Programs for Chronic Pain Management

Orlando—Approximately 100 million adults in the United States have chronic pain, more than the total amount of people with heart disease, cancer, and diabetes combined. Each year, the medical treatment costs and lost productivity associated with pain reach up to $635 billion, according to Michael R. Clark, MD, vice chair, clinical affairs, director, pain treatment programs, Johns Hopkins Medical Institutions.

Dr. Clark, who spoke during a session at Psych Congress, said patients with chronic pain have reductions in physical, psychological, and social well-being and have a health-related quality of life that is lower than patients with most other medical conditions. He added that psychological interventions, such as cognitive behavioral therapy (CBT), and focusing on self-control and self-management are effective. He cited outcome studies have found that patients with chronic pain who underwent CBT had significant improvements in pain intensity, pain behaviors, distress, depression, and coping skills.

The evidence-based guidelines recommend patients undergo interdisciplinary rehabilitation and receive integrated treatment. Dr. Clark noted a meta-analysis of 65 studies that indicated treatments provided in multidisciplinary pain clinics were effective, while combination therapies were superior to monotherapies or no therapy. The subjective and objective improvements were maintained for up to 7 years.

Patients who undergo multidisciplinary interventions are also more likely to return to work. A long-term follow-up study found half of the
patients were unemployed after receiving treatment via a pain management program, while another 30-month follow-up study found the patients’ employment status was predicted by the desire to return to work, perception of the job’s dangerousness, and education level.

Dr. Clark discussed the Adolf Meyer Chronic Pain Treatment Program and described it as “a patient-centered, systematic, organized, and rational approach for restoring the benefits of health and alleviating the consequences of sickness for patients with chronic pain.” He also mentioned the approach of former Johns Hopkins neurosurgeon, Donlin M. Long, MD, who defined the Johns Hopkins program as focusing on accurate physical diagnosis; accurate and comprehensive psychiatric and psychosocial evaluation; and individualization of therapy.

Dr. Clark suggested that psychiatrists point out problematic behaviors, insist patients take responsibility for their choices, and emphasize and reinforce productive behaviors. They should also understand what patients were like before their illness.

Although people with mental illness may feel hopeless, Dr. Clark said psychiatrists should emphasize that life can retain its meaning in spite of tragedy and is potentially meaningful under any condition.

He added that patients must:
• Accept failure
• Know that other possibilities exist
• Understand that the possibility of success is better than the reality of failure

He also said people should experience painful situations in the present and learn from them instead of distracting themselves with something else, such as regrets from the past or worries about the future.

Dr. Clark concluded the session by noting that the most effective treatment for chronic pain involves interdisciplinary rehabilitation, in which psychiatrists play a leading role. He said psychiatrists can help patients learn, plan, actively make choices, and believe change is possible.—Tim Casey