Selection for pain management programmes

No matter what the efficacy of other treatments and therapies they have undergone, the vast majority of our clients will at some stage be referred for multi-disciplinary pain management.

There is no one universal approach offered by pain clinics, who instead have at their disposal a wide range of treatments and support, which to a certain degree they can use to tailor therapy to the individual. As they cannot ‘cure’ the patient’s pain, the role of the pain clinic is best summarised as supporting a patient in developing self-help skills to control and relieve their pain. It is hoped that through these coping strategies, the patient will experience an overall improvement in their quality of life.

In addition to the more common outpatient approach, a few centres are equipped to offer inpatient programmes. The advantage of inpatient pain management is that for a limited period, usually between two and four weeks, both the patient and the multi-disciplinary team are focused entirely on working together to develop coping strategies. This is often more difficult and therefore less successful when attending as an outpatient once a week over the course of a number of weeks or months.

Selection

Most pain clinics operate some form of selection criteria. This will involve the patient attending an assessment with one or more members of the clinical team, often a specialist pain doctor and a psychologist.

When it comes to our clients who are referred for pain management, I’m occasionally surprised to find that some are deemed not suitable, either at all, or not until other issues have been addressed.

One strictly non-medical issue which we find can initially lead to exclusion is involvement in litigation. The reason commonly given for this is ‘a lack of autonomous motivation for rehabilitation‘; in other words pain clinics are not keen to treat if they perceive, rightly or wrongly, that the attendance is in response to litigation. There is a definite belief among clinicians that patients respond better to treatment once litigation has concluded. This may result from a perception that when compensation is involved there may be less incentive to fully engage in the programme with a view to improvement. In addition, many believe that the stress of the litigation process itself is an unnecessary distraction.

Study

Now, for the first time, a study has been published which examines “the process of assessing and selecting patients for a pain management programme”. The study, which appears in the British Journal of Pain, reviewed “the records of 200 consecutive patients who attended a multidisciplinary assessment” for the INPUT Programme at Guy’s and St Thomas’s Hospital in London between September and December 2014. The study provides some interesting insights into the assessment process and its outcome.

The guidelines used for assessment were those of the British Pain Society which include defined inclusion/exclusion criteria and the study authors were interested in exploring how those criteria were applied in practice.

Results

Overall, 53% of those assessed were offered a place on one of the department’s pain management programmes, with a little over 30% offered an immediate place on an inpatient programme. Of the others not discharged following assessment, 11.6% were deemed to require case management before admission to an inpatient programme, 8.1% were referred to an outpatient programme and a small number were referred for individual treatment.

However, nearly 45% were discharged entirely following assessment. “The three most frequently used reasons for exclusion were: not ready to engage with the pain management approach (35%), complex psychological or other needs needing to be prioritised (29.5%) and the patient declining a programme (19.3%).” Of these, perhaps the latter is the most surprising.

Conclusion

The authors concluded:

“Reviewing the use of inclusion/exclusion criteria revealed some challenges regarding patient selection. For example, a sizable proportion of patients were still seeking pain reduction and were not open to a self-management approach when this was the recommended treatment for them. Complex patients might need other treatment approaches before they can be considered for a programme. Having a range of pain management options of varying intensities available seems helpful in meeting individual patient need.”