Interdisciplinary Chronic Pain Management

1 Interdisciplinary Chronic pain ManagementPast, Present, and FutureRobert J. GatchelUniversity of Texas at ArlingtonDonald D. McGeary and Cindy A. McGearyUniversity of Texas Health Science Center at SanAntonioBen LippeUniversity of Texas Southwestern Medical CenterChronic pain is a significant and costly problem in theUnited States as well as throughout the industrializedworld. Unfortunately, there have been concerns about theeffectiveness of traditional medical interventions, suggest-ing the need for alternative Chronic pain treatment strate-gies. However, the introduction of the biopsychosocialmodel of pain during the past decade stimulated the devel-opment of more therapeutically effective and cost-effectiveinterdisciplinary Chronic pain Management programs.

2 Inthe present article we briefly review the history of painmanagement, discuss the major components of a true Interdisciplinary pain Management program, focus on theevidence-based outcomes that have documented the effec-tiveness of such Interdisciplinary pain Management pro-grams, and note the barriers that have blocked the wideruse of such programs. Finally, we discuss future directionsin Interdisciplinary pain : Chronic pain , Interdisciplinary care, cognitive-behavioral therapy, functional restoration, biopsychosocialmodelPain affects millions of Americans; contributes greatly to nationalrates of morbidity, mortality, and disability; and is rising inprevalence. Substantial disparities exist in the prevalence, seri-ousness, and adequate treatment of pain that affect the vulnerablepopulations of traditional public health concern.

3 pain exacts enor-mous costs both economically and in the toll it takes on people slives. Analysis performed for the committee revealed that theannual economic cost of Chronic pain in the United States is atleast $560 635 billion. This estimate combines the incrementalcost of health care ($261 300 billion) and the cost of lost pro-ductivity ($297 336 billion) attributable to pain . The federalMedicare program bears fully one-fourth of medical expen-ditures for pain ; in 2008, this amounted to at least $ billion,or 14 percent of all Medicare costs. In total, federal and stateprograms including Medicare, Medicaid, the Department ofVeterans Affairs, TRICARE, workers compensation, and oth-ers paid out $99 billion in 2008 in medical expenditures attrib-utable to pain .

4 Lost tax revenues due to productivity losses com-pound that expense. (Institute of Medicine, 2011, p. 5)The above quote is from the recently released reportRelieving pain in America, by the Institute ofMedicine, which highlights the emotional and eco-nomic toll of Chronic pain . Prevalence estimates of chronicpain in the United States vary widely, with recent estimatesranging between 30% and 40% of the adult population(Johannes, Le, Zhou, Johnston, & Dworkin, 2010 ; Tsang etal., 2008). It has been reported that approximately 100million adult Americans suffer from Chronic pain , a totalgreater than the number of individuals with diabetes, heartdisease, and cancer combined (Centers for Disease Controland Prevention, 2002; Department of Health andHuman Services, 2006).

5 Chronic pain is clearly a major health care problem inthe United States, and its significance will only continue togrow with the graying of America. Currently, there areapproximately 35 million Americans age 65 years or older,accounting for of the total population ( CensusBureau, 2001). By the year 2030, it is projected that about20% of the population will be 65 years of age or older ( Bureau, 2000). The Institute of Medicine (2011)indicated that although pain prevalence estimates vary forolder adults, Chronic pain severity and related disability doseem to increase with age. Thus, the aging of the BabyBoomer population is going to result in a rapid increase inchronic pain problems, accompanied by a similar rise inindividual and societal pain Management costs.

6 Now, morethan ever, it is vital to identify the most cost-effective waysto manage Chronic pain . Typical biomedical interventions for Chronic pain ( , opioid medication, surgery) may lack long-term ben-efit or subject the pain patient to risks that obviate the needfor an alternative approach. There has been some disputeabout the benefits of opioids medication for Chronic painconditions ( , low back pain ; Chou, 2013). Deyo andcolleagues (2011) found that over 60% of patients withnoncancer pain were prescribed opioids, and almost 20%were categorized as long-term users. After reviewingelectronic records for over 26,000 pain patients, these in-Editor s article is one of nine in the February March 2014 American Psychologist Chronic pain and Psychology special P.

7 Jensen was the scholarly lead for the special J. Gatchel, Department of Psychology, Universityof Texas at Arlington; Donald D. McGeary and Cindy A. McGeary,Department of Psychiatry, University of Texas Health Science Center atSan Antonio; Ben Lippe, Department of Clinical Psychology, Universityof Texas Southwestern Medical concerning this article should be addressed to Rob-ert J. Gatchel, Department of Psychology, College of Science, Universityof Texas at Arlington, Box 191528, 313 Life Sciences Building, Arling-ton, TX 76019-0528. E-mail: document is copyrighted by the American Psychological Association or one of its allied article is intended solely for the personal use of the individual user and is not to be disseminated March 2014 American Psychologist 2014 American Psychological Association 0003-066X/14/$ 69, No.

8 2, 119 130 DOI: ultimately determined that longer term use ofopioids was associated with increased psychological dis-tress and health care utilization. Opioid medications alsopresent a significant risk for misuse (Potter & Marino, 2013).Although they can be helpful with short-term use, opioids benefit declines as their use persists (Krashin, Sullivan, &Ballantyne, 2013), and persistent use may ultimately lead toopioid-induced hyperalgesia (Brush, 2012). Growing con-cerns about narcotics misuse and abuse have promptedcalls for improved oversight of opioid prescription prac-tices throughout the United States (Bloodworth, 2006;Gourlay, Heit, & Almahrezi, 2005). Indeed, the Centers forDisease Control and Prevention (2011) reported that oxy-codone-related deaths in the State of Florida rose 265%between 2003 and 2009.

9 This negative press has contrib-uted to state government regulations designed to curtail theoperations of pill mill clinics (which tout themselves asmultidisciplinary but offer little intervention other thanprescriptions for opioids) as well as damage to the generalreputation of organized pain interventions for Chronic pain can be equallyconcerning. Some studies have shown an increase in sur-gical interventions for Chronic pain . For example, Rajaee,Bae, Kanim, and Delamarter (2012) found a 137% increasein spinal fusion surgery for low back pain between 1998and 2008 and an increase in laminectomy proce-dures. However, there are concerns about high disabilityrates after these procedures (Tarnanen et al.)

10 , 2012).Clearly, an alternative approach for Chronic pain manage-ment is sorely needed to help improve long-term , the biopsychosocial model of pain anddisability is now widely accepted as the most heuristicapproach to the understanding and treatment of chronicpain disorders, replacing the outdated biomedical reduc-tionist model (Gatchel & Okifuji, 2006; Gatchel, Peng,Peters, Fuchs, & Turk, 2007; Turk & Monarch, 2002). Thebiopsychosocial approach describes pain and disability as acomplex and dynamic interaction among physiological,psychological, and social factors that perpetuate, and evenworsen, one another, resulting in Chronic and complex painsyndromes. As the biopsychosocial model evolved andbegan to spread through the scientific and medical com-munities, it became increasingly apparent that trying tomanage Chronic pain through biological pathways alonewas a dead end (Gatchel et al.