Economic implications of pain management. By Loeser JD. Acta Anaesthesiol Scand 1999; 43:957–95. Reprinted with permission.
Multidisciplinary pain management was an invention of John J. Bonica, M.D. He started the Multidisciplinary Pain Clinic at the University of Washington in 1960. This clinical service evolved over the years, and when John Loeser, M.D., became its director in 1982, he collaborated with Bill Fordyce, Ph.D., to create what was known as “the structured program.” The program has served as the model for pain treatment programs throughout the world, many of which have fared better than that at the University of Washington. The migration of Stephen Butler, M.D., to Uppsala, Sweden, in 2000 has given us the opportunity to contrast multidisciplinary pain management in the Nordic countries with that in the United States.
The authors of this article were early members of John J. Bonica, M.D.’s Multidisciplinary Pain Clinic at the University of Washington (Seattle, Washington). This program was started in 1960 when Bonica became the founding chairman of the Department of Anesthesiology at the University of Washington. In its original form, this was a diagnostic clinic that brought multiple medical specialists to focus on a single patient. Treatment recommendations were then made and implemented by an individual provider.
The program evolved over the first decade of its existence as more practitioners were enlisted to join the group. Wilbert (Bill) Fordyce, Ph.D., was an important addition in the mid-60s as the group gained faculty members interested in the treatment of pain. Fordyce had a limited practice of behavioral medicine within the Rehabilitation Department at this time. The clinic gained its own space in 1975 with the first expansion of the University Hospital. By 1977, the Anesthesiology Department had six inpatient beds to use in the diagnostic evaluations of pain patients. In 1978, Bonica convinced the University of Washington to establish a Pain Center, which was enriched with two psychologists whose clinical activities were to be in the domain of pain.
In 1982, John Loeser was asked to become the Director of the Pain Center. At this time, an entire ward in the University Hospital was assigned to the Pain Center, and Fordyce and Loeser designed and implemented a 3-week inpatient treatment program for patients with chronic, intractable pain.1 This was labeled “the structured program” and rapidly became a model for chronic pain treatment both in the United States and throughout the world. It existed at the University of Washington from 1983 until 1997; its demise was mainly due to socioeconomic factors that intruded into health care in the United States.
When Dr. Butler moved from the University of Washington Pain Clinic in Seattle to a new job in Sweden in 2000 as acting Chief of the Pain Center at the Academic Hospital of Uppsala, he was surprised to find some familiar programs. The first was a week-long multidisciplinary evaluation on an inpatient basis, very similar to that at the University Hospital in Seattle in the 1970s. A physiatrist, Patrik Ugge, had been to Seattle and had brought back Dr. Bonica’s concept, which functioned very well. The evaluation week is still in operation.
The second surprise was that an interdisciplinary inpatient pain program had just been transferred to “Akademiska” from a satellite hospital. This had been started several years previously by Basil Finer, M.D., an English anesthesiologist who had moved to Uppsala in the 1960s. Finer had written a few articles on hypnosis for anesthesia and for chronic pain. Bonica had read these and had invited Finer in 1973 to the watershed Issaquah Conference, where the International Association for the Study of Pain was founded. Dr. Finer was inspired and brought the concept of multidisciplinary pain management to Uppsala.
Finer was retiring, but the rest of the team, led by a psychiatrist, was given five hospital beds at “Akademiska” for the multidisciplinary inpatient pain program. Functional improvement was the goal, and various cognitive and behavioral therapies were employed. This version of the Seattle Structured Pain Treatment Program is still thriving in Uppsala.
When Dr. Butler arrived, all interns spent a week on the pain service, and anesthesia residents spent 2 months. There were also continual visitors, mostly anesthesiologists from around Sweden and the world, as well as foreign fellows. It was very easy for Dr. Butler to fit in.
The next eye-opener for Dr. Butler came after some discussions with Torsten Gordh, Jr., who had founded the pain service and was the new Chief of Anesthesiology at Akademiska. Gordh was involved with a new project. A Danish anesthesiologist, Jørgen Eriksen, was keen to start a pan-Nordic pain course for anesthesiology specialists who had finished their formal training. He had begun reading pain literature widely and realized that his results from invasive treatments were disappointing primarily because of patients’ psychosocial issues. Eriksen eventually published a landmark article in Pain on the epidemiology of chronic pain in the Danish population that proved this point.3
As a result of this research, Eriksen became fascinated with multidisciplinary* pain treatment and education. His course was intended to enlighten interventional anesthesiologists in Denmark, Sweden, Norway, Finland, and Iceland. It was a 3-day program that took place at each nation’s capital over a total duration of 2 yr. Little on acute pain, nerve blocks, pumps, and stimulators was on the curriculum. The theme was multi/interdisciplinary pain management with a focus on the psychosocial problems, not the “bio-.” Dr. Butler became one of the core teachers in this group, which consisted of two anesthesiologists from each country
Through this course, Dr. Butler has made many friends in the Nordic pain world. It is now midway through its 10th yr. On the first day of each course, he still gives an hour lecture on the history of Bonica, Fordyce, and the Seattle program from the 1970s until the 1990s. The course began with only 20 anesthesiologists in its first year but has now expanded to 45, with half coming from other specialties. By now, well over 200 Nordic physicians have completed the program. The highlight is the last stop in Reykjavik, Iceland, where there is a Jørgen Eriksen Memorial Lecture that was established after Eriksen’s untimely death from renal cancer. One of his heroes, Mark Jensen, a Fordyce-trained University of Washington psychologist from Seattle, is the featured lecturer for each Reykjavik course.
Another result of this program is that Dr. Butler has visited pain centers throughout the Nordic countries. His relationship with St. Olav’s Hospital in Trondheim has been the longest. A previous professor there, Harald Breivik, M.D., had come to Seattle for a few months in 1975, and Dr. Butler had served as his “mentor”—although it was really a two-way street. As Professor of Anesthesiology in Trondheim, and later in Oslo, Breivik promulgated the multi/interdisciplinary concept, not only in Norway but in all of Scandinavia. He founded the Scandinavian Society for the Study of Pain, an International Association for the Study of Pain chapter, as well as the Scandinavian Journal of Pain, serving as its first editor.
After the second Nordic pain course in 2001, Dr. Butler was invited back to Trondheim. St. Olav’s had an outpatient multidisciplinary pain clinic that was thriving. The team had become fascinated with the descriptions of the Seattle pain world and wanted him to run a version of the University of Washington Structured Pain Treatment Program as a pilot. After 3 weeks, four of the six patients showed some progress. After discharge to a home program, all of the patients were booked to return 6 weeks later. Three of the six actually returned, and two had made spectacular progress, with one even getting back to work.
That program was a part of the stimulus for a subsequent 5-yr project funded by the regional government at an idyllic site out on the fiord that had been a German fort during World War II. Called “Fortet,” it included a challenging physical reactivation component and various Cognitive and Behavioral Therapy components. After the 5 yr of government funding stopped, Fortet has continued in a modified form under a private group.
Multi/interdisciplinary pain management is alive and well in Norway. Five regional sites have been designated as tertiary pain centers with a common intake evaluation that includes a questionnaire and a structured interview and examination. This expands research potential.
Back to Sweden. Alf Nachemson, M.D., Ph.D., then Professor of Orthopedics at Sahlgrenska University Hospital in Gothenburg, had gone to Seattle as part of the “Boeing Project,” a team investigating predictors for acute back pain to proceed to a chronic form.4 Alf discouraged the surgical approach to chronic back pain and invited Bill Fordyce and others from Seattle to set up a variant of the University of Washington Structured Pain Treatment Program in Sahlgrenska. The program them migrated to Umeå, where it is still active and has a parallel program in a nearby regional hospital.
Iceland also has links to Seattle. An Icelandic physiatrist was an observer of the University of Washington’s Structured Pain Treatment Program and set up a very similar program at Reykjalundar.5 This program has, in addition, an extended retraining program with a successful back-to-work record. There are two other multidisciplinary pain rehabilitation programs in Iceland as well, impressive for a country with barely more than 300,000 inhabitants.
Finland should not be left out. Eija Kelso, M.D., a Past President of International Association for the Study of Pain, has made several trips to Seattle. She developed and expanded a multi/interdisciplinary pain center with a strong research base at the University of Helsinki. Acute pain and chronic pain programs are alive and well in all the universities in Finland. It should be noted that in addition to Kelso, two other past Presidents of International Association for the Study of Pain have come from the Nordic countries—one from Denmark and one from Sweden.
The political systems of all the Nordic countries are based on social democratic principles. All citizens have comprehensive health insurance under a government agency. In Norway, at least, leading pain specialists have had direct access to federal health ministers—a relationship that has facilitated the growth of pain clinics and pain research. In some Nordic countries, there are also private pain clinics, but they are reimbursed, at least partly, by government agencies. Thus, there is universal access to multidisciplinary care for acute, chronic, and cancer-related pain, although wait lists can be longer than optimal. Expertise varies, but the principle of care for all is the basis of pain management. Clearly, the University of Washington Structured Pain Treatment Program has been the model for a wide network of Scandinavian pain treatment programs.
While pain management was evolving in Nordic countries based on the University of Washington programs, a different set of developments was occurring in the United States. There was no planned governmental approach, save for that which occurred in the Veterans Administration system. Pain programs developed in many institutions, but few survived the economic healthcare chaos in the United States.
The insurance industry played a major role in the destruction of multidisciplinary pain management, for it saw this type of treatment as expensive. Furthermore, there was a bias against funding care that was not provided by an M.D. These payers largely ignored the data on efficacy and viewed return to work as an irrelevant outcome measure. Providers could earn more money doing procedures and operations—often less effective therapies for chronic pain patients—than participating in a multidisciplinary treatment program. Even continuing medical education programs were biased against multidisciplinary pain programs, as they were commonly funded by their sponsors—drug and device manufacturers. Very few clinical studies reported long-term outcomes or functional status.
Healthcare costs have soared in the United States without any measure of improvement for the general public, and pain treatment has not benefitted from this phenomenon. The intrusion of capitalism into health care has not helped the comprehensive management of chronic pain patients. As we stated in the 1999 article, “To control inappropriate care and escalating costs, we must change concepts of pain and disability and the methods of funding both of these in relation to chronic pain. The outcome of the continuing struggle between the profession of medicine, the state and capitalists will determine how and whether pain management is a part of medical care.”2
The International Association for the Study of Pain definitions distinguish multidisciplinary from interdisciplinary care. The former means a group of caregivers interact with the patient; the latter means that the providers interact with each other and the patient. The latter is the preferred mode of care. Common usage often ignores this distinction, as do we in this article. The Seattle model is interdisciplinary in all respects.