Old Pain Treatments Are New Again

Sometimes what is perceived as revolutionary is actually the rediscovery of something that was popular in previous decades. It happens in fashion, but it also happens in health care.

Widespread concerns, largely related to opioids, have led to increasing calls for safe, effective options for pain management. There has been an emerging spotlight on and interest in the interdisciplinary treatment of pain. This treatment model recognizes that pain is a whole person experience and therefore requires a multi-pronged approach that incorporates behavioral health and restorative therapies as well as medications. Recently, federal agencies have put forth a comprehensive population-level strategy addressing the broad-based needs of those with pain, recognizing that pain care should be compassionate, individualized, balanced, and team-based.

The reality is that we have known for decades that pain is an experience that impacts and is impacted by many factors. Approaching pain from a multidisciplinary, or ideally interdisciplinary, perspective is not a new concept but one developed by such pioneers and legends as Drs. John Bonica, John Loeser, and Wilbert Fordyce. Pain psychologists and those who have worked or participated in pain rehabilitation programs and have long structured their entire approach to pain care around the idea that the complexity of chronic pain requires an understanding of the whole person. Interdisciplinary chronic pain rehabilitation programs, which flourished in the 1980s, focus on acquiring meaningful skills to help optimize the self-management of pain and enhance quality of life. Decades of research have shown repeatedly that these programs are highly effective and this approach has been identified as the “gold standard” of chronic pain care.

So why, despite the evidence of superiority over unimodal treatment options, have options such as chronic pain programs declined? As with most things, there are several important factors but the biggest is the problematic insurance reimbursement for chronic pain rehabilitation programs. While there has been a growth of such programs within the US Department of Veterans Affairs, private programs across the country have struggled to remain open. Since these integrated programs use a range of approaches such as physical therapy, occupational therapy, behavioral therapy, and medical treatment, billing on a “per therapy” basis means no or low reimbursement. In some states, worker’s compensation has supported the use of pain programs to increase return-to-work and has arranged “bundling” of services. Sadly, the proliferation of these evidence-based programs remains a challenge due to finances. While most insurance plans cover, with little question or hassle, a laminectomy (common surgery to treat spinal stenosis), which costs $50,000-$90,000, they will not cover a chronic pain program that emphasizes nonpharmacological skill-building and empowers those with pain.

Another important issue is a continued lack of awareness across society that chronic pain is a disease that must be understood, evaluated, and treated from a biopsychosocial perspective. Pain neurophysiology changes when those with chronic pain are empowered to use their actions and thoughts to best serve themselves. The good news is that shifts in the populace mindset in recent years have meant more people are open and interested in the connection between our minds and bodies, ways that we can make choices to positively impact our lives, and less “Western” (read strictly biomedical) approaches to health care. It is encouraging that policy and research have pushed forward the importance of patient-centered care, where we work alongside each other to achieve the best outcomes. This whole-person approach is one that has been around for so long, but if we can harness the current momentum by using policy and evidence to support change, perhaps access to pain rehabilitation will improve and those in need will be able to access it … again.