Chronic pain is painful—that is obvious. But an approach to chronic pain that focuses on relief and management can often be more beneficial for patients than attempting to “cure” a patient’s complex underlying pain condition. In Seattle, Steven Stanos, DO, and his team have developed a rehabilitation-based program within their established traditional pain clinic that focuses on a three-pronged approach that targets biological, psychological and social factors that contribute to chronic pain.
Dr. Stanos three years ago left the Rehabilitation Institute of Chicago to launch what has been described a “pain boot camp” at the Swedish Medical Center in Seattle. The RIC functional restoration program has been well established for a number of years as a tertiary pain program within a large rehabilitation hospital facility. In Seattle, the goal was to establish a pain program within a standard pain clinic that had provided interventional pain services and medication management in the past.
Dr. Stanos and his colleagues concluded that adding a pain rehabilitation program would better serve an entire system of care, including primary care and specialists. Patients with chronic pain can enroll in a structured outpatient functional restoration day program to learn techniques that can help them return to the activities that chronic pain has prevented them from doing.
Separate from addiction or misuse problems, many times opioid use is a sign of a very narrowly focused treatment regime, Dr. Stanos said.
“Many patients referred to us with chronic pain have been placed on escalating doses of opioids, yet have had incomplete workups or failed attempts to integrate nonopioid analgesics and other behavioral health interventions that could help to assess pain-related psychological factors. Unfortunately, many clinicians don’t have resources to help them manage the ‘whole patient,’ ” Dr. Stanos said.
“For some patients, the opioids they’re taking, like any analgesic, may decrease their pain only a small amount. It’s not curing them. The opioid management issue becomes a distraction, and other patient factors were forgotten or underappreciated—the psychological part, the impact on their function at work and home, and social factors. Our goal at Swedish is to assess the unique patient factors and provide a team-based management approach for patients.”
Strength in numbers
“We’re putting our pain rehabilitation program within a traditional pain clinic and now are able to offer patients a true continuum of pain management care based on their unique needs, including medical management, interventional procedures, physical and occupational therapy, behavioral health services, and patient education,” Dr. Stanos said. “We are taking a multidisciplinary approach—usually provided at multiple settings or facilities—and putting it all under one roof, providing a more collaborative, interdisciplinary model of care.”
Patients start in groups of four. They come to the clinic for three days a week, five hours a session, for four weeks. Care is provided in individual and group settings. “Patients get to know each other and learn from each other,” he said. “It’s rare in medicine to take four strangers and have them spend a month together sharing very similar experiences around their suffering with chronic pain and to help them in the process of learning and integrating more active ways to manage their lives.”
A recent patient referred for an evaluation told Dr. Stanos, “All my friends have kind of abandoned me because all I talk about and focused on is my pain. I’ve lost that person I used to be.”
He said this patient is looking forward to participating in the program, spending time with other patients, and learning new skills.
There are often many factors that contribute to a patient’s chronic pain and pain-related disability, he said. That’s why Dr. Stanos and his colleagues take several hours to evaluate each patient for a rehabilitation program. All patients are evaluated by a behavioral-health therapist and a pain-medicine specialist. The evaluation process takes between two to three hours to complete.
“Even after this long assessment process, many times the team and the patient are just starting to understand what is happening and how we are going to move forward,” Dr. Stanos said.
Many factors contribute to chronic pain
Each patient that enters the program has a different story, he said. These include psychological factors, physical impairments and work-related injuries. The latter group of patients has “additional stressors related to returning to work, fears of not being able to provide for their families and fears of further injury if they return to work not ready.” This takes their pain problem “beyond an ‘opioid’ issue or a morphine-equivalent daily dose,” Stanos said.
“Each patient needs to be fully assessed before we can determine a proper treatment plan. Besides assessing their opioid or nonopioid medication use and efficacy, how are they sleeping? Are they depressed or anxious? What irrational thoughts may they have about their condition?” he said.
Many patients arrive at the clinic on an opioid medication regimen, and some patients need to have their medication reduced. “They may have developed an opioid-use disorder, struggle with ongoing misuse and abuse, dependency, hyperalgesia, or adverse effects may outweigh any reason to continue long-term,” Dr. Stanos said.
For those patients found not to be appropriate for continued use of opioids, “the structured setting of a pain rehabilitation program offers an optimal environment to wean or detoxify patients on opioids. The program not only offers them the emotional and educational support they need, but is also teaching them other more active ways to manage their pain. It makes opioid reduction and weaning far easier to accomplish,” he said.
Other patients may be on an opioid regimen that is appropriate and safe yet they need help in other areas such as benefits they could receive from active physical therapy like strengthening, improved aerobic capacity, or work with our occupational therapist around ergonomics and activity pacing, Dr. Stanos said.
Besides the important skills a patient can learn from a physical or occupational therapist, behavioral health interventions may include cognitive-behavioral therapy, mindfulness-based stress reduction, relaxation training, and nursing education. These are all critical components to a functional restoration approach, Dr. Stanos said.
A behavioral-health specialist, psychologist, social worker or counselor, can help a patient understand and identify signs and symptoms of depression, anxiety, as well as other psychological factors such as catastrophic thinking, fear-avoidance beliefs, maladaptive coping mechanisms, and family and co-worker interpersonal problems. Relaxation therapy helps teach patients to better control maladaptive physiologic changes in the body and learn techniques to decrease stress and pain such as deep breathing, autogenic training and imagery, Dr. Stanos said.
Nursing education focuses on teaching patients about pain physiology, the stress-pain relationship, proper diet, medication side effects, and ways to better self-manage pain and incorporate the various techniques the patient has learned from different disciplines.
“We see this time and time again. Once patients better understand the complex issues around their pain experience, the more comfortable and successful they can be in shifting to a true self-management approach, abandoning their quest to ‘cure’ their chronic pain,” Dr. Stanos said.
The clinic’s functional restoration program relies on a team-based approach where all of the members, therapists, and physicians, are learning from each other—communicating, collaborating and adjusting a patient’s treatment program to offer something that fits to their needs.
“The patient’s pain conditions may have started from an acute biomedical problem, where tissue injury and a ‘cure’ was the focus. When and if their pain becomes more chronic, a patient suffering with chronic pain may be impacted in a far more complex manner that includes physical, neurochemical and behavioral changes,” Dr. Stanos said. “We as health care providers need to assess a patient in a more biopsychosocial manner and provide care and management that reflects it.”
More than two dozen state and specialty medical societies are represented in the AMA Task Force to Reduce Prescription Opioid Abuse. The task force continues to work to reduce the stigma of pain and support efforts to ensure comprehensive treatment of pain, including non-opioid and non-pharmacologic alternatives when appropriate.