Guest Editorial
by Martin Fields, MD
 Ever since John Bonica began espousing the concept of
a multidisciplinary program to address pain symptoms in the early 1950s, a whole movement
for treating pain has developed. Today, there are more than 3,300 pain treatment
facilities and solo practitioners who identify themselves as pain specialists in the
United States.1 In my opinion, the birth of these centers has been one of the most
important medical developments in recent years. By bringing together multidisciplinary
team members working in synergy with one another, pain clinics have heightened our
capacity to address the decades-old problem of providing relief for chronic pain
syndromes.
Despite the considerable track record of these programs' documented success in dealing
with patients who cannot be successfully addressed by any other means,2 they have many
critics. They do not reduce pain, they are only palliative; they are too costly; they
require considerable time to participate; there are high drop out rates. These criticisms
have spurred clinics to individualize treatments, making them more accessible to a wider
range of patients and more cost effective.
“Chronic pain syndrome” has been used to describe persistent pain conditions
for which there is a discrepancy between the degree of identifiable disease and the
severity of the illness. The pain itself becomes a source of significant distress, which,
in turn, can aggravate the experience of the pain. In order to combat pain, we have to
address three different levels of the patient's experience: the motivational/affective
system which can augment or diminish the pain through contributing emotions, the
cognitive/evaluative system which can distort the pain by misinterpreting its meaning, and
the sensory discriminative system which often overreacts to a painful stimulus.
Multidisciplinary teams are effective, in part, because they address these different
levels of understanding of the patient's experience with the different team members
automatically focusing on different ‘levels of meaning’ of the patient’s
pain. For example, the psychologist often focuses on the cognitive/evaluative element of
the pain, thereby helping the patient to put his or her pain into a helpful perspective.
The physical therapist/ occupational therapist fundamentally addresses the sensory
discriminative system, allowing the patient to recognize that that his or her
discrimination of fatigue and pain in muscle movement is faulty. The physician primarily
addresses the motivational/affective area by encouraging the patient and providing him or
her with helpful medical information and interventions. Also, programs emphasize different
components of the regimen depending on the needs of individual patients. For example, some
patients require greater emphasis on motivation and encouragement, others on physical
therapy and so on. I believe that programs need to further develop the collaboration
between these disciplines so that the patient truly feels that he or she has a team that
understands him or her and is not treating him or her as one of a group of patients.
Another advance was the shift from inpatient to outpatient programs3 in order to
utilize the patient’s own social environment as support rather than removing the
patient from it. These outpatient programs offer a substantial cost savings.
In studying the large drop out rates for pain programs, Biller4 has provided evidence
that the program’s success may be substantially related to the patient’s
readiness to change. Patients who are ‘precontemplators’ (according to
Prochaska’s5 readiness to change treatment model) are not ready to seriously consider
treatment. These patients are not as likely to change as those in an ‘active’
stage, i.e., actively trying to master their pain problem. Based upon this model, pain
programs whose admission criterion assesses patients' readiness to change are then able to
prepare precontemplators for change. Keefe6 has suggested that these patients should be
introduced to the benefits of better managing their lives and assist in establishing a
relationship with a fellow sufferer or a health care professional who can inspire him or
her. Modern pain clinics that develop programs for those who are not ready to change widen
the net of patients who can benefit from the program.
Other programs helpful in further individualizing treatments have been added to pain
management treatments. According to Turk and Rudy,7 chronic pain patients cannot be
treated as a homogeneous group. They use different coping strategies and have different
support networks, emotional states, and pain conditions. This fact is being recognized as
pain programs emphasize marital treatment6 for some, while others have emphasized
community support treatments,8 specific exercise programs for specific diseases,9 and home
interventions.10 I believe that many more patients require individualized exercise
programs and greater degrees of supportive services in their own communities than they
currently receive. The greater our ability to provide specialized services, unique to each
individual, and to sustain the treatments most critical to that individual for sufficient
time periods for effectiveness to occur, the greater the range of patients who can benefit
from them.
It is especially important to realize that the trends toward individuality of
treatments and cost-effectiveness must advance by further dividing the patient group into
subpopulations and designing treatments critical for success of each. Gone are the days
when you can lump all patients together, assuming they all have the same problem. We are
merely beginning to address patients' concerns by practicing tailor-made programs that
take all aspects of a patient's life into account.
Martin Fields, MD, is a Chicago-based psychiatrist who treats depression in chronic
pain sufferers. He formed the first company to treat patients who had chronic mental
illness but who lived in nursing homes where they received only sporadic psychiatric care
(1992). Midwest Mental Health Care Providers, Inc., established a patient base of more
than 5,000 patients, many of whom were able to move out of the nursing homes and into
company-owned housing. Currently, he has formed Relief for Life, Inc. a company to treat
chronic medical diseases using a biopsychosocial model.
Cited References:
1. Marketdata-Enterprises, Chronic Pain Management Programs: A Market Analysis, Valley
Stream, New York, 1995.
2. Turk DC and Okifuji AK. Treatment of Chronic Pain Patients: Clinical Outcomes,
Cost-Effectiveness, and Cost-Benefits of Multidisciplinary Pain Centers. Critical Reviews
in Physical and Rehabilitation Medicine. 1998. 10:181-208.
3. Peters JL and Large RG. A randomized control trial evaluating in- and outpatient
pain management programmes. Pain. 1990. 41:283-293.
4. Biller N, Arnstein P, Caudill MA, Federman CW and Guberman C. Predicating completion
of a cognitive-behavioral pain management program by initial measures of a chronc pain
patient's readiness for change. Clin. J. Pain. 2000. 16:352-9.
5. Prochaska JO and DiClemente CC. The Transtheoretical Approach: Towards a Systematic
Eclectic Framework. 1984. Dow Jones Irwin. Homewood, Illinois.
6. Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons K, Beaupre P,
Weisberg J and Helms M. Spouse-assisted coping skills training in the management of knee
pain in osteoarthritis: long-term follow-up results. Arthritis Care Research. 1999.
12:101-111.
7. Turk DC and Rudy TE. Cognitive factors and persistent pain: A glimpse into Pandora's
Box. Cognitive Therapy and Research. 1992. 16:99-122.
8. Elliot TE, Murray DM, Oken MM, Johnson KM, Braun BL, Elliot BA, Post-White J.
Improving cancer pain management in communities: main results from a randomized controlled
trial. J Pain Symptom Management 1997. 13:191-203.
9. Martin L, Nutting A, MacIntosh BR, Edworthy SM, Butterwick D and Cook J. An exercise
program in the treatment of fibromyalgia. J Rheumatol. 1996. 23:1050-3.
10. Cott A, Anchel H, Goldberg WM, Fabich M and Parkinson W. Non-institutional
treatment of chronic pain by field management: an outcome study with comparison group.
Pain. 1990. 40:183-194.
Other References:
Bonica JJ. Evolution and Current Status of Pain Programs. Journal of Pain and Symptom
Management. 1990. 5:368-74.
Black RG. The chronic pain syndrome. Surgical Clinics of North America. 1975.
55:999-1011.
Melzack R and Wall P. The Challenge of Pain. 1982. New York:Basic Books.
— May/Jun 2001
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