Joining us at Outlook on Outcomes for the second consecutive week is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist.  See his previous entry for more on this very important topic. – Dr. Holt

Last week we looked at the unique chronic pain patient profile and concluded that clinicians must recognize pain as a biopsychosocial condition.  When the treating physician fails to address each of the biopsychosocial components and applies only medical remedies, results are often sub-optimal.  Today we’ll explore the appropriate corresponding care plan and resources.

Maladaptive coping combined with the use of medication that is addictive and induces euphoria, is a recipe for addiction.  Most chronic pain patients have long medical histories, have become functionally debilitated, and have developed fixed beliefs about their illness.  If you simply detoxify a chronic pain patient of their addictive medication, you have the dilemma of a debilitated, poorly functioning person who can easily find a new practitioner willing to treat his pain complaint with opiates.  Recidivism is a huge problem in addiction treatment; imagine what happens when a patient shows up at an unsuspecting physician’s office with an MRI showing two back surgeries.  When physicians do not take all the biological, psychological and social components into account at every visit, the patients most in need fall through the cracks.

Treating chronic pain addiction based on needs

Successful treatment is in part due to appreciating that addiction is best seen in the context of pain rehabilitation.  Physicians can often wean patients who demonstrate adaptive coping and a desire to discontinue opiates.  However, less adaptive patients or those on very high doses require more formal detoxification.  Treatment can be provided via a specialized office practice, but in many areas these reliable services do not exist.  At times, we can piece together a detoxification program followed by a rehabilitation program.  For the more complicated case, carefully selected multidisciplinary rehabilitation programs offer detoxification in the context of a highly intensive and multidisciplinary functional restoration program.  As an example, I refer you to the Rosomoff Comprehensive Pain Center’s excellent detoxification and rehabilitation results.

A major key to success for Paradigm is the company’s treating physician intervention and concurrent onsite case management intervention with the injured person, healthcare providers and significant others.  This course of action promotes entry into a rehabilitation program and ushers the injured person back into the community with a more appropriate care configuration.  The Paradigm team recognizes the resources for each individual are dependent on the intensity of their needs, what is or can be made available in their community, and the cooperation of the injured person, his treating physician and, at times, his attorney.

Outcome goal setting

Paradigm recommends the following general outcome goals be a part of any chronic pain program:

1. Medications management: the injured person should be off opiates, decrease intake of other medications, and have decreased side effects.

2. Greater functional capacity: for example, the injured person should become comfortable sitting, walking and lifting through intensive graded exercise.

3. More adaptive coping strategies through cognitive-behavioral techniques

4. Establish MMI status and functional capacity.

5. Family intervention: support the patient’s family so they can assist with greater patient independence and less sick role behaviors.

6. Independent self management and decreased reliance on the health care system.

7. Discharge the injured person to a provider that is competent in conservative care without opiate reinstitution.

Preventing iatrogenic addiction recurrence

Preventing recurrence depends upon avoiding the type of care that initially caused the problem.  Once gains are achieved it is important that the patient’s future care be conservative and focused on continuing the interventions that work:  therapeutic exercise, independent modalities and avoidance of addictive or habit forming medications.  The Paradigm team works to identify such resources and facilitates the transition which can be a bumpy road.