The evidence to support the clinical efficacy and costeffectiveness of ICPM is robust, and the studies are numerous; therefore, it is most efficient to focus on meta-analyses and systematic reviews that provide the approach with unequivocal empirical support. These studies will be reviewed briefly, and several prominent and more recent studies will be highlighted. Flor and colleagues¹¹ performed the earliest meta-analysis of ICPM in 1992. The review of 65 studies identified numerous benefits for participants: reducing medication use, reducing
emotional distress, reducing health care utilization, reducing iatrogenic consequences, increasing return to work and physical activity levels, closing disability claims, and an average pain reduction of 20%. Although the figure for pain reduction may not seem impressive, patients in these programs are generally told that pain relief is not the goal of treatment and are taught to focus on functional and emotional benefits. Not surprisingly, ICPM programs were determined to be superior to unimodal treatments as well as to no treatment and waiting list controls. The beneficial effects of the programs appeared to be stable over time. As with most large-scale reviews, it was recommended that results be interpreted with some caution due to inconsistencies in methodologies and quality of research designs and descriptions.

The area of cost-effectiveness for ICPM deserves attention because it is typically regarded as an intensive and concomitantly expensive option for chronic pain management; however, a review of the literature does not support this widely held belief. In 1998, Turk and Okifuji¹² performed a comparative analysis of ICPM programs in order to assess their cost-effectiveness as compared to surgery, chronic opioid therapy, and implantable devices. Most striking was the finding that ICPM programs were up to 21 times more cost-effective than alternative treatments for chronic pain such as surgery.¹² Okifuji and colleagues¹³ performed a review of the literature on various treatment approaches to chronic pain, analyzing the cost-effectiveness of ICPM in comparison to surgery or conventional medical treatment. ICPM compared favorably to other treatments in terms of pain reduction, management of opioid analgesics, restoration of function as measured by activity levels and return to work, health care utilization, and closure of disability claims. Additionally, the authors dispelled the myth of ICPM representing an expensive approach to pain management, calculating that its use in lieu of the other typical approaches could result in a cost savings of $5 billion per year in the United States. Turk¹⁴ obtained similar findings in a 2002 review, noting not only that ICPM is comparable to oral medications, surgery, spinal cord stimulation (SCS), and intrathecal drug delivery in terms of pain relief but also that interdisciplinary treatment can provide considerable savings in costs for medications and additional health care utilization. Turk’s¹⁴ data on cost-effectiveness are dramatic, as he determined that interdisciplinary care is 6.29 times more cost-effective than surgery, 15 times more so than conventional care, and 25 times more cost-effective than SCS. This opens up the question regarding why insurance would reimburse procedures such as SCS but deny any coverage for ICPM programs when the evidence suggests that this is misguided.

Turk and Swanson¹⁵ performed an “analysis and evidencebased synthesis” of the efficacy and cost-effectiveness of medications, surgery, SCS, intrathecal drug delivery systems, and ICPM in the treatment of chronic pain. The authors found that all of these approaches resulted in roughly the same amount of pain relief, with only ICPM determined to be essentially free of iatrogenic complications and adverse events as well as being numerous times more cost-effective than the other treatments considered in achieving therapeutic goals. Perhaps the most compelling empirical support for ICPM is provided by the 2001 and 2002 systematic¹⁶ and Cochrane¹⁷ reviews by Guzmán and colleagues and the 2003 Cochrane review by Schonstein et al.,¹⁸ as these studies involved careful analyses of trial quality. In each of these reviews, the authors determined that ICPM improves pain and function, which was not determined to be the case for less intensive treatments.

In an ICPM context and beyond, increasing functioning and optimizing quality of life often requires the reevaluation of pharmaceuticals. With a recent emphasis on reducing the use of analgesics that are not always helpful and potentially harmful, including opioids, it is worthwhile to include several studies demonstrating the role of ICPM programs in this effort. A 2013 study by Murphy et al.¹⁹ examined the outcomes of more than 700 participants who completed the inpatient ICPM program at the VA in Tampa, Florida. Since the program’s advent in 1988, veterans who enter the program taking opioids are tapered off during the course of their 3-week participation. The study compared how those who were on opioid medications at program admission fared against those who were not on opioids.¹⁹ There were no significant differences between groups at admission and all participants improved, but those on opioid analgesics at program initiation benefitted even more on several domains including catastrophizing and activities of daily living. A study and 6-month follow-up conducted by the ICPM program at Mayo Clinic in Minnesota examined treatment outcomes following opioid analgesic cessation^20,21 and found that although patients on opioid analgesics at admission reported higher levels of pain and depression relative to those not taking opioids, there were no differences in outcomes at discharge or 6-month follow-up. Clearly, further research on the effects of opioid tapering on ICPM outcomes is warranted because the Tampa and Mayo studies suggest a significant and sustained improvement in pain severity and functioning following interdisciplinary treatment regardless of previous opioid status.

Evaluating medications not only is important to patient longterm well-being but also has financial implications. A novel economic analysis was conducted in 2015 by Mayo Clinic’s Florida ICPM program in collaboration with Florida Blue, the state branch of Blue Cross Blue Shield.²² Sletten et al.²² collaboratively examined the economic impact of participation in an ICPM on health care utilization and expenditures. Results indicated decreases in overall medical costs for up to 18 months including the use of specialty care, tests, and procedures. Of note, unlike many other cost-effectiveness studies that focus on low back pain, this ICPM sample included a broad range of chronic pain conditions with an average pain duration of 8 years. The involvement of a third-party payer in this analysis represents an important model for future studies because this may be the most convincing way to garner the support of insurance companies. This is consistent with Schatman’s work on the demise of interdisciplinary pain management in the United States, in which he posited that insurers’ exclusive focus on cost-containment and profitability trumps pain patient well-being.¹⁰ In the future, it would be ideal for ICPM programs to partner together and enlist the collaboration of multiple health care plans and payer types to once again demonstrate the economic benefit of interdisciplinary care.

Given these data, the process by which third-party payers determine what is worthy of a cost investment can be puzzling. Procedures such as back surgery, which is costly and risky and yields very mixed empirical outcomes, are typically covered, yet payers are unlikely to reimburse evidence-based and lower risk ICPM programs. This in part speaks to the antiquated yet ongoing biomedical approach that much of the public, providers, and payers apply to chronic pain treatment. Although it is clearly a complex biopsychosocial experience that persists across time, chronic pain continues to be approached in the same manner as acute pain. This error is a significant reason why individuals and systems seek and support medical solutions that “cure” pain rather than understanding that pain can be best minimized and quality of life improved with a whole-person, comprehensive, self-management approach.

Before proceeding, it is important to clarify the distinction between multidisciplinary and interdisciplinary. Although the terms are often used interchangeably, they are not synonymous.
Multidisciplinary treatment suggests that there are providers from multiple disciplines treating a patient in parallel. Communication may exist, but is not required, and varies widely. Coordination of care and treatment planning is atypical and is unfortunately often fragmented. This is a common approach in primary and secondary care, in which specialists are consulted as needed and work in silos. On the other hand, interdisciplinary care is best reflected in a cohesive team composed of experts from various disciplines who share a philosophy of care and communicate routinely regarding patient treatment. They are ideally colocated, although if not, may use technology for information sharing (e.g., phone calls, e-mails, electronic medical records) as well as holding scheduled and unscheduled in-person meetings. The importance of regular communication among team members cannot be overstated, and consistency in the philosophy of patient care is critical for program success.

All ICPM is based on the biopsychosocial approach that emphasizes the complex and dynamic interaction between physiologic, psychological, and social factors. These variables and how patients respond to them can exacerbate or ameliorate the patient’s pain experience. For Bonica, the addition Fordyce contributed to the evolution of the approach by considering the emotional and behavioral sequelae of chronic pain as well as nociceptive experience was invaluable. Chronic pain is a disease of the person, and the person is often obscured by using the traditional biomedical approach without the integration of other critically relevant factors.²³ Therefore, to effectively treat chronic pain, the motivational-affective and cognitive-evaluative contributions must be weighed in addition to the nociceptive. ICPM recognizes the bidirectionality of pain and psychosocial factors, considering that emotions and maladaptive behavioral patterns can perpetuate as well as result from persistent physical discomfort. Regardless of the etiology of pain and even its comorbidities, patients who have functional impairments can improve on multiple dimensions if they are provided with appropriate guidance and are motivated by the staff to exert maximal effort. The goal is for participants to achieve management of their pain, with an emphasis on increasing self-efficacy and restoring independence and overall quality of life.

ICPM is based on the premise that no individual or discipline can “cure” the patient of all of the ills associated with his or her pain condition. Although specialization serves to enhance expertise, specialization without diversification results in limitations to what health care can offer patients whose conditions are as complex as chronic pain. This, perhaps, was the greatest wisdom that Bonica contributed to the pain treatment community. Although the specific construction of ICPM programs vary depending on factors such as available resources, the typical treatment provided includes three common elements: (1) medication management, (2) graded physical exercise, and (3) cognitive and behavioral techniques for pain and stress management.¹³ The CARF standards²⁴ identify only two defined disciplines as essential for ICPM rehabilitation programs: the pain team physician and pain team psychologist; additional health care professionals are based on the needs of the persons served. The roles of ICPM team members that are generally identified as constituting the core as well as other members that expand and enrich services provided are reviewed in the following discussion.

Core Team Members