http://neurology.medscape.com/SCP/DBT/2001/v13.n09/dbt1309.05.turk/dbt1309.05.turk-01.html

Dennis C. Turk, PhD
[Drug Benefit Trends 13(9):36-38, 2001. © 2001 Cliggott Publishing Co., Division of SCP/Cliggott Communications, Inc.]

Introduction

It is estimated that more than 60 million persons in the United States suffer from some type of persistent or recurrent acute pain sufficient to significantly impact their lives. Despite major advances in knowledge of sensory physiology, anatomy, and biochemistry, and the development of potent analgesic medications and other innovative medical and surgical interventions, relief for many pain sufferers remains elusive.

Not only does chronic pain adversely affect pain sufferers' physical and psychological well-being, it also costs society billions of dollars in lost productivity, health care expenditures, disability compensation, and tax revenues. The health care costs incurred by patients with chronic pain range from $500 to more than $35,000 a year.[1] These expenditures do not include the costs of surgical procedures, which add substantially to health care expenses. For example, the most prevalent (40% to 60%) complaint of chronic-pain patients is some form of back pain.[2] The cost of lumbar surgery is approximately $25,000, with a total of almost $5 billion annually spent on surgery for chronic back pain alone.[3] Furthermore, health care consumption may increase following initial surgery because of iatrogenic complications. Significant complications requiring additional surgery are relatively common. Some studies indicate that up to one third of the operations performed for back pain result from pain secondary to an original surgical procedure designed to alleviate pain.[4]

During the past quarter century, specialized treatment facilities -- multidisciplinary pain centers and clinics -- have been established to treat patients with recalcitrant pain problems. More than 400 pain treatment facilities have been established in the United States, with an additional 1000 worldwide. A wide range of treatments is provided at these facilities. The estimated average cost for an outpatient treatment by a pain specialist is $8100.[5] Extrapolating from available survey data, I estimate that more than $1.5 billion is spent on specialized pain treatment annually.

One treatment that may be offered at multidisciplinary pain centers and clinics is an interdisciplinary pain rehabilitation program (IPRP). IPRPs address pain reduction, functional restoration, and improvement in quality of life as alternatives to treatments designed primarily to substantially reduce, if not eliminate, pain. One fundamental concept common to rehabilitation of chronic-pain patients is the understanding that patients with complex pain problems are best served by a team of specialists with different health care backgrounds. There is no standard protocol for IPRPs; however, they tend to include a core group of health professionals, such as physicians, physical therapists, and psychologists.

Another central concept is the realization that pain is not just the result of body damage but has psychological and environmental origins as well. Equally important, IPRPs treat not only the experience of pain but also associated patient distress, dysfunction, and disability.

Given constraints on health care resources, there is a growing interest in accountability and a requirement that outcome data support both the clinical effectiveness and cost-effectiveness of treatments. The effectiveness of various treatments provided at pain treatment facilities, namely interdisciplinary rehabilitation, have been singled out by some third-party payers for special criticism. There are, however, a growing number of studies supporting both the clinical effectiveness and cost-effectiveness of these facilities in treating patients with persistent pain. In particular, a number of qualitative and quantitative reviews have summarized literature on the efficacy of IPRPs.[2,6]

Comparison With Other Therapies

Asking whether IPRPs are effective may be an inappropriate way to find out whether they are worthwhile. It might be more appropriate to ask how pain treatment facilities compare with treatments designed to reduce or eliminate pain -- such as nerve blockers, physical therapy alone, acupuncture, chiropractic therapy, long-term opioids, etc -- and on what outcome criteria; ie, how effective are IPRPs compared with alternatives such as surgery on reduction in pain, reduction in medication and health care utilization, increased physical activity, closure of disability claims, and return to work?

The outcome criteria on which to establish the effectiveness of any treatment will vary depending on who asks the question. For example, whether a patient resumes gainful employment may be the most significant outcome criterion for a worker-compensation carrier, whereas pain reduction may be less convincing. On the other hand, an MCO may view health care consumption as the most important outcome, caring less about patients' employment status. A referring physician may be more concerned about reduction in pain and opioid medication use than about whether the patient returns to work.

Several reviews and meta-analyses on treatment outcome studies have evaluated the clinical and cost-effectiveness of IPRPs.[2,6] Despite the recalcitrance of the pain problems in patients treated, the outcome data generally support the efficacy of IPRPs on a range of criteria, including pain reduction, improvements in functional activities (eg, activities of daily living [household chores; self-care, such as dressing, bathing, etc] and return to work), alleviation of depression, lessening of health care consumption, and termination of disability claims. IPRPs and more conventional measures have about the same effect on alleviating pain. It is important to acknowledge, however, that none of the tools currently available -- drugs, regional anesthesia, surgery, and rehabilitation -- consistently eliminate pain in all chronic pain sufferers.

IPRPs appear to be more effective than pharmacologic and surgical approaches in significantly reducing health care consumption, which results in the closure of disability claims and an increase in functional activities, and helping patients return to work. Interestingly, the improvements observed at IPRPs have been achieved along with concomitant reductions in opioid medication consumption. It is particularly noteworthy that reductions in pain occur in conjunction with a decrease in analgesic use.

IPRPs have also been shown to be more cost-effective than patient education and physical therapy alone, surgery, neuroaugmentive procedures (ie, spinal cord stimulators, implantable analgesic pumps), and prescriptions for long-term opioid medication.[3] One factor contributing to the comparative cost benefits of IPRPs, in contrast with neuroaugmentive modalities and long-term opioid therapy, is that no additional medical monitoring of patients treated at IPRPs is required.

To illustrate the differences in treatment outcomes between IPRPs that focus on rehabilitation and conventional alternatives, I note that based on a meta-analysis of 65 published studies of the outcomes of IPRPs, which included 3089 patients, 45% to 65% of patients treated at IPRPs returned to work following treatment.[2] These results can be compared with studies reporting that only 20% of patients return to work following surgery for pain and 25% return to work following implantable pain control devices.[7] Studies have reported that a significant percentage of chronic-pain patients treated with surgery report that their pain is worse following surgery.[8,9] Subsequent operations do not guarantee resolution of pain, and some studies acknowledge poor results achieved with reoperations.[10]

There are no randomized, controlled trials demonstrating the effectiveness of long-term use of opioids and little evidence to support the success of long-term opioid use in improving patients' functional outcomes, including return to work.[11] Moreover, in contrast to alternatives such as surgery and neuroaugmentive procedures, which report complications of treatment as high as 50%, there are no reported iatrogenic consequences for IPRPs.[12] The results of the meta-analysis mentioned above indicate that following treatment at IPRPs, patients required one third the number of surgical interventions and hospitalizations compared with patients treated by medical and surgical care. Furthermore, treatment at IPRPs resulted in closure of disability claims for one half of those receiving disability at the time of treatment. Even at long-term follow-up, patients treated at IPRPs appear to function better than 75% of chronic-pain patients treated by alternative treatment approaches.

Extrapolations from data based on the 3089 patients treated at IPRPs included in one meta-analysis indicate that savings in excess of $20 million would be achieved based on reductions in health care consumption and indemnity costs during the first year following treatment, even after factoring in the cost of treatment at IPRPs.[2] Considering that the average age of patients treated by pain specialists is 45 years, the anticipated savings until age 65 years would exceed $248 million. Using the same assumptions for the estimated 175,000 patients treated at IPRPs,[5] the financial savings would exceed $11 billion in the first year following treatment alone.

Most IPRPs include a broad range of components within a single rehabilitation package. Further research is needed to isolate the shared components of various successful treatment programs. There are no data available that identify the characteristics of patients who would most likely benefit from any of the pain treatment methods available. Studies are needed to answer the following question: What treatments delivered in what ways are most effective for patients with what set of characteristics? Successful answers will permit more clinically effective and cost-effective ways to treat the difficult population of patients with chronic pain.

In Summary

A substantial body of literature supports the assertion that IPRPs are effective in reducing pain, the use of opioid medication, and the use of health care services; increasing activity; returning persons to work; and closing disability claims. Comparisons of IPRPs with alternative pharmacologic and surgical interventions suggest that the rehabilitation programs are more effective. Not only do IPRPs appear to be clinically effective, they appear to be cost-effective, with the potential to provide substantial savings in health care and disability payments. These results are especially impressive when we realize that treatment at IPRPs targets patients with the most recalcitrant problems (ie, long duration and failure of many previous therapies).

References:

1. Bell G, Kidd D, North R. Cost-effectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. J Pain Symptom Manage. 1997;13:286-295.
2. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain. 1992;49:221-230.
3. Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Crit Rev Phys Med Rehabil Med. 1998;10:181-208.
4. Long DM, Filtzer DL, Ben Debba M, Hendler NM. Clinical features of the failed-back syndrome. J Neurosurg. 1988;69:61-71.
5. Chronic Pain Management Programs: A Market Analysis. Valley Stream, NY: Marketdata Enterprises; 1995.
6. Cutler RB, Fishbain DA, Rosomoff HL, et al. Does nonsurgical pain center treatment of chronic pain return patients to work? A review and meta-analysis of the literature. Spine. 1994;19:643-652.
7. North RB, Ewend MG, Lawton MT, et al. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery. 1991;28:692-699.
8. Franklin GM, Haug J, Heyer NJ, et al. Outcome of lumbar fusion in Washington State workers' compensation. Spine. 1994;19:1897-1904.
9. Friedlieb O. The impact of managed care on the diagnosis and treatment of low back pain: a preliminary report. Am J Med Qual. 1994;9:24-29.
10. North RB, Campbell JN, James CS, et al. Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operations. Neurosurgery. 1991;28:685-690.
11. Turk DC. Clinician attitudes about prolonged use of opioids and the issue of patient heterogeneity. J Pain Symptom Manage. 1996;11:218-230.
12. Turner JA, Loeser JD, Bell KG. Spinal cord stimulation for chronic low back pain: a systematic literature synthesis. Neurosurgery. 1995;37:1088-1096.