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American Pain Society
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Steven H. Sanders, PhD, Department Editor
Steven H. Sanders, PhD
Editor’s Note: The following article is intended to be controversial. I hope it will serve as a catalyst to stimulate responses and reactions from the membership, opening a much-needed dialogue about the current state and future of chronic pain rehabilitation. Your reactions are welcome and encouraged.
This article provides an in-depth look at the plight of chronic pain rehabilitation in the United States. It is a follow-up to one by Chapman (2000) and in keeping with a recent article by Loeser (2000). As Chapman noted, chronic pain rehabilitation programs are on the decline. In contrast, more interventional and pharmacological approaches have become the mainstream and sometimes the only option available to chronic pain patients. The intent of this article is not to debate the pros and cons of the various treatment approaches to chronic pain. Rather, it is to highlight the current state of chronic pain rehabilitation, delineate some important issues and factors that are significantly affecting its viability, and offer some suggestions to consider any efforts to save this approach to patient care. In a sense, this article could be characterized as an obituary for chronic pain rehabilitation by some and as a challenge and call to action to revitalize this model of treatment by others (including myself).
Before proceeding, it is important to define what is meant by chronic pain rehabilitation. Indeed, this can be somewhat of a difficult task and may be part of the reason its current plight is rather grave. For the purpose of this article, chronic pain rehabilitation is defined as the treatment of patients with nonmalignant chronic painful conditions by an organized interdisciplinary team, with a focus on restoring the patient to his or her highest attainable physical and emotional functioning, maximizing self-management skills, promoting independence from health care, and reducing subjective pain intensity when possible. Chronic pain rehabilitation is not a curative model. It is a restorative model, with emphasis on improving function and independence, not just reduction in subjective pain intensity. By definition, it is typically more labor intensive for the provider and patient, with active physical and behavioral/psychological therapies emphasized. The patient is mandated to take an active role in working with the treatment team and not just be a passive recipient of procedural and pharmacological interventions. Although such interventions may be part of the treatment plan, they are not the main focus of care, particularly if they foster or perpetuate passivity and dependence in the patient. It is clear that many might take issue with the preceding definition/description of chronic pain rehabilitation. Be that as it may, this article’s content is predicated on this definition.
As Chapman (2000) noted, there is strong empirical support for the efficacy of interdisciplinary pain rehabilitation programs with chronic pain patients. Multiple literature reviews (Compas, Haaga, Keefe, Leitenberg, & Williams, 1998; Sanders, Harden, Benson, & Vicente, 1999; Turk & Okifuji, 1998) have clearly demonstrated the efficacy of pain rehabilitation efforts with chronic pain patients. Likewise, the prevalence of chronic pain in the general population is continuing to maintain a significant level of occurrence (Crombie, Croft, Linton, LeResche, & Von Korff, 1999), with approximately 10% of this patient population suffering from debilitating pain. These patients often need more intense treatment than is found within the pain rehabilitation philosophy of care. In the United States alone, there are millions of such chronic pain sufferers. Without pain rehabilitation programs, these patients have very little chance of showing any kind of functional improvement or long-term positive change. Without chronic pain rehabilitation programs, what happens to these patients? In the United States, many of them end up on Social Security disability. If we review the summary data on disabled workers alone under Social Security insurance over the last decade (Social Security Disability Administration, 2001), we see the overall number of recipients has increased from approximately 3 million to more than 5 million individuals. Even if we assume no increase in the rate of growth, it will be impossible for the Social Security disability system to sustain such growth without major increases in funding (i.e., increases in taxes for us all).
Given that chronic pain rehabilitation has clearly demonstrated scientific and clinical efficacy, the number of those patients in need of such rehabilitation is not showing any signs of diminishing, and simply moving these patients to Social Security disability (as opposed to treating them) will become cost prohibitive in the not-too-distant future, the answer to the question, “Should chronic pain rehabilitation be saved?” would seem to be obvious: that is, a resounding, “Yes!” Unfortunately, as Chapman (2000) and Loeser (2000) have highlighted, there are a myriad of factors that make chronic pain rehabilitation’s salvation extremely difficult, if not impossible. Even though there are substantial clinical and economic reasons to sustain and promote chronic pain rehabilitation, it may well be too late to effectively rescue this treatment approach in today’s healthcare, financial, and political climate.
This section examines some of the major factors that have a significant influence on the survivability of chronic pain rehabilitation. Although not definitive, these factors are representative of those core influences and determinants in answering the current question. For clarity and ease of discussion, the factors have been divided into three areas consisting of clinical practice, economics, and training.
Clinical practice factors. With the rise of managed health care and shrinking resources and reimbursement, there has been a shift in clinical practice with the most dysfunctional chronic pain patients away from pain rehabilitation and more toward procedural and pharmacological solutions. As Chapman (2000) stated, “The use of muscle relaxants for patients appears to be increasingly prevalent when compared with teaching relaxation, and implanting a device is more lucrative than giving patients guidance or advice” (p. 1). Interventional and pharmacological emphasis also has increased because of endorsements by various professional medical organizations and societies through consensus statements (American Academy of Pain Medicine & American Pain Society, 1997) and promotion of practice guidelines endorsing high-tech solutions (Sanders, 2000a). This promotion has occurred, for the most part, in the absence of any quality research demonstrating efficacy of many of these pharmacological and technological approaches with debilitated chronic pain patients (Sanders et al., 1999). Such action by various professional medical organizations is not surprising, given the dominance in most of procedurally oriented physician groups like anesthesiologists. Regrettably, such approaches with the most dysfunctional chronic pain patients set the occasion for establishing long-term dependency. This includes continued medical contact for maintenance of dependency-producing medications like opioids and benzodiazepines, along with invasive techniques such as nerve blocks and stimulation devices, which typically have only time-limited effects.
Adding to the preceding practice trends is a lack of widely accepted practice guidelines on when and how to use chronic pain rehabilitation with various chronic pain patients. This has been discussed in detail over a number of years (Loeser, 2000; Sanders & Brena, 1995; Sanders et al., 1999). Not all chronic pain patients require chronic pain rehabilitation. However, those that do, need it as soon as possible. An overemphasis on pharmacological and procedural solutions can cause more harm than good with these patients (Sanders et al., 1999). Although the Commission on Accreditation on Rehabilitation Facilities (CARF) has promoted chronic pain rehabilitation program standards for more than 15 years, these standards (CARF, 2000) are not practice guidelines and have had little impact on mainstream practice. Until a generally acceptable definition of those patients who can benefit from chronic pain rehabilitation is present, along with a more accepted delineation of the nature and content of such rehabilitation, it will continue to be very difficult, if not impossible, to effectively promote and expand such rehabilitation efforts on any wide-scale level.
Economic factors. Adding to and often significantly influencing clinical practice are a number of economic realities that severely affect the viability of chronic pain rehabilitation. The rise of managed health care over the last decade, with its focus on cost containment and cost cutting, has certainly been a major deterrent for the application of chronic pain rehabilitation. As Chapman (2000) described so well, the myriad of approval issues to get treatment across disciplines and the limits set within each area can render interdisciplinary pain rehabilitation impotent. Even with demonstrations of cost-effectiveness within a group model health maintenance organization (McCarberg, 2000), there is no substantial movement toward embracing chronic pain rehabilitation within managed health care.
Given the reduction in reimbursement levels over the last decade, yet another financial deterrent to chronic pain rehabilitation is the ever-increasing demand for more revenue generation. To sustain income levels, it is quite tempting for providers to focus on pharmacological and procedural interventions for chronic pain patients. It takes little time to write a prescription, thus more patients can be seen per day. Likewise, a great deal more revenue can be generated from procedures than simple office visits. This concept is clearly reinforced at the hospital/facility level with facility fees for engaging in such a procedural focus. Although there is obviously a place for medication and procedures in managing pain, it is the indiscriminate application to those patients who may be better served within a chronic pain rehabilitation model that presents the major issue. These patients often do not get an opportunity for chronic pain rehabilitation because of benefit limits and use of misdirected intervention attempts. Although the pendulum seems to be swinging back slightly toward increased reimbursement for provider services, it is doubtful any of this will translate into more application of chronic pain rehabilitation.
A subtle but just as potent issue imbedded in the general insurance industry is the concept of rapid case closure. This sets the focus on short-term change and gains, with little interest or, for that matter, understanding of long-term implications. Unfortunately, many times this is all about saving money instead of helping patients. Whether under private insurance or workers’ compensation, this shortsightedness is obvious, with delays and often denials of funding for chronic pain rehabilitation the result.
Another very significant economic factor is found in the major push by pharmaceutical and medical instrumentation companies to promote pharmacological and procedural solutions in chronic pain management. This push is seen from the frontline family practitioner office, to national and international professional medical associations, to the legislative process (Sanders & Vicente, 2000). Let no one fool themselves. This effort and influence amounts to millions of dollars to generate billions in revenue for the pharmaceutical and medical instrumentation industries.
Training factors. In addition to the preceding factors, which are extremely potent in and of themselves, perhaps the most deadly for chronic pain rehabilitation are those found within the professional education and training arena. Given the practice factors outlined and the scarcity of chronic pain rehabilitation programs as defined herein, it has become very difficult, if not impossible, for the next generation of healthcare professionals to at least be exposed to such a rehabilitation approach with patients. This is true even within the physical medicine and rehabilitation specialty area where more and more emphasis is being put on medications and procedures for the reasons already outlined. This also is seen at the continuing education level about pain management and board certification. The boards currently offered by the American Academy of Physical Medicine and Rehabilitation are heavily influenced by anesthesiology, resulting in a clear emphasis on pharmacological and procedural interventions. In addition, and given the absence of training opportunities and continued shrinking dollars, the availability of advanced training for psychologists, nurses, physical therapists, and other healthcare professionals involved in chronic pain rehabilitation is rapidly evaporating.
Without training opportunities, there will be no one to carry on and promote chronic pain rehabilitation as defined herein. Although it might be assumed that the standards promoted by CARF would ensure adequate training, this simply is not the case. The CARF standards do not specify content, only environments. The medical and psychological professionals involved in a pain management program must have “training” in an organized program for a set period, as well as participate in continuing education. The actual content of that training is left to the discretion of the various training programs, most of which have limited opportunity for exposure to chronic pain rehabilitation. In addition, even if the CARF standards contained more content, the decline and limited application of these standards across the United States render them ineffective in producing any major changes.
Given the clinical, economic, and training factors just reviewed, chronic pain rehabilitation may well have one foot in the grave, if it is not already dead and buried. Some would say, “Good riddance, let’s give it a proper burial and move on to more productive and worthwhile ventures.” Others, like myself, say, “Let’s make sure we understand the consequences of chronic pain rehabilitation’s death before we sign a death certificate.” Namely, the loss of an empirically validated, effective treatment model that fosters patient independence and function, leading to a reduction in healthcare needs and an increase in productivity. With all the talk and rhetoric about escalating healthcare costs and the need for better clinical management, one would think that the chronic pain rehabilitation treatment model for the most dysfunctional chronic pain patient is “just what the doctor ordered.” Obviously, this is not the case.
In spite of the rather pessimistic outlook for chronic pain rehabilitation, and in the hopes that this treatment model is not truly and completely dead, the remainder of this article offers some recommendations to consider if chronic pain rehabilitation is to have any chance of survival.
If chronic pain rehabilitation has any chance of surviving and eventually thriving, there are some fundamental steps that should improve its chances. Although not definitive, these steps could have a significant effect on revitalizing chronic pain rehabilitation. It should be noted that the order of these steps is somewhat arbitrary and not intended to imply importance. All are seen as important.
If chronic pain rehabilitation programs are to survive, they must become as streamlined and cost-effective/efficient as possible (Loeser, 2000). Gone are the days of the $10,000 to $20,000 programs. Although it may be argued that those programs still in existence have already done this, there is still room for improvement. Specifically, it is recommended that consideration be given to the most recent practice guidelines for patients with chronic non-malignant pain syndrome as a general outline for efficiency and effectiveness (Sanders et al., 1999). The average cost for this program applied by myself at Siskin Hospital for Physical Rehabilitation in Chattanooga, TN, is $4,500. The outcomes for such an application are equal to those reported in the scientific literature (Turk & Okifuji, 1998). Likewise, the program described by McCarberg (2000) represents a clinically limited, but still cost-efficient, approach.
Another step toward salvation is more emphasis on reducing healthcare expenditures and returning patients to productive activity whenever possible. Granted, this can be very difficult given the contradictory forces within the U.S. disability and return to work arenas (Loeser, 2000; Sanders & Harden, 2000). However, simply reducing subjective pain intensity is not enough to justify such labor-intensive rehabilitation. With a functional focus and the most efficient methods of applying rehabilitation, alliances can and must be made with employers and those in the private and federal arenas concerned with long-term disability. These are the areas where financial and political support may be gained. There also may be some limited support in the private managed healthcare arena, but this will be much more difficult as long as the focus continues to be on short-term cost cutting.
It also is critical that chronic pain rehabilitation programs increase their presence with consumer and patient advocacy groups. These organizations have much more enlightened views on promoting health and independence versus fostering patient dependency. We also should not give up our efforts at educating and encouraging the general insurance industry to take another look at chronic pain rehabilitation as a viable part of long-term management. Although the mentality still seems to be one of short-term gains by much of the insurance industry, it would be shortsighted of us to abandon efforts at educating and persuading.
Yet another step toward salvation continues to be the promotion and expanded application of early detection methods for those patients at significant risk for developing the most dysfunctional chronic pain conditions (Sanders, 2000b, 2000c). Identifying and initiating a chronic pain rehabilitation treatment approach with these patients as soon as possible has the potential for establishing such treatment as a very valuable tool to improve clinical care and reduce costs. Particularly if early identification and intervention leads to a reduction in more costly medical procedures, which many of these patients undergo with little chance of clinical helpfulness (Sanders et al., 1999).
As we move into the 21st century, chronic pain rehabilitation is at the threshold of extinction. In the end, the social consciousness of our culture will determine its ultimate fate. This consciousness can be influenced by taking the steps just outlined. Those of us in the rehabilitation community who see the value of chronic pain rehabilitation, at the patient level on a daily basis, must lead the way. Although this may well turn out to be windmill chasing, the cause is just, the stakes are high, and the time for action is long overdue.
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