Pieces of the Puzzle: Creating a Multidisciplinary Approach to Pain Management

The past 20 years of pain management treatment have focused on prescribing more — and often stronger — pain medication. However, there has been a return to the biopsychosocial method of pain management that John Bonica, MD, developed in the 1960s to treat people coming back from World War II with complex pain and psychological problems, says Thomas Schrattenholzer, MD, pain management physician and medical director at Legacy Good Samaritan Medical Center Pain Management Center in Portland, Ore.

"It's a renaissance, so to speak, of an old method," he says.

Dr. Schrattenholzer says his center began implementing a multidisciplinary approach in 2006 with the addition of a physical therapist. Over the past five years, the center has added several others specialists to its roster. The multidisciplinary method involves treating the biological, psychological and social aspects of pain disorders, Dr. Schrattenholzer says. The name biopsychosocial comes from those three aspects.

"In the '80s, folks had been applying the biopsychosocial model to chronic pain and getting a good response from it," he says. "A lot of these programs went away because they weren't being reimbursed, and what would happen is that things that were being reimbursed, like injections and surgeries, became more the standard of what would be done."

The Legacy Good Samaritan center is attempting to create a multidisciplinary method that rivals big hospitals and academic centers, where the approach is more common.

"We're trying to apply that method in a private practice setting with the constraints of not being reimbursed," he says. "It's not easily replicated in a private practice. Most of these large, multidisciplinary programs are done within the context of a university or in the context of a large hospital system like Kaiser."

For centers looking to incorporate a multidisciplinary approach, Dr. Schrattenholzer explains three key elements.

1. Create a team of specialists. The most important thing is to recruit a team of specialists that can look at a pain patient from different angles and offer alternative treatments, Dr. Schrattenholzer says. He says the method requires three components to be successful: a physician, a psychologist or psychologist nurse practitioner and a physical therapist.

The center's first addition was a physical therapist. Since then, the center has hired a pain psychologist nurse practitioner, an anesthesiologist, a neurologist, a physician's assistant, a social worker, a pharmacist and another physical therapist. These different specialists bring diverse viewpoints that create a conversation around patient care and the best treatment plan for a particular case. Even if a center doesn't employ all of the specialists, that conversation is still important, Dr. Schrattenholzer says.

"The most important part is to create dialogue and to reach out to other members in your community that provide pain service, particularly pain psychiatrists and physical therapists who could help work on active approaches to chronic painful conditions," he says. "Oftentimes we get locked into the one thing that we do to help improve pain, and we don't reach outside our scope of practice to get other specialties to add important components such as treatment of depression or the mind/body approach to pain reduction. Those can have more value than what you are offering."

The pharmacist, who the center hired a year and a half ago, assists staff when prescribing drugs to patients to prevent any negative interactions.

"There can be some complex interactions between drugs," Dr. Schrattenholzer says. "They oftentimes work against one another. Having a pharmacist to be able to review and make medication lists has been very helpful."

Another important team member is the social worker, who helps organize the educational piece of the program and serves as a liaison between the substance abuse program and the chronic pain program. Dr. Schrattenholzer says the overlap between chronic pain and substance abuse in certain populations can be as high as 40 percent — meaning 40 percent of patients who are dependent on opioids also complain of chronic pain. Many patients, regardless of opioids use, are started with pain education services.

"A lot of what drives the pain experience is the fear of pain," he says. "Education helps you understand how a pain experience is generated and what are some things we do to magnify that pain experience. If we can remove the fear, we can oftentimes remove the magnification and reduce the overall pain experience."

The center does not get reimbursed for the social worker's services, but recognizes that education is a key piece. The lack of reimbursement has been a constant challenge for the center.

2. Create a unique plan for each patient. Each pain patient requires different treatment, and often that treatment falls out of the traditional realm of medication, medical procedures and surgery. Dr. Schrattenholzer offers the example of a patient who has a painful back condition that may lead to a disability, loss of insurance, loss of family and even a dependency on pain medication.

"We think that an epidural injection is going to help that," he says. "It's not. What we really need to do is to start treating all the things that come with a chronic pain condition."

For that reason, the Legacy Good Samaritan center staff creates a unique plan for each and every patient, and that plan starts with an intake evaluation.

"The most important thing is to make sure you conduct a good intake evaluation and tailor a program that fits the patient," he says. "The goal of the pain management program has very little to do with being on or off any particular medication. The goal is always the reduction of a painful experience and improvement in function."

Dr. Schrattenholzer gives the example of a 79-year-old man who has pain from spinal stenosis but has not had an adequate workup. Dr. Schrattenholzer would start by obtaining the man's history and ordering an MRI. Based on the results, the man would probably be recommended for a surgical evaluation. The psychologist and physical therapist can be skipped because what the patient really needs is a decompression, he says.

Another example is a 29-year-old who still has moderate to severe back pain from a degenerative disc disease even though he has already had a decompression. Obtaining the patient's history reveals a record of opioid misuse. That patient would most likely be referred to the psychologist and physical therapist.

3. Encourage staff communication. Because each patient has a unique treatment plan, communication between staff is key, Dr. Schrattenholzer says. The staff communicates through their electronic medical records as well as face-to-face conversations. Because the staff is small, specialists often run into each other in the hallways and can ask questions about patient care. But for the estimated 7,000 patients of the center, that isn't always enough.

"We also have a multidisciplinary case conference every Friday morning to go over cases that have been particularly difficult," he says. "We can then create a plan for that patient."

Related Articles about Pain Management:
7 Trends Affecting the Future of Pain Management in Surgery Centers
30 Statistics on Pain Management in Surgery Centers
Healthcare Reform and its Effect on Pain Management: Q&A With Dr. Laxmaiah Manchikanti of the American Society of Interventional Pain Physicians

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