A comprehensive approach to pain management

An increasing number of traditional addiction treatment centers with 12-Step approaches have recognized the need to provide effective treatment for chronic pain while simultaneously addressing a patient's dependence on pain medications. Treating only the chemical dependency while ignoring the chronic pain problems that paved the way for that dependency does not provide a favorable long-term prognosis.

In fact, many patients served only by traditional chemical dependency programs without a pain management component often will leave the treatment program early, signaling the ineffectiveness of such an approach. Only with a comprehensive approach-one that considers all the patient's comorbidities-can good quality of life be restored.

According to psychiatrist Murray H. Rosenthal, DO, FAPA, “Depression, anxiety, coping, somatization, sleeplessness and hypochondriasis, among other comorbidities, are prevalent in the chronic pain population and, left untreated, are associated with greater risk for poor outcomes.”1 Rosenthal believes that the symptoms of pain and common psychiatric conditions often overlap, so much so that pain itself could qualify as a psychiatric condition.

Given all this, how can we best serve patients suffering from chronic pain without becoming part of the problem? Do we encourage them to abstain from all drugs and go to meetings? Do we admit they are powerless over their pain? Do we take them off one drug while prescribing another that will only prolong their dependence? Are holistic treatment procedures and traditional cognitive-behavioral therapy sufficient without the use of psychopharmacology? And what about sleep? Since sleep poses a major concern with this population, how do we help these individuals achieve the sleep requirements they need without the use of medications?

Comprehensive program

Pain specialists have traditionally had to deal with the noncompliant patient, the addicted individual, or the patient who desires to rotate off opioids. These issues were largely responsible for the development of the Chronic Pain Management Program at Casa Palmera, an addiction treatment center based in the San Diego area. The goal was to bring together skilled, experienced professionals with state-of-the-art holistic resources for comprehensive, integrated treatment of chronic pain associated with problems of dependence on pain medication, other drugs, or alcohol.

This program utilizes the “Share the Risk” model of an interdisciplinary and holistic approach. The treatment team includes psychiatrists, psychologists, addiction specialists, primary care physicians, anesthesiologists, nutritionists, acupuncturists and physical therapists. Treatment includes music, art and massage therapy; neuro/biofeedback with brain mapping; and laser therapy.

Casa Palmera's treatment approach for pain patients is based on an understanding of the variable effects and manifestations that substances might have on a pain patient. Treatment is individualized and tailored, and a minimum of medications are used to achieve pain control, while incorporating complementary therapies whenever possible. Great care must be taken to assess properly for and differentiate among abuse, dependence, pseudo addiction (aberrant drug behaviors), addiction, tolerance and withdrawal.

It must be understood that dependence does not necessarily mean addiction. Tolerance and withdrawal are universal with prolonged opioid treatment. Therefore, to diagnose addiction requires observance of repetitive, self-endangering and/or destructive behaviors.

Joseph Shurman, MD, chairman of the Pain Management Program at Casa Palmera and Scripps Memorial Hospital in San Diego, explains it this way: “The key with pseudo addiction is that with proper pain management, retrospectively, the patient's behavior normalizes. However, with the disease of addiction, in the genetically sensitive individual, behavior deteriorates with pain management.”2

Addiction, psychopathology and pain are related, co-occurring, interdependent and compounding brain diseases. In addition, all areas of illness, including any medical comorbidity, must simultaneously be managed in the pain patient. Successful management of one without the others would be a recipe for failure in all.2 It is important to avoid treatment of one illness that is likely to exacerbate another.

Reimbursement for treatment constitutes another complicating factor in the treatment of patients suffering from chronic pain with comorbid disorders. The dilemma for those individuals who cannot afford to pay and who wish to use their healthcare benefits occurs when payment is denied for medical procedures used in pain treatment by behavioral health or addiction treatment facilities. While many facilities accept insurance reimbursement for addiction and/or behavioral health, they are not credentialed or licensed to receive reimbursement from medical insurance.

Thus, it becomes important to establish that criteria are present for medical or sub-acute detox, in addition to determining the extent of the patient's psychiatric or emotional deterioration resulting from long-term chronic pain. A thorough assessment and psychiatric evaluation often will substantiate the need for treatment, which is indeed covered by behavioral health benefits that can help toward the cost of comprehensive treatment services.

Interdisciplinary model

Shurman first developed the “Share the Risk” model's basic principles in January 2002. The model calls for an interdisciplinary team approach to address the pain patient's special needs.

The philosophy is to use multiple specialists and to decrease the overall risks of treatment-most particularly for a pain specialist who in the past may have been vulnerable to lawsuits for prescribing opioids for pain relief, particularly nonmalignant pain. The addition of a team of specialists partnering together in the best interest of the patient brings a more comprehensive treatment approach.2

Interdisciplinary teams have been shown to improve patient care in complex clinical situations and also to deliver the best possible treatment to this challenging population. The fundamental premise is that no physician-no matter how well educated, confident, compassionate, committed or meticulous-can adequately meet all of the needs of patients with chronic and intractable pain and chemical dependency.

One of the most effective models uses an integrated interdisciplinary treatment team approach to include the following:

• Working toward a common goal;

• Making collective therapeutic decisions;

• Communicating and consulting with other team members in face-to-face meetings;

• Possessing a combination of skills that no single individual demonstrates; and

• Achieving more together than what individuals could achieve alone.

Casa Palmera approaches the task of treating chronic pain by incorporating health and healing in all areas of an individual's life. Since there is limited outcome data to date, we have partnered with George Koob, PhD, Director of Neuroscience at Casa Palmera and professor and chair of the Committee on the Neurobiology of Addictive Disorders at the Scripps Research Institute, to establish objective outcome measures resulting from treatment at Casa Palmera. Validated approaches with follow-up of former patients are being used in the study.

Treatment of chemical dependency and chronic pain management reveals a crevice between medical and behavioral health treatments. Compounding this issue is the separation of chemical dependency and medical benefits. This creates a ping-pong effect: Behavioral health insurers determine that chronic pain management be covered under medical health benefits, while medical insurers determine that substance dependence be covered under behavioral health benefits. Therefore, behavioral health credentialing does not guarantee in-network facilities for chemical dependency with a co-occurring pain management program. They credential only those facilities that meet the chemical dependency criteria. This leaves countless patients in limbo to find adequate and affordable treatment.

In the future, it is hoped that more work will be done on the part of the medical profession and insurance companies to determine that comprehensive treatment paves the way for the best prognosis, thereby reducing ongoing medical costs and also resulting in a much-improved quality of life for the patient.

References

1. Rosenthal MH. Co-morbid states are the rule, not the exception, in pain practice. Practical Pain Management 2009; 9:32-40.
2. Shurman J, Bergman D, Koob G, et al. Facility profile: Casa Palmera. Practical Pain Management 2009; 9:21-5.