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

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The NlDA Reseach Monogaph series is prepared by the Division of Research

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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.

i v
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, medications, 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, vocational 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 professional 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

v i
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 system. This importance stems from the fact that acute and chronic

pain that requires therapy by physicians and other health professionals 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 distressing fact that in this age of marvelous scientific and technologic 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 mutilating 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 that pain research had been exposed to 'benign neglect," which I consider to have been a "malignant neglect." Equally

important has been the fact that knowledge currently available has

not been properly applied. This is due to a lack of organized

teaching of medical students, physicians, and other health professionals in the basic principles of diagnosis and therapy of acute

and chronic pain. Inadequate communication among investigators,

and between investigators and clinicians, has contributed to the

problem. Progressive specialization in the basic and clinical sciences has precluded interaction and cross-fertilization of ideas

and dissemination of information among the various basic science

groups and clinicians. Other major communication problems have

included the lack of an international standard terminology for pain

syndromes and the lack of national and international pain data banks

or data pools for the storage and retrieval of research and clinically relevant information.

Fortunately, during the past decade or so, there has been a surge

of interest among some basic scientists in studying the mechanisms

of acute and chronic pain syndromes and in collaborating with clinical investigators and practitioners to begin to solve some of the

major problems. As a result, we have acquired more information

about pain during this period than in the previous century. Moreover, an impressive number of physicians have manifested interest

in acquiring more knowledge about pain and its treatment. We are

also gratified by the growth of multidisciplinary and monodisciplinary pain clinics.

I must, however, interject a note of concern that some of these

facilities are being run by physicians and other health professionals

who have had no training or experience in managing patients with

chronic pain. Some well-intentioned but unqualified physicians

viii
have been attracted to this field because having a pain clinic or

pain center is the "in" thing to do. Among these individuals are

highly reputable chairmen of departments of anesthesiology, neurosurgery, or other specialities who wish to broaden the base of

their department by having such a facility. Of even greater concern is the fact that some facilities are being run by unscrupulous

physicians and non-physicians who are using the current surge of

interest in pain merely to make money, as occurred with acupuncture

clinics during the height of the public's interest in acupuncture

in 1972-75. Such individuals do not hesitate to exploit patients

who are always looking for something new to grasp in order to

relieve their persistent pain. These facilities will surely be

detrimental to the general cause of pain research and therapy, to

the current international movement in the field, and, most importantly, to the good of individual patients.

In regard to communication, the Committee on Taxonomy of the International Association for the Study of Pain (IASP) is working

vigorously and making good progress under the chairmanship of Professor Harold Merskey. They have developed a list of definitions,

published in the journal Pain and, more recently, in the Journal

of the American Medical Association. Moreover, as a preliminary

step in developing a classification, the committee has developed a

scheme for coding pain diagnoses which consists of five axes related

to pain: (1) region of the body; (2) system involved; (3) temporal

characteristics of pain and patterns of occurrence; (4) patient's

statement of intensity and time since onset of pain; and (5) etiology. Recently, the committee has requested a number of international authorities to provide a description of the various pain

syndromes. It is hoped that this task will be completed by the

time of the Third World Congress of IASP which will be held in

Edinburgh in September 1981, so that classification can be officially adopted by IASP and then submitted to the World Health

Organization (WHO) for worldwide use.

I am sure you will agree that in the future we must not only sustain but markedly increase the current momentum to expand the gains

we have made. We must mount and support a multifaceted program

consisting of greatly expanded research and research training programs, activation of highly effective teaching programs for students

and practitioners, and improvement of the various systems of communication. Since the number of pain scientists in this country

and throughout the world is very small, we must develop pain

research training programs. Professional education is the crucial

issue because most of the physicians simply do not know the basic

principles of managing acute and chronic pain. Teachers in health

professional schools apparently believe that the few lectures on

neuroanatomy and neurophysiology of pain and clinical pharmacology

of narcotic and non-narcotic analgesics given to medical students

adequately prepare them for the management of acute and chronic

pain in clinical practice. There is, however, overwhelming evidence

that this is not the case.

Finally, there is the equally important task of informing the public; members of Congress; people in Federal, State, and municipal

i x
governments; insurance carriers; science writers; and many others

so they will understand the magnitude of the human and economic

impact of pain. The recommendations from this workshop are presented in the appendix to the monograph. These recommendations

address the important issues of research, professional education

and training, and public education. I believe that the technical

workshop and the monograph on multidisciplinary pain centers and

clinics can make an important contribution to the efforts to deal

with this serious national health problem.

John J. Bonica, M.D.

President

International Association for the

Study of Pain

Director, Pain Center

University of Washington

Seattle, Washington

x
Contents

Foreword

Preface

John J. Bonica . . . . . . . . . . . . . .

A Perspective on Chronic Pain: Treatment and Research

Lorenz K.Y. Ng . . . . . . . . . . . . . .

Treatment of Chronic Pain: The Center for Pain Studies,

Rehabilitation Institute of Chicago

Robert G. Addison . . . . . . . . . . . . .

A Holistic Approach to Pain Rehabilitation: The Boston

Pain Unit

Gerald M. Aronoff . . . . . . . . . . . . .

Multidisciplinary Treatment of Chronic Pain at the

Northwest Pain Center

Joel Seres, John R. Painter, and Richard I. Newman . .

A Comprehensive Model for the Study and Therapy of Pain:

Johns Hopkins Pain Research and Treatment Program

Donlin M. Long . . . . . . . . . . . . . .

Chronic Pain as a Learned Experience: Emory University

Pain Control Center

Steven F. Brena, Stanley L. Chapman, and Roger Decker. .

Coordinated Out-Patient Management of Chronic Pain at the

University of Virginia Pain Clinic

Harold Carron and John C. Rowlingson . . . . . .

Pain and Low Back Rehabilitation Program at the University

of Miami School of Medicine

Hubert L. Rosomoff, Catherine Green, Marc Silbret,

and Renee Steele . . . . . . . . . . . . .

Comparative Aspects of Chronic Pain in the Head and Neck

Versus Trunk and Appendages: Experiences of the

Multidisciplinary University of North Carolina Pain Clinic

John Gregg and Jawahar N. Ghia . . . . . . . .

v

vii

1

12

33

41

66

76

84

 92

112

x i
Treatment of Osteoarthritis of the Spine and Herpetic

Neuralgia at the Pain Center, Mount Sinai Medical Center

Frank Moya . . . . . . . . . . . . . . . 118

Profiles of Pain Patients, Including Chronic Pelvic Pain:

University of Washington Clinical Pain Service

Terence M. Murphy . . . . . . . . . . . . . 122

A Headache Clinic's Experience: Diamond Headache Clinic, Ltd.

Jose L. Medina and Seymour Diamond . . . . . . . 130

Chronic Pain Syndrome--Four Aspects of the Problem: New

Hope Pain Center and Pain Research Foundation

Benjamin L. Crue and Jack J. Pinsky . . . . . . . 137

Current Issues in the Management of Cancer Pain: Memorial

Sloan-Kettering Cancer Center

Kathleen M. Foley . . . . . . . . . . . . . 169

Appendix--Workshop Recommendations

Research . . . . . . . . . . . . . . . . . 185

Professional Education and Training . . . . . . . . . . . . . 186

Public Education .............. 191

List of Monographs . . . . . . . . . . . . . . 195

xii
A Perspective on Chronic Pain:

Treatment and Research

Lorenz K.Y. Ng, M.D.

Pain, both acute and chronic, afflicts about one-third of the

population of the United States each year. It ranks as perhaps

the most frequent cause of suffering and disability, yet it is

only now coming to be recognized by the medical community as a

disease entity with serious individual and societal impact.

The National Institute on Drug Abuse (NIDA) has had a historical

and ongoing interest in pain and its treatment, rooted in its

concern with analgesic drugs. Since the phenomena of analgesia

appear to be closely linked to processes involved in development

of physical and/or psychological dependence, a fundamental

understanding of pain and its relief may provide us with better

insight into the addictive states and their management. Greater

knowledge of chronic pain behavior may well shed light also on

other forms of dependence and habitual behaviors and their

treatment. These behaviors appear to share certain important

commonalities with the addictive states, including their selfdestructive features, intractability to treatment, frequency of

recurrence, and high incidence of iatrogenesis.

NIDA’s early efforts led to the funding of the first controlled

study on the use of heroin in terminal cancer patients, a

subject which is presently of great interest and controversy in

this country. In fact, it was NIDA’s initiatives that prompted

the White House, through its Domestic Council, to call for

formation of a comprehensive interagency task force to review

and make recommendations in the area of pain, discomfort, and

humanitarian care. Recognizing that the time had come for

greater attention to the problem of pain, the White House, late

in 1977, asked the National Institutes of Health to convene a

Government-wide committee to address this issue.

In January 1978, the Interagency Committee on New Therapies for

Pain and Discomfort was appointed and charged with examining the

status of research, education, and organization of health care

services in the areas of chronic intractable pain and humane

care of terminal patients and with developing recommendations in

1
these two areas. Actions by the Interagency Committee included

the convening of a National Conference on Pain, Discomfort, and

Humanitarian Care in February 1979. The proceedings of this

conference have been published (Ng and Bonica 1980). The Committee submitted a report of its findings which was accepted and

praised by both the White House and the then Department of

Health, Education, and Welfare (DHEW). Subsequently, upon recommendation of the Secretary of DHEW, the Committee was reconstituted in 1980 and charged with developing an implementation plan

based on its recommendations.

NIDA, in accordance with the mandate to the Interagency Committee to follow up on the recommendations presented in its report,

convened a technical review workshop with a twofold objective:

(1) to review the experience of the major multidisciplinary pain

clinics/centers in the diagnosis, treatment, management, and

rehabilitation of patients with chronic pain, which claims among

its victims a significant percentage who are polydrug abusers

and who are dependent on narcotic analgesic drugs and various

tranquilizers; and (2) to establish guidelines and make recommendations concerning possible Federal initiatives to facilitate

collaborative research, education, and the organization of health

care services to improve the care and treatment of patients

suffering from chronic pain.

This monograph is based upon papers presented at the technical

review workshop, which was held on the campus of the National

Institutes of Health on June 20-21, 1980. It was sponsored by

NIDA in collaboration with the Interagency Committee on New

Therapies for Pain and Discomfort. Each workshop participant

was invited to describe experiences in his or her own pain

clinic/center as they related to a variety of subjects,

including but not limited to the following:

(1) Taxonomy and epidemiology of pain syndromes seen;

previous treatments received by patients and results of

these; psychological, social, and economic impact of the

patients’ pain upon self, family, and others; costs of

therapy; sources of reimbursement, and their influence on

treatment outcome.

(2) Staffing of the pain center/clinic program, and

relationship of each staff member to the therapeutic

program; treatment modalities used; criteria for evaluating

therapeutic outcome at discharge and on followup.

(3) Patterns of drug use and abuse by patients with chronic

pain; types and classes of drugs abused in relation to types

of pain syndromes; the incidence of dependence; and strategy

used in withdrawing drugs.

Because the kinds of information requested about each treatment

program were the same, the responses of the authors are variations on a common theme, differing in content and emphasis

2
because of differences among the programs and among the individuals describing them. Collectively, the papers present a picture

of the treatment of chronic intractable pain at the major multidisciplinary pain clinics/centers in the United States at the

present time.

The principal focus of the monograph is on chronic noncancer

pain and experience of the centers in the treatment and management of such pain. Two papers also discuss pain management in

patients with cancer. The preface to the volume by John J.

Bonica eloquently points out the magnitude of the problems

presented by chronic pain, which is estimated to cost the

national economy $85-90 billion each year in addition to its

more important cost in human suffering and the accompanying

disruption of normal living for the individual and family. Dr.

Bonica goes on to discuss past and current status and future

needs in understanding and treating pain, from the standpoint of

both research and therapy.

Robert Addison describes the multidisciplinary program for

management of chronic pain at the Center for Pain Studies of the

Rehabilitation Institute of Chicago, stating that the “importance of the integrated, multidisciplinary approach cannot be

overemphasized.” The ability of patients to cope with their

pain is seen to be closely related to their ways of coping with

other forms of stress.

The Center’s treatment process is presented in some detail? from

the 2-day outpatient assessment for suitability for admission to

follow-up after discharge and to assessments of program

efficacy, based on computerized analysis of self-assessment

questionnaires, administered at several stages before, during,

and after treatment. Most entering patients are unable to work

or carry on pre-injury activities. The intensive 4-week

inpatient education and treatment experience utilizes injection

techniques, physical therapy, relaxation techniques, family

intervention, psychological services, vocational counseling and

placement, and other approaches. The inpatient environment is

structured so that each patient carries maximum responsibility

for his own care, self-sufficiency rather than pain behavior is

encouraged, and the patient’s family is regularly involved.

Most patients have previously been treated for isolated physical

symptoms in treatment based on the “disease model.” Since

psychogenic factors and the problem of functional overlay

influence experience of pain as much or more than organic

abnormalities in patients whose pain has persisted over an

extended period of time, it is considered essential that each

factor in the total problem be treated in conjunction with all

others. Frequent staff conferences facilitate this approach.

In his recommendations, Dr. Addison points to the need for

cooperative, nonadversary relations among interested groups

involved in patient care and the need for expanded professional

education and research directed toward development and use of

3
predictor scales identifying those persons likely to become

chronic pain patients.

The chapter by Gerald Aronoff emphasizes the Boston Pain Unit’s

holistic approach to pain rehabilitation and the need for

patients to take an active role in their health care. It is

pointed out that chronic pain patients frequently represent the

treatment failures of the medical system, whose lives have

become significantly disrupted by the time of admission to a

pain unit. The relationship between chronic pain and mood

disturbances is stressed, in particular the pain-depressioninsomnia cycle. Regardless of which problem is primary,

treatment for this cycle, says Dr. Aronoff, should be considered

a specific therapeutic intervention for chronic pain. Focus is

also placed on a system for medication deceleration, used

successfully in a patient population which reveals at admission

a greater than 50 percent dependence on narcotic analgesics.

Observations derived from the program indicate that success does

not appear to be related to the extent of organic pathology,

although there is some correlation with the duration of

illness. The variables believed to be most essential to

successful outcome include motivation, a desire to return to a

more functional, productive lifestyle; relative absence of

secondary gain, especially financial; the absence of active

litigation; and adequate support systems.

In the description of the multidisciplinary pain program of the

Northwest Pain Center, Joel Seres and colleagues point to the

high cost of the inpatient program (averaging over $7,500 for 3

weeks in 1980) and the advantages of a full daycare model which

they are now adopting (the present cost of which is $3,250 for

all services other than the cost of the motel). Again it is

pointed out that chronic pain is attended by a high consumption

of medical resources and a high rate of iatrogenesis, such as

inappropriate drug use and possibly unnecessary surgeries. The

point is made that psychological, social, and environmental

factors appear to be more closely related to pain and to pain

relief than are such factors as severity of injury, number of

surgeries, or radiographic findings. Furthermore, our compensation and disability systems are believed to be powerful

incentives that maintain pain-oriented behaviors. Particular

emphasis is given to the need for professional and public

educational efforts in this area, emphasizing that what may work

in acute care medicine may not be appropriate for conditions

such as chronic pain. More basic and clinical research are

needed to help to define the syndrome of chronic pain and the

multiple factors which affect it and its treatment.

Donlin Long describes the Johns Hopkins Pain Research and

Treatment Program. This university-based treatment program has

two primary functions: to provide evaluation and therapy for

the individual patient and to conduct research within the

program without interfering with the care of the patient. The

secondary function of the program is to educate medical students

in management of both acute and chronic pain.

4
The Center is organized to provide both inpatient and outpatient care, based on individual diagnosis, psychiatric

evaluation, and personalized therapy. The heart of the

comprehensive pain management is the 2- to 3-week inpatient

program, administered through the Department of Neurosurgery,

involving consulting physicians, psychiatrists, clinical

psychologists, social workers, and specialized nurses. As in

other programs, the basic theme is self-help and self-responsibility. Since most patients admitted to the program are

addicted to drugs, particularly the narcotics and benzodiazepines (usually Valium), drug withdrawal is mandatory. Painrelieving procedures are utilized only in a small number of

patients after careful selection. It is emphasized that a

number of questions need to be answered before any major

improvements in pain therapy are likely to be forthcoming.

Goals for future research are to identify epidemiological,

psychological, social, and medical factors which are operating

in the current epidemic of chronic pain and to develop models

for evaluation of the effectiveness of pain therapy.

Steven Brena and his colleagues at the Emory University Pain

Control Center make the point that chronic pain is often a

conditioned socioeconomic disease, with a majority of chronic

pain patients showing pain behavior in excess of biomedical

findings and disability ratings out of proportion to actual

physical impairment. These observations are interpretable

within the framework of our understanding that biomedical data

and pain-illness behaviors are independent variables and that

chronic pain patients require evaluation and management of both

variables. One method proposed is the use of the Emory Pain

Estimate Model which provides an operational definition of

chronic pain states involving separate ratings of tissue

pathology and pain behavior based on objective data. The Emory

Pain Control Center, in operation since 1972, became a division

of the Emory Department of Rehabilitation Medicine, with

inpatient and outpatient programs, in 1976. The program is

based on principles of contingency management, employing

techniques of “cognitive behavioral modification for competent

coping in maladaptive situations of existential suffering.” The

entire contingency management program takes 18 hours of actual

treatment: 3 hours a week for 6 weeks as an outpatient or 9

hours per week for 2 weeks as an inpatient. Total cost of the

outpatient program is around $1,500 in professional fees. The

patients are educated in a variety of ways to desensitize them

to particular sensory inputs, to increase their activity, and to

accept the basic idea that chronic pain and impairment of some

bodily functions are not necessarily deterrents to meaningful

and gratifying lives.

Harold Carron and John Rowlingson discuss the University of

Virginia Medical Center’s program, which is primarily an

outpatient facility serving a predominantly rural population.

Its philosophy is to encourage the patient to assume

5

348-347 0 - 81 - 2
responsibility for all aspects of the treatment program

including drug detoxification, activity and exercise programs,

and functional performance. Their outpatient model permits

initial evaluation and institution of treatment at a much

reduced patient cost. Among the therapeutic modalities

available at the clinic are nerve blocks, pharmacological

management including drug detoxification, physical therapy,

neurostimulation, activity/social programs, and psychotherapy.

The degree of drug use and abuse seen in the clinic population

is underscored. The authors reveal that approximately 98

percent of all patients prior to the clinic visit have been

placed on nonnarcotic analgesics and 85 percent of these have

also taken prescribed narcotic analgesics. The use of benzodiazepines by 85 percent of patients prior to the clinic visit

resulted in a 60 percent drug dependence for these compounds and

made it necessary, as the initial step in therapy, to provide

for detoxification following the first visit. Drug withdrawal

is accomplished on an outpatient basis with almost total

acceptance by the patients, and followup studies indicate that

few patients return to drug abuse.

The chapter by Hubert Rosomoff and colleagues of the University

of Miami School of Medicine addresses a number of issues bearing

on outcome results. Data are drawn from a group of 125 patients

with low back pain who have gone through the program since

August 1977. Some interesting results from the study emerge.

It has been thought that compensation patients are less likely

to improve than the general population. With regard to

function, data from this study do not support this concept.

Following discharge, 88 percent of compensation cases and 84

percent of noncompensation cases are found to be fully

occupied. It is concluded that compensation status does not

bear upon final outcome of function. The data also show that

while 64 percent of compensation patients prove to be “problem

cases,” this percentage is not significantly different from that

in noncompensation cases. The authors further note that

successful adaptation appears to be as strongly related to the

patients’ belief that they can manage their problems as to

improved physical strength and mobility. The issue of the

patient and optimal treatment is a complicated one, affected by

both the nature of the problem and a myriad of concurrent

psychosocial issues.

The authors note that rehabilitation of patients with back pain

is costly and available only to a privileged few relative to the

numbers of patients that require this form of treatment. Their

study stresses the need to develop a systematic, multicenter

study of patient populations, diagnoses, the specifics of

treatment within the various settings, and outcome over time,

utilizing agreed-upon diagnostic criteria, instruments, and

evaluation techniques.

John Gregg and Jawahar Ghia summarize the experiences of the

University of North Carolina Pain Clinic, which serves as a

6
tertiary care center for outpatients as a component of the North

Carolina Memorial Hospital and also provides a coordination

function for research, pre- and post-doctoral and resident

training, and clinical services. A wide array of multidisciplinary evaluative and therapeutic services is provided. Of

interest are the data that the clinic has compiled showing the

most frequent diagnostic entities in cases of chronic pain in

the head and neck versus the trunk and appendages. For the head

and neck, the most frequently encountered admitting diagnoses

are temporomandibular joint arthritis, myofascial pain, and

migraine; for pain of the low back and extremities, degenerative disease, post-traumatic, and post-laminectomy; for upper

extremity pain, reflex sympathetic dystrophy, rheumatoid

arthritis and osteoarthritis, and post-mastectomy syndrome; for

chest pain. intercostal neuralgia. cancer, and costochrondritismyofascial pain. Of the patients sampled, 87 percent reported

that they felt they had used “too much” of some drug. The most

commonly abused drugs, in the opinion of the patients, were

narcotics, propoxyphene, alcohol, diazepam, and tobacco.

The primary pain complaints, by body regions, encountered in the

clinic are: head, face, and neck, 53 percent; back and lower

extremities, 23 percent. Chest, abdomen, upper extremities,

inguinal, flank, and pelvic pain account for smaller numbers of

cases. The predominance of the head, face, and neck complaints

seen by the clinic probably reflects the particular specialty

interests of the clinic, which is administered by co-directors

from the Departments of Oral and Maxillofacial Surgery and

Anesthesiology.

Frank Moya of the Mount Sinai Medical Center, Miami Beach,

Florida, discusses primarily the two chronic pain problems most

commonly seen in the geriatric population of Miami Beach:

osteoarthritis of the spine and herpetic neuralgia. Thirty-two

percent of the clinic population have a diagnosis of osteoarthritis of the spine as the basis of their chronic pain. A

typical patient is 72 years old and has a past pain history

which includes several years of back pain treated by various

physicians with anti-inflammatory agents and analgesics, to no

avail. While past history of surgery and drug abuse is reported

to be rare, depression is common. Therapy at the Pain Center

employs primarily an exercise program and the use of epidural

and/or subarachnoid steroids. Approximately 70 percent of the

patients are said to show improvement in this program.

The next most common diagnostic category is herpetic neuralgia,

which is found in 13 percent of all patients. A typical patient

is 73 years old and has had herpetic neuralgia for 10 months,

unrelieved by various topical and oral medications. As with

osteoarthritis of the spine, there is rarely a history of drug

abuse or surgery, but extreme depression is common. The

experience of the clinic indicates that if duration of the

neuralgia is less than 1 year, 85 percent of patients obtain

significant or complete relief through the use of sympathetic

7
nerve blocks and/or the subcutaneous infiltration of steroids

and local anesthetic. However, once the herpetic neuralgia has

been present for more than 1 year, only 55 percent of patients

are improved.

The University of Washington Pain Clinic program is described in

the chapter by Terence Murphy. Initially established by John

Bonica and Lowell White about two decades ago, this program has

over the years developed into a full-time pain clinic including

daily evaluation of newly referred patients (500 a year) plus

ongoing maintenance therapy in established patients (about 2,000

patient visits per year). There is also a six-bed inpatient

facility where patients with the most complex problems are admitted for diagnostic evaluation. A proportion of these are maintained as in-patients for the formal behavioral modification

program established by Wilbert Fordyce. The typical chronic

pain patient seen at the clinic is described as likely to be

female, about 40 to 50 years of age, with a full-year history of

back pain or headache, in whom intensive investigations have

failed to disclose a specific pathological diagnosis and this

symptom has proven resistant to conventional therapies. About

30 percent of the patients are found to take dependency-producing medications in significant amounts. Patients usually

have undergone more than one pain-related surgery. In addition,

many manifest considerable psychopathology, classified as mild

to moderate depression, somatic preoccupation, illness conviction, and denial.

Included in this report is a description of the Clinic’s experience with debilitating chronic pelvic pain. None of these

patients was deemed to have any correctable pelvic pathology,

yet 95 percent demonstrated significant pathology on psychological evaluation. Significant among these patients is the history of sexual abuse: about 65 percent give a history of incest,

rape, or sexual molestation. Forty percent had been subjected

to an incestuous relationship, usually with stepfathers or

brothers. Treatment of this group includes the use of antidepressants for depressed patients, biofeedback with levator

muscle retraining mainly in the hysterical group, and ongoing

supportive care for the borderline and character disorders.

Conventional gynecological treatment such as hormone replacement, antipruritics, etc., is used in conjunction with the above

therapy.

Jose Medina and Seymour Diamond discuss the extensive experience

of the Diamond Headache Clinic at the Chicago Medical School

Department of Neurology which has about 2,000 initial patient

visits and 14,000 followup visits per year. These authors point

out the immense social burden of headache: of 200 consecutive

new patients studied between June and September 1980, the authors

found that 3 percent did not work during the entire year because

of disabling headaches; 63 percent missed from 1 to 150 working

days (average 18.1 days) during the past year; 27 percent had

been hospitalized; 1 percent had lost jobs due to the headaches;

8
and about 21 percent felt they might be risking their jobs

because of absenteeism due to headaches. Furthermore, the

chronic headache sufferer is also a potential drug abuser. Of

the slightly over 2,000 patients studied between March 1, 1975,

and January 31, 1976, approximately 3 percent were significant

users of narcotics or a combination of analgesics and barbiturates. The paper succinctly describes the evaluation procedures

and treatment of headaches, which can be simply classified as

migraine, muscle contraction headaches, and traction headaches.

The most common type seen by a headache specialist is a combination of migraine and muscle contraction headache. The paper

discusses the use of pharmacotherapy; the relative significance

of precipitating factors; the role of diet; and the value of and

indications for biofeedback training.

The chapter by Benjamin Crue and Jack Pinsky addresses four

specific aspects of the treatment of patients with chronic pain

syndrome. They point to the problems stemming from our still

rudimentary understanding of the underlying mechanisms of chronic

pain, leading to two often diametrically opposed positions: the

peripheralist, which regards chronic pain as resulting from

continued nociceptive input from the periphery into the central

nervous system; and the centralist, which regards the chronic

pain syndrome as resulting from central nervous system phenomena

without ongoing peripheral nociceptive input. The taxonomy

problem is also underscored by these authors, as well as by

other participants at the workshop. Workers in the field of

algology face complex problems in comparing the diagnostic,

prognostic, and treatment outcome results of patients who suffer

from chronic pain syndromes. Much of this situation results

from a lack of agreed-upon definitions and classifications of

pain syndromes encountered clinically. References are given for

more complete discussion of these two important issues.

The principal focus of the chapter is the long-term evaluation

of a pain treatment program that had its origin at the City of

Hope National Medical Center in 1960 and continues at New Hope

Pain Center and Pain Research Foundation, based in Alhambra,

California. Data were gathered from questionnaires mailed to

followup patients and analyzed at various time stages after

discharge. Changes were recorded in such phenomena as:

(1) drug use, (2) continuing medical-surgical treatment,

(3) subjective pain reports, and (4) general life outlook and

attitude. Their data indicate that long-term, positive

therapeutic changes in each of the above-mentioned areas have

occurred for a large segment of their patients. The authors

emphasize that differences in patient populations, treatment

settings, and other intervening variables make it difficult to

compare outcome data from one pain treatment setting with

another unless many factors are appropriately weighted.

The concluding section of the chapter provides an interesting

operational description of a multidisciplinary team approach to

the management of pain in patients with cancer, either terminal

9
or preterminal. Pain relief therapy presupposes, of course,

that the attending physician and the pain team members agree

that all possible efforts have first been made to ameliorate the

suffering by treatment of the primary neoplastic condition (or,

at times, other pain-potentiating medical conditions). The

authors stress the need for further studies, such as those being

proposed by the National Cancer Institute, to evaluate the team

effort in pain management in cancer patients.

The chapter by Kathleen Foley highlights several important

issues related to the management of pain patients with terminal

cancer. In a survey of over 36,000 admissions to the MemorialSloan Kettering Cancer Center (MSKCC) between January 1974 and

January 1978, 9 percent of patients reported pain severe enough

to require a specific consultation from the pain service; in

another survey, also done at the MSKCC, approximately 29 percent

had pain requiring the use of analgesic drugs. This range in

prevalence rate points to the need to define more precisely the

nature of pain in cancer patients. MSKCC breaks down the pain

into three categories: (1) pain associated with direct tumor

involvement; (2) pain associated with surgery, chemotherapy, or

radiation therapy; and (3) pain unrelated to the cancer or

cancer therapy.

Evaluation and treatment of patients with cancer pain requires a

specific expertise which should include a clear understanding of

the nature of the pain and the various approaches to pain

management. Narcotic analgesic drugs are the mainstay of pain

therapy for patients with cancer. Most physicians, however,

lack sufficient knowledge of narcotic pharmacology to use these

drugs appropriately. A number of controversies have arisen,

pertaining in particular to the question of the best analgesic

regimen to use in patients with terminal cancer pain and the

question of whether physical dependence and tolerance develop.

Comparative studies of heroin and morphine in cancer patients

with pain at MSKCC demonstrate that, using equianalgesic doses,

heroin and morphine have comparable analgesic and mood effects.

While heroin did offer a more rapid onset and shorter duration

of action than morphine, it did not appear to offer any special

advantages in the management of cancer pain patients. The role

of long-acting analgesics such as methadone also remains unclarified. With respect to the development of tolerance, the experience at MSKCC suggests that, in contrast to Robert Twycross'

experience, tolerance does occur in patients with pain and

progression of disease, representing a significant practical

management problem. However, drug abuse and addiction did not

occur in the cancer patients with pain studied at MSKCC. There

is a tremendous need, it is pointed out, to develop guidelines

based on careful clinical studies, not limited experience and

anecdotal data. Escalation of drug dosage, switch to alternate

drugs, and use of combination drug therapy represent empirical

approaches to providing adequate pain relief.

The above summaries provide an overview of the experiences of

the clinics/centers in the treatment and management of chronic

10
pain. Obviously, these may differ by virtue of differences in

interest, particular expertise, geographic location, and

resources available to each center. Collectively, the data

presented by the various participants provide us with a map of

the current state of knowledge and help us to identify areas

where knowledge is deficient.

The second day of the workshop was devoted to reviewing the data

presented and to developing recommendations on areas where

further action is needed. In preparing the recommendations, the

participants worked in three study subgroups: Research, Public

Education, and Professional Education and Training. There was a

consensus on the need to recognize chronic pain as an important

medical problem and as a disease entity with its own characteristics to be further defined and understood. General and specific recommendations for short- and long-term goals were presented

by the three study subgroups. Funding of a center or office with

a mandate to implement the study of pain in all its aspects was

also recomnended. The workshop recommendations were submitted

in their entirety to the Interagency Committee on New Therapies

for Pain and Discomfort for its deliberation and use in preparation of its report to the White House. The reports of these

subgroups are presented in the appendix.

11
Treatment of Chronic Pain:

The Center for Pain Studies,

Rehabilitation Institute of

Chicago

Robert G. Addison, M.D.

ABSTRACT

The Center for pain Studies of the Rehabilitation Institute of

Chicago(fomerly known as the Low Back and Pain Clinic)has developed a multidisciplinary program for the management of chronic

pain. Typically patients present a variety of chronic pain syndromes, most frequently low back pain, which have not responded to

previous treatment including surgery, physical therapy, medication,

vogue therapies, and other pain management programs. Patient

capability to engage in normal daily activities such as standing,

walking, sitting, lifting, etc. is often limited; most are unable

to work or carry on pre-injury activities. Psychological ramifications of chronic pain appear frequently as a retreat from responsibility by the patient for his own welfare, manifested by

distinct behaviour patterns (measurable on the MMPI); however,

the ability of the patient to cope with chronic pain is largely

a function of his ability to cope with other stresses prior to

onset of pain. The patient's physical and psychological status

alters his relationships with spouse and children, straining

family well-being. Economic factors often occasion additional

alteration in personal and family relations. Frequently a spouse

not employed outside the home goes to work. Compensation programs

and aid from public agencies may provide insufficient support or,

conversely, compensation practices may establish perverse incentives toward recovery by providing the patient with net income

equal to or greater than normally received.

Admission to the Pain Clinic is determined by a two-day outpatient

evaluation, assessing patient suitability for the multidisciplinary

inpatient program by physical and psychological examinations, physical therapy and vocational therapy evaluations, interviews, and

appropriate tests deemed necessary. The inpatient program consists

of a four-week intensive education and treatment experience,

utilizing injection techniques, physical therapy, relaxation

techniques, family intervention, psychological services, vocational

counseling and placement, and other approaches within the scope of

the clinical facilities. Program efficacy is calculated by means

of computerized analysis of the pain patient self-assessmemt questionnaire, which measures chronic pain in terms of severity and

duration, and of performance of daily activities (standing,

lifting, walking, sitting, etc.) with the RIC Rehabilitation Information System (REHABIS). Patient pain perception and tolerance

1 2
in activities performance have shown significant change from

pre-treatment status, an improvement which appears to be maintained

post-discharge. Program cost effectiveness is enhanced by the

outpatient evaluation which maximizes inpatient treatment effectiveness, and by the high percentage of vocational placements.

Patients typically enter the program on multiple medications including some form of narcotic, most frequently lesser narcotics in

conjunction with analgesics. While the incidence of physiological

dependence is minimal (less than five per cent), psychological

dependence is common. Detoxification is accomplished by education,

rapid decrease of drug potency during first week, followed by

decreased frequency of administration with maintenance on mild

analgesic if needed. No medications are given pro re nata; all

are administered according to behavioural modification techniques.

TAXONOMY: PAIN SYNDROMES TREATED AT THE REHABILITATION

INSTITUTE OF CHICAGO

At the present time there is no universally accepted taxonomy of

chronic pain syndromes. Several medical specialty societies have

instigated efforts to develop a standard taxonomy. Two of them

are the International Association for the Study of Pain, which

seeks to classify chronic pain syndranes generally, and the

American Academy of Orthopaedic Surgeons which has focused on

classification of spinal diseases.

In the absence of a standard taxonomy, the Center for Pain Studies

(CPS) and other treatment facilities utilize classification systems

based on working definitions of pain syndromes presented. The

Rehabilitation Institute of Chicago (hereafter RIC) concentrates

upon treatment of six categories of chronic pain based on anatomical sites: 1) low back, 2) cervical, 3) headache, 4) cancer,

5) facial, and 6) spinal cord injury pain. A majority of patients

admitted to CPS exhibit low back pain; cervical, headache, and

spinal cord injury pain are seen as well. Cancer pain is treated

by an affiliated research entity, the Pain Management Team of the

Cancer Research Group.

The Pain Management Team of the Cancer Research Group treats pain

attendant upon 1) bone destruction by metastatic tumor, 2) distention of a hollow organ produced by obstruction due to tumor growth,

3) infiltration and canpression of a peripheral nerve, and 4)

enlargement of a solid organ. This selection is limited to pain

associated with solid tumor growth, excluding leukemia and diffuse

lymphoma. The Pain Management Team is affiliated with RIC, the

Northwestern University McGaw Medical Center, and six similarly

based research groups in the U.S.

EPIDEMIOLDGY AND ETIOLOGY: PAIN SYNDROMES TREATED AT THE

CENTER FOR PAIN STUDIES

Approximately one half of CPS patients present chronic pain

13
arising from work-related injuries: falling, prolonged or repeated

lifting, twisting, pushing or pulling, and motor vehicle accidents.

Pain syndromes of the remaining fifty per cent typically arise from

motor vehicle accidents, recreational accidents, lifting, postsurgery or post-pregnancy pain, or entail an insidious onset

unrelated to any single injury.

ORGANIC FINDINGS

Since patients come to CPS on referral from other physicians

specifically for management of chronic pain after acute care

treatment modalities have been exhausted, rarely does the examination at CPS reveal organic abnormalities requiring further treatment by conventional means. Generally, patients present minimal

clinical problems relative to pain behaviour displayed. While

CPS provides ongoing care for acute conditions other than those

associated with chronic pain in persons who are accepted for

inpatient treatment, patients whose organically based symptoms

might be relieved by surgery or other invasive procedures are

returned to their referring physicians with appropriate recommendations. When CPS examinations suggest the presence of organic

abnormalities, for example a cardiac condition, which would not

ordinarily be diagnosed in the course of orthopaedic and neurological examinations, the patient is referred to a CPS physician

consultant within the McGaw Medical Center for evaluation.

Organic findings in chronic pain patients constitute a broad and

variegated spectrum. The results of a sampling of 61 persons

with chronic low back pain evaluated as outpatients in 1977 are

instructive in this regard. EMG studies revealed abnormalities in

six patients, four of which were attributable to an old radiculopathy, one to a mild neuropathy of the suprascapular nerve, and

one clear cut abnormality not attributable to a particular nerve.

Eight yielded positive results unilaterally or bilaterally to

Fabere testing. Six instances of mild to severe paraspinal

muscle spasm were found. Impairment of ankle reflexes unilaterally

was found in three cases, bilaterally in four. Two reported impairment of knee reflexes bilaterally, one unilaterally. Three

were unable to walk on heels or on toes. Five showed marked

weakness of the extensor hallicus longus and accompanying deficiencies. While many exhibited a slightly limited range of motion in

the upper and/or lower extremities, six had moderate to severe

limitations. Equilibrium in three was moderately to severely

impaired generally or on one side.

NONORGANIC FINDINGS

Of the 61 patients evaluated, the problems of 48 were considered

to be mostly functional. One person was found having mostly

organic problems, and five had abnormalities of both an organic

and functional nature. Three had distinctively heavy functional

overlay; in two others, functional overlay was minimal.

Common indications of nonorganic phenomena centered on reports of

14
decrease or absence of sensation. Testing revealed fifteen persons

who showed a decrease or absence of sensation on one side or one

extremity with no dermatone pattern. One person reported decreased

sensation in both lower extremities with no dermatone pattern.

Decreased sensation corresponded with a dermatone pattern in two

persons. In addition, one person reported numbness in all ten

fingertips, with no other decrease in sensation.

PSYCHOLOGICAL FINDINGS

The taxonomy of patients seeninour program, fran apsychological

Point of view, has three broad classifications. First, as described in detail below, is the group of patients whose pain has

set in motion a series of stresses which results in Psychological

dysfunction. Second is the group of patients where pain, though

unpleasant in itself, directly or indirectly solves a range of

problems in their lives, such that over time pain becomes a component of their psychosocial stability and the potential of being

pain-free carries with it the attendant risk of psychological

destabilization. Third is the group where both the above factors

operate together. In this last group, the initial psychological

dysfunction (reactive to the stresses associated with pain) is

accommodated by the development of a modified psychosocial structure, and this modified structure gives heavy emphasis to the

potential secondary gains of the pain complaint. Within all three

groups, the types of pre trauma personality patterns described

below relate to the severity and resistance to change in the

psychological disturbance. Moreover, the longer the duration of

the pain complaint, the greater the likelihood of a Patient falling

into the third category discussed above.

PATIENT TREATMENT HISTORY

patients are usually referred to CPS when chronic pain proves

intractable to conventional treatment modalities administered on

a disease model, addressing only the organic sources of pain.

Standard diagnostic techniques including physical examination by

an industrial physician, family physician, orthopaedic surgeon

or neurosurgeon, a myelogram, electranyography, X-ray studies, and

laboratory studies have generally been employed prior to the

patient's appearance at CPS.

Our patients have undergone an average of no more than one surgical

procedure for the Pain-related injury prior to appearance at CPS,

although a few report as many as seven surgeries. Often surgery

has been done as a "last resort" or as an exploratory measure where

pain continues after completion of initial treatment. A previous

laminectomy, spinal fusion, open or closed rhizotomy, or dorsal

column stimulation is commonly reported.

In general the rate of surgical intervention for back pain in the

U.S. far exceeds that of other nations. A recent study by William

J. Kane, M.D., of Chicago comparing discharge statistics in the

U.S. and Sweden discovered that in 1978 the rate for lumbar

15
laminectomies for herniated intervertebral discs in the U.S. was

75 per 100,000 population nationwide. Sweden's statistics yielded

an estimated average of 11 per 100,000; Great Britain (in 1970)

reported 10 per 100,000.

In addition to surgical procedures, most patients at CPS have

undergone some combination of physical therapies, especially

ultrasound, diathermy, whirlpool, heat and/or cold packs, massage,

transcutaneous nerve stimulation (TNS), or traction.

Medications for pain used prior to admission to CPS can be categorized generally as analgesics, including narcotic and non-narcotic drugs, sedatives, including muscle relaxants and tranquilizers, and anti-inflammatory drugs. In addition a limited number

of injection procedures have been employed, usually steroids or

anaesthetic agents. A moderate number have had chemonucleolysis.

Occasionally patient histories report treatment by such unconventional therapies as acupuncture, radiofrequency, rhizotomy, biofeedback, hypnotherapy, electrical stimulation, and other unorthodox individual applications. A few histories note previous

treatment at other pain facilities utilizing various injection

techniques and/or psychological services.

Prior treatment proved wholly or partially unsuccessful in patients

referred to CPS for a variety of reasons. Generally, however,

failure to involve the patient in responsibility for the management

of his own pain, and a tendency to treat specific physical symptoms

isolated from consideration of patient attitudes, relationships,

etc., are typical. Partial successes prior to treatment at CPS

take the forms of partial cessation, change of pain site, change

from constant to episodic pain, change in kind or severity of pain,

or return of pain after cessation for a period of months or years,

especially when surgery corrected the initial pain syndrome but

is not indicated for the subsequent occurrence.

from a psychological standpoint, the usual course of patient treatment prior to arrival at CPS exacerbates the psychological conditions described above. Particularly in those patients where pain

is a solution to some pressing problem(s) in living, as well as

being the presenting problem, purely medical interventions do not

address the core of the problem, and often serve further to

obscure the core problem from both the patient and the medical

staff. The general course of events inourpatients is that all

reasonable (and some unreasonable) medical interventions are

exhausted before potential problems in the patient's psychosocial

life are examined. Iatrogenesis in such cases occurs as a result

of the following factors: 1) the delayed identification and

treatment of psychosocial issues allows them to become more

entrenched and resistant to correction; 2) the patient's

failure to obtain satisfactory relief despite multiple medical

contacts creates various forms of counterproductive interactions

between patients and physicians (adversary roles, rescue roles,

excessive dependency, etc.); and 3) the counterproductive

16
interactions in some instances set the stage for inappropriate or

unnecessary medical procedures and treatments.

IMPACT OF PAIN

Physical Impact

The physical impact of chronic pain insofar as it can be separated

from other aspects is characterized by development of pain behaviours over time, a limited capability to carry on normal daily

activities (usually including work), intake of medication often

resulting inpsychologicaldependency, a decreased range of notion,

decreased endurance, and often a change in physical appearance

including weight gain or loss, development of protective gestures

and modes of motion, as well as any disfigurement immediately

caused by the original accident or injury.

Psychological and Psychosocial Impact

Despite the numerous and varied etiologies of pain syndromes in

patients evaluated for admission to CPS, the psychological and

social impact of life with chronic benign pain does not appear to

differ clearly on the basis of diagnosis alone. Temporal factors

are most salient, with patients suffering psychological sequelae

to a heightened degree as pain continues over the course of

several years. The length of time the individual has been removed

from the work force, the number of surgical interventions and

hospitalizations, etc., do most certainly yield a patient who

evidences greater adjustment difficulties than the individual for

whom injury has been a more recent occurrence. However, in our

patient population, the psychosocial impact of life with chronic

pain appears most directly related to how such losses in functioning and alterations in lifestyle are perceived by the individual.

In essence, the ability of the patient to cope with his physical

circumstances is in large part a function of his prior level of

adaptation and his wherewithal in handling the stresses of life

before onset of pain.

There are a number of characteristics which predominate in our

patients as they present themselves for evaluation. The perception

of one's life being out of one's own control, or a lack of contingencies based on individual behaviors, a sense of helplessness

in intervening on one's own behalf is most often the general overlay to all other psychological and emotional changes. The ability

to plan long- and short-range activity is relinquished and viewed

as au impossible and fruitless endeavour.

The disruption of family relationships and functioning appears

universally. Role reversal necessitated by loss of general function

and employment has its greatest effects in families where patients'

self-esteem is in large part derived from the gratifications received via employment, at home or in the outside work force. This

appears to be the case regardless of sex or type of employment;

the greater the investment in and reliance on external sources of

17
esteem, the greater the likelihood that the psychological impact

of this loss will be a major problem. Additionally, the greater

the role rigidity within the family (and the patient's need for a

clear cut, highly circumscribed role definition), the less likely

the family unit is successfully to absorb and accomodate changes

precipitated by injury and pain. Thus, while the psychosocial

impact of chronic pain is always observable in some fashion, it is

likely to be most devastating in circumstances where individuals

have few or ineffective internal and interpersonal resources with

which to cope with change. Our current system of benefits and

remuneration becomes, for many, a source for projection of their

pain and despair; the tendency to over-prescribe analgesics

becomes a source of heightened sense of helplessness and inability

to control one's life. In sum, however, what the individual brings

to this situation, in terms of his personal organization and

psychological wherewithal, is merely heightened and challenged by

his new circumstances. Chronic pain does not produce a new person

— rather it maximally stresses the resources, abilities, and

coping effectiveness of the individual and family who were once

pain-free.

The presence of chronic pain particularly taxes family relationships. Depending upon the antecedent circumstances of family and/

or work relationships, chronic pain may serve to transpose what

would otherwise be unacceptable disability into an acceptable

one, one which in some measure alleviates previous problems

inherent in the relationship. Frequent hospitalization disrupts

family life and often family finances, tending to heighten the

patient's sense of isolation. Spouses encounter depression,

anxiety, loss of self-esteem, increased dependency and decreased

sexual function intruding on marital relations; role reversal

vis-a-vis employment often aggravates an already drastic emotional

alteration. Children may face emotional distancing by the chronic

pain patient as he becomes increasingly introverted and preoccupied

with his pain. Children often associate parental illness with

impending death, further upsetting the child's emotional equilibrium. The child loses an important role model and an accustomed

partner in recreational and social activities. Family emotional

stability on the whole may fluctuate from day to day, depending

upon the patient's level of pain.

It is rare for our staff to see patients who have previously been

consumers of psychotherapeutic services. For some, this reflects

a sense of hopelessness or passivity in response to trauma. For

many, the recommendation to the patient to pursue these services

has often been made by a physician in the context of the patient's

failure to improve, where the suggestion becomes inextricably tied

to the question of etiology and, hence, is avoided or refused by

the patient for fear that it will be viewed as acknowledgement

of such an interpretation. When psychotherapy has occurred prior

to our evaluation of the patient, it has most often been in conjunction with marital or family difficulties. One might hypothesize

that, for the patient, this is a legitimate entree into a system

not acceptable as related to himself as an individual. "The problem

18
of early psychological intervention is compounded by the fact that

few professionals appear to have the skills and understanding of

pain to appropriately recommend management approaches in addition

to traditional psychotherapy. Nonetheless, the result for most

patients is that the psychological impact of chronic disability is

experienced daily but never addressed directly prior to involvement

in intensive rehabilitation programming, often several years later.

In most cases, some aspect of the patient's dilemma, however minor,

appears directly precipitated by our system of health care delivery

for the chronic pain patient. The fashion in which the patient's

complaints and frustrations have been handled from entry into the

system does in fact set the course for the individual's acceptance

of emotional and psychological issues as relevant to the quality

of his life, the exacerbation of his pain, and his ability to

function despite losses of major proportion. Perhaps the most

critical issue is the likelihood for the patient that at some

point the suggestion will be made, covertly or directly, that his

pain is imaginary, not understandable from an orthopedic or neurological perspective, not in line with medical data at hand -- not

legitimate. For most, this occurrence leads to heightened

resistance to acknowledgement of emotional overlay for fear of

closing medical options, despite the patient's very real experience

of psychological difficulty. The search for "the answer" becomes

paramount, and intervention from a psychological framework becomes

more difficult as the situation is viewed as "either/or" by the

patient. Many patients are for the first time in their lives

faced with the awareness that our current medical knowledge is

limited, which shakes beliefs and trust which have their roots in

early childhood. Hence, the patient's confrontation of these

issues often leads to anger, hostility and projection directed

onto those on whom he is most dependent for relief and guidance.

Secondly, the prescription of analgesics for chronic pain patients,

while done most often in good faith, remains the most expedient

treatment of choice by many for short term relief. The patient,

however, is usually faced with side effects, especially depression

and impaired cognitive fuuctioning,which further feeds his sense

of inability to function, dependence on physicians, and need for

greater relief through increased dosage or a shift to more potent

medication. Additionally, the prescription of bed rest and other

passive modes of treatment in chronic vs. acute syndromes encourages

the patient's perception of himself as helpless, useless, and unproductive.

It is often the physician last seen for consultation who is most

honest and open with the patient (i.e., There is nothing more I

can do for you"), leading to the ultimate sense of betrayal we see

upon evaluation of our patients. The long-term process, then, is

often counterproductive and oppositional to the pain management

techniques we encourage patients to invest in upon their acceptance

to programs emphasizing increased physical function, independence,

and self responsibility for pain control. As this process is most

frequently a lengthy one spanning several years, it behooves us to

19
look toward early intervention and the appropriate presentation to

patients of the psychological components of physical disability as

integral versus causative aspects of illness and health related

change.

Economic Impact

Financial problem due to decrease in income may be a major source

of stress for the chronic pain patient and his family. Where insufficient funds may not be pressing, inconsistency in the amount and/

or frequency of payments may nevertheless prove troublesome. Patients who have been the primary source of income for the family

may arrange in some cases to continue working with modifications

in the kind or scheduling of work performed, in order to provide

for basic economic needs. however, those patients who have been

off the job for six months or more tend to undergo a reorientation

toward the work ethic and an adjustment in self-image which radically diminish the likelihood of their reentry into the work force

unassisted. As noted above, spouses previously not employed

outside the home frequently enter the work force; however, the

level of income generated by a spouse working for the first time

seldom equals that attained by the injured spouse if he or she

has been employed for some years.

In some cases the level of compensation provided an injured person

actually surpasses the level of "take-home" pay attained while

employed, creating a serious disincentive to work or to seek successful rehabilitation. Pending personal injury litigation poses

another substantial countermotivation to resumption of normal daily

activities, although only a small percentage of patients are still

involved in litigation by the time they reach CPS.

Various levels of income maintenance are provided for the chronic

pain patient by such organizations and agencies as Workman's

Compensation, the Illinois Department of Vocational Rehabilitation,

Illinois Public Aid, federal Social Security Disability Insurance,

and an assortment of public and private disability insurance

sources. Medicare, Medicaid, and various private and/or workrelated health insurance plans offset a substantial portion of

acute care costs, but provisions for rehabilitation care are often

limited.

Approximately fifty per cent of CPS patients are referred by

Workman's Compensation, which provides reimbursement for one

hundred per cent of patient costs for rehabilitation. Agencies

such as the Division of Vocational Services and Illinois Public

Aid reimburse all patient costs as well. Medicare provides eighty

per cent of inpatient costs, and does not cover certain specific

kinds of services such as biofeedback. Private insurers cover

varying percentages of inpatient costs, usually eighty per cent.

Coverage of psychological and rehabilitative services is uneven;

reimbursement for vocational rehabilitation generally is not

provided.

20
While economic factors potentially weigh heavily on the patient's

outlook on life and motivation to return to a normal level of

activity, experience at CPS indicates that present financial

circumstances and sources of reimbursement are less influential

factors in the program's success than is patient motivation.

Economic Impact on Society

It is estimated that six and one half million men and women are

under treatment every day for low back problems alone. Roughly

600,000-700,000 persons miss work each year due to back injuries,

costing employers approximately one billion dollars annually in

sick pay and wages for replacement personnel. The cost to society,

calculated in terms of annual disability payments expended plus

loss of taxes formerly contributed by these workers, is as high in

individual cases as it appears to be in aggregate figures. The

RIC Vocational Rehabilitation Department has recorded examples

from among CPS patients who returned to work upon completion of

the program (see Table 1).

TREATMENT IN THE CENTER FOR PAIN STUDIES

Prescreening

Since patients are referred to CPS by private physicians or third

party referrers, every effort is made to obtain and review patient

records prior to admission to the outpatient evaluation. This

prescreening and a two-day outpatient evaluation across all disciplines are designed to determine the appropriateness of a fourweek inpatient program for each individual, and to formulate prior

to admission a program suited to his or her needs.

Outpatient evaluation

The outpatient evaluation begins with complete physical examinations

by the staff orthopaedic surgeon, neurosurgeon and anaesthesiologist

in order to obtain a fresh, up-to-date assessment of the patient's

physical condition independent of personal reaction to possible

functional overlay. An EMG, routine laboratory work, and X-ray

studies are performed, as well as any special tests or evaluations

deemed necessary to gain a complete picture of the patient's

physical status (CT scans of lumbar area, cardiac evaluation, etc.).

Early in the Center's history, a gynecological examination for all

females was included in the evaluation. This component was discontinued after the first year because of the extremely limited

correlation between gynecological findings and chronic low back

pain. Cut of some sixty patients, one positive finding was made

— endometriosis,which in all probability was unrelated to the pain

complaint.

Patients are seen for an extensive psychological interview which

focuses on both pain-related issues (i.e., secondary gain, response

to disability, etc.) as well as premorbid factors (adjustment,

passive/active coping in past crises, etc.). Although no specific

21

348-347 0 - 81 - 3
criteria are utilized rigidly over time, several are considered as

basic to the decision to accept or reject patients at this point.

Patients deemed to be psychotic or to have insufficient intellectual

ability so as to be able to incorporate or integrate program

material are excluded. The patient's inability to invest himself

psychologically in terms of taking responsibility for improvement

(i.e., active participation in his own behalf, willingness to withdraw from medication or use of other external supports) is seen as

a major indicator for nonacceptance, often regardless of level of

incapacity or physical limitations. On occasion, where it is felt

that a very mixed picture is present, a recommendation is made for

a two-week trial of extended evaluation and therapy during which

time a more complete assesment can be made regarding patient motivation and likelihood to make significant improvement.

Psychological testing is completed at the time of outpatient evaluation but is used as an adjunct to treatment planning rather than

as a tool in assessing the patient's appropriateness for inpatient

treatment. As it is a rare case in which psychodiagnostic evaluation yields a significantly different patient profile than is obtained in interview, such testing has been found most useful

in the clinical and research areas.

The evaluation also includes a physical therapy evaluation, an occupational therapy evaluation, and if appropriate a vocational

rehabilitation interview and evaluation. The physical therapist

assesses physical limitations that are secondary to pain such as

gait deviations, decreased endurance and spontaneity, and poor

balance reactions. The occupational therapist assesses functional

disabilities that are secondary to pain such as dressing problems,

decreased homemaking and leisure activities and upper extremity

physical limitations. The vocational counselor evaluates the

physical requirements of the patient's former job, patient capabilities, and attitudes toward work. He tries to determine whether

there is a job available for the patient with his employer.

Upon completion of the outpatient evaluation and diagnostic procedures, a team conference determines whether the patient is acceptable for further care at the Center for Pain Studies. The

patient is not acceptable if a surgical procedure is indicated

or some other acute medical treatment is needed, the patient has

severe emotional problems, the patient functions below normal intelligence, or at the time of evaluation the patient did not have

the capacity to change "pain behaviour" patterns. While prospective inpatients must be sufficiently fluent in spoken English to

participate in therapy, all written materials have been translated

and are available in Spanish as well as in English.

The criteria for rejecting a patient are based on our treatment

results. Patients who meet any of the above criteria do not have

successful treatment outcomes. For example, patients who have

difficulty with abstract thinking find it difficult to take a concept and apply it away from the setting where they were initially

introduced to it. This patient can apply good body mechanics in

22
Table 1

Estimated Economic Gain to Society From Return to Work

of Four CPS Patients

Job

Title

Project

Engineer

Painter

Estimated Projected Gain

Prior Annual Annual Annual Annual Gain to Society

Benefits Salary Taxes to Society* by Age 65+

$8,400 $18,000 $4,320 $12,720 $216,240

$7,124 $11,856 $2,845 $9,969 $378,838

Mechanical

Electrician $13,200 $16,800 $4,032 $17,232 $241,248

Truck

Driver $9,984 $15,600 $3,744 $13,728 $178,464

*Taxes plus prior benefits.

+Based on working years remaining to age 65, assuming a constant income.
physical therapy, but does not carry the concept into work evaluation or activities of daily living such as making a bed. Within

the program the patient has to be cued constantly to apply good

mechanics; upon completion he is unlikely to incorporate them

into his lifestyle at all.

Another criterion for rejection based on active treatment of numerous patients was the pain team consensus that the patient was

not motivated toward pain managanent. A patient who refuses even

to attempt several evaluation tasks such as bending or lifting, a

patient who recognizes no relation between pain and attitude, who

seeks a solely "medical cure" of pain, who evinces unwillingness

to accept responsibility for his own treatment in other ways is not

likely to succeed in the CPS program.

Patients with emotional problems find it difficult to focus on

program concepts. They are so involved with their emotional dilemmas that outside stimuli are not incorporated into their lifestyles. These patients have been found to disrupt with their own

agenda of problems group sessions crucial to program success for

all inpatients.

Inpatient Treatment

The inpatient treatment program, a conservative interdisciplinary

management program for the treatment of chronic benign pain, usually requires four weeks for completion. The importance of the

integrated multidisciplinary approach cannot be overemphasized.

As stated above, most patients entering the CPS program have

previously received some of the individual therapies in the course

of treatment based on the "disease model," essentially the treatment of isolated physical symptoms. Since psychogenic factors and

the problem of functional overlay influence experience of pain

as much or more than do organic abnormalities in patients

whose pain has persisted over an extended period of time, it is

essential that treatment of any one factor be conducted in conjunction with treatment of the others. At CPS, this approach is

facilitated by regular conferences among all staff, by structuring

the inpatient environment such that maximum responsibility is conferred upon each patient for his own care, by use of behaviour modification techniques to encourage self-sufficiency rather than

pain behaviour, and by involvement of the patient's family through

regular family conferences.

A typical schedule for the four-week intensive program runs from

7 a.m. to 5:30 p.m. Monday through Friday. The emphasis of the

first two weeks falls on education and physical upgrading; the third

and fourth weeks emphasize application of newly acquired techniques

to work and home environments, complemented by augmentation of endurance and tolerance. In addition to attending scheduled appointments and activities, patients are responsible for such routine

details of self-care as dressing and grooming themselves (street

clothes are worn except during injections), laundering their own

clothes at facilities on the nursing floor, obtaining linens

24
provided by the Institute, arriving at all therapies on time,

cancelling in advance any appointments which might be missed, taking

all meals in the RIC cafeteria, administering medications (techniques discussed more fully in section on Medications, below),

keeping own rooms and communal lounges clean, measuring and recording daily waist measurment, temperature, and pulse. Telephones

are located only on halls, and televisions only in communal

lounges, not in patient rooms, to encourage socialization among

patients. Uninhibited direct communication between patients and

staff is highly encouraged.

Inpatient treatment begins with orientation, part of the ongoing

process of education of the patient to his problem and to his

alternatives among a range of possible solutions. The educational

process permeates all other facets of the program, e.g., physical

therapy, psychology, structure of life on the floor, in addition

to certain specifically educational components. A lecture/discussion series covers such topics as muscle function, pelvic tilt,

anatomy, sexual function, and body mechanics.

As a single diagnostic/therapeutic modality, videotaping patient

performance on an "obstacle course" has proven to be one of the

approaches, most beneficial to the patient. A videotape of his

performance on the obstacle course, which consists of ten activities such as walking, lifting, balance activities, reaching and

bending moves, etc., gives the patient a visual experience which

is then used through the first three weeks to point out his

responses to various daily activities: how he approaches tasks,

how he moves (guarding, rigidity), what his body language communicates to others, and how he uses body mechanics. The patient is

filmed once during the first week of the inpatient program and

again prior to discharge, so that improvement or lack of it in each

ration is apparent to him.

According to findings and recommendations formulated in the outpatient evaluation, many patients receive a series of epidural

and/or intrathecal steroid injections. These injections are administered by the staff anesthesiologist, who carefully explains

their purpose to the patient. Trigger point and facet injections

may also be given if appropriate.

Psychology staff utilize a variety of modalities in conjunction

with patient treatment in CPS as it is currently devised. Essentially, the basic framework employed is a cognitive and behavioural

approach to pain management, with individual and group sessions

geared toward facilitating health-related behaviour and the alteration of reinforcement contingencies around the issue of pain.

Patients are seen twice weekly in groups which combine didactic

and behaviour change approaches. Biofeedback and progressive

relaxation training occur three to four times per week on the average. Hypnosis for pain control is utilized with patients for whom

it is felt it would be profitable. Individual psychotherapy is

geared toward increasing insight into pain-related changes as well

as in exploration of alternative modes of response that are more

25
appropriate and functional. A family group meets weekly both to

educate those involved closely with the patient and to attempt

restructuring of family life away from pain-focused activity and

responsiveness. As the role and value of each particular modality

for patients often differ, attempts are made in the program to

individualize treatment as a function of patient need and orientation, with changes in treatment plan following continuous reassessment of progress or lack thereof. In general, however, above

and beyond the utilization of particular treatment modalities,

psychologists are responsible forensuringthat sound psychological

principles of learning and behaviour change are applied consistently

and integrated into all aspects of the program across all disciplines. Likewise, the psychologist functions as team consultant

with regard to behavioural management of patients and assessing

patient-staff issues which have the potential for interfering

with maximal productivity in patient and staff alike.

The program currently is staffed by one and one half full time

psychologists with several years of experience in the area of

chronic pain. Additionally the program employs a full time

bachelor level biofeedback technician supervised by Ph.D. level

personnel in provision of training to individual patients. While

in the past it was often difficult to select psychologists with

pain management experience, the growth of this area of treatment

into a full-fledged subspecialty has made the task of hiring

professionals armed with the necessary skills a much easier one.

Likewise, with the growth of our particular program, we are now

in a position to provide supervised training experience to graduate

students in clinical psychology via rotations through the clinic.

Following completion of the four-week inpatient program, patients

are given outpatient appointments ("recheck") at intervals of

six weeks, three months, six months, and one year. Due to the fact

that the RIC program draws from a patient population which is geographically very large, successful and consistent followup is often

a difficult endeavor from a psychological standpoint. Plans are

currently underway to begin long term followup by telephone interview, patient completed questionnaires, and re-administration of

psychodiagnostic tests at six month, one-year, and two-year intervals. To date, there has been little formalized patient based

psychological data regarding long term effectiveness of the

training provided during inpatient stay, although thorough charts

are available from all disciplines regarding level of improvement

in functional gains, etc., evaluated at recheck appointments.

Training in relaxation techniques, including lectures and participation in breathing and progressive relaxation, biofeedback,

autogenic techniques for achievement of deep relaxation and hypnotherapy, equip patients with methods of controlling or altering

incidence and experience of pain. Approximately nine to ten hours

of biofeedback training concentrates on control of certain physiological states, such as muscle tension, regulation of which is

frequently accompanied by a reduction of pain or a favorably

changed pain experience. Sessions with a biofeedback machine are

26
conducted in a quiet room during the first weeks; third week sessions take place in a "practical situation" setting such as at a

desk, in a kitchen, on a loading dock, etc. Relaxation techniques

are used to self-control reactions to stress, including pain,

thereby reducing muscle tension and further decreasing the duration

and intensity of pain, reversing the escalating cycle of painstress-tension-increased pain. Biofeedback training is performed

in conjunction with autogenic training. Several meetings with a

psychologist allow for evaluation of the patient's need for

relaxation techniques, teaching autogenic techniques, assessing deep

relaxation in ameliorating individual experience of pain, instruction in self-hypnosis if indicated, and discussion of emotions

which may surface in a relaxed state. Provision for continuation

of therapy or followup can be accomplished on an outpatient basis

if necessary.

Physical therapy in the CPS program, led by one and one half

physical therapists, consists of conventional modalities (excluding

whirlpool, hot packs, and traction) plus a program of exercise

consuming some three hours per day. The purposes of the exercises

are to increase mobility, range of motion, stamina, muscle tone,

and balance, to decrease the fear of movement and to correct physical limitations such as gait abnormalities. Although most exercising is done in groups on mats and in the RIC pool, individual

sessions are scheduled when necessary. Each patient is given a

home program of exercises at discharge and strongly encouraged to

make exercise a part of daily life. Physical therapy in part and

the schedule of treatment as a whole are designed to build endurance and re-acclimate the patient to participation in a full day

with many consecutive hours of activity.

Occupational therapy provides education in and supervised application of principles taught in the program, especially proper body

mechanics, breathing, and relaxation techniques. patients are

taught exercises designed to strengthen certain muscles in order

to increase range of motion in the upper and lower extremities, to

develop trunk flexibility, and to build endurance and tolerance

for daily living skills, vocational tasks, and recreational activities.

The overall objects of the occupational therapy program are to increase proper body mechanics, flexibility, balance, gross coordination, and spontaneous movement. This is accomplished by means of

1) lectures, slides, videotape and practical demonstration, 2) group

exercises with apparatus, 3) individual muscle re-education/

relaxation sessions, 4) functional mobility course participation

and review, 5) community reintegration field trips, 6) daily

living skills practice in groups and individually, 7) monitored

practice of learned skills, and 8) home exercise and activity

programs. Each patient is provided with a home program before

discharge and rechecked after six weeks for physical and functional

status.

Transcutaneous nerve stimulation therapy is given a trial if it is

27
deemed potentially useful in a particular individual.

All patients contemplating a return to work or change in vocational

status are aided by the Vocational Rehabilitation department.

Constant reinforcement of learned pain managenent techniques is

stressed in counseling and work evaluation sessions. The vocational counselor, coordinator of a team consisting of a work evaluator and a job placement specialist, works closely with patients

to determine their feelings regarding return to work issues. Components of the vocational rehabilitation service include counseling

and development of job interest, aptitude and achievement profiles,

development of positive work attitudes through group process,

assessment and redevelopment of pre-injury work skills, assessment

and upgrading of physical tolerance and endurance for work, development of pain saving and energy saving techniques suited to

patients in particular kinds of work, assessment and training of

proper body mechanics for work, identification of appropriate

job or training options, work conditioning through simulated job

activities, job seeking and job survival training, job placement

and followup, and education tbrough lecture/discussions on safety,

employer attitudes toward chronic pain, and other relevant topics.

Traditionally the "all or none rule" and a lack of light duty jobs

have barred many injured employees' return to work. Persons were

not deemed capable of working at all unless they could return all

at once to full time, full capacity employment. While the rule is

still quite prevalent among all kinds of employers, some flexibility can be introduced. The CPS Vocational Job Site Visit Team

may aid both employee and employer by job site analysis, job

modification recommendations, setting of physical tolerances,

establishing gradual job reentry schedules, and identifying new

job options with the same employer. CPS patients working through

the vocational rehabilitation program have been extraordinarily

successful.

In addition to the staff listed above, CPS also employs two residents, one full time secretary, one full time administrative assistant, one half time research assistant, and twenty-four-hour

nursing staff. Research personnel from the Pain Control in Cancer

project work closely with CPS as well.

Efficacy and Evaluation of Program Results

RIC has established REHABIS, the Rehabilitation Information System.

REHABIS data were combined with information from the CPS data

collection instrument, LOBASCA, for a study of program efficacy

begun in early 1980 (formal publication of results forthcoming-,

as submitted by Robert G. Addison, M.D.). REHABIS contains demographic, economic, medical and psychosocial information on all

first admission inpatients at RIC. LOBASCA, by contrast, is a

self-assessment questionnaire administered to the patient at four

or five different stages in his relationship with CPS from preadmission to four months post discharge.

28
For the study, three LOBASCA questionnaires from each of 140 CPS

inpatients were analyzed to ascertain whether patient perception

of pain location, intensity, duration, etc., and patient assessment of functional abilities (sitting, walking, lifting tolerances,

etc.) underwent any change in the course of treatment at CPS.

LOBASCA results show significant improvement according to all test

criteria. All admission to discharge comparisons showed marked

improvement. Some test parameters showed further improvement

discharge to followup. No decreases were observed in functional

ability admission to discharge or admission to followup.

Program efficacy for those participating in vocational rehabilitation is also measured in terms of placement statistics. Over the

last four years, the vocational rehabilitation program has steadily

increased the number of successful job or training placements.

Until 1977, placement records on CPS patients were not maintained

separately from those on other RIC patients engaged in vocational

rehabilitation. In 1977, 40.5% of CPS patients participating in

vocational rehabilitation were successfully placed; in 1978 the

percentage rose to 51%. In 1979, 70.8% were placed and in the

first six months of 1980 the percentage ran near 81.6%. 72% of the

job placements were returned to the old employer either in the

same job or a newly modified one. 28% were placed in totally new

jobs with new employers. An informal three-year followup indicates

that a substantial majority of patients have been promoted or have

transferred to better employment within three years following

program completion.

MEDICATION

A pattern of multiple medication intake including some form of

narcotic characterizes drug use by the chronic pain patient.

Analgesics, sedatives (including tranquilizers and muscle relaxants)

narcotics, and psychotropic drugs account for the greater part of

intake. The vast majority of persons referred to CPS take some

form of lesser narcotic in conjunction with an analgesic, e.g.,

acetaminophen with codeine phosphate (300 kg/ 30 mg respectively),

or acetylsalicylic acid with codeine phosphate (325 mg/ 30 mg

respectively). Stronger narcotics such as meperidine hydrochloride,

morphine, or dilaudid are used with less frequency. On occasion,

use of injectable narcotics is reported.

Patients referred to CPS generally consume medications prescribed

by a single physician, usually their family physician, or an

industrial physician, orthopaedic surgeon or neurosurgeon. Only

rarely is a patient found using medications prescribed by two or

more physicians. There appears to be no correlation between

physician specialty and type of substances prescribed.

Side effects of drug intake, as discussed above, can pose serious

obstacles to patients attempting to cope successfully with chronic

pain. Most commonly observed side effects include depression,

drowsiness, loss of contact with reality, headache, and decreased

alertness.

29
While fewer than five percent of all patients evaluated at CPS

are physiologically dependent upon their medications, an extremely

high percentage evince psychological dependency. Well over 75 per

cent have more than incidental drug intake.

The CPS inpatient program requires detoxification as part of the

standard course of treatment. As in other aspects of the program,

education is a primary component; at the outset the patient

receives a full explanation of detoxification procedures and

medical reasons for their importance. The actual strategy involves a rapid decrease in drug potency, usually over a period of

one week, with maintenance of ingestion frequency until potency

falls. After the initial step, frequency of administration is

decreased. The patient may be maintained on a mild analgesic if

needed, but all medications are administered according to behavior

modification techniques, and none are given pro re nata.

Practices tantamount to iatrogenesis appear to arise from a basic

failure on the part of most physicians to recognize the distinction

between acute and chronic pain, and the resultant necessary difference in treatment strategies. The differences are particularly

crucial in regard to patient attitudes engendered by medication.

For example, p.r.n. orders including a refill order tend to focus

the patient's attention on his pain, often reinforcing his sense

of helplessness to change it and diverting his attention away firm

personal physical and psychological resources which might otherwise

be brought to bear upon the problem. The patient frequently

develops fear and apprehension of being without medication.

Finally, the attending physician may fail to prescribe the classification of medication most appropriate to the particular task

required; that is, patients may have highly specific needs for

sleep, sedation, tranquilizer, or psychotropic effects which remain

largely undifferentiated by the prescribing physician in his choice

of medication.

RECOMMENDATIONS

1. Facilitate cooperative, non-adversary relations among interested

parties.

The chronic pain patient may be best served by recognition of his

particular needs at the earliest possible time. Interested groups

such as employers, employees, insurers, public agency officials,

etc., should collaborate on the establisbment of workable early

intervention programs for treatment of chronic pain. The targeted

patient population might be those who show no change or worsened

condition six months after acute care ends. Ongoing programs

might be redirected to include new patient populations; for example, patients deemed to be poor surgical risks might be immediately

introduced into programs which would prevent the development or

further entrenchment of pain-related functional overlay, and which

would recondition that patient to cope with the sudden circumstances

of life with chronic pain. Alternatively, patients who are acceptable candidates for surgery but predicted to be long term

30
recuperators might be admitted to a chronic pain treatment program

as soon as feasible after surgery, to counteract the establishment

of a pain-centered lifestyle.

2. Eliminate a percentage of disability through educational and

ergonomic adjustment.

It has been shown that persons employed at tasks tailored to the

capabilities of the individual worker, as opposed to persons

deemed particularly suited to a task, are significantly less

likely to suffer serious injury on the job. Workers involved in

heavy physical labor should be educated in the principles of

correct body mechanics. Guidelines estimating how much weight a

specific person can and should lift occasionally and repetitively

should be established. Devices for lifting, stacking and moving

materials difficult for workers to move because of weight or bulk

should be designed and installed in the workplace.

3. Direct research toward development and use of predictor scales.

Predictor scales identifying those persons likely to become chronic

pain patients should be established by collection of sufficient

psychological, physical, socioeconomic, and ergonomic data. The

means should be found to administer a brief test at the onset of

the problem or when the symptoms have lasted longer than are

accounted for by physiological findings. With heavy input from

vocational, psychological, and physiological treatment resources,

programs should be instituted which could abort the development of

a chronic pain situation.

4. Expand professional education on management of chronic pain.

The longer a patient is disabled the less likely he is ever to

return to a normal level of activity. Failure by both primary care

physicians and specialists to recognize the distinction between

acute and chronic pain leads in most cases to extended repetition

of acute care treatment modalities, allowing for a modified psychological orientation and for patterns of pain behaviour to become firmly engrained in the patient over time. Education of

physicians in the differences between acute and chronic pain and

the need to incorporate certain differences in treatment should be

provided.

5. Organize multidisciplinary pain control program guidelines for

practical use by medical facilities (large and small).

6. Develop reference/resource communication with the medical and

allied health fields for pain research, education and clinical

approaches.

7. Improve data collection to evaluate program results.

31
ACKNOWLEDGMENT

The Pain Mangament Team of the Cancer Research Group is supported

by National Cancer Institute Contract #N-01-CN-95417.

REFERENCE

Kane, W.G. Incidence of lumbar laminectomy in the U.S.A. From a

speech at the International Society for Study of the Lumbar Spine,

New Orleans, May 1980.

AUTHOR

Robert G. Addison, M.D.

Director, Center for pain Studies

Rehabilitation Institute of Chicago

345 East Superior Street

Chicago, Illinois 60611

32
A Holistic Approach to

Pain Rehabilitation:

The Boston Pain Unit

Gerald M. Aronoff, M.D.

ABSTRACT

The traditional management of chronic pain has generally encompassed such options as bed rest, physical therapy, potent medication,

surgery and nerve blocks. Experience has demonstrated the importance of the multi-disciplinary team in the approach to chronic pain,

particularly when the pain problem has eluded diagnosis and/or adequate treatment via conventional techniques. In an attempt to widen

the patient's choice of treatment modalities, the pain unit has

emerged as a concept effective for the management of chronic pain.

Frequently, chronic pain patients represent the treatment failures

of the medical system. By the time of admission to a pain unit,

their lives have become significantly disrupted and their pain

problem complicated by depression, disability, financial stress,

vocational difficulties, strains in interpersonal relationships,

and a great loss of productivity.

For many chronic pain sufferers there is a tendency toward passivedependent behavior (pill-taking, blocks, surgery, bed rest, unemployment, disability, etc.), and it is not uncommon for them to feel

abused by the health care system which they once entered in a

desperate attempt to find relief from their suffering. It is

essential that these unfortunate individuals with chronic pain

learn to take an active role in their health care, have an understanding of the various components involved in their pain problem,

understand their options and, wherever possible, they must be helped

to escape from the health care system.

For the purpose of this brief presentation I will focus on several

of the more important issues dealt with in our pain treatment

program.

1. Pain-depression-insomnia cycle

2. Medication deceleration (especially narcotics and sedativehypnotics)

3. Support systems

4. The distinction between a handicap and a disability

5. Ice massage

33
The above concepts are especially important, not only for their

immediate value to the patient while hospitalized, but also in the

belief that unless these issues are addressed, one can anticipate

a high recidivism, continued use of narcotic medications despite

their limited effectiveness, continued life disruption by pain and

depression, limited self-reliance, and gross abuse of the disability system.

Chronic pain remains an enigma that can mystify even the most experienced clinician. The traditional management of chronic pain has

generally encompassed such options as bed rest, physical therapy,

potent medications, nerve blocks, surgery, and at times, in the

more intractable cases, operative lesions to the central nervous

system. Although these techniques may have much to offer in

ameliorating acute pain, in treating uncomplicated chronic pain

(as opposed to chronic pain syndrome), and in relieving terminal

cancer pain, their effectiveness is marginal in dealing with the

chronic pain syndrome most often encountered in pain units.

Experience has demonstrated the importance of the multi-disciplinary

team approach to chronic pain, particularly when the pain problem

has eluded diagnosis and/or adequate treatment via conventional

methods. In an attempt to widen the patient's choice of treatment

modalities, the pain unit has emerged as a concept effective for the

management of chronic pain.

Within the context of the "therapeutic community" oriented pain unit,

we attack this major health problem in a manner different from conventional methods. Following review of medical data, a complete

physical examination, and an assessment for various physical

treatments (including biofeedback, transcutaneous electrical nerve

stimulation, physical therapy, whirlpool, massage, ice, and heat)

our approach is basically psychotherapeutic. The use of nonnarcotic analgesics, mood-altering medications, forms of individual,

group, and family psychotherapy, and peer pressure is believed to

be highly effective. These methods have been discussed in detail

elsewhere. (1,2,3,4)

Anxiety and depression are widespread phenomena in the United

States and they often concurrently amplify the experience of medical

illness. Yet, frequently, the powerful tools of psychological

medicine are ignored. We are now aware that pain is multidimensional

in that there may be numerous precipitating factors and various

concomitants. Some are clearly organic and have physiologic manifestations; however, there is a growing body of knowledge that

psychologic, neurologic, physiologic, psychosocial, ethnocultural,

motivational, cognitive, and affective (conditioned) factors all

contribute to that sensory experience that we interpret as pain.

Because of the complex nature of the chronic pain experience, it is

our contention that any treatment program designed for pain patients

must be holistic in its orientation if it is to be effective.

34
Of the many aspects involved in the treatment of the chronic pain

syndrome patient, I will limit my discussion to the following:

the pain-depressed-insomnia cycle; medication deceleration: ice

massage, support systems, and the distinction between handicaps

and disabilities.

There has been considerable discussion of the relationship between

chronic pain and affective disorders, particularly depression.

Often the depression is felt to be of a situational type related to

inactivity, reactive life changes, vocational disruption, family

strain, and other adjustments secondary to the pain process.

Frequently,however, we evaluate individuals who have a history of

depression preceding the onset of their pain, or whose depression

and pain symptoms have a complex inter-relationship. Apart from

genetic studies implicating a positive family history of depression

and other studies indicating that some individuals become depressed

because of certain life deprivations, it has recently been suggested

that depressed individuals have relative deficiencies in central

catecholamines, specifically norepinephrine, dopamine, and serotonin.

Although their role in the limbic system is unlikely to be the sole

cause of depression, they may well have a major function in emotional expression. The limbic system has also been implicated in

endorphin production and action, suggesting a role of this brain

area in the mediation of the pain experience. Stimulation of

endorphin production in the peri-aqueductal or periventricular gray

matter is believed to involve fibers that enter through limbic

sites. It is likely that depressive illness may lower the pain

threshold, i.e., increase the perception of pain. Halpern suggests

that one probable reason involves decreases in neurotransmitters;

i.e., endorphin production and/or action may be partially related

to catechol and indolamine production (5), and that through this

mechanism, depression may limit endorphin production.

Patients in pain usually suffer from insomnia, with difficulty falling asleep, frequent awakenings, and/or early morning awakenings.

These symptions are also extremely common as vegetative signs of depression. However, pain patients will inevitably attribute their

insomnia to pain rather than to depression, possibly because this is

a more socially acceptable cause. It is difficult to dissect the

pain-depression-insomnia cycle as to which problem is primary and

which is reactive. However, regardless of the origin, once this

cycle is established, it becomes self-perpetuating and requires

active intervention. There is growing evidence that the use of

tricyclic anti-depressants may be useful in this process. Again, the

catechol-indolamine system is implicated in the mechanism of action

of these compounds. The use of sedating anti-depressants in a once

daily dosage at bedtime (doxepin, amitriptyline) most generally help

the insomnia prior to any anti-depressant effect, which may take 7-21

days. What is most striking is the observation that as the insomnia

improves and patients awaken in the morning more rested, their subjective complaints of pain appear to be minimized, and clinically

these patients appear less depressed. Therefore, treatment for this

pain-depression-insomnia cycle should be considered a specific therapeutic intervention for chronic pain. It is also our impression that

barbiturates or potent sedative hypnotics are counter-therapeutic

and should not be used for this purpose, as they can worsen the

35
depression. Similarly, while diazepam and related compounds may be

efficacious in acute pain accompanied by anxiety, these drugs are

often less helpful or even harmful in chronic pain patients, as

their effects may exacerbate already existing depressive symptoms.

We have been extremely successful in developing a system for medication deceleration in our pain unit. More than 50 percent of the

patients admitted to the unit are using narcotic analgesics at the

time of admission. Some use narcotics at a daily dose commensurate

with some physical dependence. Many also have a history of extensive use of non-narcotic analgesics, such as diazepam and/or other

sedative-hypnotics. The use of narcotics is rarely indicated in

the daily management of chronic pain syndromes. Upon detailed

questioning, most patients state that the medications they take for

pain relief are only partially effective, if at all. Many report

experiencing unpleasant side effects. Although much has been

written about the euphoric effects of narcotics, we have found that

many patients openly discuss the dysphoric effects of narcotics and

sedative-hypnotics; they frequently describe their experience as

being "out of control." Many see the use of medication as a crutch

and find that prolonged usage affects their self-image and selfesteem. Many become concerned about the possibility of psychological and physiological dependence. Most important is the

realization by the patients that these medications are, in the long

run, not the answer for their pain.

Our approach to a more rational use of pain medication is, in part,

modified from that described by Fordyce. (6) As quickly as possible

following admission , all parenteral medication is replaced by oral

medication, even if this necessitates increasing the dosage to fairly large amounts. We are not concerned with the absolute number of

pills ingested daily by patients at the time of their admission. We

try to minimize confrontations on these issues because patients tend

to distort the importance of medication, often elevating analgesics

to a major position in their lives. We discourage this perspective,

and, in fact, encourage patients to de-emphasize their need for pills

by discussing medications in a very straightforward manner. We use

no PRN pain medication, since this tends to operantly reinforce both

pain and pill-taking behavior. Patients are placed on a schedule

for taking medication at specific time intervals during the 24-hour

period. They are responsible for fetching their own medication at

the nursing station at the appropriate times. No medications are

given in the patients' rooms, nor are patients reminded of medication times by staff members. Should a patient miss a scheduled

medication, he/she must then wait until the next scheduled medication time, assuming that the medication is not medically essential

(digoxin, thyroid replacement, etc.). Initially, some patients test

this system and become angry when they do not receive missed medications. However, they rapidly adjust to this regimen, and after the

first several days of the program, rarely find it a problem.

Occasionally some patients continue to test this system until they

become convinced that it is a losing proposition for them.

36
Deceleration begins after the patients have been in the program

long enough to have begun to develop alternative methods of coping

with pain. This is usually after about two weeks.

Deceleration from medication would not be possible without the tremendous assistance given by our pharmacists. All medications which

are to be tapered are combined into one large capsule. Patients

then receive decelerating doses of the active ingredients at the

normally scheduled times. This appears to be an innocuous way of

gradually decreasing the medication dosage. Patients see the same

number of pills daily, until the active ingredients are totally

withdrawn and the medication is discontinued. Rather than being

deceived, patients are completely informed about the deceleration

process. They are informed when deceleration will start and they

are told the exact number of days through which deceleration will

extend. Generally, the deceleration process averages from 9-18

days, depending upon the extent of dependence and the absolute

amount of medication taken at the time of admission. It is of note

that we have seen only one case of withdrawal using this approach,

and this reaction was not severe. It should also be mentioned that

frequently while deceleration is in progress, patients receive

doxepin at bedtime and hydroxyzine, either on schedule throughout

the day and/or at bedtime.

Our success rate in decelerating chronic pain patients from medication is quite impressive. Of all patients admitted to the pain unit

taking narcotics and/or sedative-hypnotics, 95 percent or more are

free from these medications at the time of discharge. At least twothirds of those patients who leave the pain unit off narcotic medication remain off narcotic medication at the time of their one-year

follow-up visit. We are in the process of conducting a study to

determine if these individuals will continue their drug-free status

over longer times. Our initial results appear encouraging.

It is crucial to mention that weaning patients from their medication

is simultaneously accompanied by intensive training in alternative

techniques of pain control. These involve physical therapy exercises, whirlpool, massage, biofeedback, relaxation and meditation

exercises, transcutaneous nerve stimulaton, and ice massage.

The use of ice massage for pain control is, for many patients, an

extremely efficient, safe, and inexpensive method to achieve partial

or complete pain relief for variable periods of time. The purpose

of ice massage is to decrease pain and promote relaxation by numbing

a local area superficially. Nearly all patients receive trials of

ice massage. After a minimum of three treatments, we assess the

efficacy of this particular mode of pain control for the individual

patient. The only absolute contraindication for ice massage which

we have thus far encountered is previous frostbite in the area to

be treated, or hypersensitivity to cold. It should be noted that

ice massage is a safe treatment for patients with hyperesthesia;

however, caution is advised. (7,8,9,10) Most of our experience

consists of giving ice massage to patients with chronic low back

pain, ranging from uncomplicated back strain to the most complex

37

348-347 0 - 81 - 4
post-surgical back syndromes accompanied with sciatica and/or

arachnoiditis. These individuals generally do well, with initial

pain relief extending from 15-30 minutes to as long as three hours.

The duration of pain relief usually increases after multiple applications of the ice massage technique.

In assessing results from the pain unit, we have made attempts

to better understand and therefore predict the likelihood of success

for the individual patient in the program. Those patients who

clearly are unlikely to benefit from the pain program should be

identified and discharged as quickly as possible both for their

own good and that of the therapeutic community. Generally, our

observations indicate that success does not appear to be related to

the extent of organic pathology, although there is some correlation

with the duration of illness. That is to say, individuals with

life-long pain histories and/or medical disability are less likely

to break the cycle than those for whom the pain problem is more

recent. Patients with severe primary depressive illness, severe

character disorders, or thought disorders also generally do less well

than those whose emotional disorders are reactive and developed

subsequent to the pain process. We have not found a correlation

between the number of surgeries and the likelihood to improve in

the pain program. Those variables believed to be most essential

include the following: motivation; a desire to return to a more

functional, productive lifestyle; relative absence of secondary gain,

especially financial; the absence of active litigation; and adequate

support systems.

By support systems we refer to those areas of an individual's life

which appear to be nurturant - primarily vocation, family, friends,

hobbies, church, and school. We believe that loneliness often becomes a way of life for those individuals with few "significant

others" and tenuous external supports. The chronic pain of these

patients often remains refractory to treatment because they utilize

the health care system as their major emotional supportive network.

Because relationships may reinforce mal-adaptive, self-defeating

behavior, as well as adaptive behavior, families can either

become supportive to the goals of the pain unit or sabotage

those goals. Therefore, a full assessment of composite support

systems for an individual patient is an integral component in

determining whether that patient is more motivated to remain ill

or to begin the healing process. Also, the family unit becomes a

treatment entity as handled by the social worker in our unit.

Many individuals admitted to the pain program have previously been

identified as being "totally and permanently disabled." It is

essential that the patient learns to distinguish between a handicap

and a disability. A handicap is a disadvantage that makes achievement of certain goals unusually difficult; it may be either physical

or psychologic. The vast majority of the patients encountered in

our pain program might be considered to have a handicap in the sense

that their "weak system" prevents them from using the specified or

affected body part as effectively as they had in the past. A disability, on the other hand, implies that for one of a variety of

38
reasons, physical or psychological, an individual is deemed incapable of functioning or being productive in some area. The "in

some area" is emphasized because, of the approximately 1,000 patients

seen on the Boston Pain Unit, we have yet to encounter an individual

who is "totally and permanently disabled" from everything. An

individual with severe discogenic disease who has had one or more

surgical procedures may be disabled from heavy lifting, prolonged

or repetitive bending, or tasks which involve significant overhead

reaching. That same individual, however, may be capable of a myriad

of other types of work, as yet unexplored. We have seen paraplegic

patients learn to cope with pain, resolve depression, return to

school, and become self-employed. We have seen a young athletic

woman involved in a motorcycle accident with subsequent hip disarticulation, cope with pain, resolve depression and through perseverance, become a champion skier. These are but two examples

of individuals whose personal convictions about their self-worth

prevented them from falling into the welfare system and prevented

them from being labeled as "totally and permanently disabled."

Many individuals with handicaps are not disabled, nor do they wish

to be considered as such. Furthermore, those patients who seek total

and permanent disability statements from physicians perhaps have a

problem of motivation, and therefore a psychologic disturbance

rather than an absolute physical problem must be considered. If we,

as health care providers, continue to write letters freely for

patients attesting to total and permanent disability, then we will

often be doing the patient more of a disservice than a service -

we will rob him/her of a chance to be productive and regain his/her

self-respect and the respect of others.

Patients come (are referred) to the pain unit often as the treatment

of last resort in the health care system. They are depressed,

lonely, angry, and suffering. Many leave much improved - coping

better with their pain, which is frequently diminished, less reliant

on medication (and in general on the health care system), more active,

more comfortable, less depressed and more in control of their lives.

They live in the present looking forward to the future compared to

the prior pattern of remembering the past and dulling the painful

present with medication. These are the changes which make team

work on the pain unit so gratifying.

REFERENCES

1. Aronoff, G.M., Wilson, R.R. "How to Teach Your Patients to

Control Chronic Pain", Behavioral Medicine, pp 29-35, July, 1978.

2. Wilson, R.R., Aronoff, G.M. "The Therapeutic Community in the

Treatment of Chronic Pain", pp 477-481, Vol. 32, No. 7, 1979.

3. Aronoff, G.M., Wilson, R.R., Sample, S.S. "Treating Chronic

Pain: The Team Approach", Nursing Care, pp 12,13,27, April,1978

4. Aronoff, G.M., Kamen, R. "Biofeedback - A Major Adjunct in a

Comprehensive Pain Rehabilitation Program", Unpublished

Manuscript.

39
5. Halpern, L. "Neurophysiological Theories of Pain in the

Management of Pain in Surgical Practice", Postoperative

Pain, pp 16-18, Chirurgecom, 1979.

6. Fordyce, W.E. Behavioral Methods for Chronic Pain and Illness,

pp 157-168, C. U. Mosby, 1976.

7. Waylonis, G.W. "The Physiologic Effects of Ice Massage",

Arch, Phys. Med. Rehabil. 48.1, pp 37-42, January 1967.

8.

9.

10.

Grant, A.E. "Massage With Ice (Cryokinetics) in the Treatment

of Painful Conditions of the Muscoskelatal System", Arch. Phys.

Rehabil., pp 233-238, May 1964.

Aronoff, G.M., Walls, C.M.; Wheaton, C., Carlile, J. "Clinical

Report on Ice Massage for Pain Control", Mediguide to Pain,

DellaCorte Publications, accepted for publication.

Olson, J. E., Stravino, V. D. "A Review of Crytotherapy",

Journal APTA, 52:840-853, August, 1972.

ACKNOWLEDGMENT

Special thanks to my staff, especially Wayne Evans, Ph.D., and

Pamela Enders, Ph.D.(ABD), who were kind enough to give me their

reviews.

AUTHOR

Gerald M. Aronoff, M.D.

Boston Pain Unit

Massachusetts Rehabilitation Hospital

Boston, Massachusetts 02114

40
Multidisciplinary Treatment of

Chronic Pain at the Northwest

Pain Center

Joel L. Seres, M.D., John R. Painter, Ph.D., and

Richard I. Newman, Ph.D.

ABSTRACT

The Northwest Pain Center is a three-week multidisciplinary day

care pain management program which has been operating since 1972.

Experience shows that pain problem result in excessive use of

medical resources, inappropriate medication use, and possibly

unnecessary surgeries. Significant depression and family disruption are common. In spite of powerful incentives that maintain

pain behavior, most important being the compensation and disability

systems, more than 70 percent of patients maintain objective

physicial gains resulting from pain center treatment. Studies

attempting to differentiate long-term successes from long-term

failures provide implications for treatment and evaluation strategies. Areas of need are identified in public and professional

education, and necessary future research.

THE NORTHWEST PAIN CENTER PROGRAM

The Northwest Pain Center program has treated chronic pain patients since 1972. At the present time, forty percent of patients

referred are excluded from treatment after evaluation because they

do not appear to be candidates for a self-help approach, or because they are not interested in admission. Reasons for exclusion

are rooted in results of follow-up studies (Seres et al. 1977,

Painter et al. 1980). An initial screening evaluation brings much

of this to light.

Effectiveness of the pain center is in part a function of the

milieu which is established through careful planning, revision of

strategies, and staffing approaches (Newman et al. 1978). The

Northwest Pain Center is staffed by two full-time physicians,

three full-time clinical psychologists, two physical therapists,

an occupational therapist, a vocational counselor, four nurses,

two biofeedback therapists, and a secretarial staff consisting of

six full-time persons. Appropriate physician specialists are used

as consultants for specific medical problem. The average cost of

referral had increased from $3400 in 1976 to over $7500 for the

three-week program in 1980. As a result of these increases,

41
the program has recently (June, 1980) changed to a full day-care

setting with housing being provided for out-of-town patients at a

nearby motel. patients specifically requiring hospitalization for

drug withdrawal or significant medical problems are hospitalized

only as long as needed to resolve these issues. Transportation to

the day-care program is provided. A staff member maintains liaison

at the motel and runs an evening program. The present cost of the

day care program is $3250 for all services provided other than the

cost for the motel.

The program is three weeks in duration, and each week is organized

around a general theme. Admission occurs on Monday and Tuesday of

each week. Each new patient is assigned a more senior "buddy" to

enhance the effectiveness of the milieu.

The philosophical bases for therapies used are education and

"self-help." No form of active intervention is ever used: on the

rare occasions that surgery or other interventionary procedures

seem to be indicated, patients are referred to their own physicians.

No passive modalities such as manipulation, heat, massage, or

traction are used. Patients are involved in an active program

stressing exercise and application of proper exercise principles to

posture mechanics and to daily activities. Psychotherapy in

groups, individually, and with the spouse is an important part of

the program. Daily lectures and discussion groups provide

patients with information regarding the source of the pain and the

reasonable therapies available. Vocational readiness and planning

are stressed during the last two weeks by the occupational therapist and vocational liaison person. Nurses assist patients in drug

withdrawal and daily monitoring of medical problems, with the physicians. Biofeedback and relaxation training are used as appropriate to the patient's needs. Spouse involvement at the initial

evaluation and during the last two days of therapy is urged. The

role of the Pain Center as a turning point in the patient's life

is stressed.

THE VICTIMS OF CHRONIC PAIN

Sixty-four percent of patients present with low back pain as the

major source of distress. Twenty-three percent have neck pain or

headache or both. Duration of disability has decreased from an

average of 4.5 years prior to 1976, to 4.0 years in our most

recent survey. Most patients are blue collar workers, with sawmill workers, construction workers, loggers, truckers, and other

laborers representing 40 Percent of patients seen. Other occupations represented range from college professor and management to

grocery checker. Twenty-one percent of the population have had

white collar jobs.

Seventy-six percent of our patients are covered by workers compensation. Eight Percent are covered by Federal Workers Compensation.

Typical patients have had extensive involvement with the medical

system prior to treatment: they have spent an average of eight

42
days in the hospital in the year prior to admission. Low back

patients have had an average of 1.1 surgeries in one group studied

(the first 100 patients of 1980), and 2.0 in another (Seres et al.

1978). An average of 0.72 surgeries had been performed on the

group with neck pain. Surgeries obviously had not solved the

problems; in fact, patients often report that surgery has either

been of no benefit, or has worsened their condition.

A frequent pattern in the treatment of chronic pain is the repetition of diagnostic tests; in our experience, about half of the

patients have gone through recent, unnecessary diagnostic procedures, by far the most common of which is the myelogram. Long-term

followup results (Newman et al. 1978) present pranising data to

suggest that pain center treatment reduces this tendency, with

only 16.7 percent of patients seeking further care at the fourteen

week followup, a figure which is reduced to 8.3 percent eighteen

months after discharge.

Although data are hard to obtain, it seems that approximately 3

percent of patients have surgery performed after discharge even

though such surgery has been explicitly discouraged; results have

been uniformly poor. Requests for readmission have occurred after

as many as three surgeries that had been advised against. Individual review of these cases supports the belief that the indications

for repeated surgeries are largely uncorrelated with clinical

improvement in spinal pain. If confirmed, such an observation

could have profound impact on the traditional course of pain

treatment, and perhaps more importantly, upon the course of the

injured worker with pain. Much literature which supports use of

surgery for spinal pain is anecdoctal and rests upon possibly

spurious observations. The following example (Keim 1978) suggests

the sort of data-collection error faced by the individual practitioner: "In a very large series of personally operated patients

the author can recall only one or two instances where a spine

fusion was performed and the patient was unhappy with final

results."

In fact, not only does prior treatment seem to have little positive effect upon patients, but in our experience, it often appears

to consolidate a pattern of disability which might have resolved.

In many cases, medical treatment offered by well-intentioned

practitioners has increased subjective discomfort and prolonged a

state of dependency. The following cases are offered as examples:

BJC. A 42-year-old women was contemplating a trip to Europe

when she hurt her back at home. She saw her family physician

who suggested that prior to her trip she should at least see

an orthopedic surgeon to be sure a ruptured disc was not

present. Although no neurological signs were evident, the

orthopedist suggested a myelogram to be sure that something

wasn't missed so that the patient would not have difficulty

during her trip. Due to a mixed injection, the patient

developed a severe neuritic reaction requiring complete bedrest in a hospital for three weeks following the myelogram.

Despite the mixed injection and no evidence of neurological

dysfunction or positive findings on the myelogram an explor43
atory laminectomy was performed in August 1976, four months

later. With significant increase in leg symptoms postoperatively, a repeat laminectomy was performed in May 1977 and a

L4-5 fusion in September of 1977. Because of the type of

persisting pain it was felt that central pain was the source

of the patient's distress. In November 1977 a dorsal column

stimulator was implanted. This resulted in the usual paresthetic sensations. However, the patient now noted only improvement in some of the foot pain, but no improvement in the

back or leg pain problems. A revision of the dorsal column

stimulator was performed a month later. Because of persisting difficulty, in March 1979 a revision of the lumbar fusion

was performed. The dura was explored and arachnoiditis was

found. In June 1979, the fusion was taken down and a decompressive laminectomy removing the spinous processes was performed. Because of persisting pain, the patient had been

considered for a brain implantation procedure. She attended

the Pain program three weeks in the latter part of 1979. The

following is a letter received recently from her physician at

the University of California.

Dear Dr. Seres:

Just a note to let you know how much I appreciate

your treating BJC. She has had an excellent result

through your approach to a difficult pain problem.

She is much more active now and has considerably

less pain. She is not on narcotics. I saw her in

follow-up on May 16, and she is truly a changed

person. . . .

The following case demonstrates an acceleration of well-intentioned procedures for pain relief extending far beyond the needs

of the patient.

The patient is a 34-year-old man with persisting posterior

cervical pain who was seen in the program in January 1980.

The surgical procedure which had been performed was a complete removal of all the spinous processes and laminae of his

cervical spine because of chronic cervical pain. Nowhere in

his record is there any evidence of spinal cord compression,

neurological dysfunction, sensory loss, or motor weakness.

The surgical philosophy, "If it hurts, cut it out," persists,

Clearly this patient's pain was not relieved, but rather exacerbated by the surgical procedure performed. Yet in speaking to the

surgeons involved, it became clear that their feeling was that

there was nothing to lose, and after all, the indications were

there.

Positive findings on myelography and other diagnostic tests may

have no bearing on the source of the pain. Thus treatments designed to eradicate the radiographic findings (manipulation, surgery,

44
and so forth) may not succeed. Also, in the spine, most surgical

procedures require essentially a dismantling of the anatomy which

cannot be restored.

Too often, new indications are developed and put into general use

before correlation with outcome is demonstrated. While some indicators do seem to predict successful results, others do not. Also,

short term benefit after surgical procedures seems not to last in a

significant number of patients who complain of even more severe

distress on assessment in the pain clinic setting.

DRUG USE IN CHRONIC PAIN

Inappropriate or questionable drug use is common. While it has

been widely suggested that narcotics and muscle relaxer-sedative

drugs are not likely to be of benefit in the chronic pain patient,

fully 63 percent of patients were taking one or more of these

medications. The typical patient has been using a narcotic and a

muscle relaxer for more than a year. Codeine is the most prevalent

drug, usually taken in doses of from four to eight tablets daily.

Schedule II drugs are being used by nine percent of patients. Prescription anti-inflammatory drugs are widely used in chronic pain.

Eighty percent of patients seen in 1979 had used one of those. In

fact, 16 percent were still taking them when seen for their initial evaluation. Use of such medications in non-inflammatory pain

must be questioned. Only 36 percent of patients are not using

prescription medications when they are seen. This is a rather

discouraging statistic when one considers effects which range from

no benefit to exacerbation of the problem with mental depression,

reduced cognitive efficiency, personality deterioration, and

compromised doctor-patient relationships based upon dependency and

need for prescriptions.

No clear patterns have emerged in informal observation of the

source of drug overutilization by medical specialties. In our

experience, there are a handful of individual practitioners in

each of the specialties associated with treating pain who tend to

overprescribe medications. Curiously, we have found psychiatrists

using analgesics fairly extensively, Recently, one such individual

who was prescribing 20 milligrams per day of hydromorphone for

pain relief explained that, "To deal with the psychiatric problems, we must first resolve the pain problem." The psychiatrist

actually believed that habituating the patient accomplished this.

In our experience, this is not a productive solution.

Significant withdrawal problems have not been frequent and are

usually managed successfully by increasing the dose of the medication or by slowing the rate of reduction. When drug use is excessive, individuals are detoxified prior to admission in a local,

private substance abuse program. This degree of dependency is

rare. Because of the fairly gradual reduction regimen, it is difficult to determine the extent of physiological dependency in our

population. Psychological dependency upon pain medications at the

time of admission is estimated at about three-fourths of those who

45
use prescription medications. Therefore, major emphasis in the

program is placed upon education about chronic use of pain medications. This effort is apparently rewarded with fairly good maintenance, especially with more powerful drugs (figure 1)*.

Drug withdrawal has been accomplishedthroughthe use of masked

capsules given on schedule, or through individual contract with

the patient, who monitors his or her own withdrawal regimen. The

latter procedure seems to work well, and is more in keeping with

the philosophy of self-help and self-control. It also serves as

another index of interest on the part of the patient in meaningful

change. The use of peer pressure and operant reinforcement are

critical components in this approach, requiring an established

therapeutic milieu.

EFFECTS OF CHRONIC PAIN

Psychological and Family Impact

Psychological effects of chronic pain are difficult to assess by

the time of Pain Center referral, since some psychological factors

my be assuned to preexist a chronic pain problem. Other factors

my he a result of loss of wages, loss of family role position,

and the corrosive effect of pain itself. Significant depression is

noted in 56 percent of patients at admission, and a pattern of

hysterical conversion reaction in 70 percent (table 1). Depression is probably a result of chronic pain in at least half of

those with the problem, and may have preceded the injury in the

others. The tendency toward conversion reaction is presumably a

fixed pattern of personality, but some evidence suggests that

elevations in psychological tests such as the MMPI increase during

chronic illness states. We have found that elevations in scales Hs

(Hypochondriasis) and Hy (Hysteria) are reduced following Pain

Center treatment (Seres and Newman 1976). Since these psychological factors are presumably changeable based upon the involvement

of the patient, it is difficult to see how they can be used, as

they seem to be, as criteria for amounts of compensation from

Social Security and other disability determination systems.

By subjective report, pain patients retrospectively rate themselves as having been very depressed prior to treatment, with an

average depression rating of 93 on a scale of 0 to 100 (with 100

representing the most severe depression). At the time of discharge

they estimate average depression on the same scale at 39, and

again at 39 on followup an average of 18 months later (Painter et

al. 1980). Interestingly, few patients initially admit to depression.

Chronic pain has a profound impact on the family as well; even so,

one again notes the tendency of patients to deny family problems

when they are initially evaluated. Roles are usually changed dramatically, and in many families there is an increasing resentment

which is carefully controlled, producing gradually deteriorating

patterns of communication. Separately conducted interviews with

*Tables and figures begin on page 55.

46
spouses at the time of admission reveal perceptions of family

dynamics that are quite different, a pattern which my have preceded the onset of pain. In spite of the manifest difficulties

related to chronic pain problem, divorce does not characterize

the group: eighty percent of the patients are married, a proportion which does not seem to change at followup.

COMPENSATION AS INCENTIVE FOR PAIN BEHAVIOR

A crucial factor in assessing costs of chronic pain, as well as in

fashioning treatment strategies, has to do with the canpensation

associated with maintained pain behaviors. Oregon has been the

most costly state of the 36 states whose insurance rates are set

by the National Council on Compensation Insurance (NCCI). This

rather progressive State has shown a 390 percent increase in the number of hearings requests filed in the decade 1968 to 1978. Ninety

percent of these hearings result in au increased award (Redburn

1980). Thus, Northwest Pain Center may be particularly well qualified among pain centers to comment on compensation as a secondary

gain factor related to chronic pain.

Frequently, patients state that at their age of 35 to 40, no one

will hire them at a wage comparable to the income they received

prior to a relatively minor injury. While there is merit to this

observation, it is not rare to have a patient honestly admit that

he is "going for retirement" because his lawyer says he can get

it, even though he freely admits that he is not totally disabled.

Thus, a system is apparently evolving in which some people are

working diligently toward retirement, much as others work toward

college degrees. For this reason, many patients literally defy the

treatment team to make them better. A recent patient gave up a

back brace, crutch, and leg brace which she had used for a year on

her first day in the program when she learned from other patients

that she did not have to look quite that bad in order to gain

total disability.

While percentages or degrees of disability are used by most State

Workers Compensation carriers to calculate the financial rewards

for partial disability, these do not correlate in linear fashion

with the settlement for total disability. For example, in Oregon,

a permanent and total disability may merit up to $10,060 per year

tax free for life, while a 50 percent disability represents a onetime settlement of about $18,000. Thus, incentive to achieve total

disability is quite powerful. Once this is awarded, a physician

must certify annually only that no change has taken place, not

that an individual could work. Thus, it is almost impossible for a

totally disabled individual to undergo a change in status, and he

has effected a kind of lifetime financial security virtually

unavailable to working individuals.

The concept of the "odd lot" allows the compensation board to

include such factors as age, job availability in the individual's

locale, job experience, and education, to add to the level of

medical impairment in determining disability levels. Thus, deter47
mination of disability is taken out of the hands of medical

experts, and responsibility is diffused among different disciplines. The decision becomes a part of the adversary system,

further polarizing the patient away from recovery. It should be

noted as well that this concept encourages the injured worker to

remain in or move to a community that offers nothing but heavy

labor; further, any effort to improve employability through education becomes a financial risk for the worker.

Thus, the system seems to provide a solution to a worker's employment problems through disability. The predicted high incidence of

work-associated injuries reported prior to recent lumber mill

closures in Oregon is but one example of this factor.

The Federal Workers Compensation system provides yet other problems. Patients on medical disability may receive up to three

times more in canpensation than if they opt for medical retirement. Responding to a need to return workers to the job, the

Postal System has recently begun creating job settings such that

anyone, virtually irrespective of the degree of impairment, could

perform in them. Recently, we have been told by postal employees

that they cannot go to such settings because now the stress is too

great.

A recent case illustrates the abuse of the Social Security System,

and the almost tautological approach to disability that may render

minor injuries irreversible.

A 55 year-old womam developed neck pain in 1977, while employed helping her husband with an insurance business. In

early 1978, she had a cervical laminectomy performed. Her

husband subsequently retired. Although she was fully active,

demonstrated no significant physical distress, was taking no

prescription analgesics after her stay in the pain program,

and maintained these gains for two years following discharge,

she requested a hearing after her claim for Social Security

had been denied. Physicians called to testify were asked if

the patient desired retirement at this time. Of course the

answer was affirmative. They were then asked if the patient's best interest would be served by giving her Social

Security disability; the answer was, "Since the patient wants

Social Security Disability, of course it would be in her best

interest to obtain it." On no other grounds was it felt to be

justified. On this basis, Social Security disability was

awarded. In later discussions with the patient's attorney,

the following philosophy emerged: "If I believe in my heart

that I deserve it, then I should get it." This patient, on

the basis of her success with Social Security, is presently

claiming total disability with the State Workers Compensation

system.

It seems clear that incentive factors as they relate to improved

physical measures, maintenance of improvement, and return to work,

are often not in a positive direction. It would appear that an

48
individual who has done reasonably heavy physical work cannot continue to do this after an injury stops such activity; re-entry at

a lower level or availability of jobs which are not particularly

appealing for the individual seems to provide reasons for not

actively pursuing rehabilitation. Without being a "malingerer,"

such an individual can maintain financial security by literally

choosing not to return to work.

Because of the variability in claims settlements by Federal or

State system, different degrees of liberalness associated with

Social Security determinations in various States, a progressively

larger system of advocate physicians and attorneys develops. The

patients' best interests are served by actively exploring all

possibilities within the system and delaying substantial attempts

at rehabilitation. As laws become more liberal, insurance carriers

merely petition for higher premiums. Increased costs are

passed on to the consumer; thus, there is no limiting influence

regarding the sums spent. In surveying the treatment of chronic

benign pain, one must ask, "Isn't anyone watching the store?"

EVALUATION OF THERAPEUTIC RESULTS

The Northwest Pain Center has been outcome-oriented since the

outset. Followup studies in a group of 100 consecutively-admitted

low back pain patients have been published (Seres and Newman 1976,

Newman et al. 1978). These studies demonstrated maintenance

of overall effectiveness in objective physical measures, decrease

in use of drugs, and reduced medical contacts. In an eighteenmonth followup, objective measures suggest meaningful gains in

approximately 75 percent of patients, although some tendency toward deterioration is noted. When patients are compared by employment status, it becomes obvious that full-time employment is

associated with maintenance of improved function, or with further

gains (figures 2 and 3). Part-time employment and student status

are associated with similar although less striking results; doing

nothing appears to result in significant regression of gains made.

Followup data for patients seen throughout the year 1976 were

requested of the State Accident Insurance Fund (SAIF), the largest

of the State's Workers Compensation carriers. Table 2 shows these

values for 1977, 1978, and 1979. At the time they were initially,.

seen, all patients who were referred were admitted except those

who refused. Of the 75 seen in 1976, 71 were admitted. Average

cost of referral at that time was $3,413.15. By 1979, claim that

had been opened an average of 4.5 years were closed in 58 cases

(82 percent). Despite the long term of disability, 18 (25 percent)

had returned to work. Such data are difficult to obtain, and we

have not been able to obtain similar data following our institution of a more selective admission procedure; presumably results

would be improved.

It appeared that overall treatment effectiveness would be reflected

in an increased number of patients who continue to do well or even

improve. In a study of 145 patients who responded to retrospective

49
questionnaires in 1978 (Painter et al. 1980), reasons for recidivism were investigated. Criteria for success in this study were

subjective ratings, including subjective pain relief, amount of

impairment based on pain, and mood state. As shown in table 3, the

pain center experience was felt to be helpful by 77 percent of the

patients, with an average pain reduction of 33 percent. Over the

next eighteen months, further improvement was noted by 27 percent

of the sample. On the other hand, deterioration was reported by 27

percent over the same period. A total of 73 percent are therefore

as improved as they were at discharge or even better.

Pain severity at admission and degree of pain relief as a result

of the pain center experience were not distinguishing factors

between those who continued to improve after discharge and those

whose gains dissipated (table 4). Demographic variables (table 5)

show some relationship to success, in that females seem to do

somewhat better. Contrary to usual beliefs, many younger patients

with short-term disabilities do not appear to do particularly

well; this my reflect little need on their parts to interest

themselves in rehabilitation when compensation factors make the

present situation tolerable. Marital status is likewise related to

success or regression. Duration of disability and age, however,

are not predictive. Operant and attitude factors, as measured by

outside activities, amount of help at home (table 6), continued

cure-seeking, involvement in job placement activities, and maintenance of dependency on compensation providers (table 7) seem to

be related to the distinction between the success and failure

patients. The only psychological factor which is related would

appear to be depression/insomnia (table 8).

Incentive factors, as reflected in compensation, jobs, and by

inference, job flexibility, are most powerfully related again to

the degree of success individuals enjoy in the pain center

experience (tables 9 and 10).

CONCLUSIONS

Although much has been learned about pain and its treatment, a

good deal more needs to be done in the areas of professional education, improved public knowledge about pain and its treatment,

and more powerful andprecisebasic research.

Professional Education: Appropriate Treatment of Chronic

Conditions

Acute care medicine does not work for chronic conditions. Although this observation is not widely made among physicians treating pain, it is seen, for example, in the develoment of hospices

for cancer patients. The acute-care model holds that symptoms and

signs are reflections of an underlying pathological condition.

This belief produces a predictable sequence of investigative procedures aimed at finding the "cause" of the condition, removal of

which will presumably cure the symptoms. Analgesics, sedativerelaxers, and hypnotics aggravate both physical and psychological

difficulties in chronic pain.

50
Unfortunately for the patient suffering chronic pain, physicians

are accustomed to intervening in active if not heroic ways to

alleviate suffering. Positive tests do not necessarily lead to

positive surgical results; in many cases, there is no relationship

whatever between test results and relief of pain. In general,

surgery may not be a viable option when performed for the relief

of pain. Changing the heroic mentality in concerned physicians

will require considerable training beginning as early as medical

school.

Alternative Approaches in Management

Orthopedists, neurologists, and neurosurgeons are frequently not

well versed in the use of proper body mechanics, active exercise,

and other self-help approaches in the management of chronic pain

conditions. Highly trained physical therapists should be used as

a potent educational resource for the patient rather than as a

source of palliative, passive symptom reduction.

Expanded Evaluation and Education Procedures

Directions for therapy may be augmented with the use of psychological and social evaluations. These should be performed early in

the course of treatment, rather than after invasive diagnostic

techniques and even surgeries have failed. Too frequently,

physicians see psychological evaluation as useful only in determining whether the suffering individual is 'mentally ill," malingering, or in some way "imagining" discomfort. Indeed, psychological, social, and environmental factors appear to be more closely

related to pain and to pain relief than are such factors as severity of injury, number of surgeries, or radiographic findings.

The physician should be trained to be alert to a variety of incentive factors that may encourage increased pain behavior, such as

financial reward, family sympathy, or escape from boring or

dangerous work. The physician may also provide early education to

his patient that would discourage attempts at retirement on the

basis of a minor injury. This requires training in relevant legal

matters.

Pharmacology and Pain

Unfortunately, much of the day-to-day education received by the

practicing physician regarding medications comes from the drug

companies themselves. For example, the market has recently seen

the advent of combined narcotic agonist and antagonist compounds,

with the indication that these are "safe for prolonged pain

relief." The latter assertion is simply not true. Unfortunately

opposing points of view are not nearly so persuasively presented.

PUBLIC EDUCATION

The problem of pain could be reduced significantly with public

education about such points as the limits of the medical profes51
sion in alleviating discomfort, the use and abuse of medications,

the structures involved in pain, and the nature of the compensation system and disability.

Medications

Broadcast media provide a repetitive "education" about drugs, the

effect of which is profound although virtually subliminal. Drugs

are portrayed as panaceas for pain, tension, symptoms of allergies

and colds, and so forth. Indeed, one would believe that most

medications cure the disease rather than merely alleviating the

symptoms. Side effects of medications are not really addressed,

and the general public certainly is not likely to appreciate the

fact that use of any drug involves a tradeoff. Current packaging

and advertising techniques leave the public with a picture of a

much broader array of medications than is actually available. The

concept of "extra strength" seem to imply more power, rather than

increased dosage. Such terms as "aspirin free" when applied to

acetominophin products seem to insure against the adverse effects

of salicylates (which the opposing side, incidentally, dismisses

as "upset stomach"). The public indeed comes to expect a "pain

killer" with the implication of eradication of the cause of the

pain. Unfortunately, prescription medications are perceived merely

as more powerful extensions of the highly advertised nonprescription drugs.

This mentality would appear to coincide with a broader belief that

we have a right to "feel good now." This is commingled, particularly among the younger patients, with weakening of societal

taboos against drugs. Certainly the presumed value of suffering, or

at least the expectation that some suffering is a normal part of

the human experience, has faded in recent years.

public education designed to counter this set of beliefs would

havetobe extensive and variegated. Some lessons may be learned

from people who currently avoid narcotics. In our experience many

people avoid them for reasons that are almost moralistic, citing a

long-term distrust of drugs of any kind or a general notion of

pills as being evil. This pattern tends to be associated with conservatism and perhaps with age. Thus one suspects that the utility

of a morally based educational program would diminish with time in

this population. Another segment of drug-avoiders is more pragmatic, objecting to personality changes and alterations in mentation as reasons for avoiding use of narcotics and minor tranquilizers. Curiously, lack of efficacy may not be particularly salient; many individuals taking moderate to heavy doses of narcotics

readily report that their medications "do no good," or that the

pain level remains unchanged when drugs are stopped. Yet, these

are the same patients who report they only take their medications

when they "have to."

Our experience at Northwest Pain Center demonstrates that educa52
tion can be useful on a large-scale basis, at least with an interested population. Patients have readily come to understand such

concepts as appropriateness, side effects, tolerance and habituation, mechanisms of action, and other technical aspects on the

basis of two or three hours of direct lecture with additional

informal discussion. They have eagerly learned the use of reference materials regarding drugs. The current public availability

of publications formerly available only to the physician may

herald an era of greater public awareness about drugs. Further,

the trend toward consumerism seems to encourage this kind of skepticism, and may prove an ally in the struggle against misuse of

prescription as well as nonprescription drugs.

Limits of the Medical System

Striking advances in medical care in recent years have received

wide publicity. Given success in heart surgery, including replacement valves and pacemakers, and the more publicized organ transplants, it is difficult for the lay public to accept failure of

the medical system to provide a total cure for suffering. This

faith leads to insistence on relief, which may contribute directly

to prescription-writing by the physician, and to possibly unnecessary surgery. Although there is clear need for education in this

area, the medical profession itself is not likely to provide it.

General Medical Education

By conservative estimate, seventy-five percent of operated

patients do not understand what has been done to them, and are

surprised to find out. They do not recall having been shown a

model of the affected system, nor do many recall even the most

rudimentary education regarding their own situations or the

alternatives they faced. Certainly some of this ignorance may be

the result of faulty memory or attention; nonetheless, more general

and easily available instructional material about pain-producing

structures might deter many from a career in chronic pain. Encouraging the use of second medical opinions and education about the

meaning of disagreement among doctors might also help reduce

unnecessary surgery (Gertman et al. 1980).

Compensation Factors

The public in question does not distinguish between the concepts

disability, handicap, and symptomatology. A handicap may persist

even though symptoms such as pain have abated. handicaps are not

equivalent to disability, the former being functional and the

latter legalistic in character. Again our experience is that individuals are interested in such distinctions and show considerable

interest in laws that relate to them. An unrealistic view of the

possibility of retirement based upon minor injury may perpetuate a

period of disability. Better understanding at the outset might

reduce temptation to pursue the course of disability, whether

consciously or unconsciously.

53

348-347 0 - 131 - 5
RECOMMENDATIONS FOR RESEARCH

The rapidly expanding body of knowledge about pain in recent years

has only served to highlight our ignorance in the area. We have

progressed from a rather mechanistic view of pain to the realization that it must be treated as a complex, shifting phenomenon

with biological, psychological, and social features. Basic

research is needed to help define the problem and meet its

challenges.

Basic data are still needed regarding such factors as prevalence

of drug use and variability of use among different individuals,

and prescription patterns by different medical specialty. Knowledge about physiological addition is not normally available to

the practitioner and must be studied in organized research. Direct

evaluation of the efficacy of drugs in chronic care is an area

that still needs further research; for example, if physicians and

patients knew that pain medications lost substantial efficacy over

a few weeks, this could substantially reduce incentive in both

areas for prescriptions.

Outcome research is essential for all forms of therapy currently

available. It may be seen as paradoxical that the "soft" practitioners (e.g., the pain centers) appear to be the only ones doing

hard research. long-term outcome studies of many pain-relieving

surgeries are difficult to find and frequently suffer serious

methodological short comings. The frequently observed pattern of

initial surgical success followed by deterioration mirrors the

placebo effect, and may be the only value to surgery for a defined

body of patients who will later become "chronic." Major research

projects will be needed to evaluate this possibility, including

double-blind studies using sham surgery. Outcome of drug therapies

should be studied in controlled investigations, including use of

antidepressant medications as well as analgesics. Pain centers

should likewise continue to evaluate themselves, striving for more

appropriate controlled studies.

Research is also needed in the area of outcome as it is related to

new diagnostic techniques. It would not appear that introduction

of newer tests such as the discogram and computerized tomogram has

led to a higher proportion of successful surgeries, although it

may lead to a greater number of justifications for surgery.

The most basic form of research has to do with the appropriate

match between therapy and patient. Too little is known about the

qualities of the patient who will benefit from each treatment

strategy, whether we are discussing the pain center, drug therapy,

surgery, benign neglect, or psychotherapy. So long as people are

viewed as essentially indistinguishable, little meaningful knowledge can be gained about either the problem or the efficacy of

the various approaches. We must look more to a careful definition

and understanding of the syndrome we are treating, and the multiple

external factors which may affect it, and less toward searching for indications for procedural interventions.

54
Table 1

Hysterical features 70%

Depression 56%

Character disorder 8%

Passive-aggressive features 6%

Normal 5%

Percent of patients demonstrating psychological disturbances at

admission. Values sum to more than 100 since patients may display

more than one.

Table 2

1977 1978 1979

Returned to work 5 15 18 (25%)

Involved in vocational rehabilitation 14 11 4

Continued regular medical care 43 20 15

Closed claims 2 7 56 58 (82%)

Open claims 34 13 12

Average cost of admission $3413.15

Total claims reviewed 75 (all SAIF patients seen)

Total enrolled in program 71

Cost benefit analysis for SAIF patients admitted to Northwest Pain

Center in 1976

Table 3

Pain No overall

increased change

Overall effect

Admission to followup 5% 18%

(Average pain change) (+21%) (0)

Post-discharge changes

Regression, added benefit 26 47

(Average pain change) (+23%) (0)

Overall treatment effect of pain center

Pain

reduced

77%

(-33%)

27

(-21%)

Tabled values are percent of patients reporting pain increase, no

change, or pain reduction. Values in parentheses are average

change in pain intensity for those reporting a change.

55
Table 4. CRITERION VARIABLES

Total group Failure Success

Mean S.D. Mean S.D.

7.90 1.96

4.45 2.11

7.60 1.61

Mean S.D.

Pain severity

Admission 7.96

Discharge 4.91

Follow-up 4.93

Limitations caused by pain

Admission 6.63

Discharge 3.83

Follow-up 3.71

Depression

Admission 7.93

Discharge 3.88

Follow-up 3.88

1.97

2.76

3.01

2.31

1.96

2.23

2.03

2.35

2.47

6.40 2.29 7.60 2.10

3.30 1.87 4.60 1.72

5.50 2.17 2.30 1.60

7.60 2.15 9.07 1.19

3.73 2.32 4.13 2.15

6.07 2.40 2.07 1.88

8.80 1.28

5.75 2.47

2.60 1.97

Tabled values represent scales ranging from 1 to 10, with 10

representing the highest degreee of pain or disability

respectively.

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-press.

Table 5. DEMOGRAPHIC VARIABLES

Total Fail. Succ. Fail/succ. Fail./total Succ./total

x

2

 P x

2

 P x

2

 P

Sex

Male 52.8 80.0 44.0 6.88 <0.05 9.00 <0.05 0.94

Female 47.2 20.0 56.0

Marital status

Married 77.0 87.5 48.0

Single 1.5 0 0

Separated 4.5 4.2 12.0 11.80 <0.05 3.40 22.68 <0.01

Divorced 14.3 4.2 40.0

Widowed 2.4 4.2 0.0

Age category

20–30 10.3 20.0 8.0

30–40 29.0 20.0 28.0

41–50 31.7 16.0 44.0 8.03 <0.10 8.52 <0.10 3.14

51–60 24.8 36.0 20.0

61+ 4.1 8.0 0

Total group Failure Success Fail./succ. Fail./total

Mean S.D. Mean S.D. Mean S.D. t P t P

Age 43.5 10.2 43.8 12.9 42.6 9.0 0.4 0.1

Duration of

disability 3.91 2.84 3.08 2.50 5.24 3.14 2.7 <0.05 1.6

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-press.

56
Table 6. OPERANT VARIABLES

Total group Failure Success Fail/succ. Fail./total

Mean S.D. Mean S.D. Mean S.D. t P t P

Activities 1.6 2.9 –0.8 2.6 3.2 2.3 5.8 <0.01 3.8 <0.01

Pain talk 2.3 2.5 1.4 2.8 3.1 2.1 2.2 <0.05 2.1 <0.05

Understanding 2.1 2.3 1.1 2.4 2.2 2.1 1.7 2.4 <0.05

Help 1.2 2.8 1.4 2.3 2.0 3.8 0.8 0.5

Marr. qual. 2.3 3.1 0.8 2.9 3.8 3.8 3.1 <0.01 3.8 <0.01

Tabled values represent linear transformation of rating

scales such that --5 represents the greatest possible

regression (e.g., increased pain talk, decreased outside

activities, increased help from others).

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-Press.

57
Table 7. ATTITUDE VARIABLES

Total Fail. Succ. Fail./succ. Fail./total Succ./total

x

2

 P x

2

 P x

2

 P

Further medical care

None 61.4

Regular visits 21.4

Further

diagnosis 5.5

Seek

new opinion 6.2

Desire surgery 3.4

Had surgery 2.1

Summary

No care 61.4

Reg. care 21.4

Seeking medical

solution 17.2

Positive aspects

Active 83.7

Passive 16.3

Negative aspects

Active 47.5

Passive 52.5

48.0 76.0

16.0 24.0

8.0 0

12.0 0

4.0 0

12.0 0

48.0 76.0

16.0 24.0

36.0 0

80.5 86.3

19.5 13.7

61.1 28.6

38.9 71.4

Reasons for reduced exercises

Somatic 44.6 42.9 27.8

Other 55.4 57.1 72.2

Medication use

Narc. 19.2 20.6 10.7

Tranquilizers

Minor 4.0 2.9 10.7

Major 5.6 8.8 0.0

Aspirin 53.0 47.1 53.6

Antidepressant 18.2 20.6 25.0

11.0 <0.10 17.7 <0.01 6.4

11.0 <0.01 7.5 <0.05 6.4 <0.05

0.6

3.4 <0.10

1.0

5.1

1.0

1.0

0.1

0.1

3.3 <0.10

2.3

1.4 7.5

Total group Failure Success Fail./succ. Fail./total

Mean S.D. Mean S.D. Mean S.D. t P t P

Exer. freq. 11.4 9.5 9.6 9.4 15.2 10.2 2.0 <0.05 1.0

Relax freq. 7.3 5.7 5.7 6.1 7.7 5.5 1.3 1.5

Stim. use 8.8 10.2 10.6 10.0 7.3 10.0 1.2 1.0

P.C. rating

(±3 scale) 2.0 1.1 1.3 1.3 2.5 0.8 4.0 <0.01 3.5 <0.01

Tabled values for non-parametric factors are expressed as

percent.

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-press.

58
Table 8. PSYCHOLOGICAL VARIABLES

Sleep Total Fail. Succ. Fail./succ. Fail./total Succ./total

quality

x

2

 P x

2

 P x

2

 P

Admission

R-N 85.5 84.2 88.2

R-E 5.1 5.3 5.9

S-N 1.7 5.3 0.0 0.9 1.9 0.5

S-E 7.7 5.3 5.9

Discharge

R-N 29.6 42.1 21.4

R-E 21.3 21.1 7.1

S-N 4.6 0.0 7.1 4.7 2.6 3.5

S-E 44.4 36.8 64.3

Followup

R-N 31.0 45.0 13.3

R-E 17.7 25.0 6.7

S-N 9.7 5.0 9.7 8.8 <0.05 4.4 7.3 <0.10

S-E 41.6 25.0 73.3

Total group Failure Success Fail./succ. Fail./total

Mean S.D. Mean S.D. Mean S.D. t P t P

Sleep adm. 4.6 2.3 4.3 1.7 5.2 2.5 1.4 0.9

Discharge 5.8 1.5 5.7 1.6 6.0 1.5 0.9 0.9

Follow-up 6.0 1.4 5.4 1.6 6.8 1.3 3.1 <0.01 2.2 <0.05

Tabled values for non-parametric factors for expressed in

percent. R = restless; S = sound; E = enough; N = not enough

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-Press.

59
Table 9. INCENTIVE VARIABLES

Total Fail. Succ. Fail./succ. Fail./total Succ./total

x

2

 P x

2

 P x

2

 P

Admission

Comp. 71.7 72.0

No comp. 28.3 28.0

Follow-up

Comp. 53.0 68.0

No comp. 47.0 32.0

Employment status

Disabled

by pain 40.5 56.0

Not working

Other 19.0 20.0

Empl.

part-time 8.4 12.0

Empl.

full-time 23.7 12.0

Student 8.4 0.0

Degrees

GED 19.3 20.0

Assoc. 4.8 4.0

Bachelors 6.2 4.0

Advanced 3.4 0.0

72.0

28.0 0.0 0.0

40.0

60.0 4.0 <0.05 2.7 <0.10

0.0

2.1

25.0

12.5

12.5 9.7 <0.05 8.2 <0.10 6.4

37.5

12.5

24.0

12.0

4.0

12.0

2.6 1.2 5.3

Total group Failure Success Fail./succ.

Mean S.D. Mean S.D. Mean S.D. t P

Fail./total

t P

Highest grade 11.3 2.4 10.2 2.4 12.1 2.5 2.6 <0.05 2.5 <0.05

Work history

Unskilled 5.8 9.9 3.8 6.1 11.0 14.4 2.3 <0.05 1.1

Skilled 7.1 10.3 11.8 13.8 4.5 8.4 2.3 <0.05 2.5 <0.05

White collar 2.4 5.8 2.1 6.4 0.9 2.5 0.9 0.3

Professional 1.9 5.9 0.2 1.0 1.7 5.1 1.5 1.7

Total work 17.3 10.7 17.8 12.6 18.1 12.0 0.9 0.9

Tabled values for non-parametric factors are expressed in

percent.

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-press.

60
Table 10. CORRELATIONS AMONG NUMERICAL VARIABLES AND CRITERION

VARIABLES

Variable Regression Overall change

r z P r z P

Age

Duration of disability

Highest grade

Total work (years)

Unskilled work

Skilled work

White collar, clerical

Professional

Exercise frequency

Relaxation frequency

Stimulator use

Overall rating

Mood: Admission

Discharge

Followup

Sleep: Admission

Discharge

Follow-up

Enjoyable activities

Pain talk

Understanding

Help at home

Marriage quality

0.003

–0.199

–0.214

–0.022

–0.100

0.117

0.017

–0.096

–0.146

–0.072

0.134

–0.286

0.170

0.209

–0.463

–0.136

–0.026

–0.300

–0.380

–0.219

–0.114

–0.020

–0.323

0.05

2.37

2.44

0.27

1.19

1.41

0.21

1.15

1.75

0.86

1.60

3.41

2.04

2.48

5.52

1.62

0.31

3.55

4.55

2.63

1.34

0.24

3.76

<0.05

<0.05

<0.10

<0.01

<0.05

<0.05

<0.01

<0.01

<0.01

<0.01

<0.01

0.014

0.264

0.154

0.021

0.141

–0.165

–0.015

0.103

0.282

0.067

–0.030

0.592

–0.436

0.331

0.608

0.027

0.091

0.247

0.610

0.425

0.288

0.174

0.365

0.17

3.16

1.75

0.25

1.70

1.98

0.18

1.23

3.38

0.80

0.35

7.05

5.21

3.93

7.25

0.32

1.08

2.93 <0.01

7.29 <0.01

5.10 <0.01

3.41 <0.01

2.05 <0.05

4.24 <0.05

<0.01

<0.10

<0.05

<0.01

<0.01

<0.01

<0.01

<0.01

Regression value represents arithmetic swn of change in pain

severity and limitations due to pain following discharge;

overall change represents amount of change in pain severity

and limitations between admission and follow-up.

From Painter et al. Assessing benefits of the pain center: Why some patients regress.

Pain, 8:101-113, 1980, © 1980, Elsevier/North-Holland Biomedical-Press.

61
Figure 1. Percent reduction in daily use of analgesic medication, by drug type

From Fletcher, L.J., ed., Pain Management: Symposium on the Neurosurgical Treatment of Pain, © 1977, The William & Wilkins Co.
Figure 2. STRAIGHT LEG RAISE exercise expressed in degrees, by employment categories

From Fletcher, L.J., ed., Pain Management: Symposium on the Neurosurgical Treatment of Pain, © 1977, The William &Wilkins Co.
Figure 3. KNEE-TO-CHEST exercise expressed in percent improvement, by employment category

From Fletcher, L.J., ed., Pain Management: Symposium on the Neurosurgical Treatment of Pain, © 1977, The Williams & Wilkins Co.
REFERENCES

Gertman, P.M., Stackpole, D.A., Levenson, D.K., Manuel, B.M.,

Brennan, R. J. and Janko, G.M. Second opinions for elective

surgery: The mandatory Medicaid program in Massachusetts. The N E

J of Med, 302: 1169-1174, 1980.

Keim, H.A. Indicators for spine fusions and techniques. Clin

Neurosurg, 25: 266-275, 1978.

Newman, R.I., Painter, J.R., and Seres, J.L. A therapeutic milieu

for chronic pain patients. J Hum Stress, 4 (2): 8-12, 1978.

Newman, R.I., Seres, J.L., Yospe, L.P., and Garlington, B.E.

Multidisciplinary treatment of chronic pain: Long-term followup of

low-back pain patients. Pain, 4: 283-292, 1978.

Painter, J.R., Seres, J.L., and Newman, R.I. Assessing benefits of

the pain center: Why some patients regress. Pain, 8: 101-113,

1980.

Redburn, R. Factbook for Oregon's Workers Compensation System.

Salem, Oregon: Oregon Executive Department Publication, 1980.

Seres, J.L., and Newman, R.I. Results of treatment of chronic low

back pain at the Portland Pain Center. J Neurosurg, 45: 32-36

1976.

Seres, J.L., Newman, R.I., Yospe, L.P., and Garlington, B.E.

Evaluation and management of chronic pain by nonsurgical means.

In Fletcher, L. J., ed. Pain Management: Symposium on the

Neurosurgical Treatment of Pain, Ch. 4. Baltimore: The Williams

and Wilkins Co., 1977.

AUTHORS

Joel L. Seres, M.D., Northwest Pain Center Associates, 10615 S.E.

Cherry Blossom Drive, Portland, Oregon 97216

John R. Painter, Ph.D., Northwest Pain Center Associates, 10615

S.E. Cherry Blossom Drive, Portland, Oregon 97216

Richard I. Newman, Ph.D., Northwest Pain Center Associates, 10615

S.E. Cherry Blossom Drive, Portland, Oregon 97216

65
A Comprehensive Model for the

Study and Therapy of Pain:

Johns Hopkins Pain Research

and Treatment Program

Donlin M. Long, M.D.

Abstract:

The Johns Hopkins Pain Research and Treatment Program is based

upon individual diagnosis, psychiatric evaluation, and

individualized therapy. This is done within the framework of a

concurrent program involving neurosurgeons, consulting

physicians, psychiatrists, clinical psychologists, social

workers and specialized nurses. The basic theme is self-help

and self-responsibility. Drug withdrawal is mandatory, and an

emphasis is placed upon psychotherapeutic techniques. Pain

relieving procedures are available and utilized in a small number

of patients.

INTRODUCTION

The university-based pain treatment program should serve two

primary functions. Any comprehensive pain treatment program must

provide evaluation and therapy for the individual patients seen.

However, a university program must also have specific study goals,

and these research aims must be incorporated into the framework

of the programs so that they do not interfere with patient

evaluation or care. Secondary functions of the pain treatment

program are largely educational. Most authorities now agree

that neither acute nor chronic pain is managed well by the

majority of physicians. It is important that the pain treatment

center provide a focus for expanding under-graduate and postgraduate education in pain management. In addition, the most

comprehensive and multidisciplinary of such programs should

develop guidelines for the training of a limited number of

individuals with a primary interest in the study and therapy

of pain. The Johns Hopkins Comprehensive Pain Research and

Treatment Center has been organized to try to meet all of these

goals.

66
THE PATIENT CARE PROGRAM

Philosophy Of The Program: The center is organized in both

the in-patient and out-patient mode. The basic theme is self

help and the program is entirely voluntary. Patients sign a

contract concerning their behavior and obligations during

hospitalization. Patients may elect to leave at any time without onus and may be discharged if they fail to comply with the

written contract. Family participationis required on a

limited basis.

Selection Of Patients: Patients are accepted by physician

referral only. Patient inquiries which oriqinate with patients

are actually-seen only after a physician contact is made and

complete records are available. before appointments are made for

any patient, pertinent records and X-rays are obtained from the

referring physician and reviewed by an individual member of the

Pain Treatment Center physician's staff. There are no specific

categories of patients that our protocol rejects, but we have

facilities for managing several kinds of important pain problems

in other environments. The Johns Hopkins Rheumatology Clinic

has an international reputation, and inquiries from arthritis

sufferers are directed there. An occasional arthritic patient

is accepted upon referral from a rheumatologist for a specific

purpose. We are fortunate in having a physician team specializing in the therapy of headaches so headache patients are

treated in the Pain Treatment Center environment only upon

referral from specialists in headache for the correction of

specific problems, usually drug dependency. Cancer pain is

managed in a separate clinic located within the regional Cancer

Center which is also staffed in a multidisciplinary mode and

utilizes the resources of the Chronic Pain Treatment Center.

Patients with abdominal and thoracic pain are generally

referred to appropriate speciality clinics at Johns Hopkins for

evaluation prior to admission to the Pain Treatment Center.

At the time of initial record review, several courses are open.

The first is direct referral to another specialist. The patient

may be referred directly to psychiatry, if psychiatric therapy

appears to be the most important need. The patient may be

referred to another Pain Treatment Program. The patient may be

admitted directly to the neurosurgery ward for evaluation. An

occasional patient is rejected completely. Usually, these

patients are individuals with clear-cut serious psychiatric

disturbance whose primary need is for psychotherapy.

After the patient is accepted to the Pain Treatment Program, one of

two routes is followed. The patient may simply be placed on the

waiting list and nothing further done until the time of admission.

Or the patient may begin an out-patient program. This usually will

include appropriate medical diagnostic measures, group psychotherapy, and drug management. Out-patient physical therapy is also a

possibility.

67
The patient first is seen in the Out-Patient Clinic for an

examination that takes approximately one day. If the

appropriate disposition could not be made from the record

(which is the usual case) the decision for further evaluation

and therapy is made at the time of the first visit. The outpatient evaluation consists of an examination by one of the

neurosurgical members of the team and a psychiatric interview

with a clinical psychologist or a psychiatrist. The SCL-90 is

obtained for a quick look at anxiety and depression. The patient

also maybe seen by the resident in training or by a nurse

practitioner as the initial step and reviewed by of the

neurosurgery staff. Appropriate diagnostic studies are often

carried Out in the Clinic before a disposition is made.

In-Patient Program The heart of comprehensive pain

management is the in-patient program. The Johns Hopkins Pain

Treatment Center is a self-contained 14-bed unit administered

through the Department of Neurosurgery. Patients are admitted

for between two and three weeks for an intensive program which is

looked upon as the beginning of therapy.

The staff consists of three neurosurgeons, one psychiatrist, one

clinical psychologist, one experimental psychologist, a

psychometrist for psychological testing, a nurse practitioner,

one neurosurgery resident, a social worker, a physical

therapist and a specialized nursing staff. The nursing staff

takes great responsibility for the ward management of the

patients. Even though the program is located within the

Department of Neurosurgery, its governance is multidisciplinary.

There is an Executive Committee which reports to the Chairman

of the Department of Neurosurgery. The Executive Committee

consists of two neurosurgeons who serve as co-directors of

medical services. There is an anesthesiologist who is

Director of Block Services and a psychiatrist who is Director

of Psychiatric Services. In addition to these full-time staff

members, the Psychiatry-Liaison Service consults regularly on

all patients where consultationis required and the general

staff of the Johns Hopkins Hospital is used liberally for

consultation.

The three principles of The Johns Hopkins Program are (1) accurate

physical diagnosis, (2) accurate and comprehensive psychiatric

and psychosocial evaluation, and (3) individualization of therapy

in an eclectic mode. The evaluations are integrated into a

standard program that begins immediately upon admission. After

admission, the patients are presented with the Pain Treatment

Center Contract which outlines our expectations and the patients'

obligations. They have 24 hours to accept or reject the

principles of the Pain Treatment Center and no change in their

status is undertaken until they have signed a contract unless

some drug behavior offers a serious danger. If they fail to

sign the contract, they are asked to leave after 24 hours. Once

the contract is signed, the first step is to correct what is

usually an unacceptable drug situation. The characteristics of

68
the average patient reviewed in our program are found in Table I.

Most patients seen in our program are addicted to drugs in every

sense of the word. They exhibit marked drug seeking behavior

and serious physical withdrawal signs if the drugs are discontinued. Withdrawal from medications constitutes the most

common reason for admission. Over one-fourth of our patients

are so intoxicated from their drug ingestion that they show

marked deficiencies of cognitive thinking on standard testing.

56% show significant electroencephalographic abnormalities. It

would be difficult to over estimate the importance of inappropriate drug use in these patients and it is mandatory that

this drugusebe regulatedbefore thepatients can begin even

to understand the program presented to them. Most are seriously

intoxicated, and no therapy will be effective until their medications are controlled.

TABLE ONE

DRUG STATUS OF 100 CONSECUTIVE PATIENTS

ADMITTED TO THE JOHNS HOPKINS PROGRAM

Regular use of narcotics - 95%

Regular use of psychotropics - 90%

Misusing drugs - 90%

Using drugs from multiple physicians - 50%

Withdrawal symptoms from something - 80%

All narcotics are withdrawn. There is virtually no indication

for the continued use of narcotics in chronic pain of benign

origin, except excellent pain control. Since none of our

patients enjoy pain control, the narcotics are discontinued in

all. Even more importantly, it is necessary to remove diazepam

(Valium). We have more difficulty in withdrawing patients from

this drug, see more significant withdrawal side effects, and see

more effect upon brain function than with narcotics. Barbiturates

and amphetamines are also contraindicated in chronic pain, and

these are eliminated as well. Drug withdrawal schedules depend

entirely upon the severity of intoxication and the quantities of

drugs ingested. In general, we will discontinue narcotics over

a one-week period and diazepam within five to seven days, but, of

course, large doses of drug require longer periods of time for

withdrawal.

During the time that drug withdrawal proceeds, a comprehensive

physical examination is completed and the psychiatric and

psychosocial evaluation begun. An assessment of the patient's

physical capabilities and deficiencies is made and an

69

348-347 0 - 81 - 6
appropriate physical exercise and activity program started.

This will first be in the group mode and then an individual

exercise program designed. Patients are required to care for

themselves during hospitalization and dress in street clothes.

Patients who have less physical impairnent assist those with

more. Compliance is designed to be primarily through peer

pressure rather than confrontation between nurse or physician

and patient. Regular group therapy programs are held. Patient

community meetings are employed to explore problems. Regular

family programs are made available. A social worker is employed

to assist with social problem and also provides couple's

therapy and sex counseling. Serious sexual psychopathology is

treated in a specialized clinic available for that purpose and

referrals are made if a problem of a serious nature is found to

exist.

The patient's stay is individualized according to the patient's

needs and progress. The average hospitalization is 17 days.

Pain Therapy: The standard program is required of all

patients. Even the standard program is individualized. in that

not all patients meet all aspects of it to the same degree, but

the basic principles are employed for all patients. However,

therapy of pain is completely individualized.

The major focus of the pain-relieving techniques is patient

selection and individualization. During the psychiatric

evaluation, patients are categorized into one of four areas.

These groups are meant to guide therapy that we currently have

available. They appear to be very useful from a practical

standpoint, but require significantly more study for validation.

The first of these groups is termed objective. Such patients

have a definable cause of pain, their behavior is commensurate

with the cause and their premorbid adjustment was normal. They

may be depressed and anxious as a result of their chronic

pain state, but their basic psychological makeup is normal.

These are the patients that are considered candidates for interventional procedures and no patients in other categories are

offered interventional therapies. The second major category we

term the amplified pain syndrome. These patients usually have

an insignificant physical problem and are disabled out of

proportion to their physical disability. Important factors

appear to be an underlying personality disorder or situational

stress. Frequently, these patients present with combinations

of these two major factors. It is extremely important to

recognize this group of people. In our experience a large

number of industrial injury victims fall in this category and

exhibit significant personality disorders. Interventional

procedures are never indicated for a complaint of pain without

a clear-cut organic basis and certainly should be avoided in

this group of individuals. The third group are those with clearcut affective disease. Their need is for psychotherapy just as

the need for the amplified group is for behavioral therapy.

We have a fourth unexplained category for those patients where

70
no cause of pain can be found and no psychiatric factors are

present either. It is extremely important to make certain that

psychiatric diagnoses are made on the basis of positive

findings. The absence of a physical cause of pain is not a

reason for a psychiatric diagnosis. The developmental stage in

which the patient is currently located is also determined and is

very important in determining interventional therapy.

We believe that patients with chronic pain go through the staging

described for death and dying. In the early phase of the

disease, the patients are unaccepting of their disability and

rational treatment plans. They often go from physician to

physician looking for an easy answer and are particularly prone

to accept surgical intervention. In a second phase, after

multiple failures of therapy, the patients become hostile and

angry and are particularly prone to sue. The third phase is

where most patients in chronic pain present to the Pain

Treatment Center. This is characterized by depression and drug

dependency. The fourth phase is one of rational understanding

and acceptance of disease and its treament. The object of the

program is to bring all patients into the fourth phase and to

direct them into appropriate therapy. Interventional procedures

should not be used, except for objective pain states when the

patients are in the phase of rational understanding. The use of

surgery for the complaint of pain in patients with amplified and

affective pain states is probably the most serious error

currently made in pain management.

Our interventional pain therapy begins with transcutaneous

electrical stimulation. A significant number of patients will

respond to this modality. However, because of the highly

specialized nature of our clinic and the fact that the

technique is gaining wider acceptance with the medical profession,

we now rarely see a patient who has not used it,and the number

that we can benefit with transcutaneous stimulation is dropping.

Diagnostic and a few therapeutic nerve blocks are used regularly.

Diagnostic blocks include individual nerve blocks, sympathetic

blocks, and lumbar facet blocks. Repetitive sympathetic

blocks are sometimes therapeutic in the reflex sympathetic

dystrophy syndromes. Coeliac axis blocks are sometimes

employed in chronic abdaninal pain and may occasionally be

therapeutic. We do not use neurolytic blocks.

Radiofrequency neurolysis is employed. The innervation of the

lumbar facets may be destroyed by radiofrequency current, the

so-called facet denervation. Individual roots are amenable to

differential destruction with radiofrequency current as in

intercostal nerves and the greater occipital nerves. Radiofrequency trigeminal lesions are routinely employed.

Implantable neural stimulators are also employed. Peripheral

nerve stimulators are used specifically for pain of peripheral

nerve injury origin. Spinal cord stimulators are employed

almost exclusively for the pain of arachnoiditis complicating

71
multiple operations upon the low back, and deep brain

stimulators are employed for patients with pain of central

nervous system injury origin. However, the number of patients

chosen for these procedures is small, averaging less than 5%

of the total number of patients evaluated each year.

Destructive procedures for pain relief are rarely employed

except in cancer pain. An occasional patient undergoes a

destructive peripheral nerve operation, but virtually no other

destructive procedures are utilized.

The most likely operation is reoperation upon the back or neck

to correct some major abnormality which occurs as a

complication of the previous operative procedures. Reoperation

in the patient who has undergone multiple lumbar or cervical

operations is a major decision and must be made carefully only

after conservative measures have failed. Primary indications

are significant instability, acquired spinal stenosis, continued

root compression, and arachnoiditis with intractable pain or

progressive neurological deficit.

Out-Patient Follow-Up: Following a hospitalization which

averages 17 days, patients are allowed to continue a program in

the Out-Patient Department. Follow-up of six months to one

year is routine for most patients. Some patients may be referred

to other facilities, usually for psychiatric care or for the

therapy of some previously undiscovered madical problem. Some

patients are returned to the care of their personal physicians

with the summary of in-patient activities and recommendations

for therapy. Most patients will be followed by members of the

pain treatment program team. The majority of patients are

returned for follow-up in group or individual psychotherapy, by

physical therapy, by the specialized nursing service, and for

therapy with the psychiatric social worker. Only those that

have undergone interventional procedures are followed by the

physicians of the team. Patients maybe sent back to the

physicians by other team members at any time it seems to be

important.

The Philosphy Of The Pain Treatment Center: The primary

original aim of the program is an accurate diagnosis which

includes both physical and psychosocial factors. The second

aim is individualization of therapy. Within this over-all

framework we have a number of goals. our patient care goals

are relief of pain, elimination of drug dependency, treatment

of anxiety, depression, and related psychological epiphenomena.

In addition, we would like to improve or restore social and

personal competence, reduce the dependence of the patients upon

physicians and the medical system, reduce medical costs and

restore or improve vocational function. We do not undertake

job rehabilitation primarily, but involve ourselves at this

level by diagnosis and the appropriate direction of therapy.

An important goal which is not entirely related to patient care

is the acquisition of data which would allow us to make

72
intelligent choices in the modification of social programs

that impinge upon the entire problem of chronic pain.

These goals are approached through a standardized program and

then a specific program. All patients undergo drug withdrawal

and modification of drug therapy. All patients have

appropriate psychotrophic drug therapy for insomnia and

depression. All patients undergo the beginnings of a physical

conditioning program and begin the rudiments of self help.

Transcutaneous electrical stimulation is used ubiquitously

through the program. It is unusual when a patient reaches us

now without having first tried this modality and those patients

who are relieved by such a simple technique have been selected

out of our series. Diagnostic nerve blocks are employed

routinely, but therapeutic nerve blocks are used infrequently.

Specific surgical procedures are used rarely. Approximately

10% of patients are considered candidates for interventional

procedures. Reoperation upon the low back or surgery on an

injured peripheral nerve are the most common procedures

employed. Implantable electrical stimulators are used, but

currently are considered appropriate for between 1% and 2% of

all of the patients seen. Destructive surgical procedures

virtually are not employed in this group of patients. The

so-called lumbar facet denervationis rarely used, and radiofrequency neurotany may also be occasionally employed.

The major aim in our pain therapy is to direct the patient into

the therapeutic modality best suited to the underlying

diagnosis. Patients with clear-cut organic pain generators,

who have a normal premorbid adjustment, are the only patients

considered candidates for interventional procedures. Interventional procedures are carried out only after the comprehensive

pain program has reached its limits. Patients in the amplified

category are generally candidates for behavioral therapy, and

interventional procedures are rarely used in this group.

Patients with clear-cut psychiatric disease are directed into

the appropriate psychotherapeutic programs.

The major behavioral therapies used are by suggestion rather

than through any strict behavior modification mode. Patients

are involved in a self-care self-help program, and an attempt

is made to modify their dependence upon individual physicians,

drugs, and therapy. Group psychotherapy, assistance with

family and personal matters, and occasionally individual

psychotherapy are the techniques most employed. The basic

therapeutic form is the group therapy program.

Patients with psychiatric disease are not managed in the

chronic pain program. As soon as they are identified, they

are sent to the appropriate psychiatric facility.

The basic principle behind this kind of patient selection

for therapy is to treat what is wrong with the patient rather

than to employ a doctrinaire program which is generally applied

to all patients.

73
Research In ThePain Treatment Program: It is important that

any university-based program have a significant research

component. Research projects may be wide ranging according to

the expertise of specific programs.

Our primary patient-related interests relate to a series of

epidemiological questions. The first of these is, "Are there

patient factors in chronic pain which have diagnostic,

therapeutic, or prognostic significance?" The second question

we are attempting to answer is, "Are there practice patterns or

physician characteristics that influence the complaint of

chronic pain?" We approach these questions with a multifactorial

analysis of chronic pain. In this analysis we are studying

epidemiology of chronic pain, psychiatric and psychological

characteristics of the patients, and patterns of therapy prior to

the patient's arrival at the Pain Treatment Center.

The program also has a basic research arm. The primary project

concerns the psychophysics of pain sensation in normal subjects

and in patients with chronic pain. The pathophysiology of

peripheral nerve injury is also under study. Studies on the

cerebrospinal fluid and blood levels of beta endorphin in

normal subjects and in patients with chronic pain are carried

out in collaboration with laboratories of the National Institutes

of Health. There is also a research project which studies the

effects of narcotic antagonists upon stimulation induced

analgesia. Through these studies, we are attempting to define

the psychophysical characteristics of pain and determine if the

opioid system is important in some types of pain and pain

therapy.

The program also has a major component of biomedical

engineering research. In collaboration with the Applied Physics

Laboratory of The Johns Hopkins University, we have developed a

completely implantable electronic human tissue stimulator which

can be utilized with every kind of implantable stimulator for

pain relief. We are currently engaged in developing an

implantable drug infusion pump which will deliver measured

amounts of drugs intravenously into the cerebrospinal fluid

or into body cavities.

Future Goals: Our experience to date indicates that there

are a number of questions to be answered before any major

improvements in pain therapy are likely to be forthcoming. Our

goals are to identify epidemiologic, psychological, social

and medical factors which are important in the current epidemic

of chronic pain. The entire problem needs to be characterized

both medically and from a social standpoint. The complaint of

pain has become a major social issue because of the great cost

of disability based upon pain. Changes in disability rating

system, industrial injury disabilities, and social security

disabilities will be possible only when we have the data that

characterize these groups of patients so that improvements

based upon fact are possible.

74
An important long-term goal is to develop models for the

evaluation of pain therapy. At the present time, there is little

data which allows the results of pain therapy to be analyzed

effectively. We wish to develop standard systems for

determining levels of pain disability and recording changes in

these levels with therapy.

Everyone agrees that an appropriate taxonomy of pain must be

developed. The epidemiologic and patient studies will be

important in allowing appropriate taxonomy to be developed.

Standard methods of characterizing patients and the results

of therapy will be possible only after a satisfactory taxonomy

is available.

Conclusions: Chronic pain is currently an epidemic in the

United. States and a major public health issue. This is so

because of the great cost of disabilities based loosely upon

complaint of pain and the cost of current medical therapy

directed at pain as a symptom. Pain is a complaint which may

or my not be related to a nociceptive event. It may express

distress related to internal or external events. The goals

of the comprehensive Pain Treatment Program are accurate

diagnosis, psychiatric and psychologic characterization of the

patient and evaluation of the psychosocial factors which may

be important in the complaint of pain. Therapy techniques are

many, but their success is limited. Only through continued

study of this problem are we likely to improve treatment of these

patients and so solve the social issues which have been raised.

AUTHOR

Donlin M. Long, M.D.

Department of Neurosurgery

Johns Hopkins Hospital

601 North Broadway

Baltimore, Maryland 21205

75
Chronic Pain as a Learned

Experience: Emory University

Pain Control Center

Steven F. Brena, M.D., Stanley L. Chapman, Ph.D., and

Roger Decker, M.Ed.

ABSTRACT

Chronic pain is often a conditioned socioeconomic disease. A

majority of chronic pain patients show pain behavior in excess of

biomedical findings and disability ratings out of proportion to

their actual physical impairment. Biomedical data and pain behavior

are independent variables, as the latter is heavily controlled by

socioeconomic factors. The diagnosis of chronic pain patients

requires evaluation and matching of both variables. When disability claims are present, a comprehensive vocational evaluation

should be performed and matched with biomedical and behavioral

findings. The Emory Pain Estimate Model for diagnosis of chronic

pain states is discussed briefly and techniques of vocational

evaluation are presented also. The structure of the Emory Pain

Control Program and data from treatment outcome are presented

and discussed.

Figures from Bonica (1979) have indicated that the total cost

of chronic pain is in excess of fifty billion dollars.

A study of eighty patients from the Emory University Pain Control

Center has revealed that chronic pain may have a hidden, but

greater, impact on the vocational and social lives of individuals

and on the community. The study is composed of a sample of fiftyfive men and twenty-five women (mean age 39.9 years). The data

are summarized in Tables I and II.

A further analysis of the eighty selected subjects found that

sixty-nine percent would be able to return to gainful employment

compatible with their age, education, previous work history and

transferable work skills, if properly managed medically and

vocationally.

76
TABLE I TABLE II

UNIT OF ECONOMIC LOSS FOR PAIN-DISABLED SUBJECTS UNIT OF COSTS FOR DISABILITY INCOME AND MEDICAL

Average Income Loss Average Tax Loss

Per week: $207.00 Per week: $ 41.00

Per year: $9,936.00 Per year: $1,969.00

EXPENSES FOR PAIN-DISABLED SUBJECTS

Income Support Benefits Yearly

Georgia Workmen's Compensation $5,720.00

S.S.D.I. Benefits - Family

of Four $14,100.00

Medical Costs (Average)

Hospital per diem

Surgical Expenses:

Yearly

$1,918.00

Laminectomy $7,500.00

(Range $5,000 - $10,000)

TOTAL COST OF PAIN TO TAXPAYER PER INDIVIDUAL/YEAR (WITHOUT MEDICAL EXPENSES)

ESTIMATED AVERAGE $21,814.00
The Emory data show an average annual cost of chronic pain to

society per individual of $21,814.00. Information is not available on the total number of chronic pain patients in the United

States. If a conservative estimate of 2 percent of the population

is made, the resultant pain-disabled population would be 4.6 million, with a cost to our society in excess of 100 billion dollars

per year. A 2 percent estimate is probably low, considering that

the Social Security Administration alone has estimated the total

number of disability beneficiaries in 1980 to be 5 million, up

from 2 million in 1970, with a rate of growth ten times faster

than the growth of the general population (Grossman 1980).

The roots of this gigantic problem are multiple and complex; many

of them probably reflect changes in values and work ethics in

contemporary society, where pain behaviors have been socially

accepted as legitimate ways to gain early retirement, escape from

responsibilities, or obtain drugs, etc. Unknowingly the

medical profession reinforces these social attitudes by its continuing and uncritical acceptance of the biomedical model which

considers pain only as a symptom and not as a set of behaviors.

Present legislation also reflects a medical position, by granting

open-ended disability benefits to individuals who chronically

engage in pain behavior on the assumption that these individuals

must have some biological derangement "to cause their pain."

The adversary legal system is ideal to keep an injured worker with a

mild back sprain on disability benefits for years, while manipulating physicians in endless medical investigations, to find "the

cause of the pain." Fifty-one percent of all patients with chronic

pain at the Emory Pain Control Center have disability benefits

or pending litigation associated with their pain problems; many

others report unsatisfactory family and social situations preexisting the onset of pain.

A sample of 101 consecutive patients at Emory has shown the following data-- mean age: 40 years; mean education level: 10 years;

manual labor: 64 patients; clerical work: 20 patients; technical

and managerial positions: 17. Eighty-seven reported the back as

the primary pain location (23 cervical back).

The conditioning process significantly affects responses to treatment. Out of a matched sample population of 61 patients with

chronic pain and similar degrees of tissue pathology, 35 were receiving compensation for work-related accidents and 23 were receiving no compensation for their illness behavior. Of the noncompensation group, 69 percent of the patients successfully completed the Pain Rehabilitation program by increasing significantly

their activities of daily living (ADL). In the compensation group,

a higher number of patients dropped out of the rehabilitation program, and only 43 percent demonstrated similar ADL increase

(Hammonds et al. 1978). Out of a matched sample population of 144

subjects, with comparable biomedical findings, 70 subjects had no

pending litigation and no disability benefits; 74 subjects were

receiving monetary compensation for an accident suffered at work.

All subjects received a series of six sympathetic nerve blocks

performed with a local analgesic agent (bupivacaine 0.25%) and

78
with a saline solution. Only 17.6 percent of the Workers'

Compensation patients displayed a placebo effect following

saline injections, against 35.7 percent in the no-disability group.

Among the patients with no paid disability, sixty-seven percent

reported decreased subjective pain intensity from both analgesic

and saline injections; 50 percent of the Workers Compensation

group reported similar results (Brena et al. 1980).

The work of Fordyce (1976), Sternbach (1974), and others has

clearly demonstrated that pathological changes and pain-illness

behaviors are independent variables. Diagnosis of chronic pain

patients, therefore, requires evaluation and matching of both

variables. One such method is the Emory Pain Estimate Model

(Brena and Koch 1975). The model is an operational definition

of chronic pain states and involves separate ratings of tissue

pathology and pain behavior from objective data. The amount of

tissue pathology is rated on a 0 - 10 severity scale, using

traditional biomedical diagnostic procedures. The amount of

pain behavior is rated on a 0 - 10 severity scale using the

following measures: McGill Pain Questionnaire; ADL check list;

drug use rating scale; MMPI. The matching of both sets of data

yields four different classes of chronic pain states: Class 1

patients are pain disabled with high behavior (> 5) and low pathology scores (< 5). Class 2 patients score low on both variables

(< 5) while class 3 patients score high on both (> 5). Class 4

patients score < 5 on the behavior scale and> 5 on the pathology

scale. Independent assignment to pain class of fifteen case

histories by five physicians yielded a Pearson product-moment

correlation of 0.85, indicating high inter-rater reliability of

the model (Brena et al. 1976).

Table III shows the distribution of patients to classes of chronic

Pain states (Brena and Chapman 1980).

TABLE III

DISTRIBUTION OF PATIENTS TO CLASSES OF CHRONIC PAIN STATES ACCORDING

TO DISABILITY STATES (N =144)

Workers' Compensation No Pending Disability

N-74 N=70

Class 1 72% Class 1 40%

Class 2 0% Class 2 35%

Class 3 28% Class 3 21%

Class 4 0% Class 4 3%

79
The high percent of chronic pain patients in classes 1 and 2

(72 percent in the Workers' Compensation group and 76 percent in

the group of patients with no pending disability) clearly points

out that chronic pain can persist even with relatively few biomedical findings.

The process of pain quantification and classification should be

supplemented by measurable data from vocational assessment in

Workers' Compensation cases or whenever requested in cases of

pending disability litigation. There are several systems of

vocational evaluation; among them the Hester and the Valpar systems

have emerged as leaders in the field. The Hester system consists

of a battery of twenty-two factor pure vocational tests which

measure twenty-six basic worker traits covering motor, perceptual,

and intellectual skills. The Valpar system consists of a series

of work samples that measure universal traits which are related

to a person's success in many occupations with a large variety of

job characteristics. By matching vocational evaluation with traditional biomedical investigation, psychosocial, and functional

evaluation, a comprehensive diagnostic judgment of a pain-disabled

patient can be obtained. This diagnostic judgment will eventually

help the individual to return to a state of health1 in many cases

through reversing illness behavior, preventing repetition of needless medical interventions, and insuring prompt settlement of the

disability case.

Brena et. al. (1979) have studied the relationship of chronic

pain states to impairment and disability. Consistent with prediction, they found higher impairment and disability ratings in

class 3 than in class 1 patients and the lowest ratings in

class 2 patients. Fifty-nine percent of the patients in the

study showed higher disability than impairment ratings, clearly

indicating the possibility of gainful reemployment through behavior modification and vocational counseling.

The Emory Pain Control Center has been in operation since 1973.

It first functioned as an outpatient clinic within the Department

of Anesthesiology. In 1976, it became a comprehensive Pain

Control Center, a division of the Emory Department of Rehabilitation Medicine, with inpatient and outpatient programs, education

and resource facilities, and one satellite pain clinic at the

Grady Memorial (County) Hospital in Atlanta. Various treatment

programs have been developed: a headache control program, a

cancer rehabilitation program, and a pain control program for

class 1 and class 3 pain-disabled patients based on contingency

management (CM). The thrust of the CM program is cognitive

behavior modification for competent coping in maladaptive situations of existential suffering. The patients are educated to

accept the basic idea that chronic pain and impairment of some

bodily functions are not necessarily deterrents from meaningful

and self-gratifying lives; through individual and group counseling, they are educated in how to change ways of thinking and acting

80
in order to deal more efficiently with their physical and emotional

impairments. Six target areas are identified: (1) to teach

patients to give up their dependence on drugs and to detoxify them

if they have developed a physical dependence; (2) to desensitize

them to particular sensory inputs which they have learned to

perceive as unpleasant. Phasic stimulation of the anatomic

region where the painful perception is located is achieved through

transcutaneous nerve stimulation (TNS) and nerve blocks. This treatment may also interfere with central pain modulation by effecting

changes along sensory and nociceptive peripheral pathways; (3) to

train patients to increase ADL, to perform specific exercises, and

to coach them away from obsessive attention to bodily cues; (4) to

teach patients new skills to cope with stress situations; (5) to

educate relatives in how to effectively interact with the chronic

sufferer by avoiding actions leading to reinforcement of illness

behavior and by strengthening those actions conducive toward states

of health; (6) to assist patients to resume gainful employment, via

vocational evaluation and counseling. The informed consent of the

patient before treatment is obtained through a one-hour informative videotaped lecture which is held every week at the Center.

The entire CM program takes 18 hours of actual treatment: three

hours per week for six weeks as an outpatient or nine hours per

week for two weeks as an inpatient. Criteria for hospital admission are: the patient has severe physical or emotional impairments; the patient is pain-disabled, lives alone with no relative

to monitor him/her for home-based pain rehabilitation; patient

is misusing opiates, sedative, and anti-anxiety agents; patient's

general health conditions may require prolonged nursing care following various treatment modalities. The total cost of the outpatient program is around $1,500.00 in professional fees.

Contingency management requires teamwork. Members of the Emory

Pain Team are: two full time physician Algologists; one parttime anesthesiologist; one full time psychologist; one full time

behavior therapist; three physical therapists; two occupational

therapists; and one vocational evaluator. Results from the

CM program are monitored as follows: Measures of Subjective Pain

Intensity (SPI), a 0 - 100 visual analog scale and the McGill

Pain Questionnaire; Activity Record, daily records of participation

in ADL; Medication Record; Reports from Physical Therapists and

Occupational Therapists on graded 0 - 5 improvement scales. Results from the Center's CM Program for 100 randomly selected

patients have been tabulated (Chapman et al. 1979). All of

these patients completed an outpatient CM program of six weeks

duration. Data at follow-up periods averaging twenty-one months

posttreatment indicated significant decreases in SPI (mean decreaseequals 24.4 percent of pretreatment levels) and increases

in ADL (mean increase equals minutes per day) with substantial

reductions in use of medications for pain. Changes from pretreatment to follow-up were not significantly different among groups

of patients with pending, current or no disability. Eight of

nineteen unemployed persons who had pending disability claims

had returned to work at followup. The discrepancy between these

81
data and the previously reported study from Hammonds et. al. is

likely to reflect the higher emphasis on patient education and

counseling in the present structure of the CM program versus

the earlier treatment program, which was rigidly based on operant

conditioning alone, with no vocational intervention.

Teaching programs at the Emory Pain Control Center include: a

postgraduate fellowship in Algology; monthly rotation of residents

from the Anesthesiology and Rehabilitation Medicine training

programs; a four-month rotation of interns from the Department

of Psychology. An elective course in Algology is offered to

second year medical students. Educational programs include: a

monthly pain conference for the greater Atlanta area and two annual

pain conferences which are part of the Emory University Continuing

Medical Education programs. Research facilities for both clinical

and basic studies are available through the Regional Rehabilitation and Training Center.

FOOTNOTE

1

State of health as defined by the World Health Organization:

"a state of complete physical, emotional and social well being."

REFERENCES

Bonica, J.J. The Interagency Committee on New Therapies for Pain

and Discomfort, Report to the White House. U.S. Dept. of Health,

Education and Welfare, May, 1979 pp IV-38.

Brena, S.F. and Koch, D.L. A "pain estimate" model for quantification and classification of chronic pain states. Anesthesiol Rev,

2: 8-13, 1975.

Brena, S.F., Koch, D.L., Moss, R.M. Reliability of the pain

estimate model. Anesthesiol Rev, 3:28-29, 1976.

Brena, S.F., Chapman, S.L., Stegall, P.G., Chyatte, S.B.

Chronic pain states: relationship to impairment and disability

Arch Phys Med Rehabil, 60:387-389, 1979.

Brena, S.F., Chapman, S.L., Bradford, L.A. Conditioned

responses to treatment in chronic pain patients:effects of

compensation for work related accidents. Bull L.A. Neurol Soc.

Volume 44, 1980 (in press).

Brena, S.F., Chapman, S.L., (eds.) Management of Pain in General

Practice Menlo Park, CA: Addison-Wesley Pub. Co. (1980).

Chapman, S.L., Brena, S.F., Bradford, L.A. Treatment outcome in

a chronic rehabilitation program. Presentation at the 56th

Annual Session of the Amer Congr of Rehab Med, Honolulu, HA, 1979.

82
Fordyce, W.E., Behavioral Methods for Chronic Pain and Illness.

St. Louis Mosby Press, 1976

Grossman, Honorable H.T. Personal communication.

Hammonds, W., Brena, S.F., Unikel, I. P. Compensation for work

related injuries in rehabilitation of patients with chronic

pain. So. Med J, 71: 664-666, 1978.

Sternbach, R.A. Pain Patients: Traits and Treatment. New York:

Academic Press, 1974.

AUTHORS

Steven F. Brena, M.D.

Stanley L. Chapman, Ph.D.

Roger Decker, M.Ed.

Emory University Pain Control Center

Center for Rehabilitation Medicine

1441 Clifton Road, N.E.

Atlanta, Georgia 30322

83
Coordinated Out-Patient

Management of Chronic Pain at

the University of Virginia Pain

Clinic

Harold Carron, M.D., and John C. Rowlingson, M.D.

ABSTRACT

The Pain Clinic at the University of Virginia Medical Center is a

comprehensive facility providing a coordinated team approach to

the management of chronic pain syndromes. The Clinic is primarily

an out-patient facility, although in-patient therapy in clinicassigned beds is available for special problems.

Approximately 1,500 new patients are seen annually in the Clinic's

own facilities, resulting in approximately 3,500 patient visits.

All diagnostic facilities are readily available, and all somatic

modulation and psychotherapeutic techniques are utilized for pain

management.

Referrals are accepted only from physicians and then only after

all medical records, the Clinic's Patient Assignment Inventory

Narrative (a screening brochure), and special studies are reviewed.

The initial evaluation includes, as well, history taking, physical

examination, psychological testing and interview, special studies,

specialty consultations, and family interview. A therapeutic plan

is then developed and discussed with the patientand family members.

The Clinic's philosophy is to encourage the patient to assume

responsibility for all aspects of the treatment program including

drug detoxification, activity and exercise programs, and functional

perfomance.

The Pain Clinic at the University of Virginia Medical Center is a

comprehensive facility providing a coordinated team approach to

the amelioration of chronic pain in patients with a long history

of disability who have proven unresponsive to management by any

single clinical specialty. Experience has shown that the continued private consultation referral of this group of patients

frequently ends in therapeutic mismanagement that includes further

drug habituation or exploratory surgery. Seldom are the emotional,

social, family, and occupational problems confronting the patient

taken into account under such a system. It is this system of

84
specialty management that in many instances has created the

chronic pain sufferer.

Approximately 1,500 new patients are seen annually in the pain

clinic as a part of the 3,000 to 3,500 total patient visits.

Referrals to the clinic are from physicians outside of the Medical

Center, specialty services within the center,and third party

carriers through community physicians. Patients are not accepted

other than through physician referral, with the majority of

patients being referred from Orthopedics and Neurological Surgery.

Increasing numbers are being referred by Neurology, Internal

Medicine, Rheumatology, Oncology, General and Thoracic Surgery,

and Nuclear Medicine. It is interesting that patients are rarely

referred to the Clinic from primary physicians, since those, at

least within the referral area of this institution, appear diffident in complying with the Clinic's request for full and comprehensive records.

On referralof a patient to the Clinic, the patient's physician is

requested to supply copies of pertinent hospital records and a

narrative summary encompassing physical findings, laboratory

studies, and results of therapy as evidenced on the patient's

last visit. On receipt of the referral, the patient is sent an

evaluation brochure to complete (Pain Assessment Inventory

Narrative) which is a 16-page questionnaire embodying a history of

the painful condition, depression scale, social and occupational 

attitude questionnaire, drug history, and a four-view figure of

the human body so that the patient can graphically depict

origin and distribution of his pain. When all records have been

accumulated, they are reviewed by a senior faculty member assigned

to that patient. This staff member then prepares a summary of all

positive historical and physical findings, and indicates areas of

concern and recommendations for further investigative procedures.

At this time, collateral consultations with other specialists are

set up for the date of the patient's visit and further diagnostic

studies arranged. Only after completion of this phase of the

admission procedure is the patient given an appointment for the

clinic.

On the first visit, the patient will undertake psychological tests,

following which a complete history will be taken and physical examination performed. The patient will then be seen by the Clinic

Psychologist and/or Social Worker who will also conduct interviews

with the patient and spouse or other family members. The patient

will then be referred for special studies and consultations as previously determined, and when reports on these are received (usually

the same date of initial visit) the patient will be re-presented to

a Pain Clinic conference. At this time,recommendations will be

made for therapy, thorough explanations are given to the patient,

and arrangements are made for implementation of the recommendations

either in the Clinic or by appropriate consultants.

Because of the large patient load, the University of Virginia

model is primarily an out-patient one, admitting only those

85

348-347 0 - 131 - 7
patients from remote areas who have difficulty completing roundtrip travel on the same day or, who, for physical reasons, are

unable to stay at conveniently located hotel or motel facilities.

Further, the out-patient model permits initial evalution and

institution of treatmen at a much reduced patient cost. While

there is no evidence to suggest the benefits of either in or outpatient models based upon outcome of therapy, there are indications

that the in-patient model provides earlier ambulation and physical

activities than does the out-patient model. To overcome this

deficiency, a program is being established that willprovide for

a 6-week, 1-day-per-week, out-patient program in the physical

therapy department, where the patient will be taught body mechanics, exercise regimens, and methods of increasing physical activity.

Group psychotherapy sessions will also be conducted during this time.

STAFFING

The Clinic is headed by the Director who also serves as Adminstrative Chief of the Clinic. He serves in the Clinic on a rotating

basis with two other attending pain specialists so that the Clinic

is covered by a senior physician 8 a.m. to 5 p.m. five days per

week.The Director serves a minimum of three days per week in the

Clinic to provide necessary continuity, and utilizes a portion of

his remaining time for clinical research and administrative duties.

The Clinic has one or two full-time fellows who participate in

teaching, clinical care, research, and indoctrination of new personnel. All anesthesiology residents rotate through the Clinic

for two months during their third post-graduate year of training

and for longer periods electively during the fourth year. All

Orthopedic Department residents spend one month in the clinic, as

do Rheumatology, Neurological Surgery, and Neurology residents on

an elective basis. Medical students rotate through the Clinic on

a weekly basis as part of their anesthesiology elective.

A new program that has been initiated in the Pain Clinic is one of

pain management for Nurse Practitioners in a Masters Degree program. During the first year, the majority of the graduate nursing

student's time is spent in study and sociological and psychological training under the direction of the clinic psychologist.

During the second year,the nurse practitioner evaluates new

patients, discusses them with the attending physician, presents

them to Clinic conferences, and is involved in continuing behavioral and psychological managenent of these patients. It is felt

that this class of personnel can serve as a major resource to extend the ability of the Pain Clinic physician to care for a greater

number of patients.

EDUCATION

There are thrice weekly conferences, one a didactic presentation

pertaing to some area of either pain diagnosis or management, a

second conference devoted to the psychological aspects of chronic

pain and presentation of appropriate patients, and a third joint

86
conference with the Departments of Orthopedics, Psychiatry, and

Neurology for discussion of patients admitted to the Orthopedic

Service

The Clinic maintains its own library of all current texts relating

to pain diagnosis and management as well as current journals in

the field. In addition, the Clinic has established a series of

looseleaf binders indexed by pain sydromes and therapeutic techniques into which are collected reprints and copies of all current

literature pertaing to pain problems. The clinic members also

have access to the anesthesiology and medical school libraries.

PHYSICAL RESOURCES

The Clinic is currently located at approximately 1600 square feet

of its own space within the main hospital structure. Plans have

been approved and space allocated for a move to approximately 3500

square feet as depicted in the accompanying figure.This physical

plan permits both patient evaluation and treatment and provides

adequate space so that in-patients as well as out-patients can be

seen in the Clinic for diagnosis and therapy. Psychological services are provided in the psychologist's office and in the biofeedback laboratory, and group therapy is conducted in the conference room or library Additional laboratory space is available for animal and clinical research.

87
PATIENT POPULATION

The patient population at the University of Virginia Pain Clinic

is referred from throughout the state of Virginia, the Southeastern portion of West Virginia, and the Washington D.C.metropolitan area. The average age of patients referred to the Clinic

is 43.6 years with approximately equal numbers of males and

females. The average educational level is 6th grade, and the

patients are predominantly from a rural area. Among the syndromes seen, low back pain comprises about 50% of the patient

population. Cervical and shoulder pain are responsible for an

aditional 20%, vasospastic disorders 10%, cancer pain 10%, and

other conditions the remainder. 47% of patients have had prior

surgery, 97% pharmacological management, 60% physical therapy,

and only 5% have received prior psychotherapy. Reimbursement is

approximately 60% from compensation sources and private insurance

makes up an additional 30%. A small percentage of welfare patients

are seen gratis, and private fees make up the balance. Costs of

operation of the Clinic are approximately $170,000 per year for

professional and secretarial support and another $150,000 for

nursing, drugs, supplies, space rental, housekeeping, other

services.

In the last fiscal year, approximtely 1,500 new patients were

seen and the following procedures carried out.

1. return consultation and follow-up visits - 979

2. nerve blocks - 930

3. psychological services - 655

4. neurostimulation - 138

THERAPEUTIC MODALITIES

All therapeutic modalities are available in the Clinic and a

holistic is used in the management of all patients.

Among the procedures available are nerve blocks, pharmacological

management including detoxification, physical therapy, neurostimulation, activity/social programs, and psychotherapy.

A major problem in the Virginia Pain Clinic population has been

the degree of drug use and abuse. Prior to the clinic visit,

approximately 98% of all patients had been placed on non-narcotic

analgesics and 85% of these had been subjected to narcotic analgesics. The use of benzodiazepines by 85% of patients prior to

Clinic visit has resulted in a 60% drug dependence for these

pharmacological compounds and has made it necessary to provide

for detoxication following the first visit as the initial step

in therapy. Drug witdrawal is accomplished on an out-patient

basis with almost total acceptance by the patients. Follow-up

studies indicate that very few patients return to drug abuse.

The patient is provided a written daily schedule of drug dose

reduction combined with substitutive drugs to avoid withdrawal

effects. Other psychotherapeutic agents are added to the

schedule. Patients remain in contact with the Clinic through

weekly or bi-weekly telephone calls or return visits.

88
Psychotherapy, consisting of individual, group,and family

therapy with several experimental groups of the "self help" type

under the direction of the clinic psychologist, is a major portion

of the clinic's therapeutic program. This specialist also supervises the biofeedback programs that are useful in many cases.

EVALUATION OF RESULTS

The Clinic staff has conducted several comprehensive follow-up

studies through mail questionnaires in addition to the use of

return visits, telephone calls at regular intervals, and a post

card at six months following the last visit. Published studies

indicated that most problems encountered in the pain clinic

behavioral and socioeconomic, rather than physical.They also defined the low back pain patient population as deriving from a

rural economy, with an educational level of 6 years, with the

patient involved in a repetitive,non-stimulating type of employment that was primarily physical in nature.

Long-term follow-up studies of physical and psychosocial adjustment of patients with chronic pain following treatment are rarely

reported in the literature. Few studies report a long-term comparison of results over two time periods following the out-patient

model of therapy as carried out in this clinic. A study was done,

which was an extension of an earlier one, which reported generally

positive therapeutic outcomes of low back pain treatment,

especially in view of the chronicity and intractability of the

patients treated. The study also noted extensive gender-associated

differences in treament outcome, with women reporting generally

more positive outcomes than men. Initial studies also emphasized

the need for employing multiple criteria for assessing function

and the effectiveness of pain clinic therapy, rather than a statement of improved, unchanged, or worse.

One study performed in the clinic extended in follow-up by three

years an original survey to ivestigate whether the chronic pain

state improves, stabilizes, or deteriorates on a variety of

functional measures as a consequence of elapsed time following

treatment. It was also used to determine sex-related differences

and outcome and whether they maintain themselves over time. Final

intent of this study was to determine the association between

behavioral reports of improved functioning versus the more global

rating of overall change in pain intensity and frequency once

employed as the only outcome criteria in many studies reported in

the literature.

A striking finding in the study was a substantial increase over

time in the percentage of females classifying themselves as improved in their ability to work; 32% in 1974 and 62% in 1978.

Males conversely showed only marginal improvement in disability

with 39% improved in 1974 and 44% in 1978.

89
Although some 23 of the original 151 patients on the 1974 survey

reported one or more additional surgeries for pain, on a five year

follow-up, only three reported additional surgery, representing

substantial reduction over time in this aspect of chronic pain

behavior.

The data in this study indicate generally favorable long-term

results among patients presenting themselves for treatment in an

integrated pain clinic setting. Subjective ratings indicated

improvement in several parameters: a low percentage of surgical

intervention, enhanced ability to work, and positive outcomes of

treatment attested to by over half of the patients.

Reasons for gender-related differences were unclear. It is

possible that the males' pain states were associated with greater

levels of physical impairment due to work-related accidents, a

setting predictably associated with potential for severe back

injury. Males also have a greater need to maintain the attitudes

and behaviors consistent with more profound levels of impairment

to offset cultural stereotypes requiring males to be more

physically robust and vocationally productive than females.

The results from the five-year follow-up corroborated the observation made during the initial follow-up that the isolated criteria for pain reduction and return to work are too narrow for

assessment of patient outcome.

Patients were inclined to judge improvement in terms of reduced

exposure to pain and enhanced physical functioning, lending

support to behaviorally based treatment programs which emphasize

increased levels of physical activity and inattention to painrelated behaviors.

An additional intercultural study is being conducted with the pain

clinic in Auckland, New Zealand, to determine those factors which

influence return to work following low back injury. Preliminary

data suggests that a "no-fault" compensation system, a greater

spirit of individualism and physical fitness, and a more intense

rehabilitation service are responsible for return to work of

a greater number of back pain patients in New Zealand.

Laboratory research carried on in the pain clinic includes a

recently published study on the effect of epidural steroids(a

common treatment for low back pain)on the spinal cord, spinal

meninges, and nevre roots. The study failed to reveal any significant changes at the level of injection, or one level above and

below, when either vehicle or steroid-in-vehicle was compared to

plain lidocaine injection.

Additional studies on local anesthetics as a systemic method of

pain relief have also been published. Several studies on the

use of neuroaugmentation for the relief of postoperative pain

are in progress.

90
SUMMARY

The Pain Clinic's function in the university setting is that of

education, patient care, and research. The clinic is an outpatient model with results comparable to those of in-patient

careata far less cost to both patient and society in time

and money. The Clinic's basic philosophy is to encourage the

patient to assume the responsibility for all aspects of his/her

treatment program including drug detoxification, increasing

activity and exexcise programs, and functional performance. Assistance is provided in solving of the sccio-economic, familial,

and psychological problems, either through therapy within the

clinic or with in the patient's own geographic location.

The needs of the clinic are as follows:

1. Funding for trainees;

2. Better educational progrmns for medical students;

3. Better educational program for practicing physicians,

to provide early recognition of the patient with chronic

pain;

4. Third party recognition of pain as a disease and compensation for managenent thereof.

AUTHORS

Harold Carron, M.D.

John C. Rowlingson, M.D.

University of Virginia Medical Center

Charlottesville, Virginia 22908

91
Pain and Low Back Rehabilitation

Program at the University of

Miami School of Medicine

Hubert L. Rosomoff, M.D., D. Med. SC., Catherine Green, Ph. D.,

Marc Silbret, M.D., and Renee Steele, R.N., C.R.C.

The pain and low back rehabilitation program at the University of

Miami School of Medicine is a component of the Department of

Neurological Surgery, which has long been involved in the management of pain problems. A number of traditional surgical outcome

studies (Rosomoff, Sheptak and Carroll, 1966; Rosomoff, 1969;

Rosomoff, 1973), as well as studies on pain, its definition

(Rosomoff, Bonica, et al., 1975b, 1975c, 1975d; Rosomoff, Green

and Silbret 1980) and its relationship to personality and to emotional

distress in pain of malignant or non-malignant origin have been

completed. In addition to these particular studies, on-going

program evaluation has been carried out and the results of this

study, addressing a few selected issues, are presented in this report.

The current data were drawn on a group of patients who have gone

through the program since August 1977. During this time, there

have been a significant number of modifications in the program,

leading to the present status which includes self-contained inpatient as well as out-patient units. The table of organization

for the total program is presented in Figure 1. It may be seen

that there is a medical director, who, in fact, could derive from

any medical discipline, but in this case is a neurosurgeon. There

is a director of rehabilitative services, in this case an individual with a lengthy background as a rehabilitation nurse/specialist.

A psychiatrist, two psychologists and two physiatrists complete the

core professional hierarchy of the program. The services listed

are all available to the patients, according to their needs. The

program is further subdivided into an in-patient grouping and an

out-patient unit (Figure 2 and Figure 3). The in-patient program

is under the direction of the psychiatrist, in association with the

physiatrist, and the out-patient program is under the direction of

another physiatrist. It is important to recognize that all personnel are employed on a full-time basis with total dedication to the

pain and back rehabilitation program. Both in-patient and outpatient programs are self-contained. They employ their own personnel in the form of allied health science professionals who are

under the full-time direction of the core faculty. In addition,

the program relies heavily on the services of rehabilitation nurses

92
FIGURE 1
FIGURE 2
FIGURE 3
or rehabilitation specialists for the management of the patients.

These nurses or specialists are not employed by the program, but

are provided from extra-mural sources through the State of Florida or commercial companies. They are involved with the pre-program gathering of medical information, including physician and

hospital records, X-rays, special tests, etc., and they provide

an analysis of the environmental factors at work and home which

affect the patient's illness and management of this illness.

They work with the team throughout the patient's stay, providing

continuing input to and from the patient, family and employer,

where appropriate, while entering early into planning for discharge and immediate return to work or other suitable goals of

rehabilitation, should it not be gainful employment (Steele

1977). It is the goal of the program that each graduate finish

the program and immediately enter into the goal-derived occupation

without interruptions and without delay.

The initial evaluation is a three-day process completed on an inpatient basis so as to afford 24-hour observation and surveillance

of behavior, analgesic intake, activity levels and social mannerisms, as they may affect entry into the full program in a community patient setting. During this time, pain questionnaires are

utilized for description of complaints, psychological testing is

accomplished, physician interviews and examinations are conducted

by the neurologic surgeon, the physiatrist and the psychiatrist.

Additional testing, as required, is obtained when medical issues

care identified or special needs arise. These include radiological examinations, axial lumbar tomography and EMG analysis. At

the end of this time, the patient is reviewed at conference, the

findings are discussed with the patient and family and an outline

for future management is developed. The patient usually is discharged for readmission at a later date, pending agreement by the

patient, family, referring physician and health care provider.

The principle of this evaluation is outlined as follows:

A complete re-evaluation of the patient's symptoms is desirable for

several reasons. Previous treating physicians have invariably

limited their approach to patient's symptomatology of "disc" disease, lumbosacral X-ray abnormalities, myelography, and clinical

signs like motor strength, reflexes, and the straight leg raising

signs. Less frequently recognized sources of persistent pain, such

as lumbar stenosis, myofascial pain syndromes, and facet abnormalities have often been ignored.

Patients arrive with anxieties from previous and unsuccessful

treatment for the pain problem. These must be reduced by an exhaustive, thorough review presented in simple graphic terms.

The patient is much more willing to consider adapting to residual

pain and thinking of pain control after being convinced that:

a) all reasonable diagnostic attempts have been made; b) the advantages and disadvantages of any proposed invasive procedure

have been fully explored; c) the patient has final responsibility and a free choice regarding any proposed treatments; and d)

that they will not be further injured or "paralyzed" by an aggressive physical medicine program.

96
Given the choice of living with residual pain or trying to learn

additional control measures, most patients will readily consider

physical medicine and rehabilitation methods of management and

mental and muscle tension relieving techniques, such as relaxation and biofeedback, without feeling that it implies that they

are "crazy" or that their pain is "in the head."

Furthermore, it is important to identify and deal with psychological "noise" Maximal adaptation to residual pain is best achieved

with a reduction or elimination of such "noise" which can include

fear, depression, anxiety, hostility, superstitious beliefs, labile

or impulsive mood, low frustration tolerance, tendency for violent or self-destructive behavior, sociopathic and manipulative

personality styles, severe situational stress, and the use of such

maladaptive coping mechanisms as denial, projection and displacement. An approach employing self-assessment and personality tests,

clinical psychiatric and mental status evaluation, individual and

"significant other" interviews, analysis of previous psychological

assessment by mental health professionals and rehabilitation specialists together with a three-day observation period in a rehabilitative milieu, will usually be effective in identifying apparent psychological disturbances as well as "hidden agendas."

Sometimes a week or two of further observation, along with treatment in an in-patient setting will clarify initially ambiguous

cases. Pain complaints are channelled to daily morning rounds and

weekly conferences. At all other times, the patients are encouraged

to focus on ongoing tasks and activities rather than their pain

complaints.

Once identified, psychological distortions are reviewed with the

patient in a non-judgmental fashion and an individualized program

is offered to deal with such problems. This includes such features

as group discussions and therapy, individual relaxation training,

as well as individualized counseling, psychotherapy, or family therapy. A full evening program is organized for education, distraction

and recreation. The program is thus structured to emphasize daytime

hours as task oriented and evening hours for socialization.

Patients are not excluded automatically from the program if they

carry a previous diagnosis of schizophrenia or manic depressive illness. Rather, practical, operational criteria are used to determine

eligibility. These include compliance, ability to understand and

carry out instructions, positive attitudes towards rehabilitation,

and an absence of aggressive or disruptive behaviors towards patients and staff members. When such criteria are applied, program

results for such patients begin to approach those of other patients.

If patients are found to be obese, acceptance into the program is

deferred until weight reduction to a reasonable level has been effected. Principles for decreasing and eliminating narcotic and

sedative usage include establishment of baseline usages, stabilization periods are extended during periods of extensive diagnostic

testing or the initial phase of physical medicine procedures, such

as local injections and vigorous exercise. Once treatment routines

are established, patient acceptance of detoxification schedules is

more readily achieved.

97
True integration of coping techniques requires not only exposure

to educational techniques, but constant rehearsal, probing and

testing to insure true assimilation. For those returning to

work, simulated job tasks are given to test whether concepts of

body mechanics and energy conservation have become "second nature."

Rehabilitation nurse or specialist follow-ups and/or home visits

by occupational therapists are important to maximize environmental

integration. A graded transition from total in-patient care, to a

day rehabilitation setting, to gradually reduced number of outpatient visits has proved useful in minimizing relapses and in maxmizing the shaping and integration of adaptive behaviors. The rehabilitation nurse or specialist working with the patient and program serves as an extender of care. This individual is intermediary

with the family or home treating physician, who also monitors the

home rehabilitation program, adaption to return to work or community

environment at the local level. Should the patient regress or have

a problem, the specialist can be informed immediately so as to participate in management. Most new crises are thereby aborted.

The study presented in this paper will concern itself only with

the "low back" patient, the "salvage" case who has generally been

presented to us as being totally disabled, as he or she enters our

treatment program.

The patients range in age from late teens to seventies with a mean

age of 52; 72 were men and 56 were women (Table 1).

Table 1

AGE DISTRIBUTION

(PERCENTAGES)

UP TO 20 1

20 TO 29 6

30 TO 39 25

40 TO 49 27

50 TO 59 23

60 TO 69 17

70 AND ABOVE 1

They come from a broad socioeconomic group. Occupations range

from unskilled laborers to professionals, with the great majority

involved in unskilled labor and semi-skilled labor requiring heavy

work. This distribution has serious consequences for outcome

evaluation regarding return to work. Physical limitations relevant

to lifting will have far greater impact on a laborer than on a professional whose tasks are relatively sedentary.

98
Seventy-seven of these patients were receiving compensation benefits,

while 51 were not. The compensation patients were almost exclusively

formerly employed in unskilled or skilled, but heavy labor. Diagnostically, secondary soft tissue changes or myofascial syndromes were

seen in almost all patients to a varying degree, while a substantial

number showed bony pathology on X-ray or CT scan, with or without

sigificant clinical findings. All patients had had previous treatment, ranging from having had single physical therapy interventions

to a few who had attended other pain programs. The general pattern

had been to try one modality and see modest improvement, with subsequent return of the problem, and then an attempt with another treatment approach or surgery. Many had been abandoned by the medical

community or were considered "purely psychological." Thirty-three

percent had one surgery with an additional 41 percent having had two

or more surgeries, with single and multiple laminectomies being the

most common surgical intervention. Most had little or no formal instruction in therapeutic exercises as a part of their post-surgical

management. Upon evaluation for entry into our program, they generally described moderate to severe restrictions in work, recreational

and family activities.

The program, as described earlier, is a multidisciplinary one, utilizing a variety of techniques and learning experiences to instruct

the patient in effective mastery and adaptation to the pain problem.

Time in the program is a function of rate of improvement, since patients remain as judged necessary, rather than entering for a fixed

period of time. Predicting which patients will do well, easily, or

which will require more intensive or alternative interventions has

been a major research issue, addressed through both clinical studies

and the use of psychological testing. The Millon Behavioral Health

Inventory (Millon, Green and Meagher, 1979), a psychological inventory

for medical patients, when used in conjunction with clinical evaluations, has proved helpful in identifying personality characteristics

affecting outcome.

A RESEARCH STUDY OF “PROBLEM” AND “NON-PROBLEM” PATIENTS

Clinicians are well aware that some patients have greater difficulties with compliance than do other patients, i.e., "problem patients."

In an effort to address this issue, the following study was conducted.

All patients who had come into the program were listed. Each team

member independently was asked two questions about these patients

after they had completed the program. Did they know the individuals

well enough to rate them in regard to the criteria established for

a "problem" patient? If so, the evaluator was to state if each individual was or was not a problem patient. The criteria for a problem

patient were either: they seemed to sabotage their own treatment program through behaviors such as non-compliance, breaking of appointments repeatedly, or continued inability to integrate the program;

or they actively attempted to sabotage other patients through criticism of the team or fomenting non-compliance among patients. Problem patients were those given a rating of "problem" by a majority of

therapists rating them, with at least two therapists having rated

the patient. Those who could not be rated by at least two therapists

were not included in this study.

99
Forty-four percent of those rated were listed by this definition as

problem patients: 56 percent were non-problems (Table 2 ).

Table 2

PATIENT DISTRIBUTION

(N=88)

Problem 44%

Non-Problem 56%

Psychologically, problem patients were most likely to complain of

difficulties, expectations from self and others beyond the patients'

capacities to manage, depression and a sense of social alienation,

and a belief that family and friends were not there to support them

in times of need.

Those 88 patients who were known well enough to be rated were then

compared across a number of selected, simple measures. An interesting pattern of the relationship of outcome, compensation and management problems emerged. Of the patients rated either problem or nonproblem, 59 percent were on compensation, while 41 percent were not,

in keeping with the percentages of this distribution in the total

group (Table 3).

Table 3

PATIENT DISTRIBUTION

(N=88)

Compensation 59%

Non-Compensation 41%

Turning to those patients rated as problems, 64 percent were compensation cases (Table 4). Though this is slightly higher than the total

group, it is not substantially greater, despite the popular belief

that receiving compensation benefits increases management problems.

Table 4

PATIENT DISTRIBUTION

PROBLEM PATIENTS

(N=39)

Compensation 64%

Non-Compensation 36%

100
Treatment outcome cannot be assessed independently of the context

in which patients have been evaluated and later treated. In this

presentation we will focus on the issue of the rehabilitation of

the patient with low back pain. In our program it is assumed that

both organic and psychological components are issues in the diagnosis of the patient with chronic pain. The multidisciplinary

evaluation given each patient addresses both sets of issues and

includes self-report, physical examinations, diagnostic testing

and baseline data with emphasis on the development of a structured, functionally goal-directed treatment program. Philosophically, the Pain Team is rehabilitation oriented with the team

accepting responsibility for teaching and the patient assuming

responsibility for change through the integration of learning.

Criteria for admission to the program require only that the patient is medically stable, that the problem does not require immediate medical or surgical intervention, that no major psychopathology is present and that the patient is motivated to enter

treatment.

Within this framework over 125 patients with low back pain have

been evaluated and treated over the past 2-1/2 years. Patients

ranged in age from their teens into the seventies with the majority in their thirties and forties. Approximately 60 percent were compensation patients while 40 percent were non-compensation cases. The

large majority had had previous surgical interventions and a

variety of conservative management approaches as well. Most patients were currently taking narcotics and describing severely

limited activity levels at initial evaluation. The most frequent

diagnosis was secondary soft tissue changes with or without bony

pathology and with various degrees of limitation as a function of

these problems. After completing the program the patients were

rated as to whether or not they were "problem" patients following

specific criteria. Patients were evaluated at follow-up in regard to functional level, work status, medication utilization and

mood. These data were then analyzed for the total group and in

relation to specific issues considered salient to the management

of the pain patient including the issues of compensation and

whether or not the patients were seen as "problem" patients. The

results of this study will be presented.

Encouraging as these preliminary results are, what is of greater

importance is the development of a systematic, multi-center study

of patient populations, diagnoses, the specifics of treatment

within the various settings and outcome over time, utilizing

agreed-upon diagnostic criteria, instruments and evaluation techniques. The rationale of a cost-effectiveness model to address

some of these issues will be presented. This index is useful in

comparing alternative management methods, or as a means of following a single treatment across time. This model along with a

unified diagnostic and evaluation armamentarium should serve to

aid in clarifying the issue of chronic pain and its management.

101

348-347 0 - 81 - 8
The issue of cost required to create change in patients is a serious

one. Allowing for variation within individual programs, one measure

of this cost is the total length of time patients were in the program.

The treatment length for patients who terminated AMA were not included

in this calculations so as not to artifically abbreviate these figures

Outcome figures did, however, include these patients. The average

stay for all patients in this study was 48 days, combining both inpatient and out-patient treatment (Table 5). Not all patients required

Table 5

MEAN LENGTH OF PROGRAM

(N=88)

Compensation Patients 45 Days

Non-Compensation Patients 51 Days

All Patients 48 Days

both forms of treatment, but treatment programs followed the same

model, and days in treatment can be considered to be equivalent.

It can be seen that non compensation patients remain in treatment

six days longer than compensation patients. Although explanations

are conjectural, it is posited that input from the rehabilitation

specialists serves to increase efficiency in regard to movement

through treatment and, more importantly, back to the home and work

environment.

The problem patient has an average length of stay of 55 days,

with, again, a markedly shorter stay for compensation than noncompensation patients (Table 6). Insurers, involved in a conTable 6

MEAN LENGTH OF PROGRAM

PROBLEM PATIENTS

(N= 39)

Compensation Patients 51 days

Non-Compensation Patients 61 days

All Patients 55 days

stant dialogue with the team, may encourage terminating treatment

when therapies are unproductive, according to program report. This

additional input may serve to keep the treating team more focused

on real world issues than their compassion or idealism might allow.

102
The non-problem patients stay a mean of 43 days, 12 less than for

problem patients, with a modest difference between compensation

and non-compensation cases (Table 7).

Table 7

MEAN LENGTH OF PROGRAM

NON-PROBLEM PATIENTS

(N=49)

Compensation Patients 42 days

Non-Compensation Patients 45 days

All Patients 43 days

The additional time for the problem patient is invested at the

beginning of the program, getting the individual to adapt to becoming a participant, involved and motivated toward treatment.

One of the most significant criteria for evaluating outcome is

function. As mentioned earlier, a number of issues affect reentry into the job market. Most fully to appreciate program

effectiveness, both functional activity levels and employment

must be addressed. Data on activity levels for the total sample

on whom extended telephone follow-ups were completed, numbering

52, are reported below.

The criteria for rating function are: Level I refers to full activity, including self-care, management of home, work and recreational activities. This may be in the presence or absence of discomfort and the patient may or may not be taking medications. The

aim of our program is rehabilitation and function with no guarantee

of pain relief, although strong efforts are made to reduce initial

pain complaints and prevent increased pain with increased activity.

Level II refers to a patient capable of self-care only, assuming no

responsibilities for maintenance of home or caring for others, on a

regular basis. Finally, Level III refers to that category of patients unable to fully manage self-care, who are dependent on

others to meet basic needs.

Employing these criteria, 86 percent of the total group are at full

function at follow-up which was completed two months to two years

after treatment ended, with an average time elapsed of 11 months

(Table 8). It cannot be assumed that treatment alone was the cause

of this status; however, it can be stated that the patient has

achieved this level. Twelve percent were at Level II, while only one

of the 52 respondents described self as severely restricted.

103
Table 8

FOLLOW-UP

LEVEL OF FUNCTION, TOTAL GROUP

(N=52)

I = 86%

II = 12%

III = 2%

It has been thought in the past that compensation patients were less

likely to improve than the general population. With regard to function, our data do not support this concept. At follow-up, 88 percent

of compensation patients reported full levels of function (Table 9).

Table 9

FOLLOW-UP

LEVELS OF FUNCTION, COMPENSATION PATIENTS

(N=34)

I = 88%

II = 12%

III = 0%

Non-compensation patients, admittedly a small sample, showed similar

results, with 84 percent at full levels of function (Table 10).

Table 10

FOLLOW-UP

LEVELS OF FUNCTION, NON-COMPENSATION PATIENTS

(N=18)

I = 84%

II = 8%

III = 8%

The issue of the problem patient in relation to outcome is a significant one (Table 11). Seventy-three percent of all problem

104
Table 11

FOLLOW-UP

LEVELS OF FUNCTION, PROBLEM PATIENTS

(N=22)

I = 73%

II = 23%

III = 4%

patients, in spite of difficulties in integrating the program,

achieved follow-up outcome levels of full function, with 23

percent carrying on self care. One patient reported severe

restrictions preventing even complete self care.

Ninety-seven percent of non-problem patients reported full

levels of function (Table 12). It must be remembered that a

variety of physical and psychosocial factors served to create

these differences.

Table 12

FOLLOW-UP

LEVELS OF FUNCTION, NON-PROBLEM PATIENTS

(N=30)

I = 97%

II = 3%

III = 0%

Work activity, although related to level of function, is subject to

a number of co-occurent variables, particularly previous employment

and social network support (Table 13).

Those listed as working are gainfully employed on a full time basis.

Homemaking was listed for those individuals for whom this choice was

appropriate, given age and sex, not as a category covering their

forced retirement. Those at age 65, or retired previous to injury

or illness, were categorized as retired post-treatment, if active

but unemployed. Again, this was not a category for the unemployed

or underemployed male. Students were considered such, if full time,

albeit occasionally with reduced course load. Not working were those

with resources to be employed, but for whom no placement had been

made. ADL refers to those whose activity included self care only. In

the total group, 70 percent were effectively and appropriately occupied, 16 percent were unemployed, but able to work, and 12 percent

were able to perform self care tasks only.

105
Table 13

FOLLOW-UP

WORK ACTIVITY,TOTAL GROUP

(N=52)

Working 29%

Homemaking 17%

Retired 13%

Student 11%

Not Working 16%

ADL 12%

Disabled 2%

Work activity, however, did show some real differences between compensation and non-compensation patients (Table 14).

Table 14

FOLLOW-UP

WORK ACTIVITY, COMPENSATION PATIENS

(N=34)

Working 29%

Homemaking 6%

Retired 15%

Student 15%

Not Working 20%

ADL 15%

106
Sixty-five percent of all compensation patients were carrying on appropriate work activities as previously defined. However, 20 percent

were able to work physically, but have not been placed, and 15 percent

describe themselves as only maintaining self care activities. Again,

it must be remembered that these data are self reports and dependent

on patients and their perceptions for accuracy. An interesting note

in this regard is that there appears to be as great a relationship

between the patients' belief that they could manage their problems

and successful adaptation as between improved physical strength, mobility, and good adaptation.

Turning to non-compensation patients, 78 percent were employed, homemaking, or retired, while only one individual, or 5 percent, reported work had not been found in spite of ability and willingness

(Table 15). Seventeen percent reported only ADL capabilities.

Table 15

FOLLOW-UP

WORK ACTIVITY, NON-COMPENSATION PATIENTS

(N=18)

Working 28%

Homemaking 39%

Retired 11%

Student 0 %

Not Working 5 %

ADL 17%

Work activity for the problem patient showed 69 percent productively

occupied, with one patient reporting an inability to gain employment.

Twenty-seven percent described restrictions allowing only self care

(Table 16). Table 16

FOLLOW-UP

WORK ACTIVITY, PROBLEM PATIENTS

(N=22)

Working 27%

Homemaking 9 %

Retired 18%

Student 9 %

Not Working 4%

ADL 27%

107
Seventy-seven percent of non-problem patients reported employment

or activities consonant with their goals, while 23 percent reported a capacity and willingness to work, but difficulties in placement (Table 17). The issue of employment after treatment would appear to be a major one. Thoughtful, early and aggressive job planning and placement is a central component of treatment. The involvement of rehabilitation nurses or specialists is invaluable in

this regard, especially, if the patient is to return to work immediately after concluding the treatment program.

Table 17

FOLLOW-UP

WORK ACTIVITY, NON-PROBLEM PATIENTS

(N=30)

Working 30%

Homemaking 23%

Retired 10%

Student 4%

Not Working 23%

ADL 0%

This study, along with earlier ones only served to highlight the fact

that a more uniform method for assessing treatment effectiveness in

the most general, as well as specific, sense is required. A model

has been developed, in consultation with Dr. Howard Gitlow, Associate

Professor of Marketing Science at the University of Miami, that

addresses this issue, utilizing a number of effectiveness measures

and outcome measures to arrive at an effectiveness index. This model

will soon undergo a series of field trials to determine its utility

in our clinical setting. Given this index and patient data, it may

be possible to model management to determine if changes in treatment

strategies can be found which would optimize treatment effectiveness.

The issue of the patient and optimal treatment is a complicated one,

affected by both the nature of the problem and a myriad of concurrent

psychosocial issues. Final conclusions in this regard await more extensive, comparable studies of this population than have yet been implemented. It is toward the development of such studies that our attention now turns.

SUMMARY AND CONCLUSIONS

The Pain and Back Rehabilitation Program at the University of Miami

in the Department of Neurological Surgery has been described. An

overview of the patient population has been presented. Outcome

results have been analyzed for low back pain rehabilitation against

patient compliance, compensation status, and level of function and

108
work activity. The data show that 64 percent of patients who have

been rated as problem cases are receiving compensation benefits.

That percentage is not significantly different from that which

is seen in non-compensation cases. If the cost of the program is

gauged by time in treatment, the average patient is under treatment for 48 days; non-compensation cases stay in the program an

average of six days longer.

The problem patient takes longer to treat effectively, an average

of 55 days, but within this group, the time is shorter for compensation cases. Non-problem patients, on the average, are treated

in 43 days, 12 days less than for the problem cases. These 12

additional days are taken at the onset of the program, when problem

patients must become compliant and be stimulated toward motivation

to cooperate in treatment and progress toward the goal of occupation

at discharge.

Eighty-six percent of all patients return to full activity, 70 percent are fully occupied, and a further 16 percent would be occupied

and are physically capable of being employed, but cannot be placed

in work because of prejudice against their medical history of low

back disorder. Therefore, the total of 86 percent could be fully

active, provided all could be found positions consistent with their

discharge status. An analysis of compensation versus non-compensation cases indicates that 88 percent of compensation cases are fully

occupied following discharge, and 84 percent of non-compensation

cases are fully occupied. It is clear that there is no difference

between the two categories, from which it is concluded that compensation status does not bear upon final outcome of function.

Further analysis of the data indicates that there is a higher percentage of compensation patients then non-compensation patients who satisfactorily complete the rehabilitation program and are fit to work

but for whom placement cannot be found because of their past medical

history. This number is 20 percent for the compensation cases, whereas only 5 percent of non-compensation cases have difficulty in being

placed in employment. When problem or non-problem cases are considered, it is seen that 97 percent of non-problem cases are at full

activity, whereas only 73 percent of problem cases fulfull that designation. This difference is directly attributable to the noncompliant nature of the patient who is rated as a problem, so that

personality style and mental status are important issues in respect

to outcome. Early planning and aggressive pursuit of job planning

are integral to achieving high levels of full occupation, particularly when every attention is given to return to employment immediately following completion of the rehabilitation program.

Finally, formulae have been developed to provide indices of treatment effectiveness and cost effectiveness. These are to be tested

by field trials with the ultimate goal of providing measures to determine the influence of treatment modes on cost. It is recognized

that pain and back rehabilitation is costly and available only to a

privileged few relative to the numbers of patients that require

this form of treatment. Every effort is being made to reduce

cost and time under treatment as a means of increasing efficiency

economically, as well as increasing the numbers of patients who can

be managed per unit of time.

109
REFERENCES

Millon, T., Green, C., and Meagher, R. The MBHI: A new inventory

for the psycho-diagnostician in medical settings. Professional

Psychology, 10 (4): 529-539, 1979.

Rosomoff, H.L. Neurosurgical control of pain. Ann Rev Med 1969,

20: 189-200.

Rosomoff, H.L. Anatomy and techniques for the management of pain:

Percutaneous cordotomy. Proceedings Biennial Western Conference

on Anesthesia. In Pathological and Pharmacological Considerations

in Anesthesiology edited by V.L. Brechner, M.D. Springfield:

Charles C. Thomas: 1973, 16-28.

Rosomoff, H.L., with Bonica, J.J., Fordyce, W.E., R.W. Loesser,

J.D., and Talbott, J.H. Pain: Its definition, its effect, and

its mechanisms - Part I. Modern Medicine 42: 26-35, 1974.

Rosomoff, H.L., with Bonica, J.J., Fordyce, W.E., Houde, R.W.,

Loesser, J.D., and Talbott, J.H. Pain: Why the patient suffers:

Theories and concepts of pain mechanisms, Part 2: Modern

Medicine 42: 56-63, 1974.

Rosomoff, H. L., with Bonica, J.J., et al. Pain: Its definition

its effects and its mechanisms - Part 1. Modern Medicine 42: 26-

35, September 1974.

Rosomoff, H. L., with Bonica, J.J., et al. How to learn why the

patient hurts - Part 3. Modern Medicine 43: 68-73, January, 1975.

Rosomoff, H.L., with Bonica, J.J., et al. The pain clinic--New

Promise of relief for suffering patients - Part 4. Modem

Medicine 43: 52-59, March, 1975.

Rosomoff, H.L., with Bonica, J.J., et al. The risks and benefits

of cutting pain's pathways - Part 5. Modern Medicine 43: 74-87,

April, 1975.

Rosomoff, H.L., with Bonica, J.J., et al. Helping the patient

unlearn the habit of pain - Part 6. Modern Medicine 43: 58-72,

September, 1975.

Rosomoff, H.L., Green, C., and Silbret, M. The multi-disciplinary

team approach to the diagnosis and treatment of chronic low back

pain, in Radiographic Evaluation of the Spine - Current Advances

with Emphasis on Computer Tomography, J. Donovan (ed.) 1980.

Rosomoff, H.L., Sheptak, P., and Carroll, F. Modern pain reliefpercutaneous chordotomy, JAMA 196: 482-486, 1966.

Steele, R. The obscure link. Association of Rehabilitation Nurses

Journal 2: 3-6, March, 1977.

110
AUTHORS

Hubert Rosomoff, M.D., D. Med. SC. (physiology)

Department of Neurological Surgery (D4-6)

University of Miami School of Medicine

P. 0. Box 016960

Miami, Florida 33101

Catherine Green, Ph.D.

Marc Silbret, M.D.

Renee Steele, R.N., C.R.C.

111
Comparative Aspects of Chronic

Pain in the Head and Neck

Versus Trunk and Appendages:

Experiences of the

Multidisciplinary University of

North Carolina Pain Clinic

John M. Gregg, D.D.S., Ph.D., and Jawahar N. Ghia, M.D.

ABSTRACT

The interdisciplinary University of North Carolina Pain Clinic,

in existence since 1973, is a coordination center for research,

pre and postdoctoral and resident training, and clinical services.

It functions primarily as a tertiary care center for outpatients

as a component of the North Carolina Memorial Hospital. Inpatient

consultations and therapy direction are carried out on request.

Approximately 400 new patient visits and 1,200 consults and return visits are made yearly. The clinic is administered by codirectors from the Departments of Oral and Maxillofacial Surgery

and Anesthesiology. Consultants to the clinic include the disciplines of psychiatry, neurosurgery, family medicine, pathologyoral pathology, dentistry, physical therapy, social work and

nursing. Support staff includes a head nurse, half-time transcription and half-time general secretary and a financial technician. Facilities consist of an 8-room clinic dual equipped for

patient care and clinical research. An adjacent conference room

is used for research and patient presentation conferences. In

addition to routine examining and interview rooms, a minor procedure operating room is equipped with resuscitation equipment,

suction, oxygen, anesthesia machine, a physiologic monitoring

system with polygraph, a cryosurgical unit and a radiofrequency

lesion generator. A second room is equipped for neurosensory

studies of peripheral nerve functions including a battery of

tactile-mechanical and thermal threshold stimuli tests, as well

as nerve conduction and EMG. A system for psychophysical testing

is available through tie-in with a computer, which is located in

an adjacent laboratory used for data analysis and also subhuman

primate experiments. Another room is equipped with psychophysiologic training equipment, particularly EMG biofeedback. A computer terminal on line to the University IBM 360 is located in

the Pain Clinic for use in entering patient-research data. A

library with dictating space is available for use by consultants,

postdoctoral trainees, and residents.

112
PATIENT ENTRY

Patients are seen only after referral by a physician, dentist, or

other comparable health officer. Incoming referral requests are

surveyed by the clinic directors for acceptance and assignment

of cases to the most appropriate primary manager-consultant, who

will be the attending physician, seeking secondary consultations

and carrying out correspondence. Only patients with pain of more

than 1 month duration are considered for Pain Clinic screening.

Demographic, past medical history, subjective pain inventories,

baseline anxiety and depression inventories are gathered and assembled by the clinic nurse and secretary before the initial patient visit. A specialized pain survey questionnaire has been

developed and adapted for computer data collection. Included are

assessments of pain severity, drug use and abuse, patterns of

health services (emergency room visits, surgical operations), and

impairment of function (sleep, eating, walking, hygiene, social,

vocational). A psychological screening is generated for each

patient based entirely on questionnaires. Patients are selected

for further psychological testing and interview on the basis of

the screening and at the discretion of the patient's primary

manager. Selected patients are presented at Pain Clinic Conferences, a 90-minute weekly session during which all consultants,

residents, fellows and support staff are present for discussion

and treatment planning. An average of three new patients per

week are presented and discussed. They are selected primarily on

the basis of: 1) refractoriness of problem, 2) teaching value,

3) research value, 4) miscellaneous patient factors (potential

for rehabilitation, age, distance traveled, etc.). The diagnostic and treatment planning services of the clinic are viewed as

its most important role in patient care.

PATIENT SERVICES

Evaluative services offered in or coordinated by the Pain Clinic

include: 1) Neurosensory and psychophysical examination, 2)

psychosocial adjustment evaluation, 3) peripheral vascular study,

4) differential nerve and spinal block, 5) multidisciplinary panel

review. Pharmacologic services include: 1) detoxification coordination, 2) psychotropic therapy coordination. Physiologic services include: 1) transcutaneous neural stimulation, 2) stretch

and spray physiotherapy, 3) and ultrasound. Surgical treatments

include: 1) myofascial and neural anesthetic blocks. 2) radiofrequency neurolysis, 3) cryosurgical neurolysis. Behavioral

services include: 1) relaxation therapy, 2) biofeedback (EMG and

temperature), 3) counseling (psychological, family-marital, vocational), 4) group therapy, 5) operant conditioning.

REFERRAL SOURCES AND PREVIOUS TREATMENTS

Sources of patient referrals include: 1) family physicians, 32%,

2) family dentists, 29%, 3) North Carolina Memorial Hospital or

School of Dentistry physicians and dentists, 13%, 4) private

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specialists and other clinicians (physical therapists, nurse

practitioners), 26%.

Previous treatments received by patients prior to presenting at

the pain clinic, in order of decreasing frequency, are seen in

Table 1.

Table 1

MOST COMMON PREVIOUS PAIN TREATMENTS

Head & Neck Pain Non Head & Neck Pain

1. Dental manipulations (extraction, 1. Minor tranquilizers

pulpectomy, occlusal adjustment,

splint or prosthesis construction)

2. Minor tranquilizers 2. Narcotics

3 . Narcotics 3. Laminectomy

4. Neurectomy or alcohol block 4. Braces

5 . Anticonvulsants 5. Nerve or muscle block

6. Temporomandibular joint surgery 6 . Antidepressants

7. Intracranial neurolysis or 7. Chiropracty

rhizotomy

8 . Chiropracty 8. Tractotomy

The patients presenting to the U.N.C. Pain Clinic have the

following demographic Profile.

Table 2

PATIENT DEMOGRAPHY: U.N.C. PAIN CLINIC

(N=225)

Head & Neck Pain

In State:Out State 90:10

25 mile radius 18%

Family income 17,500

Male:Female 24:76

Age Male 48 (14-87)

Age Female 40 (12-89)

Inpatient:Outpatient 6:94

Black:White 16:77

Other Race 7%

Pain duration 21+2.5 mos.

Pain-related operations 1.7+.9

Major operations, non 1+2.1

pain related

Non Head & Neck Pain

95:5

15%

16,500

45:55

43 (20-75)

47 (21-80)

15:85

8:91

1%

34+3.6 mos.

2.5+1-1

1+2.2

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The most striking demographic data were: 1) the rather high levels

of family income, perhaps a reflection of the referral basis of

clinic entry, 2) the preponderance of younger females presenting

with head and neck pain, 3) the low percentage of black patients

in proportion to the community population (approximately 30%

black), 4) the similarity of pain durations and numbers of previous operations.

PRIMARY ADMITTING COMPLAINTS AND PAIN CLINIC DIAGNOSES

Primary pain complaints according to body region are: 1) head,

face and neck 53%, 2) back and lower extremities, 23%, 3) chest

8%, 4) abdomen, 6%, 5) upper extremities, 5%, 6) inguinal 3%,

7) flank 1%, 8) pelvic 1%.

The admitting diagnoses, submitted by referring physicians were

as follows:

Table 3

UNC PAIN CLINIC ADMITTING DIAGNOSES (N=232)

Head & Neck Pain

Temporomandibular joint

arthritis

Myofascial pain

Migraine

Tic douloureux

Psychogenic pain

Atypical neuralgia

Post-herpetic neuralgia

Cancer pain

Post-Traumatic neuralgia

35%

15% Post Traumatic 23%

12% Post Laminectomy 19%

6 % Mechanical 9 %

7% Musculoskeletal/Psychological 6 %

6 % Acute disc prolapse 6 %

2 % Others 6 %

6 % Phantom limb 4 %

11% R.S.D. 4 %

Low Back and Extremity Pain

Degenerative Disease 23%

Upper Extremity Pain Chest Pain

Reflex sympathetic dystrophy 36% Intercostal neuralgia 47%

Rheumatoid arthritis & osteo- (post infectious, traumatic

arthritis 22% degenerative joint disease)

Post mastectomy syndrome 14% Cancer pain 30%

Post infectious neuritis 14% Costochrondritis-myofascial 10%

Post incisional pain 7% Post mastectomy syndrome 7 %

Post CVA pain 7% Esophagitis, cardiac origin 6%

Abdominal

Pancreatitis 33%

Unknown 21%

Post incisional 17%

Cancer pain 13%

Renal 8 %

Psychological 8 %

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UNC MULTIDISCIPLINARY PAIN CLINIC DIAGNOSES (N=232)

Head and Neck Pain

Myofascial pain dysfunction

Post-traumatic neuralgia

Table 4

Low Back and Extremity Pain

39% Psychological and compen- 61%

sation neuroses

11% Degenerative disease and 11%

face joint involvement

Atypical neuralgia (occipital 24% Arachnoiditis, peridural 10%

neuralgia and periodic maxillary adhesion or scarring

migrainous neuralgia)

Migraine 4% Myofascial pain dysfunction 6%

syndrome

Tic douloureux 5% Post-traumatic neuropathy 4%

Post-herpetic neuralgia 2% Herniated disc 4%

Psychogenic pain 6% Phantom limb 4 %

Temporomandibular joint arthralgia 3 %

Rheumatoid or degenerative

arthritis 6 %

Upper Extremity Pain

Post-traumatic conversion dystrophy 29%

Rheumatoid arthritis and osteoarthritis 22%

Post-mastectomy syndrome 14%

Post-infectious syndrome 14%

Post-incisional pain 7 %

Post CVA pain 7 %

Reflex sympathetic dystrophy 7 %

*Note: The majority of patients were found to have more than one

source or basis for pain. Data are presented for the primary

problem.

PATTERNS OF DRUG USE

Questionnaire analysis of drug use at the time of Pain Clinic admitting revealed that 32% were currently using 5 or more different

drugs, 44% were using 1 to 4 different drugs and 24% were using no

drugs. The average number of prescription and non prescription

drugs used in the previous two years is 12.6. The drugs most commonly used, in decreasing order, were as follows.

116
Table 5

MOST COMMONLY USED DRUGS AMONG CHRONIC PAIN PATIENTS, RANK

1) Codeine or synthetic Codeine (most often in combination

with acetaminophen)

2) Benzodiazepam (most often diazepam)

3) Meperidine (most often intramuscularly on emergency room

basis)

4 ) Propoxyphene

5) Meprobamate

6 ) Amitriptyline

7 ) Ibuprofen

8 ) Cafergot

9) Carbamazepine

10) Diphenylhydantoin

11) Nembutal

12) Chlorpromazine

13) Pentazocine

14) Qualude

15) Phenelzine

In response to the question "DO you think you used too much of a

drug of any kind during the last year because of pain," 87 percent of patients felt that they had used "too much" of some drug.

The most commonly abused drugs, in the opinion of the patients

were: 1) narcotics, 2) propoxyphene, 3) alcohol, 4) diazepam,

5) tobacco.

Patterns of drug abuse observed among this patient population

included multiple use of drugs from the same pharmacologic class,

procurement of drugs from multiple sources, and mixing of both

CNS depressant and stimulant agents. A ranking by Pain Clinic

consultants of drugs most abused by the U.N.C. chronic pain population revealed: 1) oxycodone, 2) meperidine, 3) benzodiazepam,

4) propoxyphene, 5) meprobamate, 6) alcohol, 7) tobacco, 8) coffee.

AUTHORS

John M. Gregg, D.D.S., Ph.D.

Jawahar N. Ghia, M.D.

UNC Pain Clinic

Dental Research Center

University of North Carolina

Chapel Hill, North Carolina 27514

117

348-347 0 - 81 - 9
Treatment of Osteoarthritis of the

Spine and Herpetic Neuralgia at

the Pain Center, Mount Sinai

Medical Center

Frank Moya, M.D.

ABSRACT

This presentation will briefly describe the operation of this

Pain Center and discuss the two chronic pain problems most

commonly seen in our geriatric population: osteoarthritis of

the spine and herpetic neuralgia.

Osteoarthritis of the spine is the most common radiologic finding in middle-aged and older people with low back pain. 32%

of our patients have this diagnosis as the basis of their chronic pain. The typical patient is 72 years old and has a past

pain history which includes several years of back pain treated

by various physicians with anti-inflammatory agents and analgesics to no avail. Past history of surgery and drug abuse is

rare; however, depression is common. Therapy at the Pain Center is primarily the use of an exercise program and epidural

and/or subarachnoid steroids. At the last visit, approximately

70% of the patients have had significant improvement.

Herpetic neuralgia is found in 13% of all patients seen at the

Mount Sinai Medical Center Pain Center. Our typical patient is

73 years old and has had PHN for 10 months unrelieved by various

topical and oral medications. Although rarely is there a history of drug abuse or surgery, extreme depression is common. If

the duration of the neuralgia is less than one year, 85% of

patients get significant or complete relief from the use of

sympathetic nerve blocks and/or the subcutaneous infiltration

of steroids and local anesthetic. Once the PHN has been present

for more than one year, only 55% of the patients are improved.

INTRODUCTION

The Pain Center of the Mount Sinai Medical Center on Miami Beach

was organized eight years ago as a private practice outpatient

facility. In 1979, almost 3000 consultations and procedures

were performed in order to assist in the diagnosis and treatment

of chronic pain problems. The patients primarily came from

throughout the Eastern half of the United States and Canada, and

118
all modern modalities of pain relief were used in their management. This presentation will briefly describe the operation

of this Pain Center and discuss the two chronic pain problems

most commonly seen in our geriatric population: osteoarthritis

of the spine and herpetic neuralgia.

THE PAIN CENTER

Functionally, the Pain Center is an integral part of the

Department of Anesthesiology. Geographically, it is located

in the office area of the Department at the Mount Sinai Medical

Center. Over the years, as the Pain Center has grown, it has

cannibalized most of the Department's office space. Fortunately, this does have the advantage of permitting the operation

of the Pain Center and the administration of the Department of

Anesthesiology at virtually the same time and space--a highly

efficient working relationship.

The Center is operated by a Medical Director assisted by two

full-time physicians (including a resident in Anesthesiology).

These physicians are in turn aided by a team of six assistants

which includes two secretaries and a registered nurse, medical

assistant, psychosocial worker, and hypnotherapist. In addition,

consultative personnel are immediately available from all

medical disciplines including physiotherapy.

Starting in 1972 with only a few patients a week, the Center

has grown to one of the largest private practice outpatient

facilities in the United States. In 1979, there were almost

3000 patient visits. The patients primarily came from throughout the Eastern half of the United States and from as far away

as Europe and South America.

The most common problems seen are chronic back pain (38%), herpetic neuralgia (13%), skeletal/myofascial pain (13%), headaches (9%) and cancer pain (5%). The chronic pain syndromes

found most amenable to therapy are back pain, herpetic neuralgia,

headaches, pancreatic cancer and causalgia. On the other hand,

the problems We found least amenable to therapy are thalamic

pain syndrome, peripheral neuritis and phantom limb pain.

The most common therapeutic modalities used in Pain Center are

trigger point blocks (20%), epidural or spinal steroids (18%),

medical hypnosis (17%), herpetic neuralgia blocks (9%), acupuncture (9%), transcutaneous neural stimulation (6%) and

psychosocial counseling, which is used in virtually all patients.

DEGENERATIVE HYPERTROPHIC SPONDYLITIS

Degenerative hypertrophic spondylitis (osteoarthritis of spine)

consists of a degeneration of the intervertebral disc associated

with reactive change in the vertebral body. It is the most

common radiologic finding in middle-aged and older people with

119
low back pain. 32% of our patients have this diagnosis as the

basis of their chronic pain. The typical patient is 72 years

old and has a past pain history which includes several years of

back pain treated by various physicians with anti-inflammatory

agents and analgesics to no avail. Past history of surgery and

drug abuse is rare (3%); however, depression is common (43%).

The therapeutic regimen at the Pain Center includes the following:

1. Medication. Psychotropic drugs are routinely used in an

effort to cope with the depression which is so commonly present.

In addition, analgesics are prescribed whenever necessary and

anti-inflammatory agents on occasion.

2. Exercise therapy including the occasional use of physiotherapy

and heat is an important part of our program. The Kraus-Weber

muscle tests are used to determine which specific Kraus exercises

should be prescribed. All of these patients are given a specific

exercise program.

3. Psychosocial counseling is used routinely in virtually all

patients.

4. Steroids, administered in the epidural or subarachnoid space

or into trigger points, are another important part of our therapeutic game plan. The steroids are usually injected along with

a long-lasting local anesthetic such as bupivacaine (Marcaine).

5. Medical hypnosis and transcutaneous neural stimulation are

also used in selected cases.

The average patient requires a total of 4 visits including the

initial consultation. The total cost for these visits and

therapy amounts to approximately $500 and the patient usually

pays this directly (to be later reimbursed by third party

carriers).

Therapeutic results. At the last visit, 70% of patients showed

improvement ranging from definite improvement to complete relief.

Followup calls placed up to 2 years later, found 58% of this

improved group of patients still showed definite or better

improvement.

HERPETIC NEURALGIA

Herpetic neuralgia is found in two forms, namely, acute herpes

zoster and post-herpetic neuralgia (PHN). 13% of all patients

seen at the Mount Sinai Medical Center Pain Center have this

condition. Our typical patient is 73 years old and has had PHN

for 10 months unrelieved by various topical and oral medications.

Although rarely is there a history of drug abuse or surgery (1%),

extreme depression is common (54%).

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The therapeutic regimen consists of the following:

1. Sympathetic nerve blocks. If the duration of pain is less

than 6 months, sympathetic nerve blocks are used.

2. A series of subcutaneous infiltrations of a steroid

(triamcinolone) combined with a long-acting local anesthetic

(bupivacaine) are used if the duration is greater than 6 months

or if the sympathetic blocks failed to produce relief.

3. Anti-depressants (e.g., Elavil) and/or tranquilizers (e.g.,

prolixin) are often useful in difficult cases.

4. Analgesics are used as necessary. However, sometimes even

the most potent narcotics are of little help to some of these

patients.

5. Finally, psychosocial counseling is used routinely in most

patients.

For refractory cases that have failed to respond to the above

measures any or all of the following are used: epidural steroids,

anti-viral agents, T..N.S., dimethyl sulfoxide (DMSO), medical

hypnosis and even, as a last resort, surgery/neurosurgery.

The average patient requires a total of 5 visits including

the initial consultation at a total cost of approximately $500.

Most patients pay this sum themselves and are later reimbursed.

Therapeutic results. At the last visit 70% of all patients

showed significant improvement (definite to complete relief).

Following calls up to 2 years later found 70% of this improved

group still showed significant improvement.

It is important to note that there is a close relationship

between the duration of the neuralgia and therapeutic efficacy.

If the duration of the neuralgia is less than one year, 85% of

patients get significant or complete relief from the use of

sympathetic nerve blocks and/or the subcutaneous infiltration

of steroids and local anesthetic. Once the PHN has been

present for more than one year, only 55% of the patients are

improved. If the duration is less than one month, approximately

90% of patients experience significant relief.

Frank Moya, M.D.

Chairman

Department of Anesthesiology and

Director, The Pain Center

Mount Sinai Medical Center

Miami Beach, Florida 33140

121
Profiles of Pain Patients,

Including Chronic Pelvic Pain:

University of Washington

Clinical Pain Service

Terence M. Murphy, M.D.

The University of Washington Pain Clinic has been in existence for

two decades and has evolved during that period of time. Initially

established by Bonica and White, espousing the concepts of multidisciplinary evaluation, it provided a comprehensive service to a

limited number of patients by a multidisciplinary group operating

on a part-time basis. Over the years, it has developed into a

full-time Pain Clinic including daily evaluation of newly referred

patients (500 a year), plus ongoing maintenance therapy on established patients (2,000 patient visits per year). There is also an

inpatient service which has recently increased to a six-bed facility.

Here the most complex patients are admitted for diagnostic

evaluation and a proportion of these are maintained as inpatients

for the formal Behavioral Modification Programs (Fordyce 1973).

The basic functioning of the clinic is as shown in diagram 1.

Patients are seen only by referral and the referring data is evaluated prior to offering an appointment. The facilities to deal with

patients have expanded in recent years and this, associated with

the increase in alternative pain treatment facilities, has resulted

in an ability to be much more responsive to such referrals. Whereas

in the initial years approximately 10 percent of patient referrals

were seen and 90 percent rejected, the reverse is true at the

moment, because the ability to see patients has expanded as the

referral load in absolute numbers has decreased.

Prior to arrival, patients have been instructed to collect comprehensive past records of medical history and treatments. They have

also completed a two-week diary, evaluation of which forms an integral part of their assessment. They are initially seen and screened

by the "managing" physician and the clinical psychologist, and an

MMPI is completed; and in those patients in whom it is indicated,

a social service evaluation is obtained. With this information in

hand, a "conference" is held between the clinicians involved and

diagnostic impressions and therapeutic suggestions are made. These

are conveyed to the patient and copies returned to the referring

122

physician and the following decisions are usually made.

At this stage, it is sometimes feasible to recommend the patient

to a specific treatment schedule, as outlined in diagram 1. This

specific therapy may include medication adjustments, transcutaneous stimulation, physical therapy, formal operant conditioning,

or some combination of the various modalities used for controling chronic pain. If, however, at the end of the initial screening evaluation, diagnosis is still obscure and therefore treatment plans cannot be confidently recommended, further evaluation

takes place. This is illustrated in the left-hand side of diagram 1. Further opinions are sought, usually from orthopedic,

neurosurgical, or psychiatric colleagues. Regular referral is

also made to other specialists (oral/general surgery, otolaryngology, etc.). When this additional information is in hand,

usually at a later date, the patient is "reconferenced" and

recommendations are made regarding treatment strategies.

PATIENT POPULATION AT THE UNIVERSITY OF WASHINGTON PAIN CLINIC

Demographic clinical and psychological data were collected on 264

patients seen consecutively at the University of Washington Pain

Clinic by completing a series of questionnaires. These included

Illness Behavior Questionnaire (Pilowsky 1975), Depression Scale

(Zung), and Scale of Life Events (Holmes). Demogaphic data (sex,

age, marital status, occupation) and clinical data (pain characteristics, diagnosis, etc.) were collected from the patient's

chart.

The findings were as follows:

Demographic Data

Females (60 percent) outnumbered males (40 percent). Two-thirds of

the patients fell between the ages of 30 and 60 years, yielding an

average age of the total sample of 45 years, and the females tended

to be slightly older than the males. Most of the patients (70

percent) were married at the time of their Pain Clinic evaluation;

and of the remaining 30 percent, half were divorced and half single.

Half of the sample had been in paid employment, a quarter had been

housewives, and the remaining 25 percent comprised a mix of retired,

14 percent; unemployed, 5 percent; disabled, 5 percent; and students,

3 percent.

Clinical Characteristics

Back pain (and leg pain) and headache together accounted for twothirds of the patient referrals.

There was no laterality predominance of pain. It occurred with

equal frequency on both sides (Hall 1975). Eighty-six percent of

the diagnoses were descriptive, indicating the anatomical site of

the pain--for example, low back pain, headache, shoulder pain, etc.

only 14 percent of the referral load had a specific pathological

124
diagnosis evident such as carcinoma, arthritis, etc.

History of Pain

The mean duration of pain was four and one-half years, but there

was a wide distribution in the sample from a low of several months

to pain of duration of 50 or more years.

In 42 percent of the referred patients, the onset of pain was

related to some physical injury, usually work related. 24 percent

of the patients related their pain onset to some illness or surgical procedure or specific life crisis such as bereavement or divorce. There were 33 percent of the patients in whom no precipitating event could be identified for the pain complaint. 40 percent

of the sample had undergone one or more pain-related procedures,

although the average number of surgeries undertaken was higher than

this (2.4).

Not surprisingly, the commonest pain-related surgeries were

laminectomy and fusion procedures for low back pain, and laparotomy and cholecystectomy for abdominal pain, and various dental

or oral surgical maneuvers for atypical face pain.

Medications

90 percent of the patients referred were using one or more medications. Two-thirds were using two drugs and one-third were using

three drugs. Aspirin, proprietary compounds, and narcotics were

the most commonly used classes of medication, and sedative hypnotics

and antidepressants were frequently found. The data on this appear

below.

DRUGS USED

Diazepam (Valium) 15%

Codeine with acetaminophen (Tylenol) 14%

Oxycodone (Percodan) 13%

Codeine with aspirin 11%

Meperidine (Demerol) 5%

Antidepressants

Doxepin 22%

Amitriptyline 14%

It should be noted that the above medications are in patients

preselected to be evaluated as outpatients. Patients with suspected major medication dependencies are usually admitted straight

to the inpatient unit and would not be included in this group.

Psychological Data

The Illness Behavior Questionnaire testifies to significant disease

conviction, affective disturbances, and denial of life's problems.

These patients are convinced that they have some as yet undetected

125
disease process, and they have a significant denial of life

problems and the relationship of these to their suffering. With

regard to the Zung Depression Inventory, these patients are more

depressed than normal samples but not as clinically depressed as

depressive patients seen in psychiatry clinics. On this test,

normal patients have a mean score of 33 while the Pain Servie

outpatient population has a mean score of 54. Depressed psychiatric

patients score in the 64 to 74 range. This characteristic has previously been described in a similar survey on patients in this

clinic by Pilowsky (1977). On the schedule of recent life events,

there was significant difference between sexes, with males experiencing greater life changes than females.

The MMPI evaluation showed no difference between the sexes, and the

well known conversion V phenomena of the depressed, tense, perplexed, and anxious individual was noted as has teen commented on

previously by Fordyce (1973), Sternback (1973), and Cox (1978).

In summary, the typical patient at the University of Washington Clinical Pain Service is likely to be female, age 40 to 50, with a 4-year

history of back pain or headache which has proved resistant to

conventional therapies. Intensive investigations of these patients

have failed to disclose a specific pathological diagnosis. They

have usually undergone more than one pain-related surgery. Thirty

percent of them take dependency-producing medications in significant amounts. They manifest considerable psychopathology, classified by mild to moderate depression, somatic preoccupation, illness

conviction, and denial (failure to recognize what is often a significant pathological milieu as a generator of their symptomatology).

The question still needs to be answered as to whether the characteristics noted above are a cause or a result of the patient's

chronic pain complaint.

It is speculated that these patients are typical of patients currently seen in Multidisciplinary Pain Clinics (Newman 1978). However, we cannot say how typical these characteristics are of people

with pain problems who are not referred to Pain Clinics. It is

likely that there is a selective referral to such clinics of the

more difficult-to-manage patients. In a study undertaken comparing

this Pain Clinic population with patients seen in a non-multidisciplinary private practice pain setting, these latter patients

showed significantly less of the above-mentioned characteristics

(Chapman 1979).

CHRONIC PELVIC PAIN

Dr. Guzinski, a gynecologist working in our clinic, has pursued a

special interest in chronic pelvic pain. The data below represents

the summary of her work on the first 100 patients.

None of these patients with debilitating pelvic pain was deemed

to have any correctable pelvic pathology. Yet 95 percent of them

126
demonstrated significant pathology on psychological evaluation,

only 5 percent of them being deemed "normal." Basically they fell

into four equally distributed psychological types. Thirty percent

were clinically depressed, as was brought out by documentation on

the MMPI and Zung Tests. Twenty percent were deemed to have

character disorders, and 20 percent were borderline syndromes. All

three subgroups had a surprisingly constant mean age of 23 to 24

years. The fourth main category were the Briquet's Syndromes

(hysterics). Twenty-five percent of the patients fell into this

group, and here there was a much wider age spread, from 19 to 60

years.

A significant aspect of the history was that of sexual abuse.

Sixty-five percent of these patients with chronic pelvic pain gave

a history of incest, rape, or sexual molestation. Forty percent

of them had been subjected to an incestuous relationship, usually

with stepfathers or brothers (not usually the natural father).

The highest incidence of incest reported in other series is 25 percent, so this group appears to have a higher than usual incidence

of this problem.

Lessons learned from patients with chronic pelvic pain are similar

to those shared by most centers dealing with chronic pain, namely

that a psychological evaluation must be presented as part of the

initial endeavor. It is usually refused if introduced at a later

stage when "organic pathology" has been ruled out. Because most

of the patients have been referred in a crisis state, it is usually

easier to obtain this sort of information when the patient is first

seen. With regard to functional evaluation of these patients,

they appear to be more active than patients with other chronic pelvic pathological states such as dyspareunia, chronic vaginitis,

etc.

So far this group has been treated with regular follow-ups. Antidepressants have been prescribed for those patients deemed to be

depressed. Biofeedback is being used with levator muscle retraining, mainly in the hysterical group, and ongoing supportive care

for the borderline and character disorders. Conventional gynecological treatment such as hormone replacement, antipruritics, etc.,

is used in conjunction with the above therapy.

Operant Conditioning

Behavioral modification as a therapeutic effort for chronic pain

patients has been a major component of the treatment options in the

University of Washington Pain Clinic for the last decade. Dr.

Fordyce and his colleagues in Rehabilitation have pioneered this

particular form of therapy (Fordyce 1973).

Some variation on this theme is frequently an integral part of

many Pain Center approaches and has proven to be effective in

reducing medication and health care utilization, in reducing the

interference of pain-limited activities, and in increasing exercise

performance and general activity. These observations have

127
been borne out by the findings in other clinics.

The initial enigma noted by Beecher (1959) that there is no simple

relationship between stimulus and response has been well borne out

in observations of the chronic pain patient. A recent study

pursued at the University of Washington Pain Clinic (Fordyce 1980)

has attempted to correlate observed pain complaints with the amount

of prescribed exercise performed by chronic pain patients when

exercising to tolerance during their evaluation or early treatment

phases in the clinic. In this situation, patients were instructed

to repeat specific exercises until pain, weakness, or fatigue cause

them to cease; and observations of the amount of exercise performed

were correlated with the observed visible or audible indications

of pain or suffering. The results of this indicate a consistent

negative relationship, i.e., the more exercise performed, the

fewer the pain behaviors.

Patient Selection for Lumbar Discectomy

Dr. Spengler and Freeman (1979) have presented a method for Selecting patients with low back pain and sciatica for lumbar discectomy

based on specific objective criteria. The four categories are

neurological signs, sciatic tension signs, personality factors

(MMPI scores), and lumbar myelography. Operative findings of 50

consecutive cases selected using this method reveal complete

nucleus pulposis herniation in 43 cases. This is in contrast to

a series of 26 patients undergoing lumbar discectanies before the

method was introduced in whom only 5 showed evidence of complete

herniation. This has reduced the number of negative disc explorations and improved early surgical results.

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Pain, 106:1, 1979.

Cox, G.B., Chapman, C.R. and Black, R.G. The MMPI and chronic

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Newman, R.I., Seres, J.L., Yospe, L.P. et al. Multidisciplinary

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Sternbach, R.A., Wolf, S.R., Murphy, R.W. and Akeson, W.M.

Traits of pain patients: The low-back "loser." Psychosom 14:226-

229, 1973.

AUTHOR

Terence M. Murphy, M.D.

Clinical Pain Service

University of Washington, RN-10

Seattle, Washington 98195

129
A Headache Clinic’s Experience:

Diamond Headache Clinic, Ltd.

Jose L. Medina, M.D., and Seymour Diamond, M.D.

INTRODUCTION

This paper discusses our experience in observing and treating headache

patients at the Diamond Headache Clinic. Our patient population

includes about 2,000 initial visits and 14,000 followup visits per year.

Headache is a great social burden. Between June 1980 and September

1980, we have studied the social importance of headache in 200

consecutive new patients who were employed. Of these new patients,

76 were male and 114 were female. Their ages ranged from 18 to

63 (average: 36). These patients answered a survey which questioned

any work-related disability caused by the headaches during the past

12 months, the number of medications taken for the headaches, the

number of physicians consulted, any hospitalizations, and marital problems possibly caused by the headaches. The patients were also asked

to comment on the possibility that they were risking their jobs because

of the headaches. Three percent of the patients did not work during

the entire year because of disabling headaches. Sixty-three percent

missed 1 to 150 working days (average: 18.1 days) during the past year.

Since the onset of the headaches, they had taken 0 to 12 various

medications (average: 3.5) and had consulted 0 to 12 physicians (average:

2.9). Twenty-seven percent of the patients had been hospitalized 1

to 10 times (average: 2 times) for 1 to 14 days (average: 5.5 days).

One percent of the patients had lost jobs due to the headaches, and

21 percent felt they may be risking their jobs because of absenteeism

due to the headaches. Only two percent of the divorced patients stated

that their headaches were a contributing factor. We have observed

a very selective headache population, but it illustrates the seriousness

of this problem.

In addition to the social significance, the chronic headache sufferer

is a potential drug abuser.1 Between March 1, 1975 and January 31,

1976, we questioned all new patients about their drug intake. The

patients included in the study were using narcotics or a combination

of analgesics and barbiturates and fulfilled the following criteria:

(a) the medication was prescribed by a physician; (b) the drug had

been used for over 6 months; and (c) the drug was taken at least 4

days per week.

130
A psychological dependency was considered if the patient’s desire to

continue the drug was due to one or more of the following:

(a) euphoria; (b) reduction of nervousness, tension or anxiety, or (c) experiencing feelings of increased physical or mental capacities. Only

those patients with withdrawal symptoms were considered to have a

physical dependency on the medications. Patients were classified as

abusers if no symptoms of psychologic or physical dependence were

present, but the daily intake of medication exceeded by 50 percent or

more the maximum recommended dose.

Of 2,369 new patients, 62 patients fulfilled the criteria for inclusion in

this study. Thirty-eight patients were using a combination of

butalbital, aspirin, phenacetin and caffeine (Fiorinal); 17, codeine; 6,

propoxyphene (Darvon); and 1, meperidine. Of ten patients (26 percent)

treated with Fiorinal, two were considered abusers, two psychologically

dependent, and six physically dependent. Two patients were considered

abusers of codeine and one of propoxyphene. The patient on meperidine

did not answer the questionnaire.

In light of the previous discussion, it is apparent that the treatment of

headache should not be undertaken lightly. Our first concern is to

obtain a very careful headache history.2 Initially, we ask the patient if

he has more than one type of headache. Quite often the patient can

differentiate two different types of headache, a daily, continuous ache

and an intermittent, throbbing headache. The characteristics of each

headache should be specified: location, frequency, severity, duration,

associated symptoms, and aura. It is vital to elicit the sleep pattern.

The patient with daily headache almost invariably has a sleep disturbance.

This may include difficulty falling asleep, or frequent or early awakening.

A positive family history is relevant in migraine, as well as the relationship

of the headache to the menstrual cycle. Medical and surgical history

and a list of previous tests performed should be recorded. The history

should also include allergies and cite the possibilities of food, alcohol or

medications as provocative factors in headache. A complete physical

and neurological examination is mandatory. Laboratory data should

include routine blood tests, skull X-ray and electroencephalogram.

It is advisable for the patients to record all their headaches in a calendar.

They should indicate the severity of the headaches, the medications

used, and the time of relief. A significant number of patients return

to the clinic with a calendar which records, instead of the two or three

headaches per month noted on the initial visit, a list of daily headaches.

This factor would greatly alter the initial diagnosis.

Headaches can be simply classified as migraine, muscle contraction

headache, and traction headache. The most common type seen by a

headache specialist is a combination of migraine and muscle contraction

headache. Ninety-five percent of the patients who come to our headache

clinic are suffering from migraine, muscle contraction headache, or a

combination of both.

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MIGRAINE

Migraine occurs more often in women than in men and is a disease of

young people. The age of onset ranges from 5 to 30 years. A family

history of migraine is found in 65 percent of migraineurs.

Although genetic traits play a strong role in migraine, the type of

inheritance is not well known. Migraine can be classified as common,

classical and cluster migraines. Their relative frequency of occurrence is

as follows: common, 84 percent; classical, 11 percent; and cluster, 5

percent. Presently, migraine is considered to be an abnormal reaction

to a number of factors.

A study3 indicated the relative significance of various factors in migraine:

anxiety and tension preceded about 70 percent of the attacks; relaxation,

45 percent; sleeplessness, 45 percent; menstruation, 39 percent; and

dietary factors, 30 percent. Migraine may be precipitated by drugs

such as reserpine, nitroglycerin, or contraceptive pills. The latter is a

recent major factor increasing the severity, frequency, and complications

of migraine. Migrainous women should be advised to avoid any contraceptive

pill.

Previously, migraine was felt to disappear during the menopause, but

doctors are employing estrogens to combat hot flashes, and this factor

accounts for the high number of migraine headaches during menopause.4

Another drug, ergotamine, may also induce migraine. Patients will

often use ergotamines on a daily basis for migraine headaches, usually 3

or 4 pills per day. Initially these pills are effective, but then they no

longer offer relief, the patients continue to increase their intake of

ergotamine. A vicious circle is created, since the medication causes an

increase in the pain. The only solution is discontinuance of the drug.

Role of Diet in Migraine

There is not a consensus about the role of diet in migraine. The

controversy led us to conduct a study on this aspect.5

During a six-week period, the patients maintained a diet on foods that

contained high amounts of tyramine and avoided items with insignificant

amounts of vasoactive substances. They then switched to the opposite

diet for another six-week period; that is, avoiding food containing tyramine,

and consuming foods with little or no vasoactive substances. They were

instructed to maintain a calendar in this manner: the time of onset of

the headache; severity; duration; type of food consumed, and the time

of its consumption. We studied the relationship of the headaches to a

particular food intake. On a scale of 10 points, alcoholic drinks rated

highest as a provocative factor with a potency of 10 points. Other

factors were: chocolate, 7; fasting, 5; citrus juices, 5; and dried fruits,

4.5.

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Pharmacological Treatment of Migraine

Our approach to the pharmacological treatment of migraine is the

prevention of the headache.6 If migraine occurs as frequently as

once per week, a prophylactic treatment is recommended. The choice

of medications includes propranolol, methysergide, cyproheptadine,

ergotamine, clonidine and antidepressants. We often use propranolol

since it has been found to be the most effective drug in the prevention

of migraine, with significant headache relief in about 68 percent of the

patients. Dosage starts at 20 mg, 4 times per day and if needed, is

increased to 40 mg, 4 times per day. Methysergide relieves migraine in

about 64 percent of migraineurs but has more side effects than propranolol.

The preferred methysergide dosage is usually 2 mg, 3 times per day.

Ergotamine tartrate is used as a prophylactic agent in menopausal

migraine. Since these women are usually receiving estrogen, we discontinue

the hormone and prescribe a combination of small amounts of ergotamine

and barbiturate (Bellergal). Cyproheptadine is very effective in migrainous

children, but it does not usually work in adults. Clonidine may be

effective, especially in dietary migraine. Tricyclic antidepressants are

particularly useful in those patients with a combination of migraine and

muscle contraction headache. Phenelzine (Nardil) has been used efficaciously,

as a “last resort” in treatment of intractable migraine, with good results.

Unfortunately, a high percentage of patients can not tolerate this medication.

Many patients suffer only an occasional migraine headache. They will

require only symptomatic treatment. In mild headaches, aspirin or

acetaminophen are the analgesics of choice. Both drugs are taken at a

dosage of 600 mg a few times per day, as needed. If a patient’s headache

is moderate or severe, ergotamine tartrate is prescribed at 2 mg orally

at the onset of the headache, may repeat 1 mg in 1/2 hour, if needed.

If ergotamine does not relieve the headache within 1 hour, it will not

be effective. Its effectiveness depends on the speed at which the drug

is absorbed in the blood. Oral administration relieves pain in 50 percent

of the headaches, and intramuscular or subcutaneous injection, 85 percent.

In some patients, the acute headache is continuous for days despite

ergotamine therapy. This is called “migrainous status.” It is most effectively

treated by avoiding ergot preparations, as they will exacerbate nausea

and vomiting, and by prescribing both a common analgesic with codeine

and steroids for about two days.

CLUSTER HEADACHE

A particularly resistant variety of migraine is cluster headache. This

type of headache usually occurs in males, is severe, unilateral, orbital,

and periorbital in nature, with all attacks occurring on the same side.

It has a duration of 10 minutes to three hours and a frequency of one

to several attacks per day. The headache is accompanied by associated

symptoms: conjunctival injection, lacrimation, nasal congestion, rhinorrhea,

and Horner’s syndrome. Characteristically, the headaches occur in

groups of several attacks daily over periods of two to eight weeks,

these periods of attacks developing one to four times yearly. The

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348-347 0 - 81 - 10
most effective therapy for this headache consists of a combination of

methysergide and steroids. Recently we have found lithium carbonate

effective, especially in those patients with complaints of almost daily

cluster headache for a year or longer.

MUSCLE CONTRACTION HEADACHE

The muscle contraction headache is a daily, continuous pain often

described as a tight band around the head. Although the pathophysiology

of the pain may be muscle contraction, its etiology is depression in

about 90 percent of the eases. In this type, patients will indicate work

or family problems as a precipitating factor. Associated symptoms such

as emotional disorders, sleep disturbances, sexual problems, and alterations

in weight are often observed. Sometimes the depression is masked or

the patient relates it to the headache itself. The depressed patient is

socially restricted but is able to work. Response to tricyclic antidepressants

is excellent.

BIOFEEDBACK TRAINING

At the Diamond Headache Clinic, many patients are treated with biofeedback

training. A combination of hand-warming and electromyograph (EMG)

feedback techniques is used, since many patients suffer from more than

one type of headache. The use of both modalities aids in achieving

greater reduction of vascular and muscle contraction headaches.

A minimum of eight sessions are usually needed to train a patient. The

sessions are composed of three stages. The first stage is skin temperature

feedback with autogenic phrases. The autogenic phrases are autosuggestive

in nature, focusing on feelings of warmth and relaxation, and are practiced

before initiating skin temperature feedback. In addition to these phrases,

patients are encouraged to focus on warm and relaxing images. Then

the patient practices raising hand temperature with a thermal feedback

instrument for ten minutes. The second stage of the session is progressive

relaxation exercises, in which the patients practice tensing and relaxing

various muscles. The third stage is electromyograph feedback. Three

electrodes are placed across the frontalis muscle. The patients receive

EMG feedback for 20-minute sessions, during which time they try to

learn to identify certain tensor points in the facial, neck, and shoulder

areas. The EMG monitors are equipped with various sensitivity levels

so that the patient can reduce his tension. We emphasize daily home

practice.

We indicate biofeedback for those patients who are responding to

preventative medication for over a year and plan to discontinue these

medications. Biofeedback allows them to stop the medications with

confidence. Another indication is for those patients whose headaches

are partially controlled with medication, that is, an improvement of 50

percent or more, who cannot tolerate additional medication. Biofeedback

134
can usually provide a decrease in the frequency and severity of the

headaches. Patients with intractable headaches may also benefit from

biofeedback. These patients will not respond to any medication until

biofeedback is added to their therapeutic regimen. Finally, another

candidate for biofeedback training wishes to avoid all medication because

of his age or innate fear of drugs. This category also includes women

who are pregnant, or desiring pregnancy, and children with migraine.

We have studied 27 patients with migraine or mixed migraine and muscle

contraction headache who were unresponsive to medications.7 They

were trained in EMG and skin temperature control at least 6 months

prior to followup. The patients continued the same preventative medication

before, during, and after training. All patients kept complete records

of the number and intensity of headaches and the amount of abortive

medications taken. These records were compared with those of the 2

months prior to biofeedback training. Significant reductions on all

three measures were noted in 13 of the 27 patients.

A retrospective study on both electromyograph and temperature feedback

was completed by mailing a questionnaire to all 556 patients trained

within the preceding 5-year period.8 Patients were asked to comment

on the effectiveness of their therapy, and 413 patients answered the

questionnaire. One hundred fifteen patients responding had migraine;

fifteen, muscle contraction headache; and 283, mixed migraine and

muscle contraction headache. Ninety percent of the patients indicated

that the biofeedback techniques had helped them to relax. One hundred

sixty patients (39 percent) believed that biofeedback had helped their

headaches permanently, 133 patients (32 percent) found temporary relief,

lasting from 1 to 36 months, and 120 patients (29 percent) did not feel

that biofeedback had helped their headaches. We feel that biofeedback

is a major advance in therapy for chronic headache.

TRACTION HEADACHE

Traction headaches are caused by organic brain disorders producing

painful distortions of intracranial structure. In these patients, the

headache is usually associated with focal neurological symptoms. Its

treatment depends on the etiology of the condition. Fortunately, this

kind of headache is not frequent.

135
REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

Medina, J.L., and Diamond, S. Drug dependency in patients with

chronic headache. Headache 17: 12-14, 1976.

Diamond, S., and Medina, J.L. The headache history-key to diagnosis.

In: Appenzeller, O., ed. Pathogenesis and Treatment of Headache.

New York: Spectrum Publications, Inc., 1976. pp. 1-7

Pearch, J. General review, some etiological factors in migraine.

In: Cumings, J.N., ed. Background to Migraine. London: Heinemann

Books Ltd., 1971. pp. 1-7.

Kudrow, L. Hormones, pregnancy and migraine. In: Appenzeller,

O., ed. Pathogenesis and Treatment of Headache. New York:

Spectrum Publications, 1976.

Medina, J.L., and Diamond, S. The role of diet in migraine. Headache

18: 31-34, 1978.

Diamond, S., and Medina, J.L. Review article: Current thoughts

on migraine. Headache 20: 208-212, 1980.

Medina, J.L., Diamond, S., and Franklin, M. Biofeedback therapy

for migraine. Headache 16: 115-118, 1976.

Diamond, S., and Medina, J.L. Value of biofeedback in the treatment

of chronic headache: The patient’s opinions. Res. Clin. Stud.

Headache 6: 155-159, 1978.

AUTHORS

Jose L. Medina, M.D.

Seymour Diamond, M.D.

Diamond Headache Clinic, Ltd.

The Chicago Medical School

Department of Neurology

Chicago, Illinois 60625

136
Chronic Pain Syndrome

Four Aspects of the Problem:

New Hope Pain Center and Pain Research Foundation

Benjamin L. Crue, M.D., and Jack J. Pinsky, M.D.

The problems concerning chronic pain are manifold and cannot be

covered comprehensively in any one monograph. Among the problems

that prevent a more complete understanding of chronic human pain

are those associated with a lack of agreed definitions and classifications of pain syndromes (the "taxonomy" problem); problem

stemning from a still rudimentary understanding of the underlying

neurochemistry and neurophysiology (pain as a sensation vs. a perception); and the problems inherent in organizing any health care

delivery system (increasing numbers of "pain clinics" and "pain

centers," many utilizing multidisciplinary pain teams but divided

between those with a "peripheralist" viewpoint and those utilizing

a "centralist" position).

The present authors would like to address four specific aspects of

the treatment of patients with chronic pain syndrome. Two will be

reviewed in summary; more extensive views have been reported by us

elsewhere. These two aspects are a physiological view of the psychology of pain, the peripheralist vs. the centralist position

(1,2,3); and taxonomy for diagnosis and information storage relating

to patients with chronic pain (4). The other two, to be treated

more extensively, are long-term evaluation of pain unit treatment

for patients with chronic intractable benign pain syndrome (5)

and the team concept in management of pain in patients with cancer (6).

I . A PHYSIOLOGICAL VIEW OF THE PSYCHOLOGY OF PAIN--

THE PERIPHERALISTS VS. THE CENTRALIST POSITION

The relationships between psychological and physiological models,

when applied to the study of human chronic pain, remain difficult

to correlate. Generally, the use of the term "real" or "organic"

pain continues covertly to represent the presence of ongoing

pathophysiology. The suffering aspects of human pain states are

more often relegated to represent the psychologic aspects of the

pain experience and often are referred to as "psychogenic pain"

or the "reactive component" of the pain. As can be seen, the

division of "real," "organic," from "imagined," "hysteric," and

137
"functional" descriptions tends to give a skewed perspective about

the biopsychosocial nature of the chronic pain syndrome in man.

In addition, this dichotomy etymologically intimates that there is

"more science," hence more useful treatment knowledge available

(and fewer unfavorable social stigmata) when one pursues an

"organic" view. However, other views and treatment outcome studies,

based upon currently available knowledge, do not suggest that this

"organic" direction is the more correct or heuristic one (5,7).

Most physiologists and psychologists have related to chronic pain

in man as though there is continued nociceptive input from the

periphery into the central nervous system. It is assumed that the

latter then "responds with pain behavior." Essentially, this is

the position of the peripheralist. The centralist's position is to

question and doubt the necessity for postulating this continued peripheral input in chronic pain. We regard chronic pain syndrome as

a result of central nervous system phenomena without the need for an

ongoing peripheral nociceptive arm to complete the clinical picture.

Again, this view is covered in more detail in other publications (1,4).

With this as background, when we study pain in relation to imperfectly understood brain neurophysiological functioning, using

psychological conceptualizations, we have even further difficulties.

We do not have a good working definition of pain that covers all

aspects of all situations and is acceptable to both clinicians and

experimental investigators. From a clinical standpoint, working

with patients with chronic pain, the best pragmatic definition of

pain upon which we have been able to agree is: "Pain is anything

that the patient says it is."

From a physiological standpoint, we do not know whether pain is a

sensation or a perception; it has aspects of both. Chronic pain

(with its obvious central mechanisms, in spite of a usual past peripheral etiology) can better be considered a perception; but it is

entirely possible that even acute pain (including pain experimentally produced in the laboratory, in either man or animal) is also

not truly a sensation but, even in this context, is a central nervous system phenomenon that is better considered as a percept.

Therefore, when some try to consider pain as a response and attempt

to correlate it with a behavioristic psychological conceptualization of pain, there is often an obvious but variable gap between

"pain behavior" and the subjective nature of the specific individual's total suffering experience.

II. TAXONOMY FOR DIAGNOSIS AND INFORMATION STORAGE RELATING TO

PATIENTS WITH CHRONIC PAIN

Workers in the field face complex problems in comparing the diagnostic, prognostic, and treatment outcome results of patients who

suffer from chronic pain syndromes. Much of this situation results

from a woefully inadequate classification system for the storage of

relevant information concerning individuals' pain histories.

Trials at this have been made by our group and are reported in more

detail elsewhere (4). However, obtaining this information remains

138
so cumbersome and time consuming as generally to prevent accumulation of this data.

Also, it continues to be difficult to avoid the problem of recreating the mind/body, organic/functional dilemmas with which we

have always to contend. The increasing importance of the centralist conceptualization of chronic pain syndromes in man leads one

to the necessity of recognizing in these syndromes the most frequent and overwhelming importance of psychological factors.

Psychologic nosology must come to be regarded as a unifying factor;

it cannot be treated as a foreign but necessary ingredient whose

presence is reluctantly tolerated.

III. LONG-TERM EVALUATION OF PAIN UNIT TREATMENT FOR PATIENTS

WITH CHRONIC INTRACTABLE BENIGN PAIN SYNDROME (CIBPS) (5)

At our comprehensive, multidisciplinary, and interdepartmental pain

center, we have evolved two different pain teams over the last 20

years. The programs had their origin at the City of Hope National

Medical Center in 1960 and continue at our current New Hope Pain

Center and Research Foundation (7,8,9,10). One, for the treatment

of chronic intractable benign pain syndromes, is centered around

a therapeutic milieu inpatient program with a multimodal treatment

approach directed by a psychiatrist. The second works to ensure

optimum treatment for patients with pain due to cancer. It is

under the direction of neurosurgery, neurology, and anesthesiology,

and has been functioning as a separate team entity for 3 years.

The work of the cancer pain team is treated in section IV, below.

Chronic pain is the complaint of pain and suffering that persists

regardless of a long history of medical and paramedical treatments.

In chronic pain no detectable significant active pathophysiological

processes can be identified as the sources of ongoing afferent nociceptive stimuli, similar or analogous to those stimuli generated by

demonstrable active tissue pathology (or altered physiology) that

are commonly associated with acute pain in man. When thorough and

multilevel medical-surgical attention has been given to a person

with ongoing, usually constant, non-cancer pain, there must be

clinical recognition and acceptance at some point that there no

longer is any ongoing peripheral pathology to be corrected. Yet

there is the complaint of chronic pain that is ongoing, and often

constant, with many of the epiphenanena associated with suffering

and pain. In addition, chronic pain and its attendant epiphenomena

threaten to, or actually become, the central focus of the sufferer's

existence and, thus, form a more complete chronic intractable benign

pain syndrome (CIBPS). This syndrome has been defined as an ongoing problem with pain that:

1) cannot be shown to be causally related in the here-and-now with

any active pathoanatomic or pathophysiologic process;

2) has an antecedent history of generally ineffective medical and

surgical interventions for the pain problem; and

3) has come to be accompanied by a disturbed psychosocial functioning that includes the pain complaint with the epiphenomena

that accompany it.

139
Included in the common epiphenomena of CIBPS are:

1) mood and affect changes that are in themselves significantly

dysphoric;

2) drug dependency or abuse, of varying severities, with their

attendant CNS side effects;

3) multiple surgeries or pharmacologic treatments with their own

morbid side effects, separate from the drug dependency issue;

4) escalating psychosocial withdrawal with increased loss of gratiffications from these interactional inputs;

5) interpersonal conflict with significant others;

6) increasing hopelessness and helplessness as increasing dysphoria does not give way in the face of mounting numbers of

"newer" or different therapies;

7) decrease in feelings of self-esteem. self-worth, and selfconfidence;

8) decreasing ability to obtain pleasure from the life process,

contributing to profound demoralization and, at times, significant anhedonia, if no depression;

9) escalating physical incapacity secondary to disuse because of

fear of increasing pain discomfort. at the least, and a fear

of causing more bodily harm–based on the belief that their

ongoing pain is a signal of increasing bodily damage; and

10) conflicts with medical care delivery personnel (doctors, nurses,

therapists, technicians) with resulting dissatisfactions and/

or hostilities.

This paper describes self-report outcome data from consecutive

patients with CIBPS at our Pain Center who have been admitted to

the Inpatient Pain Unit treatment program after evaluation in our

Outpatient Pain Clinic (from January 1974 through November 1978),

where and when it was clinically decided that their problems with

chronic pain could not be treated successfully on an outpatient

basis. Criteria for admission have been reported elsewhere (9).

The inpatient treatment program consists of an 8-bed (currently

12-bed) unit in which a group therapeutic milieu approach is used,

phenomenologically similar to a well-functioning open psychiatric

unit, in the midst of a general medical-surgical setting. The

treatment is multimodal and uses physical and occupational therapy,

autogenic training, progressive muscle relaxation training, imagery

techniques, and biofeedback training-all embedded in a heavy time

commitment to group psychotherapy with an eclectic approach. This

report refers to outcome results when the program was of 7 weeks

duration. As in any good multimodal treatment approach to chronic

pain, it involves a multidisciplinary team with medical leadership.

Each member of the team is an expert in his or her own field and

strives to become increasingly sophisticated in the overall human

problems in these patients with chronic pain. A full description

of the varied personnel and modalities of treatment in this program

has been presented in an earlier publication (9).

Demographics

The complaint of chronic pain is ubiquitous in the adult medical

care delivery system. Because of this, it is sometimes assumed

that chronic pain is a coherent and unitary entity that can be

viewed in the same way by all who interact with people who have an

ongoing chronic intractable pain problem. It has been stressed

that an ongoing problem with pain that represents a person's major

life focus is a multifaceted biopsychosocial problem. Therefore

140
it is necessary to examine demographic characteristics of the people with these pain problems, so that comparisons of any significant

differences in populations and treatment outcome can be studied

among the patient population treated within one center, as well as

differences between populations treated at different treatment facilities. Tables 1, 2, and 3 include the numbers of patients in our

admission and followup data; the general descriptors of our population with regard to age, duration and location of pain; and the number of pain-related surgeries.

Outcome data from follow-up patient-mailed questionnaire responses

and pain ratings were analyzed at various stages of follow-up for

151 out of 211 patients admitted for treatment during the period

from January 1974 through November 1978 (see Table 1). This represents 72% of all patients who were admitted for treatment, and 83%

of those patients who completed treatment. The percentage of those

completing treatment and remaining in follow-up can be seen to have

been only slightly greater for women than for men. For the studied

period, the treatment program has an 87% completion rate (183 patients) and a 13% (28 patients) dropout rate of those who left

against medical advice or before completion of treatment.

The ratio of patients admitted was 28% male to 72% female, and the

percentages at completion of treatment were 25% and 75% respectively.

The women ranged in age from 17 to 77, with a mean age of 54 years,

while the men ranged in age from 25 to 79, with a mean age of 53

years. The reason for the larger percentage of women in our treatment program seems best answered by the fact that younger male patients whose pain complaint is related to on-the-job injuries (with

unsettled litigation or disability status) have not been eligible

for our treatment program. We made a clinical research judgment in

this regard in an attempt to somewhat decrease some variables that

confront all clinical researchers.

The maximum number of patients in treatment (beds available) and

the length of our treatment program dictated the number of patients

we were able to treat, and we always had a bed-waiting list for

treatment. As our treatment program was based in an eleemosynary

and research institution, we felt our admission policy was a reasonable position for us to take. There is an undeniable need for

treatment programs including those patients we excluded. In fact,

this was available in other facilities. The same general circumstance also seems to be a reason for the older average age of our

patients, in that our patients have either already been declared

totally disabled before applying for treatment, or they have not

been in the work force for years (women with families and home

work), or they have been retired from the work force through total

disability, natural attrition, or other reasons.

Table 2 presents percentage breakdowns by sex for duration of

pain, as well as for anatomical distribution of pain, for 151

patients who completed the treatment program. Table 3 presents

data on the mean number of pain-related surgeries by anatomic location of chronic pain. When we consider the pre-admission incidence

of surgeries related to the pain complaint, 60% of the sample had

141
had such surgery, with 41% having had two or more pain-related surgeries. Overall, the 127 patients with pain syndromes (other than

cephalgia) had a mean of 1.9 pain-related surgeries per patient,

with a range of 0 to 30.

Results

This report analyzes several categories of patient data including:

1) reported medication usage; 2) medical-surgical treatment for pain

post-discharge; 3) pain ratings; and 4) results of an open-ended

question about chronic pain, general life outlook, and attitude.

The outcome data to be discussed here are from admission data and

post-discharge follow-up questionnaire data responses. Individual

patients included in this report are at various levels of followup from 3 months to 5 years post-discharge. Therefore, the number

of patients at each time period post-discharge varies. While our

earliest patients (1973, 1974) did not receive questionnaires

early post-discharge, as use of the full questionnaire was begun

in 1975 and has been continued for all patients since that time,

each patient has been asked to respond to questionnaires at the

3-month, 6-month, 1-year, 2-year, 3-year, 4-year, and 5-year

times post-discharge. Therefore, an individual patient in this

follow-up study my have responded to from 1 to 3 follow-up

questionnaires. Results are reported for 151 patients who responded to a total of 299 questionnaires.

1) Reported Medication Use:

The medication study compared our Pain Unit pharmacy records at

admission with self-reported medication usage taken from the

follow-up questionnaire. All medications included in Table 2 were

admistered in a patient single-blind manner, in opaque capsules

4 times a day, on a time-contingency basis only (on a fixed

interval schedule), except as noted below. At discharge, virtually all patients are receiving no analgesic or psychoactive

medication. Table 4 presents the medication groups and dose

levels selected by one of the authors (JJP) to define the level

of drug use by patients in this study. This was done prior to

the availability of any of these outcome results, and with a view

toward concordance with generally clinically used, minimally

effective, therapeutic dosages for some drug groups (i.e., tricyclic antidepressants, etc.); and toward minimizing low-dose use of

others (i.e., opioids), where the problem of misuse or abuse are

legitimate concerns.

Tables 5a,b,c compare admission drug use for all patients with

follow-up data for subsets of patients at each time interval. It

should be noted here that all those patients at the 4-year time

interval of follow-up, and approximately one-half of those at the

3-year time interval, did not receive medication in the abovementioned, single-blind, time contingency form. At that time in

the past, this single-blind form of drug treatment for all

medications was not available to us. However, the goal of

clinically decreased drug use pursued.

(text continues on page 148)

142
TABLE 1

GENERAL ADMISSION, COMPLETION, AND FOLLOW-UP DATA

Admitted to Completed Failed to

Treatment Treatment Completed Treatment

152 134 18

In Follow-Up

Post-Treatment

WOMEN 113

Mean age: 54:

Range: 17-77 years

MEN 59 49 10 38

Mean age: 53:

Range: 25-79 years

TOTALS 211 183 28 151
TABLE 2

PRE-TREATMENT PAIN HISTORTES:

DUPATION AND LOCATION OF PAIN

Duration: 1-3 years

4-7 years

> 7 years

Location: Back

Neck

Neck and Back

Head

Other (includes thoracic,

abdominal, pelvic and

extremity pain syndromes)

TABLE 3

Male

(n=38)

18%

34%

4%

24%

1%

21%

8%

26%

MEAN NUMBER OF PAIN-RELATED

SURGERIES PRIOR TO ADMISSION

Total

Back

Neck

Neck and Back

Head

Other (includes thoracic, abdominal,

pelvic, and extremity pain

syndromes)

Female

(n=113)

16%

3%

50%

38%

1%

6%

20%

20%

Chronic Pain-Related

1.7

2.7

1.2

1.6

0.7

1.4

144
TABLE. 4 DRUG DOSAGE AND DOSAGE CRITERIA*

*Use in excess of criteria is defined as major drug use for this study.
TABLE 5A

POST-TREATMENT FOLLOW-UP OF SELF-REPORT DRUG USE
POST-TREATMENT FOLLOW-UP OF SELF-REPORT DRUG USE

(continued)
POST-TREATMENT FOLLOW-UP OF SELF-REPORT DRUG USE

At admission, the most commonly used medication groups were nonprescription analgesics, opioids, minor tranquilizers, tricyclic

antidepressants, and barbiturates, in that order. The percent

of patients using oral opioids at admission would appear to be

low for patients newly admitted to an intractable pain treatment

Program. However, the overwhelming majority of all patients

admitted have immediate and distant past histories of having used

148
narcotic-type medications. These may have been discontinued because of undesirable side effects, disinclination on the part of

their treating physicians to continue to prescribe for them, or

fearfulness on the patient's part about "addiction." Also, if

narcotic use at admission was at or below the criterion level

shown in Table 4, the patient was started in our therapy program

with no narcotics, and his or her recorded use listed as "none".

Our data do not appear to be significantly different in this

regard than that reported by others working with patients with

chronic pain who used their modified classifications of drug use

and drug dependency.

There is a definite shift in opioid use over time that reflects a

continued "none" or "below" criteria use of these drugs, when

compared to the status pre-treatment. There is a corresponding

shift over time to an increased, but below criteria, use of nonprescription analgesics. The 4-year group has a low "n" and is

not typical in this light, but their differences as a treatment

group have been mentioned above.

The minor tranquilizers, tricyclic antidepressants, and barbiturates were the next most frequent drug groups used at admission

by our patients. As can be seen, there is a high report of "none"

for all three groups across time. Again, for the minor tranquilizers and barbiturates, when the pre-admission use was reported as

at or below criteria as per Table 4, the patient was often given

"none" at admission. Also, the admission use of "below" criterion

level for the minor tranquilizers includes those patients who may

have been using barbiturates at a "below" or "above" level preadmission who were given minor tranquilizers in replacement at a

"below" dosage level at admission. It is clear that when reported

use of these two drug groups is viewed over time, there is no significant increase in use until the 3-year post-treatment level, at

which time the pattern is less clear, although there then seems to

be an increased "below" criterion level use.

The tricyclic antidepressant use in this study needs special

comment. This group of drugs is widely used in chronic pain

management. The reasons for this are understandable, but it is

not in the scope of this paper to discuss this issue. It is

also not within the scope of this report to comment in a statistical frame of reference about the overall usefulness of this

group of drugs in the management of chronic pain. However,

those patients who have been referred to our inpatient program

generally have had a clinical trial with these drugs, usually

without significant improvement in their pain syndromes. Therefore, we have seen a number of patients who are taking "above"

criterion levels (whom we maintain at that level at admission),

and then decrease and discontinue their use within 7 to 10 days

after admission. The post-treatment use of this group of drugs

remained infrequent over time.

149

348-347 0 - 81 - 11
When all the medication groups surveyed are viewed overall, there

is a greater percentage of patients using no medication postdischarge, which maintains well past the 1-year level, when compared to the use at admission. There is also a shift to lower

dose medication usage generally, and a specific shift away from

the oral opioid group to low-dose use of the non-prescription

analgesic group post-discharge. When one views total drug use in

all the medication groups in Table 4, the picture is more mixed;

but there is a definite tendency for the "above" criteria use to

remain well beneath that used at admission, although there is an

increased (but apparently plateaued-off) use at the "below"

criteria level.

2) Post-Discharge Report of Medical Treatments for Pain:

Table 5 summarizes a review of the self-reported treatment in

these areas that patients received at all follow-up levels after

discharge from the Pain Unit. It must be recalled that in the

histories of patients with CIBPS there are many forms of medical

intervention. The reported changes over time in drug use have

been covered above. When the other forms of treatment are considered, as listed in Table 6, it can be seen that there has been

an apparent major change for this population in medical-surgical

treatment received that persists over the span of our follow-up

time.

Earlier we indicated that the portion of our patient population

whose pain complaint was other than cephalgia had had almost two

surgeries per patient for pain. Overall, 60% of the 151 patients

in this study had had at least one surgery for their basic pain

compliant. A most striking element in this sphere of follow-up

data is that post-treatment more than 90% of our total population

have not had any surgery and/or nerve block procedure for their

chronic pain problem. Only 13 out of 151 patients (or 9%) have

had one or both of these types of medical treatment (3 patients

had surgery alone, 1 patient had a nerve block and surgery, and

9 patients had nerve blocks). The numbers of patients'

responses, and the percentage of each group at different time

intervals of follow-up who had not had any invasive procedures,

indicate that there is no clear evidence of any significant

change in this pattern over time. These results seem to reflect

the "take" of the Pain Unit treatment process that emphasizes

solutions to the CIBPS other than peripheral site "fix-it" pmcedures in the acute pain medical model.

3) Self-Report Pain Ratings:

The next section of the study (see Figure 1) examined patient

self-report pain ratings at admission, discharge, and follow-up

on an analog pain estimate scale, which is converted to a 0-100

scale for scoring. Difficulties in assessing results of complex

treatments for pain by the use of pain scales have previously

been reported and discussed.

150
TABLE 5

POST-DISCHARGE MEDICAL TRERATMENTS FOR PAIN - EXCLUDING DRUG TREATMENT
FREQUENCY DISTRIBUTION FOR SELF-REPORT PAIN RATING

152
The frequency distribution of analog pain estimate ratings for

admission, discharge, and each time interval of follow-up had

been plotted. The frequency distributions of scores are not normal distributions. Some are skewed, and others are bi-or multimodal. Therefore, the analog pain estimate ratings were analyzed

using non-parametric sign tests with two-tailed probabilities. We

cannot say whether such non-normal distributions are typical for

only our groups of patients, or whether such distributions are

found with analog pain ratings from other pain centers, who also

do long-term follow-ups, or whose pain patient populations may

differ from ours.

Data were available for admission; discharge; and the 3-month,

6-month, 1-year, and 2-year follow-up time intervals. For the

analog pain estimate, all admission vs. discharge comparisons

were significant at or below the .01 level of probability, with

only one significant at the .05 level. A much greater proportion

of patients reported a decrease in pain ratings from admission

to discharge than reported an increase. All admission vs.

follow-up comparisons were also significant at the .01 level or

less, with the exception of a small number of patients who were

in the 2-year follow-up group. However, the change in this group

was also in the direction of a pain decrease.

We would expect these patients to give high pain ratings at

admission and somewhat lower ones at discharge, and hope that

some patients would maintain the decreased level of pain at

follow-up. Therefore, it is not surprising that all follow-up

intervals indicated showed no significant changes in self-reported

pain when compared to the levels at discharge, as measured by

analog pain estimate ratings. The pain decreased after treatment

and no further major changes in self-reported pain rating occurred.

4) Pain, Attitude, and Life Outlook-Self-Report:

A central goal addressed in our treatment approach is an improved

quality of life in spite of any residual pain and suffering.

Therefore, we felt it was important to record relatively spontaneous attitudinal responses of patients. The last section of this

report examines the results of a content analysis of 299 openended patient responses (of 151 patients) spread over the time of

this study. The form of the question, by design, did not direct

the patient that he must make a response. To a general question

about chronic pain, general life outlook and attitude, responses

were rated for pain as worse, the same, improved, or no mention.

Attitude was rated as negative, neutral, positive, or no mention

(see Table 7). What we have labeled as attitude seems to represent a mixture of mood and coping skills.

Figure 2 shows the distributions of rated patient self-report

responses at each time interval of follow-up. Overall, posttreatment, 18% had pain rated as improved, 41% as the same, 13%

as worse, and 28% as no mention. Corresponding figures for

attitude post-treatment were 57% positive, 7% negative, 1%

153
TABLE 7

RATING GUIDE FOR OPEN-ENDED QUESTION

ABOUT PAIN, LIFE OUTLOOK, AND ATTITUDE
Questionnaire Responses about Pain, LIfe Outlook and Attitude

Rated Patient Self-Reports
neutral, and 55% no mention. As you will note, there is a strong

bias that when attitude is expressed, it is likely to be positive,

and next likely to be not mentioned at all. A cross-tabulation of

attitude in relation to pain indicates that while there is some

trend for positive attitudes and improvement in pain to correspond,

the relationship is not simple.

Of those patients with a pain rating of worse, 34% also have a

positive attitude rating; of these patients whose pain is rated as

unchanged, 75% have a positive attitude rating; and more predictably, of those with a rating of improvement in pain, 75% have a

positive attitude rating. Therefore, a positive attitude rating

can occur with all categories of self-reported pain, from worse to

improved, and it is almost always coincident with self-reports of

increased or maintained psychosocial and physical activities. A

very common result post-treatment is that of significantly

increased activity levels of "up time." This appears to be the

most easily achieved treatment goal. This probably relates to the

highly structured and prominent physical and occupational therapy

regimen common to our own as well as other known pain treatment

programs.

For further data analysis, we plan to compare these pain and

attitude ratings with the patients' self-reported pain ratings on

the analog pain estimate scale, to see whether or not there is a

consistency between what we get from an open-ended question and

what we get via direct patient self-report on rating their own

level of pain, when requested to do just that. This will also

help clarify what is happening in the "no mention" category. With

this initial data analysis complete, we new plan an in-depth

analysis of groups of patients, for whom we have multiple levels

of follow-up, in a repeated measures design, utilizing additional

psychometric tests and clinically pertinent data.

Discussion

Defining the population of patients with chronic benign pain syndromes who are selected for special treatment programs is essential. For example, in some reports the treatment, gender, and age

are not mentioned. In another treatment facility, current

litigation (Workman's Compensation, or others) related to the pain

complaint did not affect admission to treatment, as it did in our

program. Also, in the studies mentioned above, over 25% of the

patients admitted to the chronic pain treatment program had surggical treatment for their pain problem subsequent to admission to

the program whose outcome results were being reported. This, for

example, is in stark contrast to the total of only 9% incidence of

surgery for the pain complaint across all treatment and follow-up

in our clinical experience (Table 6).

Long-term follow-up is another central issue with these clinical

states. In one of the studies cited above, there were less than

25 patients in the study after 1 year of follow-up. Also, there

was no information about the varying length of hospital stay for

treatment, with a range of 13% to 36% of those who started

156
treatment present at any subsequent level of follow-up, from 6

months to 2+ years.

Earlier studies reported by the Mayo Clinic group refer only to a

6-month follow-up of 21 of 50 patients admitted for treatment for

chronic pain in a prescribed chronic pain management program. In

a continuing study reported more recently, results of treatment of

200 patients admitted in their inpatient treatment program were

presented. Only 38% of the total 200 patients treated had participated in follow-up at 1 year post-discharge. This included only

those patients who had moderate improvement, or better, at discharge. In contrast, 7% of our total admissions responded to at

least one level of follow-up, and this amounted to 8% of those

who completed treatment. The Mayo Clinic program also included a

patient population different from ours. These differences include

a greater percentage of men; patients with Workmen's Compensation

and medicolegal complications; a significantly shorter, less

intensive treatment period (20 days average vs. 46 days in our

program); and more patients requiring some mechanical assistance

(one-third as opposed to less than 5 percent in our ambulatory

inpatient program).

Apparently common all reported treatment programs is an emphasis

on increased physical functioning, usually including performance

and endurance. In our experience, when a patient remains in

treatment, his or her general physical conditioning and level of

activity almost universally improve significantly. This category

of improvement seems onmipresent in all types of pain treatment

program, regardless of patient population or treatment program

biases. There seems to be a high incidence of short-term improvement in most parmeters monitored, when there have been reasonable

pre-admission understanding of the treatment program by the patient

and an acceptance of such treatment.

Differences in patient populations and treatment setting are likely

to include intervening variables of major proportions, thus making

outcome comparisons difficult. In addition, these problems of outcome evaluation do not take into account the individual weighting

of improvement in one sphere over that in another, in any given

individual patient with pain. Because of the differences discussed

above, it is difficult to compare one treatment setting with another unless many factors with appropriate weighting are included

in judging outcome results. We might add, however, that the authors of studies mentioned above, and others, have indicated that

special inpatient treatment situations were indicated for and helpful to patients with intractable chronic pain problems. We feel

our data indicate that there may be an even greater increase in

long-term effectiveness of treatment if the multidisciplinary,

multimodal, treatment team program is of sufficient length and

intensity in all aspects of the biopsychosocial spheres.

157
Conclusion

The general clinical syndrome of chronic, non-cancer, intractable

pain is the main concern of this portion of our report. The generally recognized human suffering related to this syndrome is of

paramount concern. However, the concomitant problems of families,

medical, and paramedical people, who always are present struggling

with the problems generated by the process of ongoing pain, are

also part of this process. because of the chronicity of the

problem, the effect of therapeutic interventions must be viewed

primarily in a long-term perspective, in order to learn about the

lasting nature of the interventions. Short-term changes, even

when therapeutically Positive, have been experienced by all involved-only often to be followed by the return of the painful

pre-existing state and its epiphenomena.

For an initial overview of the results of our multimodal, multidisciplinary, medically based treatment approach to this difficult

medical problem, in the truest sense a biopsychosocial problem, we

have focused on some of the changes in the most common phenomena

accompanying these pain syndromes: 1) drug use, 2) continuing

medical-surgical treatment, 3) subjective pain reports, and 4)

general life outlook and attitude.

In each of the above-mentioned areas, we have assessed the data

shared with us by a rather large percentage of our patients. The

general thrust of this data indicates that long-term, positive,

therapeutic changes have occurred for a large segment of these

patients, who usually had not had histories of such prolonged

therapeutic occurrences prior to their Pain Unit treatment.

The benefits of long-term diminution and de-escalation of opioid

analgesics and CNS depressants, as well as an overall decrease in

use of pharmacologic agents, are readily apparent to patients,

families, and treating physicians. The apparent relative decrease

in patients attempting to resolve their chronic pain state by

tissue invasive or destructive procedures, or ever-escalating

narcotic or mood-altering drug use, are perhaps the most interesting and medically significant outcomes of the teaching and treating

of patients with CIBPS. This is particularly the case when there

is a concomitant increase in sense of well-being, that is reflected

in more positive life attitudes, mood, and goals involving increased

psychosocial activities. The fact that all of this can and does

occur, with or without a significant reduction in self-assessed

pain, further underscores the intricacies of establishing therapeutic goals and assessing their outcomes for these truly

biopsychosocial syndromes.

We feel that these results represent a major, fairly long-term,

positive, clinical shift in groups of patients who notoriously have

had significant problems in previous attempts to favorably alter

their chronic pain experience.

158
IV. TEAM CONCEPT IN THE MANAGEMENT OF PAIN IN PATIENTS WITH

CANCER (6)

As our Pain Center developed over the last two decades, it became

obvious that the patients with pain due to intractable malignant

disease were, in general, easier to treat "successfully" than were

the patients with chronic intractable benign pain syndromes.

Therefore, the neurosurgeons found it necessary, mainly for

optimum treatment of chronic benign pain patients, to enlist the

expertise of other individuals, both professional and paraprofessional; and, the team concept for the treatment of chronic

benign pain evolved (as has subsequently been the case at many

other pain centers). While the majority of personnel, time and

resources in our Pain Center were committed to the evolution of

the chronic benign pain team, at the same tine the Neurosurgical

Service continued to treat the pain syndromes in patients with

underlying malignant disease. These patients were often seen on

other services at our Medical Center, referred to the Pain Center

through our inhouse Tumor Board, or referred to the Neurosurgical

Department of the Pain Center directly from a number of outside

referral sources. A variety of neurosurgical procedures such as

posterior approach stereotactic percutaneous cordotomy and

percutaneous trigeminal tractotomy, as well as open operative

intervention such as sacral rhizotomy, have been carried out by

our Neurosurgical Department for patients with cancer pain at our

Pain Center, with an acceptable "success" rate over the intervening years. However, as the pain team concept was successfully

applied to patients on the chronic intractable benign pain unit in

the Pain Center, there was often considerable overlap with both

the professional and paraprofessional members also assigned to the

Neurosurgery and Neurology Departments who were managing the

patients with pain due to cancer. Almost serendipitously, and

admittedly with little conscious forethought at times, many of the

team concepts of treatment (that had been learned in the treatment

of the chronic intractable benign pain patients) were then found

to be satisfactory as they inextricably spread back into the

treatment regimen of the patients with cancer pain, on both the

Neurosurgery and Neurology inpatient services here at our Pain

Center. A formal Monday morning weekly conference of the entire

staff related to the treatment of the patients with cancer pain on

the Neurosurgery and Neurology inpatient services was established

in 1977. As the conference members began to interact at their

weekly conference, it became obvious that we had, in fact, a second

pain team in existence in our Pain Center, this one for the cancer

pain patients. It was composed of some overlapping (but, in

general, different) professional and paraprofessional personnel;

but, it included many of the same goals and treatment techniques

that we had cane to utilize in the chronic benign pain team.

Therefore, it was decided to recognize this second team effort,

for patients with pain related to underlying malignant neoplasms as

the cause of their pain and suffering, as a distinct separate pain

team entity, functioning under the combined direction of the Neurosurgery and Neurology Services. The present administrative framework of our Pain Center is depicted, as of January 1979 (Figure 3).

159


Goals of the Cancer Pain Team

The main goals of the cancer pain team, as it now functions on the

Neurology and Neurosurgery Services, can be placed under two

headings: 1) evaluation for therapy; and, 2) patient support.

The patient support aspect can likewise be divided into two headings: a) attempted pain relief and rehabilitation; and, b) attempted

pain relief and terminal care.

1) The cancer pain team per se does not do as much investigative

evaluation for appropriateness of treatment on the inpatients with

pain from malignancy (already admitted in a neurology or neurosurgery bed within the Pain Center) as is comparably done by the

pain team for the patients being admitted to the Pain Unit with

chronic intractable benign pain. In the chronic benign patients,

there has always been considerable triage and screening within the

outpatient clinic before going on the tentative bed-waiting list,

and then further screening by psychometric evaluation, as well as

interviews with the social worker, pharmacist, and psychiatrist

prior to being admitted to the final bed-waiting list for admission

to the benign Pain Unit. However, a considerable amount of the

investigation of the idiosyncratic psychodynamics that leads to

planned individual and group psychotherapy on the Pain Unit is

then accomplished after admission by all the benign pain team

members, as well as by the individual attending physicians.

Conversely, on the Neurosurgery Service, the patients with cancer

pain are usually not admitted for treatment of their particular

intractable pain problem unless a specific attempt at neurosurgical therapy to relieve the pain has been tentatively decided

on, and directly discussed with the patient, and usually his

family, prior to admission. This is less true on the patients

with pain problem admitted for diagnosis on the Neurology Service

where, on occasion, an underlying malignancy is discovered, and

then a decision has to be made regarding further treatment. This

usually involves more of the cancer pain team, of course, as the

patient is discussed at the Cancer Pain Team Conference. However,

the majority of the cancer pain patients who are seen by the cancer

pain team members are on the Neurosurgery Service, and they are

then discussed at the weekly Monday morning conference. These

patients have usually been admitted for a tentative specific

therapy. Many of these patients have already been on other

services at the Medical Center (such as the Oncologic Surgery or

Hematology Service), where the neurosurgeons have originally been

called in to see the patient in consultation. Often psychotherapeutic support from Social Service, Nursing, Rehabilitation, and

consultation with the Neurology-Neurosurgery Service clinical psychologist has been obtained before the patient is advised

concerning admission, or transfer, for a specific recommended

neurosurgical pain-relieving procedure (such as sacral rhizotomy,

percutaneous cordotomy, etc.). If the recommendation is accepted

by the patient and his original attending physician, the patient

is then transferred to our Pain Center on the Neurosurgical Service.

This has worked so well in the past, with several trained neurosurgeons interested in cancer pain problem (who have each been at

160
the Pain Center for many years), that it perhaps delayed the

realization of what other cancer pain team members might well have

to contribute to further improve the total treatment situation.

The care of the patient with cancer pain had not often seemed to

be as complex a problem as had been the arranging for interdepartmental and multidisciplinary care for the chronic intractable

benign pain patient on the Pain Unit.

The second way that the patients with cancer pain are admitted on

the Neurosurgery Service is by referral from one of the in-house

Tumor Boards. There, a professional member from our pain team is

always in attendance; and the recommendation for possible admission

for a neurosurgical or anesthesiological blocking procedure to

relieve pain occurs at this level. There is thus concurrence by

the Onwlogy Surgical staff, as well as by the chemotherapists,

immunotherapists, radiation therapists, pathologists, etc., at the

regular Tumor Board conference. In addition, if these patients are

referred to Neurosurgery, they are then screened after Tumor Board

in the Neurosurgery Outpatient Clinic, before acceptance and

admission on the Neurosurgery Inpatient Service for a specific

procedure.

The third source of cancer pain patient admission is by direct

referral from the outside, when we have adequate records from the

referring physician (as no patient is seen at our Pain Center except on written referral from his/her present treating physician).

If there is any question about either the diagnosis or any

further indicated tumor treatment, the patient (who is always seen

in the Outpatient Neurosurgical Clinic before admission to the

inpatient service for a specific operation can always be referred

to our Tumor Board for further multidisciplinary professional

oncological advice.

Therefore, regardless of which of the three routes leads to the

patient with cancer now being housed on the Neurosurgery (and

occasionally on the Neurology) Service of our Pain Center, there

has already been considerable knowledge acquired and investigation

done concerning the diagnosis and past and proposed further treatment of his malignant disease. This occurs before the projected

tentative anesthesiological or neurosurgical intervention, prior

to the patient being presented to our cancer pain team on the ward

in the weekly conference. However, this in no way should be taken

to minimize the demonstrated value of the additional information

that is now gained, after admission, from other professional team

members, as well as the input from the Nursing Service, Social

Service, or the various members of the Rehabilitation Department.

The patient is investigated in further depth as an inpatient, and

then presented to the cancer pain team at the Monday morning

weekly conference. This presentation makes possible more useful

information about his total picture as a suffering human and makes

possible the start of a more complete biosocial treatment necessary

in many near-terminal situations (this will be discussed further

below under the individual duties of the various specific cancer

pain team members).

161
2) When it cares to the support goal, the value of the combined

pain team approach cannot be overemphasized. The neurosurgeon,

neurologist, and anesthesiologist are ultimately responsible (as

individual attending physicians) for the patient's medical care,

and it is they who usually decide tentatively on the projected

treatment for which the patient has been hospitalized. However,

there is no question but that the further input from the team members often has a profound influence on altering the tentative

projected specific pain-relieving intervention, or its timing.

This has definitely been in the best interest of the patient.

There is also an overwhelming value in the support role that the

trained and informed paramedical staff can give to the busy

attending physician, in supporting not only the patient, but also

his or her significant other (as well as other members of the

family) during this period of usually undeniable life crisis and

inevitable stress. The final decision regarding further care to be

recommended to the patient is usually reached jointly at the

weekly team conference by the attending physician and the other

pain team members. The initial treatment plan has, by then, often

been subsequently and appropriately changed or updated. This

occurs as the patient is observed further, new information is obtained, or his clinical situation changes (often by improvement in

the pain complaint while on conservative management, antidepressants,

and team reassurance)– which on many occasions obviates the need

for (or at least postpones) any surgical pain-relieving procedure.

The patients, when initially discussed at weekly cancer pain team

conference, usually fall into one of two broad categories from the

standpoint of therapeutic goals as well as pain relief:

a) Those patients who have potential for significant rehabilitation.

The evaluation of such potential can then be done. This includes consideration of where the patient will go after leaving

the Pain Center. He may be transferred to a convalescent

hospital, return home or, on rare occasion, even be rehabilitated

so that he can return to useful, gainful employment (perhaps

even to his premorbid occupation).

b) The second group includes those severely ill, cancer pain

patients where it involves only an attempt at pain relief (by

a nerve block or surgical procedure), followed by supportive

terminal care, as the patient is not truly classifiable as being

rehabilitatable.

All of this evaluation for possible pain relief therapy presupposes,

of course, that the attending physician and all of the pain team

members have agreed that every possible attempt has already

been made to ameliorate the suffering by treatment of the primary

underlying neoplastic condition (or, at times, other painpotentiating medical conditions). This is again made easier by

having available, in addition to the regular cancer pain team

members, consultants who are called in whenever there are specific

problems relating to the possibility of further surgical eradication, radiation, chemotherapy, or immunotherapy; also, additional

consultation that further investigation of medical conditions,

162
such as cardiac failure, anemia, poor nutrition, etc., are not

indicated. The patients with cancer pain are thus evaluated by

the team, usually in a neurosurgical preoperative mode, assessing

risks as seems indicated. This will be discussed further under the

duties of the specific pain team members to be described below.

Make-up of the Cancer Pain Team - - Job Descriptions of Members

The attending physician in charge of each patient on the Neurology,

Neurosurgery, or Pain Anesthesiology Service is really the cancer

pain team leader, as far as the treatment of that specific individual patient with pain from cancer is concerned. In addition to

the neurosurgeons and neurologists, our full-time pain anesthesiologist also acts as an attending physician and admits patients

for evaluation for possible therapeutic nerve block as indicated.

The medical function of the physicians in the investigation and

the establishment of diagnoses, the evaluation of risk, and the

decision concerning the optimum pain relief procedure indicated,

are all medical decisions familiar to the readers of this journal

and will not be discussed further here.

The clinical psychologist routinely attends the Monday morning

cancer pain team meeting and sees those patients on the Neurology,

Neurosurgery, or Pain Anesthesiology inpatient services when asked

by the attending physician for consultation. These services are

available for evaluation of the presumed underlying psychodynamics

and their relationship to the pain and suffering problem, or for

help with any acute crisis situation. This may be accomplished

either by interview or, when indicated, by more formal psychometric evaluation. Consultation is also available for neuropsychological assessment of cognitive functioning which can aid

both patient and staff in adaptation to changes in the patient's

ability, behavioral capacity, and resultant affect. The clinical

psychologist is often utilized in helping support the individual

patient and family through consultation with the attending

physician and contact with the entire pain team, and, more directly

(when occasionally indicated), through more prolonged psychotherapeutic contact with the patient and his or her family.

The role of the Social Service worker in our Pain Center has been

described previously in relation to the chronic intractable benign

pain team and Pain Unit. This same Social Service worker assigned

to the Pain Center also spends considerable time and effort with,

and is an invaluable member of, our pain team relating to patients

with cancer pain on the Neurology and Neurosurgery Services.

Investigation and evaluation of the patient's autobiography, past

history, family history, work history, and financial concerns is

ascertained in a detailed clarity that the attending physician

seldom obtains. In many instances this information has been

invaluable in decisions concerning the proper medical modality for

further therapeutic attempts at relieving pain, as well as a

decision concerning the possibility of rehabilitation and further

management of the individual cancer pain patient. The Social

Service worker also supplies considerable psychotherapeutic support

163
to the patient and his family.

Another important pain team member is the neurology and neurosurgery nurse specialist. The nurseworks in a supervisory and

teaching role, and coordinates the treatment of the patient with

pain on the Neurology, Neurosurgery, and Pain Anesthesiology

inpatient services. This specialist must coordinate with the floor

nurse team leader for patients within the Pain Center and act in a

teaching role in education concerning specific nursing problems

encountered in this type of neurosurgical patient, both pre- and

post-operatively. The neurosurgery and neurology nurse

specialist, furthermore, functions in an advisory capacity by

evaluating the nursing aspects of the pain patients (with neurosurgical pain-relieving procedures) as they are followed after

surgery in both the recovery room and in the intensive care unit

(geographically located elsewhere within our medical facility).

For these patients who are only having diagnostic tests that

necessitate hospitalization (particularly those procedures having

high anxiety potential, such as myelography or angiography), the

nurse does pre-procedure instruction, as well as follow-up.

Furthemore, all of the nursing members assigned on the Neurology,

Neurosurgery, and Anesthesiology Pain Services have often proved

invaluable in the evaluation and treatment of pain patients, both

pre- and post-pain-relieving operative procedures. The regular

day shift nursing floor team leader assigned to the neurology and

neurosurgical service is also a regular member of the weekly

cancer pain team conference. Another frequent participant is the

clinical nursing supervisor who is in charge of the neurology/

neurosurgery floor among other responsibilities.

The pharmacist on the Pain Center is familiar with all of the

patients in the 24-bed Pain Center and with the "purple capsule" -

single-blind routine used on the chronic benign Pain Unit. Therefore, in the total treatment of patients with drug abuse problems

(or where the pain, in spite of the known underlying cancer, is

considered to be largely psychodynamic, with much fear and

anxiety, etc.), the pharmacist works very closely, on an individual basis, with the patient's attending physician. The patientblind medication regimen is often used in the care of patients

with pain and suffering due to cancer. This can thus provide a

necessary, temporary lifting of responsibility from the patient

with regard to his or her dilemma between hope for pain relief

and psychologically feared drug dependency. On many occasions,

by the use of appropriate tranquilizers or antidepressants, and

by discontinuing specific unwise narcotic use, the pain (even in

patients with cancer) can often be adequately reduced without

nerve block or neurosurgical operative intervention.

The members of the Rehabilitation Department on the cancer pain

team are routinely the physical therapist and occupational therapist. The physical therapist does a thorough evaluation of the

patient's present abilities and rehabilitation potential from a

physical standpoint and helps evaluate and record the disability

status cause by the physical impairtment. The occupational

164
therapist investigates the patient and does a thorough evaluation

and an estimation of the patient's potential for rehabilitation.

Whether the patient has a nerve block, or a neurosurgical

procedure, for the relief of pain, the physical therapist and

occupational therapist follow through in treatment as prescribed

by the attending physician, after consultation and discussion at

the weekly pain conference with the entire cancer pain team. The

vocational rehabilitation counselor and recreation therapist are

also available when needed from the Rehabilitation Department as

assigned to the Pain Center for either pain team, and are often

utilized in the treatment of specific cancer patients with pain.

The discharge planning nurse, also a regular member of the pain

team, supervises discharge planning and evaluates from a nursing

viewpoint the probable need for ongoing care after the patient

has left the Pain Center. The importance of this discharge planning cannot be overemphasized. It is correlated with the Social

Service worker's treatment plan, for the patient and his family,

for post-discharge care of the individual cancer pain patient.

Correlation with visiting nurses in the home is thus expedited,

and a better transition experience is provided for the patient,

while far less time is required from the attending physician.

Lastly, the neurology and neurosurgery secretary is a regular

member at the pain team conference and takes notes for the

patient charts, keeps the pain conference records, and also sees

that they are promptly entered in the charts so that questions of

third-party payors, PSRO, or in-house utilization committee

reviewers can have an adequate clinical base for their reviews.

The secretary also remains an invaluable aid in reminding pain team

members concerning the status of the follow-through on the decisions

reached at the weekly pain team conference.

Other specialty consultants such as physicians in Radiation

Therapy, Oncological Surgery, or Medical Oncology are asked to

come to the weekly cancer pain team conference as individually

indicated by the cases under discussion. The weekly conferences

are also attended by the pain fellows, or residents in Anesthesiology, Neurology, or Neurosurgery, as they rotate through our

Pain Center. Individual professional visitors often also attend

the conferences. This relates to our commitment to the importance

of teaching and the widening of professional skills in the understanding of patients with pain.

Results

The authors, after experience over the last two years with the

function of this multidisciplinary cancer pain team (with its

weekly conference) under the auspices of Neurosurgery, Neurology,

and Pain Anesthesiology, have been pleased with the way the team

has functioned to provide demonstrated improverment in cancer

patient evaluation and care. This is the reason for writing the

present article. The aid given by this team approach to each

attending physician in the evaluation and increased total care of

165
patients with cancer pain, who may require nerve block or neurosurgical intervention, in ascertaining the psychodynamics of the

suffering process in each patient (where there is often a large

psychological overlay and where family anxieties, probable job

loss, and other econanic concerns all play their role) cannot be

over-emphasized.

While the patient is cared for at the Pain Center as an inpatient,

plans are also made for continuing patient care after discharge.

These plans include routine follow-up by a physician at the outpatient clinic and, as necessary, continuing follow-up by Physical

Therapy, Occupational Therapy, or Social Service. Psychological

support for the patient and his family, when indicated, is also

arranged. At times the patient with uncontrolled cancer, even with

some residual pain, can be rehabilitated to leave the hospital for

a considerable period of time. Tentative plans for future rehabilitation, with presumed limitations due to progression of the underlying malignant disease, are contemplated and discussed.

In patients where no significant level of rehabilitation appears

possible, the terminal care (either after operative attempts at

pain relief, or at times without the necessity of anesthesiological

or neurosurgical pain relief intervention) has certainly been

facilitated by the use of the pain team concept in these cancer

patients with pain. While this institution at the present time

does not have an intermediate care, continuing care, or a

custodial facility, and, while we do not have an area set aside

as a "hospice" per se, several beds on the Neurosurgical and

Neurological Services within our inpatient pain center over the

last several years have been utilized for patients treated here

pre-terminally who then evolve a more terminal advanced malignant

disease state where severe pain is often a feature of their total

symptom complex. These patients are often maintained for a considerable time, and it is fortunate that at our former eleemosynary

institution we were able to keep a small number of patients for

terminal care, as well as for attempted pain relief.

Patients with severe cancer pain, even if they probably cannot be

rehabilitated, are evaluated by the attending physician and the

entire cancer pain team to see if the pain can be helped in spite

of the advanced nature of the underlying condition. No operative

intervention, or even nerve block, is considered until the patient

has been totally evaluated and attempts made to favorably modify

the life situation and to relieve anxiety by the use of antianxiety agents such as tranquilizers and the newer pharmacological

antidepressants, etc., along with psychotherapeutic support from

the trained social service, nursing, and psychological personnel.

However, by the use of nerve blocks (such as alcohol injection

retroperitoneally for cancer of the head of the pancreas, etc.);

or, by the use of stereotactic neurosurgical procedures (that are

now often done percutaneously), we can offer patients with pain

from terminal cancer (even in far-advanced stages) some pain

relief for their terminal weeks or months without open operative

166
intervention, as would have been necessary a few decades ago.

When pain persists in spite of all attempted psychological support,

tranquilizers, and antidepressants, and where neurosurgical intervention has either been contraindicated or is no longer totally

effective, then the patients are maintained on analgesics and

narcotics (at times by self-administration in the form of letting

the patient regulate his own dose of Schlessinger's solution -

which we use instead of Brompton's mixture). This has often been

adequate for pain relief while letting the patient maintain an

optimum mental quality for his remaining days and weeks. While

the above-described way of working with a few terminal cancer

patients with pain, at any one time, is in no way a substitute for

a larger hospice, it has certainly improved the care of the

terminal patient with cancer within our own institution, both for

the unfortunate cancer victim and for his surviving family.

In the opinion of the authors, results have demonstrated the usefulness and effectiveness of the multidisciplinary team concept

in the approach to therapy of pain and suffering in patients with

cancer, either terminal or pre-terminal. It is well understood by

the authors that this preliminary article is being written without

adequate controls, or even detailed statistics. It is believed,

however, that the pain team concept as applied to cancer patients

with pain has been rewarding enough medically that this article is

justified. Of course, no specific financial study was done, and

no comment can be made on the "cost-effectiveness" factor. It is

understood by the authors that the National Cancer Institute is

presently considering funding several pain centers around the

country to help in the formation of similar cancer patient pain

texts, for the type of approach described above. In the proposed

NCI study there reportedly will be attempts made at control

groups, to see if verification of the results of the team effort

in such cancer pain patients can be substantiated. It is the

opinion of the present authors that such a value will be found.

We believe it has already been demonstrated over the last few

years by our cancer pain team that had operated at City of Hope

Medical Center Pain Center, and continues to function in essentially the same manner at our New Hope Pain Center. This is

verified by the results in our cancer pain patients, as observed

by both their families and our team members. However, the ethical

problem of withholding standard treatments believed to be of

benefit to cancer Patients in order to have a true control group

will probably be a very difficult one to solve.

167
REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Crue, B.L. A physiological view of the psychology of pain.

Bull Los Angeles Neurol Soc, 44:3-18, 1979.

Pinsky, J.J. Chronic, intractable, benign pain: a syndrome

and its treatment with intensive short-term group psychotherapy.

J Human Stress, 17-21, Sept. 1978.

Nemiah, J.C. In "Somatoform Disorders," Ch. 21.2, Vol. 2,

p. 1538, Comprehensive Textbook of Psychiatry/III. Third

edition edited by Kaplan, H.I.; Freedman, A.M.; and Sadock, B.J.

Baltimore: Williams & Wilkins, 1980.

Agnew, D.C.; Crue, B.L.; and Pinsky, J.J. A taxonomy form for

diagnosis and information storage for patients with chronic

pain. Bull Los Angeles Neurol Soc, 44:28-37, 1979.

Pinsky, J.J.; Griffin, S.E.; Agnew, D.C.; Kamdar, M.D.;

Crue, B.L.; and Pinsky, L.H. Aspects of long-term evaluation

of pain unit treatment program for patients with chronic

intractable benign pain syndrome (CIBPS): Treatment outcome.

Bull Los Angeles Neurol Soc, 44:150-181, 1979.

Crue, B.; Felsööry, A.; Agnew, D.; Kamdar, M.; Randle, W.;

Griffin, S.; Sherman, R.; Menard, P.; and Pinsky, J. The

team concept in the management of pain in patients with

cancer. Bull Los Angeles Neurol Soc, 44:196-210, 1979.

What is the current thinking of chronic pain treatment?

Editorial in Behavioral Medicine, February 1981, p. 9.

Crue, B.L., ed. Pain and Suffering-Selected Aspects. Springfield, Ill.: Charles Thomas, 1970. 204 pp.

Crue, B.L., ed. Pain--Research and Treatment. New York:

Academic Press, 1975. 413 pp.

Crue, B.L., ed. Chronic Pain--Further Observations from City

of Hope National Medical Center. New York: Spectrum

Publications, 1979. 581 pp.

AUTHORS

Benjamin L. Crue, M.D., Director

Jack J. Pinsky, M.D.

New Hope Pain Center and Pain Research Foundation

Alhambra Community Hospital

100 South Raymond Avenue

Alhambra, California 91801

168
Current Issues in the Management of Cancer Pain: Memorial

Sloan-Kettering Cancer Center

Kathleen M. Foley, M.D.

ABSTRACT

Recent attention to the management of cancer pain in the mass

media (TV, books, newspapers) and the medical press provides ample

evidence to suggest that many cancer patients are not receiving

appropriate therapy for their pain. Since cancer therapy is often

not curative, only palliative, specific attention to the management of pain in such patients is essential. However, the management of cancer pain requires a specific approach and expertise.

Narcotic analgesics are the mainstay of therapy in the management

of such patients, yet physicians lack sufficient knowledge of

narcotic pharmacology to use these drugs appropriately. Recent

controversy has arisen in 3 specific aspects of narcotic drug

therapy: 1) the choice of a narcotic drug and its method of

administration; 2) the development of tolerance, and 3) the risk

of substance abuse, drug dependence, and addiction.

Choice of Narcotic Drug a Method of Administration: Comparative

studies of heroin and morphine in cancer patients with pain at

MSKCC (Houde et al.) demonstrate that, using equianalgesic doses,

heroin and morphine have comparable analgesic and mood effects.

No controlled studies have addressed the efficacy of oral liquid

narcotic solutions compared to other forms of available oral analgesics. More importantly, the role of long-acting analgesics such

as methadone remains unclarified. There is a tremendous need to

develop guidelines based on careful clinical studies, not limited

experience and anecdotal data.

Development of Tolerance: In contrast to Twycross' experience,

tolerance occurs in cancer patients with pain and progression of

disease, representing a significant practical management problem.

169
Escalation of drug dosage, switching to alternate drugs, and the

use of combination drug therapy represent empirical approaches to

provide adequate pain relief. What factors influence tolerance

remain unstudied in this population.

Risk of Substance Abuse, Drug Dependency a Addiction: From a

review of patterns of drug abuse in 103 patients (86 with cancer)

followed in MSKCC's Pain Clinic, escalation of drug dosage was

associated with the progression of disease, and successful antitumor therapy with reduction or cessation of drug use. Substance

abuse and addiction did not occur in the cancer group (Kanner et

al.). Although fear of addiction limits narcotic use by both

physicians and patients, there are no published long-term data to

support the thesis that chronic use of narcotic analgesics causes

addiction.

Recent attention to the management of cancer pain in the mass

media (television, books, newspapers) and the medical press

provides ample anecdotal evidence to suggest that many cancer

patients are not receiving appropriate therapy for their pain.

Since therapy directed toward cancer is often not curative and

only palliative, specific attention to the management of pain in

such patients is essential. However, the approach to and management of cancer pain requires a specific expertise. This expertise

can only be gained from a clear understanding of the nature of the

pain and the medical, psychological, physiological, pharmacological and social variables influencing the pain complaint in this

group of patients. An extensive body of data on these variables

is currently lacking, and this lack of information has partially

thwarted the approach to and management of pain in such patients.

Before considering cancer pain as a distinct entity, it is

important to place it in the framework of other types of acute or

chronic pain states.

In the management of any patient with pain, it is of paramount

importance to recognize that pain is only a symptom, not a diagnosis. Pain perception, then, is not simply a function of the

amount of physical injury sustained by the patient. Rather, it is

a complex state determined by multiple factors including age, sex,

cultural and environmental influences, and multiple psychological

factors. The methods of pain management and the goals of adequate

therapy vary for each individual patient. Patients suffering from

pain can be divided into 2 major groups: those with acute pain and

those with chronic pain. The point at which acute pain becomes

chronic is not known, but pain lasting for more than 6 months

is usually considered a chronic pain. Patients with acute pain

are characterized by a well-defined temporal pattern of pain

onset, usually associated with subjective and objective physical

signs. These signs are commonly associated with hyperactivity of

the autonomic nervous system and include tachycardia, hypertension, diaphoresis, mydriasis, and pallor, which serve as

objective signs to the physician, substantiating the patient's

complaint of severe pain. In contrast, chronic pain is the

170
persistence of pain with a less well-defined temporal onset in

which the signs of autonomic nervous system hyperactivity are

absent. Evaluation of the pain complaint is often difficult

because the physician has limited objective signs on which to

determine the severity of the patient's pain. It is this lack of

a useful diagnostic tool to confirm the severity of pain that

makes pain such a difficult symptom to evaluate and to treat.

Recognition of these 2 different types of pain is particularly

important in the management of patients, and their responses to

treatment are often different for each of these groups. Acute

pain is relatively easy to recognize and more amenable to

therapeutic approaches. Patients with acute pain can usually be

treated for the cause of their pain and are more likely to respond

to analgesic drugs and to a series of other available modalities.

In chronic pain, the persistent pain has usually failed to respond

to those modalities directed at the treatment of the cause of the

pain. In general, these patients respond poorly to the use of

analgesic agents and have developed significant changes in

personality, lifestyle, and functional ability. Such patients need

a management approach which encompasses not only the treatment of

the cause of their pain but also of the complications which have

ensued in their functional ability, their social lives, and their

personalities. It is this particular group of patients that

challenges physicians in the management of pain. It is also this

group that colors physicians' attitudes toward the management of

patients with acute pain problems. Within the group of patients

with chronic pain, 3 types of patients emerge: the first type is

the patient with chronic medical illness in whom pain is an

intinate part of the disease process , e.g., pain with metastatic

disease, pain with rheumatoid arthritis, sickle cell anemia, or

hemophilia. These patients may have pain-free intervals or may

live with a continuous mild degree of pain with acute

exacerbations of severe pain. This latter group responds to a

series of modalities including analgesic drugs. The second type

of patient is the patient with chronic pain in whom the pain,

which began as a definable pain syndrome, has become a disease

unto itself. Although the site may vary from face to lower back,

it is the pain that consumes daily life and limits activity.

The third type is the patient with chronic pain without

a definable cause. These patients characteristically complain of

diffuse myalgias and arthralgias, have multiple diagnostic studies

and often multiple surgical procedures without any clear evolution

of a definable pain syndrome. Patients with cancer have both

acute and chronic pain. The management of acute pain in this

group of patients includes the treatment of the cause of their

pain, most commonly metastatic tumor, and the use of analgesic

drugs. The management of chronic pain presents a more difficult

clinical problem. Such management includes the use of analgesic

drugs and a series of other specific modalities directed at the

particular pain problem, e.g. nerve blocks, transcutaneous

electrical stimulation, etc. In general, the majority of cancer

patients with pain fit into the group of patients with chronic

medical illness and pain. However, there is a very small

percentage of patients (from our experience, less than 5%) in whom

348-347 0 - 81 - 12 171
the pain becomes the patient's focus, separate and distinct from

their underlying illness, and in these patients it is the management of their chronic pain state that deserves full attention.

The predictive factors determining who will complain of pain

and who will develop chronic pain in this group of patients

remain undetermined. There are no prospective studies of cancer

patients prior to the onset of their pain, and the existing

studies are on patients who had pain at the time of their psychological assesment. From our own studies (Pasternak & Foley,

1980) of the personality traits and cognitive style in chronic

pain patients, we could not distinguish patients with cancer and

chronic pain from patients with chronic pain from non-malignant

causes. Using a battery of psychological tests, there were no

significant differences between these two groups.

However, there were significant differences between chronic pain

Patients with cancer and a control population of patients with

cancer and chronic non-painful illness. These preliminary studies

sugqest the profound influence of pain in altering psychological

variables, but do not provide the necessary prospective data.

Since cancer patients often move from an acute pain state to a

chronic one, they represent the experimental model of human pain

and offer tremendous opportunity for longitudinal studies

assessing the impact of chronic pain on the psychological state of

such patients.

From our current state of knowledge, then, recognition of the

differences among the particular group of patients with pain does

not allow a hard and fast approach to their treatment. Any

approach must be modified depending upon the underlying nature of

the patient's disease and the patient's response to initial

attempts at therapy. In an attempt to study some of these

variables in patients with cancer pain, we undertook a series of

surveys to obtain data on the nature and prevalence of pain in

this population at Memorial Sloan-Kettering Cancer Center

(MSKCC).

Data on the prevalence of pain in patients with cancer come

predominantly from terminal care facilities; 50%-60% of patients

are reported to have pain (Lipman, 1975; Exton-Smith, 1961).

These data do not report the incidence of pain in patients undergoing active therapy for cancer and do not attend to the causes of

the pain. Of the 36,800 admissions to MSKCC between January 1974

and January 1978, 4,240 (or 9%) of patients had pain of

significant magnitude and complexity that required a specific

consultation from the Pain Service. A survey of the entire inpatient population of MSKCC during a one-week period revealed

that, of 540 patients evaluated, 156 (or 29%) had pain requiring

the use of analgesic drugs. Postoperative pain was not included

in this study. Certain tumors were associated with a high

incidence of pain. For example, 85% of the patients with primary

bone tumor and 52% of the patients with carcinoma of the breast

had pain, whereas only 5% of patients with leukemia had pain. On

the pediatric ward, 13 of the 39 in-patients had pain, and in 8 of

the 13, primary bone tumors were the major cause of pain. In a

172
second review, 397 of 420 patients approached for study agreed to

personal interviews. Of these, 152 (38%) complained of pain;

39 of these 397 patients were terminal, and 23 of the 39 (or 60%)

had pain (Foley, 1979). From these 2 surveys and from a review of

our outpatient clinic population and inpatient consultation

service, the specific syndromes in patients with cancer have been

classified into 3 major categories. The rationale for this

categorization was twofold: 1) to detail a series of specific pain

syndromes, facilitating their diagnostic approach, and 2) to

provide a common ground for discussing therapeutic approaches used

in the management of such patients. It is readily apparent from

the literature on cancer pain that there is no common data base to

discuss diagnostic and therapeutic approaches used in the management of cancer patients. From our clinical experience, it is

obvious that there is a series of common pain syndromes which

occur in this population, but they are often misdiagnosed because

general physicians are unfamiliar with their modes of

presentation. For example, 18% of patients in our outpatient

clinic had an incorrect diagnosis at the time they presented with

their clinical pain syndrome. Awareness of these common pain

syndromes has led us to detail the nature of pain as it occurs in

cancer patients into a series of pain syndromes. They include

(see Table 1):

(A) Pain syndromes associated with direct tumor involvement. This

group) accounts for approximately 78% of pain problems in our inpatient population and approximately 62% of patients in an outpatient clinic study (Kanner & Foley, 1981). Metastatic bone

disease, nerve compression or infiltration, and hollow viscus

involvement are the most common causes of pain from direct tumor

involvement. These pain syndromes generally present as an acute

pain problem which, when appropriately diagnosed and treated,

result in dramatic resolution of the pain.

(B) Pain syndromes associated with cancer therapy. This group

accounts for 19% of pain problems in an in-patient survey and

approximately 28% of patients in an out-patient survey, and

includes those patients in whom pain occurs in the course of or as

a result of surgery, chemotherapy, or radiation therapy. Each of

these syndromes has a characteristic pain pattern and clinical

presentation. The pain is often chronic and severe, and treatment

for these patients is often difficult and disappointing.

Identification of the cause of the pain as not due to tumor

clearly alters the patient's therapy. For example, in a patient

with aseptic necrosis of the hip occurring during the course of

treatment of Hodgkin's disease, hip replacement and not further

chemotherapy or radiation therapy provides dramatic relief

of the pain and markedly alters the patient's psychological state,

relieving him of fear of recurrent disease. Within this category

is a series of patients who develop chronic pain in the setting of

a history of cancer; and for some of these patients it is the

chronic pain problem, not their underlying disease, that becomes

the major issue. For such patients, then, the approach must

include not only attention to their pain but also to the manage173
TABLE 1. SPECIFIC PAIN SYNDROMES IN PATIENTS WITH CANCER

A. PAIN SYNDROMES ASSOCIATED WITH DIRECT TUMOR INFILTRATION

1. Tumor infiltration of bone

a. base of skull syndromes

1) juqular foramen metastases

2) clivus metastases

3) sphenoid sinus metastases

b. vertebral body syndromes

1) C2 metastases

2) C7, T1 metastases

3) L1 metastases

c. sacral syndrome

2. Tumor infiltration of nerve

a. peripheral nerve

1) peripheral neuropathy

b. plexus

1) brachial plexopathy

2) lumbar plexopathy

3) sacral plexopathy

c. root

1) leptomeningeal metastases

d. spinal cord

1) epidural spinal cord compression

3. Tumor infiltration of hollow viscus

B. PAIN SYNDROMES ASSOCIATED WITH CANCER THERAPY

1. Postsurgery syndromes

a. postthoracotomy syndrome

b. postmastectomy syndrome

c. postradical neck syndrome

d. phantom limb syndrome

2. Postchemotherapy syndromes

a. peripheral neuropathy

b. aseptic necrosis of the femoral head

c. steroid pseudorheumatism

d. postherpetic neuralgia

3. Postradiation syndromes

a. radiation fibrosis of brachial & lumbar plexus

b. radiation myelopathy

c. radiation-induced second primary tumors

d. radiation necrosis of bone

C. PAIN SYNDROMES NOT ASSOCIATED WITH CANCER OR CANCER THERAPY

1. Cervical & lumbar osteoarthritis

2. Thoracic & abdominal aneurysms

3. Diabetic neuropathy

174
ment of many of the psychosocial problems that arise because of

the continuous painful illness. Treatment of these patients

remains difficult and controversial at best.

(C) Pain syndromes unrelated to the cancer or the cancer therapy.

From our in-patient survey, approximately 3% of patients have pain

unrelated to‘their cancer or their cancer therapy. As high as 10%

of patients in an out-patient clinic survey had pain unrelated to

their cancer or cancer therapy. The pain syndromes in this group

of patients include the wide variety of common pain problems that

occur in the general population, including diabetic neuropathy,

rheumatoid arthritis, osteoarthritis, and osteoporosis. Similarly,

accurate diagnosis in this group of patients clearly alters both

their therapy and prognosis.

Since the majority of pain problems in patients with cancer tend

to be acute or subacute, analgesic drug therapy represents the

mainstay of therapy for this group of patients. From our 1977

survey of the in-patient population at MSKCC, of the 152 patients

complaining of significant pain: 126 were receiving analgesics,

94 patients were receiving a narcotic analgesic alone or in

combination with a non-narcotic, 32 patients were receiving a nonnarcotic analgesic alone, and in 26 patients no analgesics were

prescribed. Of interest, 23 of these 26 patients were receiving

steroids as part of their chemotherapy regimens. Only 5 patients

were receiving antidepressant drugs, specifically amitriptyline.

Of the 94 patients receiving narcotic analgesics, 63 patients were

receiving them for less than 3 weeks, 21 were receiving them for

less than 15 weeks, and 10 patients had been taking narcotic analgesics for greater than 20 weeks. The most commonly used narcotic

analgesics in this population included Darvocet (propoxyphene plus

acetaminophen), Percodan (oxycodone plus aspirin), Percocet

(oxycodone plus acetaminophen), levorphanol, and methadone. For

parenteral use, the most commonly used drugs included morphine,

neperidine, levorphanol, methadone, and hydromorphone. 85% of the

patients who received analgesics reported good to excellent relief

of their pain; 5% reported only mild relief, and 10% reported no

relief. Of interest, of those patients reporting no relief, mild

analgesics (propoxyphene plus acetaminophen, or meperidine) had

been prescribed for complaints of severe pain, suggesting

undermedication as an important cause of inadequate analgesia.

In order to assess the patterns of analgesic drug use in an

out-patient cancer pain clinic, we then reviewed the charts of all

new patients seen in the out-patient clinic at MSKCC during a

2-year period from January 1, 1977 to December 31, 1978. Of

119 patients, 103 charts were available for detailed analysis.

86 patients had pain and a cancer diagnosis; 17 patients had

chronic, non-malignant pain diagnoses. At the time of their first

evaluation in the Pain Clinic, 65 patients were receiving narcotic

analgesics alone or in combination with other medications.

22 patients were not taking any analgesics; 5 were taking only

non-narcotic analgesics, and 11 patients were taking either

sedative, psychotropic, or anticonvulsant drugs. Aspirin and

175
acetaminophen were the most commonly used non-narcotic analgesics,

whereas Percocet (oxycodone plus acetaminophen) and meperidine

were the most commonly used narcotic analgesics. The other

narcotic analgesics in use included Percodan (oxycodone plus

aspirin), codeine, and levorphanol. All drugs were prescribed for

oral use, and no patient was receiving drugs parenterally. The

amount of drug intake ranged from the analgesic equivalent of

5-150 mg of parenteral morphine sulfate per 24 hours (MS/24 hrs)

and varied with the nature of the pain. Patients with tumorrelated pain were taking significantly higher doses of narcotic

analgesics than were the patients with non-tumor pain. Of the 38

patients not receiving any narcotic analgesics, 3 were begun on

such drugs following their initial evaluation in the Pain Clinic.

These 3 patients had metastatic bone disease. At the end of

3 months, follow-up data were available on 81 of the original 103

patients. 45 patients were receiving narcotic drugs, 42 of whom

had been taking narcotic analgesics at the initial evaluation.

Within this group of 45 patients, 3 patterns of drug use were

evident. Group 1 consisted of 14 patients who had increased or

doubled their amount of narcotic analgesic in the 3-month period.

13 of these patients had a malignant origin of their pain, and

12 of 13 were dead by the 6-month follow-up. Escalation of their

drug intake was associated with rapidly progressive disease. This

sharply contrasts with only 11 deaths in that same period among 62

cancer patients who did not increase their drugs. Group 2

included 14 patients who either reduced their drug intake (N=11)

or discontinued their drugs (N=3). In this group the reduction of

drug intake was associated with concurrent anticancer therapy and

pain relief. In the 17 patients who maintained their stable drug

intake, all had evidence of non- progressive disease or a

non-malignant pain syndrome. 36 patients were not receiving

narcotic drugs at the end of 3 months. Six-month follow-up data

were available on 76 patients of the original 103 patients.

23 patients were dead, and 53 were still alive. Drug intake data

were available on 53 patients at this 6-month follow-up, and 28

(or 53%) were still taking narcotic analgesic drugs. Of the 28

patients receiving narcotics, 25 had tumor-related pain and 3 had

benign pain. In the cancer patients receiving narcotic analgesics

for pain relief, there was no evidence of drug abuse. No patients

overdosed with their medication, took more than was prescribed, or

illicitly tried to buy or sell their narcotic drugs. In contrast,

2 of 17 patients with chronic non-malignant pain abused their

drugs, continually took more than prescribed amounts, and

overdosed on the drugs prescribed. Both these patients had a long

history of drug abuse behavior prior to their admission into the

Pain Clinic.

This limited survey provides some useful clinical data on the

patterns of analgesic drug use in a cancer population and poses

some interesting questions. What is the best analgesic reqimen

for such patients? To what degree does the development of

physical dependence and tolerance occur? How complete is cross

tolerance? Does chronic narcotic administration for the treatment

of pain result in psychological dependence or drug abuse? The

176
answers to these questions remain unknown but lie in carefully

controlled clinical studies on patients receiving narcotic

analgesics for pain, such as the cancer patient. However, it is

this lack of data that has led to controversy about the use of

analgesic drugs in patients with cancer pain. The controversy is

focused on three main issues:

1) The choice of an analgesic and its method of administration.

The English hospice movement promulgated the use of an oral

analgesic cocktail - the Brompton cocktail or mixture - in the

management of patients with terminal illness and pain. This

mixture, consisting of a narcotic analgesic, heroin, a phenothiazine, cocaine,and alcohol in a sweetened syrup, was given to

patients on a regular basis with the dose of the analgesic adapted

to the individual needs of the patient. Clinical studies of this

mixture by Twycross led to the removal of cocaine from the cocktail, as it did not provide additive analgesia. Further studies by

Twycross demonstrated that morphine in equianalgesic doses could

be substituted far heroin with comparable analgesic effects.

Mount (1976) also reported the successful use of oral morphine in

controlling pain in patients with terminal illness, and he used

only liquid oral morphine in a 10% alcohol solution, flavored for

the individual needs of the patient. Kaiko et al. (1980) studied

the analgesic efficacy of heroin in patients with both postoperative and chronic cancer pain and showed that there were no

significant differences between morphine and heroin in their

analgesic efficacy, effects on mood, or side effects. Heroin did

have a more rapid onset of action and a shorter duration of effect

as compared to morphine. It did not, however, appear to offer any

special advantages to morphine in the management of the cancer

pain patient. Therefore, there is no demonstrable clinical study

to support the thesis that legalization of heroin will improve the

analgesic management of the cancer pain patient. Similarly, no

controlled studies have compared the efficacy of oral liquid

narcotic solutions to other forms of available oral analgesics.

More importantly, the role of analgesics with a long plasma halflife, e.g., methadone, 17-24 hrs; levorphanol, 15-17 hrs (Dixon et

al. 1980) remains unclarified. How does the long plasma life relate

to the duration of effect and development of side effects? Anecdotal reports have suggested that methadone has limited usefulness in

cancer pain management (Ettinger 1979). Our own studies have demonstrated that the pharmacokinetics of methadone vary by 50% among cancer patients receiving the drug for pain relief (Inturrisi 1981).

These are only a few examples of the tremendous need to develop

guidelines based on careful clinical studies, not limited

experiences or anecdotal data.

2) The development of tolerance. In contrast to Twycross'

experience, tolerance occurs in patients with pain and progression

of disease, representing a significant practical management

problem. Previous studies by Houde (1967) have demonstrated the

development of tolerance in cancer patients receiving narcotic

analgesics for pain relief. The relationship of increasing pain

177
severity, with increasing requirements for narcotic drugs, to the

development of tolerance to such drugs represents an important and

unanswered question; and specific studies to further assess these

clinical phenomena are in order. In our group of patients without

progression of disease who were stabilized on a set dose of

narcotic drug and had adequate pain control, tolerance did not

appear to represent a major clinical problem. Perhaps this group

of patients is comparable to those reported by Twycross. In certain

patients, however, it is necessary to increase amounts of narcotic

drug to control pain adequately, as exemplified in the 13 patients

in our series who markedly escalated their drug use with

evidence of increasing pain and progression of disease.

Escalation of drug dosage, switching to alternative drugs, and use

of combination drug therapy represent empirical approaches to

provide adequate pain therapy. For example, in patients with

intractable pain who become tolerant to the analgesic effects of

increasing dosages of druqs such as levorphanol, switching to an

alternative narcotic, such as methadone, at a dose of one-half the

equianalgesic dose often provides adequate analgesia. Is this

phenornenon incomplete cross tolerance or does it reflect inherent

differences in druqs or specific receptor affinities?

3) Risk of substance abuse, druq dependency and addiction.

Although fear of addiction limits narcotic use by both physicians

and patients, there are no published long-term data to support

the thesis that chronic use of narcotic analgesics causes addiction.

Yet it is this profound fear of addiction that plays a major role

in physicians' underuse of narcotic analgesics in medical illness.

In fact, there is limited available published data to determine

the degree of tolerance, physical dependence, substance abuse or

addiction in patients receiving narcotic analgesics for any type

of chronic medical illness and pain. Many of the published

studies do not adhere to strict definitions for drug use and

abuse, making any review of such data practically impossible.

However, in an attempt to review the available data on the subject

of chronic pain and addiction, information on narcotic drug use

could be obtained from several sources. In 1925, Kolb described

the personality types of 230 narcotic addicts and reported that 9%

of these addicts were "persons of a normal nervous constitution to

whom an opiate had been prescribed to the point of addiction to

relieve the suffering of some prolonged physical condition."

Pescor in 1939 reported that 3.8% of patients admitted to the

Drug Addiction Center at Lexington, Kentucky, had been addicted to

morphine given for "legitimate" reasons. Rayport (1954) used the

term "medical addict" and defined such a patient as "one who

states that he first received narcotics from a physician to the

point of addiction in the course of treatment of illness." He

divided medical addicts into 3 subclasses based on the fate of

178
their illness: Group 1 with self-limited illness, Group 2 with

reversible illness, and Group 3 with irreversible illness.

Studying a representative group of 1,020 male opiate addicts

consecutively admitted to the Public Health Service Hospital in

Lexington, Kentucky, he found the incidence of medical patients

addicted to narcotics was 27% among whites and 1.2% among blacks.

This high incidence figure is often quoted to support the

anecdotal data that the use of narcotic analgesics in patients

with chronic illness leads to narcotic addiction. However, these

data present a very biased view of the subject. In a more recent

prospective study (Porter & Jick, 1980) monitoring the incidence

of narcotic addiction in 39,946 hospitalized medical patients, of

11,882 who received at least one narcotic preparation, there were

only 4 cases of reasonably well-documented addiction in patients

who had no history of addiction. Their data, taken from a survey

on a general population, suggests that medical use of narcotics is

rarely, if ever, associated with the development of addiction.

Further studies of prescription drug abuse provide other indirect

data. The studies by Swanson (1973), Maruta (1979), Gault (1968),

Bakewell & Wikler (1966), Ewing & Bakewell (1967) studied the

abuse of analgesics in patients with chronic illness and found the

abuse of non-narcotic analgesics or combination drugs to be a more

common event than the use of narcotic analgesics. In fact, there

are no data available on the patterns of drug use in patients with

chronic pain in which specific attention has been paid to the

degree of tolerance, physical dependence, or addiction in any of

the patients receiving narcotic analgesics. This lack Of

carefully defined retrospective or prospective drug studies offers

limited support to the belief that chronic narcotic use for

analgesia is associated with a high risk of addiction. Analysis

of the patterns of drug intake in our series of cancer patients

suggests that drug abuse and drug addiction should not be the

primary concern of the prescribing physician. Our data suggest

that drug use alone is not the major factor in the development of

addiction, but other medical, social, and economic conditions seem

to play an important role. This phenomenon has been wellsupported by the studies of the US military personnel addicted to

opiates in Viet Nam (Robins 1973). This natural experiment demonstrated that drug-using behavior was strongly dependent on a series

of factors, including underlying personality and social, environmental, and economic issues, all of which greatly influence and

alter the risk of addiction. Studies designed to evaluate these

issues and to answer the questions are sorely needed. In summary,

the evaluation and treatment of patients with cancer pain requires

a specific expertise which should include a clear understanding of

the nature of the pain and the various approaches of pain management. Carefully controlled clinical studies are lacking, and

there is a need for a strong impetus to develop guidelines of care

based on facts, not anecdotes.

ACKNOWLEDGMENT

Supported in part by the Rita Allen Foundation, and in part by

NIDA grant DA-01707.

179
REFERENCES

Bakewell, W.E., Jr., and Wikler, A. Incidence in a university

hospital psychiatric ward. J Amer Med Asso 196:710-713, 1966.

Dixon, R., Crews, T., Mohacsi, C., Inturrisi, C.E., and Foley,

K.M. Levorphanol: radioimmunoassay and plasma concentration

profiles in dog and man. Res Comm Chem Path Pharm 29:535-548,

1980.

Ettinger, D.S., Vitale, P.J. and Trump, D.C. Important clinical

pharmacologic considerations in the use of methadone in cancer

patients. Cancer Treat Rep 63:457-459, 1979.

Ewing, J.A., and Bakewell, W.E. Diagnosis and management of

depressant drug dependence. Am J Psychiat 123:909-917.

Exton-Smith, A.N. Terminal illness in the aged. Lancet

2:305-308, 1961.

Foley, K.M. Pain syndromes in patients with cancer. In: Bonica,

J.J., and Ventafridda, V., eds. Advances in Pain Research and

Therapy. Vol. 2. New York: Raven Press, 1979. pp. 59-15.

Foley, K.M. The management of pain of malignant origin. In:

Tyler, H.R., and Dawson, D.M., eds. Current Neurology. Vol.2,

Chapt. 18. Boston: Houghton Mifflin, 1979. pp.279-302.

Gault, M.H., Rudwall, T-C., and Redmond, N.I. Analgesic habits of

500 veterans: incidence and complications of abuse. Canad Med Ass

J 98:619-626, 1968.

Houde, R.W. Systemic analgesics and related drugs. In: Bonica,

J.J., and Ventafridda, V., eds. Advances in Pain Research and

Therapy. Vol. 2. New York: Raven Press, 1967.

Inturrisi, C.E., Foley, K.M., Kaiko, R.F., Colburn, W.A., and

Houde, R.W. Methadone: pharmacokinetics and effects in cancer and

chronic pain patients. (submitted for publication)

Kaiko, R.F., Wallenstein, S.L., Rogers, A., Grabinski, P., and

Houde, R.W. Relative analgesic potency of intramuscular heroin

and morphine in cancer patients with postoperative and chronic

pain. National Institute on Drug Abuse Research Monograph, Proc

42nd Annual Sci Meeting, Comm Prob Drug Dep, Inc., 1980 (in

press).

Kanner, R.M., and Foley, K.M. Patterns of narcotic drug use in a

cancer pain clinic: recent developments in chemotherapy of

narcotic addiction. Ann NY Acad Sci, 1981.

Kolb, L. Types and characteristics of drug addicts. Ment Hyg

9:300, 1925.

180
Lipman, A. Drug therapy in terminally ill patients. Am J Hosp

Pharm 32:270-276, 1975.

Maruta, T., Swanson, D.W., and Finlayson, R.E. Drug abuse and

dependency in patients with chronic pain. Mayo Clin Proc

54:241-244, 1979.

Mount, B.M., Ajemian, I., and Scott, J.F. Use of Brompton mixture

in treating the chronic pain of malignant disease. Canad Med Ass

J 115:122-124, 1976.

Pasternak, S.R., and Foley, K.M. Personality traits and cognitive

style in chronic pain patients. Doctoral dissertation, Teachers

College, Columbia University, 1980.

Pescor, M.J. The Kolb classification of drug addicts. Publ

Health Rep, Supp 155. United States Public Health Service,

Division of Sanitary Reports and Statistics, 1939.

Porter, J., and Jick, H. Addiction rare in patients treated with

narcotics. New Eng J Med 302(2):123, 1980.

Rayport, M. Experience in the management of patients medically

addicted to narcotics. J Am Med Ass 156(7):684-691, 1954.

Robins, L.N. A follow-up of Vietnam drug users. Special Action

Office Monograph. Sci. A:1-23, 1973.

Swanson, D.W., Weddige, R.L., and Morse, R.M. Abuse of

prescription drug. Mayo Clin Proc 48:359-367, 1973.

Twycross, R.G. Clinical experience with diamorphine in advanced

malignant disease. Int J Clin Pharmacol 9:184-198, 1974.

Twycross, R.G. Value of cocaine in opiate containing elixers.

Br Med J 2:1348, 1977.

Twycross, R.G. Choice of strong analgesic in terminal cancer:

diamorphine or morphine. Pain 3:93-104, 1977.

AUTHOR

Kathleen M. Foley, M.D., Memorial Sloan-Kettering Cancer Center,

1275 York Avenue, New York, New York 10021.

181

Appendix

Workshop Recommendations

Research - Kathleen Foley, M.D.

Strongly supported the finely detailed recommendations

of the Interagency Committee in the areas of urgent research

needs. (The Interagency Committee on New Therapies for

Pain and Discomfort-Report to the White House May 1979).

In addition, submission was made by the Research subgroup as

follows:

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

That chronic pain (acute pain also) be recognized

as an important medical problem in this country

and receive priority rating in the evaluation

and treatment of patients in research funding.

Develop a taxonomy for chronic pain states to

allow a series of further studies to follow.

1. Presently there are taxonomy studies in pain

being developed by The International Association

for The Study of Pain (IASP).Request NIH support

to implement-and facilitate work of this committee.

Study natural history of acute and chronic pain.

1. Include epidemiology of pain

2. Develop a national study in which various chronic

pain states are evaluated.

3. Patterns of care, economic, social, political

impact of chronic pain would be part of study.

Recognition of chronic pain as a disease state

with its own characteristics.

Chronic pain should be recognized as having research

goals:

1. neuroanatomical

2. neurophysiological

3. neuropharmacological

4. behavioral-psychological

5. socio-economic

6. ergonomic

Establish specific committee for supervision of pain

research grants.

1. Specific funds for research in pain to be alloted

to this committee.

2. Not dependent on money from other agencies.

Develop series of specific pain centers with

specific expertise.

1. Training center for physicians for research

and clinical training in acute and chronic

pain.

2. Development of new methods for treatment of

pain.

Develop National Data Bank for all pain studies.

185
Professional Education and Training -

Hubert Rosomoff, M.D.

I. Supports the premise that chronic pain be

recognized as a disease entity.

1. Separate funding for education, research, public

information,and clinical management.

2. Separate study section and council.

3. Separate clinical management categories.

II. Education short term goals:

1. Funding to be available for training programs

for all categories of health professionals.

2. Start with funding to establish pain programs

to start soon.

III. Accept Dr. John Bonica's recommendations as follows:

A. Preliminary Tasks

1. Epidemiologic studies on acute and chronic pain.

2. Survey by DHHS in collaboration with the IASP

and APS and U.S. school of medicine, dentistry,

nursing and other allied health professions.

a. What education and training students are

receiving about pain in their schools.

3. Survey of directors of residency programs of

various specialties requesting similar

information.

4. For 2 and 3 use forms easy to fill out.

5. Survey of AMA Committee on Education and, finally

followup by emphasizing the importance of pain

as a public health problem and the reasons for

deficiencies and importance of teaching and

education and training.

a. Use articles in medical journals.

b. Materials sent out to the above groups.

B. Undergraduate Education and Training (students of

medicine, dentistry. nursing, psychology, social

work, and other allied health professions)

1. Core curriculum for medical students

a. Lectures on basic aspects of pain by basic

science and clinical algologists.

1. The importance and magnitude of pain

as a public health, sociologic, and

economic problem.

186
2. Definition between acute and chronic pain.

3. Lectures on neuroanatomy, neurophysiology,

biochemistry, psychology, and behavioral

aspects of acute pain emphasizing wholistic

approach.

a. Emphasis of deleterious physical,

psychologic, and behavioral effects and

complications of inadequately relieved

severe acute pain.

4. Lecture on mechanisms of chronic pain and the

psychologic, social, and behavioral effects

on patient and family.

5. Description of special acute pain problems and

chronic pain syndromes including etiology,

mechanisms, pathophysiology, and symptomatology.

b. Clinical aspects (to be taught in clinical years)

1.

2.

3.

4.

5.

6.

7.

8.

9.

Press for retention of basic knowledge.

The review of various aspects of acute and

chronic pain problems.

Basic principles of managing acute and

chronic pain.

Evaluation and proper use of analgesics and

related drugs--narcotics, non-narcotics,

psychotrophic drugs, etc., including

advantages, disadvantages, indications,

contradictions, and complications.

Evaluation and proper use of psychologic

techniques, behavior modification, hypnosis,

biofeedback, psychiatric care.

Evaluation and proper use of diagnostic

and therapeutic nerve blocks.

Evaluation and proper use of neurostimulating techniques, TNS, brain

stimulation, and spinal cord.

Evaluation and proper use of neurosurgical techniques.

The multidisciplinary approach to pain

problems.

2. Selective Courses

a. Pretest of knowledge presented in-core

curriculum.

b. Lectures, seminars, conferences to

discuss specific pain problems.

187

348-347 0 - 81 - 13
1. Acute pain such as postoperative,

postburn, post-traumatic, acute

pancreatitis, etc.

2. Chronic pain syndromes, trigeminal

neuralgia, causalgia and other

reflex sympathetic dystrophy, low

back pain, arthritis, cancer, etc.

C. Test After Clerkship

I. Elective clerkship for dental students.

2. Elective clerkship for nurses, social

workers, etc.

3. Sources of information

a. Copies of lectures

b. Reprints of key articles

c. Small (100-500 pages) monograph or

syllabus on pain and its aspects as

taught in the core curriculum clerkship.

d. Motion pictures

e. Audio-visual techniques

f. Audio tapes

g. Attendance of symposia on pain held

locally.

4. Examination

a. Written or practical examination to

evaluate educational and training

effort.

D. Graduate Students (Interns and Residents in

Family Medicine or Special Training)

1. Examination to evaluate retention of

knowledge presented in undergraduate

courses.

2. Didactic course of lectures and seminars

with focus and emphasis on pain problems

encountered by each group.

3. Team conferences (e.g., surgeon, anesthetist,

nurse, social worker) for postoperative pain.

a. Lectures and seminars on aspects

relevant to pain care.

b. Discretion of specific patients with

various pain problems.

C. Teaching rounds.

188
4. Sources of Information

a. Same as A. 5

b. Syllabus or monograph for each

specialty.

c. Postgraduate courses on pain at state

regional, and national meetings.

d. Attendance of pain clinic conference

considering pain relevant to particular

specialty.

E. Graduate Courses for Practicing Physicians and

Other Health Professionals

1. One- to two-day courses, intensive, basic

and clinical aspects.

2. Series of lectures over period of two months.

3. Week-long refresher course, intensive review

of basic and current aspects and clinical

demonstration by panel of basic scientists

and clinical algologists.

4. One month clinical refresher course in pain

clinic.

5. Fellowship for training of clinical algologists

for periods of 6 months, 12 months, and 2 years.

6. N.B. all above should have examinations before

and after course to evaluate efforts.

7. Circuit courses, one-day course by team of basic

and clinical algologists.

a. Develop panels of basic scientists and clinical

algologists to put on two- to five-day course in

different parts of country, pre-course and

post-course testing.

8. Panel of basic and clinical algologists to

participate in meetings of county, state, national

societies, and community hospital staffs.

9. Develop audio tapes and audio-visual tapes on

special topics, e.g., postoperative pain,

causalgia, neuralgia, back pain, etc.

10. Attendance of APS and IASP meetings.

11. Health agencies, legal professionals, legislators,

insurers, etc.

189
F. Establish and Sponsor Special Workshops on Pain

1. Economics

a. cost containment

b. quality control

c. providers

d. beneficiaries

2. Legislation

3. Medical-legal aspects of pain

G. Long Term Goal

1. Funding of program

a. Clinical pain management

b. Clinical pain management facilities

190
Public Education -- Joel Seres, M.D.

I. Specific Goals

1. Dissemination of Information

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

k.

Define chronic pain as a major health, social,

and economic problem.

Classify the problem in broad terms for public

understanding of:

1. acute pain

2. chronic pain

3. cancer pain

Design educational programs on differences in

treatment of acute and chronic pain.

Survey public on present state of knowledge

of pain.

On the availability of a second opinion regarding

medical care:

1. how obtained

2. where obtained

3. what to do when second opinions are difficult

to get.

Identify existing resources regarding dissemination

to public.

Differentiate between impaired function versus

limitation for public

Identify family role and significant others on

pain and its therapy.

Identify effects of chronic pain on totality of

person and their environment (family, social

relationships, vocational).

Educate as to seeking of help-no need to sit

and suffer.

Create clearing house specifically for pain

similar to NCI Cancer Information Clearing

House, but separate from that which exists

for other diseases states.

191
II. Agree with Subcommittee's suggestion that ad-hoc working

groups be formed depending on issues to be considered.

As suggested in Subcommittee's report, participants in

the ad-hoc working group might include:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Persons who have experienced various degrees of

pain and discomfort associated with terminal illness

Persons who have experienced various health-related

practices associated with terminal care

Boards of public and private education agencies

Civic, religious, and social groups

Employers and labor organizations

Health education specialists

School teachers and administrators

Adult educators

Community organizers

Outreach workers and counselors

Social service specialists

Communications media personnel

Psychologists, sociologists, and anthropologists

Health and education professional associations

Community councils

Medical school administrators

Medical association officials

State and local medical society representatives

State and local public health officers

American Public Health Association representatives

Health planners and organizers of health

education programs

22. Insurance industry representatives

23. State compensation officials

24. Attorneys defense and plaintiff

25. Federal agencies--Social Security, etc.

192
III. Audience

1. Members of Congress

2. Staff of NIH and other Federal health agencies

3. Staff of state health agencies

4. Committees on education and training of undergraduate, graduate, postgraduate studies of AMA,

state and county medical societies

5. Staffs of nongovernmental health agencies and

groups interested in various health problems

in which pain is a special problem:

a. American Cancer Society and other cancer groups

b. American Arthritis Association

c. American Heart Association, etc.

6. Biomedical science writers and other news media

7. Key TV people

8. Staff of insurance companies and-third party

bearers of health services

9. Members of various large national and international organizations, e.g. Kiwanis, Lions, etc.

10. The public in general

IV. Mechanism for Public Education

1.

2.

3.

4.

5.

6.

7.

8.

9.

Newspaper articles

Special articles in lay journals

TV programs

TV documentaries

Short brochures for lay people containing information

about:

a. the general aspects of pain

b. special pain problems

Develop panels of speakers for personal presentations

Write small books for lay diffusion of information

News magazines

Telethons

193
V. Content of Information to Public

1. Current status of pain diagnosis, therapeutic

modalities and agents

a. Drugs and their use-control of nausea due

to chemo and radiation therapy

1. Marijuana and THC

b. Management of pain

1. Early (Aspirin, DMSO etc.)

2. Terminal (heroin, morphine etc.)

C. Proper administration of medication

1. Drug abuse

2. Drug dependence

3. Addiction

2. Modalities for pain

a. Acupuncture, biofeedback, hypnotherapy, etc.

3. Status of programs emphasizing humanitarian

care of terminally ill, i.e., hospices

4. Pain centers and how they work

VI. Short Term Coals

1. Provide mass media presentation to public

a. problems

b. availability of treatment

C. education

2. Funding

a. public (government agencies)

b. private (insurance companies, etc.)

3. Data gathering of public state of knowledge

4. Ad-hoc committee to develop programs, content

organization

5. Early meeting date to continue process

VII. Long term goals

1. Develop programs based on data received

2. Develop material to meet these specific needs

3. Develop approach for dissemination of this material

4. Hire public education people to implement all

of the above.

194
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1 FINDINGS OF DRUG ABUSE RESEARCH. Not available from NCDAI.

Vol. 1: GPO out of stock NTIS PB #272 867/AS $27.50

Vol. 2: GPO out of stock NTIS PB #272 868/AS $27.50

2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH

1975. Jack Elinson, Ph.D., and David Nurco, Ph.D., eds. Not

available from NCDAI.

GPO out of stock NTIS PB #246 338/AS $14

3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE? Bruce J.

Bernard, Ph.D., ed.

GPO Stock #017-024-00486-3 $2.25 NTIS PB #246 687/AS $14

195
4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette, Ph.D., ed.

GPO Stock #017-024-00488-O $1.10 NTIS PB #247 096/AS $6.50

5 YOUNG MEN AND DRUGS: A NATIONWIDE SURVEY. John A. O'Donnell,

Ph.D., et al. Not available from NCDAI.

GPO Stock #017-024-00511-8 $2.25 NTIS PB #247 446/AS $14

6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. Jay R.

Williams, Ph.D.

GPO Stock #017-024-00512-6 $1.05 NTIS PB #249 092/AS $6.50

7 CANNABINOID ASSAYS IN HUMANS. Robert Willette, Ph.D., ed.

GPO Stock #017-024-00510-0 $1.95 NTIS PB #251 905/AS $12.50

8 Rx: 3x/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Blaine, M.D.,

and Pierre Renault, M.D., eds.

Not available from GPO NTIS PB #253 763/AS $12.50

9 NARCOTIC ANTAGONISTS: NALTREXONE PROGRESS REPORT. Demetrios

Julius, M.D., and Pierre Renault, M.D., eds.

GPO Stock #017-024-00521-5 $2.55 NTIS PB #255 833/AS $15.50

10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

Ph.D., and Louise B. Blevens, eds. Examines methodological issues

in surveys and data collection. Not available from NCDAI.

GPO Stock #017-024-00571-1 $2.60 NTIS PB #266 691/AS $20

11 DRUGS AND DRIVING. Robert Willette, Ph.D., ed. Reviews

research on effects of drugs on psychomotor performance, focusing

on measures of impairment by different drugs at various levels.

GPO Stock #017-024-00576-2 $1.70 NTIS PB #269 602/AS $14

12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

Demetrios A. Julius, M.D., eds. Theoretical and clinical papers

concerned with the intrapsychic determinants of drug addiction.

GPO Stock #017-024-00642-4 $2.75 NTIS PB #276 084/AS $15.50

13 COCAINE 1977. Robert C. Petersen, Ph.D., and Richard C.

Stillman, M.D., eds. Reports the extent and limits of current

knowledge about cocaine, its use and misuse.

GPO Stock #017-024-00592-4 $3 NTIS PB #269 175/AS $17

14 MARIHUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

ed. Technical papers on which the 6th Marihuana and Health report

to Congress was based.

GPO Stock #017-024-00622-O $3 NTIS PB #271 279/AS $20

15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm.

Sharp, Ph.D., and Mary Lee Brehm, Ph.D., eds. Review of inhalant

abuse, including an extensive bibliography.

GPO Stock #017-024-00650-5 $4.25 NTIS PB #275 798/AS $26

196
16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne

Rittenhouse, Ph.D., ed. Task Force report on research

technologies and implications for studying heroin-narcotic use.

GPO Stock #017-024-00690-4 $3.50 NTIS PB #276 357/AS $18.50

17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D.,

et al., eds. Includes epidemiology, etiology, consequences of

use, and approaches to behavioral change. From a NIDA-supported

UCLA conference.

GPO Stock #017-024-00694-7 84.50 NTIS PB #276 353/AS $27.50

18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D., ed. Theoretical and empirical studies

of nonpharmacologic factors in development of drug tolerance.

GPO Stock #017-024-00699-8 $2.75 NTIS PB #276 337/AS $14

19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen,

Ph.D., ed. Papers from the VI World Congress of Psychiatry which

deal with drug issues of particular interest worldwide.

GPO Stock #017-024-00822-2 $4.50 NTIS PB #293 807/AS $24

20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FOR STUDY.

Norman A. Krasnegor, Ph.D., ed. Techniques used to study basic

processes underlying abuse of drugs, ethanol, food, and tobacco.

GPO Stock #017-024-00794-3 $3.75 NTIS PB #288 471/AS $20

21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

Ph.D., and Richard C. Stillman, M.D., eds. Pioneering volume for

clinicians and researchers assessing what is known about the

problem of PCP abuse.

GPO Stock #017-024-00785-4 $4.25 NTIS PB #288 472/AS $23

22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF

ANALGESICS, NARCOTIC ANTAGONISTS, AND HALLUCINOGENS. Gene

Barnett, Ph.D.; Milan Trsic, Ph.D.; and Robert Willette, Ph.D.;

eds. Reports from an interdisciplinary conference on the

molecular nature of drug-receptor interactions.

GPO Stock #0l7-024-00784-2 $5.25 NTIS PB #292 265/AS $33.50

23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A.

Krasnegor, Ph.D., ed. Discusses factors involved in the onset,

maintenance, and cessation of the cigarette smoking habit.

Includes an agenda for future research.

GPO Stock #017-024-00895-8 $4.50 NTIS PB #297 721/AS $17

24 SYNTHETIC ESTIMATES FOR SMALL AREAS: STATISTICAL WORKSHOP

PAPERS AND DISCUSSION. Joseph Steinberg, ed. Papers from a

workshop cosponsored by NIDA and the National Center for Health

Statistics on a class of statistical approaches that yield needed

estimates of data for States and local areas. Not available from

NCDAI.

GPO Stock #017-024-00911-3 $5 NTIS PB #299 009/AS $21.50

197
25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman

A. Krasnegor, Ph.D., ed Papers present commonalities and

implications for treatment of dependency on drugs, ethanol, food,

and tobacco.

GPO Stock #017-024-00939-3 $4.50 NTIS PB #80-112428 $20

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

ed. Reprint of the behavioral section of the 1979 Report of the

Surgeon General on Smoking and Health; introduction by editor.

GPO Stock #017-024-00947-4 $4.25 NTIS PB #80-118755 $15.50

27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. Not available from

NCDAI.

GPO Stock #O17-024-00981-4 $8 NTIS PB #80-175482 $35

28 NARCOTIC ANTAGONISTS: NALTREXONE PHARMACDCHEMISTRY AND

SUSTAINED-RELEASE PREPARATIONS. Robert Willette, Ph.D., and

Gene Barnett, Ph.D., eds. Papers report research on inserted

sustained-release and long-acting drug devices, and on possible

use with the narcotic antagonist naltrexone. In press.

29 DRUG ABUSE DEATHS IN NINE CITIES: A SURVEY REPORT. Louis A.

Gottschalk, M.D., et al. Epidemiologic study providing dsta on

drug-involved deaths and procedures for their investigations.

Not. available from NCDAI.

GPO Stock #017-024-00982-2 $4.25 NTIS PB #80-178882 $15.50

30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES.

Dan J. Lettieri, Ph.D.; Mollie Sayers; and Helen Wallenstein

Pearson, eds. Volume presents summaries of the major contemporary theories of drug abuse by each of 43 leading theorists.

GPO Stock #0l7-024-00997-1 $8.50 Not available from NTIS

31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed. The text of the 8th Marijuana and Health report to Congress

and the background scientific papers on which this summary report

was based.

GPO Stock #017-024-01010-3 $5 NTIS PB #80-215171 $18.50

32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz. A

collection of methods for the quantitative analysis of several

important drugs of abuse by the technique of gas chromatographymass spectrometry.

GPO Stock #017-024-01015-4 $5 NTIS PB #81-133746 $17

34 PROBLEMS OF DRUG DEPENDENCE, 1980: PROCEEDINGS OF THE 42ND

ANNUAL SCIENTIFIC MEETING, THE CDMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. Comprehensive

assemblage of ongoing research on drug abuse, addiction, and new

compounds.

GPO Stock #017-024-01061-8 $7 NTIS PB #81-194847 $32

198

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