Multi-disciplinary Pain Management: It works…why isn’t it used?

1. Multi-disciplinary Pain Management:It works…why isn’t it used? David A. Williams, Ph.D. Associate Professor of Medicine / RheumatologyAssociate Director, Chronic Pain and Fatigue Research Center Associate Director, Center for the Advancement of Clinical Research University of Michigan Medical Center Ann Arbor, Michigan

2. Early Approaches to Pain Management • Surgical/Procedural • Trepanning (headache) • Blood letting (acute side pain) • Stimulation • Eels • Acupuncture • Topicals • Oil, sulfur rubs • Life Style Change • Sexual abstinence • Exercise • Hot spas • Heliotherapy, rest

3. Early Approaches to Pain Medications • Ancient Egypt • Berry-of-the-poppy plant - Headache • A frog-warmed-in-oil - Burn • Fermenting goat dung - Burn • Beer - General vehicle • India (1st C.) • Hemp (cannabis) - Anesthetic • Early Greek Medicine • Willow Bark - Childbirth Ethel E. Thompson

4. Early Practitioners of Pain Medicine “Cross-trained” • Babylonian Physicians • Priest-Physician-Pharmacist combination • Used ritual and incantations to make treatments more effective • Arabian Physician • Astrologer or Magician • Importance gauged by turban height or sleeve length • Leveraged social authority to make treatments more effective • Indian Physician Illness Classifications (6 B.C.) • Curable by magic • Not curable by magic • Curable • Incurable Ethel E. Thompson

5. With time: More science – less magic • Cures were king • A cure is rendered at all costs (even dubious ones) • Pain was a secondary consideration

6. When pain was the primary problem, the curative model was followed…

7. Revolutionary Approach to Pain Pain is of Primary Importance

8. Curative Model Rehabilitative or Management Model

9. PAIN TREATMENT CONTINUUM Diagnosis Oral Medications PT, Exercise, Rehabilitation Behavioral Medicine Corrective Surgery Therapeutic Nerve Blocks Oral Opiates Implantable Pain Management Devices Neurostimulation Intrathecal Pumps Neuroablation

10. Multi-Disciplinary Pain Program Models • Pain Consultation Team • Multidisciplinary Programs • Multidisciplinary Outpatient Programs • Multidisciplinary Inpatient Programs • Pain Service

11. Pain Consultation Team • Multidisciplinary group • Provides consultation services only • not ongoing treatment Referral Consultation Team Neurology Anesthesiology Pharmacy Psychology Nursing Recommendation

12. Multidisciplinary Clinics • Comprised of 2 or more disciplines • Goal is to provide coordinated and more comprehensive care to patients for more complex chronic pain problems • 3 general subtypes • Psychoeducational clinic (mild and motivating) • Problem-based clinic (e.g. headache, LBP, FM) • Comprehensive multidisciplinary clinic • Inpatient or outpatient

13. Anesthesiology – nerve blocks Kinesiotherapy – pool therapy; activity Neurology – eval. treatment Nursing – patient care Physical Medicine – exercise; modalities Physical Therapy – exercise; modalities Psychology – eval. and treatment Occupational Therapy – UE eval and treatment Vocational Rehab – job eval and training Chronic Pain Disciplines and Roles (Core)

14. Dietetics – nutrition and diets Educational therapy – skill enhancement Internal Medicine - consultation Neurosurgery - consultation Orthopedics - consultation Pharmacy – medication support Psychiatry – psychotropic treatment; addiction mgt Recreational Therapy – social activities Social Work – community support Chronic Pain Disciplines (Adjunctive)

15. Pain Service • An organized group of pain programs, clinics, and other services • Provides the widest range of patient evaluation and intervention services possible, as well as regional/national patient or program consultation and staff training

16. Multi-Disc Pain Management 1970’s-80’s

17. Multidisciplinary Pain Management

18. Managed Care Multidisciplinary Pain Management Practice

19. Perception of High Costs

20. Multidisciplinary Pain Management

21. Surgery P.T. Psych Meds

23. Curative Model Rehabilitative or Management Model

24. Single Discipline Outpatient Pain Clinic • Easiest to implement • Requires fewest resources • Limited to a single discipline • (e.g.., Anesthesiology Pain Clinic)

25. How are pain interventions doing today?

26. Pain Medications • Second most commonly prescribed drug class • Does not eliminate pain • Long term Opiates • (32% reduction) • Anti-Convulsive / Depressants • (1:3 will have 50% reduction) • Rarely below 4 (0-10 rating) Turk (2002), CJP

27. Surgery • Spinal fusion • (75% still had pain) • Repair for herniated disk • (70% still had pain) • Repeat surgery • (66% still had pain) Turk (2002), CJP

28. Spinal Cord Stimulators • 61% rated pain as “uncomfortable” – “horrible” after 4 years • Actual pain relief across studies is 18.6% Turk (2002), CJP

29. IDDS • Mixed Pain • Highly selected sample (n=16) • (57% pain reduction) • Mixed Pain • (25% reduction) • Neuropathic Pain • (39% pain reduction) Turk (2002), CJP

30. MultidisciplinaryPain Programs • Pain reduction across studies • (37%) • Comparable to other modalities • Goes beyond pain reduction • Return to functional work 48%-65% • IDDS had 0% RTW despite pain relief Turk (2002), CJP

31. % Pain Reduction for Chronic Pain Turk (2002), CJP

32. Costs to Return One Patient to Functional Work Turk (2002), CJP

33. Multidisciplinary Programs Comparably effective at pain relief Better at functionalrestoration Lower Cost

34. So why are multi-disciplinary treatments not used more? ?

35. Demand is for Quick Relief • Much profit possible in pain relief interventions • Pain interventions have industry backing • Patient expectations are for quick relief • Curative approaches often involve procedures • Standardized • Short time horizon for outcome • Quantifiable in cost • Widely available • Finite patient burden

36. Multi-disciplinary Pain Rehabilitation • Less profitable business venture • Smaller advocacy voice • Less consistent with patient expectations • Greater patient burden • Outcomes depend on patient participation • Longer time horizon • Less standardized across centers • Less widely available • More difficult to quantify costs

37. Conclusions • We do have single modality interventions for pain • Modestly effective • Costly • Considerable adverse event profile • We also have multidisciplinary treatments for pain • Modestly effective • Often less costly and fewer side-effects • Improves both pain and functional status • Patients prefer “interventions” despite costs and modest effects • Dislike outcomes depending upon participation

38. Content Then Poppy Plant Willow bark Hemp Beer Eels Acupuncture Oils Blood letting Exercise Heiliotherapy Content Now Opioids Aspirin Cannabinoids Beer TNS Acupuncture Creams/oils Surgery Exercise Light therapy How far have we come? • Enhanced • Technology • Automation • Efficiency • Less • Human contact • Follow-up The science is advancing…

39. What seems to be missing is the magician