As we have explored in Chaps. 1, 2 and 5, the multidisciplinary pain program pendulum has swung back to the days before Dr. Bonica. The reason is clear—changed reimbursement patterns with increasing emphasis in the healthcare system on uncoordinated and unimodal care. When discussing nonoperative or conservative care with a colleague, Dr. David Hanscom, author of Back in Control recalls that the physician had no exposure at all to multidisciplinary approaches in his medical training (Hanscom 2012). All he had been taught was to “write ‘physical therapy’ on a prescription pad and send the patient on his or her way,” writes Dr. Hanscon. Too many medical professionals graduating today do not even know the definition of conservative (nonoperative) care, writes Dr. Hanscom, which is 6–12 months of physical therapy visits, 1–3 cortisone injections and “an evaluation by a psychologist who specializes in pain.” Even so, they can be quick to say conservative treatment has “failed” and the next step is surgery without a full grasp of a multidisciplinary approach.

Clearly, “pain clinics” that do not offer a multidisciplinary approach but rather “shot jocks” promoting injections, nerve burnings and excessive surgery have supplanted comprehensive pain programs such as Dr. Bonica and his colleagues originally envisioned. “Pill mills” promoting opioids also have done their part to supplant multidisciplinary care, though the government has begun to regulate such operations and the overuse of opioids in society in general, due to the shocking numbers of opioid abuse-related deaths in the United States, viewed as an epidemic. As we noted in Chap. 5, opioids have no place in the long-term treatment for chronic pain, frequently making pain worse through opioid-induced hyperalgesia” or OIA (Rosenquist 2014). I have personally treated patients who were terrified to titrate off opioids because they were afraid of returning pain, only to find they were in less pain once off the opioids. After a decade of unprecedented opioid prescription in the United States, two government-sponsored research papers published in the Annals of Internal Medicine in 2015 revealed that there have been only short-term studies of opioid pain relief and there are almost no data supporting their use beyond 6 weeks not to mention the long-term use (Fauber 2015).

The swing of the pendulum is especially concerning because it hails back to older theories of pain which have been cast in doubt by newer ones we know and discuss in Chap. 3. Specifically, cutting and interrupting peripheral body parts to “cover up” pain relies upon the Door Bell theory and ignores more recent and plausible theories including the Matrix Theory of pain, the Spinal Cord Mechanisms theory, the Brain-Based Pain Modulation theory, Neuroimmune Interactions and Pain Genetics. An overview of the major theories of pain is found in Chap. 3. Treatments like blocking the nerve pathway with epidurals, burning nerves to facet joints and surgery to treat normal, age-related degenerative changes of the spine without nerve compression or instability are based on a single, outdated theory of pain. These treatments disregard other significant advances that have occurred in understanding the complex human experience of pain. When medical professionals ignore the many other theories of pain, it is like they still believe the sun revolves around the earth, a belief popular before Galileo and before the solar system and its complexity were discovered.

Of all approaches to treating chronic pain, multidisciplinary treatment has the “strongest evidence-base for efficacy, cost-effectiveness, and lack of iatrogenic complications,” says the International Society for the Study of Pain (ISAP 2012). This opinion is echoed among other medical associations as well as many government-related groups. Yet, the number of multidisciplinary pain programs has plummeted from 1000 in 1999 to just 150 in 2012 says the ISAP which means there is now only one program per 670,000 in the United States. This is in sharp contrast to 11 European countries and Canada where the number of multidisciplinary pain programs is increasing, says ISAP stake holders.

The reason, of course, is obvious. The US healthcare system is financially-driven and “composed of myriad stakeholders says ISAP,” notably the insurance industry. In addition to a “pill mentality” which drives the US’ huge opioids use, the fact that the US system is for-profit “also speaks to the overutilization of interventional techniques and spinal surgery.” Except for the Department of Veterans Affairs, the US health system functions according to the “business ethic” of profitability charges ISAP and has “less concern for human suffering.” Yet, adds ISAP, multidisciplinary programs “could potentially save countless billions of dollars every year.”

Noting that multidisciplinary programs are not “cash cows” to the institutions that run them, Schatman observed that, “Sadly, while chronic pain management practitioners function under ethical codes of conduct which emphasize the primacy of the patients’ well-being, the business ethos and ethics of the healthcare insurance, and hospital corporations may not be directly compatible or supportive of such ethically sound medical care” (Schatman 2006).

We are increasingly seeing a “commodification” of healthcare services in which “surplus provision” is not funded, writes Schatman and multidisciplinary programs find themselves competing with “quick fixes” like opioids for third-party funding. Yet, as we reviewed in Chap. 5, Treatments That Have Questionable or Controversial Evidence, surgery, opioids and blocks, in most cases do not outperform the long-term outcomes of conservative and multidisciplinary care and sometimes are substantially inferior, even as they cost more! “The pharmaceutical approach, alone is often insufficient to treat the multiple and compound issues that instigate and perpetuate a particular patient’s pain,” Schatman says. Many researchers charge that the United States suffers from “short-termism” in many of its sectors like Wall Street and environmental policy—refusal to look at the long-term costs of immediate actions that appear sensible or profitable. Certainly treating chronic pain with uncoordinated, unimodal care which is not cost-effective when viewed on a long-term basis is another example of such short-term thinking.

There is another irony in the healthcare system embracing chronic pain treatments that are not evidence-based. “Multidisciplinary chronic pain programs place a heavy emphasis on restoring independence to their patients” writes Schatman—yet in the current system, patients lack “the autonomy to choose the treatment which is most likely to restore his or her independence.”

It is not a mystery why multidisciplinary pain programs are effective over the long-term in helping patients manage and control their pain. As we saw in Chap. 3, almost all the pain theories from the Gate Theory to the Matrix, Neuroimmune and Mixmatch theories recognize pain as much more complicated than the simplistic Door Bell Theory (which says when a patient has pain there is a pain generator at the “door”). If pain were as simple as a “visitor at the door,” there would always be a clear pain generator and thus chronic pain would be rare. But, instead, chronic pain in the United States has grown from 50 million a few decades ago to 100 million today (Wells-Federman 1999; American Academy of Pain Medicine 2011). Pain would also not occur in limbs which are paralyzed or amputated if the Door Bell theory explained all pain nor would peripheral blocks fail to work.

Moreover, if pain were as simple as a “visitor at the door,” fear, anger and anticipation of pain would not worsen pain as studies have clearly demonstrated. Cognitive Behavioral and relaxation therapies, psychological counseling and a change in attitude would not be so effective in reducing pain, as we reviewed in Chap. 4. Nor would antidepressant and antiseizure medications be effective in chronic pain if the pain were totally and only caused by a pain “visitor” at the door—a single pain generator.

Unlike unimodal, uncoordinated and “quick fix” pain treatment, multidisciplinary pain programs use a rehabilitation approach in which a “cure” for the pain or the underlying condition causing the pain is not the goal/aim. Rather the focus is on empowering patients and their families with knowledge and skills to improve function, decreasing the use of dependence-producing narcotics, providing physical and psychological skills and improving the quality of life of individuals with chronic pain, as seen in Table 8.1. Efforts are also made to return the patient to gainful employment where applicable.

During the golden age of chronic pain rehabilitation, Lipchik et al. found that “pain beliefs and attributions of pain control are amenable to change” with multidisciplinary treatment (Lipchik et al. 1993). The researchers found that patients’ feelings of no control over their pain and tendency to cede control of their pain to medical professionals or family—two factors known to increase pain—diminished with even short-term multidisciplinary treatment which, in turn, “had a significant impact” on the patients’ “subjective pain intensity.” Patients given multidisciplinary care also “showed a reduction in the endorsement of the belief that their pain was an inexplicable mystery,” reported the researchers (Lipchik et al. 1993).

Multidisciplinary treatment is also useful in getting the patient to decrease “pain behaviors” and replace them with “well behaviors.” As we have noted in Chaps. 1–4, pain behaviors usually increase the subjective experience of pain; patients will often “feel” the way they act when they exhibit behavior like limping, signing, grimacing in pain and “guarding” against expected pain from normal activities. Pain behaviors can also stand in the way of the exercise and physical therapy which are almost always beneficial in chronic pain patients. Until we educate patients, that “hurt” is not “harm” and that activity can be beneficial, patients will usually shy away from activities that would strengthen them and lessen their pain. Doing something which “hurts” so that “hurt” eventually becomes less, is certainly a counterintuitive concept and it is important that we convey it to our pain patients.

“The psychology of the healthcare provider may be as important as the psychology of the patient,” write Vranceanu et al. (2009). Clinicians may believe that biopsychosocial factors behind chronic pain are not within their domain, that they will “resolve after the nociception is addressed” or have an exaggerated belief in their own abilities to heal. They may also downplay biopsychosocial factors because of their stigmatization in society and/or believe that a patient’s psychopathology is worse than it really is, declining involvement.

Clinicians can find patients with chronic pain “very frustrating” and worry that treating complex pain conditions will take too much time write Vranceanu et al. Some clinicians may use a “paternalistic model of decision making,” encouraging a patient to be passive and denying him the chance to learn self-efficacy write the researchers. “A passive approach to treatment has been shown to increase disability and distress in many pain conditions.” Clearly, all of these clinical “pitfalls” are highly unlikely with multidisciplinary care with its emphasis on biopsychosocial factors, team approach and encouragement of the patient’s active participation in treatment. Even the family is encouraged to become active participants in multidisciplinary care, offering their opinions of what seems to work and what progress is being made.

Studies of multidisciplinary pain programs, as we noted in previous chapters, have established positive outcomes, especially when compared to unimodal care. A 2003 study in The Spine Journal found that low back pain patients who completed a multidisciplinary rehabilitation program showed greater improvement on physical and mental measures and lost fewer days of work than those who received usual care (Lang et al. 2003).

A meta-analysis conducted by Flor et al. found patients treated with multidisciplinary care were twice as likely to return to work than untreated or unimodally treated patients and were functioning better than 75 % of those not treated with multidisciplinary care at follow-up (Flor et al. 1992). Multidisciplinary treatment was found superior to no treatment or unimodal treatment and benefits were maintained over a period of time, said the researchers—findings that they called “impressive.” Both patients’ subjective assessment of their pain and objective measures like return to work and usage of the healthcare system improved compared to groups not given multidisciplinary treatment.

On the basis of his own experience and published data Dr. Loeser estimates that patients who have completed multidisciplinary pain rehabilitation consume 60 % less opiates, visit medical professionals for pain 60 % less often and are 60 % more likely to return to work (Loeser 2014). Additionally, their physical activity increases by 300 % writes Dr. Loeser. Instituting follow-ups to multidisciplinary rehabilitation is important, adds Dr. Loeser, so patients retain these gains (Table 8.2).

Patients in a 2000 Denmark study enrolled in a multidisciplinary program did better than those in a general practice program on all instruments from pain to emotional state to quality of life to opioid consumption, writes Dr. Loeser. In fact, patients in the general practice group did not improve at all over a 6-month period while those in the multidisciplinary program did.

Multidisciplinary pain programs “offer the most efficacious and cost-effective, evidence-based treatment for persons with chronic pain,” according to a 2006 Journal of Pain study Dr. Loeser quotes. “Unfortunately, such programs are not being taken advantage of because of short-sighted cost-containment policies of third-party payers” (Burchiel 2014).