Chronic Pain Rehabilitation Programs

Number: 0237

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses chronic pain rehabilitation programs.

1. Medical Necessity

   Aetna considers a screening examination medically necessary for members who are being considered for admission into a chronic pain rehabilitation program.
   
   Aetna considers a chronic pain rehabilitation program medically necessary (unless otherwise specified) when applicable criteria are met: 

   1. Outpatient chronic pain rehabilitation program when all of the following criteria are met (see section on contraindications below):
      
      
      1. If a surgical procedure or acute medical treatment is indicated, it has been performed prior to entry into the pain program; and
      2. Member has been experiencing chronic pain for more than 3 months; and
      3. The cause of the member's pain is unknown or attributable to a physical cause (i.e., not purely psychogenic in origin); and
      4. Member has completed a pre-program psychological and behavioral health evaluation to assess for comorbid conditions that may contribute to, exacerbate, or maintain chronic pain symptoms (e.g., posttraumatic stress disorder [PTSD], depression, anxiety, alcohol and substance use disorder [SUD]) and, if identified, member has been receiving treatment for that condition and continues to have refractory or intractable pain; and
      5. Member has documented failure, intolerance, or inadequate response to standard single-modality treatment methods (e.g., pharmacologic therapy, physical/occupational therapy); and
      6. Pain has resulted in persistent limitations in member's activities of daily living (ADLs) or impaired social/vocational functioning; and
      7. Referral for program entry has been made by a physician (MD or DO). A nurse practitioner (NP) or physician assistant (PA) may provide the referral when they are operating within their state's legal scope of practice; and 
      8. Member is considered medically and psychologically stable and capable of participating in outpatient sessions without safety concerns; and
      9. Program will include the following components:
         
         
         1. Assessment and monitoring;
         2. Administration of a validated pain rating scale or tool;
         3. Development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes;
         4. Overall treatment management (including medication management)
         5. Facilitation and coordination of any necessary behavioral health (BH) treatment;
         6. Pain and health literacy counseling;
         7. Any necessary chronic pain related crisis care; 
         8. Ongoing communication and care coordination between relevant practitioners furnishing care (e.g., primary care provider, physical/occupational therapy, BH therapists);
         9. Initial face-to-face visit at least 30 minutes provided by a physician or qualified health professional practicing within their state's legal scope of practice (e.g., NP or PA);
            
            Note: Dependence on narcotics or other controlled substances is frequently part of the presentation of a person with chronic pain. In persons with moderate to severe substance use disorders, detoxification must be considered and evaluated prior to enrollment into a pain management program. Refer to an Addiction Medicine specialist should be strongly considered in these persons. 
   2. Inpatient chronic pain rehabilitation programs
      
      Entry into an inpatient chronic pain rehabilitation program for up to 21 days when member meets all of the following criteria (see section on limitations and contraindications below):
      
      
      1. If a surgical procedure or acute medical treatment is indicated, it has been performed prior to entry into the pain program; and
      2. Member has refractory chronic pain that has not improved after a minimum of 6 weeks or completion of a an outpatient multidisciplinary chronic pain management program, whichever is shorter, absent a contraindication to such treatment (see contraindications below); and
      3. Member meets two or more of the following criteria that are associated with intractable pain:
         
         
         1. Inability to perform ADLs independently;
         2. Needs extensive psychological or behavioral therapy;
         3. Pain syndrome with comorbidity requiring supervised medical management and 24-hour nursing care (e.g., complex regional pain syndrome [CRPS] with autonomic instability, chronic pain with severe psychiatric impairment, complicated polypharmacy withdrawal, neuropathic pain syndrome with neurologic compromise);
         4. Member requires a temporary separation from a detrimental home environment to facilitate a renewed focus on their well-being and recovery from pain; and
      4. Referral for program entry has been made by a physician (MD or DO). A nurse practitioner (NP) or physician assistant (PA) may provide the referral when they are operating within their state's legal scope of practice; and
      5. The inpatient multidisciplinary pain management program includes the same program components as the outpatient multidisciplinary chronic pain management program (see above);
         
         Note: Dependence on narcotics or other controlled substances is frequently part of the presentation of a person with chronic pain. In persons with moderate to severe substance use disorders, detoxification must be considered and evaluated prior to enrollment into a pain management program. Refer to an Addiction Medicine specialist should be strongly considered in these persons. 
   3. Contraindications for entry into a chronic pain rehabilitation program are considered not medically necessary and includes the following:
      
      
      1. Member exhibits aggressive and/or violent behavior;
      2. Member exhibits imminently suicidal tendencies;
      3. Member has previously failed an adequate multidisciplinary (e.g., Commission on Accreditation of Rehabilitation Facilities [CARF] accredited) chronic pain management program;
      4. Member has unrealistic expectations of what can be accomplished from the program (i.e., member expects an immediate cure);
      5. Member is medically unstable (e.g., due to uncontrollable high blood pressure, unstable congestive heart failure, or other medical conditions);
      6. Member is unable to understand and carry out instructions;
   4. Limitations for inpatient chronic pain rehabilitation program includes the following: 
      
      
      1. Most inpatient chronic pain treatment programs require both medical and psychological evaluations before admission into the program. These evaluations should be performed on an outpatient basis; inpatient admission for these evaluations is considered not medically necessary;
      2. Participation in inpatient pain management programs for more than 21 days is subject to medical necessity review;
      3. Continued inpatient chronic pain treatment is considered not medically necessary for members who are not participating (e.g., failure to attend scheduled treatment sessions) in the program;
      4. An inpatient chronic pain management program is considered not medically necessary for persons who have failed a prior adequate multidisciplinary (e.g., CARF accredited) chronic pain management program;
   5. Modality-oriented pain clinics and single disciplinary pain clinics are considered not medically necessary and inappropriate for comprehensive treatment of members with chronic pain;
   6. Neuropsychological evaluation/testing is not medically necessary for members with chronic pain being considered for treatment solely with narcotic pain medication. See CPB 0158 - Neuropsychological and Psychological Testing.

2. Experimental, Investigational, or Unproven

   The following interventions are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established:

   1. Foundation PISM (Ethos Laboratories) functional biomarker urine test panel for chronic pain management and for all other indications;
   2. NeuroFlow (remote monitoring physiologic parameters) for monitoring individuals in pain management and for all other indications.

3. Related Policies

   • CPB 0011 - Peripheral Electrical Nerve Stimulation for Pain
   • CPB 0016 - Back Pain - Invasive Procedures
   • CPB 0132 - Biofeedback
   • CPB 0158 - Neuropsychological and Psychological Testing
   • CPB 0194 - Spinal Cord Stimulation
   • CPB 0232 - Back Pain - Noninvasive Treatments
   • CPB 0250 - Occupational Therapy
   • CPB 0306 - Laboratory Tests for Depression and Other Psychiatric Disorders
   • CPB 0462 - Headaches: Nonsurgical Management
   • CPB 0965 - Drug Testing in Pain Management and Substance Use Disorder Treatment
   • CPB 0325 - Physical Therapy

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes not covered for indications listed in the CPB:
0117U	Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain
96132 - 96133	Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed
96146	Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only
99453	Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
99454	Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
99457	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)
Other CPT codes related to the CPB:
64553 - 64595	Neurostimulators
90785	Interactive complexity (list separately in addition to the code for primary procedure)
90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services
90832 - 90838	Psychotherapy
90845 - 90853	Psychotherapy for crisis
96130	Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
96131	Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure)
96156 - 96171	Health behavior assessment, or re-assessment and intervention
97010 - 97546	Therapeutic procedures
HCPCS codes covered if selection criteria are met:
G3002	Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (when using g3002, 30 minutes must be met or exceeded.)
G3003	Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month (list separately in addition to code for g3002, when using g3003, 15 minutes must be met or exceeded.)
ICD-10 codes covered if selection criteria are met:
F10.120– F19.988	Mental and behavioral disorders due to psychoactive substance use
F32.0 – F32.A	Depression
F41.0 – F41.9	Anxiety disorder
F43.10 – F43.12	Post-traumatic stress disorder
G89.21 - G89.3	Chronic pain, not elsewhere classified
G89.4	Chronic pain syndrome
G90.50 – G90.59	Complex regional pain syndrome I
ICD-10 codes not covered for indications listed in the CPB:
I50.1 – I50.9	Congestive Heart failure
R03.0	Elevated blood-pressure reading, without diagnosis of hypertension
R45.6	Violent behavior
R45.851	Suicidal ideations

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Background

Chronic pain is a widespread and persistent health problem in the United States, affecting millions of adults and significantly reducing quality of life. The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience linked to actual or potential tissue damage, often serving as a warning symptom of a medical condition or injury, highlighting its multidimensional biological, psychological, and social components. In such instances, addressing the underlying medical issue is essential and may alleviate the pain. However, pain can persist even after successful treatment of the initial condition or when the underlying issue cannot be effectively managed. According to the IASP, chronic pain is characterized as pain that persists or recurs for more than 3 months, often becoming a primary clinical condition that necessitates targeted diagnostic evaluation and multidisciplinary management. This definition, widely accepted by U.S. professional organizations such as the American Academy of Pain Medicine, underscores the understanding that chronic pain is a complex, multifactorial disorder rather than merely a symptom, frequently involving neuroplastic changes, functional impairment, and significant emotional distress (IASP, 2021).

Chronic pain rehabilitation programs consist of intensive, multidisciplinary approach designed to improve functioning and quality of life for individuals with chronic, intractable pain. These programs utilize a team of specialists (physicians, psychologists, physical/occupational therapists) to help patients manage symptoms, reduce medication reliance, and return to daily activities.

Chronic low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia are among the most prevalent forms of chronic musculoskeletal pain. Due to the lack of a single therapy that consistently provides benefits, a multimodal treatment approach is recommended. Various nonpharmacologic, noninvasive treatments can lead to small to moderate improvements and can be combined with pharmacological or more invasive options. Systematic reviews and guidelines indicate that different forms of exercise are effective in enhancing pain relief and function for patients with chronic pain. Cognitive behavioral therapy and mindfulness techniques have shown effectiveness in achieving small to moderate short- and long-term improvements in chronic low back pain, while cognitive behavioral therapy may also provide small short- and intermediate-term benefits for fibromyalgia. Multidisciplinary rehabilitation has been shown to be effective for short- and intermediate-term improvements in pain and function for chronic low back pain and fibromyalgia. Patients are encouraged to pursue a variety of therapies that align with their preferences and motivations, as no single pain therapy consistently yields significant benefits for chronic musculoskeletal pain. On average, patients experience small to moderate improvements in pain intensity and function from any individual therapy, reinforcing the recommendation for a multimodal treatment strategy that maximizes benefits while minimizing risks. A comprehensive pain management plan should prioritize self-management and may include physical and psychological approaches, medications, therapeutic injections, and surgery. Additionally, patient education on neurophysiology as part of a self-management program has proven effective for chronic low back pain and may also alleviate pain and non-pain symptoms in fibromyalgia. While patient education regarding diagnosis, activity, lifestyle modifications, and weight reduction is recommended for osteoarthritis, its empirical support is limited, and no benefits have been established for chronic neck pain (AAFP, 2026).

Multi- or interdisciplinary pain rehabilitation involves coordinated care from a team that may include various clinicians, physical or occupational therapists, and behavioral therapists, and is recommended for patients with low back pain that do not adequately respond to first-line treatments. This approach typically results in small to moderate short-term improvements in pain, function, and disability, as well as small intermediate-term benefits for pain and function, although assessments of long-term benefits show varying results, ranging from minimal to no improvement. Evidence regarding the effectiveness of this rehabilitation for lumbar radiculopathy is insufficient. A Cochrane review indicated that, after 2 years, pain, disability, and work outcomes were similar for patients undergoing spinal fusion and those receiving multi- or interdisciplinary pain rehabilitation. This rehabilitation approach has been shown to provide short-, intermediate-, and long-term functional improvements and intermediate-term pain reduction for patients with fibromyalgia. The cost-effectiveness of this treatment may be enhanced by targeting patients who are most likely to benefit, such as those with severe functional deficits, inadequate responses to less intensive therapies, or significant psychosocial issues. The American Academy of Family Physicians (AAFP) state that multi- or interdisciplinary pain rehabilitation appears to be effective for short- and intermediate-term improvements in low back pain and fibromyalgia, with cost-effectiveness potentially increased through careful patient selection (Flynn, 2020).

Davin et al. (2025) highlight that chronic low back pain is a costly condition and the leading cause of disability globally. A recent call to action has pointed out the overuse of low-value healthcare as ineffective and potentially harmful in managing back pain. Interdisciplinary pain programs (IPPs) combine physical therapy and behavioral pain treatments to empower patients to actively manage their pain, thereby reducing stress, disability, and reliance on low-value care. Although IPPs are considered "cost-effective," there is limited research on healthcare utilization patterns among patients who complete these programs, particularly in relation to value-based care. This study aimed to describe the healthcare utilization patterns of adult patients (N=143) participating in an IPP for chronic low back pain, compared to those who did not complete the program (N=112) and those eligible but who chose not to participate (N=76). The study evaluated healthcare utilization over a 12-month period before and after IPP participation, focusing on categories such as outpatient resources, specialist visits, imaging, pain interventional procedures, and acute care utilization, as well as opioid use based on inpatient and outpatient orders. The results indicated that overall healthcare utilization did not significantly differ among the three groups in the 12 months before and after the IPP. However, subgroup analyses revealed significant reductions in opioid prescriptions, x-rays, and emergency department visits in the IPP group after the program, along with increased engagement in behavioral pain management. These findings suggest that participation in an IPP for chronic low back pain can lead to reduced reliance on certain healthcare services and may influence future value-based healthcare decisions, potentially impacting overall costs.

Chronic neuropathic pain is defined as persistent pain resulting from a lesion or disease affecting the somatosensory nervous system, which conveys information about the body, including the skin, musculoskeletal system, and visceral organs. This type of pain can arise from lesions or diseases involving either peripheral or central components of the somatosensory nervous system, with chronic pain characterized by its persistence or recurrence for 3 months or longer. Neuropathic pain may manifest as spontaneous pain (either continuous or episodic) or as an exaggerated response to painful stimuli (hyperalgesia) or a painful reaction to normally non-painful stimuli (allodynia). A diagnosis of neuropathic pain necessitates a history of nervous system injury, such as a stroke or nerve trauma, or a disease like diabetic neuropathy, along with a neuroanatomically plausible pain distribution. Both negative sensory symptoms (such as decreased or lost sensation) and positive sensory signs (like allodynia or hyperalgesia) must align with the innervation territory of the affected nerve structure. Confirmation of the diagnosis of definite neuropathic pain is achieved through imaging techniques, neurophysiological assessments, or laboratory tests that demonstrate the lesion or disease in the nervous system. Neuropathic pain is a significant cause of physical impairment and emotional and psychosocial distress, necessitating a multimodal treatment approach that includes specific pharmacological interventions (IASP, 2021).

Heutink et al. (2012) evaluated a multidisciplinary cognitive behavioral treatment program for individuals with chronic neuropathic pain following spinal cord injury (SCI). The intervention consisted of educational, cognitive, and behavioral elements. A total of 61 participants were randomized to either the intervention group or the waiting list control group across four Dutch rehabilitation centers. Primary outcomes included pain intensity and pain-related disability (measured by the Chronic Pain Grade questionnaire), while secondary outcomes included mood (assessed by the Hospital Anxiety and Depression Scale), participation in activities (measured by the Utrecht Activities List), and life satisfaction (evaluated using the Life Satisfaction Questionnaire). Measurements were taken at baseline, and at three and six months follow-up. The primary statistical technique employed was random coefficient analysis. The analyses revealed significant changes over time in both primary outcomes (t1 - t2) and two out of four secondary outcomes (both t1-t2 and t1-t3). Significant intervention effects (Time*Group interactions) were found for anxiety and participation in activities, but not for the primary outcomes. Subsequent paired t-tests indicated significant changes in the intervention group that were not observed in the control group, including decreases in pain intensity and pain-related disability, reductions in anxiety, and increases in participation in activities. The authors concluded that these findings suggest that a multidisciplinary cognitive behavioral program may have beneficial effects for individuals with chronic neuropathic pain following spinal cord injury.

Pain rehabilitation programs represent an innovative strategy for managing intractable pain, aiming to equip patients with the skills necessary to control their pain and enhance their ability to function independently. A hospital-level pain rehabilitation program involves a coordinated multidisciplinary team that delivers a focused treatment plan in a controlled environment, addressing the physiological, psychological, and social dimensions of pain. These programs typically incorporate diagnostic testing, skilled nursing, psychotherapy, a structured tapering of pain medications, and physical and occupational therapy to maximize physical fitness (mobility and endurance) within the limits of the patient's disabilities. Additionally, they may utilize mechanical devices and various activities to alleviate pain or alter the patient's response to it, such as nerve stimulators, hydrotherapy, massage, ice therapy, systemic muscle relaxation training, and diversional activities. Nurses play an important role in these programs by continuously observing and assessing patients' conditions and responses, ensuring that the environment does not reinforce pain behaviors. The daily operations of the program are overseen by a physician, who provides general and, when necessary, direct supervision. An inpatient program may be deemed reasonable and necessary for patients whose pain has a physical origin, has not responded to standard treatments, and has led to a significant loss of independent functioning. It is important to recognize that chronic pain patients often experience accompanying psychological issues, making psychological treatment a vital component of the multidisciplinary approach. However, patients whose pain symptoms arise from mental health conditions rather than physical causes typically do not benefit from pain rehabilitation programs (CMS, n.d.).

The literature suggests that generally up to 3 weeks of inpatient care may be required to modify pain behavior. Any chronic pain rehabilitation that may be needed after that can usually be effectively provided on an outpatient basis. Although many multidisciplinary pain facilities offer both inpatient and outpatient treatment programs, there is little evidence to indicate that inpatient programs are more effective than outpatient ones. Outpatient chronic pain rehabilitation programs frequently provide services in group settings, even though these services are delivered according to each patient's individualized treatment plan.

There is sufficient evidence that multidisciplinary pain treatment clinics and centers are effective for managing appropriately selected patients with chronic non-malignant pain. Studies have shown that chronic pain patients who have completed these programs experience lasting reductions in pain and psychological distress. These studies have demonstrated improvements in both subjective pain ratings and objective measures, such as reduced use of narcotic pain medications, increased rates of return to work, and decreased utilization of the healthcare system.

A systematic evidence review by the Swedish Council on Technology Assessment in Health Care (SBU, 2006) concluded that "rehabilitation programs, referred to as multimodal rehabilitation (usually a combination of psychological interventions and physical activity, physical exercise, or physical therapy), result in greater pain reduction, a higher number of people returning to work, and shorter sick leaves compared to passive control and/or limited, separate interventions." The SBU assessment also found that multimodal rehabilitation improves long-term functional ability in fibromyalgia patients more effectively than passive control or limited, separate interventions.

An assessment of multidisciplinary pain programs for chronic non-cancer pain, prepared for the Agency for Healthcare Research and Quality (Jeffery et al., 2011), found that multidisciplinary pain programs have been extensively documented in the standard medical literature. The 183 papers considered in the AHRQ assessment followed a biopsychosocial model of chronic pain, incorporating treatment components in each of four areas: medical, behavioral, physical reconditioning, and education. Most of the studies included in the AHRQ assessment were observational before-after designs. Although several different clinical conditions were studied, 90 percent of the studies focused on chronic back pain, the most frequently addressed condition in the literature. The report noted that differences were apparent between studies conducted in the United States and those in Europe; recent European studies were more likely than U.S. studies to include inpatient delivery of multidisciplinary pain program treatment. The declining access to multidisciplinary pain program treatment in the United States is highlighted as a key issue faced by the community of chronic pain sufferers and researchers.

Chronic cancer-related pain is defined by the IASP as pain resulting from the primary cancer or its metastases (chronic cancer pain) or from its treatment (chronic post-cancer treatment pain), and is considered distinct from pain caused by co-morbid diseases. It is important to establish a strong likelihood that the pain is due to cancer or its treatment; however, this distinction may be vague. On average, cancer patients report experiencing two different types of pain, which necessitates careful assessment to differentiate between pain stemming from the cancer itself, its treatment, or co-morbid conditions. Overlapping pain is common; for example, post-surgical pain from thoracic surgery for lung cancer may be worsened by cancer recurrence in the same area. Clinicians must identify the predominant cause of the pain to inform treatment decisions. The diagnostic criteria require that chronic pain (lasting longer than 3 months) is present, with at least one of the following — pain caused by an active tumor (including metastases) or pain resulting from cancer treatment (such as surgery, chemotherapy, or radiotherapy) — and the pain is not be better explained by another chronic pain diagnosis (IASP, 2021).

The National Comprehensive Cancer Network (NCCN, 2026) states that chronic cancer pain in adults is defined as persistent or recurrent pain lasting more than 3 months. The NCCN clinical practice guidelines on adult cancer pain indicate that non-pharmacologic interventions may be particularly important for vulnerable populations, such as frail or older adults, who may have reduced tolerance for standard pharmacologic treatments or may prefer alternatives. This underscores the necessity for a team-based approach to pain management that incorporates a wide range of treatment options. Pain relief or functional improvement may be achieved through cognitive, spiritual, physical, or nutritional modalities, including but not limited to cognitive behavioral therapy (CBT), cognitive restructuring; nutritional consultations; biofeedback; relaxation training; graded task assignments, goal setting, pacing, and prioritizing; transcutaneous electrical nerve stimulation; acupuncture; and instruction in therapeutic and conditioning exercise. The NCCN also recommends non-opioid analgesic management, as well as the use of antidepressants, anticonvulsants, and topical agents, while prioritizing patient safety. Furthermore, the NCCN cites a systematic review and meta-analysis on opioid use disorder (OUD) in patients with cancer-related chronic pain, which recommends a multidisciplinary approach to optimize outcomes. This approach includes regular monitoring and early referral to or coordination with appropriate services, such as behavioral health and substance use specialists.

Hölzl and colleagues (2025) highlight that scientific pain associations advocate for specialized treatment for patients with chronic pain through interdisciplinary multimodal pain therapy (IMPT) in various clinical settings. However, existing structural requirements often hinder the implementation of comprehensive IMPT programs for a range of conditions. The authors report on the outcomes of a modified IMPT program implemented at the Pain Center of the University Hospital Mannheim. In a retrospective analysis involving 106 day-care patients with chronic pain, the authors investigated the effects on four major pain domains—pain characteristics, function and impairment, well-being and quality of life, and mental health, including depression—two years post-program entry. Patients were categorized based on ICD-10 diagnoses into musculoskeletal, neuropathic, persistent pain with psychosocial factors, and a small group with tumor-related pain. Results indicated significant improvements across most pain domains, particularly in function and well-being, with the most notable outcomes observed in neuropathic and tumor pain, while patients with persistent pain disorders showed the least response. The findings suggest that an individualized IMPT can be effectively implemented in outpatient settings catering to a variety of patients with chronic pain, while also highlighting the varying success rates across different pain types, thus defining the potential and limitations of generic IMPT approaches.

According to the Institute for Chronic Pain, individuals who benefit most from chronic pain rehabilitation programs are those experiencing moderate-to-severe persistent pain who have accepted that their condition is chronic and incurable, and who wish to engage in meaningful life activities despite their pain. These programs aim to achieve five key goals: reducing pain, facilitating a return to work or other meaningful activities, addressing issues related to living with pain such as anxiety, irritability, depression, sleep disturbances, and strained relationships, decreasing reliance on narcotic pain medications, and minimizing overall dependence on the healthcare system. Chronic pain rehabilitation emphasizes self-management, which involves making healthy lifestyle changes and enhancing coping skills to better manage pain. These interdisciplinary programs typically include psychologists, physical therapists, physicians, and nurses, and may also feature occupational therapists and vocational rehabilitation specialists. Conducted daily over three to four weeks, either on an outpatient or inpatient basis, these programs serve as a "chronic pain school," where patients learn to live well despite their condition. Core therapeutic components include pool therapy, stretching and core strengthening, low-impact aerobic exercises, relaxation therapies, coping skills training, individual psychotherapy, non-narcotic medication management, tapering of narcotic medications as needed, and life/work exposure therapy, often delivered in small group settings. Research shows that participants typically achieve a 40% reduction in pain and many taper off narcotic medications, with about 50% returning to work, compared to 20-36% of patients returning to work after spine surgery. Despite initial doubts about their ability to participate, many patients who succeed in these programs have lived with chronic pain for years, often struggling with daily tasks and emotional distress. Chronic pain rehabilitation programs are designed to support the most disabled and distressed individuals, and they have proven effective in helping them regain functionality and improve their quality of life (McAllister, 2022).

In 2009, the Veterans Health Administration (VA) adopted a stepped‑care model with primary care and specialty consultation as the default for pain management and only tertiary, interdisciplinary programs (Commission on Accreditation of Rehabilitation Facilities [CARF]‑accredited) for complex cases—i.e., inpatient is not routine; it is reserved for higher‑acuity indications within a tertiary tier.

Per Chen (2006), a chronic pain rehabilitation team is composed of various healthcare providers, typically including physical and occupational therapists, psychologists, nurses, and pain physicians, with some programs also incorporating medical social workers, vocational rehabilitation counselors, and recreational therapists. Physical therapists play a crucial role in educating patients on improving biomechanics, posture, flexibility, strength, and conditioning, while occupational therapists enhance patients' abilities to perform daily living and homemaking tasks, often simulating work environments. The integration of work and recreational activities is addressed by various team members, including physical and occupational therapists, recreational therapists, vocational counselors, and medical social workers. A key member of the team is the health psychologist, who utilizes cognitive behavioral therapy (CBT) to help patients identify and modify maladaptive thoughts and behaviors, fostering self-reliance through techniques such as operant conditioning, stress management, and goal setting. Other essential team members include medical social workers for community resource evaluation, rehabilitation nurses for medication management and education, and vocational rehabilitation specialists for training options. While physicians coordinate the team's activities and educate patients, they ideally take a minimal role post-diagnosis to encourage patient self-management of chronic pain. Outpatient pain rehabilitation programs provide individualized treatment plans, even in group settings, and typically last from two to 12 weeks, with contact hours ranging from three to 280. Research indicates that programs with over 100 hours of professional contact yield better outcomes. Therapy can be delivered individually or in groups, with group therapy offering peer support and a sense of shared experience among participants. Collaborative efforts among healthcare team members can also enhance staff morale, addressing the complexities of chronic pain management. The emerging model of multidisciplinary teams in treating chronic conditions like diabetes and obesity can be adapted from successful chronic pain programs.

The Commission on Accreditation of Rehabilitation Facilities (CARF) publishes the Medical Rehabilitation Standards Manual, which details the essential components, team structure, assessment processes, scope of services, and program expectations for an interdisciplinary pain rehabilitation program. A person-centered interdisciplinary pain rehabilitation program employs a collaborative team approach to meet the needs of individuals with persistent pain. By utilizing a biopsychosocial framework, the program tailors treatment to empower participants to self-manage their symptoms, enhance their functional abilities, engage in daily life roles, and improve their overall quality of life. It also addresses chronic opioid use for pain management when necessary, demonstrating a commitment to maintaining its status as a specialized rehabilitation program for those with persistent pain. The program promotes the appropriate use of healthcare services by participants and their support systems, encouraging efforts to enhance personal health and wellness throughout their lives. It provides valuable information, services, and resources to enrich the lives of individuals within their families, communities, and roles. Additionally, the program leverages current research and evidence to deliver effective rehabilitation while advocating for advancements in care through participation in pain research. It actively represents the interests of individuals with persistent pain to various stakeholders, including regulators, legislators, educational institutions, research funding organizations, payers, and the broader community.

The CARF Interdisciplinary Pain Rehabilitation Program includes the following components:

• Assessment and ongoing monitoring
• Use of validated, standardized assessment tools
• Development and maintenance of an individualized, person‑centered rehabilitation plan
• Interdisciplinary treatment management
• Behavioral health integration
• Medication oversight / medication taper support
• Patient education including pain literacy and self‑management training
• Crisis planning and safety management when needed
• Ongoing, documented coordination and communication among all treating providers.

Chronic pain rehabilitation programs may be inpatient or outpatient, but inpatient delivery is now considered uncommon and are reserved for patients with severe functional impairment, complex medical comorbidities, or situations requiring 24‑hour supervision such as complex medication withdrawal. The standard of care today is the multidisciplinary outpatient or day‑treatment model, which provides evidence‑based functional restoration with significantly lower cost and comparable clinical outcomes (Chen, 2006; Gauntlett-Gilbert and Brook, 2018).

Foundation PI^SM

Foundation PISM is a urine test analysis by liquid chromatography tandem mass spectrometry (LCM/MS) of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid). Results of an algorithm are reported as a pain-index score that is intended to indicate the likelihood of atypical biochemical function associated with pain. There is a lack of evidence in the peer-reviewed published medical literature of the clinical validity and utility of this test.

Gunn et al. (2020) reported on a retrospective observational study to determine and evaluate the prevalence of abnormal biomarker findings in a population of patients with chronic pain. Investigators employed a pain-specific biomarker test panel that evaluates biomarkers of systemic inflammation, oxidative stress, neurotransmitter turnover, and micronutrient status to determine the prevalence of abnormal findings in 17,834 unique patient samples analyzed at a national reference laboratory (Ethos Laboratories, Newport, KY). Patient biomarker results were considered abnormal if they were outside of the 95% confidence interval reference ranges established using a healthy population of donors who had no history of chronic pain or opioid use. The investigators found that 77% of patients with chronic pain exhibited at least one abnormal biomarker result (n = 13,765). The most common abnormal biomarker finding was elevated quinolinic acid, which was observed in 29% of patients (n = 5,107). Elevated pyroglutamate, indicative of glutathione depletion, was observed in 19% of patients (n = 3,314). Elevated xanthurenic acid, indicative of vitamin B6 insufficiency, was observed in 17% of patients (n = 3,025). Elevated levels of the acrolein metabolite 3-hydroxypropyl mercapturic acid were observed in 21% of patients (n = 3,667). Elevated methylmalonic acid, indicative of a vitamin B12 deficiency, was observed in 10% of patients (n = 1,827), whereas abnormally low levels of neurotransmitter metabolites were observed in 8% of patients (n = 1,456). The investigators noted that a limitation of this study was that medications and conditions other than those associated with chronic pain were not evaluated as potential causes of abnormal biomarker findings.

McGeary et al. (2022) examined the effects of inter-disciplinary pain management on pain-related disability and opioid reduction in poly-morbid pain patients with two or more co-morbid psychiatric conditions. This study was a two-arm, randomized controlled trial (RCT) examining a three-week intervention with assessments at pre-treatment, post-treatment, six-month, and twelve-month follow-up. A total of 103 military veterans with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or post-traumatic stress disorder (PTSD) were randomly assigned to usual care (n = 53) and inter-disciplinary pain management (n = 50). All subjects reported recent persistent opioid use. Trial participants had high levels of co-morbid medical as well as mental health conditions. Interventions entailed the experimental arm—a three-week, inter-disciplinary pain management program guided by a structured manual; and the comparison arm—treatment as usual (TAU) in a large Department of Veterans Affairs medical facility. Main outcome measures included Oswestry Disability Index (ODI; pain disability); Timeline Follow-back Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all post-treatment observations (post-treatment, six-month follow-up, twelve-month follow-up) entered simultaneously to create a single post-treatment effect. Veterans with poly-morbid pain randomized to the inter-disciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to TAU at post-treatment, six-month, and twelve-month follow-up. Aggregated mean pain disability scores (i.e., a summary effect of all post-treatment observations) for the inter-disciplinary pain program were -9.1 (95% CI: -14.4 to -3.7, p = 0.001) points lower than TAU. There was no difference between groups in the proportion of subjects who resumed opioid use during trial participation (32% in both arms). The authors concluded that these findings offered the first evidence of short-term and long-term inter-disciplinary pain management effectiveness in poly-morbid pain patients; however, further investigation is needed to examine how to decrease opioid use in this population.

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