We have all heard that there are many “different roads to Rome.” Similarly, there are many roads to managing pain and most pain patients you will see are on the undesirable “road” of narcotics, injections, surgery, rest from activity, disability, anticipatory fear, activity avoidance, and excessive focusing on their pain, often with the encouragement of their family. When people when they think of a “road less traveled” many remember the beautiful poem by Robert Frost, called The Road Not Taken on the topic, and pictured in Fig. 2.1 (2002)

But too often this “road” is characterized by uncoordinated medical care and unimodal treatments that are not evidence-based as we see in Table 2.2. In fact, despite today’s arsenal of popular new pain treatments, the incidence of adults who report chronic pain has grown from 50 million a few decades ago to 100 million (Wells-Federman 1999; American Academy of Pain Medicine 2011). Clearly, this road is not working.

The multidisciplinary pain rehabilitation road is less traveled but infinitely more effective. It involves elimination of narcotics (which are seldom useful in chronic pain), identification of appropriate medication(s), addressing the patient’s psychological, social and emotional issues and educating the patient about pain and pain management. Rather than the “cure” for chronic pain which patients have sought in surgery or medications, the multidisciplinary road offers them a “cafeteria” of treatments from different disciplines. These include different medications such as antidepressants and antiseizure drugs, education and empowerment, physical therapy such as stretching, self-mobilization and aerobic exercises, strengthening and endurance building and Transcutaneous Electrical Nerve Stimulation (TENS) or cognitive and behavioral techniques like altering thought patterns, distraction and mental imagery.

The goal of multidisciplinary pain rehabilitation is to induce in the patient a sense of self-efficacy and self-responsibility as a partner in his own pain management. This happens as the patient is taught how to increase activities at work or home without fear or strain and how to achieve a new perspective of his pain and life through working with a psychologist, when needed. As patients are empowered by members of the multidisciplinary team, they learn self-management and are able to control their pain instead of having it “control” them. Often there is an “aha” moment or a Gestalt in which the patient realizes that recovery is up to him and he participates in the treatment in a new way.

Of course treating chronic pain with a multidisciplinary rather than traditional approach is not without controversy. There are also intense philosophical conflicts regarding the treatment of chronic pain which we will explore in this book.

Many trace the multidisciplinary team concept to Tacoma General Hospital where John Bonica, an anesthesiologist, and his colleagues recognized that chronic pain patients needed more than a physician to improve their function in the 1940s. Dr. Bonica recruited a group consisting of John D. Loeser, M.D., a neurosurgeon, Wilbert Fordyce, Ph.D., a psychologist, a physiatrist, and physical and occupational therapists and sought to develop a biopsychosocial model of pain management (IASP 2012). Interestingly, the new approach focused on improving function as opposed to eliminating pain.

Treating a patient with a team of professionals including the patient himself and ideally the patient’s family has two salutary results. It produces coordinated care in which the “left hand knows what the right hand is doing” (a feature that is seriously lacking in our healthcare system) and it enfolds the patient in decision-making process. The key differences between conventional and multidisciplinary treatment are shown in Table 2.3.

“A treatment that is simply handed to a patient without his or her input….is less likely to work or be adhered to,” says Scott M. Fishman, M.D. one of the nation’s leading pain experts and author of several pain texts (Fishman 2012a, b, p. 67). “Patients are best served by being put in the role of chief executive officer of their treatment regimens,” he writes.

When first instituted, pain programs with multidisciplinary teams flourished in the United States. Teams could include physical and occupational therapists, exercise physiologists, rehabilitation nurses, social workers, vocational therapists, therapeutic recreation therapists, ergonomics specialists, dieticians, pharmacists, and even members of the clergy. The multidisciplinary pain programs, also called interdisciplinary programs, were a good example of holistic medicine—treating the person not just the symptoms. They exemplified a biopsychosocial approach to health in which the body and the brain are acknowledged to be interconnected and work together. But sadly, due to a shifting healthcare reimbursement environment, multidisciplinary pain programs are disappearing in United States even as their popularity grows in the rest of the world.

John D. Loeser, M.D. one of Dr. Bonica’s original team members and considered a leader in the multidisciplinary pain approach today in the United States, has lamented how multidisciplinary rehabilitation in the United States is disappearing due to overreliance on narcotic pain killers. “This often occurs with little or no attempt to assess patients’ real needs, as if chronic pain were a purely medical problem and psychological and social factors of no account,” he said in the International Association for the Study of Pain’s magazine Insight (2013). Four key precepts of multidisciplinary treatment are seen in Table 2.4.

It is noteworthy that before the idea of a multidisciplinary team developed, chronic pain was regarded as a purely medical problem—and the pendulum has swung back. Then and now, treatment is too often focused on masking the pain with anti-anxiety drugs, narcotic pain drugs, injections and surgery without probing emotional and cultural factors—literally “treating the pain and not the patient.” Treatments like spinal fusions and disk surgery, spinal cord stimulators, steroid and painkiller injections, nerve ablation, and of course long-term prescription of narcotics have become the norm in pain care, especially in the United States. At the same time, the incidence of adults who report chronic pain has doubled. Clearly, the newer methods are not working.

It should be no surprise that changes in the way health care is delivered and reimbursed are at the heart of these changes. Chronic pain treatment in the United States is increasingly “dictated by what insurance providers will pay for rather than by individual patient needs,” and, at best, such treatment is “inappropriate, and at worst is dangerous,” maintains Dr. Loeser, who is Professor Emeritus, of neurological surgery, anesthesiology and pain medicine at the University of Washington. “Health professionals, not insurance providers or managers and politicians, must once again be in charge of medical planning and decision making.”

Lynn Webster, M.D., former president of the American Academy of Pain Medicine (AAPM) agrees. “All payers should offer a comprehensive, interdisciplinary pain program to patients who have disabling pain,” wrote Dr. Webster in an article titled, “We Have an Epidemic on Our Hands and the Status Quo Is Failing Us” in Pain Medicine News (Webster 2013) . “In addition, all payers should make available cognitive behavioral therapy to people with chronic pain. At minimum, these benefits should be similar to the 2008 federal law mandating parity for mental health treatment.” I strongly agree with his Dr. Webster’s statement.

A 2008 study in the journal Spine found people kept on opioids for more than 7 days during the first 6 weeks after an injury were more than twice as likely to be disabled and out of work a year later (Fauber and Gabler 2012). A study of 300,000 Workers’ Compensation claims by the Workers Compensation Research Institute found pain and day-to-day function do not improve in workers when they stay on opioids (Fauber 2012).

Multidisciplinary pain rehabilitation, on the other hand, is effective for pain patients and cost-effective for providers according to medical literature. The “multidisciplinary treatment ameliorates pain, functional restoration, and quality of life with medium to high-effect sizes even for patients with a long history of chronic back pain,” says a paper in the Journal of Clinical Rheumatology (Moradi et al. 2012). “Results demonstrate that participation in a [multidisciplinary] chronic pain program is an effective intervention for selected patients with refractory pain,” echoes a study in Pain Physician (McAllister et al. 2005). “Primary care-based treatment of chronic pain by interdisciplinary teams (including behavioral specialists, nurse case managers, physical therapists, and pharmacists) is one of the most effective approaches for improving outcomes and managing costs,” concluded an article in Translational Behavioral Medicine (Debar et al. 2012).

In Denmark, implementation of clinics with multidisciplinary teams cut the rate of lumbar disk surgery in half in just 4 years. (Rasmussen et al. 2005). Before the team-based clinics, patients with low back pain (LBP) were “referred unsystematically to various diagnostic methods,” write the authors in a 2005 article in Spine and there was a “high degree of uncertainty about both diagnosis and prognosis.” After the multidisciplinary nonsurgical spine clinics were in operation, patients benefited from a faster and more “competent evaluation,” an education program geared to general physicians that stressed “the benefits of a more conservative approach” and a “local media campaign stressing the concept of ‘watchful waiting.’”