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American Pain Society
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Steven H. Sanders, PhD, Department Editor
Stanley L. Chapman, PhD
Chronic pain rehabilitation programs are themselves in need of rehabilitation. Although hard statistics regarding such programs are difficult to obtain, 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. After rapid growth during the 1980s and through the mid-1990s, the number of inpatient or intensive outpatient chronic pain management programs accredited by the Rehabilitation Accreditation Commission (CARF) actually declined from 122 to 113 (S. Lucht, personal communication, February 23, 2000) from early 1999 to early 2000. In its 1998 standards, CARF defined such programs as requiring 25 hours of treatment per week (CARF, 1998). Concurrent with the decline in intensive programs is the rise of procedural interventions and medication, which receive a great deal of support from medical technology and pharmaceutical companies. 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. Healthcare specialists have to determine whether this apparent shift in treatment emphasis away from rehabilitation is a healthy development for the patients they serve.
Chronic pain rehabilitation programs may close because they easily can go broke treating patients whose spirits and lives are the most broken. Managed care insurance programs place an emphasis on treatment from primary care physicians. Specialists are allowed to be used primarily as consultants rather than as providers. The trend for more care to be provided by generalists creates problems for pain patients who need rehabilitation. Indeed, CARF’s 1999 standards mandate that medical direction of intensive pain rehabilitation programs be conducted by physicians with 2 years’ postresidency experience in an interdisciplinary pain rehabilitation program and annual participation in accredited continuing medical education in pain rehabilitation (CARF, 1999). The need for special knowledge and training to treat many patients with chronic pain was integral in the establishment of the American Board of Pain Medicine. Unfortunately, primary care physicians have little time to study the specifics of chronic pain management and may not even be aware of rehabilitation approaches.
An additional hurdle for financing interdisciplinary rehabilitation is the fact that many insurance companies now have separate divisions for approval of medical and mental health care that require coordination among and application to both divisions. Program personnel often find that one or more professionals are not included on a prospective patient’s approved list of providers. Furthermore, companies are not organized to approve a package of treatments. A cohesive and structured program cannot be designed if one patient is given approval for six group visits when 15 visits had been planned, a second patient is limited to only six physical therapy sessions, and a third patient is offered 20 individual psychology visits when only six had been planned, but is not authorized for group sessions. In many cases, authorization is given for a limited number of sessions with an “offer” that more visits can be applied for after lengthy documentation of patient progress and continuing need. This offer effectively negates a rehabilitation program that requires advanced planning and continuity. Housing is an additional problem for patients who do not live within a reasonable driving distance from a rehabilitation center.
Partly because of these problems, rehabilitation programs often provide service primarily to patients receiving workers’ compensation, but even in those cases, treatment is becoming increasingly difficult to finance. More states are reducing benefits (often to the level of Medicare rates), limiting the term of liability of insurance, or both. The latter results in insurers becoming less concerned with the kinds of long-term outcomes that rehabilitation approaches emphasize. Some patients eventually receive disability from other sources such as Social Security, which allows them to settle quickly with the workers’ compensation insurer, thus providing another reason for the insurer to focus on short-term rather than long-term results.
The difficulty in financing interdisciplinary pain rehabilitation programs is ironic in light of the positive outcomes and long-term cost savings that have been documented in many long-term outcome studies. Indeed, outcomes from such programs have been documented to a greater degree than for most medication- or procedure-based treatments for chronic pain. Flor, Fidrych, and Turk (1992) reviewed findings from 65 studies conducted at interdisciplinary pain programs, all of which provided empirical clinical outcome data on groups of patients using multiple measures. Patients included in the studies were those with the greatest amount of psychosocial dysfunction associated with chronic pain. The review revealed a statistically superior outcome for interdisciplinary treatment in comparison with standard medical treatments, single discipline interventions, and no treatment. Improvement was observed not only in patients’ pain, mood, and activity levels, but also for cost-sensitive outcome variables such as return to work and reduced use of the healthcare system. The benefits were found to be quite stable over follow-up intervals averaging 95 weeks posttreatment. Turk and Okifuji (1998) provided an updated meta-analytic review and came to the same basic conclusions: Treating patients with chronic pain at interdisciplinary pain centers is more cost-effective and produces better outcomes than monodisciplinary approaches.
Reviewers who have formulated clinical practice guidelines for chronic pain management have reached the same basic conclusions (Compas, Haaga, Keefe, Leitenberg, &: Williams, 1998; Sanders, Harden, Benson, &: Vicente, in press; Sanders et al., 1995). Sanders et al. (in press) defined chronic pain syndrome as characteristic of patients with persistent pain and as having two of the following four criteria: deterioration in function, progressive increase in healthcare use, mood disturbance, and clinically significant anger and hostility. Analyzing outcome only from studies using a prospective controlled research design with quantifiable objective outcome measures, Sanders et al. (in press) found that patients with chronic pain syndrome “are best treated in an integrated interdisciplinary program.” They also reported a lack of convincing evidence for the efficacy of opioid-based analgesics, sedative-hypnotic medications, or procedures such as implantable spinal stimulators, continuous infusion devices, and brain stimulation. Compas et al. (1998) used similar criteria for inclusion and analysis of effective treatments for chronic low-back pain, and concluded that operant-behavioral therapy and cognitive-behavioral therapy, the major backbones of interdisciplinary rehabilitation, clearly were efficacious. Studying 309 patients undergoing interdisciplinary rehabilitation at three major pain centers, Chapman, Jamison, Sanders, Lyman, &: Lynch (in press) found that such group and individual psychological and educational approaches received very high ratings for helpfulness from patients, both at posttreatment and at 3- to 6-month follow-up. Medical procedures, such as trigger-point injections, sympathetic nerve blocks, and epidural steroid injections, were rated as significantly less helpful, despite their considerably higher mean cost.
Some caveats in analyzing these results need to be emphasized. Ratings of treatment efficacy can be manipulated by biased measurement methods, and the results clearly vary depending on the foci of treatment, how treatments are presented, the goals and outcomes measures used, and the population studied. While the aforementioned reviews generally included the most scientific studies available, their subject populations comprised a minority of the patient population with chronic pain (i.e., those with the most dysfunction). Results probably would have been different with different populations. For example, considerable evidence exists for the efficacy of epidural steroids for the treatment of acute pain (Green, Burke, Weiss, &: Langan, 1980) and for medications such as anticonvulsants for treating patients with chronic peripheral neuropathy (Whitaker, Kennedy, &: Small, 1999).
The fact that exclusion criteria for many invasive medical procedures (including, for example, primary depression, major psychosocial dysfunction, and high scores on the hypochondriasis scale of the MMPI) may be markers for inclusion in rehabilitation programs (Block, 1996; Chapman, 1999; Nelson, Kennington, Novy, &: Squitieri, 1996) implies that it is necessary to provide careful assessment before deciding on any treatment course. Clearly, it is better to ask, “What combinations of treatments, presented for what duration or intensity, provide the most cost-effective results for which outcomes and goals for which patients?” than “Is treatment X better than treatment Y?”
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 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.
Block, A.R. (1996). Presurgical psychological screening in chronic pain syndromes. Mahwah, NJ: Lawrence Erlbaum Associates.
Chapman, S.L. (1999). Pain rehabilitation programs. In S.E. Abram &: J.D. Haddox (Eds.), The pain clinic manual (2nd ed.) (pp.7185). Philadelphia: Lippincott, Williams, &: Wilkins.
Chapman, S.L., Jamison, R.N., Sanders, S.H., Lyman, D.R., &: Lynch, N.T. (in press). Perceived treatment helpfulness and cost in chronic pain rehabilitation. Clinical Journal of Pain.
Commission on Accreditation of Rehabilitation Facilities (1998). 1998 Standards manual for and interpretive guidelines for medical rehabilitation. Tucson: Author.
Commission on Accreditation of Rehabilitation Facilities (1999). 1999 Standards manual for and interpretive guidelines for medical rehabilitation. Tucson: Author.
Compas, B.E., Haaga, D.A.F., Keefe, F.J., Leitenberg, H., &: Williams, D.A. (1998). Sampling of empirically supported psychological treatments from health psychology: Smoking, chronic pain, cancer, and bulimia nervosa. Journal of Consulting and Clinical Psychology, 66, 89112.
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Nelson, D.V., Kennington, M., Novy, D.M., &: Squitieri, P. (1996). Psychological selection criteria for implantable spinal cord stimulators. Pain Forum, 5, 93103.
Sanders, S.H., Harden, R.N., Benson, S.E., &: Vicente, P.J. (in press). Clinical practice guidelines for chronic non-malignant pain syndrome patients. II. An evidenced-based approach. Journal of Back and Musculoskeletal Rehabilitation.
Sanders, S.H., Rucker, K.S., Anderson, K.O., Harden, R.N., Jackson, J.W., Vicente, P.J., &: Gallagher, R.M. (1995). Clinical practice guidelines for chronic non-malignant pain syndrome patients. Journal of Back and Musculoskeletal Rehabilitation, 5, 115120.
Turk, D.C., &: Okifuji, A. (1998). Efficacy of multidisciplinary pain centres: An antidote to anecdotes. Bailliere’s Clinical Anaesthesiology, 12, 103119.
Whitaker, A.L., Kennedy, D.T., &: Small, R.E. (1999). Adjuvant agents for managing chronic pain. APS Bulletin, 9(2), 1, 1316.
Stanley L. Chapman is associate professor in the department of anesthesiology at Emory University School of Medicine in Atlanta, GA.
