Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

Why We Do What We Do

The Institute for Chronic Pain has a new content page on our website entitled: Why Healthcare Providers Deliver Ineffective Care. As is our custom, we announce such additions to the website on our blog and provide a little introduction to it. The content on this new page of the website is particularly important to me because providing content like it is one of the reasons why I founded the Institute. It’s not too far of a stretch to say that it’s why we do what we do. By way of introduction, then, I’d like to explain.

I founded the Institute for Chronic Pain for a number of reasons, but one of them continues to this day. Indeed, I am reminded of it most everyday.

The reason is others and mine persistent frustration over what seems like an almost endless delivery of ineffective healthcare within the field of chronic pain management. At the time of the Institute’s formation, in late 2012, the previous decade had seen an exponential increase in the delivery of procedures and therapies for chronic pain, most notably, spinal injections, spinal surgeries, and the long-term use of opioids. The use of these procedures and therapies had far surpassed the field’s traditional and empirically-supported treatment – the interdisciplinary chronic pain rehabilitation program, which had been the mainstay of treatment for twenty or thirty years by the end of the last century. For all those previous years, patients had benefited from such programs and with each decade the field had published more studies and meta-analyses demonstrating their effectiveness. In the mid-1990’s to the early 2000’s, the field began to change and change rapidly. The use of spinal injections, spinal surgeries, and opioid medications became prolific, far exceeding the use of interdisciplinary chronic pain rehabilitation programs. As a result, interdisciplinary chronic pain rehabilitation programs began to close their doors in great numbers for lack of patients.

One might consider such a sea change within the field of chronic pain management a natural progression of the field: due to scientific advances and discoveries, one set of therapies came to predominate over an older form of therapy. However, it wouldn’t be accurate.

The older form of therapy, interdisciplinary chronic pain rehabilitation programs, remained (and still remains today) the more empirically-supported treatment. In other words, such programs remain the more effective treatment and yet, as a field, we routinely deliver care that is not as effective as we could deliver – we routinely provide spinal injections, surgeries and opioid medications to patients with chronic pain, and tend to forego recommending the more effective option of interdisciplinary chronic pain rehabilitation programs. While recognition of this problem is growing and gaining momentum, this state of affairs continues to this day.

Typical responses by the healthcare system: empirical-based healthcare

Many in the field, who recognize this problem, attempt to resolve it by focusing on changing the practice patterns of providers – encouraging them to recommend less orthopedic-related care, such as spinal injections, spinal surgeries, and opioid medications, and instead recommend more nervous system-related care, such as interdisciplinary chronic pain rehabilitation.

Specifically, leaders in the field attempt to educate and persuade healthcare providers to make recommendations based on what the available scientific research tells us is most effective. This ideal for guiding the practice of healthcare is called ‘empirically-based healthcare.’ The word ‘empirical’ in this context means scientific and phrases such as ‘empirically-based’ or ‘empirically-supported’ when used in the context of treatments means that the scientific evidence supports the effectiveness of the given treatment.

This goal to have the scientific evidence for or against treatments guide our recommendations is important. It should lead the field to make more recommendations for those treatments that science tells us are effective and lead us to make less recommendations for treatments that have been shown to be less effective. Indeed, who wouldn’t argue that we should be focusing our care and resources on treatments that are the most effective?

Health insurance companies and professional provider organizations

Typically, health insurance companies or different types of provider organizations lead the drive to change provider practice patterns within the field of chronic pain management. Insurance companies periodically institute policy changes that encourage the use of empirically-supported treatments and various professional organizations develop guidelines for what constitutes appropriate care for different chronic pain conditions. In my geographical area, for instance, local insurance companies have twice attempted to mandate that patients receive non-surgical second opinions, such as psychological evaluations for rehabilitation care, before obtaining spine surgery. I personally have also served on two different guideline development committees for the management of back pain.

While admirable, these attempts never succeed in producing a significant change in the practice patterns of healthcare providers. They fight a steep uphill battle. Many of the forces for maintaining the status quo of providing ineffective healthcare on a widespread basis remain powerful and complicated. They are difficult to resolve. We discuss many of these problems in the new content page of our website.

Despite these problems, the actions of insurance companies and professional organizations are necessary. For after all, providers are an important part of the healthcare equation. They are the ones who make the recommendations and deliver the care. It’s obviously important therefore that they become convinced to recommend care that science has shown to be most effective.

While necessary, a sole focus on changing provider practice patterns is not sufficient to bring about widespread change in the field. Such a focus leaves out the role of patients who, in large measure, have a say in the care they receive. Any change to the field of chronic pain management must also focus on changing societal beliefs about chronic pain and how to best treat it.

The role of the Institute for Chronic Pain

To meet this need, we developed the Institute for Chronic Pain. While insurance companies and professional organizations play a necessary role in attempting to change the ‘supply’ side of care (i.e., what tends to get recommended by healthcare providers), the Institute for Chronic Pain focuses on changing the ‘demand’ side of care (i.e., what patients and their families expect and want when seeking chronic pain management).

Why is the latter important?

Through much of my career I have worked within interdisciplinary chronic pain rehabilitation programs. I have evaluated countless patients for such programs and a common experience upon evaluation and subsequent recommendation of the treatment is that patients refuse it.

Now there often are many reasons why people can’t or won’t pursue such a recommendation, but a common one is that the recommendation to participate in an interdisciplinary chronic pain rehabilitation program simply doesn’t make sense to them. It’s understandable given our societal belief systems about the nature of chronic pain. Many in our society understand chronic pain as something that is the result of a long-lasting orthopedic injury and as such they think that the most effective approach is to pursue orthopedic-related interventions, such as injections or surgery, that treat the spine or other joint that is the site of pain. As a result, given these societal beliefs, patients can come to refuse to participate in an interdisciplinary chronic pain rehabilitation program, in favor of seeking less effective orthopedic-related care – spinal injections, spinal surgery, and use of opioid pain medications.

To this problem, we have been actively attempting to produce content that explains how chronic pain is typically a nervous system-related condition, not an orthopedic condition, and so therefore should be mostly treated through interdisciplinary chronic pain rehabilitation. We have reviewed how the field is in the process of a paradigm shift, a change in how experts in the field understands the nature of chronic pain and what the field considers to be the most effective treatments for it. We have reviewed the contrasting ways of understanding chronic pain and have reviewed how basic science indicates that chronic pain is the result of a nervous system condition called central sensitization. We have reviewed and clarified the relationships between chronic pain and a number of the most common complicating conditions, such as anxiety, depression, trauma, insomnia, fear-avoidance, and catastrophizing; in so doing, we have explained that these conditions commonly complicate the course of chronic pain because they too are nervous system-related conditions. We have reviewed how interdisciplinary chronic pain rehabilitation focuses on reducing central sensitization and thereby such programs reduce the typical cause of pain and suffering. On our social media sites, such as Facebook, Twitter, and Linkedin, among others, we post (on an almost daily basis) news reports on published studies of the relationship between chronic pain and the nervous system, particularly the brain. In all, the Institute for Chronic Pain devotes much of its resources to changing our societal beliefs about the nature of chronic pain and how best to treat it. Our aim is to bring our common societal understandings into line with the consistent findings of the basic and applied science of pain.

In short, as our mission states, we aim to change the culture of how chronic pain is managed.

In response to these efforts to change our societal understanding of the nature of chronic pain, there remains a common reaction to which we, as the Institute for Chronic Pain, have not yet responded, at least not until now. Within the public at large, but also within the clinic when reviewing the above information with individual patients, there remains doubt that orthopedic-related care, such as spinal injections, surgeries and use of opioids, are less effective than interdisciplinary chronic pain rehabilitation. The doubt continues due to the following reason: people don’t believe it simply because orthopedic-related therapies are so much more commonly performed than interdisciplinary chronic pain rehabilitation therapies. If what we say is true – that science tells us that orthopedic-related therapies are less effective, then it would mean that the field of chronic pain management has gotten it absurdly wrong. But this conclusion, for many, seems too hard to believe. In other words, the difference between how many in the field actually practice and how science informs us that we should practice seems too incongruous to be believable.

Understandably, then, the question thus remains: ‘How could the healthcare system have gotten it so wrong? These therapies (spinal injections, spine surgeries, opioid medications) just simply have to be the most effective treatments or healthcare providers wouldn’t recommend them as often as they do.’

To this question, we put together and published the new webpage, entitled: Why Healthcare Providers Deliver Ineffective Care.

Author: Murray J. McAllister, PsyD

Date of last modification: 1-20-2015

An Alternative to Opioids for Chronic Pain

It’s an interesting fact about the field of chronic pain management that there is a safe and effective alternative to the use of opioids for chronic pain, but relatively few people know about it. The alternative to opioids is an interdisciplinary chronic pain rehabilitation program.

Chronic pain rehabilitation programs

Interdisciplinary chronic pain rehabilitation programs are a traditional form of treatment that provides patients with the ability to self-manage pain and return to work, all without the use of opioid medications. They bring about these goals by providing chronic pain patients with the opportunity to 1) make a number of lifestyle changes, which, when done over time, reduce the physiological basis of pain, and 2) learn a number of advanced ways to better cope with the pain that remains chronic. Patients learn both of these two prongs of self-management from a safe and supportive team of chronic pain rehabilitation experts who coach patients on how to do them.

For the motivated patient who is open to learning and wiling to practice these changes and skills, it becomes possible over time to self-manage pain without opioid medications and do it successfully. Many people with chronic pain learn to do it everyday in interdisciplinary chronic pain rehabilitation programs. As such, they are the traditional alternative to opioids for the management of chronic pain.

While currently not as common as other types of pain clinic (such as long-term opioid management clinics or interventional pain clinics), most every major city across the United States, Canada, Western Europe, Australia, and New Zealand has a chronic pain rehabilitation program. Most of the well-known destination healthcare centers through out the world have an interdisciplinary chronic pain rehabilitation program. Many smaller, local clinics have such programs too. Literally, countless numbers of patients go through interdisciplinary chronic pain rehabilitation programs everyday and in doing so they learn how to live well without opioid medications despite having chronic pain.

Interdisciplinary chronic pain rehabilitation programs have high quality research evidence that demonstrate their effectiveness as an alternative to opioids (Chou, et al., 2007; Gatchel & Okifuji, 2006). There are numerous well-designed studies that show patients routinely have considerably less pain once they complete an interdisciplinary chronic pain rehabilitation program. On top of it all, they are no longer taking opioid medications. That is to say, following participation in such a program, they have less pain than when they were taking opioids, but are now no longer on opioids (Becker, et al., 2000; Cosio & Linn, 2014; Crisostomo, et al., 2008; Meineche-Schmidt, Jensen, & Sjogren, 2012; Murphy, Clark, & Banou, 2013; Rush, et al., 2014; Townsend, et al., 2008).

Despite the large number of programs and despite the well-documented evidence supporting their effectiveness, many people with chronic pain who are seeking care, perhaps even a majority, remain unaware of chronic pain rehabilitation programs as an option available to them – let alone know that it is a safe and effective alternative to opioids for chronic pain.

A short history of chronic pain management

It wasn’t always this way. For a few decades prior to the 1990’s people with chronic pain obtained treatment in interdisciplinary chronic pain rehabilitation programs on a much more routine basis. Moreover, there were significantly more interdisciplinary chronic pain rehabilitation programs in existence (Gatchel, et al., 2014; Schatman, 2012). So what changed?

In the decades prior to the 1990’s, it was significantly less common to manage chronic pain with opioids. As such, interdisciplinary chronic pain rehabilitation programs were largely the only type of pain clinic there was. Patients with chronic pain knew of them and tended to seek out care within them.

With the advent of widespread use of opioids in the 1990’s, interdisciplinary chronic pain rehabilitation programs tended to get overshadowed. Some pain clinics offering this traditional model of chronic pain management closed and new pain clinics, offering long-term opioid management, opened in large numbers.

There are many possible reasons for this state of affairs. The newer form of chronic pain management is more lucrative than interdisciplinary chronic pain rehabilitation programs. Long-term opioid management tends to obtain insurance reimbursement easier than interdisciplinary chronic pain rehabilitation programs. The use of opioids also appears to at least temporarily resolve the need for interdisciplinary chronic pain rehabilitation programs. Who wants to go through the hard work of making large-scale lifestyle changes and learn advanced ways of coping to reduce pain if a medication can temporarily reduce it for you? (A similar argument could be made with regard to the widespread use of interventional procedures and spine surgeries beginning in the late 1980’s and into the 1990’s). Moreover, an increasingly common belief among patients, providers and society generally is that it is impossible to manage chronic pain well without opioids – that intolerable suffering would be the inevitable result. When firmly held, this belief subsequently leads to a great deal of skepticism about the wealth of clinical and research evidence that shows interdisciplinary chronic pain rehabilitation programs are a safe and effective alternative to opioids for chronic pain.

An alternative to opioids for pain that few know about

So, we have an odd state of affairs at present in the field of chronic pain management. We know that we have a safe and effective alternative to opioids for chronic pain but few people know of it or take advantage of it, at least relative to the number of people who manage their pain with opioids.

How do you think the field should tell the public about interdisciplinary chronic pain rehabilitation programs? Why do you think they have difficulty getting widely recognized as an effective alternative to opioids for chronic pain? If you find yourself skeptical of the above-noted research, what would convince you to participate in such a program?

References

Becker, N., Sjogren, P., Bech, P., Olson, A. K., & Eriksen, J. (2000). Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: A randomized controlled trial. Pain, 84, 203-211.

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Cosio, D. & Linn, E. (2014). Efficacy of an outpatient, multidisciplinary VA pain management clinic: Findings from a one-year outcome study. Journal of Pain, 15(4), S110.

Crisostomo, R. A., Schmidt, J. E., Hooten, W. D., Kerkvliet, J. L., Townsend, C. O., & Bruce, B. K. (2008). Withdrawal of analgesic medication for chronic low-back pain patients: Improvements in outcomes of multidisciplinary rehabilitation regardless of surgical history. American Journal of Physical Medicine & Rehabilitation, 87(7), 527-536. doi: 10.1097/PHM.0b013e31817c124f

Gatchel, R. J., (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130. doi: 10.1037/a0035514

Gatchel, R. J. & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 17(11), 779-793.

Meineche-Schmidt, V., Jensen, N., & Sjogren, P. (2012). Long-term outcome of multidisciplinary intervention of chronic non-cancer pain in a private setting. Scandinavian Journal of Pain, 3(2), 99-105.

Murphy, J. L., Clark, M. E., & Banou, E. (2013). Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Journal of Pain, 29(2), 109-117.

Rush, T., Huffman, K., Mathews, M., Sweis, B., Vij, B., Scheman J., & Covington, E. (2014). High dose opioid weaning within the context of a chronic pain rehabilitation program. Journal of Pain, 15(4), S111.

Schatman, M. E. (2012, December). Interdisciplinary chronic pain management: International perspectives. Pain: Clinical Updates, 20(7), 1-5.

Townsend, C. O., Kerkvliet, J. L., Bruce, B. K., Rome, J. D., Hooten, W. D., Luedtke, C. L., & Hodgson, J. E. (2008). A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Pain, 140(1), 177-189.

Author: Murray J. McAllister, PsyD

Date of last modification: 4-20-2013

Institute for Chronic Pain – One Year Anniversary

The Institute for Chronic Pain celebrates this month its one-year anniversary of going live with our website and blog.  The Institute for Chronic Pain is an educational and public policy ‘think tank’ devoted to changing the culture of how chronic pain is managed. We imagine a day when the management of chronic pain is guided by the principles of empirical-based healthcare (i.e., pursuing only those treatments that research has shown to be effective). Our public face is our website and blog, where we provide academic-quality information that is accessible to patients, their families, as well as providers and third-party payers.

In this last year, our main goal was to establish the website as a leading source of information on chronic pain and its treatments, particularly chronic pain rehabilitation.

In this next year, our main goal is to grow our stakeholder community. We want to be a trusted source of high quality information to patients and their families. We also want to increase our presence among the provider and third party payer communities. We expect to provide content by an increasing diversity of experts in healthcare and from academia. Outreach to third party payers will also be essential, providing information on empirically-based treatments for chronic pain.

To these ends, we ask you to become a stakeholder with us in the future of a more effective and cost-effective healthcare system for the management of chronic pain syndromes. Please like us or follow us on:

The more we learn together, the more effective our care will be as providers and consumers of chronic pain management.

In closing this celebration announcement, I’d like to re-post our first introductory blog post (in a slightly edited fashion). Originally published on October 7, 2012, it remains a fresh statement of our guiding vision. Thank you for being a stakeholder in this future.

_________________________________________________________________________

Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.

 Changing the culture of how chronic pain is managed

Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.

Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.

It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.

  • As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
  • As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
  • We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
  • As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured; we tend to recognize the chronicity of  other chronic conditions, such as diabetes or heart disease, but tend to forget it when it comes to chronic pain.
  • Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
  • As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
  • As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
  • As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
  • As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures, which are largely ineffective

The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.

To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.

In short, we need to change the paradigm that underlies chronic pain management.

Analogy to the change in our cultural understanding of cigarette smoking

Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago.  In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.

A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. Providers began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.

Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked, and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.

It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.

On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from what they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.

On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.

All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking.  They have been largely effective in making a profound and beneficial impact on our health.

The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.

It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.

The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:

  • We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
  • Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
  • Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
  • We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
  • We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.

The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.

Goals of the Institute for Chronic Pain

The Institute has set out a number of methods for achieving the resolution of these goals.

  • We provide a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
  • We provide this blog through our website.
  • We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
  • We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
  • We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
  • We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
  • We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
  • We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.

Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.

We hope that you will join us in this endeavor. Join our community and be part of this change.

____________________________________________________________________

Author: Murray J. McAllister, PsyD

Date of last modification: 10/7/2013

5 Benefits of a Chronic Pain Rehabilitation Program: A Patient’s Perspective

The Institute for Chronic Pain (ICP) would like to welcome a guest post by Jen of Pain Camp. Camper Jen, as she goes by, is the founder of Pain Camp, which is a wonderful blog and website on chronic pain from the perspective of someone who has chronic pain and has participated in a chronic pain rehabilitation program. Her site, as well as her personal story, is one of how to go from SURVIVING to THRIVING despite having chronic pain. Her spirit is admirable and her testimony is inspiring. Her guest blog post today is on her experience of the benefits of participating in a chronic pain rehabilitation program.

The ICP hopes that you check out Pain Camp. It’s well worth it. In fact, it has recently been nominated for 2013 National Association of Social Workers Media Awards for best website category.

Here’s the guest blog:

5 Benefits of a Chronic Pain Rehabilitation Program: A Patient’s Perspective

I was 35 years old and sitting in my primary care physician’s office complaining of terrible headaches and neck pain. I’d been afflicted with the pain for over a month and there was no improvement despite chiropractic treatment and massage (unlike the times before). I felt like my doctor was not listening to me at all. In tears, I begged for an explanation. Why wasn’t the pain going away this time? What was wrong with me?

I was diagnosed with chronic pain syndrome. It was March of 2011. For the following six months, I visited many different doctors and participated in many different types of “therapy.” I had several tests, procedures and medication trials. I was not getting any better. In fact, I was only getting worse, and I had the additional diagnoses to prove it.

After six months of that chaos, I was ready to explore another approach. I had already worked with the interventional pain specialists; opioids were not an option (I’m in recovery); and the majority of my pain related diagnoses would not be improved with surgery at that point in time. The only other thing to try was a chronic pain rehabilitation program (CPRP).

The particular CPRP that I went to was a 3 week-long program. There were eight patients in the program that stayed during the week and went home on the weekends. From the second I entered the facility, I was challenged. I was also given incredible gifts. Here are five of the most valuable benefits from my experience:

1. I’m not a victim!

I struggled over the first few days with the structure. Despite having severe pain, I was expected to participate in daily pool therapy, exercise in the gym 3x/week, and get to classes (on time). It was clear that staff was not there to pity me, and the environment at the rehab facility was not one that supported a defeatist attitude.

I was not feeling validated in my self-pity so I met with the Clinical Director. She gave me a challenge that turned my perspective around. I was indeed allowed to feel my emotions and be upset (validation). However, I needed to put a time limit on them. I could allow myself a 30-minute emotional meltdown if I needed it and then figure out action steps to move on.

From that point on, I was more open to the information that I was learning in class. I became an empowered patient rather than one that was helplessly clinging to any hope of a “cure”. Yes, I had Chronic Pain. Yes, it wasn’t a fair situation. And yes, I still needed to figure out how to live my life partnering with the pain rather than working against it.

2. I’m not alone!

One of my fears going into the program was that I wouldn’t have anything in common with the other patients. I was younger and well-educated with a professional career. To my surprise, I did have those things in common with some of the other patients. Even more comforting was spending entire days and evenings with people who were just like me. They understood chronic pain from my perspective. They’d had life changes because of the pain. They were at a point of acceptance and ready to make changes like I was. We were all in the same boat.

The staff told us that they did follow up with the patients many years later. One common theme among the CPRP patients, even many years later, was that creating relationships with the other people in the CPRP was one of the most beneficial points. I would have to agree as I formed two very solid friendships during my time at the CPRP. I still get together with these two women. They understand my pain and they do not judge me. We positively support and encourage one another on the most challenging days. These two friendships were an unexpected and invaluable benefit from the CPRP.

3. I can function!

Before I was admitted to the CPRP, I was going to four to six doctor appointments a week and trying to hold my full-time job. I’d already resigned from my part-time position. I’d given up all hope that I would ever be able to engage in: exercise, housework, cooking, family activities, spending time with friends. These were just extra tasks that I couldn’t afford energy-wise. I was miserable. The CPRP taught me that I didn’t need to be afraid of exercising. I also learned proper body mechanics for household tasks. I was reminded of the importance of humor and how spending time with my friends again could aid in healing.

4. I will pace!

I have been told that I have a “Type A Personality.” Even with the pain, I was still trying to run my life at the pace of the hare. God help you if you were a turtle trying to slow me down. Over-achiever and giving 100% of my all to every activity in life. In the CPRP, I learned that by holding onto this harried lifestyle, I was making my Chronic Pain situation worse.

In the CPRP I learned it is crucial that I pace and conserve my energy. I have my days when I feel “well” (as well as can be) and then I have my more challenging days. On my “well” days, I need to be mindful of pacing so that I do not overdo things. Energy conservation is the key. On the more challenging days, I need to be mindful of resting and formulating a plan of action to resume activities. This requires more structure in my life and scheduling periods of rest and healing activities. These are things that I didn’t have prior to the CPRP. Making sure I get enough sleep, proper nutrition and restorative yoga is also part of my pacing routine.

5. I have hope!

When I entered into the CPRP, I was hopeless. I didn’t think that my situation could improve. I was depressed. I was anxious. I was full of fear. By participating in the CPRP, I was shown that there is another way of life for those with chronic pain. Yes, my life would be different and would have to change. However, the CPRP taught me that I was in charge of managing this new life.

Of course, there was a process of grieving my old lifestyle. I also had to grieve the loss of my dream to be able to work 60 hours a week, pay off my school loans and retire at the young age of 60. By grieving these losses, I was able to formulate new goals and dreams. I was able to develop hope that I would be okay with my “new” life with chronic pain by my side. I gained hope and that hope continues to grow every day.

While participating in a CPRP was certainly not on my life’s agenda, it was definitely a gift that was given to me. I am grateful that I was able to participate in a CPRP. I learned that I was not helpless, nor was I alone. I was challenged to develop new skills for living my life with chronic pain. I was given a basic set of tools to move from surviving to thriving.

It is my hope that one day the CPRP is the first stop in the patient’s care plan for Chronic Pain, rather than the last. I believe that the CPRP is what offers the most benefit to patients with chronic pain and can get us back to a level of functioning that is productive and has meaning.

Author: Camper Jen of Pain Camp

Date of Last Modification: 2/22/2013

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