New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers Editor: Lorenz K.Y. Ng, M.D. National Institute on Drug Abuse NIDA Research Monograph 36 May 1981 DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse Division of Research 5600 Fishers Lane Rockville, Maryland 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 The NlDA Reseach Monogaph series is prepared by the Division of Research of the National lnstitute on Drug Abuse. lts primary objective is to provide critical reviews of research problem ares and techniques, the content of state-of-the-art conferences, integrative research review and significant original research. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisory Board Avram Goldstein, M.D. Addiction Research Foundation Palo Alto, California Jerome Jaffe, M.D. College of Physicians and Surgeons Columbia University, New York Reese T. Jones, M.D. Langley Porter Neuropsychiatric lnstitute University of California San Francisco, California Jack Mendelson, M.D. Alcohol and Drug Abuse Research Center Harvard Medical School McLean Hospital Belmont, Massachusetts Helen Nowlis, Ph.D. Office of Drug Education. DHHS Washington, D.C. Lee Robins, Ph.D. Washington University School of Medicine St Louis, Missouri NIDA Research Monograph series William Pollin, M.D. DIRECTOR, NIDA Marvin Snyder, Ph.D. DIRECTOR, DIVISION OF RESEARCH, NIDA Robert C. Petersen, Ph.D. EDITOR-IN-CHIEF Eleanor W. Waldrop MANAGING EDITOR Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers ACKNOWLEDGMENTS This monograph is based upon papers presented at a conference which took place on June 20-21, 1980, at the National Institutes of Health, Bethesda, Maryland. Koba Associates, Inc., Washington, D.C., provided administrative support for the conference under NIDA Contract No. 271-79-3607. The U.S. Government does not endorse or favor any specific commercial product or conmodity. Trade or proprietary names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this material is prohibited without specific permission of the copyright holders. With these exceptions, the contents of this monograph are in the public domain and may be used and reprinted without special permission. Citation as to source is appreciated. Library of Congress catalog card number 81-600060 DHHS publication number (ADM) 81-1089 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of BioSciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. iv Foreword At one time or another, pain is a matter of intense personal interest and concern to almost every one of us. Acute pain warns of a physical condition needing correction; yet all too often pain becomes chronic, a persistent and seemingly useless burden that inflicts suffering and disability out of all proportion to any discoverable physical pathology. Taken together, the costs of chronic pain to individuals and their families, to employers, insurers, and treatment providers are enormous. The person who suffers such pain seeks help, often with increasing desperation, through a health care system which is now awakening to the importance of chronic pain as a medical entity that demands a new body of knowledge reflected in professional training and in new approaches to treatment. In traditional treatments, medica- tions, often including narcotic drugs, have played a prominent part. A large proportion of patients become psychologically dependent upon these drugs and some become physically addicted. Multidisciplinary pain clinics or centers, often university-based, are emerging as institutions in which new understanding of the nature of pain and pain-related behavior is being developed and applied. Neurologists, orthopedic and neurological surgeons, psychiatrists and psychologists, anesthesiologists, social workers, specialized nurses, physical and occupational therapists, voca- tional counselors, and others, all may be part of the therapeutic team; but the patient's own active role in achieving a level of function as nearly normal as possible is central. As part of this process, elimination of all or most analgesic medication is stressed. The particular interest of the National Institute on Drug Abuse in the work of the pain centers is based on its mandate to encourage research on narcotic and other drugs, the use or misuse of which may result in drug abuse or dependence, and to publish information about such research and its practical applications. In this monograph, the pain clinics and centers report on their staffing and organization, the problems for which patients are treated, drugs taken by entering patients, therapeutic approaches used, costs of treatment, and methods for long-term evaluation of treatment effectiveness. Goals for future research and profes- sional and public education are also presented. v Strong beginnings have been made in this field. We hope that this sharing of ideas among active treatment practitioners will lead to further progress in alleviating the suffering caused by that most widely shared of human afflictions: pain. Marvin Snyder, Ph.D. Director, Division of Research National Institute on Drug Abuse vi Preface Despite recent encouraging trends in pain research and therapy, the management of patients with acute and chronic pain remains one of the most pressing issues of the American health care sys- tem. This importance stems from the fact that acute and chronic pain that requires therapy by physicians and other health profes- sionals afflicts some 45 percent of Americans annually. In many patients with chronic pain, and in some with acute pain, it is inadequately relieved. Consequently, pain is the most frequent cause of suffering and disability which seriously impairs the quality of life of many Americans. Accurate statistics from national epidemiologic studies on the prevalence of pain and its impact on the national economy are not available; however, data from numerous local and regional surveys and those published by various Federal and private agencies permit one to extrapolate and compute reasonable cost estimates. These indicate that acute and chronic pain costs the national economy between $85-90 billion annually. The available data suggest that nearly one-third of the American population has persistent or recurrent chronic pain. Over 50 million individuals are either partially or totally disabled for periods of days, weeks, or months, and some permanently. In most patients with back disorders, arthritis, headache, cancer, and other chronic painful conditions, it is not the underlying pathology but the pain that primarily impairs the patient's carrying out a productive life. On the basis of these data, it is estimated that as a result of chronic pain, well over 700 million work-days are lost which, together with health care costs and payments for compensation, litigation, and quackery, total nearly $60 billion annually. Even more important is the cost in human suffering. It is a dis- tressing fact that in this age of marvelous scientific and techno- logic advances, millions of patients suffer persistent pain which produces serious physical, emotional, and affective disorders. Moreover, in addition to the economic impact, pain has serious emotional and sociologic effects on members of the family. Despite its overwhelming clinical importance, pain research, until recently, was virtually neglected, and the advances in diagnosis and therapy have not been commensurate with most other biomedical scientific achievements. vii Many patients with non-malignant chronic pain do not respond to the usual medical therapy and, indeed, an impressive number are exposed to high risks of iatrogenic complications including drug toxicity, drug addiction, and multiple, often useless, and sometimes mutilat- ing operations, A significant number of these patients give up medical care and consult quacks. Some become so discouraged and so desperate as to contemplate, or even commit, suicide. Patients with cancer pain, which must be considered a form of chronic pain, fare no better. Indeed, there are numerous reports which indicate that many of the 250,000 Americans who have severe pain from advanced cancer live the last part of their lives with pain that is unrelieved. The reasons for this serious deficiency in our health care system can be grouped into three major categories: (1) voids in our knowledge about pain and its mechanisms; (2) inadequate or improper application of the knowledge and therapies currently available; and (3) problems with communication. Until very recently, pain research was neglected by the biomedical scientific connmmity, the National Institutes of Health (NIH), and other Federal and private research agencies. This fact was acknowledged by the then newly formed Interagency Committee on New Therapies for Pain and Discomfort when it stated