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10 Articles in Volume 17, Issue #6
A Plea for Proper Opioid Tapering
Centers of Excellence in Pain Management: Past, Present, and Future Trends
Comorbid Pain and Childhood Obesity
Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians
Justification of Morphine Equivalent Opioid Dosage Above 90 mg
Letters to the Editor: Dependence vs Addiction, Opioid Metabolism
Opioid Rotation From Opana ER Following FDA Call for Removal
Psoriatic Arthritis: Established, Newer, and Emerging Therapies
Sleep-Wake Disorders and Chronic Pain: Reciprocal and Interactive Effects
What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?

Centers of Excellence in Pain Management: Past, Present, and Future Trends

Pain management administered with an interdisciplinary approach has proven to offer the most effective and best opportunity to manage chronic pain.
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Since 2007, the American Pain Society has recognized and rewarded excellence in the quality of pain management. This award program was developed to identify United States-based pain management care teams for their exemplary quality of care. The Clinical Centers of Excellence in Pain Management Award1 has been quite successful in highlighting the best interdisciplinary care programs in the field, ranging from those successfully managing acute and chronic pain to trauma and palliative care settings that treat pain and other terminal conditions.

A hallmark of these programs has been the use of state-of-the-art, evidence-based, and patient-centered treatment. Table 1 lists past award winners, which include a variety of successful university- and community-based programs. The Cancer Treatment Centers of America, Southeastern Regional Medical Center in Atlanta (shown above) was given the 2016 award for community-based programs.

Adding to this list of effective interdisciplinary pain management programs are those that are “customized” for the needs of a specific pain management center. For example, the Eugene McDermott Center for Pain Management at the University of Texas Southwestern (UT Southwestern) Medical Center at Dallas2 has modified its interdisciplinary program to an 8-session program consisting of 2 sessions per week for 3 hours per session. One hour is devoted to individual cognitive behavioral therapy, individual physical therapy, and psychoeducational group therapy. Physician visits for medication management and other treatments occur outside these 8 sessions.

The interdisciplinary team meets once per week to discuss new and established patients, as well as patients who have completed the program or who need additional booster sessions. The team is composed of a case manager, psychologist, physical therapist, nurse, pain management physician and, of course, the patient.

The cost of the full program is approximately $4,000. The effectiveness of this program has been well documented.3

Catastrophic patients may be referred to other treatment programs for services prior to entry into the interdisciplinary pain program. Examples of these referrals are for detoxification from multiple drugs or high doses of opioids, as well as for psychiatric stabilization.

The interdisciplinary approach to pain management has evolved at the Centers of Excellence in Pain Management.

The interdisciplinary approach has been expanded, using a “hub-and-spoke model” to support other clinical programs, such as the spine clinic and perioperative pain management programs at UT Southwestern. Programs for headache, cancer pain and a pain medical home are currently in development. The interdisciplinary program has been a cornerstone of local alternatives to chronic opioid therapy in addressing the prescription opioid epidemic.

Another example of a more tailored approach in a community setting is that of the West Coast Spine Restoration Center in Riverside, California.4 The program consists of a Quantitative Functional Capacity Evaluation (QFCE) to initially determine the level of deconditioning and physical readiness to enter the treatment program. Also, depending on the level of deconditioning and if they are post-surgical, the patients first enter a pre-program conditioning program.

The Pre-Program consists of therapy 2 to 3 times a week for 1 hour. The Pre-Program can run up to 12 weeks, or until the patient is physically conditioned enough and/or has had enough post-surgical healing to begin the actual treatment programs with no interruptions or missed days of treatment. Should the patient require medication detoxification, then this must be completed during the pre-program period.

The patient then enters 1 of 2 treatment programs: the Non-Operative Return to Work Program (5 days a week for 3 hours a day for 6 weeks) or the Post-Operative Return to Work Program (5 days a week for 3 hours a day for 8 weeks). Both programs include the QFCE, return-to-work counseling, and functional restoration (FR) classes. These FR classes cover basic topics, such as: reviewing pain theories to educate patients about why pain sometimes persists; education about the dangers of chronic opioid use; stress management topics (eg, relaxation, time-based pacing of activities, regular physical conditioning, etc); wellness issues (eg, sleep hygiene, proper nutrition, moderation in smoking and alcohol, etc); and planning for possible “flare-ups,” as well as relapse prevention methods.

Once patients are discharged from any of the treatment programs, they are either released to work or, if the physician does not believe they are quite ready for work due to their physical job demands, the patient enters a follow-up Return to Work Program, which consists of the patient having unlimited usage of the therapy center (using it like a gym membership), attending therapy a minimum 3 days a week for 1 hour each day, with therapist supervision, for up to 4 weeks.

The cost of the complete Non-Operative Return to Work Program is $4,000, and the cost of the complete Post-Operative Return to Work Program is $5,500. Clinical effectiveness of these programs has been well documented.5,6 Finally, Stanos has provided an excellent review of 4 other successful interdisciplinary programs across the United States.7

Overall, the treatment and cost-effectiveness of many comprehensive interdisciplinary pain management programs have been well documented in the evidence-based scientific literature.8-12 Indeed, in their comprehensive evidence-based clinical practice guidelines for low back pain, Chou and associates had earlier rated the use of interdisciplinary treatment as having a “strong” recommendation, as well as having “high” quality of evidence.13

Since that time, the evidence-based outcomes for the success of interdisciplinary pain management have continued to grow in the United States as well as other countries, such as Canada,14 Denmark,15,16 France,17,18 Germany,19 and Japan.20 It has also been effectively used in the US military.21

Financial Problems Shutter Some Programs

According to the International Association for the Study of Pain, “Of all approaches to the treatment of chronic pain, none has a stronger evidence basis for efficacy, cost-
effectiveness, and lack of iatrogenic complications than interdisciplinary care.”22

Last updated on: August 16, 2017

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