Does Your Pain Clinic Teach Coping?

As we’ve discussed in an earlier post, not all pain clinics are alike. To be sure, all pain clinics provide therapies aimed at reducing pain. Some, however, don’t stop there. They set out to systematically coach patients to cope better with pain that remains chronic.

Types of Pain Clinics

Despite the fact that they all operate under the name ‘pain clinic’, there are at least four different types of clinics.

Interventional pain clinics:  Interventional pain clinics tend to focus on minimally invasive procedures, or ‘interventions’, coping with painwhich aim to reduce pain. To be fair, most interventional pain providers would assert that they also aim to improve functioning, which means increasing a patient’s ability to engage in the activities of life, such as being able to engage in household chores or returning to work. However, interventional pain clinics primarily aim to increase functioning by attempting to reduce pain, under the assumption that people will be able to do more when their pain is reduced (i.e., in an inverse relationship that as pain reduces functioning increases).

Examples of minimally invasive procedures that one might obtain at an interventional pain clinic are epidural steroid injections, nerve blocks, radiofrequency neuroablations, spinal cord stimulator implants and intrathecal drug delivery device implants.

Notice that nowhere within this list is there specific time and resources set aside to teach patients how to cope better with pain that remains despite the use of the afore-mentioned procedures. While certainly individual clinics and/or providers might vary, most interventional pain clinics concentrate on providing procedures, not providing groups or classes or even one-to-one time to coach people on how to live well with pain that remains refractory to procedures.

The observation is not a complaint. It’s just not what they do, just as bankers typically don’t provide legal advice, even though in some areas of the respective fields there is some overlap.

Long-term opioid management clinics:  Long-term opioid management clinics tend to provide access to the long-term use of narcotic pain medications. The aim of this type of clinic is to reduce pain and secondarily increase functioning. Akin to the interventional pain management aims, the assumption is that when pain is reduced, patients with pain will be able to do more and thereby their functioning increases.

Long-term opioid management clinics typically provide access to opioid, or narcotic, medications on an indefinite basis. Usually, patients see the healthcare providers on some regular interval to obtain a prescription of medications that lasts only until their next appointment. Oftentimes, this interval of time is monthly, though sometimes it’s shorter or longer in duration. Typically, the two main reasons such care comes to an end is when patients abuse the medications, in which case the patient is potentially referred to a substance dependence treatment program, or when patients become too tolerant to the medications and the medications are therefore no longer effective, in which case the patients are referred to another type of pain clinic.

Often, in long-term opioid management clinics, there might be a little bit more emphasis on coping with pain than in interventional pain clinics. So, providers might encourage exercise, staying active, the use of diaphragmatic breathing, or the use of more traditionally passive coping strategies, such as ice, heat, home traction units, or TENS units.

However, the primary focus of long-term opioid management clinics typically remains on providing access to opioid medications. Of course, there might be some exceptions, but for the most part the care in such clinics aim to reduce pain through the use of opioids and the elementary basics of coping that they teach are intended to complement opioids, not substitute for their use.

Orthopedic and surgery clinics:  Orthopedic and surgery clinics provide invasive procedures aimed to reduce pain. Surgery clinics make the same assumption about functioning as the previous two clinics do — that the primary purpose of the procedures is pain reduction and secondarily to increase function. How this assumption typically plays out in surgery clinics is that patients commonly remain off work prior to and immediately after obtaining a surgical procedure and, once a procedure reduces pain, patients go back to work.

Examples of procedures that surgery clinics perform are arthroscopic surgeries of various joints, joint replacement surgeries, and spine surgeries, such as laminectomies, discectomies, and fusions.

Chronic pain rehabilitation clinics:  Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care that aim to reduce pain, but primarily increase function. In this way, chronic pain rehabilitation clinics are different. Chronic pain rehabilitation clinics point to clinical and scientific evidence that pain is one of many factors that determine a patient’s functioning – one’s ability to remain engaged in the activities of life, such as work. What clinical experience and science tells us, in other words, is that how one responds to adversity, such as pain, is as important as how significant the adversity is – especially in terms of how one goes on to live with the adversity.

The importance of this observation cannot be underestimated. It elevates the importance of increasing coping to the same degree of importance that reducing pain has. So, to take an example, if we want to help people with chronic pain return to work, then we can approach this problem in two different ways: 1) we can focus on reducing pain, under the above-noted assumption that when pain is reduced people can subsequently return to work; or 2) we can teach people with chronic pain to respond more effectively to the pain so that they know how to cope with pain so well that the pain is no longer as problematic, or disabling, as it once was and subsequently they learn how to return to work even with pain.

Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care, which means it’s care that focuses on what the patient can do to reduce pain and live better despite having pain. Patients learn to engage in various lifestyle changes, which, when done over time, reduce pain. More importantly, because chronic pain is typically chronic and cannot be entirely cured, patients also learn how to change the ways they react to pain so that they can still do things in life, such as return to work and engage in other daily activities of life, even though they continue to have pain. In other words, chronic pain rehabilitation clinics provide systematic education on how to remain functional in life despite having pain.

In this way, chronic pain rehabilitation clinics teach coping in a way that no other pain clinic does. In fact, they tend to emphasize coping over pain reduction because they base their approach on acceptance of the fact that chronic pain is really chronic. There tends to be no misleading anyone, as typically, chronic pain can only be reduced so much in whatever clinic one seeks care. Rather than repetitively trying to cure an incurable, or chronic, condition, chronic pain rehabilitation aims to increase patients’ abilities to cope with pain and help them to get so good at dealing with it that pain is no longer the showstopper that it once was. Patients come to learn, in other words, to accept pain, remain grounded in the presence of pain, and make an intentional choice to go to work and remain at work (or some other similar activity of life) despite having pain. With practice and expert coaching from the staff of the chronic pain rehabilitation clinic, pain becomes no longer the central focus of life, but rather is something that is just a side issue, with work, family and other activities being the most central aspects of life.

Coping with pain

Sometimes, patients with chronic pain won’t believe that such progress is possible. They might be sensitive to the possibility that one could have chronic pain and remain at work, and so tend to assert that it is impossible. They might also fear the sting of stigma if they acknowledge that they might be able to learn a thing or two about how to cope better with pain. Instead, they might assert that they already know how to cope with pain and that they cope better than anyone else could, who might find themselves in a similar situation.

In these ways, some people can have difficulty with openly acknowledging that they don’t cope as well as they’d like or could.

However, the possibility of getting better through learning to cope better doesn’t have to be perceived in this way. Most people would say that there is nothing wrong with you if you don’t know how to read very well, or don’t know how to change a tire on your car, or don’t know how to speak a foreign language, or don’t know how to play basketball very well. It’s okay to not know how to do certain things really well.

In fact, most people think learning new things is good. It’s admirable to learn something really well. In learning, the person who learns has to acknowledge and be okay with the fact that they don’t know everything already. In most situations of learning, no one ever has a problem with this aspect of learning.

If you are okay with learning how to cope with pain really well, then chronic pain rehabilitation clinics might well be very helpful to you. Everyday, people with moderate to severe chronic pain learn how to cope so well with pain that they become much more functional in life. They go back to work. They attend family functions again. They do household chores and do fun things again with friends and family. In other words, they get back into life. Of course, in order to learn how, you’d have to be okay with being in a student role. But, again, most of the time, we think that learning is a good and admirable thing to do. The same can be true of learning how to cope better with pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 3-23-2016

Your Doctor Says That You Have Chronic Pain: What Does That Mean?

Your injury was many months ago. You initially saw your primary care provider who sent you to a pain clinic. The provider at the pain clinic who evaluated you may have been a surgeon who told you to come back after you have gone to the interventional pain provider and physical therapist. You subsequently underwent evaluations and started care with each of these providers. You had this procedure and that procedure. You went to physical therapy. You did it all in the hopes that they would find the source of the pain and fix it. None of it really worked, though. At best, some of them were helpful for a few days or weeks but pain seemed to always return to the level it was previously. So, you decided to go back to the surgeon. You underwent a surgery and followed it up with more physical therapy. Perhaps, you had to go through a revision of the surgery a few months later. Maybe the surgery or surgeries didn’t help. Maybe, your pain was worse afterwards. Or, maybe it helped for a few months, but again the pain returned. Then, you go to another pain clinic and the provider there tells you that you have chronic pain.

What does that mean?

Frequently, definitions of chronic pain characterize it as pain that lasts longer than three or six months and then leave it at that. While the timeframe is accurate, this definition leaves out a whole lot. There’s more to chronic pain than just the time frame. Let’s look at what more there is and come back to the timeframe in a bit.

The understanding that your pain is chronic signals a change in what your providers think is the primary cause of your pain. When pain is chronic, the source of your pain is no longer the initial injury that started the pain. Rather, if your pain is chronic, then the source of pain has become the nervous system. It’s no longer an orthopedic problem, but a nervous system problem.

What happens is that, once having an injury and coming to have pain, the nervous system can change. It can become stuck in a persistent state of reactivity. Over time, the nervous system becomes so sensitive that any little movement hurts. Leaning over hurts. Standing back up hurts. Sitting down and getting up from a chair hurt. Walking hurts and so on. These simple, everyday movements shouldn’t be painful; but they are. They are painful because the nervous system has become stuck in a persistent state of reactivity. This state of reactivity has led the nerves in the area of your initial injury and the corresponding nerves in the spinal cord and brain to become so sensitive that simple, everyday movements hurt.

Patients often come to think that these movements are painful because the initial orthopedic injury, such as to the spine, has made their spine permanently fragile. Along the way, they may have been told that they have degenerative disc disease. This way of making sense of the pain naturally leads you to think that you have a disease that is inevitably going to deteriorate your spine, making it more and more fragile. As such, it’s natural to think that simple, everyday movements hurt because the spine is so fragile.

Over the last several years, however, basic science has studied how commonly degenerative changes of the spine occur in people with chronic back and neck pain as well as how commonly degenerative changes occur in people without back or neck pain. It turns out that degenerative changes of the spine are as common, if not more common, in people without spine-related pain. Basic science has also tracked the natural outcomes of degenerative changes of the spine over many years. It turns out that most of the time degenerative changes get better. Sometimes, they stay the same, but they typically don’t get worse.

With such research, we now know that “degenerative disc disease” is a misnomer. That is to say, it is a misleading term. Degenerative changes of the spine are neither a disease nor are they inevitably going to get worse. Now, I’ll save the details and references for another post, because the issue of degenerative disc disease is such a big topic. For now, you can visit the content page on degenerative disc disease at the Institute’s web page.

Suffice it to say that it is not accurate to think of “chronic pain” as a long-lasting acute injury, such as an orthopedic condition of the spine. The initial injury that started the pain may have long since healed. Rather, chronic pain is a nervous system condition whereby the nervous system is stuck in a persistent state of reactivity that has made the nerves highly sensitive. As such, simple, everyday movements hurt.

Besides the term “chronic pain,” researchers and providers call this condition “central sensitization.” The nerves at the site of the injury, say, for example, your low back, are part of the peripheral nervous system. These nerves send chemical information, what we might call a ‘pain signal,’ to the spinal cord and from there the signal takes an elevator up to the brain, where there, it registers as pain in the low back. The spinal cord and brain make up the central nervous system. With chronic pain, the peripheral nerves at the site of your pain, for example, your low back, and the central nervous system have become stuck in a persistent state of reactivity that leads them to react like a ‘hair trigger.’ Any little movement can set them off.

Often, with chronic pain, the site of pain is also sensitive to touch or pressure. Pushing on the area causes pain. A simple bump is likely to cause more pain than it should, were it not for the nervous system’s reactivity and sensitivity. Sometimes, in more severe cases, simple touch can hurt.

Patients with chronic pain are not making this stuff up. It’s really happening and it is real pain. What’s happening is that the nervous system problem is maintaining the pain.

So, when your provider tells you that you have chronic pain, it means that he or she no longer sees your condition as primarily an orthopedic problem, but a nervous system problem. The timeframe of three to six months is important because the pain of most acute injuries subsides after this number of months. Sometimes, of course, pain continues and becomes chronic. In these cases, as described above, the nervous system reorganizes and becomes sensitized. In this way, the pain of an acute injury transitions to the pain of central sensitization, or chronic pain.

So, your provider tells you that you have chronic pain. Now what? Just as your pain has transitioned from acute pain to chronic pain, you must transition your treatment strategies. Under your provider’s direction, you will likely do two broad categories of things. First, you will likely stop undergoing orthopedic treatments, such as spinal injections, surgeries, and physical therapies that are geared towards resolving an injury. Second, you will start obtaining treatments for the nervous system problem that you now have. There are a number of them that are proven effective. What are these?

Before listing these treatments, a brief caveat is in order. A number of treatments are proven effective, but “effective” does not mean curative. We do not have any cures for chronic pain. This fact brings us to another important part of the definition of “chronic pain.” Chronic pain is chronic. The word “chronic” itself means that it will last indefinitely. It doesn’t mean terminal. You won’t die from it. Rather, what it means is that it is not fixable and it is something you will likely have for the rest of your natural life.

Nonetheless, there are a number of treatments that are effective in the sense that they have all been shown in research to either reduce pain or improve functioning or reduce the need for on-going healthcare services, including the use of opioid medications. The known effective treatments for chronic pain are the following:

  • Cognitive behavioral therapy
  • Relaxation exercises, including mindfulness-based therapies
  • Mild aerobic exercise, including pool therapy
  • Anti-epileptic medications
  • Antidepressant medications, particularly tricyclic antidepressants
  • When done altogether in a coordinated fashion, these therapies are called a chronic pain rehabilitation program

The common denominator of all these therapies is that they target the nervous system and reduce its reactivity over time. All of them have multiple clinical trials showing their effectiveness.

Recently, a few clinical trials of yoga and tai chi have been published showing that these too are effective. It seems reasonable given their quieting effect on the nervous system. However, because of the insufficient number of studies, I think it is too soon to draw firm conclusions. My guess, though, is that more studies will come in time and that these therapies will also some day firmly be established as effective. Many chronic pain rehabilitation programs already incorporate them.

Author: Murray J. McAllister, PsyD

Date of last modification: 3/18/2013

What to Keep in Mind When Referred to a Pain Clinic

It would be nice if once you were diagnosed with chronic pain your provider would hand you an instruction manual. It could be titled something like, “How to Navigate the Healthcare System When It Comes to Chronic Pain.”

Instead, patients are typically referred to what loosely gets described as “a pain clinic.” They go and subsequently get care from the pain clinic. As they do so, they usually come to think that whatever care they get is what pain clinics do.

What patients commonly don’t know at this point is that there are multiple types of pain clinics and each type goes about treating patients in very different ways.

What are the different types of pain clinic? Roughly speaking, there are four kinds of pain clinic.

  • Chronic pain rehabilitation programs that provide coordinated, daily, interdisciplinary therapies that focus on self-managing pain, returning to work, and fostering independence from the healthcare system
  • Opioid management clinics that prescribe narcotic pain medications on a long-term basis and aim to reduce pain and improve function
  • Interventional pain clinics that perform spinal injections, nerve-burning procedures, and implantable devices, all of which aim to alleviate pain
  • Surgery clinics that perform spinal, orthopedic, and/or nerve-related surgeries, all of which aim to alleviate pain

Notice that each of these kinds of pain clinics provides different types of care – even for the same condition. Some focus on what the provider can do for the patient, particularly through performing procedures such as surgeries or injections on the patient. Some provide long-term access to certain types of pain medications. Some focus on what the patient can do to manage a chronic condition and reduce reliance on medications and procedures.

When you are first referred to a pain clinic, you might not know that there are various treatment options even for the same condition. I often tell patients that chronic pain management is not like the care that you might receive for strep throat. With strep throat, it might not ever matter what provider you see. Whoever you see, they are likely to treat you in the same way. Largely, there is conventional agreement as to how to treat strep throat. There is no such conventional agreement with the common chronic pain conditions that are treated in pain clinics. Chronic low back pain, chronic neck pain, fibromyalgia — what have you, they are all likely to be treated differently in the different pain clinics.

So, the first thing to keep in mind when being referred to a pain clinic is that you will likely be referred to one of the four types of clinic. The second thing to keep in mind is that the care you receive is not the only type of care you can receive for the condition that you have. In other words, it’s helpful to know that you have options. If you go to a different type of clinic, you will likely be provided with a different type of care. This point naturally leads to the question of which type of care is the best care for your condition?

The question brings us to the third thing to keep in mind when being referred to a pain clinic. You should know something about the relative effectiveness of each of the different types of pain clinics. From this knowledge, you can decide to get the care that is most effective.

Given that we are talking about chronic pain, it bears reminding that there aren’t cures for chronic pain. So, when it comes to types of chronic pain clinics, effectiveness is gauged by the following criteria:

  • How much a treatment reduces pain
  • How much a treatment increases functioning, such as returning to work
  • How much it allows for reductions in healthcare use, including how much it reduces the need for opioid, or narcotic, medications

It stands to reason that when you are referred to a pain clinic you don’t want to pursue just whatever type of pain clinic that you get referred to. Rather, you can make a more thoughtful decision about which type of pain clinic to go to. From this vantage point, it stands to reason that you want to first go to the pain clinic that has the most effective treatments, as defined above.

The following is a list of resources that you can use to see for yourself the effectiveness of various treatments. For the layperson, it might be easiest and/or most convenient to cut to the chase and focus on the Introduction and Conclusion sections of the articles. You can also print the articles off yourself and bring them to appointments with your healthcare providers. They might aid in the discussions you have about treatment recommendations. (If any of the links don’t appear to work properly, simply refresh the screen for the site that the link brings you to).

When getting referred to a pain clinic, it would be helpful to have reviewed the above information. With this information, it might be helpful to discuss with your provider the following questions:

  • What type of pain clinic are you getting referred to?
  • What other types of pain clinics might be options for you?
  • How did your provider decide to refer you to one type of pain clinic over the others?
  • Is the type of pain clinic that you are getting referred to consistent with your values and goals for care?
  • Is the type of pain clinic to which you are getting referred consistent with established clinical guidelines of professional pain organizations?
  • Is your healthcare provider knowledgeable of the established guidelines of professional pain organizations? (This issue would have to be a delicate and respectful discussion…)
  • Are the goals of the pain clinic realistic for the type of pain you have? (i.e., you might ask yourself, ‘Do I have chronic pain? and, if so, is it realistic to believe that procedures can alleviate my pain?’ or ‘Is it realistic to think that I can take narcotic pain medications for the rest of my life?’)

These questions may also be asked of the providers to whom you get referred. You might also want to revisit them with your referring provider later down the road, after you have been seen at the pain clinic.

In summary, you will be better prepared to discuss your care at the pain clinic if you know the following:

  • There are multiple types of pain clinic
  • Each pain clinic may treat you differently, even for the same condition
  • You have reviewed the links above that provide information on the relative effectiveness of the various kinds of therapies and procedures that the different pain clinics pursue
  • You have reviewed the above questions for yourself and have discussed them with your providers

Author: Murray J. McAllister, PsyD

Date of last modification: 3/4/2013