Comprehensive Pain Program Outcomes Evaluation: A Preliminary Study in Hawai‘i
Ira D. Zunin MD, MPH; Steve Orenstein PhD; Mahana Chang MA; and Sungkun Cho MS
The aim of this study was to provide a preliminary outcome evaluation of the Comprehensive Pain Program (CPP) that was developed in Hawai‘i to treat chronic pain patients. The CPP is a biopsychosocial intervention designed to interrupt the pattern of social isolation and to minimize pain-related depression that contributes to reduced quality of life, poor function, and increased utilization of resources. The CPP consists of a comprehensive pre-treatment screening process and a 12-week Intensive Outpatient Program (IOP). Primary elements of the IOP include group psychotherapy, acupuncture, mind/body training, and therapeutic movement. thiry-five participants from a total of five cohorts completed the IOP (i.e., three sessions a week, each lasting three hours for a 12-week period). The CPP demonstrated success in six outcome areas: 1) utilization of healthcare resources, 2) functional capacity, 3) quality of life, and 4) psychological functioning, such as somatization, depression, and anxiety. Post-treatment, patients demonstrated statistically significant decreases in somatization, depression, and anxiety, and statistically significant improvement in quality of life. Patient outcomes further showed substantial improvements with regards to functional capacity, as well as significant decreases in the utilization of healthcare resources. In conclusion, the preliminary evaluation of the CPP suggests additional studies with a larger sample size and comparison groups are warranted to further evaluate critical components of the treatment regimen, clinical outcome, and cost-effectiveness.
The treatment of chronic pain is one of the most challenging issues facing the health care industry today. Unlike acute pain, chronic pain persists far beyond expected periods of normal resolution and often occurs in the absence of sympathetic arousal.1 The National Institute of Health2,3 suggests as many as 50 million people nationwide experience chronic pain, affecting more Americans than diabetes, heart disease and cancer combined. Estimates suggest that the cost of chronic pain management in the United States may be as high as $100 billion annually.2 Chronic pain is the most common cause of long-term disability, and is also widely associated with secondary depression and other psychiatric problems as well as alcoholism and prescription drug dependence.2,3
Literature has shown that comprehensive chronic pain programs “offer the most efficacious treatment for chronic pain patients” and are more cost-effective than traditional medical treatments.4 Gatchel and Okifuji5 reviewed numerous studies on comprehensive chronic pain programs, and results further support the treatment efficacy and cost-efficiency of such programs for chronic pain.
No epidemiological studies have ever been reported for the State of Hawai‘i, but it is reasonable to assume, in light of the national figures, that there are thousands of people in Hawai‘i suffering from chronic pain conditions at any one point in time and that the monetary and social costs are proportional. Current methods of treatment typically involve patients seeking different services from multiple providers with minimal coordination of care.
It was hypothesized that participation in the 12-week program (IOP) would result in significant post-treatment improvement in psychological functioning (i.e., somatization, depression, anxiety), quality of life, and physical function at work and/or home, and reduced utilization of healthcare resources, specifically Schedule II opiates.
A total of 35 (14 men and 21 women) chronic pain patients aged 25 to 76 (M=48.55 years) completed the 12-week intensive outpatient chronic pain program, across five cohorts. Patients were referred for screening if they met any of the following criteria: pain that is disproportionate to that of the diagnosis, recovery time exceeding expected resolution, sustained or increased use of triptans and/or opiate analgesics, prolonged or frequently recurring absenteeism, noncompliance with previous medical treatment plans, history of frequent changes in physician, history of multiple concurrent physicians, high emergency department utilization, and/or a history of poorly coordinated care. Participants in the study had a pain duration of at least one year, and the most common diagnoses were back and neck pain, abdominal and pelvic pain, headache, fibromyalgia, and chronic post-traumatic pain
To measure the psychological function of participants, each individual completed the Symptom Checklist-90-Revised6 (SCL-90-R), the Pain Patient Profile7 (P3) and the Millon Clinical Multiaxial Inventory-III8 (MCMI-III). Test results were reviewed by the program’s chief psychologist and medical director and each participant underwent an individual psychological consultation.
Quality of life
To measure the quality of life of participants, each individual was given the Quality of Life Inventory9 (QOLI) and self-report data was taken during intake.
Clinical assessment of each participant was performed by the medical director.
Utilization focused primarily on the amount of Schedule II opiates prescribed.
All patients referred for screening first received an initial consultation by the CPP medical director to determine if they were candidates for formal screening. Primary criteria for formal screening included high utilization (i.e., high number of different Schedule II opiates and/or high dosage levels of Schedule II opiates), poor quality of life (as reported by self-report and psychometric testing), poor function (on the basis of clinical assessment results and self-report), willingness to participate in the program, and no initial evidence of key exclusion criteria such as marked cognitive deficits, schizophrenia, severe bipolar disorder, and active suicidal ideation. Patients were considered candidates for Level I screening on the basis of this initial consultation and clearance.
Level I screening involved an evaluation by the medical director that was comprised of a comprehensive medical history and physical examination and a review of all available medical records and diagnostics. Particular care was taken to acquire and review all records describing the clinical course including specialty consultations, hospitalizations, previous procedures, and prescription drug use, as well as illicit drug use. On the basis of Level I screening, if candidates continued to demonstrate motivation to participate in the IOP and did not meet any exclusion criteria, they were cleared by the medical director for Level II screening.
Level II screening included computerized psychometric testing, consultation with the chief psychologist, and an additional visit with the medical director. Psychometric testing included the Beck Depression Inventory-II as a screening tool, SCL-90-R, P3, QOLI and MCMI-III. Results of the psychometric testing were reviewed by the chief psychologist and a case conference between the chief psychologist and medical director determined each participant’s candidacy for the intensive outpatient program (IOP).
The chronic pain IOP is a comprehensive biopsychosocial intervention intended to interrupt the pattern of social isolation and to reduce pain-related depression that contributes to reducing quality of life, poor function, and increased utilization of resources. The CPP treats chronic pain as a behavior, using cognitive behavioral strategies to help interrupt the “pattern of suffering,” and takes into consideration kinship structure and other social impacts. All participants received care with their specific cohort in a group setting and were expected to attend three sessions a week, each session lasting three hours, for a 12-week period. Primary elements of the program included group psychotherapy, acupuncture, and manual therapy focused on pain management, mind/body training, including breathing exercises, meditation, and visualization, and therapeutic movement, including elements of physical therapy, Feldenkrais (therapeutic movement focusing on neuromuscular re-education), and therapeutic yoga. Supplementary group sessions focused on pain education, education on the pharmacology of pain medicine, lifestyle, diet, and risks and benefits of herbs and supplements. Furthermore, each cohort received an introduction to Ho‘oponopono, an ancient Hawaiian practice focused on bringing relationships into equilibrium. These sessions were led by an indigenous Hawaiian practitioner. Concurrently, at a minimum of every two weeks, all participants received an individual re-evaluation by the medical director which included a medication review and attention to individual program goals. Data including somatization, depression, anxiety, quality of life, functional ability, and utilization of healthcare resources were assessed, pre-treatment (i.e. level II screening), post-treatment and one-year post pre-treatment screening.
The data and questionnaires from 20 participants across four cohorts who completed the comprehensive pain program, were analyzed (i.e., seven from the first cohort, three from the second cohort, six from the third cohort, and four from the fourth cohort). Participants’ age and gender were shown not to be significantly different among cohorts. Therefore, all participants were combined for subsequent analyses. Kolmogrov-Smirnov test were performed to determine if data were normally distributed. Results indicated that all of the variables (i.e., somatization, depression, anxiety, global severity, and quality of life) were normally distributed. Means and standard deviation are presented in Table 1.
Trends in the effects of the comprehensive pain program
To examine the effects of the comprehensive pain program on the outcome variables over time, trend analyses were conducted. Results indicated that the trends of all the outcome variables were linear. There was a significant decrease in somatization (F (1,19)=18.90, p=.000), depression (F (1,19)=14.21, p=.001), anxiety (F (1,19)=15.54, p=.001), and a significant increase in quality of life (F (1,19)=7.98, p=.011) (see Figure 1, Figure 2, Figure 3, Figure 4, Figure 5).
Differences in the effects of the comprehensive pain program
In order to examine the differences of the effects of the comprehensive pain program on the outcome variables over time, a one-way repeated measures ANOVA was performed. Results revealed that significant effects were noted in all of the outcome variables; somatization (F (2,38)=9.61, p=.000), depression (F (2,38)=7.99, p=.001), anxiety (F (2,38)=8.59, p=.001), and quality of life (F (2,38)=7.78, p=.001). Subsequently, a Bonferroni post-hoc test on the differences in the effects of the comprehensive pain program was performed to identify the location of the significant effects. The results demonstrated that significant differences existed between pre-treatment and one-year follow-up for somatization (MD=7.75, p=.001); pre-treatment and post-treatment (MD=7.25, p=.005), and pre-treatment and one-year follow-up (MD=9.30, p=.004) for depression; pre-treatment and post-treatment (MD=5.30, p=.004), and pre-treatment and one-year follow-up (MD=8.35, p=.003) for anxiety; pre-treatment and post-treatment (MD=-10.05, p=.004), and pre-treatment and one-year follow-up (MD=-8.65, p=.032) for quality of life.
Function at work and/or home
The data from 35 participants across five cohorts who completed the comprehensive pain program were analyzed through a clinical assessment by t
he medical director and via self-report. 64% had been disabled or partially disabled during the 12 months prior to entering the program. 85% of the disabled participants returned to gainful activity or were cleared to work following the program. At one year, the data from the first four cohorts was analyzed, and 100% of those who had returned to gainful activity were still gainfully engaged (see Figure 6).
Utilization of opiate analgesics
The data from 35 participants across five cohorts who completed the comprehensive pain program were analyzed via clinical assessment by the medical director. 77% had been on high level Schedule II opiate analgesics during the twelve months prior to the program. 96% of this group had reduction in high level opiate use by 25% or more following the program. 81% had reductions of 50% or more, and 50% had reductions by 100% following the program. At one year, the data from the first four cohorts was analyzed. 100% of those who had substantially reduced high level opiate use maintained reduced utilization.
In general, respondents manifested a decrease in their utilization of high level Schedule II opiates, and an increase in their overall level of functioning both at work and at home. The results of the psychometric testing indicated decreases in somatization, depression, and anxiety, as well as an increase in quality of life. These results suggest the possibility that the multidimensional format of the program leads to the multidimensional outcomes observed in this study. The primary limitation of this study was the small sample size. However, outcomes are consistent with previous studies, supporting the effectiveness of a comprehensive pain program in the reduction of opiate analgesic utilization, symptoms of somatization, depression, and anxiety. Importantly, an increase in functional capacity and overall quality of life was also demonstrated. It is premature to generalize the results of this study due to the size of the sample. However, this study suggests the need for further research in the area of intensive outpatient programs as a modality for both treatment and interpersonal support, specifically for patients suffering from chronic pain. Future studies should focus on this aspect of the intensive outpatient program as it relates to chronic pain and other bio-psycho-social health issues.
This study was supported by HMSA and ZEIR.
- Integrative Healthcare Group & Rehabilitation Center, Honolulu, HI 96814 (I.D.Z., S.O., M.C.)
- Department of Psychology, University of Hawai‘i at Manoa, Honolulu, HI 96822 (S.C.)
Ira D. Zunin MD
Integrative Healthcare Group & Rehabilitation Center
932 Ward Ave.
Honolulu, HI 96814
Ph: (808) 535-5555; Fax: (808) 535-5556
1. American Chronic Pain Association. Available at:
Accessed December 17, 2007.
2. National Institutes of Health. NIH Guide: New Directions in Pain Research I. September 4, 1998. Available from
Accessed December 17, 2007.
3. National Institute of Health. Fact Sheet: Pain Management. August 2007. Available from
Accessed December 17, 2007.
4. American Pain Society. Executive Summary of the APS Task Force on Comprehensive Pain Rehabilitation Report. Winter 2006. Available from http://www.ampainsoc.org/pub/bulletin/win06/report1.htm.
5. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and costeffectiveness of comprehensive pain programs for chronic nonmalignant pain. The Journal of Pain. 2006;7:779-793.
6. Derogatis LR. SCL-90-R administration, scoring, and procedures manual II. Towson, MD: Clinical Psychometric Research; 1983.
7. Tollison DC, Langley JC. Pain Patient Profile Manual. Minneapolis: National Computer Services; 1995.
8. Millon, C, Davis R. Manual for the Millon Clinical Multiaxial Inventory-III. Minneapolis, MN: National Computer Systems; 1994.
9. Frisch MB. Manual and Treatment Guide for the Quality of Life Inventory. Minneapolis, MN: National Computer Systems; 1994.