Until just 50 years ago, pain was seen as a purely medical problem, and merely a symptom of some other disease or injury. But since then, pain has come to be recognized as a major health condition, even a disease, in its own right. And chronic pain involves much more than biology alone; psychological and social contributors turn pain into something that affects every aspect of a person’s life as well as those around them, according to what’s known as the biopsychosocial model of pain.
Still, despite this improved understanding, an estimated 100 million Americans live with some form of chronic pain, including around 20 million people who are disabled with what researchers call “high-impact chronic pain” (see related IASP Pain Research Forum news story). For the most part, in the U.S., treatment of chronic pain is limited to a handful of medical treatments that don’t work for everyone. But experts say this complex condition requires a multidisciplinary approach to care: one that uses a variety of treatment strategies and includes healthcare professionals from many different fields. And, critically, it requires the engagement of patients in managing their pain.
What is multidisciplinary care?
At its core, multidisciplinary pain care includes evaluation and treatment by a range of healthcare professionals who may confer with one another, and often with the patient as well. In addition to medical treatments like drugs or surgery, some therapies, such as cognitive-behavioral therapy (CBT), aim to help patients better cope with their pain and with the functional limitations that often accompany it.
“It’s an integrated model where clinicians are coordinating the treatment,” said Beth Darnall, a pain psychologist at Stanford University (see related RELIEF podcast with Darnall).
Which professionals should be on the pain care team? Babita Ghai, a pain specialist at Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India, said that the crucial players include a pain physician, physical therapist and psychologist, but nurses and specialists such as psychiatrists, neurologists, neurosurgeons, and addiction specialists may also be included.
Eija Kalso, a professor of pain medicine at the University of Helsinki, said the professionals on the team might also include a geriatrician for elderly patients, a gastroenterologist, or a rheumatologist, depending on the needs of the individual. Ideally, care should include a nutrition specialist and someone to help patients establish lifestyle choices that will improve their function, like getting enough sleep. And, she says, it’s very important to include young physicians who specialize in general practice.
“They are very valuable, because at the end of the day they’ll take responsibility for pain management in primary care,” according to Kalso.
Multidisciplinary care might also include complementary therapies such as yoga or other gentle movement, mindfulness or meditation, massage, acupuncture, or biofeedback, among others. But Darnall said that medical treatments are still a crucial part of multidisciplinary care.
“There is a persistent misperception that this is an either-or conversation, that it’s either medicine or psychology, that treatment is biomedical or it’s behavioral. No—it’s integrated,” Darnall emphasized.
And, she said, research shows that when patients receive integrated, whole-person care, they have better responses to medical treatments.
“Who can argue with better outcomes? Everyone wins: doctors, the healthcare organization, and most importantly, patients,” said Darnall.
It’s important to be clear about what treatments are supported by the evidence and should legitimately be included in multidisciplinary care, said Christin Veasley, director of the advocacy organization Chronic Pain Research Alliance. The extent to which pain management consists of medical treatments versus complementary therapies depends on the situation. Movement and contemplative practices “all play an important role,” said Veasley, “but there comes a point, with pain at a certain severity, where you need pharmacological interventions or devices to modulate the biological level of pain.”
For example, she continued, “you wouldn’t say to someone coming out of surgery, ‘just meditate.’ So complementary approaches can be very helpful when pain is at a low-to-moderate level, they can help a person decrease the impact that stress has on pain severity, for example, but once pain gets to upper-moderate to severe levels, as one patient put it, ‘you can tai chi all day and it won’t make a difference.’”
A good multidisciplinary pain management plan is highly individualized, too, says Veasley.
“Someone with chemotherapy-induced neuropathic pain,” said Veasley, referring to pain from nerve damage caused by cancer treatment, “along with a sleep disorder and gastrointestinal issues will require a different treatment regimen than someone with migraine, depression and cognitive dysfunction. We need better science to understand what patient groups will benefit from what treatments.”
That would be an improvement over “giving every patient a list of 40 things and saying, ‘here, let’s just start trying and see.’ That’s literally what we do now, because we have such a limited evidence base to inform us of which treatments may work for whom,” Veasley continued. Some therapies, though, such as mindfulness, CBT, and reducing negative thinking, can be universally beneficial for people with chronic pain. “Those transcend across pain conditions to all chronic illness, to improve the ability to cope.”
Language matters, too, according to Veasley. “The term ‘multidisciplinary care’ means something different to everyone,” she said. “For some, it means a team of people working collaboratively on your care.” For others, the term might suggest “that you’re receiving multiple treatment modalities from different specialists at the same time, but with no coordination among them. We need to do a better job of defining what we’re talking about.”
These experts agree it’s not enough for the pain care team to exist in the abstract. That is, they should work in close proximity to one another and confer directly about each individual patient to craft a treatment plan.
“A major aspect is to work in collaboration, with better patient outcomes as the single aim,” said Ghai. When the team works collaboratively, she says the care goes a step beyond multidisciplinary to become interdisciplinary.
Kalso agrees. “We need to sit at the same table when we discuss a patient. By being together and communicating with each other, we learn from each other and become more competent.”
The arc of history
The roots of multidisciplinary pain care can be traced back to the legendary anesthesiologist John J. Bonica, who established the world’s first multidisciplinary pain clinic in 1947 in Seattle. Bonica, who moonlighted as a professional wrestler during medical school and suffered from chronic pain himself, saw the impact that chronic pain had on the soldiers and veterans he saw during and after World War II, and he was determined to address pain as a condition in and of itself.
“Bonica realized that pain didn’t always go away when the wounds healed,” said John Loeser, a professor emeritus at the University of Washington in Seattle who worked under Bonica in the 1960s and 70s. “He recognized that many veterans had very complex problems, psychological and physical, which was more than one doctor could deal with.”
So Bonica developed a team approach to treating chronic pain and assembled a cadre of professionals who could treat pain in different ways.
Bonica made another important contribution to pain care in that he paid attention to what patients were able to do following treatment, rather than only consider how much pain they reported. Loeser, who later headed the University of Washington pain clinic together with psychologist William Fordyce, further developed Bonica’s initial concept into a multidisciplinary program centered on the individual patient and improving their functional ability.
“Until then, the goal was to alleviate the pain, whereas our goal was regaining meaningful activity, in whatever way that’s appropriate,” said Loeser.
Bonica and later Loeser and Fordyce promoted their model of care widely. “We were reasonably good talkers and we liked to travel, and we had a huge stream of visitors from all over the world, which helped promulgate this type of care. The idea caught on and spread like fire throughout the world,” Loeser said.
Today, multidisciplinary pain clinics are found across Europe and other parts of the world, but only a handful still operate in the U.S., Loeser said. That’s because, during the 1990s, insurance companies stopped paying for many of the treatments used in multidisciplinary care, more concerned about the bottom line than patient outcomes.
“How we reimburse physicians now is crazy; we push needles and surgeries, which make more money,” Loeser said. “We push people away from multidisciplinary pain management. Here in the U.S., we have allowed capitalism to intrude into health care. In contrast, where almost all societies have a socially based healthcare plan run by the government, they perceive this to be very viable.”
In the long run, multidisciplinary care is more cost effective than medical treatments alone, Loeser said.
“The outcome data published shows that, for chronically disabled patients with pain, this is by far the most successful treatment—and it’s economically successful, because the emphasis is not on pain itself, but what you’re able to do,” according to Loeser. Putting people back to work also puts money back into the economy.
Darnall said that while “it was not a utopia by any means,” there was a broader infrastructure for pain care in the U.S. in the 1980s. “But rather than expanding, there was a fairly rapid dismantling of that system,” because insurance reimbursements dried up. “Follow the money; look at what gets reimbursed. Without that, it all falls apart.”
Multidisciplinary care is undergirded by a better recognition of the multitude of factors that contribute to the experience of chronic pain, according to Kalso.
“The concept of multidisciplinary care is based on the biopsychosocial model of pain,” said Kalso (see related RELIEF article). Medical care often focuses squarely on the “bio” component and the physical body, she said, but that approach falls short.
“To provide efficient pain treatment or management, you need to target all three parts. What still surprises me every day is that people talk about the body and the psyche as though they’re two different entities. But it’s obvious these are so interlinked. And everything is in constant communication with society: society affects us, and what we do affects society,” Kalso explained.
“You certainly can’t treat chronic pain adequately without the biopsychosocial approach,” Veasley said. “If you have someone who comes in with a chronic pain condition, but you don’t ask them about their mood, their social support system, how they’re functioning socially, and their sleep, then you’re not collecting all the information needed to develop an informed treatment plan. It’s not just about being multidisciplinary in treating the pain itself, but in considering the non-pain co-morbidities patients are experiencing as well,” referring to the presence of other health conditions that often accompany pain, such as anxiety and depression. “If you treat pain but not insomnia, it’s likely pain is not going to improve at the level that it could.”
Although the medical establishment still has a long way to go in addressing the complexity of chronic pain, Loeser said, “there’s no question that we’re more aware in medicine of the mind-body relationships nowadays, particularly in the pain world. Placebo responses and responses to a variety of nontraditional treatment strategies such as mindfulness clearly represent the recognition that health is not just a personal thing; it’s also a social thing. Pain is a very personal, private event, but what we say about pain is very socially cogent.”
“We have put forward a medical model that makes patients dependent on doctors to ‘fix’ the pain problem,” Darnall said. “And it’s a reductive and flawed model. Medicine is critical, but it must be integrated in an entire package of whole-person care, which puts the patient at the center of health and wellness. So they’re improving their health but also developing the ability to control their lives, symptoms and function. If people can get back to doing things that are meaningful to them, they’re moving in the direction of improving function.”
Educate, engage and empower
Patient education is a crucial first step to successful multidisciplinary pain care.
“Chronic pain management, first and foremost, is patient education – that’s mandatory,” said Ghai. “You can’t manage chronic pain without it – it’s not treatable.”
That not only includes informing patients about the physical disease process of chronic pain, but also establishing trust, a key part of the “psychosocial” aspect of treating pain.
“First we tell them, ‘we believe you,” said Ghai. Roughly “80 percent of our patients say, ‘no one has ever listened and believed me,’ and they cry when you patiently listen.”
“Trust is a huge piece” of successful pain management, Veasley agreed. “There is so much distrust of the medical system in this patient community. Women especially have been told so many times, ‘there’s nothing wrong with you, it’s purely psychological.’ There is certainly enough evidence that patient education and empowerment are key to living and coping well with all chronic diseases, including chronic pain.”
In addition to not being taken seriously, many patients are uniformed about pain, or have been misinformed, sometimes by healthcare professionals.
Back at the University of Washington, Loeser said, “most patients we saw had fairly inadequate knowledge about how the body works. So on day one, we sat with the patient, got all their tests, and went over them together to try to correct misinterpretations. It was a major education project, so the patient understands what we’re doing and why. They’re informed of every step.”
“The patient education piece is critical,” said Darnall. “We provide patients with free access to a two-hour skill-based pain management class very early on, ideally as soon as they come to the pain clinic. An understanding of how these pieces fit together, combined with evidence-based tools to steer one’s own outcomes, can enhance patient engagement in multimodal care, especially behavioral medicine ” such as CBT.
That’s important because patients can feel stigmatized by the inclusion of psychological therapies, particularly if others have suggested that the pain is “all in their head.” In Indian culture, Ghai said, “if you’re referred to a psychiatrist, patients believe it’s taboo. They feel abandoned.”
But, she said the aim of a psychologist or psychiatrist is not to identify the roots of pain but to help people to live better with it. “It’s not that it’s primarily a psychological issue that led to pain, but someone living in chronic pain for years is bound to have psychological issues” as a result, Ghai said.
Patient education can also help manage expectations about what can be achieved and what means will be used to get there, said Kalso.
“It’s important for patients to come in with realistic wishes. Sometimes they think they will come to the pain clinic, we’ll give them a magic drug, and the pain will disappear,” she said.
Instead, Kalso said patients should work together with the management team to regain function.
“We believe it’s important to provide patients with goals and also a future, so they don’t stick to thinking, ‘this is what I used to do, and I can’t do anything if I can’t do everything I used to do,’” she said.
Bringing back multidisciplinary care
Evidence shows that integrated, multidisciplinary care is the “best practice” for managing chronic pain, as recognized by major health organizations including the U.S. Department of Health and Human Services (HHS). But for the vast majority of patients in the U.S., it’s not available. How can multidisciplinary care make a comeback?
“It’s hard to put into practice with this current system,” said Loeser. “Capitalism is a great system, but it’s not good for medicine. The way we’re set up, people who have absolutely nothing to do with healthcare are making decisions about how much care and what kind” is appropriate. “This is crazy. This should be decided by healthcare providers and patients, not the insurance companies. But they hold the purse strings.”
Darnall said everyone is in agreement on the best practice for chronic pain care. “The NIH [U.S. National Institutes of Health], the CDC [U.S. Centers for Disease Control and Prevention], the FDA [U.S. Food and Drug Administration], and HHS – all these agencies are calling for an integrated, multidisciplinary approach to treating pain, yet the nation lacks the infrastructure to deliver it. It rings hollow when we can’t provide patients with meaningful access to these treatments.”
Loeser also lamented the lack of medical training in pain. “A fundamental problem is we need to educate physicians about the nature of pain. Most medical schools focus on primary care, where about 50 percent of patients have pain as a complaint, but pain is only about one to two percent of the curriculum.”
In Europe, patients have better access to interdisciplinary care, but even with the infrastructure in place, barriers still exist. Kalso said one thing that could help is better lines of communication between professionals.
“Primary care physicians should have easier ways to communicate with pain clinics, such as a video conference with specialists, and they should have access to psychologists, physical therapists, and pain nurses,” according to Kalso. Putting the right tools in the hands of primary care physicians, Kalso said, could potentially help people with acute pain avoid developing chronic pain.
In the absence of comprehensive care, Veasley said, many patients craft their own multidisciplinary treatment.
“This is what patients do already: they do self-care, education, try pharmacological and non-pharmacological treatments, until they find what works for them,” according to Veasley.
“I’m a very optimistic person,” says Ghai, particularly when she sees increasing efforts to educate providers about pain in India. “I have seen more and more physicians from different specialties coming together, talking to each other” and integrating psychology, medicine, and yoga, for example.
“Awareness of the multidisciplinary approach to chronic pain management is spreading,” Ghai continued, “and I hope in coming years it will percolate down” to the level of primary care. Recent efforts, she says, “are not enough, but I’m optimistic to see a brighter future.”
Stephani Sutherland, PhD, is a neuroscientist and freelance journalist in Southern California. Follow her on Twitter @SutherlandPhD