Each year, more than 300 patients with chronic pain take part in a three-week program at the at Mayo Clinic in Rochester, Minn.听Their complaints range widely, from听specific problems such as intractable lower-back pain听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鈥檚 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鈥檚 clinical director, and many previous opioid users听who finish the treatment report six months later that they have been able to stay off opioids.听Just as important, he added, they have learned strategies to deal with their pain.
Insuring Your HealthBut such a program is not for everyone.听Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program鈥檚 billing codes, he said. Mayo鈥檚 insurance team sometimes advocates on patients鈥櫶齜ehalf if they鈥檙e good candidates for treatment, but success isn鈥檛 assured.
Mayo鈥檚 program isn鈥檛 the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients鈥 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听clinical psychologist with a specialty in behavioral pain management,听talked with me about听the program.
The transcript has been condensed and edited for clarity.
Q: How do pain medications work? By blunting the pain?
Wesley Gilliam, the clinical director of the Mayo Clinic鈥檚 pain rehabilitation center, says the use of medication and relaxation exercises can help relieve pain.听(Courtesy of the Mayo Clinic)
They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They鈥檙e not effective in the long term.
Opioids are central nervous system depressants. They soothe people who are in distress. Many people aren鈥檛 demonstrating improved functioning when they take opioids; it鈥檚 calming their nerves. It鈥檚 chemical coping.
Q: In treating pain, does it matter what鈥檚 causing it or how severe it is?
Pain is pain. The fundamental approach to self-managing it doesn鈥檛 change based on the cause or severity of the pain.听
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]听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鈥檛 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鈥檛 take a medical approach. It鈥檚 a biopsychosocial approach, [which]听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鈥檚 environment responds to the person鈥檚 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鈥檚 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.听When I refer to functioning, I mean getting back into important areas of your life such as work, social activities and recreation. If you鈥檙e waiting for pain to go away, you鈥檙e 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鈥檙e in chronic pain and it鈥檚 poorly managed, the nervous system can get out of whack. Your body behaves as if it鈥檚 under stress all the time, even when it鈥檚 not. Your muscles may be tense and your heart and breathing rates elevated, among other things.
With meditation and relaxation exercises, we鈥檙e trying to听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.听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.听This doesn鈥檛 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.听All aspects of our treatment 鈥 cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy 鈥 are all designed to settle the nervous system.
Q: Does insurance typically cover the program?听
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鈥檛 cover our billing codes. If we deem a patient a good candidate, we鈥檒l 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 these programs do save money over the long term in health care costs and reduced health care utilization.
If we鈥檙e going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You can鈥檛 just treat the symptom, you have to treat the whole person.
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