Pain Rehab Program Signals 'Profound' Treatment Shift

Pauline Anderson

April 30, 2018

VANCOUVER, British Columbia — Patients with chronic pain completing a comprehensive, multidisciplinary pain rehabilitation program use significantly fewer healthcare resources except in the area of behavioral health, new research shows

"We were surprised to see such a profound change" in use of health resources even within the first few months of completing the pain rehab program, study author Christy Hunt, DO, resident physician, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Costly Problem

Over half of Americans report having chronic pain, defined as pain that lasts at least 3 months.

"We know that chronic noncancer pain is a costly problem and a significant burden to patients," said Hunt. "As caregivers, we are always looking to how we can best take care of these patients in the most appropriate fashion."

Many patients who enroll in a pain rehabilitation program have chronic noncancer pain that is very refractory to treatment.

"These are patients who despite lots of procedures, despite medications including opioids, are just not getting better," said Hunt.

Throughout the intensive 3-week outpatient pain rehab program, patients access physical, occupational, and medical therapies and taper their opioid doses. In addition, they address any comorbid conditions they may have, including depression, trauma, anxiety, and poor sleep.

A previous study showed that participation in such a rehab program can reduce medical costs, but it didn't examine behavioral health utilization, diagnostic procedures, or therapeutic injections or surgeries, said Hunt.

For this new study, researchers looked at healthcare utilization of 25 patients at 3, 6, 12, and 18 months before and after participation in the pain rehab program.

From data extracted from electronic health records, they examined the number of health-related visits: to primary care doctors, to specialists including pain practitioners, to physical therapists (physiotherapists, occupational therapists, chiropractors), to emergency departments and urgent care centers, and to behavior health experts (for example social workers, psychologists, and counsellors).

The researchers also looked at various categories of medications, including psychoactive drugs such as antidepressants, sleep medicines, and analgesics (including opioids).

Strong Statistical Evidence

In addition, researchers examined diagnostic procedures (eg, electrocardiography for atypical chest pain) and therapeutic procedures (including surgeries and injections).

They were not able to look at healthcare expenditures.

At all four time points, the overall utilization patterns showed increased use of behavioral health resources and decreases in other care categories, said Hunt.

"Even in a study with only 25 patients, we see strong statistical significance all the way through 18 months."

For example, in a comparison of findings from 18 months after the program to those 18 months before the program, there were a significant decline in visits to primary care doctors and specialists (P < .0001) and in therapeutic procedures (P < .05) and an increase in behavioral health services (P < .0001). 

But the biggest jump in behavioral health resources was in the first 3-month comparison period.

"It's likely that these patients were not being adequately treated for comorbid depression, anxiety, and trauma," before enrolling in the program, said Hunt.

This shift toward behavioral treatments may address the impact of pain and promote improved functioning and quality of life, but is this cost-effective?

That question can only be definitively answered with access to cost data, said Hunt.

However, she stressed that while it's important to reduce costs, "it's also important that patients are still getting good care."

These results are encouraging enough to warrant a larger study using a matched cohort that could possibly look at costs as well as health service use, she said.

Substantial Shift

Commenting on the study for Medscape Medical News, Patrick J. Tighe, MD, associate professor of anesthesiology, and program director, Perioperative Analytics Group, University of Florida, Gainesville, said it "represents a substantial shift" in caring for pain patients.

And it looks like it's a shift in the right direction.

Tighe noted that many of the pain care modalities used less often by study patients completing the pain program "carry very high personal costs as well as financial costs that are borne by patients, their caregivers and the health system at large."

Behavioral health services are not without costs, but, said Tighe, study patients who accessed these services "may have received great benefit from those encounters."

The shift in pain care approaches highlighted by the study "looks very favorable," but "more work needs to be done to learn more,"  he said.

No funding sources or conflicts of interest were reported.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 293. Presented April 27, 2018.

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