Special Report: Is the Biopsychosocial Model in Pain Management In or Out?

The International Association for the Study of Pain (IASP) revised the definition of pain in 2020 to say pain is: “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”¹

In late 2021, the Agency for Healthcare Research and Quality (AHRQ) released a research report conducted by the Pacific Northwest Evidence-based Practice Center (EPC) regarding the effectiveness of comprehensive and integrative biopsychosocial types of pain management treatment models.² Skelly et al wrote a systematic review of 57 RCTs for the report, titled Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms.

Skelly et al defined the two types of programs they evaluated as:

• integrative pain management programs (IPMPs) – primary care based, with embedded or easy access to multidisciplinary providers and services
• comprehensive pain management programs (CPMPs) – receive referrals from primary care or other sources and provide multidisciplinary services separate from a primary care environment

The objective of the AHRQ report described above was to evaluate the effectiveness and harms of pain management programs based on the biopsychosocial model of care, particularly in the Medicare population. Key findings included:

• IPMP programs demonstrated small improvements in chronic pain and function in the short term compared to usual care or waitlisted patients. The IPMP programs reviewed had “statistically significant but clinically unimportant effects on pain,” wrote the authors, with a moderate SOE for these factors.
• IPMP programs had greater utilization of long-acting opioids and other medications such as NSAIDs, antidepressants, and capsaicin compared to usual care models.
• CPMP programs demonstrated moderate levels of improvement in function immediately after the intervention and in the short term. Small changes in pain were found when compared to usual care, or those on a waitlist after intervention in the studies assessed.
• The limited scope review observed insufficient evidence regarding changes in opioid prescribing with CPMP models compared to usual care models.

The AHRQ report may have far-reaching implications for pain management practices, clinicians, patients, payers, and other interested stakeholders. Therefore, it’s important to accurately contextualize the report’s findings to avoid misinterpretation. The analysis has several limitations due to the narrow scope of studies analyzed, terminology used in the review, and categories of pain studied.

Report Limitations and Prior Data

Skelly et al stated in the report that the purpose of the study was to assess various types of pain management programs for Medicare beneficiaries in order to enhance reimbursement and coverage. Yet, a majority of studies included in the analysis had younger patient populations. The mean age was 57 years for the IPMP programs and 45 years for the CPMP programs evaluated.² (Disclaimer, Medicare also covers individuals with disabilities under age 65.)

• “Programs that address a range of biopsychosocial aspects of pain, tailor components to patient need, and coordinate care may be of particular importance” for the Medicare population; and
• “Although use of selected individual treatments may serve some patients, a broader range of therapies that address the full scope of biopsychosocial concerns available in formal programs may benefit others.”

These concluding statements seem to contradict the primary conclusions by the reviewers that IPMP and CPMP programs offer small to modest benefits based on the limited studies included in their review.

Contrasting this report, multiple studies have shown that biopsychosocial models such as functional restoration models and interdisciplinary programs for pain management are indeed effective for improving patient outcomes.³˒⁴

Amy Goldstein, director of the Alliance to Advance Comprehensive Integrative Pain Management (AACIPM), and a managing consultant at Healthcare Collaboratives, LLC, highlighted some weak areas within the AHRQ report. AACIPM brought together stakeholders representing people with pain, providers, payers, and others to discuss and respond to AHRQ’s open comment period, as the findings of the systematic review will impact payment design and healthcare delivery far beyond the Medicare program.

Tina L. Doshi, MD, MHS, assistant professor of anesthesiology and critical care medicine, at Johns Hopkins University School of Medicine, shared her thoughts on the AHRQ report as well. “The findings of the AHRQ review should not be interpreted as evidence that biopsychosocial approaches to pain do not work. It would be a direct contradiction to our mechanistic understanding of pain (and human disease in general) as having biological, psychological, and social influences.”

Dr. Doshi explained that “the major efforts shaping current public policy and pain research, including the Federal Pain Research Strategy, the NIH HEAL Initiative, and the Pain Management Best Practices Inter-Agency Task Force report, have all emphasized the importance of the biopsychosocial approach to pain care. Instead, the AHRQ report should draw attention to the fact that we need better biopsychosocial treatment options available, and as the authors suggest, we should examine which biopsychosocial approaches are most effective for a particular pain patient population.”

Terminology Is Tricky: Multidisciplinary, Interdisciplinary, and More

The AHRQ report interchanges the terms “multidisciplinary” and “interdisciplinary” to define biopsychosocial pain management programs selected for review, along with what defines IPMP and CPMP programs. While the agency acknowledges that the terminology used in different studies reviewed is a confounding factor in assessing the efficacy of these programs, they make their own interpretation of terminology in their analysis and subsequent conclusions.

According to the IASP definitions, there are distinct differences between “multidisciplinary” and “interdisciplinary” models:⁶

• Interdisciplinary teams comprise multiple disciplines but work together with shared goals.
• Multidisciplinary teams do not share common goals; individuals on these teams work separately and have their own patient outcome goals.

Is the Biopsychosocial Model a Concept Only?

When asked about the criticism and legitimacy of the biopsychosocial model in pain management, Dr. Twillman explained that, “Part of the problem is that integrative pain management is more of a philosophy than a coherent intervention in which the same treatment modalities are used for all patients. The core of the biopsychosocial approach to pain management is determining each individual’s needs across the biological, psychological, and social realms (and, I and others would add, the spiritual realm as well) and tailoring a pain care plan that addresses that individual’s needs… The scientific method is built around being able to use one care plan for one group of subjects and another for a second group and comparing outcomes. That’s not really feasible if true integrative pain care is being used.”

He added that a lack of concentration of studies, the short-term nature of patient follow-up, and constraints with the types of pain conditions considered, made it difficult to reach a conclusion regarding program efficacy.

Biopsychosocial Adoption Remains Stagnant

Overall, the AHRQ report further illuminates the challenges and barriers that currently exist with biopsychosocial type pain management models and programs, including significant disparities in terminology used by clinicians and researchers to describe different programs in action. These factors further hinder adoption of integrated and comprehensive pain management programs. The analysis should be carefully considered in clinical decision-making to avoid increasing treatment access barriers, and reimbursement issues.

Dr. Twillman added, “With respect to the science, I think there is likely a need to ‘meet in the middle.’ The hard-core methodologists need to help us develop research models that can accommodate the less-structured nature of integrative pain care, while the front-line clinicians need to be more mindful of collecting data systematically and over longer terms, in order to facilitate those new research models. It’s a cliche that every report like this will call for more research, but in this case, it’s not just ‘more’’ that we need but also ‘different.’”

Overall, the current AHRQ review has discernible limitations which diminish its broad findings. Better designed comparative effectiveness studies of IPMP and CPMP pain programs are needed to determine the relative strength of each type of program. Future studies should take into account patient age, comorbidities, pain category and program type. It’s important for pain practices to utilize an individualized approach since chronic pain has complex multidimensional facets.