Interdisciplinary Pain Programs Steer Low Back Pain Patients Toward Higher-Value Care

Chronic low back pain is a pervasive and costly condition, recognized globally as the leading cause of disability. Despite its prevalence, treatment often involves an overuse of “low value” healthcare services that are neither effective nor without potential harm.

A recent Cleveland Clinic study (N Am Spine Soc J. 2025;21:100584) sheds light on how interdisciplinary pain programs (IPPs) can significantly reorient healthcare utilization patterns for chronic low back pain by moving patients away from low-value interventions toward more effective, high-value care, thus influencing care decisions and future costs.

“For clinicians managing patients with chronic low back pain, this research underscores the critical role of interdisciplinary pain programs in fostering patient self-management, reducing reliance on potentially ineffective treatments, and promoting a more sustainable and patient-centered approach to care,” says the study’s lead and corresponding author, Sara Davin, PsyD, MPH, Director of Cleveland Clinic’s Comprehensive Pain Recovery Program.

“Chronic pain, including persistent low back pain, is a complex condition in which imaging may not correlate with the degree of pain due to emotional, social and individual variability in experiencing pain,” she continues. “After other serious underlying causes of pain are worked up medically and ruled out, chronic back pain should be treated according to clinical guidelines, which advocate prominent roles for behavioral and physical therapies to reduce pain-related fear and promote active self-management. This approach decreases patients’ tendency to pursue forms of care that may increase fear while offering little added value after the initial workup. This is not to say there’s no role for other forms of treatment, such as injections or surgeries, in chronic back pain. However, these are not first-line approaches in most cases.”

Study rationale and design

IPPs, which integrate physical therapy and behavioral pain therapy, aim to empower patients with skills to actively manage their pain, reduce distress and disability, and lessen dependence on low-value services for ongoing treatment. While IPPs are widely considered effective and cost-effective, detailed understanding of their impact on healthcare utilization patterns, particularly within a value-based care framework, has been limited.

Value-based care emphasizes patient outcomes relative to treatment costs. Prior research from Cleveland Clinic (Spine. 2019;44[24]:1715-1722) showed that an IPP improved physical function, fatigue and quality of life for patients with spine pain. “This new study sought to expand on those findings by evaluating patterns of healthcare utilization by adults with chronic low back pain before and after IPP participation, exploring how treatment choices align with value-based care principles,” Dr. Davin explains.

The observational cohort study included 331 adult patients who were eligible for Cleveland Clinic’s three-month IPP. The program’s core components include weekly cognitive behavioral therapy-based group sessions and twice-weekly individual/group physical therapy sessions, with care coordinated by spine medicine providers as needed. Patients were not mandated to taper opioids or cease marijuana use, but they received education on these topics to support informed self-care decisions.

The research categorized patients into three groups:

• 143 IPP graduates, who completed the program
• 112 dropouts, who participated in at least one appointment but did not complete the program
• 76 eligible nonparticipants in the program

Healthcare utilization data were extracted from electronic health records for 12 months before the IPP enrollment date (for those who enrolled) or eligibility date and 12 months after the IPP graduation date; for those who did not complete the program or did not participate at all, data were collected for 12 months after their enrollment or eligibility date. Utilization categories included outpatient resources, specialist visits (such as physical therapy, behavioral health, neurology, pain clinic and spine specialists), imaging (MRI, CT, X-ray), procedures (injections, surgery), acute care (emergency department [ED] visits, hospitalizations) and opioid use. Relative value units (RVUs) were used to standardize the measurement of utilization of physician services.

Results show shifts in care

The study’s key findings reveal some notable shifts in healthcare engagement among IPP graduates:

Reduced low-value care. Patients who completed the IPP showed significant reductions in several areas often considered low-value for chronic pain management. Specifically, there were significant decreases from the year before the program to the year after the program in X-rays (from 62.94 to 44.06 per 100 patients), ED visits (from 32.87 to 13.29 per 100 patients) and neurology visits (from 89.51 to 3.50 per 100 patients) (all P < .001).

Decreased opioid prescriptions. While not reaching statistical significance for within-group comparison, outpatient opioid prescriptions for IPP graduates decreased from 49.7% before the program to 40.6% after. Notably, when comparing across groups in the year following the IPP, graduates had the lowest rate of outpatient opioid orders, 40.6%, compared with 50.0% for IPP dropouts and 57.9% for nonparticipants, a statistically significant difference (P = .042). “This suggests IPP participation can help facilitate reduced opioid use,” Dr. Davin notes.

Increased high-value care. Conversely, IPP graduates showed a statistically significant increase in behavioral health appointments from the year before to the year after the program (from 13.29 to 83.92 visits per 100 patients). “This indicates a healthy engagement in high-value care to reinforce pain self-management skills,” Dr. Davin says. Physical therapy utilization was highest during the IPP and, while decreasing post-IPP, remained at a nonstatistically higher rate than in the two comparator groups, consistent with empowering patients to transition to home exercise programs.

RVU trends. RVUs for IPP graduates significantly decreased from 20.3 in the year prior to 14.8 in the year following the IPP (P < .001), suggesting a reduction in the overall value of physician services utilized. Interestingly, IPP dropouts and nonparticipants showed similar pre/post reductions in RVUs as well as reductions in other utilization categories, such as visits to primary care, neurology, spine specialists and the ED. However, the crucial difference was the lack of significant increase in pain-related behavioral therapy among these groups, as well as the minimal reduction in X-rays and ongoing low utilization of physical therapy for IPP nonparticipants, suggesting continued pursuit of low-value care.

Study takeaways

These findings carry several notable implications for clinical practice, Dr. Davin and her Cleveland Clinic co-authors conclude:

• IPPs as a gold standard. The study reinforces that IPPs can be a high-value treatment option, aligning with national imperatives to shift pain care models toward value-based approaches.
• Care paradigms can be shifted. IPPs can effectively steer patients away from low-value diagnostic imaging (particularly X-rays and, to a lesser degree, MRI/CT), acute care (ED visits) and potentially harmful opioid use while pointing them toward active self-management strategies and behavioral health support. “This is particularly relevant given the emphasis on reducing routine imaging and opioid reliance in current pain management guidelines,” Dr. Davin says.
• Empowerment over forced reduction. The authors underscore that opioid reduction among IPP graduates occurred without a forced taper, but rather through providing education and empowering patients with active pain-coping strategies. This model supports a patient-centered approach where individuals learn to reduce reliance on chronic opioid therapy voluntarily.
• Engagement barriers need to be addressed. Despite the utilization improvements for IPP graduates, the study also revealed high rates of dropout and nonparticipation. Clinicians should be aware of factors predicting disengagement, such as high pain-related fear, helplessness, mood/anxiety disorders and substance use. Strategies like pre-IPP psychoeducation or self-management skills training could enhance engagement.
• Future directions for pain care. A need for broader strategies remains, including creation of targeted patient education on appropriate healthcare use for chronic pain and adoption of models where chronic pain-trained primary care providers can act as a “healthcare quarterback” for patients when needed.

“For clinicians who care for patients with chronic low back pain,” Dr. Davin concludes, “integrating IPP referrals into comprehensive pain management strategies offers a powerful avenue to improve patient outcomes, empower self-management and align care with value-based models.”