Interdisciplinary Treatment for Chronic Pain
Contributed by Daniel Bruns, PsyD
Studies by the National Center for Health Statistics1 and the Centers for Disease Control2 confirm that pain is by far the most common reason why patients see a physician: something hurts. Although no data is available, given that the workers’ compensation system revolves primarily around the treatment of injury, the prevalence of pain in the workers’ compensation system is probably even higher than that observed in the primary care system.
In the United States population at large, at least 116 million US adults are burdened by chronic pain,3 and in a study of a random sample of community members, 27% reported having chronic low back pain.4 Pain is not only common, it is also an extraordinarily costly condition, with an estimated annual national economic cost of $560–$635 billion.3 Because of the challenges that pain presents to our society, the U.S. Institute of Medicine concluded, “Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions” (p. S-3).3
Despite the prevalence of pain, training for professionals in the treatment of pain has been lacking. Remarkably, a study by the Institute of Medicine also discovered that no American medical school required a class in pain, and only 3.4% of schools offered an elective class in pain. As a result, medical schools do not expose the physician to the full scope of options for pain treatment, and until recently, have not informed medical students of the risks of opioids.3 Recently, however, efforts have been made to correct this, and peer-reviewed online CME coursework is now becoming available.5,6
In the U.S., the treatment of pain has relied heavily on the use of opioid pain medications. Opioids (a.k.a. narcotics) are powerful pain-relieving medications and are very widely used in the U.S.. For example, even though the US accounts for only 4.6% of the global population, the U.S. accounts for 99% of the global consumption of hydrocodone.7 While the humane treatment of pain is a professional responsibility, in the US the number of deaths from prescription pain medications each year exceeds the number of deaths from cocaine and heroin combined,8 and also exceeds the number of deaths from motor vehicle accidents.9 This rapidly growing rate of iatrogenic addiction10 and opioid-related deaths has been referred to alternately as a “crisis”11 or an “epidemic.”10
A common mistake in pain treatment is to think of pain as solely a symptom of tissue damage. In fact, pain is an extraordinarily complex sensory experience, with biological, psychological, and social components. Imaging studies of the brain show that while acute pain is primarily associated with activation of sensory areas of the brain, chronic pain is more closely associated with the brain’s emotion center.12,13 Because of that, effective treatments for pain must address both its psychological and biological aspects.3
A review of the evidence determined that psychological tests are the scientific equal of medical tests,14 and can sometimes exceed the ability of medical tests to predict the outcome of medical treatments for pain.15,16 Similarly, psychological interventions have been shown to be effective treatments for pain.17 Psychological treatments to improve pain-coping skills can produce improvements in functioning that equal those of surgery.18,19 However, one study found that surgery was 168 times more expensive than psychological treatments, and involved significant risks.20 In contrast, psychological interventions are safe, effective, and economical treatments for pain. Despite that, studies show that psychological treatments are generally underutilized.21
Unlike many states, Colorado’s system of medical treatment guidelines integrates medical and psychological treatments. This approach not only offered more comprehensive care, but produced an estimated $859 million savings in one year.20 Overall, the interdisciplinary approach to pain treatment has been shown to produce better outcomes while reducing expenditures, and that is why it has become the standard of care.
1. National Center for Health Statistics. Vital health statistics: Reporting chronic pain episodes on health surveys. Vol Series 6: Cognition and survey measurement. Washington DC: Centers for Disease Control: US Department of Health and Human Services; 1992.
2. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009. 2010; http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf. Accessed July 22, 2013.
3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington D.C.: National Academies of Science; 2011.
4. Smith BH, Elliott AM, Hannaford PC, Chambers WA, Smith WC. Factors related to the onset and persistence of chronic back pain in the community: results from a general population follow-up study. Spine. 2004;29(9):1032-1040.
5. Goldman BL. Interdisciplinary Rehabilitation of the Injured Worker With Chronic Pain. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog/item/id/680436/q/q=injured*20worker*20chronic*20pain&c=141.
6. Bruns D, Disorbio JM. The Assessment of Factors Associated with Delayed Recovery. A Biopsychosocial Paradigm. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog?dp=0&c=141&q=biopsychosocial+paradigm&f1=1.
7. International Narcotics Control Board. Narcotic drugs: estimated world requirements for 2011—statistics for 2009. 2010; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659213/ - ref6. Accessed October 1, 2015.
8. Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Morbidity and Mortality Weekly Report (MMWR) 2012; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm?s_cid=mm6101a3_w. Accessed August 9, 2012.
9. Centers for Disease Control and Prevention. Prescription drug abuse and overdose: Public Health Perspective. 2012; http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.pdf. Accessed October 1, 2015.
10. Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic. Am J Public Health. 2014;104(11):2023-2029.
11. Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.
12. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(Pt 9):2751-2768.
13. Mansour AR, Farmer MA, Baliki MN, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restorative neurology and neuroscience. 2014;32(1):129-139.
14. Meyer GJ, Finn SE, Eyde LD, et al. Psychological testing and psychological assessment. A review of evidence and issues. Am Psychol. 2001;56(2):128-165.
15. Carragee EJ, Barcohana B, Alamin T, van den Haak E. Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. Spine. 2004;29(10):1112-1117.
16. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35.
17. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.
18. Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122(1-2):145-155.
19. Brox JI, Nygaard OP, Holm I, Keller A, Ingebrigtsen T, Reikeras O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648.
20. Bruns D, Mueller K, Warren PA. Biopsychosocial law, health care reform, and the control of medical inflation in Colorado. Rehabilitation psychology. 2012;57(2):81-97.
21. Robbins H, Gatchel RJ, Noe C, et al. A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies. Anesth Analg. 2003;97(1):156-162.