Chapter 80. The Role of Pain Clinics

In the past 30 years, pain centers have revolutionized the management of complex chronic pain problems. Before discussing important clinical issues, a brief history is presented to give the reader background and perspective.

Several factors contributed to the development of the multidisciplinary pain center. One common observation was need for a facility for the vast group of patients who did not respond to conservative treatment measures and were not appropriate for, or did not respond to, interventional approaches. These patients had chronic pain syndromes with concomitant poor coping, dysfunctional pain behaviors, excessive health care utilization, self-limitations in activity level, medication dependency problems, emotional disturbance, work loss, and global life disruption. (I have emphasized for many years that the term chronic pain syndrome is not a diagnosis, but a descriptive term having some or all of the foregoing noted characteristics.) Another observation was the increasing recognition of the importance of psychosocial factors in the development and maintenance of chronic pain syndrome. This clinical observation made by Beecher1 in 1959 was strengthened further through theoretic formulations.2

In the 1950s, our methods for treating chronic pain consisted primarily of bed rest, medication, nerve blocks, or surgery. Currently, bed rest generally is thought to be contraindicated for most chronic nonmalignant pain syndromes. Opioids, often the medications of choice during the 1950s, then fell into disfavor through the 1980s. They are now again being used selectively to treat nonmalignant pain with the recognition that opioids may provide adequate analgesia to maintain high-activity level and prevent work loss and disability.3 The indications for nerve blocks and surgery are being redefined and used more selectively. Whereas pain centers once were considered treatments of last resort, currently this is often the judgment reserved for invasive treatments. Concepts regarding the treatment of chronic pain changed dramatically, as has the health care system generally in the United States. Health care providers have recognized that early patient referrals may eliminate needless or multiple surgeries, reduce health care costs, and promote the patient’s return to productivity, and earlier referral to pain centers appeared to be more commonplace. Insurance carriers ultimately benefit from chronic pain programs when successful outcomes reduce health care costs. Ineffective surgical procedures, multiple physician visits, medication dependency, iatrogenic complications, and lost workdays may be reduced.4,5

Throughout the 1960s, pain centers were rare in the United States and even less common outside this country. These facilities were on the fringes of medical acceptability even during the early 1970s. Patients who had multiple surgeries or numerous nerve blocks were not considered to have been treated radically, and yet, patients treated in pain programs with operant conditioning, biofeedback, psychotherapy, and rehabilitation often caused many raised eyebrows.

In 1976, Medical World News listed approximately 30 major comprehensive pain centers distributed throughout the United States. By 1979, this number had grown to 278 (according to a questionnaire survey conducted by the American Society of Anesthesiologists). By 1983, the number of alleged pain programs had grown to more than 1000.6 These numbers represent questionnaire surveys, and there has been no attempt to validate the accuracy of the information provided. Although it is suggested that there are differences in methods, program content, and delivery systems in these various facilities, details regarding their efficacy are not available. In recent years, clinicians are hanging up signs, advertising in local publications, or advertising on the Internet, claiming to be pain programs or specialists without prior experience in the treatment of pain or any specific pain credentials. It is estimated that there are now 1500 to 2000 pain treatment programs in the United States.7

The first multidisciplinary pain centers were founded separately by Drs John Bonica and Benjamin Crue. Although different in structure and conceptual framework, both radically changed the treatment of patients with chronic pain syndrome and served as prototypes for the pain centers that followed. As pioneers in the pain movement, both Drs. Bonica and Crue advocated the multidisciplinary team approach to manage intractable chronic pain syndromes. Despite this, there were some fundamental differences in regard to the role of invasive treatments in their pain programs. Dr. Bonica, an anesthesiologist, more frequently used nerve blocks diagnostically or therapeutically. Dr. Crue, a neurosurgeon, viewed chronic nonmalignant pain more as a psychosomatic process, rarely used invasive techniques, and advocated a more behavioral-biopsychosocial and physical rehabilitative approach. Despite these different viewpoints, both programs were successful. Even now, more than 45 years after the inception of these programs, it is unclear whether one approach is preferred over the other. We do not have adequate statistical data to condemn or support one type of pain program over another, but, rather, we are learning that the crucial factor is more likely to depend on the type of pain problem, type of patient, and experience of the treating physicians and support team; we need to accumulate better data to improve specificity of treatments. In my opinion, this is part of the problem.

Throughout the development of the multidisciplinary pain centers (MPC), there has been a move away from the model that treats chronic pain as an extension of acute pain. Over time, there has been increasing importance placed on central factors in the cause and maintenance of chronic pain and associated suffering. Current treatment approaches offer strategies for peripheral management of pain but evaluate the impact of central factors.8

By 1979, the American Pain Society, in an attempt to get a better understanding of the status of formal pain management programs in the United States, established a special committee, chaired by this author, to investigate the problem and develop guidelines for classifying pain treatment facilities. The following represents the most complete classification of pain programs currently available. The types and descriptions of these pain programs has not changed significantly and include:

• 1. Unidisciplinary programs having one discipline and including either MDs or non-MDs.
• 2. Interdisciplinary programs including at least one physician in an interactional system with nonphysicians as part of the treatment team.
• 3. Multidisciplinary programs including two or more physicians and nonphysicians.
• 4. Pain clinics in which pain treatment teams are organized in an outpatient setting.
• 5. Pain units that specialize in inpatient programs localized in a separate geographic area specifically for the management of pain.
• 6. Comprehensive pain center that has a program with an inpatient and outpatient pain clinic, facilities for pain research, and teaching programs. Generally treats a heterogeneous population of patients.
• 7. Syndrome-oriented programs that are specific to certain types of pain (such as cancer, arthritis, back pain, fibromyalgia, or headaches).
• 8. Modality-oriented pain programs, based on the method used, ranging from transcutaneous electrical nerve stimulation (TENS) to acupuncture, physical therapy, psychotherapy, and biofeedback clinics. The types of modality-oriented programs possible are almost endless. Although some of these programs may offer legitimate services, it also was thought that others may use fringe therapies that border on quackery.

In 1982, the American Pain Society established a committee on Standards for Pain Treatment Facilities, which I was also privileged to chair. Our charge was to gather information and develop guidelines to establish national standards for pain facilities in the United States. It was decided, at that time, that since the American Pain Society was a scientific organization, it would not be involved in on-site surveys or directly participate in the accreditation process. Concurrently, the Commission on Accreditation of Rehabilitation Facilities (CARF) convened a national advisory committee that met in Chicago in July 1982 to develop standards for chronic pain and multidisciplinary inpatient and outpatient programs. The committee accomplished its task, and by January 1983, these standards were published. Throughout the development and implementation of these standards, CARF solicited the assistance of the American Pain Society and the American Academy of Pain Medicine (AAPM). I served as the liaison member from the Board of Directors of APS and AAPM to CARF, and believe that the standards developed reflect the national advisory view that nonphysicians, especially nurses, psychologists, and physical therapists, are often the essential team members in MPCs.

The CARF Standards from 1983 to 1998 were for multidisciplinary and interdisciplinary chronic pain management programs. At the 1998 CARF National Advisory Committee meeting, it was decided to modify the standards for programs now referred to as Interdisciplinary Pain Rehabilitation Programs. The standards can be obtained directly from CARF. In the program description CARF states that “an Interdisciplinary Pain Rehabilitation Program provides outcomes-focused, coordinated, goal-oriented interdisciplinary team services to measure and improve the functioning of persons with pain and encourage their appropriate use of health care systems and services. The program can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. Information about the scope of the services and the outcomes achieved is shared by the program with stakeholders.”9

In the 1980s and early 1990s it appeared that the aforementioned changes represented an

improvement in meeting the needs of an unfortunate population, who for years became invalids within the health care system. Managed care has unfortunately changed that, and most patients find that their insurers are reluctant to pay for interdisciplinary pain care despite accumulating data that demonstrate its clinical usefulness and cost effectiveness.10–12 Unfortunately, changes in the health care system brought about by managed care currently threaten the survival of the MPC concept.

In 1990, the International Association for the Study of Pain published desirable characteristics for pain treatment facilities. In doing so, they defined pain treatment facilities as multidisciplinary pain centers, multidisciplinary pain clinics, pain clinics, and modality-oriented pain clinics. Their guidelines included recommendations for staffing, represensation of various specialties, and communications among these health professionals, credentials of the director or coordinator, and services that should be offered. They also made recommendations regarding space, record keeping, support staff, licensing, protocols, and educational programs.13

Patients with chronic pain, in their desperate search for the elusive cure, often “chase windmills” and convince their doctors to do many invasive tests and procedures. As a result of their pain behavior, many have iatrogenic complications, suffering, and disability. Those involved in the treatment of these patients must find improved ways to detect this highly susceptible population, establish a therapeutic alliance, and short circuit their pain careers. Our health care system cannot rely solely on the traditional methods of medical and surgical approaches often used with this population.

We should not ask people to live with pain if there is an acceptable treatment to alleviate it and if the potential benefits outweigh the potential risks and side effects. Therefore, I believe that, in all pain treatment facilities, the assessment must begin with a review of the patient’s medical status, past medical records, especially those pertaining to prior pain evaluations and treatments, prior pharmacologic trials, and an updated physical examination. This investigation should be done by those experienced in the evaluation of chronic pain. Through the years, I have been distressed by the many clinical recommendations offered by inexperienced consultants. When seeing a patient with chronic pain syndrome, they frequently order extensive diagnostic studies and invasive therapies, whereas more experienced consultants follow a more conservative course. As pain clinicians, our goal should be to develop and provide the most effective therapies for the various pains we treat. Clinical research on the spectrum of pain disorders may help us delineate not only the treatments of choice but also the methods involved in their implementation.14,15

Regarding the patient’s educational level, their average education ranged from a sixth grade level or less in a rural environment at the University of Virginia Pain Clinic16 to more than 12 years of education in the predominantly urban population at the Boston Pain Center17 to a more mixed population at the Charlotte-based Presbyterian Center for Pain Medicine.18

Back pain was the primary site of pain in most MPCs; this was consistent with chronic pain complaints in the general population.19 At the Boston Pain Center, 45% of recent patient admissions were for back pain; this figure was 50% at the University of Virginia. Murphy20 reported that back and headache together accounted for two thirds of patients at the University of Washington. Some MPCs focus exclusively on patients with back pain.21

Based on a review of more than 1000 pain center patients who had one or more prior spinal surgeries and persistent back pain, I recommended criteria for patients who should have a second opinion before elective surgery (Table 80-1).

Because low back surgeries are being done more selectively and less frequently, pain centers should be viewed as a positive alternative for treatment, not only by concerned physicians and health care providers but also by cost-conscious insurance carriers and employers.14

Despite some evidence indicating that narcotic addiction in medical patients is low,22 many patients with chronic pain have been described as dependent on narcotic medications when admitted to MPCs.23 Carron and Rowlingson16 reported that 85% of their admissions had received narcotic analgesics. At the Boston Pain Center,17 55% of patients were admitted to the program while they were taking narcotic medication; this figure was 43% at the University of Washington.20 After narcotic medications, benzodiazepines were administered most frequently. Carron and Rowlingson16 reported that 85% of their patients had received benzodiazepines, resulting in a 60% drug dependence that necessitated incorporation of detoxification as a part of treatment. In other programs, the percentage of patients taking sedative-hypnotics was substantially lower, with 9% of patients at the Boston Pain Center admitting to having received benzodiazepines. At the University of Washington, 15% of patients had been taking diazapam.

Studies from MPCs, however, have often provided conflicting data regarding the use of opioid analgesics for nonmalignant pain.24–31 It must be noted, however, that much of these data were uncontrolled, anecdotal, and without adequate information provided to reach definitive conclusions. For example, patients were queried about opioid use. Generally this involved short-acting opioids with an analgesic half-life of 3 to 4 hours. Yet the opioids were often prescribed every 6 to 8 hours. Patients were asked whether they had sustained benefit, significant functional improvement, or improved ability to cope with pain. Generally the responses were not affirmative, and it was concluded that opioids were ineffective for their chronic pain.

I suggest that the conclusions were unwarranted, misleading, and often reflective of inadequate or inappropriate opioid prescribing without adequate attention to pharmacodynamics or pharmacokinetics. As some of the patients responded to an interdisciplinary pain center approach, this further reinforced the conclusion that opioids should not be used in chronic pain. As recently as 12 years ago, one of the outcome measures for a successful multidisciplinary pain center was the percentage of patients “successfully” tapered from opioids during the treatment program and maintained off of opioids during follow-up. In retrospect, I can say that many of these patients had not done well prior to their admissions when they were taking opioids and therefore justification of the medication taper was not difficult. With 20/20 knowledge in hindsight, however, I suspect that many of us may have done a disservice to a small group of patients, “detoxified” or treated for “drug dependence,” who might have benefited from long-term opioid treatment but for whom we dogmatically refused to prescribe opioids.16,32 We now know that controlled-release opioids have a significant role in a carefully selected subgroup of chronic pain sufferers.

In terms of surgical treatment, many patients admitted to MPCs have had previous surgery. Murphy20 reported that 40% of admissions have had one or more pain-related surgeries (average, 2.4 procedures). Gottlieb and coworkers21 reported an average of two surgical procedures. At the Boston Pain Center,17 a survey indicated an average of 1.29 surgeries, although our previous study of 104 consecutive admissions revealed an average of 1.8 pain-related surgeries per patient.33 Crue and Pinsky34 found that 60% of their patients had had one or more surgical procedures (average, just under two per patient).

Vocational status is an important consideration when dealing with these patients because the presence of chronic pain syndrome may interfere markedly with vocational functioning. Seres and colleagues35 reported that 40% of their admissions were “disabled” by pain. At the Boston Pain Center (BPC), more than 50% of admissions were labeled unemployed due to pain. The average time out of work was 29.4 months.17

Most patients at the BPC (1976–1994) and at the Presbyterian Center For Pain Medicine (PRCPM) (1994–1999) were involved in pain-related litigation from work injuries and personal nonindustrial accidents. A pilot study36,37 at the BPC included a retrospective review of 50 patients who had been discharged between 1985 and 1987 and had returned for follow-up (all had received workers’ compensation). The study suggested that, for those who sustain work-related injuries late in their careers and in whom limited education decreases their retraining potential, secondary gain factors may compromise improvement and return to a functional state. Other factors believed to adversely influence return to work included (1) being out of work more than 1 year, (2) negative treatment course and poor mastery of pain, (3) poor work history with little incentive to return to work; (4) major psychopathology, (5) narcotic dependency, (6) primary, secondary, and tertiary gain, (7) litigation, and (8) delay in return to work after discharge from the pain center.

Our policy at the BPC, which continued at the PRCPM, was that only motivated patients without major conscious secondary gain or suspected malingering were admitted to the pain program. At the BPC we often recommended to patients who had litigation pending that they resolve these issues and if their pain problem persisted, they could then contact us to structure a treatment program for them at that time. The attrition rate after claims closure and litigation resolution was high.14 This policy has been reconsidered as we have found that there are many industrially injured patients with chronic pain syndrome who through no fault of theirs, having been compliant with treatment recommendations, nonetheless have ongoing pain and suffering in need of treatment. We now believe that they should not be denied treatment because of having unresolved workers’ compensation issues or personal injury litigation if the patient is motivated to participate in the full treament program.

Malec and associates38 found that no patients were employed or in training at the time of admission. Vasudevan and colleagues39 reported that only 19% of their patients were employed when admitted.

In general, the typical MPC admission may be described as a patient in his or her mid-40s, with slightly less than a high school education, working most probably in a skilled or unskilled occupation but no longer able to work as a result of back pain. The average patient probably is receiving short-acting narcotic analgesics at admission and has had more than one surgical procedure.

Because chronic pain has such disruptive effects on people’s lives and physical functioning, it is not surprising that psychological and social functioning also is affected. The psychosocial aspects of pain have been reviewed elsewhere in this volume, and many books have covered this topic.19,40–44 Herein the discussion is confined to delineating the psychological characteristics of patients admitted to MPCs. Keep in mind that patients seen in private practice settings may differ from these patients with regard to their psychological characteristics. Chapman and colleagues45compared depression and so-called illness behavior in patients treated in pain clinics or private practices. They found that those treated in private practices were significantly less depressed and showed less conviction of disease, bodily preoccupation, and hypochondriasis. They had less affective disturbance.

Typically, the patient with chronic pain admitted to a MPC is not psychologically minded and has little understanding of the role that psychological issues play in the pain problem. The patient often vehemently denies that there is any psychological component to the pain problem and can be rigidly defensive, using most often denial and repression (an unconscious mechanism wherein psychological issues and conflicts are kept out of the patient’s awareness). Emotional conflicts often are expressed through somatic symptoms and are discharged in autonomic, vascular, or neuromuscular responses. They have been described as alexithymic.46

Patients may share some or all of the following characteristics: (1) preoccupation with pain, (2) strong needs for dependency and nurturance that may be denied directly and sought through so-called pain behavior, (3) feelings of loneliness and isolation, (4) self-defeating behavior patterns, (5) anger, and (6) hostility.

Seres and coworkers35 reported that 70% of their patients had hysterical features, and more than 50% were depressed. Gottlieb and colleagues21 found that virtually all (71 of 72 patients in their study) had moderate to severe psychopathologic disorders (indicated by significant deviations on standardized psychological tests).

Research using the Minnesota Multiphasic Personality Inventory (MMPI) showed that patients treated in MPCs (and patients with chronic pain in general) achieve significantly elevated scores on the hypochondriasis, depression, and hysteria scales of that test.47 This profile has been referred to as the neurotic triad and suggests a high level of depression, denial of emotional conflicts, and a tendency toward the expression of needs through somatic symptoms. Some investigators suggest that this pattern reflects premorbid neurotic symptoms that contribute to the development of the pain syndrome; others view the pattern as reflecting the emotional problems that result from the chronic pain experience.48 In support of the latter interpretation, there is evidence to suggest that patients with chronic pain cannot be differentiated from those with chronic disease on the basis of their MMPI profiles.49

In looking at the backgrounds of chronic pain admissions, some similarities are found. Some of these were addressed by Engel50 in his classic treatise on the so-called pain-prone patient. They have been updated by Blumer and Heilbronn.51 These latter authors proposed the term pain-prone disorder to identify a distinct subgroup of patients with characteristic clinical, psychodynamic, biographic, and genetic features. Some of these features are: continuous pain of obscure origin, hypochondriac preoccupation, desire for surgery, denial of conflicts, prepain workaholism, idealization of self and family relations, and depression. In the family history, there is a high incidence of alcoholism, depression, and relatives with chronic pain. Past abuse by a spouse and sexual abuse by a parent or sibling also may occur. This author believes that many such patients who later in life develop even a minor illness or injury that becomes chronic are indirectly telling us that they are tired of not getting their needs met. Their symptoms are their way of saying, “Now it’s my turn to be taken care of.”

It has been this author’s belief that many patients consulting primary care physicians or specialists with headaches, back pain, diffuse myalgias, abdominal pain, and other symptoms such as fatigue and nonrestorative sleep have underlying depression and somatization. Through physical symptoms, they are communicating that their life hurts and they are unable to deal with multiple stressors.52 (Yet this somatization is generally not diagnosed because most pain clinicians do not take an adequate psychosocial or developmental history.) Instead, patients develop a socially acceptable symptom and get a socially acceptable treatment: analgesics, muscle relaxants, benzodiazepines “to relax muscles,” a variety of sleeping pills, and so forth. But the stressors continue, and frequently act as perpetuating factors in the chronic pain process. Vague symptoms, overinterpretation of mild diagnostic test “abnormalities” (which more likely represent normal variations), and subjective complaints of tenderness by overly aggressive and inexperienced (at working with chronic pain patients) physicians result in iatrogenically disabled patients who develop invalid lifestyles not because of their condition but as a result of the treatment.

Whether the psychological dysfunction preceded or followed the onset of the pain problem, by the time the patient is admitted to a MPC, there is often global life disruption. Addison53 states that characteristics common on evaluation include “. . the perception of one’s life being out of one’s own control, or a lack of contingencies based on individual behaviors, a sense of helplessness in intervening in one’s own behalf is most often the general overlay to all other psychological and emotional changes.”

During the past decade, MPCs have coalesced into similar forms, with common underlying philosophies, assumptions about treatment, and organization.54,55 A major characteristic is the integration and interdependency of their components.56 This interdependency means that, despite the diversity of disciplines represented in a MPC, patients are given a message about the nature of their problem and the proposed treatment that is consistent with the philosophy and assumptions of the center as a whole.

The BPC and PRCPM treatment programs focused on several major patient problem areas, including:

• Clarification of the etiology of the pain
• Clarification of the reasons to or not to pursue further diagnostic evaluation or interventional approaches
• The pain–depression–insomnia cycle
• Medication use and abuse issues
• Pain-related physical dysfunction
• Psychosocial factors affecting the pain syndrome
• The distinction between impairment and disability
• Early return to work, school, or other productive activity
• Quality of life issues.

It is crucial to the effective functioning of the MPC that staff are aware of these treatment objectives and can convey the appropriate messages to patients. If a new staff member or consultant arrives whose orientation differs from that of the program, the nature of the treatment milieu changes. For instance, a common goal of many MPCs is medication reduction. I believe this emphasis is appropriate if the medication cannot be demonstrated to bring about therapeutic efficacy but not for medications felt to be of benefit. Pain center consultants must be made aware of the team treatment philosophy or the integrity of the MPC message may be compromised, even if the recommendations are not implemented. Inconsistency in communication fosters division of staff (splitting) and may interfere with effective MPC treatment.

Assumptlons Underlying MPC Treatment

An assumption of virtually all MPCs is that chronic pain syndrome always involve psychological, social, biologic, and medical factors.57 This assumption is inherent in the gate control theory2 and has been accepted widely throughout the community of pain clinicians. Crue58 as early as the 1960s made the statement that, although accurate, was inflammatory to many medical and surgical audiences. Namely, that chronic pain is always psychosomatic. He was not implying that there was not underlying pathophysiology, but that chronic pain not only affected organs systems but also affected people, their personalities, and their social systems. Aronoff59 emphasized that “any treatment program designed for pain patients must be holistic in its orientation if it is to be effective” (Table 80-2). This assumption does not mean that psychosocial factors are only sequelae to a more fundamentally biologic or medical malady, nor does it mean that patients treated in a MPC have primarily psychogenic pain. The prevalence of pain disorders associated with psychological factors (only) in MPCs is remarkably low. However, the prevalence of pain disorders associated with psychological factors and a medical condition is much higher.60 We must recognize the complex relationship between chronic pain, life stressors, and psychopathology. Chronic pain changes people’s lives. Some adapt better than others. For some, the stress of chronic pain is overwhelming and activates or reactivates previously quiescent emotional-behavioral disorders. Our goal must be “above all do no harm. .” Our treatments should be geared to improving quality of life.

Pain Center Goals

• I. Clarify the diagnosis. Review medical records and the need for additional diagnostic studies or invasive procedures.

• II. Improve pain control (eliminate pain if possible) through biopsychosocial therapies:

  • A. Help the patient to be more comfortably active, with a return to a functional and productive life.

    B. Promote the use of alternative noninvasive pain-control therapies other than potent medications when possible.

    C. With individually structured exercise programs, reduce the patient’s fear of reinjury.

    D. Teach proper body mechanics and postural awareness.

    E. Evaluate limitations and restrictions.

• III. Improve psychological functioning:

  • A. Define and address psychosocial issues influencing chronic pain syndrome.

    B. Evaluate drug-seeking behaviors and treat substance problems if present.

    C. Treat depression and its frequently associated insomnia.

    D. Address primary, secondary, and tertiary gains from pain.

    E. Assess family system.

    F. Strengthen support network (e.g., personal, family, and community).

    G. Define and treat cognitive distortions contributing to dysfunctional pain-disability behaviors.

• IV. Provide access to occupational and vocational rehabilitation and any other significant health care personnel and resolve disability when possible.

• V. Communicate with the patient’s referring physician by discharge summary, telephone, or personal meetings to obtain any information that will assist in the continued management of the patient.

• VI. Reduce inappropriate use of the health care system.

• VII. Decrease the cost of medical care associated with chronic pain syndrome.

(Adapted from Aronoff GM, McAlary PW. Pain centers: treatment for intractable suffering and disability resuiting from chronic pain. In: Aronoff GM, (ed.). Evaluation and Treatment of Chronic Pain. 2nd ed. Baltimore, Md: Williams & Wilkins, 1992:417.)

The staff in MPCs generally view the pain syndrome itself as the focal point of treatment, not only as a symptom of some underlying pathophysiologic process. Thus, legitimate directions of treatment are to reduce pain behaviors, life disruption, inappropriate medication usage, and secondary gain; and to increase activity level, physical functioning, and improve vocational status.

The focus on the syndrome of chronic pain in MPCs can be in opposition to the expectation of patients. It is common for patients to expect that pain itself will be the focus of treatment, or perhaps that they will receive another extensive diagnostic evaluation to discover the underlying cause of pain. This discrepancy between patient expectations and MPC orientation needs to be resolved during treatment (as patient and staff come to a common conceptualization of the nature of the pain problem).42 However, for treatment to be successful, they must believe that they have been appropriately evaluated; that is, what should have been done, has been done.

Another assumption shared by MPCs is the emphasis on the advantages of patients’ taking an active role in their rehabilitation. Although research regarding the influence of the so-called locus of control on rehabilitation is equivocal, it is believed that this may reflect difficulties in operationalizing the concept of active responsibility rather than problems with the concept itself.

Active responsibility and independence are orientations shared by many chronic disease specialities, and they differ markedly from those of acute medical care. Patients also may dislike the emphasis placed on independence, seeing this as inadequate caretaking by the staff, who are seen as not understanding the nature of their problem. This discrepancy often is based on patients’ (and some clinicians’) failure to differentiate acute from chronic pain problems.

A related assumption is that “curing” pain (in the sense of alleviating the cause of nociception) is not always possible. Crue and Pinsky34 take a centralist, rather than a peripheralist, point of view and argue that, in its chronic form, pain does not require continued nociceptive input. These authors state, “We regard chronic pain syndrome as a result of central nervous system phenomena without the need for an ongoing peripheral nociceptive arm to complete the clinical picture.” Not all MPC staff share the centralist viewpoint that cure (in the acute care sense) is not the ultimate focus for treatment of pain syndromes.

Staffing of a Multidisciplinary Pain Center

The core specialities represented at MPCs are usually similar. This similarity occurs because the assumptions are operationalized.54,55 Also, CARF has delineated staffing guidelines that often are followed by pain centers, not only because of clinical efficacy but also as a result of the importance of certification in some regions.

Conformity with CARF guidelines for inpatient MPCs requires the services of a physiclan, psychologist or psychiatrist, physical therapist, specialized nursing care, access to a dietician’s services, and social services. In addition, many pain centers have occupational therapy and/or vocational services as an integral part of the program.

Medical Director

As noted in the CARF guidelines,9 the medical director of the pain program does not need to be the clinical director, although frequently the same person serves in both capacities. Current guidelines are as follows:

• A. Qualifications for medical director include:

  • 1. Board certification in his or her specialty area.

    2. Certification as a Fellow of the Royal College of Physicians and Surgeons of Canada or a certificate of the Canadian College of Family Physicians (Canada).

    3. Certification as a specialist by the National Board of Health and Welfare (Sweden).

• B. Demonstrating the equivalent of two years’ full-time postresidency experience in an interdisciplinary pain rehabilitation program.

• C. Membership in a regional or national multidisciplinary pain society.

• D. Participation at least annually in continuing medical education in pain rehabilitation that is accredited by the Accreditation Council for Continuing Medical Education (ACCME) or the American Osteopathic Association (AOA).

• E. Participation at least annually in continuing medical education in pain rehabilitation.

I believe that the medical director should have adequate clinical skills in the evaluation and treatment of pain to allow for the formulation and implementation of an appropriate treatment plan for the given patient population. With these patients, who are at risk for iatrogenic complications, it is as important (perhaps more so) for the physician to know when not to request additional invasive diagnostic studies and procedures than when to request them. Although this clinical decision often is difficult, it must be emphasized that if we pursue the diagnostic evaluation past a certain point, it often is counterproductive, contraindicated, and may contribute to iatrogenic impairment and disability. Defining that certain point involves combining the science and art of medicine.This point is emphasized because in a fee-for-service health care system frequent use of interventional approaches carries a significant financial incentive. This author has been in the field long enough to have evaluated many patients exemplifying excessive use of these procedures for marginal clinical indications. This has damaged the credibility of the field of pain medicine with those who pay for health care as well as patients with poor outcomes from unnecessary treatments.

Services Offered at Pain Centers

A similarity of services is also common in MPCs. These usually consist of medical services (including evaluation, supervision, and medication monitoring) and speciality consultation. Psychological services include evaluation and testing, and group, individual, and family psychotherapy. The psychologist also can be involved in program development, research, and program management.

Physical therapy is a crucial component to any MPC. Often a good physical therapy examination can reveal problems that have been overlooked previously. These include biomechanical dysfunctions, myofascial restrictions, diminished endurance, and functional status in relation to the patient’s daily vocational and/or leisure activities. Methods offered by physical therapy range from more traditional acute pain treatments (such as heat or cold packs, whirlpool, and ultrasound) to TENS and strengthening, flexibility, and endurance exercises. Some pain centers, in an attempt to emphasize functional improvement and independence, limit physical therapy involvement to evaluation and active exercise programs; others use active and passive modalities as needed. In recent years with diminishing reimbursement for health care, this author has been dismayed to find many programs utilizing lesser experienced or trained therapists or therapy assistants who are woefully inadequate to deal with this difficult population.

Systematic relaxation training and biofeedback are common features of MPCs because environmental stressors and elevated emotional tension are prevalent in patients with pain and can exacerbate painful conditions. There appears to be little difference in the efficacy between biofeedback and general relaxation training (such as progressive muscle relaxation or autogenic training).61,62 Both biofeedback and general relaxation training are more effective in pain reduction than no treatment. Biofeedback methods include electromyography (EMG), temperature, and electrodermal response (EDR). Cognitive-behavioral treatments have demonstrated significant improvement in treatment outcome when combined with other types of pain management.

The nature of the nursing care often can be the most important way of communicating treatment assumptions to patients, especially if the nursing component in the MPC is strong. Sample and colleagues63 state: “The Pain Unit nurse is a unique practitioner. As in all hospitals, the nurse has a major responsibility for the total well-being of the patient. She must exercise accurate clinical judgment and have understanding of pain mechanisms, psychosocial aspects of the chronic pain syndrome, operant conditioning, and behavior modification.”

The role of social services in pain programs often is to provide family counseling and educate patients and their families about the impact of chronic pain on family functioning.64,65 Interventions, in general, assume that chronic pain affects the entire family, not just the patient, and that family members can provide either strong support for behavioral change and necessary life modifications or they can sabotoge treatment goals. It is essential to assess the patient’s interactions with his or her significant other as part of the evaluation and treatment process.

Vocational services are offered by an increasing number of MPCs as return to work or other productive activity becomes a more integral aspect of the patient’s rehabilitation. The extent of services varies widely, from referral to state vocational rehabilitation agencies to comprehensive vocational evaluation, job analysis or work-hardening programs, and job placement as part of the MPC program. Several professional specialties may take part in MPC vocational services; these include certified vocational counselors, social workers, occupational therapists, and physical therapists.

A formalized educational program also is common in MPCs. Topics are offered that are relevant to patients with chronic pain (and their significant others) and include discussion about medications, depression, body mechanics, the role of psychological factors in pain, the importance for the person in pain to take an active role in the “getting well” process and in making decisions about his or her future rather than taking a victim role. More formalized stress management and assertiveness training programs often are included. The goal of educational programs is to give these patients information that they can use to move out of a position of helplessness66 to one where they can feel more in control of their lives, with their pain syndrome and its sequelae assuming a less dominant position in their lives.

Although perhaps not accurately considered a service, the milieu and therapeutic community atmosphere is a crucial aspect of treatment in many MPCs. The supportive and sometimes confrontational atmosphere of other patients who also have problems with pain often is one of the most powerful factors in promoting change to a more productive and less pain-focused life. Group interaction is encouraged and activities are managed to maximize socialization among patients and promote group cohesiveness. Unfortunately, the therapeutic milieu has becoming a casualty of the many changes in the MPC brought about by managed care and other current changes in health care reimbursement.

Although physicians generally are beginning to recognize the pain center as an important community resource, it is equally important to understand which patients may be appropriate for a referral to the MPC. Usually a referred patient has a chronic nonmalignant pain syndrome that has been unresponsive to conventional therapy and is associated with significant life disruption. Often the patient has tried physical therapy, psychological therapy, and medication sporadically, all without significant or sustained benefit.

Most comprehensive MPCs treat a heterogeneous population of patients with chronic pain who have problems including intractable headache syndromes, neuropathies, complex regional pain syndrome I (CRPS, also known as reflex sympathetic dystrophy), CRPS II (causalgia) chronic low back pain, rheumatologic, phantom limb, thalamic, facial, gastrointestinal, and other nonmalignant pains. Many therapeutic techniques used in the management of chronic nonmalignant pain syndromes also may be effective in chronic cancer pain syndromes. Generally, however, these patients are treated in separate programs because of our recognition of the distinct diagnostic and therapeutic challenges in each group.

Pain can disrupt the patient’s life, causing prolonged unemployment, medication dependency, or depression. When asked directly, these patients often deny depression, but this can be assessed through questions regarding their vocational, marital, or financial disruptions; possible recent deaths of significant others in their lives; decreased concern about personal appearance; changes in sleeping or eating habits; and the presence of social isolation.

It often may be appropriate to refer a patient to a MPC if there is excessive pain behavior during consultation or examination, pain complaints in excess of that expected from the physical findings, pain that has persisted despite extensive evaluation or treatment, and pain for which surgery or nerve blocks are not believed to be treatments of choice. Despite the ubiquity of psychosocial and economic dysfunction, these patients’ chronic pain is real (with the exception of malingering), and they should not be given the impression that you, as their physician, believe it is not. Many patients believe that referral to a pain center means that their pain is “all in their heads.” For instance, one patient said he was referred to the BPC because ours was a place for people who “think they have pain.”

Treatment at a pain center begins with the referral. Ideally, referring physicians indicate to their patients, positively and supportively, that they would like to try a new approach to the management of the patient’s chronic pain. The referring physician then explains that, because the pain clearly is a complex process that does not seem to be resolving adequately, a comprehensive pain center would provide a better setting in which to deal with the many complicated medical, psychological, and social factors that have become intertwined. Many patients may think that, if either medical or surgical intervention has not helped them, then their pain must be imaginary. Reassurance that this is not the case can contribute to a more positive attitude toward pain rehabilitation. The following are criteria for patients appropriate for referral to a pain center:

• Patient has been adequately evaluated.
• Pain is refractory to conventional treatments.
• Significant life disruption
• Associated psychosocial difficulties
• Pain-related medication problems or substance abuse
• Significant pain behavior or poor coping
• Patient is motivated to change.
• Resolution of the pain problem is more important to the patient than maintaining secondary gains and/or disability.

It is important that physicians tell their patients that the pain center treatment program generally is not primarily involved in looking for a cure for pain through new diagnostic procedures. Although MPCs offer medical evaluation and diagnostic services, these should generally be performed prior to the treatment program. Otherwise, many referred patients expect these to be either the only services offered or those that are emphasized most. Patients who expect to have their previous diagnostic evaluations repeated often express considerable anger and hostility when it is not forthcoming; this, in turn, may interfere with rehabilitation. Therefore, in general, diagnostic evaluations should be done prior to MPC treatment. That is not to say that the treatment program may not involve consultations with appropriate medical subspecialists and result in further diagnostic testing; however, it must be emphasized that this is not the primary reason for the admisssion.

Finally, it is essential that the patient leave the referral meeting with some sense of hope. Patients are discouraged by the prospect of having to “learn to live with it.” They are aware that, for them, treatment has failed, and they often feel discouraged and depressed. Patients may be more hopeful if they realize that, despite previous treatment failures, they can be helped at a pain center equipped to address the complexities of their pain problems.

When determining appropriate candidates for referral, the importance of the patient’s motivation cannot be overemphasized. Poorly motivated patients sometimes respond to the pain center milieu, but they often resist demands to participate fully in the active treatment regimen. A patient strongly motivated to return to an active and productive life has a better prognosis for success in a MPC.

Most of this discussion applies to both outpatient and inpatient programs. Having evaluated and treated thousands of patients with chronic pain, Aronoff and McAlary67 concluded that most of these patients can be treated effectively in a structured outpatient day program. Patients traveling a great distance can be housed in a nearby hotel. This avoids costly hospitalization and more realistically simulates typical activities of daily living. For many patients, this is an easier transition from the treatment program back to their usual lives.

It is my belief that treatment for those with difficult chronic pain problems should be based on a wellness model, recognizing that generally pain does not make them “sick” (in the acute medical sense of the word) but rather that it interferes with their optimal functioning in various areas of their lives. These patients generally do not require around-the-clock medical or nursing care.

Recommendations for In-Hospital Pain Treatment

Currently, recommendations for in-hospital treatment include the following:

• • Patients requiring diagnostic testing best provided in a hospital

  • • • Those with unstable medical illness requiring inpatient monitoring and around-the-clock nursing or medical supervision

      • Those who are not ambulatory or independent in activities of daily living

  • Patients with major medication dependency, especially with a substance abuse disorder (some of these patients are best treated in chemical dependency centers; others who are highly motivated may be treated as outpatients)

  Those who are acutely suicidal or have unstable major psychiatric disorders (some are best treated in a psychiatric unit)

  Those who previously have been unsuccessful with outpatient pain center treatment (assuming the patient was motivated, and the center was credible).

At present, because hospitals must respond to the economic and administrative pressures of maintaining their patient census, the option of inpatient versus outpatient pain treatment unfortunately may be influenced as much (or more) by these factors as by the best interest of the patient.5

If I were to subdivide the chronic pain population I have worked with at the BPC and PRCPM, approximately one third of the patients truly desire to be involved actively in their health care, with the goal of suffering less with pain, using less medication, and returning to a more active productive life than was the case at the time of their admission. This group generally is reasonably self-motivated and eagerly awaits training in new techniques to help them live better with pain and suffer less. Another one third of this population consists of those who have learned to be patients with pain; that is, they have developed goal-directed conditioned pain behaviors (learned helplessness), often maintaining these unconsciously. Nonetheless, these patients are “stuck,” and investigation has revealed patterns of self-defeating behaviors. Although somewhat more defensive than those in the first group, these patients are at least receptive to participating in a structured program designed to maximize function and minimize dysfunction and to replace maladaptive coping with more adaptive techniques. They can learn not to be disabled by pain. Generally, these two segments of the chronic pain population do well in multidisciplinary pain programs. We have had a major impact on the quality of their lives and also serve society by returning to it more functional members. It is the remaining one third of this population that is the greatest concern. Although this group tends to be the most “abused” by the health care system, it is also the group that abuses the health care system and society.

Increasingly, it appears that there are some patients who cannot be helped, who at some time may not want to be helped, and whose agenda of being enmeshed in the health care system has nothing to do with receiving health care but, rather, with receiving benefits. We must identify this segment of the population more efficiently and not treat them. Regardless of a patient’s complaints, after we have established that the tools at our disposal are unlikely to ameliorate their symptoms, we should establish a series of recommendations, and if the patient is unable or unwilling to consider these, at this point the system may have fulfilled its responsibility adequately to the patient and should no longer attempt to treat them.5,68

We should not underestimate the importance of a physician’s authoritative guidance; this can be offered as supportive paternalism or maternalism. Patients will either live up to our expectations that they need not be disabled or, conversely, become invalids unnecessarily through learned helplessness. It is our ethical responsibility to improve a patient’s health whenever possible. Their physical, emotional, social, and spiritual well-being is more likely to be realized with the self-esteem that results from feeling useful (often from gainful employment) rather than from disability (which frequently is preventable).

Survival of the MPC

Despite the increasing recognition of the efficacy of MPC in treating motivated pain patients with refractory pain associated with dysfunctional pain behaviors, deconditioning from limiting ADLs, and associated life disruption, the survival of the MPC concept is a serious concern of pain medicine physicians and has become a dominant focus for discussion at meetings of the AAPM, APS, and other national and regional pain meetings.

With blatant disregard for extensive research supporting clinical and cost efficacy of the MPC concept in the management of chronic pain and associated suffering and disability, access to care and adequate pain treatment is extremely limited (by payers) for most chronic pain sufferers. Despite more than three decades of evolution advocating the importance of treating pain as a biopsychosial process, often health care reimbursement and the structure of many managed care systems prevent or discourage this. As a result, many excellent MPC treatment programs have had to either close, reinvent themselves as “occupational medicine functional restoration” programs, or significantly reduce the services they provide. While philosophically we have progressed from the Cartesian dualistic concept that viewed illness as being either physical or emotional, in reality many of those who pay for health care have compartmentalized reimbursement so that “mental health” benefits are handled from a different payer than physical medicine benefits, imposing further disincentives for interdisciplinary pain treatment programs.

Kulich has commented on the crisis facing MPC programs in Massachusetts, where many health care professionals refuse to treat injured workers because of poor reimbursement (personal communication, report to the American Chronic Pain Foundation). He says, “Because the reimbursement fee schedule for injured workers was so low, patients could only access treatment in large hospital settings where costs could be shifted, while many pain facilities closed due to this issue. .” Currently, no interdisciplinary pain center can treat this patient population, as the reimbursement rates now fall so far below costs.

The American Chronic Pain Association, a patient advocacy group, indicates that “education of people with chronic pain is being threatened at a time when support of health-related and general education is being strengthened.” Cowan notes that reduced funding has caused the elimination of many MPCs, limiting access to care by a population in great need (personal communication). She adds, “Witholding the important services available through MPCs is equivalent to withholding education from our children or withholding education dollars from other disease-prevention programs proven to be effective. . Therefore, instead of being threatened, MPCs should be supported through managed care programs as an important source of providing people with education and support. Through such services, unncessary, costly care is avoided; people learn to manage their pain; and quality of life is enhanced.”

Chapman,71 in a recent article addressing problems facing MPCs states, “One frequently hears of programs closing down or modifying their treatment protocols to meet their own survival needs rather than meeting the needs of the patients they serve. . .” He discusses fundamental problems within the managed (“mangled”) care systems and workers’ compensation systems adversely affecting the survival of MPCs and a reimbursement system that rewards procedural interventions preferentially to pain rehabilitation or the use of cognitive-behavioral techniques geared toward functional restoration. He concludes, “The present danger lies in the fact that a major subset of patients whose lives and function have been the most pervasively affected by pain are losing the opportunity to participate in the precise mode of treatment (i.e., comprehensive interdisciplinary pain rehabilitation) that has been proven to be the most effective in helping them to improve their ability to function and their productivity. Unfortunately, the reasons for this have more to do with politics, profit, and the structure of current insurance than with evidence-based quality care.”

Steig et al,72 in an article titled “Roadblocks to Effective Pain Treatment” states that “the new stewards of American health care (the payers, government, managed care organizations, and countless other intermediaries) have created administrative barriers that affect access to care for pain patients and beleaguered physicians who try to care for them. .” The authors discuss the multiple social and political issues that create roadblocks, including organized medicine’s failure to meet the needs of people in pain. In their conclusion, they discuss the burden on primary care physicians of treating patients with complex chronic pain that requires the expertise of a pain specialist. They state,” Whenever possible, early referral to a recognized pain specialist may help to prevent the vortex of events that often leads to permanent disability. The primary care physician must recognize, however, the difference between specialists who offer palliative care (pain management), such as anesthesiolgists who specialize in nerve blocks, from those who are trained to evaluate and treat all of the medical and social issues associated with chronic pain (pain medicine). While there is compelling evidence that referral to pain medicine clinics improves the quality of life of chronic pain suffers, the risk of caring for this population has been gradually shifting unfairly from payers to health care professionals. .”

The National Pain Foundation (NPF) is a nonprofit educational organization created to address chronic pain as a major public health problem. Created by leaders in pain management, the NPF serves as an objective and easily accessible resource for the growing population of pain patients, their health providers, and insurers. The NPF will establish an extensive network of information regarding proven, integrated approaches to pain management that will draw from traditional, alternative, and behavioral approaches to pain management. The NPF is built on the belief that early intervention with appropriate pain management can change the course of people’s pain and their lives. The mission of the NPF is to create a highly accessible information network that will empower individuals to make optimum use of available resources to manage chronic pain. I am currently chairing a committee that is addressing issues related to access to care in an attempt to increase public and political awareness of this crisis in health care.

My career has been the full-time practice of pain medicine for the past 25 years. Most of that time, I was medical director of the Boston Pain Center, a large interdisciplinary inpatient and outpatient program in Boston, Massachusetts. In more recent years, I have been medical director of a primarily outpatient pain program (in Charlotte, NC) with inpatient capability for patients meeting the criteria mentioned earlier in this chapter. I have participated in the pain treatment of more than 13,000 chronic pain sufferers, and have observed the remarkable transition of many individuals whose lives revolved around pain and suffering, disability, and learned helplessness and were enmeshed in the health care system to regaining control of their lives and again becoming functional and productive members of society as a result of the MPC treatment they received. I applaud their efforts and those of my very capable staffs.

Unfortunately, many MPCs have become casualties from the multiple forces described above. For many of the survivors, the vitally important therapeutic milieu has become extinct. Clinicians who remain in the field are often being asked to compromise their professional integrity to provide services that are cost effective, although it is less clear that they are clinically effective. They are often being asked (or forced) to work with physicians, nurses, therapists, and others with little or no training in chronic pain mangement. Those with PhDs are being sacrificed for MA level therapists, RNs for LPNs, registered PTs for PT assistants or exercise physiologists. In so doing, the qualtity of care rendered to the populations being served is compromised.

Our hospital has recently closed the MPC as a result of reimbursement issues. Fortunately, we have a strong anesthesia pain clinic staffed by physicans with an understanding in the concepts of pain medicine and I continue to work closely with them as a consultant. When faced with the complex chronic pain syndrome patient not appropriate for an interventional approach, not having responded to an interventional approach or requiring a pain rehabilitation approach, they do not hesitate to refer the patient. Many of them are now seen in my office without the benefit of a support team of therapists or a therapeutic milieu. Often, in addition to my treatments, I will coordinate, as best I can, other treatment with therapists or physicians. I rarely, if ever, see these consultants and there is no opportunity to have interdisciplinary meetings to benefit patient care. The real casualties in this process are the chronic pain patients, many of whom will never realize what they are missing, what is possible for them, and all that we should be able to offer them but cannot. They are rapidly losing access to optimal chronic pain care.