Recent evidence-based centre reviews by the Agency for Healthcare Research and Quality have exposed flaws in comprehensive and integrative pain management models. But is this criticism legitimate?
Complexity is key to chronic pain. It requires quantitative and qualitative assessments that assess individual characteristics and their impact on quality of life, function, and long-term outcomes. Different diagnostic criteria, treatment methods, and assessment approaches for managing pain can have an impact on the prognosis as well as the treatment course.
The Biopsychosocial Model and Defining Pain
In 2020, the International Association for the Study of Pain (IASP) revised the definition of pain to include: “an unpleasant sensory or emotional experience that is associated or resembling that which is associated with actual or potential tissue injury.”
The Agency for Healthcare Research and Quality (AHRQ) published a report by the Pacific Northwest Evidence-based Practice Center (EPC) in late 2021. It examined the effectiveness and harms of integrated and comprehensive pain management programs.
Skelly et al. defined the two types they evaluated as:
- Integrative pain management programs (PMPs), which are primary care-based and have embedded or accessible access to multidisciplinary providers and services, are called primary care.
- Comprehensive pain management programs (PMPs), which can be referred from primary care or other sources, provide multidisciplinary services apart from primary care.
Reviewers found that 14 of the 57 studies were of poor quality. The majority (49) of RCTs were comprehensive-type programs. Patients with specific types of chronic pain, such as fibromyalgia or musculoskeletal pain, were eligible for inclusion. Analyses were based on comparisons between usual care and waitlist, as well as medication treatment, physical therapy, or psychological therapy. The reviewers determined each program’s strength of evidence rating (SOE) based on their assessment of medication use, pain outcomes, and function.
AHRQ Report on Biopsychosocial Pain Management Programs
The AHRQ report outlined above aimed to assess the effectiveness and harms associated with pain management programs based on the biopsychosocial care model, especially in the Medicare population. These were the key findings:
- IPMP programs showed minor improvements in chronic pain and function over time compared to waitlisted patients or usual care. With a moderate SOE, the IPMP programs were found to have “statistically significant but not clinically important effects on pain,” according to the authors.
- IPMP programs used more long-acting opioids than usual care models.
- CPMP programs showed moderate improvements in function in the immediate aftermath of the intervention and in the short term. In the studies evaluated, there were no significant changes in pain compared with usual care or patients on a waiting list.
- A limited scope review found insufficient evidence to support changes in opioid prescribing patterns with CPMP models compared with usual care models.
CPMP and IPMP models offered only minor to moderate benefits to chronic pain management when it came down to function, as well as limited improvements in short-term pain management compared with usual care. The inclusion of only limited data did not cause any serious harm.
What does the AHRQ Report mean for integrative and comprehensive pain practices?
The AHRQ report could have profound implications for pain management practitioners, clinicians and patients, payers, and other stakeholders. To avoid confusion, contextualizing the AHRQ report’s findings is essential. This analysis has several limitations due to the limited scope of the studies reviewed, the terminology used in the review and the categories of pain.
Prior Data and Report Limitations
Skelly et al. reported that the study aimed to evaluate pain management programs for Medicare beneficiaries to increase reimbursement and coverage. However, most of the studies included in this analysis involved younger patients. The median age for IPMP programs was 57, and for CPMP programs, it was 45.
The reviewers concluded that:
- Programs that address various biopsychosocial pain aspects, tailor components to patient needs, and coordinate care may be critical to the Medicare population.
- “Although some patients may be able to use a few individual therapies, others may benefit from a broader range of treatments that address all of their biopsychosocial concerns.
These conclusions seem to contradict the initial conclusion of the reviewers that IPMP and CPMP programmes offer little to no benefits based on the limited studies in their review.
Multiple studies contradict this report and have shown that psychosocial models such as functional restoration and interdisciplinarity pain relief programs are effective in improving patient outcomes.34
Amy Goldstein, director at the Alliance to Advance Comprehensive Integrative Pain Management and a managing consultant at Healthcare Collaboratives, LLC, pointed out some weaknesses in the AHRQ report. AACIPM brought together people in pain, providers, payers and other stakeholders to discuss and respond to AHRQ’s open comments. The systematic review’s findings will significantly impact healthcare delivery and payment design.
“AHRQ admits that the strength of the evidence supporting this systematic review is weak,” said Ms Goldstein. “With fewer than 10 random controlled trials providing the basis for all statements regarding the effectiveness of IPMPs and none of these focusing on underserved communities, chronic pain is particularly prevalent in patients experiencing healthcare disparities.” Although chronic pain is a common problem for patients with healthcare disparities, these people were not included in the review sample.
Tina L. Doshi, MD, MHS, assistant professor of critical care medicine and anesthesiology at Johns Hopkins University School of Medicine, shared her thoughts about the AHRQ report. “The AHRQ review’s findings should not be taken as proof that biopsychosocial approaches to pain are ineffective. This would directly contradict our current mechanistic understandings of pain (and other human diseases) as having biological and psychological influences.
Dr. Jordan Sudberg stated that the significant efforts to shape current pain research policy, including the Federal Pain Research Strategy, the NIH HEAL Initiative, and the Pain Management best practices Inter-Agency Task Force report, have all stressed the importance of a biopsychosocial approach in pain care. The AHRQ report should instead emphasize the need for better biopsychosocial treatments. According to the authors, we must examine which biopsychosocial options are most effective for particular patient populations.
Gary W. Jay MD, FAAPM, is a professor of neurology at the University of North Carolina Chapel Hill. He recommended that AHRQ review past successful biopsychosocial pain management models to better contextualize programs.
Terminology is tricky: Multidisciplinary, interdisciplinary and more.
AHRQ uses “multidisciplinary” or “interdisciplinary” interchangeably to describe biopsychosocial pain management programs. This is in addition to what defines IPMP/CPMP programs. Although the agency recognizes that different terminology is confusing in assessing the efficacy of these programs, it also makes its own interpretations in its analysis and conclusions.
The IASP definitions state apparent differences between multidisciplinary and interdisciplinarity models.6
- Multidisciplinary teams can comprise multiple disciplines, but they all work together towards common goals.
- Multidisciplinary teams don’t share the same goals. Individuals on these teams work independently and have their own patient outcomes goals.
Because the models are different, it is difficult to use them interchangeably. Continue reading for more information on terminology.
Is the Biopsychosocial model a concept only?
Dr Twillman addressed the legitimacy and criticism of the biopsychosocial approach to pain management. He said, “Partially, the problem is integrative pain management is more a philosophy than an intervention in which the same treatment methods are used for all patients. The biopsychosocial approach to pain management focuses on assessing each patient’s needs in the psychological, biological, and spiritual realms. Then, a pain plan is created that meets the individual’s specific needs. If integrative pain management is being used, this is not possible.
Dr Twillman also pointed out other critical flaws in the AHRQ report. Dr Twillman stated that the evidence in the AHRQ report has flaws that are well-known to integrative pain management professionals. “There are very few studies that combine different treatments and subject characteristics, making it difficult to draw coherent conclusions.”
He said that it was difficult to conclude program effectiveness due to a lack of concentration, short-term patient follow-up and limitations with the types of pain conditions being considered.
Biopsychosocial Adoption Remains Stagnant
The AHRQ report reveals the difficulties and obstacles in biopsychosocial pain management programs and models. It also highlights significant differences in the terminology used by researchers and clinicians to describe the different programs in practice. These factors also hinder the adoption of comprehensive and integrated pain management programs. The analysis should be considered carefully in clinical decision-making to avoid reimbursement and treatment access issues.
Johnathan H. Goree MD, director of both the Chronic Pain Division at the University of Arkansas for Medical Sciences and the Chronic Medicine Fellowship at the University of Arkansas for Medical Sciences, noted that “there are some challenges to complete efficient, comprehensive, holistic pain care including reimbursement, logistics, but limited literature has shown that it improves holistic health.” He hopes to overcome these obstacles and figure out how much it would offer over the traditional model of pain management.
Dr. Jordan Sudberg said, “About the science. I think there is likely to be a need for meeting the middle’. The methodologists must help us create research models that can accommodate the more structured nature of integrative pain management. Front-line clinicians must be more careful about collecting data over extended periods and systematically facilitating these new models. Although it is a common misconception that reports like these will require more research, we need both more and ‘different in this instance.