INFORMATION Refer to: Pepitone-Rockwell F, Rosenblatt R, Corkill G: Pain clinic model for community practice (Information). West J Med 131:166-170, Aug 1979
to operate with the limited existing resources. Patients were evaluated by the clinic team members and then referred back to their primary care physicians with a comprehensive recommendation
Information
for treatment. Treatment was provided at the University Medical Center only when it could not be obtained at the community level to minimize the cost of the program. Although currently operating in a university medical setting, this pain clinic is applicable as a model for a community pain clinic. This paper outlines the functioning of the University of California, Davis, School of Medicine pain clinic and, using statistical data collated over the preceding four years, projects the types of pain problems that can be anticipated
Pain Clinic Model for Community Practice FRAN PEPITONE-ROCKWELL, PhD RICHARD ROSENBLATT, MD GUY CORKILL, MD Sacramento, California THE EFFECTIVE MANAGEMENT of chronic, benign pain remains a problem despite recent advances in explaining its pathophysiology. Because narcotics and other modalities of pain control are often ineffective, the therapeutic resources available to physicians are limited. Pain clinics staffed by teams of physicians and other health professionals have been established to provide a wider range of patient care expertise. This multidisciplinary concept was conceived by John Bonica,' an anesthesiologist who recognized the limited resources and effectiveness of solo practitioners attempting to manage complex pain problems. Bonica's multidisciplinary team approach included professionals from the following medical and surgical specialities: psychiatry, psychology, physical medicine, clinical pharmacology and family practice. Although proposed in 1953, this concept has taken hold only in the last ten years, with numerous pain clinics now active nationwide. Originally, pain clinics were primarily hospital based and most emphasized care of inpatients. In contrast, the pain clinic at the University of California, Davis, School of Medicine was planned from its inception in 1975 to offer consultative services only. The clinic, using the multidisciplinary approach, tailored its program to meet the specialized needs of the medical community, and From the Departments of Psychiatry (Dr. Pepitone-Rockwell), Anesthesiology (Dr. Rosenblatt) and Neurostirgery (Dr. Corkill), University of California, Davis, School of Medicine. Reprint requests to: Fran Pepitone-Rockwell, PhD, Department of Psychiatry, UCD-Sacramento Medical Center, 4430 V Street, Sacramento, CA 95817.
166
AUGUST 1979 * 131
* 2
at the community level.
Goals of the Pain Clinic The implicit goal of every pain clinic is to eliminate suffering by patients with chronic pain. In many instances, this objective cannot be fully achieved. The operational objectives, whether explicitly stated or not, are as follows: * Identify those patients whose source of pain (usually organic) can be identified and treated conventionally. * Identify those patients whose source of pain is known but unamenable to current therapy. * Identify those patients whose pain has neither an identifiable cause nor definitive treatment. The latter two groups make up most of the patients in any pain clinic population and these patients, while least amenable to treatment, are frequently the abusers of medical resources: physician time, unnecessary admissions to hospital and needless operations and overuse of multiple drugs. At the very least, pain clinics can protect these patients from the high-cost, highrisk, intensive medical and surgical environment. Treating these patients conservatively, prescribing only medications that are necessary and counseling against further surgical procedures is both economically advantageous and humanitarian. Patients often come to a pain clinic ostensibly to make the simplistic demand for relief from their pain. Yet, chronic pain patients as a group are notorious for having covert objectives. Alleviation of their pain, in many instances, is not one of their goals. Sternbach2 has written extensively on this process, categorizing it as a variant of gamesmanship. In fact, many chronic pain pa-
INFORMATION
tients derive an almost perverse delight in highlighting the physician's inability to relieve their pain. Any practitioner involved in pain management should be thoroughly acquainted with the dynamics of these gamelike interactions. A primary care physician often refers a chronic pain patient for improved care or because he or she is either overwhelmed or intimidated by this patient. A person with complex pain problems can physically and emotionally drain the solitary physician who is treating him or her. Therefore, education and support of referring physicians have become additional goals of- the pain clinic.
Evaluation of the Chronic Pain Patient Chronic pain problems present a complex interaction of organic, social and psychological processes. By the time a patient is referred to a pain clinic, a purely neuroanatomical approach to diagnosing the cause of pain will probably fail. Hence, in evaluating a chronic pain problem, most pain clinics pursue a comprehensive physical and psychological work-up of the' patient. Our current diagnostic profile includes the following items: * A letter from the referring physician. * Pertinent old records and diagnostic studies. * Completion of the Minnesota Multiphasic Personality Inventory (MMPI) by both patient and spouse. * Composition of a one-day pain diary. * An account of "my pain" by the patient. * A comprehensive list of all medications with respective dosage schedules. * Completion of a standardized pain questionnaire. * A general medical examination. * Pertinent medical and surgical specialty ex-
aminations. * A psychiatric consultation. * A home visit and evaluation by
a social worker. * A drug screen of urine and blood specimens. * Appropriate laboratory tests (for example, x-ray films, electromyogram, bone scan, estimated sedimentation rate). The unique aspects of the pain clinic evaluation, other than physicians' consultations and associated diagnostic studies, are the pain diary, questionnaire and social worker's home visit. The
pain diary is intended to provide the pain clinic members with a detailed chronologic description of the patient's pain written at the time of its occurrence. The psychological interdependence of pain and the patient's environment is often shown in the pain diary. Difficulties arise in accurately describing pain; as a result, pain questionnaires have been developed by several investigators to try to categorize, using standardized terminology, the type and degree of pain. The pain questionnaire currently used in the University of California, Davis, School of Medicine pain clinic was developed by Dr. Prithvi Raj, from the Texas Neurological Institute, and has proved satisfactory. The home visit by the social worker is very important because chronic pain in a family member can profoundly affect a home environment, resulting in psychopathologic responses by the spouse and occasionally the patient's progeny. The home visit documents these changes and is of major importance in developing a treatment plan. Our experience has been that the nature and cause of the pain is rarely established by means of diagnostic studies. However, several occult neoplasms have been disclosed on bone scans, undiagnosed neuropathies are sometimes noted by the electromyogram (secondary to alcoholism, diabetes, and heavy metal poisoning) and analgesic abuse is routinely observed on urine drug screens. Nevertheless, the overall success rate of diagnostic studies in finding the cause of pain compared with that of conventional tests in finding the cause of organic disease is poor. The pain clinic evaluation is intended to be a thorough, comprehensive review of the patient's problem. An administrative assistant coordinates the data collection because the patient's case is reviewed only on completion of the prerequisites. It is essential that the patient, the spouse and clinic members be present and comprehensive current reports completed on the day of the clinic evaluation. The chronic pain patient is interviewed by clinic members who then interview the patient's spouse. Often a totally different description of the patient's pain is given by the spouse. The treatment plan is developed by the team members after assimilating the patient's data andinformation from the interviews. Finally, the patient and spouse together are informed of the conclusions and the prospective treatment plan is discussed with them. A member of the clinic THE WESTERN JOURNAL OF MEDICINE
167
INFORMATION
notifies the referring physician of the findings and proposed treatment plan, and a letter summarizing the plan is sent.
Treatment Regimens for Chronic Pain Patients Chronic pain management protocols are as varied as the patients, and each must be tailored to meet individual needs. Nevertheless, there are common elements. Related Conventional Management If a definitive treatment for the patient's pain exists, it should be used initially (for instance, carbamazepine therapy for trigeminal neuralgia or excision of stump neuroma for amputee pain). Analgesic Medications Patients requiring analgesics should be maintained on a drug regimen appropriate for their pain. Mild to moderate pain can normally be alleviated by nonnarcotic analgesics and severe pain best managed by methadone. Selection of a drug with a low potential for habituation and abuse is essential. Commonly prescribed analgesics such as Dilaudid (hydromorphone hydrochloride) and Percodan (a combination of oxycodone, acetylsalicylic acid, phenacetin and caffeine) are clearly contraindicated and simplicity of prescription is sought. Where possible, a threelevel prescribing practice is used: acetylsalicylic acid for mild pain, codeine for moderate pain and methadone for severe pain. Clearly, this should be modified on occasion but it is a basic guideline for analgesic therapy.
Detoxification Abuse of analgesics and sedatives is common among chronic pain patients. In our experience, multidrug dependence is best managed with inhospital detoxification; the risks of withdrawal are minimized and long-term compliance improved. Detoxification should be managed only by experienced physicians because significant potential risks are involved. Emotional Support Because psychic alterations are the norm in persons suffering from chronic pain, behavioral change is an essential part of their treatment. Depression, with its many manifestations, is most commonly observed. Psychotropic medications, psychotherapy and group counseling have been 168
AUGUST 1979 * 131
* 2
tried with varying degrees of success. Newer modes of behavioral change (hypnosis and biofeedback) are also proving effective. Combining several of these modalities appears to be the treatment of choice. Transcutaneous Stimulation A new and exceedingly useful tool for managing chronic pain is the transcutaneous electrical stimulator. This wallet-sized device delivers electrical impulses to the body noninvasively to stimulate components of the nervous system, which results in local analgesia. Although its efficacy varies substantially depending on the type, location and severity of the pain, this strategy has the advantage of being innocuous and may be prescribed with confidence early in any form of chronic pain management. Physical Therapy For many patients deterioration in physical status accompanies chronic pain. Often, it is the patient's physical condition, not the pain, that prevents him or her from resuming a normal life. Therefore, physical therapy is an integral part of the treatment plan.
Occupational Disability and Rehabilitation Counseling Occupational disability is another common accompaniment to many chronic pain syndromes. Most chronic pain patients eventually learn to adapt to their pain, but many are unable to return to their original jobs. With occupational counseling and vocational rehabilitation, many of these unemployed persons can resume work. Many patients do not desire an invalid's lifestyle. Rehabilitation counseling can provide patients, particularly the young, with the opportunity or face-saving rationale they need in order to change-and this is sometimes welcome. Social Service Counseling Chronic pain in a family member can be very destructive to a marriage and the home environment. Supportive family counseling is indicated and is often beneficial. We have briefly outlined the clinic's approach to treatment of chronic pain. But our limited knowledge of the nature, variety and pathophysiology of chronic pain prevents us from implementing a standard treatment protocol. Recent recognition of the role of endorphins in emo-
INFORMATION TABLE 1.-Demographic Data of Pain Patients: 1976-1978 Women
Number of Patients ... 47 (56.6%) Age (years) Range .... 18-84 Mean ..... 44.8 Number
Marital Status Married .. Divorced .. Widowed.. Single .... Unknown . Type of Pain LowBack . Chest ..... Other (limb, hip, etc) .
Men
Total
36 (43.4%)
83 (100.0%)
21-74 44.3 Number
Number
(percent)
(percent)
(percent)
33 (70.2) 4 ( 8.5) 4 (8.5) 4( 8.5) 2 ( 4.3)
32 (88.9) 0 0 4 (11.1) 0
65 (78.3) 4 ( 4.8) 4 (4.8) 8( 9.6) 2 ( 2.4)
14 (29.8) 6 (12.8)
20 (55.6) 1 ( 2.7)
34 (41.0) 7 ( 8.4)
27 (57.4)
15 (41.6)
42 (50.6)
tional status and pain transmission may point the way to more effective treatment of this common malady.
Funding of a Pain Clinic The newness of pain clinics with their unconventional programs has impeded reimbursement, a predicament exacerbated by the expense of the mutidisciplinary team approach. Many private insurance carriers, unfamiliar with this multidisciplinary concept, have challenged pain clinics as bona fide providers of health service and have refused payment. Governmental health programs aggravate matters further by requiring supplemental reports and then rarely reimbursing the full charge. Often, a pain patient is unable to pay, being unemployed and having already exhausted his or her insurance coverage. All of these factors complicate billing and collection. Accordingly, the University of California, Davis, pain clinic uses a single, all-inclusive fee (exclusive of laboratory tests), rather than pursuing individual, fee-for-service billing by the participants of the pain clinic. This has substantially reduced the paper work involved, and reimbursement rates have improved as third party carriers have become familiar with the fee profile.
Operating Experience Since 1976 the pain clinic at the University of California, Davis, School of Medicine has evaluated 83 chronic pain patients. This apparently limited number is deceptive because of the long
10 w7 5432-
0-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
AGE GROUPINGS
Figure 1.-Age distribution of pain clinic patients.
and arduous task of developing community referrals. At present, a waiting list in excess of 50 patients exists-with referrals threatening to exceed the capabilities of the clinic. This is a very common problem for pain clinics and is indicative of the incidence of chronic pain problems. Of the 83 patients evaluated, 47 (56.5 percent) were women and 36 (43.4 percent) were men (Table 1). This is in contrast to the 2:1 female to male ratio noted in community general practices and in the frequency of hospital admissions, and may reflect the higher number of men with occupational injuries. Ages ranged from 18 to 84 years with nearly identical median ages for men and women (Figure 1). The incidence of chronic pain is not limited to middle age-both young and old are affected. The relative infrequency of referred cases of chronic pain in young and old may reflect pediatricians' and gerontologists' (geriatricians') unfamiliarity with the diagnosis. Most of the chronic pain patients in this clinic population were married. The rate of divorce, anticipated to be high due to the stress on the home environment, proved unusually low. This was the case regardless of whether the chronic pain patient was a man or woman. In fact, none of our male patients were divorced. The incidence of chronic pain among single or widowed patients was proportional to their numbers in the overall population. The anatomic distribution of pain in this clinic population reflects the preponderance of back pain in society. The incidence rate of head and back pain was second, followed by pain in the chest and the extremities. The specialty profiles (Table 2) of the referring physicians reflect the anatomic distribution of the pain. Neurologists, neurosurgeons and orthopedists referred approxiTHE WESTERN JOURNAL OF MEDICINE
169
INFORMATION TABLE 2.-Physicians Refe rring Patients to Pain Clinic: 1976i-1978
Number (83)
Specialties
Percent
General Practice ....... .... 23 ....... 16 Neurology .... ....... 9 Orthopedics ....
Neurosurgery
8 ..... 5 Family Practice ..... Physical Medicine and Rehabilitation 5 3 ......... Internal Medicine ....... Psychiatry ...................... 2 2 ........ General Psychiatry ....... Dermatology ........... ......... 1 Obstetrics-Gynecology ......1...... .
...........
Anesthesiology .........1......... 1 ..................... Department of Rehabilitation ....1.. Unknown ....................... 5 Location Community Based ................ 55 University of California, Davis, School of Medicine ....... ...... 24 Unknown ....................... 4
Hematology
mately 40 percent of the patients, and 35 percent were referred by primary care physicians. It is of interest that most of these latter patients had been seen earlier by a neurologist, neurosurgeon or orthopedist. The remaining patients were referred by various other specialties. Two thirds of the patients seen in the pain clinic were not university patients, attesting to the success in attracting community referrals. A cursory study of types of pain and the specialty of the referring physician indicates no significant differences between university and community patients. There-
170
AUGUST 1979 * 131
* 2
fore, the statistical data presented can be construed as fairly representative of the variety of problems a community pain clinic can anticipate.
Summary Drug abuse, psychiatric premorbidity and a complex interaction of social and psychological factors affect the treatment of chronic pain. A physician's frustration and resentment regarding a chronic pain patient's needs and skillful manipulation by the patient further complicate management. The multidisciplinary team approach to the management of chronic pain has much to offer: advice against unnecessary surgical procedures; counseling; detoxification; the conservative' use of medication; supportive psychiatric, physical or occupational therapies, and retraining to resume a normal life. Fiscal viability is difficult to achieve for such a pain clinic unless care is taken to adjust patient mix, obtain prepayment to some extent and obtain commitment for preferential charging for facilities. Fundamental to the successful functioning of a pain clinic is the dedication, availability and patience of the clinic coordinator, the one member of the staff who should be employed full time in the program. REFERENCES 1. Bonica JJ: General clinical considerations, In Bonica JJ, Procacci CA, Pagni CA (Eds): Recent Advances on Pain. Springfield, IL, Charles C Thomas, 1974, pp 274-298 2. Sternbach RA: Pain Patients. New York, Academic Press, 1974, pp 52-78
to operate with the limited existing resources. Patients were evaluated by the clinic team members and then referred back to their primary care physicians with a comprehensive recommendation
Information
for treatment. Treatment was provided at the University Medical Center only when it could not be obtained at the community level to minimize the cost of the program. Although currently operating in a university medical setting, this pain clinic is applicable as a model for a community pain clinic. This paper outlines the functioning of the University of California, Davis, School of Medicine pain clinic and, using statistical data collated over the preceding four years, projects the types of pain problems that can be anticipated
Pain Clinic Model for Community Practice FRAN PEPITONE-ROCKWELL, PhD RICHARD ROSENBLATT, MD GUY CORKILL, MD Sacramento, California THE EFFECTIVE MANAGEMENT of chronic, benign pain remains a problem despite recent advances in explaining its pathophysiology. Because narcotics and other modalities of pain control are often ineffective, the therapeutic resources available to physicians are limited. Pain clinics staffed by teams of physicians and other health professionals have been established to provide a wider range of patient care expertise. This multidisciplinary concept was conceived by John Bonica,' an anesthesiologist who recognized the limited resources and effectiveness of solo practitioners attempting to manage complex pain problems. Bonica's multidisciplinary team approach included professionals from the following medical and surgical specialities: psychiatry, psychology, physical medicine, clinical pharmacology and family practice. Although proposed in 1953, this concept has taken hold only in the last ten years, with numerous pain clinics now active nationwide. Originally, pain clinics were primarily hospital based and most emphasized care of inpatients. In contrast, the pain clinic at the University of California, Davis, School of Medicine was planned from its inception in 1975 to offer consultative services only. The clinic, using the multidisciplinary approach, tailored its program to meet the specialized needs of the medical community, and From the Departments of Psychiatry (Dr. Pepitone-Rockwell), Anesthesiology (Dr. Rosenblatt) and Neurostirgery (Dr. Corkill), University of California, Davis, School of Medicine. Reprint requests to: Fran Pepitone-Rockwell, PhD, Department of Psychiatry, UCD-Sacramento Medical Center, 4430 V Street, Sacramento, CA 95817.
166
AUGUST 1979 * 131
* 2
at the community level.
Goals of the Pain Clinic The implicit goal of every pain clinic is to eliminate suffering by patients with chronic pain. In many instances, this objective cannot be fully achieved. The operational objectives, whether explicitly stated or not, are as follows: * Identify those patients whose source of pain (usually organic) can be identified and treated conventionally. * Identify those patients whose source of pain is known but unamenable to current therapy. * Identify those patients whose pain has neither an identifiable cause nor definitive treatment. The latter two groups make up most of the patients in any pain clinic population and these patients, while least amenable to treatment, are frequently the abusers of medical resources: physician time, unnecessary admissions to hospital and needless operations and overuse of multiple drugs. At the very least, pain clinics can protect these patients from the high-cost, highrisk, intensive medical and surgical environment. Treating these patients conservatively, prescribing only medications that are necessary and counseling against further surgical procedures is both economically advantageous and humanitarian. Patients often come to a pain clinic ostensibly to make the simplistic demand for relief from their pain. Yet, chronic pain patients as a group are notorious for having covert objectives. Alleviation of their pain, in many instances, is not one of their goals. Sternbach2 has written extensively on this process, categorizing it as a variant of gamesmanship. In fact, many chronic pain pa-
INFORMATION
tients derive an almost perverse delight in highlighting the physician's inability to relieve their pain. Any practitioner involved in pain management should be thoroughly acquainted with the dynamics of these gamelike interactions. A primary care physician often refers a chronic pain patient for improved care or because he or she is either overwhelmed or intimidated by this patient. A person with complex pain problems can physically and emotionally drain the solitary physician who is treating him or her. Therefore, education and support of referring physicians have become additional goals of- the pain clinic.
Evaluation of the Chronic Pain Patient Chronic pain problems present a complex interaction of organic, social and psychological processes. By the time a patient is referred to a pain clinic, a purely neuroanatomical approach to diagnosing the cause of pain will probably fail. Hence, in evaluating a chronic pain problem, most pain clinics pursue a comprehensive physical and psychological work-up of the' patient. Our current diagnostic profile includes the following items: * A letter from the referring physician. * Pertinent old records and diagnostic studies. * Completion of the Minnesota Multiphasic Personality Inventory (MMPI) by both patient and spouse. * Composition of a one-day pain diary. * An account of "my pain" by the patient. * A comprehensive list of all medications with respective dosage schedules. * Completion of a standardized pain questionnaire. * A general medical examination. * Pertinent medical and surgical specialty ex-
aminations. * A psychiatric consultation. * A home visit and evaluation by
a social worker. * A drug screen of urine and blood specimens. * Appropriate laboratory tests (for example, x-ray films, electromyogram, bone scan, estimated sedimentation rate). The unique aspects of the pain clinic evaluation, other than physicians' consultations and associated diagnostic studies, are the pain diary, questionnaire and social worker's home visit. The
pain diary is intended to provide the pain clinic members with a detailed chronologic description of the patient's pain written at the time of its occurrence. The psychological interdependence of pain and the patient's environment is often shown in the pain diary. Difficulties arise in accurately describing pain; as a result, pain questionnaires have been developed by several investigators to try to categorize, using standardized terminology, the type and degree of pain. The pain questionnaire currently used in the University of California, Davis, School of Medicine pain clinic was developed by Dr. Prithvi Raj, from the Texas Neurological Institute, and has proved satisfactory. The home visit by the social worker is very important because chronic pain in a family member can profoundly affect a home environment, resulting in psychopathologic responses by the spouse and occasionally the patient's progeny. The home visit documents these changes and is of major importance in developing a treatment plan. Our experience has been that the nature and cause of the pain is rarely established by means of diagnostic studies. However, several occult neoplasms have been disclosed on bone scans, undiagnosed neuropathies are sometimes noted by the electromyogram (secondary to alcoholism, diabetes, and heavy metal poisoning) and analgesic abuse is routinely observed on urine drug screens. Nevertheless, the overall success rate of diagnostic studies in finding the cause of pain compared with that of conventional tests in finding the cause of organic disease is poor. The pain clinic evaluation is intended to be a thorough, comprehensive review of the patient's problem. An administrative assistant coordinates the data collection because the patient's case is reviewed only on completion of the prerequisites. It is essential that the patient, the spouse and clinic members be present and comprehensive current reports completed on the day of the clinic evaluation. The chronic pain patient is interviewed by clinic members who then interview the patient's spouse. Often a totally different description of the patient's pain is given by the spouse. The treatment plan is developed by the team members after assimilating the patient's data andinformation from the interviews. Finally, the patient and spouse together are informed of the conclusions and the prospective treatment plan is discussed with them. A member of the clinic THE WESTERN JOURNAL OF MEDICINE
167
INFORMATION
notifies the referring physician of the findings and proposed treatment plan, and a letter summarizing the plan is sent.
Treatment Regimens for Chronic Pain Patients Chronic pain management protocols are as varied as the patients, and each must be tailored to meet individual needs. Nevertheless, there are common elements. Related Conventional Management If a definitive treatment for the patient's pain exists, it should be used initially (for instance, carbamazepine therapy for trigeminal neuralgia or excision of stump neuroma for amputee pain). Analgesic Medications Patients requiring analgesics should be maintained on a drug regimen appropriate for their pain. Mild to moderate pain can normally be alleviated by nonnarcotic analgesics and severe pain best managed by methadone. Selection of a drug with a low potential for habituation and abuse is essential. Commonly prescribed analgesics such as Dilaudid (hydromorphone hydrochloride) and Percodan (a combination of oxycodone, acetylsalicylic acid, phenacetin and caffeine) are clearly contraindicated and simplicity of prescription is sought. Where possible, a threelevel prescribing practice is used: acetylsalicylic acid for mild pain, codeine for moderate pain and methadone for severe pain. Clearly, this should be modified on occasion but it is a basic guideline for analgesic therapy.
Detoxification Abuse of analgesics and sedatives is common among chronic pain patients. In our experience, multidrug dependence is best managed with inhospital detoxification; the risks of withdrawal are minimized and long-term compliance improved. Detoxification should be managed only by experienced physicians because significant potential risks are involved. Emotional Support Because psychic alterations are the norm in persons suffering from chronic pain, behavioral change is an essential part of their treatment. Depression, with its many manifestations, is most commonly observed. Psychotropic medications, psychotherapy and group counseling have been 168
AUGUST 1979 * 131
* 2
tried with varying degrees of success. Newer modes of behavioral change (hypnosis and biofeedback) are also proving effective. Combining several of these modalities appears to be the treatment of choice. Transcutaneous Stimulation A new and exceedingly useful tool for managing chronic pain is the transcutaneous electrical stimulator. This wallet-sized device delivers electrical impulses to the body noninvasively to stimulate components of the nervous system, which results in local analgesia. Although its efficacy varies substantially depending on the type, location and severity of the pain, this strategy has the advantage of being innocuous and may be prescribed with confidence early in any form of chronic pain management. Physical Therapy For many patients deterioration in physical status accompanies chronic pain. Often, it is the patient's physical condition, not the pain, that prevents him or her from resuming a normal life. Therefore, physical therapy is an integral part of the treatment plan.
Occupational Disability and Rehabilitation Counseling Occupational disability is another common accompaniment to many chronic pain syndromes. Most chronic pain patients eventually learn to adapt to their pain, but many are unable to return to their original jobs. With occupational counseling and vocational rehabilitation, many of these unemployed persons can resume work. Many patients do not desire an invalid's lifestyle. Rehabilitation counseling can provide patients, particularly the young, with the opportunity or face-saving rationale they need in order to change-and this is sometimes welcome. Social Service Counseling Chronic pain in a family member can be very destructive to a marriage and the home environment. Supportive family counseling is indicated and is often beneficial. We have briefly outlined the clinic's approach to treatment of chronic pain. But our limited knowledge of the nature, variety and pathophysiology of chronic pain prevents us from implementing a standard treatment protocol. Recent recognition of the role of endorphins in emo-
INFORMATION TABLE 1.-Demographic Data of Pain Patients: 1976-1978 Women
Number of Patients ... 47 (56.6%) Age (years) Range .... 18-84 Mean ..... 44.8 Number
Marital Status Married .. Divorced .. Widowed.. Single .... Unknown . Type of Pain LowBack . Chest ..... Other (limb, hip, etc) .
Men
Total
36 (43.4%)
83 (100.0%)
21-74 44.3 Number
Number
(percent)
(percent)
(percent)
33 (70.2) 4 ( 8.5) 4 (8.5) 4( 8.5) 2 ( 4.3)
32 (88.9) 0 0 4 (11.1) 0
65 (78.3) 4 ( 4.8) 4 (4.8) 8( 9.6) 2 ( 2.4)
14 (29.8) 6 (12.8)
20 (55.6) 1 ( 2.7)
34 (41.0) 7 ( 8.4)
27 (57.4)
15 (41.6)
42 (50.6)
tional status and pain transmission may point the way to more effective treatment of this common malady.
Funding of a Pain Clinic The newness of pain clinics with their unconventional programs has impeded reimbursement, a predicament exacerbated by the expense of the mutidisciplinary team approach. Many private insurance carriers, unfamiliar with this multidisciplinary concept, have challenged pain clinics as bona fide providers of health service and have refused payment. Governmental health programs aggravate matters further by requiring supplemental reports and then rarely reimbursing the full charge. Often, a pain patient is unable to pay, being unemployed and having already exhausted his or her insurance coverage. All of these factors complicate billing and collection. Accordingly, the University of California, Davis, pain clinic uses a single, all-inclusive fee (exclusive of laboratory tests), rather than pursuing individual, fee-for-service billing by the participants of the pain clinic. This has substantially reduced the paper work involved, and reimbursement rates have improved as third party carriers have become familiar with the fee profile.
Operating Experience Since 1976 the pain clinic at the University of California, Davis, School of Medicine has evaluated 83 chronic pain patients. This apparently limited number is deceptive because of the long
10 w7 5432-
0-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
AGE GROUPINGS
Figure 1.-Age distribution of pain clinic patients.
and arduous task of developing community referrals. At present, a waiting list in excess of 50 patients exists-with referrals threatening to exceed the capabilities of the clinic. This is a very common problem for pain clinics and is indicative of the incidence of chronic pain problems. Of the 83 patients evaluated, 47 (56.5 percent) were women and 36 (43.4 percent) were men (Table 1). This is in contrast to the 2:1 female to male ratio noted in community general practices and in the frequency of hospital admissions, and may reflect the higher number of men with occupational injuries. Ages ranged from 18 to 84 years with nearly identical median ages for men and women (Figure 1). The incidence of chronic pain is not limited to middle age-both young and old are affected. The relative infrequency of referred cases of chronic pain in young and old may reflect pediatricians' and gerontologists' (geriatricians') unfamiliarity with the diagnosis. Most of the chronic pain patients in this clinic population were married. The rate of divorce, anticipated to be high due to the stress on the home environment, proved unusually low. This was the case regardless of whether the chronic pain patient was a man or woman. In fact, none of our male patients were divorced. The incidence of chronic pain among single or widowed patients was proportional to their numbers in the overall population. The anatomic distribution of pain in this clinic population reflects the preponderance of back pain in society. The incidence rate of head and back pain was second, followed by pain in the chest and the extremities. The specialty profiles (Table 2) of the referring physicians reflect the anatomic distribution of the pain. Neurologists, neurosurgeons and orthopedists referred approxiTHE WESTERN JOURNAL OF MEDICINE
169
INFORMATION TABLE 2.-Physicians Refe rring Patients to Pain Clinic: 1976i-1978
Number (83)
Specialties
Percent
General Practice ....... .... 23 ....... 16 Neurology .... ....... 9 Orthopedics ....
Neurosurgery
8 ..... 5 Family Practice ..... Physical Medicine and Rehabilitation 5 3 ......... Internal Medicine ....... Psychiatry ...................... 2 2 ........ General Psychiatry ....... Dermatology ........... ......... 1 Obstetrics-Gynecology ......1...... .
...........
Anesthesiology .........1......... 1 ..................... Department of Rehabilitation ....1.. Unknown ....................... 5 Location Community Based ................ 55 University of California, Davis, School of Medicine ....... ...... 24 Unknown ....................... 4
Hematology
mately 40 percent of the patients, and 35 percent were referred by primary care physicians. It is of interest that most of these latter patients had been seen earlier by a neurologist, neurosurgeon or orthopedist. The remaining patients were referred by various other specialties. Two thirds of the patients seen in the pain clinic were not university patients, attesting to the success in attracting community referrals. A cursory study of types of pain and the specialty of the referring physician indicates no significant differences between university and community patients. There-
170
AUGUST 1979 * 131
* 2
fore, the statistical data presented can be construed as fairly representative of the variety of problems a community pain clinic can anticipate.
Summary Drug abuse, psychiatric premorbidity and a complex interaction of social and psychological factors affect the treatment of chronic pain. A physician's frustration and resentment regarding a chronic pain patient's needs and skillful manipulation by the patient further complicate management. The multidisciplinary team approach to the management of chronic pain has much to offer: advice against unnecessary surgical procedures; counseling; detoxification; the conservative' use of medication; supportive psychiatric, physical or occupational therapies, and retraining to resume a normal life. Fiscal viability is difficult to achieve for such a pain clinic unless care is taken to adjust patient mix, obtain prepayment to some extent and obtain commitment for preferential charging for facilities. Fundamental to the successful functioning of a pain clinic is the dedication, availability and patience of the clinic coordinator, the one member of the staff who should be employed full time in the program. REFERENCES 1. Bonica JJ: General clinical considerations, In Bonica JJ, Procacci CA, Pagni CA (Eds): Recent Advances on Pain. Springfield, IL, Charles C Thomas, 1974, pp 274-298 2. Sternbach RA: Pain Patients. New York, Academic Press, 1974, pp 52-78
