Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minn. Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.
In this 40-year-old program, that’s a deal breaker. Participants must agree to taper off pain medications during their time at Mayo.
More than 80 percent of the patients who enroll stay for the entire program, said Wesley Gilliam, the center’s clinical director, and many previous opioid users who finish the treatment report six months later that they have been able to stay off opioids. Just as important, he added, they have learned strategies to deal with their pain.
But such a program is not for everyone. Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program’s billing codes, he said. Mayo’s insurance team sometimes advocates on patients’ behalf if they’re good candidates for treatment, but success isn’t assured.
Mayo’s program isn’t the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients’ reliance on addictive medications to manage their pain. But as the nation weathers an opioid epidemic, there are too few programs like these around the country to address the need, Gilliam said.
Gilliam, a clinical psychologist with a specialty in behavioral pain management, talked with me about the program.
The transcript has been condensed and edited for clarity.
Q: How do pain medications work? By blunting the pain?
They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They’re not effective in the long term.
Opioids are central nervous system depressants. They soothe people who are in distress. Many people aren’t demonstrating improved functioning when they take opioids; it’s calming their nerves. It’s chemical coping.
Q: In treating pain, does it matter what’s causing it or how severe it is?
Pain is pain. The fundamental approach to self-managing it doesn’t change based on the cause or severity of the pain.
Q: How does someone wind up at a program like yours?
Virtually all of our patients have tried and exhausted primary and secondary treatment options for pain.
[In] primary care, a patient comes in with a complaint, and a treatment plan is developed. It generally involves encouraging the patient to be active, to stretch, maybe the doctor initiates a non-opioid medication like a non-steroidal anti-inflammatory (NSAID) or an antidepressant.
If the patient continues to complain of chronic pain, the primary care provider will step up to level two and refer someone to a neurologist or maybe a pain psychologist or pain anesthesiologist.
If patients don’t respond, they start to think about step three, which is a pain program like Mayo.
Q: How does the Mayo program work?
People come to us every weekday from 8 a.m. to 4 p.m. for three weeks.
We don’t take a medical approach. It’s a biopsychosocial approach, [which] acknowledges not only the biological aspect of pain, but also recognizes that psychological and social variables contribute to how people experience pain.
That is not to say that pain is imagined, but rather how people experience pain is influenced by mood, anxiety and how that person’s environment responds to the person’s symptoms.
A more medical approach tends to focus on targeting and eliminating symptoms at the expense of the recognition of individual differences.
Q: What does that mean for the patient who’s in pain?
People need to accept that they have pain and focus on their quality of life. Some approaches reinforce in patients that the only way you can function is if you reduce your pain, as measured on a pain scale from zero to 10.
We focus on how to get you back into your life by focusing on function instead of eliminating symptoms and pain. When I refer to functioning, I mean getting back into important areas of your life such as work, social activities and recreation. If you’re waiting for pain to go away, you’re never going to get back into your life. When that happens, people get despondent, they get depressed.
Q: So how do you help people manage it?
When you’re in chronic pain and it’s poorly managed, the nervous system can get out of whack. Your body behaves as if it’s under stress all the time, even when it’s not. Your muscles may be tense and your heart and breathing rates elevated, among other things.
With meditation and relaxation exercises, we’re trying to teach people to learn to relax their bodies and hopefully kick in a relaxation response.
If I have low-back pain, for example, during periods of stress muscular tension is going to exacerbate the pain in my back. We focus on helping people to disengage from their symptoms.
By learning to relax in response to stress, muscular tension can be diminished and the experience of pain eased. This doesn’t require a medication or a procedure, just insight and implementation of a relaxation skill.
Relaxation/meditation training is one component of a much broader treatment package. All aspects of our treatment — cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy — are all designed to settle the nervous system.
Q: Does insurance typically cover the program?
Insurance companies may want to see patients complete more conservative treatment approaches before approving an interdisciplinary pain rehabilitation program like ours.
There are patients whose policies don’t cover our billing codes. If we deem a patient a good candidate, we’ll write letters saying they should be accepted.
There are a very select few who have paid out-of-pocket for our program. This is a significant minority, however. The program can cost up to $40,000 for someone with other complicated medical problems in addition to chronic pain.
There are studies that show these programs do save money over the long term in health care costs and reduced health care utilization.
If we’re going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You can’t just treat the symptom, you have to treat the whole person.