A number of studies now demonstrate the efficacy and cost-effectiveness of an integrated, multidisciplinary and behavioral approach to treating chronic pain disorders.  All of us are familiar with the frustration of trying to help these complex and often needy patients in rushed traditional office visits.  Our traditional biomedical model falls particularly short in chronic pain, which generally is caused not only by anatomic or pathophysiologic factors but also involves the conditioning of neurophysiologic systems by pain and by psychosocial experience.  Trauma experienced early in life, for example, is clearly associated with the later development of these disorders.  The typical pain patient’s medical history, with a sequence of failed treatments as a series of specialists try to find and remediate one particular anatomic or physiologic factor at a time, often with poor pain control in the meanwhile, further promotes a pathological conditioning process.  Finally, the use of adjuvant medications, such as anticonvulsants and antidepressants, is often quite effective for pain but poorly accepted by patients who have not been instructed in the mechanisms by which these medications work and may not give them an adequate trial.

     What is needed is a treatment model that addresses the stress and psychosocial dysfunction that the experience of chronic pain and disability creates as well as determining and treating the underlying physical pathology creating and maintaining the pain.  No single prescription will cure a lifetime of hurt, but coordinated treatment which takes these factors into account has proven to be much more successful in improving patients’ functional status and quality of life. This concept is making headlines in the lay press[i] as well as the medical literature[ii].  In a study by Caudill et al, 87% of the patients attending such a program felt they were able to more effectively manage their symptoms and were less depressed, anxious and fatigued by the end of the program, and costs were reduced by a third over a one-year follow-up period in these patients.[iii]

      An integrative pain management program based on this model was conducted at the Full Circle Center for Integrative Medicine in Arcata.  We developed a curriculum based on the Caudill program and the programs developed at the Mind Body Medicine Institute (Herbert Benson’s program in Boston). After a one-on-one 60 min intake with Dr. Basch, groups of 8 – 10 patients met every other week for 2 hours with a physician and a mental health professional for a total of 14 sessions, with aftercare available once a month for those participants interested in continuing this work.  The time was used for:

1. a didactic component on medications, nutrition, exercise, sleep, herbal therapies, etc. (different topics each time),
2. learning and experiencing an exercise to evoke the relaxation response (abdominal breathing, imagery, chair yoga, mindfulness meditation as taught by Jon Kabat-Zin, etc.)
3. a cognitive behavioral therapy component (stress management, communication skills, goal setting, pacing/adaptation/delegation, and so on)
4. a more traditional support group check-in. 
5. a group medical visit with discussion of medications and side effects;  medications were adjusted based on discussions occurring in the group as well as on the pain diaries that patients used to document their functional status and pain relief. 

There was “homework” for the groups, including pain diaries, a relaxation CD recorded by the physician and one of the therapists which was provided free to the patients to use to practice relaxation at home, and various exercises based on the curriculum for each week, including a gratitude journal, an exercise log, goal-setting worksheets, a log of automatic thoughts, and so on.  Feedback from patients involved in these groups was positive with few exceptions, even from many of the patients who were skeptical about them when the concept was introduced.  One patient achieved blood pressure control since starting to meditate, which had eluded him for the past 8 years.  A number of patients were able to decrease or stop pain medications altogether, though this was not an explicit goal of the program.  Other benefits in terms of decreasing isolation and depression were also realized.