Introduction:

IPCA offers expert evaluation of treatment of acute, subacute and chronic pain conditions.  One part ot the IPCA clinic is the IPCA Chronic Pain Management Program (CPM).  The CPM Program is built to help people with chronic pain improve physical function, rely less on the healthcare system for support, and minimize the unpleasantness and prevent/reduce the unwanted emotional, cognitive, and motivational effects of persistent chronic pain, even if the severity of the sensory part of the pain remains unchanged. The core of the Chronic Pain Management Program is the behavioral pain medicine program at IPCA. This is led by a specially trained psychologist. A patient in the CPM will go through cognitive and behavioral individual or group training and may also be prescribed medications, complimentary/Alternative treatments, physical therapy and have procedural treatment as part of the Chronic Pain Management Program at IPCA.

Background:

Often, we cannot completely eliminate the source of pain - anyone with rheumatoid arthritis or chronic back pain will confirm that this is true.   When pain lasts for more than 3 to 6 months the unpleasantness and misery aspect of the pain often becomes more of a problem than the sensory "ouch-factor".  Persistent chronic pain can lead to negative emotional, cognitive, and motivational consequences. 

People who have no experience of moderately to severe pain lasting more than 3 months often have trouble understanding the "unpleasantness/miserableness" side of pain; it is beyond their experience.  This misunderstanding can lead people to ask "why can't people with pain just ignore it, like I do when I have something that hurts?"  Nevertheless, the medical evidence that there is more to chronic pain than just the sensory experience is so convincing that our National Institute of Health has reclassified chronic pain as a disease entity - the NIH no longer considers chronic pain to be a mere byproduct of some other disease (like diabetes, arthritis, cancer, etc).  Chronic pain is a disease of the nervous system that has emotional, motivational, and cognitive effects that transend the sensory experience.  The Chronic Pain management program at IPCA is designed reverse this.

A psychologist with special training in Pain Medicine is a key member of a multidisciplinary pain clinic.  This psychologist leads the Behavioral Pain Medicine program, which is the core of the Chronic Pain Management Program.  In fact, definitions of multidisciplinary pain clinics require that a psychologist be an integral part of the Chronic Pain Management team. 

Here are examples of what the psychologist does:

• The psychologist provides evidence based, proven treatment - one on one and pain groups which emphasize cognitive and behavioral treatment techniques that are now I recommended part of pain treatment based on recent of national guidelines for treating pain. 
  • This treatment can help a person who has had pain longer than 3 months feel a lot better - even if there is no treatment available to decrease the sensory (the ouch-factor) component of their pain. 
  • This treatment can increase the chances that other treatments will work well.  For example, we address and reduce psychosocial issues that would be likely to undermine good treatment results with surgery, physical therapy, etc.
• The pain psychologist does a very important patient assessment:
  • The assessment helps the IPCA team identify people at risk for developing chronic pain, and therefore this assessment guides us to interventions to prevent chronic pain. 
  • The  assessment helps patients avoid pain treatment that is unlikely to work.   The assessment helps the IPCA team identify people with chronic pain who are unlikely, because of psychosocial factors, to respond to treatments like inections and surgery.

The evidence for a Behavior Pain Medicine centered Chronic Pain Management Program:

IPCA's Chronic Pain management program is evidence-based.  The following are a sample of the national guidelines and medical literature supporting our premise that 1. If one cares about achieving the best treatment outcomes then psychosocial factors are important to understand  2. Treatment that addresses psychosocial factors and helps reduce the unpleasantness of chronic pain is effective and is therefore medically necessary:

• The American Pain Society recently published national evidence based guidelines for treating chronic back pain.  The guidelines make 8 recommendations, the second of which is: "Intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis for patients with nonradicular low back pain who do not respond to usual, non-interdisciplinary therapies."  (Chou R Spine May 2009; Vol 34(10):1066-1077)
• A study by Carragee showed that poor coping skills increases - by three fold - the risk that a person will develop low back pain.  (Carragee ET Spine 2004 May 15;29(10):1112-1117)
• A study by Niemisto showed that depression, anxiety, and poor coping skills are more important than physical factors in predicting the outcome of medical and physical therapy treatment of back pain.  (Niemisto L J Rehab Med 2004 May;36(3):104-109)
• A study by Watson showed that depression and anxiety are more important than physical factors in predicting return to work after treatment of back pain.  (Watson P European J Pain 2004 Aug;8:359-369)
• Two randomized prospective studies showed that treatment of psychosocial factors is effective pain therapy - as or more effective than what patient's "traditionally" receive:
  • A study by Linton showed that cognitive behavioral thearapy was more effective than patient education plus conservative medical therapy for back pain - missed work days were much less in the cognitive/behavioral therapy group. (Linton S Spine 2000 Nov 1;25(21):2825-31)
  • A study by Ivar showed that cognitive/behavioral therapy plus excercise was as effective as spine fusion surgery for back pain. (Ivar B Spine 2003 Sept 1;28(17):1913-21)

How do patients get into the Chronic Pain Management Program at IPCA? 

At IPCA we screen every patient at their consult visit with the physician.  When it appears that the patient may be a candidate for the Chronic Pain Management Program we do a multidisciplinary evaluation (provided the patient's health plan covers this service) that includes the physician specializing in pain medicine and the psychologist specializing in medical and health psychology.  Treatment planning takes psychosocial factors into account.  The treatment plan may include individual or group cognitive and behavioral therapy, stress management, coping skills training, biofeedback, and other techniques to address chronic pain, psychosocial factors, and enhance the chances of successful treatment.  The treatment plan may also include medications, complementary and alternative medicine treatment, physical therapy, procedures, consultations with mental health professionals and more.

To Primary Care Providers:

Your patients are screened at referral and at the intitial physician consultation to see if they require the Chronic Pain Management program at IPCA.  Once they are triaged to this clinic, evaluation and treatment are coordinated through regular multidisciplinary rounds, and participation of the Primary Care Provider is essential for success.  Primary Care Providers are asked to participate in at least the first rounds discussion of their patients telephonically.

Some health plans do not cover The Chronic Pain Management Program.  Your complicated patients will often need (require is more appropriate terminology) this program but some - most notably APIPA nsured patients -cannot access it because the Behavioral Pain Medicine evaluaton is not covered.  Complicated patients should not be treated by pain clinics piecemeal with just medications or just procedures because outcomes are rarely good.  The information at the end of this article includes a letter which you can send to your patient's insurance to advocate for evidence-based proper treatment.

To our patients:

Even if pain has not been present very long, psychological stress can increase the chance that pain will become chronic and we can teach skills to prevent that.  We can teach skills to decrease the negative impact of pain - and any pain treatment (spine surgery or injections would be a good example) - on your life.   

We certainly believe that our patients have the pain they say they have.   We know that when people have had pain for more than 6 months, many parts of their lives may have been affected.  Some examples are work, recreational activities, family activities and relationships, and mood.  You may at first have doubts about the behavioral pain medicine evaluation, but it has several important purposes. These include the following:

Help you make tough decisons about how agressive you want to be - when is enough enough?  In general, we help you take an active role in managing your pain - so it doesn't manage you. 

Spend more of your time engaged in the productive and satisfying activities that you want to do

 and -

What you can do if your health insurance plan denies coverage for the IPCA Chronic Pain Program behavioral pain medicine evaluation.

If you are a candidate for the IPCA Chronic Pain Management Program your IPCA doctor will request behavioral pain medicine evaluation and testing for you.  This is the first step of the Chronic Pain Management Program. 

You may find that your insurance company denies coverage for the behavioral pain medicine evaluation.  This would mean that your insurance has denied you access to the Chronic Pain Management Program.  The following information is intended to help you understand why insurance companies deny coverage for the behavioral pain medicine evaluation, and on page 2 we have included a letter fom us, for you to use when communicating with your health insurance company.

Insurance companies deny coverage for the IPCA behavioral pain medicine evaluation and testing for two reasons:

You can help your insurance company understand.

• The behavioral pain medicine evaluation, testing and treatment that your doctor has ordered is pain treatment, not "mental health" treatment. Your insurance company may need your help understanding that the IPCA psychologist will be treating a medical condition, not a mental health condition.  A good analogy would be: the counselling patients in cardiac rehabilitation programs recieve - it has nothing to do with mental health - it is about changing behaviors.
• The behavioral pain medicine evaluation, testing and treatment that your doctor has ordered is evidence-based medical practice - there is research to show that this evaluation is needed.

Your doctor has already made it clear in your clinic notes that you are NOT being referred for mental health services, and your insurance company has these notes.  The information that you are reading right now is available on line to your health insurance plan representative, 24 hours a day.  This is often not enough, but it is all your doctor can do.

Click "Next" below to go to page two of this document to view a letter to an insurance company that has denied coverage for behavioral pain medicine services.  You can print this letter and use it to help educate your insurance company.