Multi-disciplinary Multi-disciplinary Pain Management:Pain Management:

It works…why isn’t it It works…why isn’t it used?used?

David A. Williams, Ph.D.David A. Williams, Ph.D.

Associate Professor of Medicine / RheumatologyAssociate Professor of Medicine / RheumatologyAssociate Director, Chronic Pain and Fatigue Research Associate Director, Chronic Pain and Fatigue Research

CenterCenterAssociate Director, Center for the Advancement of Associate Director, Center for the Advancement of

Clinical ResearchClinical Research

University of Michigan Medical CenterUniversity of Michigan Medical CenterAnn Arbor, MichiganAnn Arbor, Michigan

Early Approaches to Pain Early Approaches to Pain ManagementManagement

Surgical/ProceduralSurgical/Procedural Trepanning (headache) Trepanning (headache) Blood letting (acute side Blood letting (acute side

pain) pain) StimulationStimulation

EelsEels AcupunctureAcupuncture

TopicalsTopicals Oil, sulfur rubsOil, sulfur rubs

Life Style ChangeLife Style Change Sexual abstinenceSexual abstinence ExerciseExercise Hot spasHot spas Heliotherapy, rest Heliotherapy, rest

Early Approaches toEarly Approaches to Pain Medications Pain Medications

Ancient EgyptAncient Egypt Berry-of-the-poppy plantBerry-of-the-poppy plant - Headache - Headache A frog-warmed-in-oilA frog-warmed-in-oil - Burn- Burn Fermenting goat dungFermenting goat dung - Burn- Burn BeerBeer - General vehicle- General vehicle

India (1India (1stst C.) C.) Hemp (cannabis)Hemp (cannabis) - Anesthetic- Anesthetic

Early Greek MedicineEarly Greek Medicine Willow BarkWillow Bark - Childbirth - Childbirth

Ethel E. Thompson

Early Practitioners of Pain Early Practitioners of Pain Medicine “Cross-trained” Medicine “Cross-trained”

Babylonian PhysiciansBabylonian Physicians Priest-Physician-Pharmacist combinationPriest-Physician-Pharmacist combination

Used ritual and incantations to make treatments more Used ritual and incantations to make treatments more effectiveeffective

Arabian PhysicianArabian Physician Astrologer or MagicianAstrologer or Magician

Importance gauged by turban height or sleeve lengthImportance gauged by turban height or sleeve length Leveraged social authority to make treatments more Leveraged social authority to make treatments more

effectiveeffective

Indian Physician Illness Classifications (6 Indian Physician Illness Classifications (6 B.C.)B.C.) Curable by magicCurable by magic Not curable by magicNot curable by magic CurableCurable IncurableIncurable Ethel E. Thompson

With time: More science – With time: More science – less magicless magic

Cures were king Cures were king A cure is rendered at all costs A cure is rendered at all costs (even (even

dubious ones)dubious ones) Pain was a secondary considerationPain was a secondary consideration

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

Revolutionary Approach Revolutionary Approach to Painto Pain

Pain is of Primary Importance

Rehabilitative or Management Model

Curative Model

PAIN TREATMENT PAIN TREATMENT CONTINUUMCONTINUUM

DiagnosisOral Medications

PT, Exercise, RehabilitationBehavioral MedicineCorrective Surgery

Therapeutic Nerve BlocksOral Opiates

Implantable Pain Management DevicesNeurostimulationIntrathecal Pumps

Neuroablation

Multi-Disciplinary Pain Multi-Disciplinary Pain Program ModelsProgram Models

Pain Consultation TeamPain Consultation Team Multidisciplinary ProgramsMultidisciplinary Programs

Multidisciplinary Outpatient Multidisciplinary Outpatient ProgramsPrograms

Multidisciplinary Inpatient Multidisciplinary Inpatient ProgramsPrograms

Pain ServicePain Service

Pain Consultation Pain Consultation TeamTeam

Multidisciplinary groupMultidisciplinary group Provides consultation services onlyProvides consultation services only

not ongoing treatmentnot ongoing treatment

Anesthesiology

Psychology

Neurology

Pharmacy

Nursing

Consultation Team Referral

Recommendation

Multidisciplinary Multidisciplinary ClinicsClinics

Comprised of 2 or more disciplinesComprised of 2 or more disciplines Goal is to provide coordinated and more Goal is to provide coordinated and more

comprehensive care to patients for more comprehensive care to patients for more complex chronic pain problemscomplex chronic pain problems

3 general subtypes3 general subtypes Psychoeducational clinic (mild and Psychoeducational clinic (mild and

motivating)motivating) Problem-based clinic (e.g. headache, LBP, Problem-based clinic (e.g. headache, LBP,

FM)FM) Comprehensive multidisciplinary clinicComprehensive multidisciplinary clinic

Inpatient or outpatientInpatient or outpatient

Chronic Pain Disciplines and Roles Chronic Pain Disciplines and Roles (Core)(Core)

Anesthesiology – nerve blocksAnesthesiology – nerve blocks

Kinesiotherapy – pool therapy; activityKinesiotherapy – pool therapy; activity

Neurology – eval. treatmentNeurology – eval. treatment

Nursing – patient careNursing – patient care

Physical Medicine – exercise; modalitiesPhysical Medicine – exercise; modalities

Physical Therapy – exercise; modalitiesPhysical Therapy – exercise; modalities

Psychology – eval. and treatmentPsychology – eval. and treatment

Occupational Therapy – UE eval and Occupational Therapy – UE eval and treatmenttreatment

Vocational Rehab – job eval and trainingVocational Rehab – job eval and training

Chronic Pain Disciplines Chronic Pain Disciplines (Adjunctive)(Adjunctive)

Dietetics – nutrition and dietsDietetics – nutrition and diets

Educational therapy – skill enhancementEducational therapy – skill enhancement

Internal Medicine - consultationInternal Medicine - consultation

Neurosurgery - consultationNeurosurgery - consultation

Orthopedics - consultationOrthopedics - consultation

Pharmacy – medication supportPharmacy – medication support

Psychiatry – psychotropic treatment; Psychiatry – psychotropic treatment; addiction mgtaddiction mgt

Recreational Therapy – social activitiesRecreational Therapy – social activities

Social Work – community supportSocial Work – community support

Pain ServicePain Service

An organized group of pain An organized group of pain programs, clinics, and other programs, clinics, and other servicesservices

Provides the widest range of Provides the widest range of patient evaluation and patient evaluation and intervention services possible, as intervention services possible, as well as regional/national patient well as regional/national patient or program consultation and staff or program consultation and staff training training

Multi-DiscPain Management1970’s-80’s

Multidisciplinary Pain Management

Multidisciplinary Pain Management

Practice

Managed Care

Perception of High CostsPerception of High Costs

Multidisciplinary Pain Management

Meds Psych

P.T.

Surgery

Rehabilitative or Management Model

Curative Model

Single Discipline Outpatient Single Discipline Outpatient Pain ClinicPain Clinic

Easiest to implementEasiest to implement Requires fewest resourcesRequires fewest resources Limited to a single disciplineLimited to a single discipline

(e.g.., Anesthesiology Pain Clinic)(e.g.., Anesthesiology Pain Clinic)

S IN G L E D IS C IP L IN E P A IN C L IN IC S

A n es th es io log yP a in C lin ic

N eu ro log yP a in C L in ic

P sych o log yP a in C lin ic

R eferra l S ou rce :A m b u la to ry C are

How are pain interventionsHow are pain interventions doing today? doing today?

Pain MedicationsPain Medications

Second most commonly prescribed Second most commonly prescribed drug classdrug class

Does not eliminate pain Does not eliminate pain Long term Opiates Long term Opiates

(32% reduction) (32% reduction) Anti-Convulsive / DepressantsAnti-Convulsive / Depressants

(1:3 will have 50% reduction)(1:3 will have 50% reduction) Rarely below 4 (0-10 rating)Rarely below 4 (0-10 rating)

Turk (2002), CJP

SurgerySurgery

Spinal fusionSpinal fusion (75% still had pain)(75% still had pain)

Repair for herniated diskRepair for herniated disk (70% still had pain)(70% still had pain)

Repeat surgeryRepeat surgery (66% still had pain)(66% still had pain)

Turk (2002), CJP

Spinal Cord StimulatorsSpinal Cord Stimulators

61% rated pain as61% rated pain as “uncomfortable” – “horrible” “uncomfortable” – “horrible” after 4 yearsafter 4 years

Actual pain relief across studies Actual pain relief across studies is 18.6%is 18.6%

Turk (2002), CJP

IDDSIDDS

Mixed PainMixed Pain Highly selected sample (n=16)Highly selected sample (n=16) (57% pain reduction)(57% pain reduction)

Mixed PainMixed Pain (25% reduction)(25% reduction)

Neuropathic PainNeuropathic Pain (39% pain reduction)(39% pain reduction)

Turk (2002), CJP

MultidisciplinaryMultidisciplinaryPain ProgramsPain Programs

Pain reduction across studiesPain reduction across studies (37%)(37%) Comparable to other modalitiesComparable to other modalities

Goes beyond pain reductionGoes beyond pain reduction Return to functional work 48%-65%Return to functional work 48%-65%

IDDS had 0% RTW despite pain reliefIDDS had 0% RTW despite pain relief

Turk (2002), CJP

% Pain Reduction for % Pain Reduction for Chronic PainChronic Pain

Turk (2002), CJP

Costs to Return One Patient Costs to Return One Patient to Functional Workto Functional Work

Turk (2002), CJP

Multidisciplinary ProgramsMultidisciplinary Programs

Comparably effectiveat pain relief

Lower Cost

Better at functionalrestoration

So why are multi-So why are multi-disciplinary treatments disciplinary treatments

not used more?not used more?

Demand is for Quick Demand is for Quick ReliefRelief

Much profit possible in pain relief Much profit possible in pain relief interventionsinterventions

Pain interventions have industry backingPain interventions have industry backing Patient expectations are for quick reliefPatient expectations are for quick relief Curative approaches often involve Curative approaches often involve

proceduresprocedures StandardizedStandardized Short time horizon for outcomeShort time horizon for outcome Quantifiable in costQuantifiable in cost Widely availableWidely available Finite patient burdenFinite patient burden

Multi-disciplinary Pain Multi-disciplinary Pain RehabilitationRehabilitation

Less profitable business ventureLess profitable business venture Smaller advocacy voiceSmaller advocacy voice Less consistent with patient Less consistent with patient

expectationsexpectations Greater patient burdenGreater patient burden

Outcomes depend on patient participationOutcomes depend on patient participation Longer time horizonLonger time horizon Less standardized across centersLess standardized across centers Less widely availableLess widely available More difficult to quantify costsMore difficult to quantify costs

ConclusionsConclusions We do have single modality interventions We do have single modality interventions

for painfor pain Modestly effectiveModestly effective CostlyCostly Considerable adverse event profileConsiderable adverse event profile

We also have multidisciplinary treatments We also have multidisciplinary treatments for painfor pain Modestly effectiveModestly effective Often less costly and fewer side-effects Often less costly and fewer side-effects Improves both pain and functional statusImproves both pain and functional status

Patients prefer “interventions” despite Patients prefer “interventions” despite costs and modest effectscosts and modest effects Dislike outcomes depending upon Dislike outcomes depending upon

participationparticipation

How far have we come?How far have we come?

Content Content ThenThen

Poppy PlantPoppy Plant Willow barkWillow bark HempHemp BeerBeer EelsEels AcupunctureAcupuncture OilsOils Blood lettingBlood letting ExerciseExercise HeiliotherapHeiliotherap

yy

Content NowContent Now OpioidsOpioids AspirinAspirin CannabinoidCannabinoid

ss BeerBeer TNSTNS AcupunctureAcupuncture Creams/oilsCreams/oils SurgerySurgery ExerciseExercise Light Light

therapytherapy

Enhanced•Technology•Automation•Efficiency

Less•Human contact•Follow-up

The science is advancing…

What seems to be missing is What seems to be missing is the magicianthe magician