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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.

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); (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

Unfortunately, despite their well-documented effectiveness, many interdisciplinary pain management programs have had to close because of financial problems. These are primarily caused by the refusal of third-party insurance payers to fully reimburse for such programs because of their internal cost-containment policies.22

As Gatchel and colleagues have noted: “A key major barrier to the wider authorization and use of interdisciplinary pain management programs has been that third-party payers have lacked an understanding of such programs and have remained unenlightened about the long-term cost savings of such programs relative to traditional, outdated pain treatment approaches. These payers view such comprehensive programs as too costly ‘up front,’ without realizing that costs can be saved in the long run.

“Moreover, as a means of cutting costs, managed care organizations have been ‘carving out’ portions of the integrated comprehensive programs by sending patients to outside providers for their various needs (because they have contracted with such providers, who cost them less) even though such providers do not have an understanding of true interdisciplinary care. This fragmented care dilutes the successful outcomes of integrated programs…”21

In addition, an important consequence of such imprudent cost-cutting attempts has been the gradual decrease in effective interdisciplinary pain management programs, as earlier highlighted by Schatman.23 However, as we demonstrated in the 2 programs sampled from different parts of the country—1 at the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center at Dallas and the other at the West Coast Spine Restoration Center in Riverside, California—these are not expensive programs, especially in light of the positive treatment outcomes they produce.

Thus, we face a major conundrum: Chronic pain is now an epidemic in the United States.24 Effective interdisciplinary pain management treatment of this epidemic is now available, but it is not being maximized because of third-party payers’ misconceptions of such programs and their unwarranted cost-containment policies. So, what can be done to solve this problem?

Potential Solutions

A starting solution is to promote a major education campaign directed at insurance companies, as well as state and federal workers’ compensation boards, to demonstrate the positive outcomes of interdisciplinary pain management programs.

Simultaneously, we recommend reinstituting the importance of the Commission on Accreditation of Rehabilitation Facilities (CARF) but with more regular monitoring of those programs once they are accredited. In the past, CARF was viewed as a “Good Housekeeping seal of approval” for pain management programs. Unfortunately, many CARF- accredited programs “scammed” the system by having the full complement of interdisciplinary pain management personnel required during the original CARF accreditation process and visit, but then decreasing the number of required personnel after accreditation, regressing back to single-modality pain clinics to save personnel costs.

As a result, the outcomes from these “diluted” programs were poor, thus reinforcing many third-party payers’ perceptions of clinical ineffectiveness. Going forward, it must be demanded that, once accredited, CARF has routine, unannounced visits to programs to ensure compliance with the demands of true interdisciplinary pain management.

Primary Care Physician Education

There has been an increase in the use of telehealth/telemedicine-based delivery methods.25 These methods need to be more widely used by primary care physicians for at least initial consultations for appropriate referral to the best interdisciplinary care programs in the area. Also, exposing primary care physicians to evidence-based clinical practice guidelines should be emphasized.26

In an effort to reduce the costs of interdisciplinary care, there is now a growing interest in transdisciplinary care.10,27 Transdisciplinary pain management is a natural extension of the biopsychosocial model of interdisciplinary pain management. It uses the cross-training of disciplines to decrease costs and increase the number of patients who can be served.

In this type of care, the various health care providers learn each others’ skill sets. For example, evidence shows physical therapists can learn to effectively administer cognitive behavioral therapy and other wellness skills in a protocolized manner.27 Nurse practitioners can do the same. Moreover, there is no reason that the physician-nurse team, as well as a pain specialist-psychologist, cannot be trained to supervise group conditioning exercises and stretching. This can increase the efficiency of interdisciplinary programs, while also increasing capacity to serve the large population of patients with chronic pain who do not have access to interdisciplinary care. It can also reduce the overall costs of interdisciplinary care because the cost of a physical therapist may be lower than that of a psychologist or nurse practitioner, or vice versa. Also, this cross-training will help maintain treatment progress when certain team members are absent from work. It will also further reinforce the importance of having all treatment team members focus on the biopsychosocial functioning of the “whole patient” to maximize treatment effectiveness.

Another solution is to develop reliable metrics related to “pay-for-performance.” There are 2 metrics that may be used for this purpose.

First, the National Institutes of Health (NIH) invested approximately $60 million to develop the Patient-Reported Outcomes Measurement Information System (PROMIS), which involves self-reported measures that are associated with chronic pain (pain intensity, pain quality, pain interference, pain behavior, pain impact, physical function, depression, anxiety, fatigue, satisfaction with social roles, and sleep disturbance). PROMIS is psychometrically sound and has been demonstrated to be both reliable and valid after large-scale testing. Moreover, the measures are anchored to a representative US population and have a mean score of 50 and a standard deviation of 10.28 A statistical platform was developed to score and assess the results of patient responses. These can be saved in a database that can be confidentially disclosed to document changes.

The second required metric should involve more objective socioeconomic outcomes, such as return-to-work rates, medication reduction, reduction in surgeries, resolution of workers’ compensation/litigation cases, and subsequent reduction in health care utilization rates associated with the original pain-causing injury. There are now reliable statistics in the scientific literature that have documented such rates after effective interdisciplinary pain management.10 In the development of contracts between third-party payers and health care providers, certain levels of improvement would need to be obtained to receive full reimbursement.

Summary and Conclusions

There is no doubt that appropriately administered interdisciplinary pain management is effective and can be successfully used in the current epidemic climate of chronic pain in the United States and worldwide. Unfortunately, past outcomes of such programs have been significantly diluted by the plethora of “pain clinics” that did not offer true interdisciplinary care. To remain profitable, many such clinics reduced the number of personnel required to run an effective interdisciplinary pain management program. Moreover, many third-party payers grouped these “pain clinics” with true interdisciplinary pain management programs without realizing the major differences between them.

Simultaneously, in their cost-containment zeal, the only programs that they focused on were the ineffective pain clinics that were not truly interdisciplinary in nature. In effect, they threw the “baby out with the bathwater” (in this case, the baby is truly effective interdisciplinary pain management programs). As a result, third-party payers need to be educated on what true interdisciplinary care is, so they can make better authorization decisions.

Also, better metrics are needed to document treatment outcomes. The 2 we suggested are the use of the PROMIS for evaluating self-reported outcomes, in addition to more objective socioeconomic outcomes. These measures could be used as metrics in determining “pay-for-performance” reimbursement rates.

Finally, other important new areas, such as transdisciplinary care and telemedicine/ telehealth, should receive greater attention to produce even greater cost savings. Health care providers and insurance payers need to think outside the box. This is especially important in light of the major pain and opioid epidemic that exists in the United States.

Last updated on: April 9, 2019

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