Chronic Pain Management: Guidelines for Multidisciplinary Program Development (Pain Management)

300 Pages·2007·1.39 MB·English

by  Michael E. Schatman

CHRONIC PAIN
MANAGEMENT
GUIDELINES FOR
MULTIDISCIPLINARY
PROGRAM DEVELOPMENT
CHRONIC PAIN
MANAGEMENT
GUIDELINES FOR
MULTIDISCIPLINARY
PROGRAM DEVELOPMENT
Edited by
Michael E. Schatman
Consulting Clinical Psychologist
Bellevue, Washington, USA
Alexandra Campbell
American Academy of Pain Management
Sonora, California, USA
Foreword by
John D. Loeser
PAINMANAGEMENT
AdvisoryBoard
WalterL.Nieves,M.D.
TallmanMedicalCenter
Suffern,NewYork,U.S.A.
SunilPanchal,M.D.
PresidentofCOPE
(CoalitionforPainEducation)
Tampa,Florida,U.S.A.
WilliamK.Schmidt,Ph.D.
Consultant
Davis,California,U.S.A.
MarshaStanton,M.S.,R.N.
Consultant
SealBeach,California,U.S.A.
1.EthicalIssuesinChronicPainManagement,editedbyMichaelE.Schatman
2.ChronicPain,GaryW.Jay
3.ChronicPainManagement:GuidelinesforMultidisciplinaryProgram
Development,editedbyMichaelE.SchatmanandAlexandraCampbell
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LibraryofCongressCataloging-in-PublicationData
Chronicpainmanagement:guidelinesformultidisciplinaryprogram
development/editedbyMichaelE.Schatman,AlexandraCampbell.
p.;cm.–(Painmanagement;3)
Includesbibliographicalreferencesandindex.
ISBN-13:978-1-4200-4512-3(hb:alk.paper)
ISBN-10:1-4200-4512-1(hb:alk.paper)
1.Chronicpain–Treatment. 2.Painclinics. I.Schatman,MichaelE.
II.Campbell,Alexandra,PhD. III.Series.
[DNLM:1.Pain–therapy. 2.ChronicDisease. 3.Combined
ModalityTherapy. 4.Pain–rehabilitation. 5.PainClinics–organization
& administration. 6.PatientCareTeam. WL704C55852007]
RB127.C49632007
616(cid:2).0472–dc22 2007012048
VisittheInformaWebsiteat
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Foreword
The idea that chronic pain is a medical problem was born with the pioneering
workofJohnJ.Bonica,M.D.,attheendofWorldWarII.Chronicpainenteredthe
world of academicmedicinewhenDr. Bonica was appointedthe founding Chair-
man of Anesthesiology at the University of Washington in 1960. The term, multi-
disciplinary pain clinic (MPC), was invented by Dr. Bonica, originally to describe
an approach to the diagnosis and treatment of chronic pain patients by a group
of physicians who interacted with each other as well as with the patients. In the
1960’s,alsoattheUniversityofWashington,WilbertFordyce,apsychologistinthe
Department of Rehabilitation Medicine, recognized that a behavioral approach to
the treatment of chronic pain patients could be more successful than injections,
pills or surgery. He started a behavioral pain management service in Rehabilita-
tionMedicineandbroughthisprinciplesofpainmanagementintothemultidisci-
plinarypainclinic.OtherpsychologistsbroadenedtheFordyceapproachtoinclude
cognitive-behavioralstrategiesandincreaseditseffectiveness.In1983,Dr.Fordyce
andIstarteda20-bedinpatientandoutpatientmultidisciplinarypainclinicthatwas
independentofanysingleacademicdepartment.Thisservedas theprototypefor
multidisciplinary pain clinics throughout the world, in part because of our active
teaching programs and openness to visitors. Physicians of many specialties, psy-
chologists,nurses,physicalandoccupationaltherapistsandvocationalcounselors
wereallintegralmembersofourteam.
Manyotherhealthcareprovidersalsoplayedimportantrolesinthedevelop-
mentofmultidisciplinarypainmanagement;theCommissiononAccreditationof
Rehabilitation Facilities (CARF) adopted our model as the accreditation standard
for multidisciplinary pain clinics. Multidisciplinary pain clinics were developed
throughout the world, often with varying content and emphasis to fit the needs
ofthepatientstheytreatedandtheproviderstheyhadavailable.Incountrieswith
rationalhealthcaresystems,thisformofpatientdiagnosisandtreatmentseemsto
haveprospered,asithasbeenrecognizedasmoreeffective,lesshazardous,andless
costlythantraditionalapproachestotreatingchronicpainpatients.Basedsquarely
upon a biopsychosocial model rather than the prevalent biomedical model, mul-
tidisciplinary pain management has been seen as a threat to biomedicine and the
industry’simperativetoconsumeexpensivehealthresources.
IntheUnitedStates,withanon-systemofhealthcareandthedramaticintru-
sion of economic factors into health care decisions, MPCs have not fared as well
andthenumberofprogramshasdecreasedsteeplyinthepasttenyears.Thereare
many factors that have contributed to the relative demise of MPCs. First, a label-
ing issue: Any group of two or more health care providers can call themselves a
iii
iv Foreword
multidisciplinarypainclinicandiscapableofdeceivingthepublicastowhatthey
offerinsofarasdiagnosticandtreatmentoptions.Thisisacommonoccurrenceand
hasbroughtconsiderabledisreputetobonafideMPCs.Second,decisionsaboutwhat
forms of health care are to be offered are not made uniquely by doctors and their
patients. Instead, insurance companies and large hospitals and academic medical
centers ignore both the moral imperatives to treat chronic pain and the available
outcomesdataontreatmentefficacyandoftenwillnotfundMPCs.Forlarge,Amer-
icanhospitals,especiallythoseassociatedwithamedicalschool,revenuegeneration
isthemajordeterminantofwhatservicestheinstitutionwilloffer.MPCisnotseen
asavaluecomparedtocosmeticsurgery.Third,paymenttoprovidersisskewedin
favorofproceduresandsurgeries,puttinggreateconomicpressuresonthosewho
provideapersonalservicewithoutaproceduralintervention.Fourth,procedural-
ists have done a much better job lobbying funding agencies and the public as to
theutilityoftheirinterventionsthanhavethosewhorunMPCs.Fifthly,thereisno
singleoptimalplanforhowtorunanMPCandwhatitscontent,durationoftreat-
mentandteammembersshouldbe.Thishasmadeitdifficultforfundingagencies
toevaluateprograms andcomparecosts andefficacy. Finally,organizedmedicine
hasneveracceptedthevalidityofmultidisciplinarypainmanagementandthereare
manyimpedimentstoitsimplementationinthemedicalcommunity.
Thisbookisdesignedtocombatmanyoftheproblemsthatconfrontmultidis-
ciplinary pain management in the United States today. A stellar group of contrib-
utorshasaddressedtheproblemsofbuildingandmaintainingamultidisciplinary
pain clinic. The emphasis is upon outcomes, not personal anecdotes. Multidisci-
plinarypaincareisthebesttreatmentwenowhavefortherehabilitationandrelief
ofsufferingofchronicpainpatients.Chronicpainpatientsalwayshavepsychoso-
cial factors that influence their disability and suffering; pills and surgery do not
address these at all. This volume will be an important tool in the restoration and
continueddevelopmentofmultidisciplinarypainmanagementintheUnitedStates
andtheremainderofthedevelopedworld.
JohnD.Loeser,M.D.
ProfessorofNeurologyandAnesthesiology
UniversityofWashingtonMedicalSchool
Seattle,Washington,U.S.A.
Preface
Chronic pain of benign origin results in staggering costs, to society as a whole as
wellastotheindividualsufferer.Althoughitisimpossibletoaccuratelydetermine
thetotaleconomiccostofchronicpaintosociety,itscombineddirectandindirect
annualcostintheUnitedStateswasestimatedin2001tobealmost$300billion(1).
Ahugeproportionoftheeconomiccostassociatedwithchronicpainconsistsoffees
fortreatmentswhichhavenotbeenfoundtobeparticularlyefficacious.Thesewere
estimatedin2001tobeabout$125billionannually(2).Itshouldbenotedthatboth
ofthesefiguresareconservative,asneitherhasbeenadjustedforinflation.
Of greater moral importance, however, is the overwhelming non-economic
cost of chronic pain to the people that it afflicts. Those affected include not only
thepersonwhoexperiencesthepaindirectly,butlovedonesaswell.Lossesexpe-
riencedbypatientswithchronicpainincludenotonlythephysical,butvocational,
financial,social,sexual,recreational,emotional,andspiritual.Arecentqualitative
studyfoundthatinadditiontosocioeconomiclossesandfinancialhardships,peo-
plewithchronicpainexperienceddecreasesinself-worth,positiveexpectationsfor
thefuture,andhope(3).Otherstudies(4)–(8)haveidentifiedincreasesinfeelingsof
despair,lossofmeaningoflife,lossesoffreedom/independence,threattointegrity,
roleloss,anddisorganizationofthepatient’s“beingintheworld”astheworstcon-
sequencesofchronicpainconditions.Chronicpainisclearlyadiseaseoftheperson,
notsimplyofthebody.
Despite the fact that traditional medical approaches to treating chronic pain
such as surgery, medications and other invasive interventions, do little, if any-
thing, to restore the chronic pain sufferer’s overall quality of life, these traditional
approachescontinuetobeconsideredthefirstlineofoffenseagainstchronicpain.
Thisisparticularlydishearteninggiventhelackofempiricalsupportfortheclinical
efficacy of these approaches in terms of long-term pain relief, much less for their
abilitytoimpactthemyriadindirectnegativeeffectsofthechronicpainexperience.
The good news is that for many years, pain practitioners have possessed a treat-
mentmodelthatcanhelppeoplewithchronicpainrestoretheirlives.Thebadnews
is that the health insurance industry, as a whole, is becoming progressively less
willingtofundthistreatmentapproach.Asisdiscussedthroughoutthistextbook,
comprehensive multidisciplinary chronic pain management has been empirically
demonstrated,beyondadoubt,tobeaclinicallyeffectiveandcost-efficientapproach
to the treatment of chronic pain of benign origin. The ethical failure of the insur-
ance industry, however, has led to a dramatic decrease in the availability of such
programsoverthepastdecade(9),(10).
v
vi Preface
We appreciate the inspiration of the American Academy of Pain Manage-
ment in our decision to produce this book which we hope will serve two pur-
poses. The first is to arm the multidisciplinary pain practitioner with a concise
resource that powerfully presents overwhelming evidence regarding the efficacy
and cost-efficiency of multidisciplinary chronic pain management, particularly in
comparisontothetraditionalandineffectiveapproachesthatcontinuetobeoveruti-
lizedinthetreatmentofchronicpain.Wehaveenlistedtheparticipationofleading
authoritiesintheworldofmultidisciplinarychronicpainmanagementtocontribute
chapters on this topic. Our second purpose is to provide a “how-to” manual for
multidisciplinarychronicpainmanagementprogramdevelopment.Wehavebeen
fortunate to obtain the participation of chronic pain clinicians/academicians who
arecertainlyexpertsinthisarea.
ChronicPainManagement:GuidelinesforMultidisciplinaryProgramDevelopment
isdividedinto5sections.FollowingaForewordbyJohnLoeser,oneoftheeminent
pioneers in the field, the first section covers the history and empirical support of
multidisciplinarychronicpainmanagement.Thissectionincludesachapteronthe
historyofthemultidisciplinaryapproachtochronicpain(MarciaMeldrum),anin
depth analysis of the clinical efficacy and cost-efficiency of the multidisciplinary
approach in comparison to “traditional” approaches (Dennis Turk and Kimberly
Swanson),andapresentationoftheliteratureonproblemsassociatedwith“carving
out” specific services from programs that need to be offered as coherent wholes
(RobertGatchel,NancyKishino,andCarlNoe).Forthoseofuswhohavepracticed
painmanagementfromamultidisciplinaryapproachandhaveseentheproblems
associated with efforts that treat the “pain” but not the “person,” the superiority
ofthemultidisciplinaryapproachisveryobvious.Forthosewhoseunderstanding
ofchronicpainismorelimited,however,thechaptersinthissectionservetoerase
anydoubtregardingtheefficacyofthemore“person-centered”approachtochronic
paintreatment.
The second section of this text covers the need for multidisciplinary chronic
painmanagementgiventhecountlessproblemsassociatedwithotherapproaches.
Thissectionincludesachapteronmultidisciplinarytreatmentasanalternativeto
chronic opioid therapy (Jane Ballantyne) and spinal surgery (Richard Guyer and
Andy Block), both of which have been heavily criticized as overutilized and of
questionableefficacy.Thissectionalsoincludeschaptersontheuseofapproaches
that have been empirically demonstrated to be of limited efficacy when provided
inaunimodalfashion,butwhichcanbevaluablecomponentsofacomprehensive
chronicpainmanagementprogram.Chaptersareprovidedoncomplementaryand
alternative medicine(CAM) (GabrielTan and Mark Jensen) and on interventional
approaches(MikeHatzakisandMichaelSchatman).
The next section of the book focuses on people who are actually treated
throughmultidisciplinarychronicpainmanagementprograms,aswellasonthose
who are sometimes not treated at all. We were fortunate to have a patient (Debra
Benner)whoexperiencedfirst-handthebenefitsofbeingtreatedinaprogramthat
wasdevelopedbythebook’sfirsteditor(MES)andwhosetrainingandworkasa
hospitalchaplainprovideuniqueinsightsintopainmanagementthatfewarefor-
tunate enough to experience. Additionally, a chapter in this section by one of the
greatchampionsofvulnerablepopulations(RayTait)allowsthereadertoconsider
issuesofdistributivejusticeinthefieldofchronicpainmanagement.
Preface vii
Thefourthsectionofthetextbooklooksatclinicalelementsofacomprehen-
sivepainmanagementprogramthatmakeittruly“multidisciplinary.”Thesection
includesabroadchapteronthe“nutsandbolts”ofputtingtogetheracomprehen-
sive interdisciplinary/multidisciplinary treatment team, delineating the functions
of all of the members (Steven Stanos). This chapter is of great importance, as it
outlines the need for communication and cooperation between various types of
healthcareprofessionalswhosetrainingmaynotnecessarilybebasedonthesame
underlying assumptions about illness and disease. The other chapter in this sec-
tiondiscussestheroleofpsychologicalassessmentinmultidisciplinarychronicpain
management (Allen Lebovits). As these programs place a heavy emphasis on the
psychological sequelae of chronic pain as well as upon the patient’s nociceptive
experience, the value of psychologists providing other treatment team members
with an understanding of a patient’s psychodynamics as they relate to his or her
painisessentialifthepatientistoachievesuccess.
Thefifthandfinalsectionofthisbookisthelongest,dealingwiththeadmin-
istrative/financialaspectsofdevelopingamultidisciplinarychronicpainmanage-
mentprogram.Atpresent,itisnottheclinicalefficacyofmultidisciplinarychronic
painprogramsthatisinquestion;rather,itistheabilityoftheseprogramstoremain
effectiveintherapidlychangingeconomicclimatewhilemaintainingfinancialvia-
bility. The first chapter in this section addresses strategies for developing strong
policies and procedures, which are likely to contribute to the consistency of treat-
mentthatisprovidedtochronicpainpatients(PaulaSpoonhourandMichaelSchat-
man).Whileeachmultidisciplinaryprogramislikelytohaveitsownuniquequal-
ities,internalconsistencyisessentialifreferralsourcesandthirdpartypayorsare
toconsideraprogramseriously.Thenextchapteraddressestheimportanceofout-
comesmeasurementanddatacollectioninmultidisciplinarychronicpainmanage-
ment as a means of documenting and improving the quality of programs (Kevin
Vowles,RickGross,andLanceMcCracken).Thethirdchapterinthissectionspeaks
to pain program accreditation (Alexandra Campbell). While any licensed health
careprofessionalcanclaimtoprovidechronicpainmanagementservices,meeting
thestandardsnecessaryforaccreditationcancontributesignificantlytoaprogram’s
legitimacy,bothintheeyesoftheinsuranceindustryandpotentialreferralsources.
Thenextchapterprovidesstrategiesforobtainingreimbursementfortheprovision
ofmultidisciplinarychronicpainmanagement(RonKulichandMichaelAdolph),
thenecessityofwhichisobviousifthistreatmentmodelistocontinuetobeviable.
The authors take the perspective that programs need to be run like businesses if
theyaretosurviveinahealthcareindustryclimatethatconsiderscost-containment
and profitability to be more important than the welfare of those who suffer from
chronicpain.Thefinalchapterinthebookdiscussestheverysuccessfulmodelfor
multidisciplinarychronicpainmanagementthathasbeendevelopedandnurtured
in one of the nation’s largest and best known health maintenance organizations,
KaiserPermanente(BillMcCarberg).
Wearehighlyappreciativeofalloftheauthorswhocontributedtheirtimeand
efforttowritechaptersforwhatwebelievetobeanimportantandtimelyvolume.
Awidevarietyofhealthcareprofessionalsarerepresentedamongtheauthorsbut
they share the common thread of believing in multidisciplinary chronic pain man-
agement,andhavededicatedtheirprofessionallivestopracticingand/orfurther-
ing the field. In a presentation at the Eighth World Congress of the International