain conditions in the United States estimated lost productivity annually at $61.2 billion.2 Other monetary costs include lost wage and disability compensation, lost tax revenue, job absenteeism and disruption in the workplace. Additionally, there are indirect costs, including the lost productivity of spouses and other caretakers of chronic pain patients.
Irrespective of the financial burden of inadequately treated chronic pain, the greatest hardship is that experienced by the patients themselves. Schatman3 has suggested that the debate between practitioners regarding the period of time an individual must suffer from pain in order to be labeled “chronic” is actually meaningless; rather, “chronicity” is determined by the widespread dysfunction which the chronic pain sufferer experiences across a wide range of areas of his or her life. These areas of function include not only the physical, but the emotional, social, recreational, vocational, financial, and legal spheres as well. Healing of chronic pain necessitates helping patients regain control of all of these areas of their lives, as their widespread dysfunction is generally more overwhelming than is the nociceptive experience of pain itself. These patients have typically lost their independence and are reliant upon medications and the aid of others—all contributing to the development of behavioral patterns of general passivity.4-7
Unlike purely nociceptive pain, there is often no “cure” for intractable pain of neuropathic or idiopathic origin. Yet, such pain may still often be successfully treated. Numerous meta-analyses and critical reviews8-14 of integrated multidisciplinary chronic pain management programs offer clear evidence that such programs offer these chronic pain patients the greatest opportunity for relief of their suffering and return to functional lifestyles. Frequently, the prior lack of effective “cure” or treatment of such patients are the result of inadequate diagnoses or sufficiently comprehensive therapeutic approaches. Many times, such clinical epiphanies occur in multidisciplinary settings at which point more effective treatment subsequently occurs. In addition to supporting their clinical efficacy, meta-analyses and reviews8-14 have all supported the cost-efficiency of multidisciplinary chronic pain management programs. In a review by Turk in 2002,13 multidisciplinary chronic pain management was determined to be superior to singular treatments including surgery, pharmacologic intervention, spinal stimulators and intrathecal opioid pumps, in terms of pain reduction, improved physical functioning, and returning patients to the workforce. It is also important to recognize that these unimodal treatment options are often associated with iatrogenic complications and adverse events, which is certainly not true of multidisciplinary chronic pain management programs. In terms of longevity of benefits of integrated multidisciplinary programs, a follow-up study of patients 13 years following treatment was supportive of maintenance of gains.15 Furthermore, multidisciplinary treatment of chronic pain has been associated with reduced utilization of medical services compared to chronic pain patients treated through other approaches, even in countries with national health insurance.16
The Struggles of Multidisciplinary Chronic Pain Management Programs
Despite the body of literature8-16 supporting the clinical efficacy and cost-efficiency of integrated multidisciplinary chronic pain management programs, the number of such programs in the United States is decreasing steadily. According to the Committee for the Accreditation of Rehabilitation Facilities (CARF),17 the number of accredited interdisciplinary chronic pain management programs in the United States has decreased from 210 in 1998 to only 84 in 2005. A similar, although less dramatic decline has been reported by Marketdata Research,18 which looked at the number of programs accredited by either the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the American Academy of Pain Management (AAPM), or CARF. The public is likely unaware of the decreasing availability of multidisciplinary chronic pain management, as many were previously unaware of its existence. Additionally, disinformation regarding the treatment of pain is likely to contribute to the public’s incomprehension of the decreasing availability of interdisciplinary chronic pain management. Recent public awareness campaigns regarding JCAHO’s declaration that pain will now be considered a “fifth vital sign” and the declaration of this being the “Decade of Pain Control” by Congress erroneously suggests that effective treatment of chronic pain of non-malignant origin is becoming a priority of society. These proclamations are certainly inconsistent with the data that has been presented by CARF17 and Marketdata Research.18 What could be the cause of the progressive decline in programs which clearly provide the best treatment option to so many patients who suffer from chronic pain?
Ethical Standards and Chronic Pain Management
Few who dedicate their professional lives to the treatment of chronic pain patients would argue that this is not a difficult population with which to work. Dealing with chronic pain sufferers’ maladaptive emotional and behavioral responses to their physical discomfort makes their treatment extremely complex, and can certainly be emotionally draining for the practitioner. In a presentation, Dr. John Bonica was referred to as the “world champion of pain.”19 Given his personal and professional dedication to the amelioration of suffering, this title was appropriately bestowed upon him. Certainly, all practitioners who work with chronic pain patients need to be “champions of pain” if they are to be effective. Chronic pain practitioners function under the ethical standards of their professions, whether it is medicine, nursing, psychology, physical and occupational therapy, biofeedback, or any other profession which is represented on a multidisciplinary treatment team. Additionally, organizations such as the American Academy of Pain Management,20 the American Academy of Pain Medicine,21 and the American Pain Society,22 to which many pain practitioners belong, each has a code of ethics. All of these codes place an emphasis on the well-being of the pain patient, and one would assume that the vast majority of chronic pain practitioners make an effort to function ethically as well as striving to be effective as clinicians.