In a report from the Agency for Healthcare Research and Quality, 5% of the US population with complex chronic diseases account for 50% of total health care expenditures.26 Osteoarthritis and other nontraumatic joint disorders account for 44% of expenditures in this top 5% of patients. This is highly relevant to pain medicine because up to 68% of adults with high impact chronic pain have some form of arthritis32 that is incompletely responsive to conventual therapies.28 Thus, clinically effective and economically sustainable models of chronic pain care are urgently needed.

Integrated treatments for chronic pain are broadly based on the biopsychosocial model which posits pain as a reciprocating assimilation of physiological, psychological, social, and environmental factors.2,9 The biological underpinnings of the biopsychosocial model are supported by the pain matrix, which is recognized as a hierarchical multilevel neural network that processes painful stimuli.15 This processing spans the encoding of nociceptive stimuli and memory formation of pain experiences,15 which can be further modulated by immune and endocrine mechanisms.33 Although pain is an individual-specific experience, clinical symptoms represent a complex constellation of interrelated, multifaceted behaviors and environmental factors that are key drivers of pain-related impairments in physical, emotional, and social functioning.21 A broad array of integrated treatments has been described, but clinician access to these care models is limited, in part, by 2 key foundational barriers, which include (1) incomplete knowledge about the distinguishing characteristics of the most widely deployed models and (2) awareness of stakeholder alignment that is critical to achieving optimal value for all involved stakeholders. In this context, a stakeholder is generally defined as a person (eg, patient, clinician) or organization (eg, health care system, payer) with a vested interest in the treatment of chronic pain. The objectives of this commentary are two-fold. First, working definitions of multidisciplinary, interdisciplinary, and transdisciplinary pain care models will be provided from the perspective of 3 key stakeholder groups including the patient, clinician, and payer. Second, the engagement of each stakeholder in the care model will be conceptualized as a specific vector, defined as each stakeholder's pursuit of a desired value. The extent of vector alignment or convergence will be posited to yield the optimal goals of the care model for all engaged stakeholders.

Integrated pain care models generally extend the biomedical model of pain care where pain-targeted treatments are provided by individual clinicians. When other care modalities are indicated, patients are referred for specialty care. However, the lack of shared goals among stakeholders could impede the referral process. For example, patient preference could affect acceptance of the requested service, lack of clinician availability and coordination of care could delay scheduling, and limited or absent insurance benefits could avert the entire referral process even when patient acceptance and clinician availability are aligned.20 The limiting features of the biomedical model can be addressed by adopting more integrated models of care.

Multidisciplinary, interdisciplinary, and transdisciplinary care models can be conceptualized as anchors on a continuum of care characterized by the progressive integration of resources across disciplinary lines.4,18,37 The multidisciplinary model, which is the first anchor, is defined as 2 or more health care professionals from different disciplines sharing responsibility for decision making while working independently, in tandem or in parallel, to develop and implement care plans (Fig. 1, panel A).12 Multidisciplinary teams generally comprise pain medicine physicians, pain psychologists, primary care providers, nurses, pharmacists, physical therapists, and occupational therapists. Key components of this model include formation of collaborative action plans that fully encompass the exigencies of patients and effective team communication, usually in the form of clinic notes, focused on integrating the perspectives of each discipline. Individual practitioner vectors operate in a synchronous manner but continuing research suggests the lack of effective communication within the team, which partly relies on clinic notes, challenges optimal vector alignment which can adversely affect clinical outcomes.5,30 The clinical and cost-effectiveness of multidisciplinary pain care have been recognized for more than 2 decades,11,14,19,41,42 and more recent studies confirm these findings.1,6,22,25 However, widespread dissemination of multidisciplinary pain care has been curtailed,7,36 in part, by the model framework which is constructed without direct input from patients or payers. As a result, highly structured treatment protocols may not specifically address individual patient needs and, similarly, payers may be reluctant to reimburse for preselected services that have limited clinical relevance to some patient groups.31,39 Despite the critical shortcomings in the core architecture of the multidisciplinary care model, the synergy of partly aligning the payer vector was evident in a retrospective study where health care costs were significantly reduced in a group of adults receiving multidisciplinary care for a broad range of chronic pain diagnoses.38

Figure 1.:

Multidisciplinary (panel A), interdisciplinary (panel B), and transdisciplinary (panel C) care models exist on a continuum of care characterized by the progressive integration of resources across disciplinary lines.

The interdisciplinary model, which is the second anchor on the integrated care continuum, is defined as 2 or more health care professionals working jointly across disciplinary boundaries while espousing shared treatment philosophies (Fig. 1, panel B). Although members of the health care team and treatment modalities are similar to the multidisciplinary model, an important distinguishing characteristic of the interdisciplinary model is the coordination and provision of patient care “under one roof at the same facility.”16 This ensures an environment of continual communication among team members which frequently includes care team meetings and discussion of treatment plans. Key elements of interdisciplinary care include teaching patients to use cognitive-behavioral techniques to modify maladaptive pain responses, graded exercise, and medication management to relieve the adverse effects of analgesic polypharmacy.8,35 Patients are generally expected to participate a highly structured treatment protocol spanning multiple weeks. The clinical outcomes,3,13,27,43 cost-effectiveness,17 and the process for accrediting interdisciplinary pain care facilities24,27 have been established.3,13,17,27,43 However, widespread deployment has been limited, in part, by the model framework which does not fully account for the payer vector.8,29,36 For example, in a prospective study of adults receiving interdisciplinary care for chronic pain, clinical outcomes were adversely affected by the lack of insurance benefits for physical therapy services.34

The optimal end point of the integrated pain care continuum is the transdisciplinary model which will be posited to provide a hitherto unrecognized opportunity to optimally align all stakeholder vectors (Fig. 1, panel C). This model is characterized by stakeholders sharing a conceptual framework that transcends idiosyncratic theories and concepts while simultaneously promoting the flexible exchange of discipline-specific roles to generate new knowledge and solutions for actualizing mutually shared values.4,12,23 When applied to delivering pain care, key stakeholders including patients and patient advocacy groups, clinicians, and payers engage from program inception to identify mutually shared values and then cooperatively design and implement effective treatment protocols. Similar to the interdisciplinary model, coordination and delivery of care occurs in a single facility, and patient schedules are flexible to accommodate patients' readiness to engage in subsequent stages of treatment. This flexibility also enhances the capacity to individualize treatment and promotes system resiliency by mitigating the impact of unanticipated events like missed appointments and provider absences. In addition, clinical communication and decision making are dynamic and not confined to scheduled team meetings. The recontextualization of patient engagement and treatment preferences, pursuit of evidence-based outcomes by clinicians, and incorporating measures of cost effectiveness and resource utilization by payers could further bolster the sustainability of this integrated care model. The potential synergistic effects of transdisciplinary care were reported in a single retrospective study involving 3296 patients with chronic pain.40 The stakeholder group that developed and deployed the treatment intervention was comprised of physicians, reconditioning specialists, complementary medicine and behavioral health experts, patients, and health insurance professionals (see Acknowledgements section in the study by Strigo et al.40 ) from a large managed care health plan. The 1-year transdisciplinary care intervention was organized into 3 phases (rescue, restore, and re-entry), and based on individual needs and preferences, patients were flexibly scheduled to receive care in 4 departments (medical, physical reconditioning, complementary care, and behavioral health) that worked in a truly integrated manner (see Supplemental Material 1 in the study by Strigo et al.40 for a program description). Evidence-based treatment plans were individualized based on patient expectations and choices.10,40 At 1-year follow-up, patients experienced significant improvements in pain interference, pain-related disability, pain catastrophizing, depressive symptoms, and anxiety symptom severity.40 Referrals to the transdisciplinary pain care program were initiated by the managed care health plan stakeholder and the costs were fully aligned with the payer's value of providing comprehensive pain care.

In summary, integrated pain care models are best conceptualized to exist on a continuum of care characterized by the progressive integration of knowledge and resources across disciplinary lines. Although the effectiveness of multidisciplinary and interdisciplinary models is widely recognized, widespread and sustained deployment has been limited, in part, by incomplete alignment of stakeholder vectors. By contrast, the transdisciplinary model is posited to provide an optimal framework for aligning key stakeholder vectors towards achieving mutually shared values at optimal levels. Strategic deployment of pain care centers of excellence based on the transdisciplinary model could accelerate widespread dissemination of this clinically effective and economically sustainable intervention for chronic pain.

Disclosures

The authors have no conflicts of interest to declare.

References [1]. AlMazrou SH, Elliott RA, Knaggs RD, AlAujan SS. Cost-effectiveness of pain management services for chronic low back pain: a systematic review of published studies. BMC Health Serv Res 2020;20:194. [2]. Bevers K, Watts L, Kishino ND, Gatchel RJ. The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. US Neurol 2016;12:98–104. [3]. Bujak BK, Regan E, Beattie PF, Harrington S. The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis. Pain Manag 2019;9:417–29. [4]. Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med 2006;29:351–64. [5]. Choiniere M, Peng P, Gilron I, Buckley N, Williamson O, Janelle-Montcalm A, Baerg K, Boulanger A, Di Renna T, Finley GA, Intrater H, Lau B, Pereira J. Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada. Reg Anesth Pain Med 2020;45:943–48. [6]. Chowdhury AR, Graham PL, Schofield D, Cunich M, Nicholas M. Cost-effectiveness of multidisciplinary interventions for chronic low back pain: a narrative review. Clin J Pain 2021;38:197–207. [7]. Clark ME. Cost-effectiveness of multidisciplinary pain treatment: are we there yet? Pain Med 2009;10:778–9. [8]. Clark TS. Interdisciplinary treatment for chronic pain: is it worth the money? Proc (Bayl Univ Med Cent) 2000;13:240–3. [9]. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet 2021;397:2082–97. [10]. Cormier S, Lavigne GL, Choiniere M, Rainville P. Expectations predict chronic pain treatment outcomes. PAIN 2016;157:329–38. [11]. Cunningham JL, Rome JD, Kerkvliet JL, Townsend CO. Reduction in medication costs for patients with chronic nonmalignant pain completing a pain rehabilitation program: a prospective analysis of admission, discharge, and 6-month follow-up medication costs. Pain Med 2009;10:787–96. [12]. D'Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care 2005;19(suppl 1):116–31. [13]. Elbers S, Wittink H, Konings S, Kaiser U, Kleijnen J, Pool J, Koke A, Smeets R. Longitudinal outcome evaluations of interdisciplinary multimodal pain treatment programmes for patients with chronic primary musculoskeletal pain: a systematic review and meta-analysis. Eur J Pain 2022;26:310–35. [14]. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. PAIN 1992;49:221–30. [15]. Garcia-Larrea L, Peyron R. Pain matrices and neuropathic pain matrices: a review. PAIN 2013;154(suppl 1):S29–43. [16]. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014;69:119–30. [17]. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7:779–93. [18]. Giusti EM, Castelnuovo G, Molinari E. Differences in multidisciplinary and interdisciplinary treatment programs for fibromyalgia: a mapping review. Pain Res Manag 2017;2017:7261468. [19]. Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511–6. [20]. Hadi MA, Alldred DP, Briggs M, Marczewski K, Closs SJ. ‘Treated as a number, not treated as a person’: a qualitative exploration of the perceived barriers to effective pain management of patients with chronic pain. BMJ Open 2017;7:e016454. [21]. Hooten WM. Chronic pain and mental health disorders: shared neural mechanisms, epidemiology, and treatment. Mayo Clin Proc 2016;91:955–970. [22]. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015;350:h444. [23]. Lotrecchiano G. The science-of-team-science, transdisciplinary capacity, and shifting paradigms for translational professionals. J Transl Med Epidemiol 2013;1:1001. [24]. MacDonell CM. Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation. In: Practical Psychology in Medical Rehabilitation. Cham, Switzerland: Springer; 2017:533–8. [25]. Maeng DD, Baylor K, Bulger JB, Han JJ. Impact of a multidisciplinary pain management program on patient care utilization and cost of care. J Pain Res 2018;11:2375–83. [26]. Mitchell EM. Concentration of healthcare expenditures and selected characteristics of high spenders, U.S. civilian noninstitutionalized population, 2019. In: Statistical brief (medical expenditure panel survey (US)). Rockville, MD: Agency for Healthcare Research and Quality (US), 2022. [27]. Murphy JL, Palyo SA, Schmidt ZS, Hollrah LN, Banou E, Van Keuren CP, Strigo IA. The resurrection of interdisciplinary pain rehabilitation: outcomes across a veterans affairs collaborative. Pain Med 2021;22:430–43. [28]. Nalamachu SR, Robinson RL, Viktrup L, Cappelleri JC, Bushmakin AG, Tive L, Mellor J, Hatchell N, Jackson J. Multimodal treatment patterns for osteoarthritis and their relationship to patient-reported pain severity: a cross-sectional survey in the United States. J Pain Res 2020;13:3415–25. [29]. Nicholas MK. Managed care policies and pain management programs. Anesth Analg 2003;97:1. [30]. Peng P, Choiniere M, Dion D, Intrater H, Lefort S, Lynch M, Ong M, Rashiq S, Tkachuk G, Veillette Y, Group SI. Challenges in accessing multidisciplinary pain treatment facilities in Canada. Can J Anaesth 2007;54:977–84. [31]. Pilitsis JG, Khazen O, Wenzel NG. Multidisciplinary firms and the treatment of chronic pain: a case study of low back pain. Front Pain Res (Lausanne) 2021;2:781433. [32]. Pitcher MH, Von Korff M, Bushnell MC, Porter L. Prevalence and profile of high-impact chronic pain in the United States. J Pain 2019;20:146–60. [33]. Rabbitts JA, Palermo TM, Lang EA. A conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain in children and adolescents. J Pain Res 2020;13:3071–80. [34]. Robbins H, Gatchel RJ, Noe C, Gajraj N, Polatin P, Deschner M, Vakharia A, Adams L. A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies. Anesth Analg 2003;97:156–62, table of contents. [35]. Sanders SH, Harden RN, Vicente PJ. Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic nonmalignant pain syndrome patients. Pain Pract 2005;5:303–15. [36]. Schatman ME. The role of the health insurance industry in perpetuating suboptimal pain management. Pain Med 2011;12:415–26. [37]. Scott CM, Hofmeyer AT. Acknowledging complexity: critically analyzing context to understand interdisciplinary research. J Interprof Care 2007;21:491–501. [38]. Sletten CD, Kurklinsky S, Chinburapa V, Ghazi S. Economic analysis of a comprehensive pain rehabilitation program: a collaboration between Florida Blue and Mayo Clinic Florida. Pain Med 2015;16:898–904. [39]. Staudt MD. The multidisciplinary team in pain management. Neurosurg Clin N Am 2022;33:241–9. [40]. Strigo IA, Simmons AN, Giebler J, Schilling JM, Moeller-Bertram T. Unsupervised learning for prognostic validity in patients with chronic pain in transdisciplinary pain care. Sci Rep 2023;13:7581. [41]. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain 2002;18:355–65. [42]. Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Crit Rev Phys Rehabil Med 1998;10:181–208. [43]. Ward R, Rauch SAM, Axon RN, Saenger MS. Evaluation of a non-pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans. Health Serv Res 2023;58:365–74.