Guest
editorial:
Multidisciplinary pain clinics
versus opioid treatment for chronic pain:
Collaborators or antagonists?
Jennifer Schneider, M.D.
Published
in Geriatrics, Nov-Dec 2008, p. 38
A recent letter from me, published in PPM, has
aroused some reader comment regarding the roles of multidisciplinary pain
clinics and pain management physicians like myself who use an armamentarium of
pain medications for the treatment of chronic pain. For example, Dr. William Dicks Director
of Chronic Pain and Behavioral Health Management Services at Bemidji Meritcare in
Physicians
who practice primary care see the entire spectrum of chronic pain patients,
some of whom would benefit from a more accurate diagnosis, others from non-drug
therapies, and yet others from combinations of exercise, other modalities, and
various pain medications including opioids. Certainly
many would benefit from a multidisciplinary pain clinic such as Dr. Dicks
describes. The difference between Dr. Dicks' outlook and mine is that I am the
first to accept that those patients who are doing poorly on medication
management and who have the right insurance, or can afford the cost of a
protracted multidisciplinary pain program would benefit, at least in the short
run. However, he apparently believes that there is no need for PCPs to become
more knowledgeable about, and more willing to prescribe, opioids,
because apparently opioids are a class of medications
that should rarely be used (except, presumably, for acute pain).
In
the last issue of PPM, Dr. Forest Tennant reported an outcome study of some 30
patients who are doing well on long-term opioids.
Dr. Tennant’s report concerns a selected group of patients, who
represent a subgroup of chronic pain patients. Dr. Dick discounts Dr.
Tennant’s report, which is a retrospective study of his own long-term patients and
not a rigorous prospective placebo-controlled long-term trial. Unfortunately, such trials do not yet
exist.
But
what about studies of pain clinic graduates? To begin with, since patients who
are doing well on opioids are unlikely to sign up for
pain clinics, their patient population is already a highly selected sample of
patients seeking a different approach. And once they complete the comprehensive
pain clinic program, what happens to them?
Ask their PCPs how those patients who return from the multidisciplinary
clinic are doing two years later, and you will find out that a significant
number are once again back on their pain meds -- not because they are
inherently drug abusers seeking euphoria, but rather because once they are no
longer receiving intensive, hours-per-day multidisciplinary treatment, and are
back home, the benefits of that treatment may dissipate. Currently there
are no published long-term outcome studies of pain clinic graduates. A
relatively short-term study was just published by the Mayo Clinic, which
reported on the 6 month outcome of 373 consecutive patients admitted to a
comprehensive pain rehabilitation program. Those who arrived on opioids (about half) were withdrawn from opioids before discharge. Both groups had significant
improvement in pain and activity at 6 months (Townsend et al, 2008). This is a
start, but it is important to remember that the patients on opioids
whom they saw were a sub-group selected for the fact that they were not doing
well on their opioids; otherwise they would not
likely have enrolled in the Mayo program. These results cannot be extrapolated
to the whole spectrum of opioid-using patients.
I
believe that multidisciplinary pain clinics tend to see patients who are doing
poorly on opioids, and they provides a comprehensive
alternative; pain specialists like myself, on the other hand, tend to see
patients who've "tried everything" except opioids and are doing poorly. Our
approach generally includes not only opioids but also
anti-inflammatories, anti-depressants, anti-seizure
medications (for neuropathic pain), as well as a focus on improving function by
means of exercise and increased activity. Both multidisciplinary pain
clinics and pain specialists like me have a list of patients who have benefited
from our particular approach. This does not mean that there is no place
for the other's approach. Rather, there are chronic pain patients who are
better off without chronic opioid treatment, and
there are chronic pain patients whose life is improved by being on those
medications. Most patients, whether or not they are on opioids, do better when they are simultaneously involved in
an exercise program. It's not an either-or situation.
It’s time that pain management
specialists forego criticizing other specialists’ treatment methods and recognize that different patients benefit from different
approaches. And in order to
facilitate evaluation of which types of treatments are most likely to work, we
need well-planned long-term follow-up outcome studies that include both opioid users in outpatient pain practices and graduates of
multidisciplinary pain clinics. Ideally, such studies should include all the
patients in each program rather than case reports of successes. Only in this manner will we eventually
know which approaches are most effective for which types of patients.
Reference:
Townsend CO, Kerkvliet JL, Bruce BK,