Catastrophizing and Chronic Pain

It’s not uncommon to exclaim, at the beginning of a pain flare, “I’m not going to be able to stand it!” Another might express, “Now, I’m not going to be able to do anything today!” Yet, another takes it as a given that the increased pain is an indicator that the underlying health problem is getting worse. From this assumption, it’s easy to start thinking about how the future holds nothing but increasing disability, wheelchairs, and suffering.

These sentiments are examples of catastrophizing.

What is catastrophizing?

Catastrophizing is what we do when we see something through the lens of it being the worst-case scenario. We believe and feel that something is worse than it actually is.

We all do it. Everyone catastrophizes at least occasionally. Some of us do it a lot. Most of us are somewhere in between. The point, though, is that we all do it.

The most common example of catastrophizing is simple worrying. When we worry, we don’t ponder good things happening to us. We don’t even tend to think about minimally bad things happening to us, such as inconveniences or hassles. We don’t tend to waste a lot of time worrying about those things. Rather, it’s the really bad stuff that we tend to worry about. It’s the worst-case scenarios that hold our attention and get us worked up.

Now, the thing about catastrophizing is that we tend to overestimate the likelihood that the worst-case scenarios will occur. Of course, worst-case scenarios are possible. Sometimes, they do in fact occur. If, however, we step back and take a real objective look at them, we might compare how often they occur with the countless number of times when they don’t occur. The comparison is stark. Worst-case scenarios are possible, but they are not likely. They tend to be once or twice in a lifetime events. When catastrophizing, though, we see the worst-case scenario as all-but-inevitable or, worse yet, already happening. There’s an assumption of certainty about it. That is to say, this sense of certainty comes about by overestimating the likelihood of the worst-case scenario.

Like anyone else, people with chronic pain can catastrophize. Take the common sentiments expressed in the above examples. When experiencing a pain flare, common automatic reactions are that you aren’t going to be able to stand it or that now you’ll never get anything done or that you think the increased pain is indicative of an inevitable worsening of the underlying health condition that initially started the pain. There is a sense of certainty that goes along with these automatic reactions. You just “know” that you won’t ever be able to stand it, or that you’ll never be able to get anything done, or that increasing disability is inevitable. However, if you can step out of the moment, and hold on your judgment of such certainty, you might begin to reflect on how true, really, these sentiments are.

What makes you so sure that you’ll ‘never be able to stand it’? How do you ‘know’ that this pain flare is going to be the whopper of all whoppers? Maybe it would be best to hold judgment, and see if it will be as bad as you anticipate. It might just turn out to be a run-of-the-mill flare. In fact, it is much more likely that it will be an average pain flare than the one that you’ll ‘never be able to stand.’

How warranted is your certainty that you’ll ‘never be able get anything done’? How likely is that scenario to occur? With a little creativity, there is almost always going to be something that you can do, even while experiencing a pain flare. Maybe you could sit and pay bills. Maybe you could call someone who you have been meaning to call but haven’t gotten around to it. Maybe you are at work and you decide to use the afternoon to catch up on reports and emails. You sit for a while at the computer and then you stand for a while at the computer, putting a few books under the keyboard, so you can still work at the computer. You also might take breaks to walk the hallway or stretch or both. Now, it won’t be the most productive day you’ll ever have, but, with pacing and a little adaptability, it’s much more likely that you’ll be able to do something productive.

What about the certainty that your pain flare is a sign of your inevitable decline? How true is that worst-case scenario? Of course, it is possible, but it’s not very likely. The nature of chronic pain is that pain waxes and wanes – pain flares come and pain flares go. What’s the likelihood that this pain flare is the one that won’t ever go away and from which you’ll start the decline into becoming wheelchair-bound? Isn’t it much more likely that this pain flare, like the others that come before it, will come and go?

While always possible, worst-case scenarios are low probability events. When we catastrophize, though, we overestimate the likelihood that the worst-case scenario will occur and become certain that it will happen or is already happening. We lose perspective on the problem and become certain that it is worse than it actually is.

Catastrophizing influences our perceptions

The sense of certainty that goes along with catastrophizing colors our perceptions, making what we experience worse than it actually is. This fact is what leads psychologists to categorize catastrophizing as a form of cognitive distortion. Catastrophizing distorts what it is we perceive.

It’s not very mysterious. Rather, it’s super common. We can think of any number of examples. Suppose your boss makes a critical remark about you and later looks at you strange after you say something in a meeting. You associate these events with some problems you have been having at work and before you know it you are taking the boss’ remark and the look as confirmation that any day now you are going to be let go. If you don’t step out of the moment, and gain some perspective on how you are perceiving these events, your experience is that you simply and unquestionably are in the process of getting fired and it can’t get much worse. To take another example, suppose you are arguing with your spouse and he or she walks out of the room hurt and angry. Your first thought is that your last hurtful remark put your spouse over the edge and that he or she is now leaving you. Your immediate reaction is one of ‘Don’t leave me!’ For the moment, your thoughts are going a million miles an hour and you have all the accompanying feelings of fear, anger, and abandonment. If you don’t step out of the moment, get grounded, and reflect on what’s going on, your experience is that your marriage is unquestionably ending and it can’t get much worse. In both these cases, we see that catastrophizing distorts our experience of what is really happening.

Catastrophizing tends to happen when we are ungrounded, vulnerable, anxious, or upset already and then something bad happens. In such cases, it’s hard to see the problem clearly. We are too ungrounded or anxious or upset. As such, the overall experience of the problem is that it is worse than it actually is. Conversely, when a problem occurs during a time that we are grounded, focused, supported, and confident, we deal much better with it because, in part, we see the problem more accurately.

The two parts that make up experience

This last notion leads to an exceptionally important, yet often overlooked, fact about human experience. We tend to think that whatever it is that we experience is solely due to what is happening to us. That is to say, we often simply assume that the quality and intensity of our experiences are only due to the qualities and severity of the external things that occur to us. It’s as if we forget that there’s a perceiving subject, who has these experiences.

Now, of course, what we experience is determined in part by external events – what they are, whether they are bad or good, and how bad or good they are. But, our experience is also determined in part by where we are at when these events occur.

When we are grounded and present, we might notice the beautiful sunset and fully appreciate it. The sunset subsequently might have a big impact on us. If, however, we are lost in our thoughts, or fretting because we are stuck in rush hour traffic, we might hardly even notice the beautiful sunset, let alone appreciate it, and subsequently it has little to no impact on us. It’s the same external event, but two very different experiences and the experience is determined by how we are at the time of the external event.

Human experience is made up from two parts: 1) the things that happen to us and 2) how we are when things happen to us. When we are grounded, supported, confident and well-rested, we tend to experience the same event differently than when we are anxious, upset, vulnerable, lonely, abandoned, or overly tired and fatigued.

Catastrophizing is one of the ways that we color our perceptions of events when we come to the event feeling anxious, upset, vulnerable, left alone, or fatigued.

Catastrophizing is all-too-human

Sometimes, people are reluctant to acknowledge that they catastrophize. You can sometimes feel judged when people tell you that you’re making a mountain out of a molehill. You might automatically want to respond with assertions that the problem really is that bad — it really is catastrophic — and then feel invalidated when they don’t believe you.

It’s important to remember, though, that we all do it. It’s part of our all-too-human condition. Human beings are not perfect. We are not omnipotently objective observers of the things that happen to us. We have all sorts of beliefs, attitudes, and feelings that bias and distort our perceptions. And, yes, we also catastrophize. All of us sometimes perceive things as worse than they really are. Some people do it rarely while other people do it a lot. Most of us are somewhere in between, catastrophizing more than rarely and less than all the time.

A good healthcare provider tends to remind us of things that we already know, but tend to forget in our day-to-day routines. One of these reminders is that it is a mark of health to be able to admit our imperfections. The first step towards getting better with regard to a problem is always to admit that you have the problem. In the case of catastrophizing, it’s a mark of health when we can acknowledge that we catastrophize, especially at the time when we are actually doing it. Indeed, an important health skill is the ability to step out of any given moment, reflect on what’s going on, and come to see the problem more clearly. By gaining perspective on the problem, we reduce the distress that’s associated with the problem and the problem comes to no longer have such a big impact on our lives. The problem comes to be less problematic as we initially experienced it to be.

This process is one of the many ways that people come to cope better with problems in life, including chronic pain. That is to say, we come to cope better with a problem when we get better at catching ourselves catastrophizing it, acknowledge that we are doing it, and reality-checking it. We thereby come to see the problem more clearly and subsequently we cope with it better– the problem becomes less distressing and less impairing.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-24-2013

Chronic Pain and Insomnia

Insomnia is common among people with chronic pain. It’s also problematic. It typically makes your pain worse and saps your abilities to cope. Understanding and overcoming insomnia is therefore important to successfully self-manage chronic pain.

Overcoming insomnia is possible for most people with chronic pain. Like most good things in life, though, it takes some work. There are no quick fixes when it comes to overcoming insomnia. There are actually a number of steps in the process. First, it’s helpful to understand the cyclical nature of chronic pain and insomnia. Second, it’s helpful to understand something about the three basic treatment options that are available for insomnia. Third, pursue one or some combination of these options.

Understanding the cyclical nature of chronic pain and insomnia

It’s common to think of chronic pain as the sole cause of insomnia – as if it’s a one-way street from chronic pain to insomnia. In some ways, of course, it makes sense as pain does in fact make it hard to sleep at night. Pain is a function of our nervous systems and when in pain our nervous systems are reactive. Our normal physical, emotional, and cognitive responses to pain are indicative of this reactive nervous system as well: we remain tense, alarmed, and focused on the pain. None of these automatic reactions to pain are conducive to falling or remaining asleep!

From these observations about pain and its effect on sleep, it seems logical that the best thing to do is to get rid of the pain. This approach, however, is insufficient in most cases of chronic pain.

First, this approach assumes that we can get rid of chronic pain. The reality, though, is that we can’t get rid of it. This fact is one of the things we mean when we use the adjective “chronic.” The most powerful procedures and medications can only reduce chronic pain, and don’t tend to get rid of it. So, there is no way around the fact that most people with chronic pain go to bed with pain. Even if it’s reduced, pain can continue to disrupt sleep.

Second, even if there was a way to fully cure chronic pain, it still might not be sufficient to overcome insomnia once you have it. Certainly, pain can start a bout of insomnia. However, insomnia is almost invariably maintained by more factors than just pain. One common factor is anticipatory anxiety about experiencing another night of insomnia. As you experience an insufficient amount of sleep night after night, it’s almost inevitable that you’ll start to worry about not sleeping as it comes time to go to bed. The arousal associated with this worry –as a form of anxiety or nervousness – can itself prevent you from falling asleep. In other words, insomnia can come to maintain itself!

Third, anxiety of all types can cause or maintain insomnia. People with chronic pain can become anxious for any number of reasons: loss of work; how to pay the bills; people not understanding what you are going through; loss of social or recreational activities; loss of your role in the family; and so on. People with chronic pain can also have anxiety disorders unrelated to their chronic pain. All of these issues can initiate and/or maintain insomnia.

Indeed, in most people with chronic pain, insomnia has multiple contributing causes. Certainly, pain can be one of those causes, but typically it is not the only cause. Moreover, these multiple contributing causes can come to exacerbate each other, making a vicious cycle of chronic pain and insomnia.

For example, say that chronic pain initially causes insomnia in someone. Over time, the insomnia becomes further complicated by nightly bed-time anticipatory anxiety about not getting enough sleep. At some point, worry sets in about loss of work, medical bills, strained marriage, and so forth. All of these factors come to maintain the insomnia over and above the role that pain has in maintaining insomnia. This chronic lack of sleep further stresses the person’s nervous system, making the reactive nervous system even more reactive. As such, the stress of it all makes the original chronic pain worse via its effects on the nervous system. As a result, we have a vicious cycle of chronic pain causing insomnia, which, in turn, makes the chronic pain worse.

This state of affairs reduces the individual’s ability to cope with pain and any of the other life’s stressors. Chronic pain and chronic insomnia can take its toll on anyone. This decreasing ability to cope fosters a greater sense of stress, which, in turn, elicits further pain and insomnia.

Chronic pain and insomnia are therefore complex phenomena that occur in a cyclical nature.

Therapies to address these problems must reflect this complexity. It just isn’t realistic to think that there can be simple, easy or quick fix to insomnia related to chronic pain.

Therapies for insomnia related to chronic pain

Many people rely on so-called “sleeping pills” to cope with insomnia. These pills are from two classes of medications that are technically called hypnotics (e.g., zolpidem) and benzodiazepines (e.g., diazepam). While common, their use is controversial in the healthcare field.

A number of problems are associated with their use. While providing short-term relief, they do not actually cure insomnia. Upon stopping their use, insomnia typically returns and, in the case of using benzodiazepines, the insomnia typically returns worse than when you initially started the use of the medication (Longo & Johnson, 2000). Moreover, the use of hypnotics has been associated with sleep-walking and other behaviors performed while sleeping (Morganthaler & Silber, 2002). In addition, it’s generally known that both classes of medications aren’t very effective. When compared to placebo, people taking hypnotics fall asleep on average 12.8 minutes sooner and people taking benzodiazepine medications fall asleep 10 minutes sooner (Buscemi, et al., 2007). Lastly, their use reinforces subtle, yet important, beliefs about yourself and your abilities to overcome insomnia. Namely, they foster associations that insomnia is a medical problem and that you need to rely on medicines to resolve this medical problem. In other words, they serve as a nightly reminder that you can’t overcome it yourself. You remain, in a word, helpless and must rely on something external to you (i.e., the pill) to do it for you. Now, of course, no one has these thoughts on an overt basis when going to bed at night after taking these medications. But, these subtle beliefs inevitably come to mind when the prospect of reducing the use of these medications is raised. After their long-term use, people can become quite concerned about reducing their use. The prospect is almost inevitably distressing and leaves people feeling helpless to the return of insomnia. What we are really talking about, here, is a subtle form of psychological dependence – the belief that you need the “sleeping pill” in order to sleep at night.

For all these reasons, the use of hypnotics and benzodiazepines for insomnia is controversial.

Chronic pain rehabilitation providers typically prefer to use a combination of two other types of therapies. These therapies are the use of tricyclic antidepressants and cognitive behavioral therapy.

Tricyclic antidepressants are old style antidepressants that are typically no longer used for depression. They are, however, used for chronic pain and insomnia. One of them, amitriptyline, is one of the most effective pain medications available (Hauser, Wolfe, Tolle, Uceyler, & Sommer, 2012; Wong, Chung, & Wong, 2007). They are also somewhat sedating and so are used at night to aid in falling and staying asleep. They do not produce a sense of dependency as often seen in hypnotics and benzodiazepines.

Cognitive behavioral therapy for insomnia is a short-term psychotherapy, usually provided by the psychologist on the chronic pain rehabilitation team. Cognitive behavioral therapy by itself can resolve insomnia once and for all. It breaks the vicious cycles of insomnia and creates new patterns of sleeping. However, it takes a whole lot more work than taking a pill.

Cognitive behavioral therapy requires a multi-pronged effort over time on the part of the patient. It involves the following:

  • Sleep hygiene changes
  • Regular use of relaxation exercises
  • Regular mild, low impact aerobic exercise
  • Cognitive interventions in which you learn how to overcome worry, or anxious thinking
  • Cognitive interventions in which you change your conceptualization of sleep to a more accurate and healthy understanding
  • Stimulus control (i.e., breaking patterns or associations that have developed over time between being in the bedroom and being awake)
  • Sleep restriction (i.e., intentionally limiting when you lay down to sleep or remain asleep in order to develop a normal sleep-wake cycle within the 24-hour day)
  • Tapering hypnotic or benzodiazepine medication use

Cognitive behavioral therapy is generally considered the most effective treatment for insomnia (Mitchell, Gehrman, Perlis, & Umscheid, 2012; Riemann & Perlis, 2009; Smith, et al., 2002; Taylor, Schmidt-Nowara, Jessop, & Ahearn, 2010).

While cognitive behavioral therapy is hard work, it neatly fits into the established protocols of a chronic pain rehabilitation program. As we have discussed in previous posts, chronic pain rehabilitation programs are cognitive behavioral based programs that already involve engaging in regular mild aerobic exercise, regular relaxation exercises, lifestyle changes some of which overlap with fostering sleep hygiene, and cognitive interventions for managing pain which have some overlap with those for managing insomnia.

The right approach for you

Whenever you decide upon a therapy that’s best for you, it is important that you discus it with your healthcare providers and allow them to be part of the decision making process. They are working for you and should have your best interests in mind. They also have an expertise in the field as well as knowledge of you as an individual, which puts them in the best position to advise you on what’s best.

It’s also important to get advice from healthcare providers who practice in the manner that’s right for you. As discussed in a previous blog post, all pain clinics are not alike. There are chronic pain rehabilitation clinics. There are long-term opioid management clinics. There are interventional pain clinics. There are spine surgery clinics. They can all go by the name of a “pain clinic.” Some of these clinics may be more prone to recommend hypnotic or benzodiazepine medications for your insomnia. Some of these clinics, specifically clinics with chronic pain rehabilitation programs, are apt to be more prone to recommend tricyclic antidepressants and cognitive behavioral therapy for your insomnia.

 

References

Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T. P., & Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs. Journal of General Internal Medicine, 22, 1335-1350.

Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40.

Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavior therapies. Sleep Medicine Reviews, 13, 205-214.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buyesse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.

Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients. Journal of Clinical Sleep Medicine, 6(2), 169-175.

Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-16-2013

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

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

What is rehabilitation?

People often equate ‘rehabilitation’ with physical therapy. It’s something a patient does following an injury or a complicated surgery. Still others think of ‘rehab’ as a treatment for alcoholism or drug addiction. A few years ago, a British soul singer had a hit single with the song “Rehab.” The lyrics were about whether to check herself into substance dependence treatment or not. ‘Rehabilitation’ can also be a form of vocational counseling. Injured workers re-learn how to go back to work in what’s called ‘vocational rehabilitation.’ Yet another example is the treatment that patients often get after they suffer a heart attack. Patients in such situations participate in ‘cardiac rehab,’ in which they learn healthy lifestyle changes, such as exercise, smoking cessation, dietary changes, weight loss, and stress management. Similarly, a traditional form of chronic pain management is a treatment called ‘chronic pain rehabilitation.’ Chronic pain rehabilitation programs are an interdisciplinary treatment that involves learning healthy lifestyle changes that reduce pain over time and learning improved ways of coping with the pain that remains chronic.

Why are all these different types of therapies called ‘rehabilitation’? What do they have in common?

Rehabilitation model of care

These questions imply that we should step back a bit, away from the particulars of these different treatments, and understand that all these treatments share an underlying model of care. It’s called the ‘rehabilitation model of care.’ Let’s explain what it is and, in doing so, it will be helpful to differentiate it from another model of healthcare, the acute medical model.

The rehabilitation model of healthcare focuses on what the patient can do to get better. Patients learn healthy lifestyle changes and ways of coping that lead to improved health when done over time. ‘Self-management’ is the term that refers to these health-improving changes. The rehabilitation model of care is typically best suited for chronic conditions, conditions for which there are no cures. Rehabilitation helps patients to get better by reducing the impact that a chronic condition has on their lives. That is to say, by learning how to successfully self-manage a chronic condition, patients can keep the condition in check and move on with the rest of their lives.

The rehabilitation model of healthcare differs from the acute medical model of care. The latter is the model of care that underlies the delivery of many medications and surgical procedures. Its emphasis is on what the healthcare provider can do for the patient. Its goal is to alleviate symptoms and, ideally, bring about a cure. It tends to be best suited for acute conditions, such as injuries and infectious illness.

Both models of care have their time and place. It’s safe to assume that no one is going to attempt to self-manage an acute appendicitis or try to find the right specialist to cure alcoholism. Rather, we focus on acute care procedures when having appendicitis and other curable conditions; we focus on rehabilitation and self-management when having chronic conditions, such as alcohol dependence.

Chronic conditions

The lynch pin that determines the type of care to pursue is whether the condition is chronic or not. If the condition is chronic, then there are no cures for it. So, rehabilitation is the preferred treatment approach. Sometimes, there are medications that can help to manage a chronic condition. Some examples are insulin for diabetes, or high blood pressure and high cholesterol medications for heart disease, and antidepressants and anti-epileptics for chronic pain. Sometimes, too, certain surgical procedures can keep a person with heart disease alive, but ultimately it still does not cure the underlying disease. So, when having a chronic condition, most patients are referred to some type of rehabilitation care where the focus is on what patients can do to minimize the condition and minimize its impact on them.rehabilitation

The rehabilitation model of care is used with some of the most significant health problems of our day: diabetes, heart disease, chronic pain, among others. With diabetes, it tends to be called ‘diabetes education’ or ‘diabetic self-management.’ The focus is on accepting the chronicity of the condition, dietary changes, weight loss, exercise, and stress and mood management. With heart disease, the approach is called cardiac rehabilitation. The focus is on accepting the chronicity of the condition, dietary changes, weight loss, smoking cessation, exercise, stress and mood management. With regard to chronic pain, the rehabilitation model of care is used in chronic pain rehabilitation programs. The focus of such programs is on accepting the chronicity of pain, exercise, relaxation therapies, and cognitive behavioral strategies that reduce pain, insomnia, stress, anxiety, and depression. The goals for any of these types of programs are for the patient to successfully self-manage their chronic condition and be able to live well despite having it.

Key differences between the acute medical and the rehabilitation models of care

The following table highlights the key differences between the acute medical model and the rehabilitation model of care.

Acute Medical Model of Care                          Rehabilitation Model of Care

Ideal of care is to provide a cure or ‘quick fix’ Ideal of care is to assist patients in making healthy changes (accept, adapt, compensate, cope, ‘move on’) and live well despite having the condition
Goal is to return to premorbid functioning (how the patient was prior to onset of the condition) Goal is to get better than how ever the patient is today
Hope lies in what the healthcare provider can do for the patient Hope lies in the patient taking back control
Power lies in the expertise of the provider (relies on an ‘external locus of control’) Patient becomes empowered (relies on an ‘internal locus of control’)
The therapeutic relationship tends to be hierarchical; the provider is the expert, active agent; the patient is a passive recipient of care The therapeutic relationship is less hierarchical; provider is like a coach who educates and motivates the patient; the patient is like an athlete who practices and implements the changes
Progress is qualitative: cured yes/no Progress is incremental: by degrees
Can have spectacular results, but also iatrogenic results Progress is slow; rehabilitation is relatively benign
Has a point of diminishing returns (i.e., the more procedures patients get for the same condition, the less likely they tend to be beneficial) The longer you do it and the more you do it, the better you get
Well-suited for acute injuries and illnesses Well-suited for chronic conditions

 Author: Murray J. McAllister, PsyD

Date of last modification: 1/11/2013

Effectiveness of chronic pain rehabilitation programs

It often comes as a surprise to patients that chronic pain rehabilitation programs are typically the most effective form of treatment for patients with chronic (non-cancer) pain syndromes. As a society, we tend to assume that medications, procedures and surgeries are not only effective, but are the most effective treatments for chronic pain. But, it’s not the case.

Criteria for Effectiveness

In the field of chronic pain management, we tend to use certain criteria by which to measure the effectiveness of treatments. These criteria are the following:

  • Pain reduction
  • Improvement in functioning (such as, return to work rate)
  • Reduction in the need for opioid, or narcotic, pain medications
  • Reduction in the use of healthcare services for pain, more generally

These standard criteria make sense. A treatment is judged effective to the extent that it reduces pain, helps people return to work, helps them to need less narcotic pain medications, and helps patients to not have to see their healthcare providers as much.

chronic pain rehabilitation program

Pool therapy in a chronic pain rehabilitation program.

Let’s review each of these criteria one at a time, comparing how chronic pain rehabilitation programs do with other standard medical care (which might include narcotic and non-narcotic pain medications, procedures and surgeries) for chronic pain.

Pain Reduction

  • 20-40% average reduction in pain following participation in chronic pain rehabilitation programs (Gatchel & Okifuji, 2006; Turk, 2002)
  • 30% average reduction in pain with standard medical care (Gatchel & Okifuji, 2006)

Return to Work Rates

  • 60% rate of return to work following participation in chronic pain rehabilitation programs (Flor, Frydrich, Turk, 1992; Gatchel & Okifuji, 2006)
  • 27% rate of return to work with standard medical care (Gatchel & Okifuji, 2006)

Reductions in Opioid, or Narcotic, Pain Medication Use

  • More than 60% of patients are able to taper from opioid pain medication use following participation in chronic pain rehabilitations (Tollison, Kriegel, & Downie, 1985; Tollison, Hinnant, & Kriegel, 1991; Turk, 2002)
  • Less than 10% of patients are able to taper from opioid pain medications with standard medical care (Tollison, Kriegel, & Downie, 1985; Tollison, Hinnant, & Kriegel, 1991)

Reductions in Healthcare Utilization

  • 68% reduction in overall medical costs following participation in chronic pain rehabilitation programs (Gatchel & Okifuji, 2006)
  • Generally not reported in efficacy studies of medication management, interventional procedures, or surgeries, though 15-20% of those receiving spinal surgery will require re-operation (Gatchel & Okifuji, 2006; Turk, 2002)

Chronic pain rehabilitation programs are powerful interventions. They have significantly higher rates of return to work, significantly greater reductions in opioid, or narcotic, medications use, and significantly greater reductions in the need to seek on-going healthcare for chronic pain.  The comparable statistics between such programs and standard medical care for the criteria of pain reduction is remarkable when considering that over half of patients in chronic pain rehabilitation programs are also tapering opioid, or narcotic, medications.

In all, such outcomes are what make most experts in chronic pain management conclude that chronic pain rehabilitation programs are the most effective treatment approach for patients with chronic pain syndromes.

References

Flor, H., Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analysis. Pain, 49, 221-230.

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, 7, 779-793.

Tollison, C. D., Hinnant, D. W., & Kriegel, M. L. (Eds.). (1991). Psychological concepts in pain. Philadelphia, PA: Lea & Febiger.

Tollison, C. D., Kriegel, M. L., & Downie, G. W. (1985). Chronic low back pain: Results of treatment at the pain therapy center. Southern Medical Journal, 78, 1291-1295.

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Author: Murray J. McAllister, PsyD

Date of last modification: 12/6/2012

Thoughts & Prayers

The Institute for Chronic Pain is saddened by the recent outbreak of fungal meningitis from tainted steroid used in interventional pain management procedures.  As of this writing, over 400 cases have been reported and 29 deaths. Our thoughts and prayers go out to those who are ill and to the families of those who have lost their lives.

Author: Murray J. McAllister, PsyD

Date of last modification: 11/4/2012

Institute for Chronic Pain Blog: Introductions

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

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, as we do with other chronic conditions, such as diabetes or heart disease.
  • 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.

* *

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. They 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 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.

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

  • We have 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: 10/7/2012