Facility Profile: Casa Palmera
The contemporary Casa Palmera in Del Mar (a small coastal community of San Diego, California) opened its doors in June 2005. The ninety-five (95) bed residential treatment center was dedicated to the care of individuals with addictive, eating, and emotionally traumatic disorders. As time went on it became apparent that another population of patients, with many shared characteristics and often co-occurring with Casa’s patients, was vastly under- or mistreated in our community and the nation, namely those with chronic pain and comorbid medication/drug dependence. It was the commitment to state of the art treatment for this patient population that led to the creation of Casa Palmera’s newest clinical program.
“Share the Risk” Model
Dr. Joseph Shurman, MD, nationally recognized specialist in Pain Medicine, first developed the “Share the Risk” model’s basic principles in January of 2002 in San Diego, California. Interdisciplinary teams have been shown to improve patient care in a number of complex clinical situations and also deliver the best possible treatment to this challenging population. The “Share the Risk” fundamental premise is that no physician—no matter how well educated, confident, compassionate, committed or meticulous—can adequately meet all the needs of patients with chronic and intractable pain and chemical dependency.
Instead, the model calls for an interdisciplinary team approach to treat this special needs pain patient. Share the Risk was initiated when, in early 2000, physicians prescribing opioids for pain relief, particularly nonmalignant pain, were being sued for giving too little, giving too much, or even for “murder.”1,2 Several publications had made the statement that up to “seventeen percent (17%) of doctors who treat pain were investigated each year, and that a pain treating physician was arrested and charged criminally somewhere in the United States every day.”3,4 Although these statements are debated, depending on whom you speak to, the model was started in response to this problem. At the same time, the program—using multiple specialists—was extremely beneficial for the patient since it decreased the overall risks of treatment. The core of the model is elaborated through the five P’s as follows:
- P1-Professional Pain Management Delivery System
- P2-Patient Advocacy and Education Support
- P5-Physical Therapy and Integrated Techniques.
The “Share the Risk” model includes pain specialists, psychologists/psychiatrists, addiction specialists, pharmacists, and other agents and organizations. This professional pain management delivery system was one of the first in the country to:
- involve an addictionologist early on with patients taking moderate to high doses of opioids for nonmalignant pain;
- involve a psychologist or psychiatrist, because the risk of suicide can be up to three times higher in these patients5;
- utilize patient advocacy and educational support;
- work with the DEA;
- focus on documentation and record keeping precautions; and
- employ sleep disorder consultations and cognitive testing for driving safety in conjunction with the use of physical therapy and complementary techniques.6
“Share the Risk” was a major catalyst for the development of an educational program called “Emerging Solutions in Pain.” Emerging Solutions developed a comprehensive design to assist pain management physicians in overcoming the challenges they encounter by providing practical tools and resources. It has an advisory board of national leaders in pain management and addiction. The program includes a “tool kit” and a website (emergingsolutionsinpain.com), and is especially valuable for physicians who do not have access to other specialists.7
The ultimate goal of the “Share the Risk” model was to bring together various resources among clinicians and the community in order to provide the best overall care for the chronic pain patient. In applying the “Share the Risk” model, both the clinician and patient benefit. Thorough documentation, outside con-sultation, and urine screening all reduce risk in the clinical encounter. The “Share the Risk” model has continued to expand and to offer assistance to both physicians and patients in the treatment of chronic pain and chemical dependency.
The Best of Eastern and Western Medicine Plus Neuroscience
Some of the significant problems pain specialists have to deal with are the noncompliant patient, the addicted individual, or the patient who desires to rotate off opioids. These issues have specifically led to the development of the Chronic Pain Management Program at the Casa Palmera Care Center. The goal was to bring together skilled, experienced professionals—together with state of the art “holistic” resources—for the comprehensive and simultaneously integrated treatment of chronic pain associated with problems of dependence upon pain medication, other drugs and/or alcohol, utilizing the “Share the Risk” theme of an interdisciplinary and holistic approach. The team includes psychiatrists, psychologists, addictionologists, internists, pri-mary care physicians, anesthesiologists, nutritionists, acupuncturists, physical therapists, music/art and massage therapists, biofeedback, laser therapy, and more.
The “Share the Risk” group has had great difficulty in adequately serving the noncompliant patient, the drug dependent patient who wants to get off opioids and/or benzodiazepines, or the patient who turns up with an abnormal urine screen for illicit drugs. Where does one send such a patient? Pain specialists have had great difficulty with referrals to some of the major addiction centers because of the dilemma of helping these patients manage their inevitable post-detox pain. This was the major problem with all the in-house pain centers that evolved during the 1970’s, where people were hospitalized for many weeks and detoxified, but still left with inadequately or under-treated pain. Over time, most of these centers closed. This unacceptable situation further motivated the development of the Casa Palmera concept, that of the “integrated” treatment of chronic pain and co-occurring drug dependence. Casa hopes to take this model and expand it throughout the United States in order to help educate physicians, health care professionals, and patients.
Casa Palmera Team Approach
On a continuum of team models (see Figure 1), Casa Palmera utilizes an integrated interdisciplinary treatment team approach. The following descriptions of some notable team models are presented for comparison.
Multidisciplinary Team Model