An Alternative to Opioids for Chronic Pain
It’s an interesting fact about the field of chronic pain management that there is a safe and effective alternative to the use of opioids for chronic pain, but relatively few people know about it. The alternative to opioids is an interdisciplinary chronic pain rehabilitation program.
Chronic pain rehabilitation programs
Interdisciplinary chronic pain rehabilitation programs are a traditional form of treatment that provides patients with the ability to self-manage pain and return to work, all without the use of opioid medications. They bring about these goals by providing chronic pain patients with the opportunity to 1) make a number of lifestyle changes, which, when done over time, reduce the physiological basis of pain, and 2) learn a number of advanced ways to better cope with the pain that remains chronic. Patients learn both of these two prongs of self-management from a safe and supportive team of chronic pain rehabilitation experts who coach patients on how to do them.
For the motivated patient who is open to learning and wiling to practice these changes and skills, it becomes possible over time to self-manage pain without opioid medications and do it successfully. Many people with chronic pain learn to do it everyday in interdisciplinary chronic pain rehabilitation programs. As such, they are the traditional alternative to opioids for the management of chronic pain.
While currently not as common as other types of pain clinic (such as long-term opioid management clinics or interventional pain clinics), most every major city across the United States, Canada, Western Europe, Australia, and New Zealand has a chronic pain rehabilitation program. Most of the well-known destination healthcare centers through out the world have an interdisciplinary chronic pain rehabilitation program. Many smaller, local clinics have such programs too. Literally, countless numbers of patients go through interdisciplinary chronic pain rehabilitation programs everyday and in doing so they learn how to live well without opioid medications despite having chronic pain.
Interdisciplinary chronic pain rehabilitation programs have high quality research evidence that demonstrate their effectiveness as an alternative to opioids (Chou, et al., 2007; Gatchel & Okifuji, 2006). There are numerous well-designed studies that show patients routinely have considerably less pain once they complete an interdisciplinary chronic pain rehabilitation program. On top of it all, they are no longer taking opioid medications. That is to say, following participation in such a program, they have less pain than when they were taking opioids, but are now no longer on opioids (Becker, et al., 2000; Cosio & Linn, 2014; Crisostomo, et al., 2008; Meineche-Schmidt, Jensen, & Sjogren, 2012; Murphy, Clark, & Banou, 2013; Rush, et al., 2014; Townsend, et al., 2008).
Despite the large number of programs and despite the well-documented evidence supporting their effectiveness, many people with chronic pain who are seeking care, perhaps even a majority, remain unaware of chronic pain rehabilitation programs as an option available to them – let alone know that it is a safe and effective alternative to opioids for chronic pain.
A short history of chronic pain management
It wasn’t always this way. For a few decades prior to the 1990’s people with chronic pain obtained treatment in interdisciplinary chronic pain rehabilitation programs on a much more routine basis. Moreover, there were significantly more interdisciplinary chronic pain rehabilitation programs in existence (Gatchel, et al., 2014; Schatman, 2012). So what changed?
In the decades prior to the 1990’s, it was significantly less common to manage chronic pain with opioids. As such, interdisciplinary chronic pain rehabilitation programs were largely the only type of pain clinic there was. Patients with chronic pain knew of them and tended to seek out care within them.
With the advent of widespread use of opioids in the 1990’s, interdisciplinary chronic pain rehabilitation programs tended to get overshadowed. Some pain clinics offering this traditional model of chronic pain management closed and new pain clinics, offering long-term opioid management, opened in large numbers.
There are many possible reasons for this state of affairs. The newer form of chronic pain management is more lucrative than interdisciplinary chronic pain rehabilitation programs. Long-term opioid management tends to obtain insurance reimbursement easier than interdisciplinary chronic pain rehabilitation programs. The use of opioids also appears to at least temporarily resolve the need for interdisciplinary chronic pain rehabilitation programs. Who wants to go through the hard work of making large-scale lifestyle changes and learn advanced ways of coping to reduce pain if a medication can temporarily reduce it for you? (A similar argument could be made with regard to the widespread use of interventional procedures and spine surgeries beginning in the late 1980’s and into the 1990’s). Moreover, an increasingly common belief among patients, providers and society generally is that it is impossible to manage chronic pain well without opioids – that intolerable suffering would be the inevitable result. When firmly held, this belief subsequently leads to a great deal of skepticism about the wealth of clinical and research evidence that shows interdisciplinary chronic pain rehabilitation programs are a safe and effective alternative to opioids for chronic pain.
An alternative to opioids for pain that few know about
So, we have an odd state of affairs at present in the field of chronic pain management. We know that we have a safe and effective alternative to opioids for chronic pain but few people know of it or take advantage of it, at least relative to the number of people who manage their pain with opioids.
How do you think the field should tell the public about interdisciplinary chronic pain rehabilitation programs? Why do you think they have difficulty getting widely recognized as an effective alternative to opioids for chronic pain? If you find yourself skeptical of the above-noted research, what would convince you to participate in such a program?
References
Becker, N., Sjogren, P., Bech, P., Olson, A. K., & Eriksen, J. (2000). Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: A randomized controlled trial. Pain, 84, 203-211.
Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.
Cosio, D. & Linn, E. (2014). Efficacy of an outpatient, multidisciplinary VA pain management clinic: Findings from a one-year outcome study. Journal of Pain, 15(4), S110.
Crisostomo, R. A., Schmidt, J. E., Hooten, W. D., Kerkvliet, J. L., Townsend, C. O., & Bruce, B. K. (2008). Withdrawal of analgesic medication for chronic low-back pain patients: Improvements in outcomes of multidisciplinary rehabilitation regardless of surgical history. American Journal of Physical Medicine & Rehabilitation, 87(7), 527-536. doi: 10.1097/PHM.0b013e31817c124f
Gatchel, R. J., (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130. doi: 10.1037/a0035514
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, 17(11), 779-793.
Meineche-Schmidt, V., Jensen, N., & Sjogren, P. (2012). Long-term outcome of multidisciplinary intervention of chronic non-cancer pain in a private setting. Scandinavian Journal of Pain, 3(2), 99-105.
Murphy, J. L., Clark, M. E., & Banou, E. (2013). Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Journal of Pain, 29(2), 109-117.
Rush, T., Huffman, K., Mathews, M., Sweis, B., Vij, B., Scheman J., & Covington, E. (2014). High dose opioid weaning within the context of a chronic pain rehabilitation program. Journal of Pain, 15(4), S111.
Schatman, M. E. (2012, December). Interdisciplinary chronic pain management: International perspectives. Pain: Clinical Updates, 20(7), 1-5.
Townsend, C. O., Kerkvliet, J. L., Bruce, B. K., Rome, J. D., Hooten, W. D., Luedtke, C. L., & Hodgson, J. E. (2008). A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Pain, 140(1), 177-189.
Author: Murray J. McAllister, PsyD
Date of last modification: 10-5-2019
About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.
The assertions and opinions of this piece are solely those of the author and do not represent the views of Courage Kenny Rehabilitation Insitute, part of Allina Health.