1. Multi-disciplinary Pain Management: It works…why 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

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

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

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

5. With time: More science – less magic Cures were king Cures were king A cure is rendered at all costs (even dubious ones) A cure is rendered at all costs (even dubious ones) Pain was a secondary consideration 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. Rehabilitative or Management Model Curative 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 Pain Consultation Team Multidisciplinary Programs Multidisciplinary Programs Multidisciplinary Outpatient Programs Multidisciplinary Outpatient Programs Multidisciplinary Inpatient Programs Multidisciplinary Inpatient Programs Pain Service Pain Service

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

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

13. 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

14. 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

15. Pain Service An organized group of pain programs, clinics, and other services 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 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 1970s-80s

17. Multidisciplinary Pain Management

18. Multidisciplinary Pain Management Practice Managed Care

19. Perception of High Costs

20. Multidisciplinary Pain Management

21. Meds Psych P.T. Surgery

23. Rehabilitative or Management Model Curative Model

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

25. How are pain interventions doing today?

26. Pain Medications Second most commonly prescribed drug class Second most commonly prescribed drug class Does not eliminate pain Does not eliminate pain Long term Opiates Long term Opiates (32% reduction) (32% reduction) Anti-Convulsive / Depressants Anti-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

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

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

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

30. Multidisciplinary Pain Programs Pain reduction across studies Pain reduction across studies (37%) (37%) Comparable to other modalities Comparable to other modalities Goes beyond pain reduction Goes beyond pain reduction Return to functional work 48%-65% Return to functional work 48%-65% IDDS had 0% RTW despite pain relief 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 Lower Cost Better at functional restoration

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

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

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

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

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

39. What seems to be missing is the magician

40. What about the perception of high costs?

41. Costs of Chronic Pain Back Pain: $86.2B/yr Back Pain: $86.2B/yr $33.6B/yr Health Care $33.6B/yr Health Care $43B/yr Disability Compensation $43B/yr Disability Compensation $4.6B/yr Lost Productivity $4.6B/yr Lost Productivity $5B/yr Legal Services $5B/yr Legal Services Migraine: $13B /yr Migraine: $13B /yr Rheumatoid Arthritis: $14B/ yr Rheumatoid Arthritis: $14B/ yr Costs of treating chronic pain exceed the combined costs of treating: Costs of treating chronic pain exceed the combined costs of treating: Coronary artery disease Coronary artery disease Cancer Cancer AIDS AIDS Turk (2002), CJP

42. Health Care Costs: Chronic Pain Patients Average $12,900 - $18,833 / yr Average $12,900 - $18,833 / yr Medications Medications $4600/yr Opioids (low dosage) $4600/yr Opioids (low dosage) $1300 / yr Anti-Convulsant (low dosage) $1300 / yr Anti-Convulsant (low dosage) Surgeries - $15,000 per operation Surgeries - $15,000 per operation Average number of surgeries (failed back): 1.7 Average number of surgeries (failed back): 1.7 Spinal Cord Stimulators Spinal Cord Stimulators $76,180 over 5 years $76,180 over 5 years Implantable Drug Delivery Systems Implantable Drug Delivery Systems $82,893 - $125,102 over 5 years $82,893 - $125,102 over 5 years Turk (2002), CJP