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Pain Centers

When going to a pain clinic, there is one thing that patients should always keep in mind: It’s that not all pain clinics are alike.  

 

More often than not, patients are referred to one type of clinic or another, without knowing that there are different types of clinics with different ways of treating chronic pain. Moreover, the different types of clinics are not all similarly effective. Research on the effectiveness of different types of common treatments for chronic pain show wide variations in how effective they are.  

 

Patients typically find it helpful to know about these different types of clinics, their different types of treatments, and their relative degree of effectiveness.

 

By most conventional healthcare standards, there are generally four types of pain clinics: 

  • Clinics that focus on surgical procedures, such as spinal fusions and laminectomies

  • Clinics that focus on interventional procedures, such as epidural steroid injections and nerve blocks

  • Clinics that focus on long-term opioid (i.e., narcotic) pain medication management

  • Clinics that focus on chronic pain rehabilitation programs

Sometimes, clinics combine these approaches. For instance, interventional pain clinics commonly combine their focus on interventional procedures with long-term opioid management. Other times, surgeons and interventional pain physicians combine their efforts and have clinics that focus on both surgeries and interventional procedures. Nonetheless, it is conventional to think of pain clinics along these four types of care – surgeries, interventional procedures, long-term opioid medications, and chronic pain rehabilitation programs.

 

The fact that there are different types of pain clinics is indicative of another important fact that patients should know. It’s that the healthcare field doesn’t agree on how best to treat people with chronic pain.  

 

Surgery clinics

Patients with chronic neck or back pain often seek care at spine surgery clinics. While spinal surgeries have been performed for about a century for conditions like fractures of the vertebrae or other forms of spinal instability, spinal surgeries for the purpose of chronic pain management began about forty years ago. Knoeller, S. M., Seifried, C. (2000). Historical perspective: History of spinal surgery. Spine, 25, 2838-2843. McDonnell, D. E. (2004). History of spinal surgery: One neurosurgeon’s perspective. Neurosurgical Focus, 16, 1-5. Typical spine surgeries are laminectomies, discectomies, and fusions. A laminectomy is a surgical procedure that removes part of the vertebral bone. A discectomy is a surgical procedure that removes disc material, usually after the disc has herniated. A fusion is a surgical procedure that joins one or more vertebrae together with the use of bone taken from another area of the body or with metallic rods and screws.  

 

Patients often think of spine surgery as a cure for chronic neck or back pain. While acknowledging that spine surgeries can be helpful for some patients, a good spine surgeon should correct this misunderstanding and state that spine surgeries are not cures for chronic spine-related pain.  

 

Patients are commonly surprised to learn that there are few studies on the effectiveness of back surgeries for chronic spine-related pain. 

 

Mirza and Deyo Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823. reviewed five published, randomized clinical trials for fusion surgery. Two had significant methodological problems, which prevented them from drawing any conclusions. One of the remaining three showed that fusion surgery was superior to conservative care. The other two compared fusion surgery to a very limited version of group-based cognitive behavioral therapy. These two studies found no differences between the surgical and psychological interventions at one and two year follow-up periods.  

 

In a large clinical trial, Weinstein, et al., Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296, 2441-2450. compared patients who received surgery with patients who did not receive surgery and found no difference on average. They followed up with the patients two years later and again found no difference between the groups. However, in a later article, they showed that the surgical patients had less pain on average at a four year follow-up period. Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

 

Surgery for sciatica in the first few months after onset has been shown to provide more rapid relief than conservative approaches. However, by one-year follow-up, the differences will no longer be apparent and the degree of pain that patients have is the same – whether they had surgery or not. Peul, W. C., et al. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245-2256.

 

Reviews of all the research conclude that there is only minimal evidence that lumbar surgeries are effective in reducing low back pain Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. [Cochrane Review]. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience. and there is no evidence to suggest that cervical surgeries are effective in reducing neck pain. Nikolaidis I., Fouyas, I. P., Sandercock, P. A., & Statham, P. F. (Updated December 14, 2008). Surgery for cervical radiculopathy or myelopathy. [Cochrane Review]. In Cochrane Database of Systematic Reviews, 2010 (1). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

 

Interventional pain clinics

Interventional pain clinics are the newest type of pain clinic, coming to be quite common in the 1990’s. Interventional pain physicians are typically anesthesiologists or physiatrists who have received added training in a variety of interventional pain management procedures, including epidural steroid injections, different types of nerve blocks, nerve burning procedures called ‘radiofrequency neuroablations,’ and implantable pain control devices, such as spinal cord stimulators and intrathecal drug delivery devices.  

 

Research on the outcomes of epidural steroid injections consistently shows that they are no more effective on average than injections filled with placebo. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

 

There are two published clinical trials of radiofrequency neuroablations and both found that the procedure was no better than a sham procedure, which is a feigned procedure that is essentially the procedural equivalent of a placebo. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344. Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

 

A spinal cord stimulator is a device that is surgically implanted into the body and typically used to reduce pain of a limb. Research on the effectiveness of spinal cord stimulators suffer from poor quality. A number of reviews of this research conclude that there is limited evidence to support their effectiveness. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093. Taylor, R. S., Van Buyten, J., & Buchser, E. (2005). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine, 30, 152-160. Turner, J. A., Loeser, J. D., Deyo, R. A., & Sanders, S. B. (2004). Spinal cord stimulation for patients with failed back syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain, 108, 137-147.  

 

Intrathecal drug delivery systems (aka “pain pumps”) are also implanted devices that deliver medications directly into the spinal fluid. Research on the effectiveness of these devices also suffer from poor quality. In their review, Turner, Sears, & Loeser Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195. found that intrathecal drug delivery systems were modestly helpful in reducing pain. However, because all studies are observational in nature, support for this conclusion is limited. Patel, V. B., Manchikanti, L., Singh, V., Schultz, D. M., Hayek, S. M., & Smith, H. S. (2009). Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. Pain Physician, 12, 345-360.

 

Long-term opioid management clinics

Another type of pain clinic is one that focuses primarily on prescribing opioid, or narcotic, pain medications on a long-term basis. The practice of long-term opioid management for chronic, non-cancer pain began in earnest about twenty years ago. This practice is controversial and there is by no means agreement among healthcare providers that it should be provided as commonly as it is. Passik, S. D., Heit, H., & Kirsch, K. L. (2006). Reality and responsibility: A commentary on the treatment of pain and suffering in a drug-using society. Journal of Opioid Management, 2, 123-127. Von Korff, M., Kolodny, A., Deyo, R. A., & Chou, R. (2012). Long-term opioid therapy reconsidered. Annals of Internal Medicine, 155, 325-328.

 

Advocates for long-term opioid therapies highlight the pain relieving properties of such medications, but research demonstrating their long-term effectiveness is limited. Chou, R., Ballantyne, J. C., Fanciullo, G. J., Fine, P. G., & Miaskowski, C. (2009). Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. Journal of Pain, 10, 147-159. Ballantyne, J. C. & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. Clinical Journal of Pain, 24, 469-478.

 

Addiction, Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin.  D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127. tolerance, opioid-induced hyperalgeisa, Angst, M.  & Clark, J. (2006). Opioid-induced hyperalgesia: A quantitative systematic review. Anesthesiology, 104, 570-587. hormonal changes, Vuong., C., Van Uum, S. H., O’Dell, L. E., Lutfy, K., Friedman, T. C. (2010). The effects of opioids and opioid analogs on animal and human endocrine systems. Endocrine Review, 31, 98-132. and mental cloudiness Kamboj, S. K., Tookman, A., Jones, L.  & Curran, H. V. (2005). The effect of immediate-release morphine on cognitive functioning in patients receiving chronic opioid therapy in palliative care. Pain, 117, 388-395. are also factors that make the use of long-term opioid therapies controversial.

 

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are another type of pain clinic that focuses on teaching patients how to manage pain and return to work – and to do so without the use of opioid medications. They have an interdisciplinary staff of psychologists, physicians, physical therapists, nurses, and oftentimes occupational therapists and vocational rehabilitation counselors.

 

The therapeutic interventions of interdisciplinary chronic pain rehabilitation programs consist of cognitive behavioral therapy, mild aerobic exercise and other types of physical therapy, and non-narcotic pain medication management. The goals of such programs are reducing pain, returning to work or other life activities, reducing the use of opioid pain medications, and reducing the need for obtaining healthcare services. 

 

Chronic pain rehabilitation programs are likely the oldest type of pain clinic, having been developed in the 1960’s and 1970’s. Chen, J. J. (2006). Outpatient pain rehabilitation programs. Iowa Orthopaedic Journal, 26, 102-106.

 

Multiple reviews of the research highlight that there is high quality evidence demonstrating that these programs are moderately to substantially effective. Flor, H., Fydrich, T. & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

 

In his review of the research, Turk Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain, 18, 355-365. found that patients in chronic pain rehabilitation programs reduce pain on average by approximately 35%, even after reducing opioid pain medications.  

 

Multiple studies show rates of returning to work from 29-86% for patients completing a chronic pain rehabilitation program. 30 These rates of returning to work are higher than any other treatment for chronic pain.  

 

Additionally, a number of studies report significant reductions in utilizing healthcare services following completion of a chronic pain rehabilitation program. For example, Gatchel & Okifuji 30 reviewed multiple studies showing that 60-90% of program completers do not seek additional healthcare services for their chronic pain, even at one year follow-up.  

 

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog.

 

References

Last Updated on Monday, 26 October 2015 00:12

Published on Friday, 27 April 2012 14:03

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