Multi-disciplinary

Pain Management:
It workswhy isnt it
used?
David A. Williams, Ph.D.
Associate Professor of Medicine / Rheumatology
Associate Director, Chronic Pain and Fatigue Research
Center
Associate Director, Center for the Advancement of
Clinical Research

University of Michigan Medical Center

Ann Arbor, Michigan
 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
 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
 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
 With time: More science
less magic
Cures were king
A cure is rendered at all costs (even
dubious ones)
Pain was a secondary consideration
When pain was the primary
problem, the curative
model was followed
 Revolutionary Approach
to Pain

Pain is of Primary Importance

 Curative Model

Rehabilitative or Management Model

 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
 Multi-Disciplinary Pain
Program Models
Pain Consultation Team
Multidisciplinary Programs
Multidisciplinary Outpatient
Programs
Multidisciplinary Inpatient
Programs
Pain Service
 Pain Consultation
Team
Multidisciplinary group
Provides consultation services only
not ongoing treatment

Consultation Team Referral

Anesthesiology Neurology

Psychology Pharmacy

Nursing
Recommendation
 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
Chronic Pain Disciplines and Roles
(Core)
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
(Adjunctive)
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
 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
Multi-Disc
Pain Management
1970s-80s
Multidisciplinary Pain Management
Managed Care

Multidisciplinary
Pain Management
Practice
Perception of High Costs
Multidisciplinary Pain Management
Surgery

P.T.

Psych
Meds
 Curative Model

Rehabilitative or Management Model

 Single Discipline Outpatient
Pain Clinic
Easiest to implement
Requires fewest resources
Limited to a single discipline
(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

R e fe r r a l S o u r c e :
A m b u la t o r y C a r e

A n e s t h e s io lo g y N e u r o lo g y P s y c h o lo g y
P a in C lin ic P a in C L in ic P a in C lin ic
How are pain interventions
doing today?
 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

 Surgery
Spinal fusion
(75% still had pain)
Repair for herniated disk
(70% still had pain)
Repeat surgery
(66% still had pain)

Turk (2002), CJP

 Spinal Cord Stimulators
61% rated pain as
uncomfortable horrible
after 4 years
Actual pain relief across studies
is 18.6%

Turk (2002), CJP

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

Mixed Pain
(25% reduction)
Neuropathic Pain
(39% pain reduction)

Turk (2002), CJP

 Multidisciplinary
Pain 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

% Pain Reduction for
Chronic Pain

Turk (2002), CJP

Costs to Return One Patient
to Functional Work

Turk (2002), CJP

Multidisciplinary Programs

Comparably effective
at pain relief

Better at functional
restoration

Lower Cost
 So why are multi-
disciplinary treatments
not used more?
 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
 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
 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
 How far have we come?
Content Content Now
Then Opioids
Poppy Plant Aspirin Enhanced
Willow bark Cannabinoid Technology
Hemp s
Automation
Beer Beer
Efficiency
Eels TNS
Acupuncture Acupuncture
Oils Creams/oils
Less
Blood letting Surgery
Human contac
Exercise Exercise Follow-up
Heiliotherap Light
y therapy

The science is advancing

What seems to be missing is
the magician