Are you ready for a chronic pain rehabilitation program?

How do you know if you are ready to participate in a chronic pain rehabilitation program?

Chronic pain rehabilitation programs defined

Chronic pain rehabilitation programs are a traditional form of chronic pain management. They are intensive, interdisciplinary therapies that typically occur on a daily basis. They coach patients how to self-manage chronic pain and the common secondary stressors that result from pain, such as insomnia, depression, anxiety and stress. They also help patients return to work. Lastly, they help patients to reduce the need for on-going healthcare services for chronic pain.

Criteria for participating in a chronic pain rehabilitation program

Healthcare providers typically use three criteria to determine whether a patient is a good candidate for a chronic pain rehabilitation program. The criteria are the following:

  • Noncancer pain lasting longer than six months
  • All reasonable medical options for the treatment of the pain have been exhausted
  • The patient accepts that his or her pain is truly chronic and needs to learn how to self-manage chronic pain

The third one is the kicker. The vast majority of patients referred to chronic pain rehabilitation programs have chronic pain and have exhausted all reasonable options for their pain disorder. Their providers know it and the patients tend to know it too. It’s easy for both providers and patients to know when pain is chronic. It’s lasted longer than six months, usually for years. However, knowing that pain is chronic is different from accepting that pain is chronic.

Accepting that chronic pain is really chronic

Unlike their healthcare providers, patients with chronic pain face the challenge of accepting the chronicity of their pain. Acceptance is an emotional process that patients go through when having chronic pain.

For many patients, the initial phase of acceptance is fraught with refusals to accept it. ‘There just simply has to be a way to fix this problem,’ one might say at this point. As such, patients commonly continue to seek evaluation and care from specialist after specialist in attempts to find a cure for their pain disorder. At this point in the process of acceptance, the underlying belief is that hope lies in finding a cure and that without a cure there is no hope. Given this belief, it makes sense that patients might know that they have chronic pain (in the sense that they know it is lasting a long time, maybe even years), but yet refuse to accept that their pain is truly chronic (in the sense that there is no cure). For if the belief is that the only way to have hope is to find a cure, then to give up hope of a cure is tantamount to becoming despondent. Hopelessness is a powerful motivator that fuels on-going refusals to give up hope in a cure.

When patients are at this point in the process of acceptance, they are not yet ready for a chronic pain rehabilitation program. They typically don’t succeed in learning to successfully self-manage chronic pain because their motivation lies elsewhere. Namely, their hope lies in finding a cure. They haven’t yet accepted that their chronic pain is truly chronic. They haven’t yet found a new way to have hope.

This observation is not a criticism. It’s just that such patients don’t meet criteria for being a candidate for a chronic pain rehabilitation program. They have not fully accepted the chronicity of their pain and instead they prefer to seek care other than self-management or rehabilitation.

Accepting that you can’t manage pain with opioids for the rest of your life

Difficulties with accepting the need to self-manage pain without opioid medications is another common struggle that gets in the way of participating in a chronic pain rehabilitation program. Many patients have worked through the afore-mentioned problems with accepting that there is no cure, but have found hope through long-term opioid management. They recognize that they have chronic pain and that chronic really means chronic. Nonetheless, they have kept from becoming hopeless by managing their pain with the long-term use of opioid pain medications. As such, they have been able to go on with life even in the absence of a cure.

Some patients in this position recognize that their long-term use of opioid medications is not sustainable indefinitely. They recognize that the medications lose their effectiveness over time. They have increased their dose at different times, but with each increase in their dose, they have eventually become tolerant yet again. They recognize that they can’t periodically increase their dose indefinitely. As such, they understand that the use of such medications cannot be a viable long-term way to manage pain.

This problem of opioid medications becoming ineffective over time is called tolerance.

It too is a difficult problem to accept. It is common for patients to struggle with accepting that the long-term use of opioid medications won’t be effective indefinitely. The implication is that at some point patients will need to learn how to self-manage pain without the use of such medications. Patients commonly struggle to accept that need too. It’s easy to put these problems off and deal with them another day. In other words, it’s easy to refrain from accepting them.

When patients aren’t at a point of accepting that they need to do something about these problems, they aren’t ready to participate in a chronic pain rehabilitation program. They oftentimes don’t believe it is possible to successfully self-manage chronic pain without the use of opioid medications. As such, they don’t succeed in learning how to do it in a chronic pain rehabilitation program.

This observation too is not a criticism. It’s just that such patients don’t meet criteria for being a candidate for a chronic pain rehabilitation program when they have not fully accepted the chronicity of pain and their need to self-manage it.

Acceptance of the need to learn how to self-manage pain

Patients are good candidates for participating in a chronic pain rehabilitation program when they accept both. They accept the chronicity of their pain and the need to learn to self-manage their pain. Of course, they don’t know how to successfully self-manage pain yet, but they have reached a sufficient degree of acceptance that they are ready to learn. As a result, they seek out participation in a chronic pain rehabilitation program and often succeed in their goals – to be able to live well, engage in life and work, while at the same time managing their chronic pain at tolerable levels.

Accepting the chronicity of pain opens up a whole new way of getting better and a whole new way of having hope.

Authored by Murray J. McAllister, PsyD

Posted on 2/4/2013

7 thoughts on “Are you ready for a chronic pain rehabilitation program?

  1. This is a great post! You are exactly right about the patient needing to be in a stage of acceptance and probably the contemplation stage of change at least. I went to “pain camp” and it was one of the best things that I have done for myself in terms of learning how to help with chronic pain symptom management. Yes I still have flares and when they happen I have to go back to the basics and work on the acceptance piece again. I’m not wasting my time in doctor’s offices anymore searching for the next pill, injection, surgery or cure. I’m focused on living my life and most of the time I’m enjoying it! 🙂

    • Hi, thank you for your kind words. I love the name “pain camp”! You are exactly right that acceptance is an on-going process of coming to terms with chronic pain over time. At first, it’s like you fight the pain, trying to get rid of it or avoid it at all costs, seeking one type of specialty care after another, or re-doing procedures that have already been done, but with new providers or at a new clinic. Certainly, there’s a time and place for some acute medical model care (procedures, etc), but there’s a point of diminishing returns with them. After awhile, each new procedure tends to have less and less chance of success and more and more chance of causing further problems. Developing a greater level of acceptance at this point tends to be helpful and in the best interest of the patient.

      The process of acceptance leads to the recognition that pain isn’t going away and a change in your relationship to pain, as it were. Moving away from trying to get rid of it or avoid it, and towards accepting it and learning to manage it. Successful self-management of chronic pain looks like accepting it and coping with it so well that for the most part it’s relegated to the background of your day-to-day life. When self-managing well, chronic pain becomes like a box fan on in the room – it’s still there, going on, making noise, but it no longer holds your attention. You are able to ‘move on’ with the rest of your day-to-day life. You only tend to really notice it when something brings your attention back to it.

      You’re right, when it comes to highjack your attention again when flaring, there’s a tendency to go to war with it again, fighting it, trying to get rid of it, or avoid it. But like the old saying goes: if you can’t beat ‘em, join ‘em. You go back to basics, like you said, and accept it, learn to live with it and relegate it back into the background of life.

      While not easy to do, your testimony shows that it is possible. Despite chronic pain, it’s possible to be meaningfully engaged in the activities of life, feeling like your heading somewhere, enjoying life for the most part (which, really, is what we’re all attempting to do). I bet you were open and worked really hard in your chronic pain rehabilitation program, as well as afterwards, given your success. It’s great to hear about it and thanks for sharing it.

  2. I,too have Worked hard at alleviating the pain in my 40 years of dealing with chronic pain. I also recognize the need to receive my treatments on a regular basis because of the nature of an incurable man made disorder (medical error from epidurals) such as opioids, infusions. It is unfair to simply expect every patient to follow your directives which I find stringent. You are assuming that each chronic pain survivor responds the same way to chronic pain which is not true. I prefer to say that each survivor will eventually come to term with their shortcomings and will achieve a quality of life. The Self Management for Chronic Conditions and Chronic Pain courses initiated from McGill University of Montreal and later , reviewed by Stanford university is an excellent start to ensure that chronic pain is accepted and dealt with according to each survivor needs. Your criteria, in my humble opinion,are far too rigid.

    • Hi Louise,

      Thank you so much for your thoughts and comments! Also, thanks for your interest in the ICP! I’d like to respond to your thoughts — would that be okay? (Based on your comments about ‘criteria,’ I think you are responding to the blog post and not the comments that have already been made. If I’m mistaken, please forgive me and let me know!)

      I’d first like to say that you are exactly correct that chronic pain rehabilitation programs are not a treatment for everyone. In chronic pain management, there is no ‘one size fits all’ type of treatment.

      In fact, I suppose, the point that not everyone will benefit from a chronic pain rehabilitation program is one of the points of the blog post. I had hoped with the post to lay out what the criteria are for deciding when a patient is a good candidate for a rehabilitation program and when a patient is not. The implication is that sometimes patients are a good candidate for the treatment and sometimes patients are not — just like sometimes patients are a candidate for surgery and sometimes they are not a candidate for surgery. Of course, in either instance, they have legitimate chronic pain.

      I spend much of my time in clinic doing evaluations of patients for whether they will benefit from our chronic pain rehabilitation program. Patients are referred to us by primary care providers, neurologists, rheumatologists, interventional pain providers, surgeons, and the like, and I see whether they will benefit from our program. If they wouldn’t, it’s okay and I try to refer them to a treatment that would be more beneficial. With the post, I had hoped to lay out what the main criteria are for whether patients will benefit from chronic pain rehabilitation. Sometimes patients are a good candidate for a program and sometimes they are not.

      You say, “Its unfair to simply expect every patient to follow your directives which I find stringent.” I fear, Louise, that you might be perceiving some critical judgement by me if you or someone else isn’t a candidate for a chronic pain rehabilitation. I want you to know that I do not imply any such judgement in the post. There’s no implication that everyone should be a candidate. Good people with real, legitimate chronic pain can sometimes not be a candidate for chronic pain rehabilitation, just as sometimes good people with real, legitimate chronic pain are not a candidate for spine surgery, for instance.

      It’s a bit like a primary care provider who evaluates when a sore throat might benefit from antibiotics or not. Sometimes, of course, sore throats are viral and won’t benefit from antibiotic treatments. Sometimes sore throats will benefit antibiotic treatment. Either way, the sore throats are real and legitimate and the people who have the sore throats are good people. It’s just that some will benefit from antibiotic medications and some will not. It’s not that those who will benefit from antibiotics are better than those who won’t benefit. Of course, there is no implied ‘directive’ that all people with sore throats should have a type of sore throat that benefits from antibiotics. Good people are still good people if they have a viral infection and won’t benefit from antibiotics.

      Similarly, good people with chronic pain are sill good people if they wouldn’t benefit from a chronic pain rehabilitation program.

      Chronic pain rehabilitation programs are one option among many options for chronic pain management. They can be very helpful to many folks with chronic pain, but at the ICP we would never want to suggest that chronic pain rehabilitation program are helpful for everyone with chronic pain. I hope the clarification is helpful!

      Thanks for your interest in the ICP!

  3. Based on a quarter century of caring for people with chronic pain, I believe the majority of chronic pain patients are willing and able to accept the chronicity of their disease. Perhaps the lack of acceptance is also a problem with the medical providers who are eager to rush in with the “newest” and “best”, or most popular treatment…..hoping that their new “treatment” will magically cure the pain. In my experience, chronic pain patients remained stable for years on a set dose of medication with a balanced albeit it small improvement in daily functioning. Regardless, acceptance that chronic pain is just that …..a chronic disease…is the stepping point for making the most of a bad condition. Sadly the medical profession too often makes a bad condition worse.

    • Thank you Pain with Dignity for your comments. You raise some very interesting points! You indicate that the majority of your patients accept the chronicity of their pain. I really don’t know what the rate of acceptance is in patients presenting for care. It would make a really good research question as to what is the rate of acceptance in patients with chronic pain! Regarding healthcare providers not accepting the chronicity of pain, I completely agree! Please see our latest blog pain on overtreatment and the ICP page on “Why the healthcare system refuses to accept the chronicity of chronic pain.” Thanks for your support of the ICP!

Leave a Reply