(p. 402) Chronic Pain
The following case involves Patient M, a patient with chronic low back pain (CLBP), who participated in an interdisciplinary treatment program that included eight sessions of biobehavioral treatment with a therapist trained in pain management techniques. Before describing the interdisciplinary treatment regimen in detail, a little of Patient M’s clinical history is relevant, as well as his reason for referral to this program. Patient M is a 34-year-old Caucasian divorced male who has supported himself and his family primarily as a warehouse manager for eight of the last ten years. Patient M was injured when an inexperienced coworker accidentally dropped some crates of equipment off a front-loader in the warehouse. In bracing for the impact, Patient M strained the muscles in his lumbar/lower back region and damaged vertebral discs L4, L5, and S1. Consequently, he now experiences deep referred pain to his right sciatic nerve and radiating pain from his lower back into his shoulder and neck region.
He has a self-reported history of substance abuse (mostly THC/marijuana and alcohol). For at least the past two years, he has been on disability leave from work while receiving workers’ compensation supplemental to his prior income. Previous treatment for his injuries included prescriptions for opiate pain relievers, eight sessions of physical therapy, and recommendations for bed rest to avoid aggravating his injury. After 18 months of minimal, non-extant relief, Patient M was referred to this interdisciplinary program by his primary care physician as part of a rehabilitation plan to help restore M’s physical and behavioral functioning levels to the point that he might be able to return to work in a modified environment. The following is a description of the intake and assessment procedures used by the biobehavioral therapist in Patient M’s case.
Key Principles and Core Knowledge
A stepwise approach was used to arrive at a clinical conceptualization of the potential biopsychosocial problems that might be confronting Patient M in his (p. 403) rehabilitation (Gatchel, Kishino, & Minotti, 2010). Gatchel (2005) has previously recommended this strategy for its demonstrated time-efficiency and cost-effectiveness for biopsychosocial assessments of patients. Because every patient is unique, it would be far too time-consuming to develop an individual strategy for each patient’s case. Instead, the stepwise approach, when used by trained clinicians, allows for the recognition that there is no single assessment or method for every patient case. By training and experience, clinicians have a large battery of assessment tools and techniques they can choose from, along with their seasoned judgment, for particular patient types that are typical in their clinical setting. Assessment is then based upon clinical judgment and experience for broad diagnoses, along with findings from prior clinical research that illuminate techniques for measuring more specific symptoms.
In addressing the full picture of a patient with chronic pain from the biopsychosocial perspective, it is highly desired to have a thorough medical examination conducted by a member of the interdisciplinary treatment team prior to involvement in clinical interviews with the biobehavioral clinician. The purpose of this is not only for confirmatory findings regarding prior diagnoses, but to also rule out any comorbid factors that might impair the patient’s rehabilitation. Additionally, this medical intake evaluation will evaluate range of motion, areas of tenderness, and neurological symptoms, as well as gate and posture. Patient M’s physical examination only confirmed prior diagnostic findings from his referring physician.
Also included in Patient M’s intake evaluation was a functional capacity evaluation (FCE) by the staff physical therapist. This is highly desired in cases that involve disability if there are adequate personnel, equipment, and space to perform the FCE. These are further used to support the diagnostic findings and provide valuable information, along with the medical evaluation, for the biobehavioral clinician to apply to his or her treatment agenda. The FCE helps to quantify range of motion, muscle strength and endurance, lifting capacity, and cardiovascular endurance. The results of Patient M’s FCE helped to determine that much of his muscle strength and endurance had atrophied or diminished in the time since his injury but that, with a tailored exercise and physical therapy treatment plan, he could regain much of what had been lost. The prognosis from his physical findings was positive overall, although Patient M found it disheartening that he would still require some at-work accommodations that included a modified work environment. His feelings toward these recommendations would be addressed during treatment with the biobehavioral clinician.
In the case of Patient M (i.e., a patient with CLBP resulting from a work-related injury), an initial clinical interview was conducted that included a mini-mental status examination to rule out potential confusion or cognitive impairment. If Patient M had produced symptoms indicative of cognitive impairment (disorientation to time, place, or person), he would then have been referred out for a more (p. 404) comprehensive neuropsychological examination, as these symptoms would take priority over his intake into the pain management program and would have interfered with the validity of the remaining intake measures as well. Because such symptoms were not present with Patient M, the more comprehensive portions of the clinical interview were directed at the following: personal and familial mental health history; any head injury or traumatic brain injury history; life-change stressors such as loss of income, divorce/separation, or reduced physical functioning since the injury; prior work history (including level of job satisfaction and number of job changes); financial history; and any legal, financial, or workers’ compensation issues related to the current injury that remain unresolved.
In the case of Patient M, it was determined that he (along with his mother and some siblings) had a familial history of moderate unresolved depression. In his particular case, he also experienced some ideation regarding death but a resolve not to commit suicide. Most of these depressive symptoms were comorbid to his reduced physical functioning and stressors related to losses of both income and productivity. Just one year prior to his injury, he and his wife of seven years separated, and their divorce became final within six months following his injury. His reduced income and productivity were the source of interpersonal conflict between him and his ex-wife, mostly regarding disputes of child support payments for their two sons (ages seven and five at the time). Patient M had worked for the warehouse where he was injured for eight years, after a friend helped him get an interview to become the manager there. Prior to this, he had performed similar work at a competitor company for four years. Patient M had a high school education and had maintained consistent employment following graduation from public school. He was receiving workers’ compensation payments at the time of his assessment and treatment in the pain management program.
Referring back to the stepwise approach (Gatchel, 2005; Gatchel, et al., 2010) to biopsychosocial assessment, it could then be determined, based upon the clinical interview, what further assessment tools to include in the intake evaluation for Patient M. In order to make sound clinical judgments based upon empirical findings, assessment tools should have well-defined norms to allow for patient comparisons. Because Patient M’s case is one of CLBP, his evaluation included the SF-36, the Pain and Disability Questionnaire (PDQ), the Beck Depression Inventory-II (BDI-II), a visual analog scale (VAS), and the Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985). High elevations on any of these measures would be deemed indicative of pathology and thereby would require additional, more comprehensive, testing of biopsychosocial indices. Patient M’s depressive symptoms and dysfunctional coping skills, demonstrated with the BDI-II and MPI, respectively, required more comprehensive evaluation on the part of the therapist.
While there are many comprehensive psychosocial evaluation tools available for use, the ones with the most corresponding empirical data in pain populations thus far include the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID-I & SCID-II). Due to the nature of the clinical practice in the pain (p. 405) management program, the MMPI-2 was administered in Patient M’s case. Some important items regarding a patient’s psychosocial profile are brought to light with the results produced by the MMPI-2 that partially help to determine whether short-term or long-term biobehavioral therapy will produce positive results with regard to his or her rehabilitation.
Some background on the empirical basis for using the MMPI-2 in this clinical setting includes prior research by Gatchel and colleagues (Gatchel, Mayer, & Eddington, 2006), who conducted research with both the SCID I and II, and results obtained with the MMPI-2 in the same sample. The sample was composed of patients with chronic occupational spinal pain disorders. Results from the MMPI-2 demonstrated four particular and distinct profile patterns of interest. While the majority of participants in this sample produced a normal profile from their MMPI-2 responses (demonstrating no significant pathology), there were three additional profiles that indicated a potential role of psychopathology in such chronic pain patients. Prior research with pain populations had to this point identified the Neurotic Triad (NT) and Conversion V (CV) profiles as significant for preoccupation or focus on somatic or bodily concerns. A key difference between these two diagnostic patterns is that individuals with NT profiles (elevations on Scales 1 [Hypochondriasis], 2 [Depression], and 3 [Hysteria]) typically respond well to treatment for musculoskeletal pain. In contrast to this, pain patients who respond with the CV profile (elevations on Scales 1 [Hypochondriasis] and 3 [Hysteria], with scale 2 [Depression] diminished by comparison) do not seem to benefit as much from treatment. The use of the MMPI-2 as a pre-treatment screening measure has become standard procedure in many pain treatment programs because multiple studies have reproduced the above findings with these profiles (Bradley, Prokop, Margolis, & Gentry, 1978; McGill, Lawlis, Selby, Mooney, & McCoy, 1983; Turk & Fernandez, 1995).
The fourth profile mentioned above, which was identified by Gatchel and colleagues (Gatchel et al., 2006), had been previously described in the psychiatric literature as a “Floating Profile” and is a significant indicator of psychological distress and turmoil. Individuals who produce such profiles are often identified as having an Axis II personality disorder, often meeting criteria for the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision; DSM-IV-TR) Cluster B category of borderline personality disorder. Gatchel and colleagues (Gatchel et al., 2006) have designated this as the “Disability Profile” (DP) for the specific purpose of identifying patients who may have symptoms that would require more intensive interdisciplinary care. In order to be “flagged” for interdisciplinary staffing in this pain management practice, a patient would have to produce a minimum of four elevations on the Clinical Scales of the MMPI-2. During staffing, it will often be decided to provide more cognitive behavioral therapy (CBT), based, in part, on evidence that such patients typically lack a singular specific coping style with which to manage life stressors, and thereby experience much severe emotional distress, leaving them more resistant to traditional psychiatric and behavioral medicine approaches (Gatchel et al., 2006).
(p. 406) In two studies sampled from two very different socioeconomic stratifications, Gatchel and colleagues have demonstrated that more than one-half of chronic occupational or chronic heterogeneous pain disorder patients were identified as having the Disability Profile/MMPI-2 response pattern (Gatchel et al., 2006). More than two-thirds of patients from both chronic pain populations produced the DP code type. Findings also showed that, while patients with a normal profile were significantly more likely to retain work one year after treatment than the other three code types, pain patients with the DP code type were exponentially more likely than those with a normal profile to have at least one Axis I diagnosis. Among patients with a DP code type, there was also a preponderance of Axis II personality disorder symptoms based upon clinical interview and MMPI-2 results (Gatchel, et al., 2006).
The findings pertaining to Patient M’s depressive symptoms, from his initial assessment with the biobehavioral clinician, flagged him for further evaluation with the MMPI-2. The results of his MMPI-2 further supported the prior findings, but also indicated that Patient M would respond well to biobehavioral interventions that include CBT and biofeedback, as he had produced a Neurotic Triad on the MMPI-2. The elevated Depression, Hypochondriasis, and Hysteria scales were indicative of somatic concerns with Patient M, as well as supportive of a positive outcome from interventions for musculoskeletal pain. Patient M’s case was staffed at the weekly interdisciplinary team meetings, which allowed the physician, physical therapist, and biobehavioral clinician to each share their conceptualization of the patient, and to then arrive at a unified set of goals for his treatment formulation.
Initial Case Formulation
Through a comprehensive, stepwise approach to assessment of Patient M’s history and symptoms, key questions were addressed prior to beginning treatment. Chief among these was the question of whether Patient M would truly benefit from the interdisciplinary treatment modality (and biobehavioral therapy in particular). The answer to this, based on the evaluation findings, was yes. Additional concerns were his self-reported history of substance abuse, particularly for alcohol, but this was not something that the treatment team felt would necessarily preclude Patient M from participating in treatment. Instead, the issue was “flagged” in his file for further probing during his one-on-one biobehavioral sessions with the trained clinician.
After the group decision was made to accept Patient M into interdisciplinary treatment, the biobehavioral clinician contacted him via telephone and discussed further specifics of what treatment would entail. The administrator for the practice then prepared all of Patient M’s appointments in advance and coordinated (p. 407) biobehavioral and physical therapy appointments to occur on the same day, within the same two-hour block. In general, his eight biobehavioral treatment sessions would include training in self-regulatory coping skills, progressive muscle relaxation training, and biofeedback within a CBT framework. Specifically, these sessions consisted of the following (Gatchel, Peterson, McGeary, & Moore, 2009; Gatchel et al., 2003; Whitfill et al., 2010):
• Session 1: The patient was introduced to the overall structure of the program and how the different components and team members interacted with one another. This session also introduced the patient to the gateway theory of pain and how emotions and coping techniques may contribute to either pain symptoms or pain relief. An introduction to diaphragmatic breathing, central to relaxation training, was also provided in this session.
• Session 2: The therapist continued to focus training on relaxation skills and introduced the concept of biofeedback by taking baseline readings of thoracic-muscle tension with electromyography, diaphragmatic breathing via strain gauge, and peripheral temperature at a digital extremity. This session also included a guided progressive muscle relaxation session with a tensing-relaxing modality.
• Session 3: This session continued training with biofeedback, along with Patient M practicing with the read-outs, and included a guided progressive muscle relaxation session focusing on passive relaxation.
• Session 4: Biofeedback training continued, while rehearsal and planning of relaxation skills for both anticipated and unexpected stressors was discussed with the patient.
• Session 5: Distraction methods for coping with painful symptoms and stimuli were introduced, along with the self-rewarding concept of scheduling pleasant activities in order to reduce stress. Biofeedback and progressive muscle relaxation training with the patient’s preferred modality (tense-release or passive) was also included in this session.
• Session 6: The therapist introduced, and practiced with Patient M, the concept of disputing “thinking errors” or automatic thoughts with non-productive feelings or behaviors associated with them. Biofeedback was put aside during this session to focus more on the complex process of identifying and disputing automatic thoughts that might be deterring Patient M’s progress in rehabilitation. His homework in this session was also aimed at identifying and correcting more of these types of thoughts.
• Session 7: A review of Patient M’s homework regarding “thinking errors” opened this session, which then moved into a review of the patient’s progress thus far. Biofeedback was reinstituted one last time during this session and included the introduction of a third guided progressive muscle relaxation focusing on simultaneously relaxing one group of muscles while relaxing another. The patient was also prepared for his termination session coming up at the end of the week.
(p. 408) • Session 8: This session primarily reviewed all the new coping skills and progress that Patient M had made by this point, with an emphasis on continuing to practice those skills in order to maintain his gains. Planning for future stressors and coping with pain relapse were also emphasized before this final session concluded.
Within the treatment sessions, homework was assigned that included self-talk/thought logs to be returned at the beginning of each session, so that maladaptive thoughts regarding pain could be addressed. Also included were additional strategies aimed at improving Patient M’s self-efficacy through the development of multiple skills that improve pain coping (including distraction, pacing, and self-reward systems). Furthermore, his concurrent physical therapy included an emphasis on flexibility and core strengthening that, combined with the pacing skills and cognitive coping skills from CBT, would help him to achieve a more reasonable degree of rehabilitation.
Development of an Intervention Model
The intervention with an interdisciplinary treatment program that includes a CBT component is standard practice in this pain management program. However, it became standard practice and was applicable to the case of Patient M and others like him because of the abundance of empirical, evidence-based support for interdisciplinary treatment of musculoskeletal pain. The biopsychosocial (BPS) model of chronic pain serves as the framework for such interdisciplinary care, and the BPS model is now recognized as the most comprehensive and heuristic approach to the evaluation and management of chronic pain conditions (Gatchel, 2005; Gatchel et al., 2003; Turk & Monarch, 2002; Turk & Rudy, 1987). The treatment strategy, based on the BPS model, necessarily calls for an interdisciplinary treatment approach, composed of providers from multiple clinical and medical disciplines who will collaboratively treat cases from their respective areas of expertise, including medicine, physical therapy, behavioral health, nursing, and other arenas. Due to the nature of the pain management clinic in which Patient M was being treated and, even more specifically, his chronic pain condition, no alternative treatment modalities were considered as necessary options at this point in time. Further reasons for applying the BPS model and interdisciplinary treatment strategy are described below.
Because of the degree of challenges presented by treating chronic patients (even within the empirically sound interdisciplinary model), a comprehensive stepwise assessment approach (as described earlier) is recommended for use in such settings in order to determine whether a patient is an optimal candidate for the services offered (Miller et al., 2005). In addition to this, these comprehensive assessments are useful in predicting treatment success and for normative comparisons, based upon previous research findings (Gatchel, 2001). Also, as described in some detail earlier, the pragmatic applications of these comprehensive BPS assessments help (p. 409) to uniquely tailor treatment goals based upon evaluative findings. Factors illuminated by these methods include psychosocial variables for clinical syndromes; personality disorders; and drug use. Of particular interest is the identification of chronic pain patients who present with personality disorders, as these individuals are at higher risk for being denied treatment either by their insurance carrier or by traditional treatment facilities because mental health issues are often “carved out” from medical treatment (Dersh, Polatin, & Gatchel, 2002).
The emphasis of the biopsychosocial model is a focus on the complex interactions among biological, psychosocial, and sometimes even related legal variables that patients with chronic pain conditions encounter. By their very nature, these interactions may perpetuate and exacerbate a chronic pain syndrome, such as Patient M’s case of unresolved CLBP resultant from a work-related injury. More about some of the concerns he experienced regarding his rehabilitation and workers’ compensation follows later in this discussion, with regard to secondary gain issues. Because of the interactive and synergistic dynamic of these multiple domains, Patient M, like many other chronic pain patients, found that his chronic pain-related disability affected his life with many adverse, negative consequences that were not all within his realm to control. Thus, the comprehensive assessment and treatment approach of an effective interdisciplinary program is designed to address physiological and psychosocial issues from a holistic, all-encompassing design that addresses not only the individual patient’s needs, but those of his or her social support network, including friends, family, coworkers, and so on. This dynamic approach has the potential to far surpass the outdated, traditional biomedical reductionist model, which breaks down medical diagnoses into separate and distinct physical and psychosocial components. Further, the BPS model allows for more individual patient considerations. This latter point is of great import, as Gatchel and colleagues (Gatchel, Lou, & Kishino, 2006) have demonstrated that individuals differ quite significantly in at least the following three areas: (a) frequency with which they report physical symptoms; (b) their tendency to visit physicians when experiencing identical symptoms; and (c) in their responses to the same treatment. Because of these idiopathic differences, many times the very nature of a patient’s treatment outcome has little to do with his or her objective physical conditions.
Nonspecifics in This Case
As mentioned previously, Patient M was forced to deal with his financial compensation by his employer’s workers’ compensation insurance, with the resultant fear of potentially losing that based upon his performance in the interdisciplinary treatment program. Compensation received for injuries (e.g., workers’ compensation, short- and long-term disability, and personal injury litigation) is an important domain addressed by the BPS model. For persons receiving compensation for a work-related injury (or even personal injury compensation), research has borne out that objective outcomes, including return-to-work, future health care (p. 410) utilization, and recurrent injury rates, are substantially lower when compared to rates from the general population for similar injuries, regardless of the severity of injury or treatment (e.g., Gatchel, 2005; Gatchel et al., 2010). Patient response to treatment may often be closely tied to financial secondary gain when compensation for illness or injury comes into play. Initially, during Patient M’s first week in the interdisciplinary treatment program, he expressed anxiety regarding the potential loss of his financial package and this, in turn, affected his motivation during both physical and biobehavioral components of treatment. When these issues were specifically addressed by the biobehavioral clinician, a separate appointment was arranged with a consultant to the team who specialized in workers’ compensation and return-to-work accommodations. This appointment occurred during his second week of treatment, and it seemed to help ease some of his concerns. However, these are issues that face most, if not all, patients receiving compensation for injury at some point.
With these concerns raised, it is important to understand what secondary gain actually entails. Secondary gain is broadly described as a set of behaviors (conscious or unconscious) that include an individual’s attempt to avoid activities (work, for instance), pursue financial compensation (perhaps through personal litigation or workers’ compensation claims), or attempt to receive non-financial means of support that would not otherwise be afforded to him or her (Dersh, Polatin, Leeman, & Gatchel, 2004). The following information further emphasizes the important relationship between secondary gain and compensation injuries. Already noted earlier are the often dynamic interactions among the biopsychosocial components of pain. When considering the concept of secondary gain, it may also occur to the reader that the treatment of chronic pain patients, like Patient M, can be even further complicated when there are simultaneous interactions among the constructs of pain and the related constructs of disability and impairment. While these three constructs do not typically display high concurrence with one another, it is vital to have an awareness of the differences among the three in order to fully understand the complexities associated with addressing them (Gatchel, 2005; Gatchel et al., 2010). Misunderstanding these domains may result in improper treatment goals and outcomes for chronic pain patients. Much of this complexity revolves around the evidence that, quite often, there is a high degree of discrepancy among levels of chronic pain, impairment, and disability. This disconnect among these three domains in the evaluation of CLBP was noted in a report by Waddell that demonstrated correlations among the three constructs, but no significant overlap among them (Gatchel et al., 2010).
While these conceptual domains are related to one another, the relationships among them are not direct. There is a wide range of differences from one patient to the next with regard to these domains (Turk & Melzack, 2001). It is because of these individual differences that the interdisciplinary team meets to staff all of the patients who are deemed appropriate for interdisciplinary care, as in the case of Patient M. Clinicians must make themselves aware of the relationships among these constructs during their clinical interviews and intake evaluations with chronic pain patients. An example of this occurred with Patient M’s medical (p. 411) evaluation, which demonstrated very little objective physiological impairment, but he self-reported high levels of pain during his biobehavioral assessment and functional capacity evaluation. His disability rating, based on his performance during the functional capacity evaluation, fell somewhere between his self-reported pain levels and his medical results.
Strategies for Dealing with Problems in Therapy
All of the discrepancies seen in Patient M’s results relate back to the aforementioned issue of secondary gain in the context of compensation injuries. Many clinicians who are naïve to the processes involved in the biopsychosocial model—and, indeed, most providers trained from the standard biomedical approach are naïve to these concepts—might perceive these discrepancies as evidence of malingering. However, there are often more complex issues at play. If these issues had not been sufficiently addressed during biobehavioral treatment sessions (and at the intake and mid-treatment team staffings), Patient M’s progress might have been impaired or sabotaged by his secondary gain issues. Prior to his first appointment and, during his acceptance into the program, he was verbally informed about the missed appointments policy of the program, specifically that more than one cancellation with less than 24 hours notice, a single no-show appointment, or more than two cancellations with 24 hours notice would cause his treatment with the pain management program to terminate. In addition to this, these criteria were reiterated by the program administrator during her portion of the patient debriefing and appointment scheduling. Finally, a non-contractual “Patient Agreement” was included in Patient M’s intake paperwork that he was required to read and sign, stating his understanding of these terms should he be accepted into the program.
Further issues did subsequently arise with Patient M during treatment, and these were in regard to his cognitive distortions concerning his levels of impairment and disability, worries over early termination of his workers’ compensation benefits, and some additional behaviors that initially indicated a lack of commitment on his part to actively participate in treatment. All of these issues were confronted directly with Patient M during his biobehavioral treatment sessions. Before detailing Patient M’s treatment complications further, it is important to understand that these are not issues unique to Patient M or this pain management practice in particular. Though arriving at an accurate conceptualization of levels of pain, impairment, and disability can be complex when secondary gain issues are at play, it is important to note that, as in the case of Patient M, many patients receiving (or looking to receive) some form of compensation do report significantly higher symptoms across self-report measures of these indices than do patients without the secondary incentive (Gatchel et al., 2010). Further, they also tend to self-report and display more emotional lability, as witnessed in reports of increased anxiety and depression, when compared with similar patients with no such secondary gain issues. All of these self-report measures (p. 412) were somewhat more elevated for Patient M than his physiological measures indicated were likely.
Early on, it appeared that Patient M was producing some resistance to participating in treatment. A reexamination of his clinical evaluations, along with a frank discussion among Patient M, his biobehavioral clinician, and a workers’ compensation consultant, were employed to address some potential secondary gain issues that might have been “holding him back.” Clinical awareness regarding the norms for pain patients who produce the MMPI-2 pattern witnessed in Patient M’s evaluation helped to determine that he had a preoccupation with his condition which, in understanding, was helpful in preparing for his course of treatment. Patient M, like many others in his situation, needed to be educated about the realities related to his particular secondary gain, in this case his workers’ compensation benefits. It is therefore extremely beneficial to either educate oneself as a clinician in this arena, or simply find a professional already trained to understand and explain these details to patients. For patients in this pain management program, a consultant was available for those concerned about return-to-work and workers’ compensation issues. The one-on-one meeting that Patient M had with this consultant helped to alleviate many of his misunderstandings, and this increased his motivation to participate in his own rehabilitation.
As is typical with many chronic pain patients, Patient M’s self-report measures did not immediately improve dramatically during initial treatment, but his functional measures assessed during physical therapy did improve. These functional findings provided a rich source of feedback during biobehavioral counseling sessions with his clinician. Functional improvement, along with a better understanding of his secondary gain issues, helped to improve some of his self-report scores. However, the focus of treatment was being met and, after all, the emphasis on rehabilitation is not complete or immediate alleviation of symptoms. Many times, in these situations, patients misunderstand what they are actually receiving (or as compensation) and continue to display disability or impairment. When they come to understand that the financial trade-off is significantly less than what they are giving up to maintain their level of function, then many times they are more motivated to participate in treatment. Issues about which the workers’ compensation consultant informed Patient M included the possibility that he and other injured workers may be unable to regain employment in the job market as potential new employers view them as a “pariah.” Trust and rapport had already been established with Patient M and members of the interdisciplinary team. Therefore, it was somewhat less complicated to break down for him the very complex disability systems that he and other patients were not likely aware of (Gatchel, et al., 2010).
One of the early ethical considerations or concerns the treatment team encountered was whether or not to continue or renew prescriptions for some of Patient (p. 413) M’s opiate medication for pain analgesia during the time that he participated in the program. More specific to this was the concern that he might be at risk for potentially abusing or misusing his prescription pain killers. These concerns were addressed with an additional measure, with its use instituted in cases where analgesic misuse is suspected within this setting. The Pain Medication Questionnaire (PMQ; (Adams et al., 2004; Gatchel, 2010) is designed for use in a chronic population to assess potential misuse or abuse of prescription pain medications. During its initial design, Adams and colleagues (2004) demonstrated a positive relationship between higher PMQ scores and other concurrent measures of substance abuse, psychopathology and physical/life functioning. Holmes and colleagues identified further characteristics associated with patients who obtain high PMQ scores. Some of these characteristics include a history of substance abuse problems; higher incidence of requests for early prescription refills; and a treatment dropout rate more than twice that of low-scoring patients. While Patient M self-disclosed a history of alcohol abuse and THC/marijuana use, these alone were not alarming enough to prevent his entry into the interdisciplinary treatment program. Upon further probing, Patient M had not smoked marijuana since he was in his early twenties, though he still had some resonating guilt associated with that use, based upon his conservative upbringing. Furthermore, his alcohol consumption, though higher than recommended, was considered moderate (no more than 3–4 drinks, on no more than 2–3 days a week), and he did not appear to self-medicate his pain symptoms with alcohol. A high score on the PMQ, in addition to these items, would likely have raised more concern, but his score was in the lower range, and the decision to not only treat him in the pain management program, but also to renew his opiate prescriptions, was based upon the objective findings with the PMQ.
The “Art” of This Case
One might feel that it takes a degree of “art,” or in this case informed experience, to adequately assess whether a CLBP like Patient M has the potential to misuse his pain medications, thereby sabotaging his own treatment success. Part of the informed decision to treat Patient M is solidly based on the science of the measure used to determine his likelihood to misuse prescription medications. One of the advantages of administering the PMQ is that it has well-demonstrated reliability and validity (Gatchel, 2010). The PMQ has demonstrated significant reliability when studied (with a test–retest reliability coefficient of 0.86; and with good internal consistency: Cronbach’s α of 0.73). The PMQ has also demonstrated good validity (when compared with other measures of substance abuse/use, as well as those specific for known opioid abuse). The PMQ is also a relatively brief, 26-item self-report instrument requiring only a third-grade reading level, making it easy to administer and to use in various clinical settings (Gatchel, 2010).
Using the PMQ can help physicians to decide whether prescribing pain medications for a particular patient is sound in a variety of ways. The PMQ, (p. 414) when included in a patient’s chart, demonstrates due diligence in monitoring prescription use and potential abuse/misuse in the event of any potential Drug Enforcement Agency (DEA) audit (Gatchel, 2010). The biobehavioral clinicians can tailor their treatment plan to the specific needs of the patient and, if called for, may include education about the potential dangers of misuse and tolerance buildup. Screening “flags” for potential medication misuse might be based on scores from the PMQ. These types of flags or alerts might be used in determining that a patient will require more drug screenings during the course of treatment. High scores on the PMQ may also alert physicians not to provide early refills of medications, nor to merely refill them over the phone. Instead, refills for high-risk patients must be approved during an in-office visit so that the physician may once more evaluate any signs of misuse. Documentation in the patient’s medical chart in case of a DEA audit must be consistent for these evaluations.
Common Mistakes to Avoid
One of the common pitfalls that many pain management professionals tend to fall into (indeed, this potentially occurs in all professions) is to see all cases as monochromatic. Without paying attention to the individual details of a case, such as with determining whether to treat a pain patient with opioid analgesics, one runs the risk of undertreating some patients, while overmedicating or supporting a newly developed addiction in others. Instead of having an all-patient-encompassing policy of no refills or, conversely, refills-for-all policy, basing decisions on empirical evidence and individual circumstances allowed Patient M to receive the appropriate amount of analgesic medication while also participating in a comprehensive interdisciplinary pain management program. It is in fact true that many patients who abuse or misuse pain medications are likely to have comorbid psychosocial conditions, including Axis II personality disorders, and Axis I depression and anxiety disorders. These may also need to be considered in treatment, in addition to the original reason for referral—the pain condition itself. Pain-reducing medications play a vital role in chronic pain management, particularly for patients with chronic and persistent pain.
Unfortunately, because of the cultural and legal stigma associated opioid narcotics, treatment providers have often participated in black-or-white strategies for their use, resulting in overuse and underuse in different circumstances (Gatchel, 2010). Much of this needless fear can be alleviated by making certain to document the steps taken in order to minimize the risk of potential abuse/misuse of prescription analgesics. Instruments like the PMQ help with documenting treatment, as with the case of Patient M. Patient M, while atypical of some patients who are on long-term opioid treatment, was able to be closely monitored by all (p. 415) members of the treatment team because of the documentation in his chart. Pain medication is only one tool in the toolbox of comprehensive interdisciplinary care, meaning that documentation of all treatment modalities was also included in Patient M’s chart, and any issues that raised flags or questions were followed up with colleagues at team staffings. Patient M’s staffings included discussions of his particular pharmacotherapy, biobehavioral treatment progress, physical therapy, and physician care.
Relapse Prevention and Termination
It is important to note that a sound “exit strategy” needs to be in place in order to discontinue the use of pain medications when a patient is not attaining the appropriate goals of treatment. This did not turn out to be an issue for Patient M, but referrals for detoxification programs and drug rehabilitation specialists were on hand should colleagues from this arena be needed. In summing up, Patient M successfully completed the interdisciplinary treatment program. In order to prevent relapse into some of the cognitive distortions encountered during his treatment, booster sessions with the biobehavioral clinician were set up at one-month, three-month, and six-month intervals following discharge. A one-year follow-up, comprehensive evaluation was pre-arranged so that the treatment team could determine whether their program worked in the case of Patient M. Indeed, one year later, Patient M was working full-time, albeit with some accommodations, at his prior place of employment, and was still using some of the pacing, relaxation, and coping strategies that he had learned as part of his comprehensive care with the biobehavioral clinician. Interdisciplinary pain management has proven to be effective for many chronic pain patients like Patient M and, in fact, the research supports this treatment strategy. Gatchel and Okifuji (2006) have identified interdisciplinary pain management to be the most treatment- and cost-effective method of pain management.
One of the initial concerns with Patient M was a self-reported history of substance abuse (mostly THC/marijuana and alcohol), which concerned the treatment team with regard to refilling his pain prescriptions. Clinical administration of Pain Medication Questionnaire helped to determine that misuse was not truly a “flagging” concern for Patient M. An additional treatment obstacle did threaten to compromise treatment success early on, however. In the nearly two years prior to treatment in the program, he had been receiving workers’ compensation supplemental to his prior income. His fear of losing this source of income prior to being fully rehabilitated was addressed through consultation with a specialist informed about workers’ compensation issues. Patient M was referred to this interdisciplinary program by his primary care physician as part of a rehabilitation plan to help restore M’s physical and behavioral functioning levels to the point that he might be able to return to work in a modified environment.
A stepwise approach was used to arrive at a clinical conceptualization of the potential biopsychosocial problems that might be confronting Patient M in his (p. 416) rehabilitation. Additional test administration with the MMPI-2 identified some characteristics that needed to be addressed with Patient M in treatment and, once they were, he successfully completed all aspects of his treatment protocol, lending further credibility to the interdisciplinary treatment paradigm and also to his own resolve.
Adams, L. L., Gatchel, R. J., Robinson, R. C., Polatin, P. P., Gajraj, N., Deschner, M., et al. (2004). Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. Journal of Pain and Symptom Management, 27 (5), 440–459.Find this resource:
Anagnostis, C., Gatchel, R. J., & Mayer, T. G. (2004). The Pain Disability Questionnaire: A new psychometrically sound measure for chronic musculoskeletal disorders. Spine, 29, 2290–2302.Find this resource:
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory Manual (2nd ed.). San Antonio. TX : Psychological Corporation.Find this resource:
Bradley, L. A., Prokop, C. K., Margolis, R., & Gentry, W. D. (1978). Multivariate analyses of the MMPI profiles of low back pain patients. Journal of Behavioral Medicine, 1, 253–272.Find this resource:
Butcher, J. N., Dahlstrom, W. D., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). MMPI-2 (Minnesota Multiphasic Personality-2): Manual for administration and scoring. Minneapolis : University of Minnesota Press.Find this resource:
Dersh, J., Polatin, P., & Gatchel, R. (2002). Chronic pain and psychopathology: Research findings and theoretical considerations. Psychosomatic Medicine, 64, 773–786.Find this resource:
Dersh, J., Polatin, P. B., Leeman, G., & Gatchel, R. J. (2004). The management of secondary gain and loss in medicolegal settings: Strengths and weaknesses. Journal of Occupational Rehabilitation, 14 (4), 267–279.Find this resource:
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, B. W. (1994). Structured clinical interview for Axis I DSM-IV disorders. New York : Biometrics Research Department, New York State Psychiatric Institute.Find this resource:
First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Lorna, B. (1994). Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II) (Version 2.0). New York : New York State Psychiatric Institute.Find this resource:
Gatchel, R. J. (2001). A biopsychosocial overview of pre-treatment screening of patients with pain. Clinical Journal of Pain, 17, 192–199.Find this resource:
Gatchel, R. J. (2005). Clinical essentials of pain management. Washington, DC : American Psychological Association.Find this resource:
Gatchel, R. J. (2010). Is fear of prescription drug abuse resulting in sufferers of chronic pain being undertreated? Expert Review of Neurotherapeutics, 10 (5), 637–639. doi: 10.1586/ERN.10.22Find this resource:
Gatchel, R. J., Kishino, N. D., & Minotti, D. E. (2010). The three major components of behavior used for assessing pain: Problems faced when there is discordance among the three. Psychological Injury and Law, 3 (3), 212–219. doi: 10.1007/s12207–010–9081–0Find this resource:
(p. 417) Gatchel, R. J., Lou, L., & Kishino, N. (2006). Concepts of multidisciplinary pain management. In M. V. Boswell & D. E. Cole (Eds.), Weiner’s pain management: A practical guide for clinicians (7th ed.). Sonora, CA : CRC Press.Find this resource:
Gatchel, R. J., Mayer, & Eddington. (2006). MMPI disability profile: The least known, most useful screen for psychopathology in chronic occupational spinal disorders. Spine, 31 (25), 2973–2978.Find this resource:
Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. The Journal of Pain, 7 (11), 779–793. doi: http://dx.doi.org/10.1016/j.jpain.2006.08.005Find this resource:
Gatchel, R. J., Peterson, A. L., McGeary, D. D., & Moore, M. E. (2009). A randomized trial of musculoskeletal disability in a military population: A preliminary investigation leading to the Strong Star investigation. Paper presented at the 11th Annual Military Health Research (MHRF), Kansas City, MO. Retrieved fromFind this resource:
Gatchel, R. J., Polatin, P. B., Noe, C. E., Gardea, M. A., Pulliam, C., & Thompson, J. (2003). Treatment- and cost-effectiveness of early intervention for acute low back pain patients: A one-year prospective study. Journal of Occupational Rehabilitation, 13, 1–9.Find this resource:
Holmes, C. P., Gatchel, R. J., Adams, L. L., Stowell, A. W., Hatten, A., Noe, C., et al. (2006). An opioid screening instrument: Long-term evaluation of the utility of the Pain Medication Questionnaire. Pain Practice, 6 (2), 74–88.Find this resource:
Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale Multidimensional Pain Inventory. Pain, 23, 345–356.Find this resource:
McGill, J. C., Lawlis, G. F., Selby, D., Mooney, V., & McCoy, C. E. (1983). The relationship of Minnesota Multiphasic Personality Inventory (MMPI) profile clusters to pain behaviors. Journal of Behavioral Medicine, 6, 77–92.Find this resource:
Miller, B., Gatchel, R. J., Lou, L., Stowell, A., Robinson, R., & Polatin, P. B. (2005). Interdisciplinary treatment of failed back surgery syndrome (FBSS): A comparison of FBSS and non-FBSS patients. Pain Practice, 5 (3), 190–202.Find this resource:
Oslund, S., Robinson, R. C., Clark, T. C., Garofalo, J. P., Behnk, P., Walker, B., et al. (2009). Long-term effectiveness of a comprehensive pain management program: Strengthening the case for interdisciplinary care. Baylor University Medical Proceedings, 22 (3), 211–214.Find this resource:
Sternbach, R. A. (1974). Pain patients: Traits and treatment. New York : Academic Press.Find this resource:
Turk, D. C., & Fernandez, E. (1995). Personality assessment and the Minnesota Multiphasic Personality Inventory in chronic pain: Underdeveloped and overexposed. Pain Forum, 42 (2), 104–107.Find this resource:
Turk, D. C., & Melzack, R. (2001). Handbook of pain assessment (2nd ed.). New York : Guilford.Find this resource:
Turk, D. C., & Monarch, E. S. (2002). Biopsychosocial perspective on chronic pain. In D. C. Turk & R. J. Gatchel (Eds.), Psychological approaches to pain management: A practitioner’s handbook (2nd ed.). New York : Guilford.Find this resource:
Turk, D. C., & Rudy, T. E. (1987). Towards a comprehensive assessment of chronic pain patients. Behavioral Research and Therapy, 25, 237–249.Find this resource:
Waddell, G. (1987). Clinical assessment of lumbar impairment. Clinical Orthopedic Related Research, 221, 110–120.Find this resource:
(p. 418) Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36 Health Survey: Manual and interpretation guide. Boston : The Health Institute, New England Medical Center.Find this resource:
Whitfill, T., Haggard, R., Bierner, S. M., Pransky, G., Hassett, R. G., & Gatchel, R. J. (2010). Early intervention options for acute low back pain patients: A randomized clinical trial with one-year follow-up outcomes. Journal of Occupation Rehabilitation, 20, 256–263.Find this resource:
Wright, A. R., & Gatchel, R. J. (2002). Occupational musculoskeletal pain and disability. In D. C. Turk & R. J. Gatchel (Eds.), Psychological approaches to pain management: A practitioner’s handbook (2nd ed., pp. 349–364). New York : Guilford.Find this resource: