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

Epidural steroid injections: FDA provides safety warning

Last month, the United States Food & Drug Administration (FDA) issued a warning on the safety of epidural steroid injections for back and neck pain. Epidural steroid injections, they said, “may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.” They advised providers who perform epidural steroid injections and their patients to discuss these risks prior to making the decision to undergo the procedure.

When used for back or neck pain, epidural steroid injections deliver steroid into the epidural space of the spine. The steroid has anti-inflammatory properties. The goal is to reduce inflammation around the nerves of the spine and thereby produce a temporary reduction in pain.

The FDA states that this warning is unrelated to the issue in 2012 when a number of patients became ill and even died because they had been injected with steroid that had been contaminated in the manufacturing process.

Timely nature of the FDA warning

This warning is important because epidural steroid injections are an increasingly common procedure for chronic back or neck pain. Their widespread use has occurred over the last twenty to twenty-five years. From 1994-2001, their use increased by 271% in the US (Friedly, Chan, & Deyo, 2007). From 2000-2008, their use increased another 186% (Manchikanti, L., et al., 2013).

Epidural steroid injections are not FDA-approved for back or neck pain

This widespread use of epidural steroid injections is controversial. Research shows that on average epidural steroid injections are ineffective for chronic back and neck pain (see, e.g., Bickett, et al., 2013, Staal, et al., 2008) or for radicular pain, such as sciatica (Iverson, 2011). At best, in some clinical trials, epidural steroid injections have been shown to provide statistically significant improvements in the leg pain of sciatica, but the improvements are so small that from the real world perspective of a patient the improvements are irrelevant (Carette, et al., 1997; Quraishi, 2012). No published studies show that epidural steroid injections reduce disability related to back or neck pain.

Proponents of the procedure often argue that that the use of epidural steroid injections can reduce the need for spine surgery. However, empirical research does not support this argument (Carette, et al., 1997).

Due to the lack of evidence for the effectiveness of epidural steroid injections, a number of pain experts question their widespread use (Deyo, 2009; Schofferman, 2006; Taylor, 2011).

The FDA, in their warning, explicitly emphasizes this lack of evidence for the effectiveness of epidural steroid injections. They state that the use of epidural steroid injections for the treatment of back or neck pain is not an FDA-approved procedure because the procedure has not been shown to be effective.

References

Bickett, M. C., Gupta, A., Brown, C. H., & Cohen, S. P. (2013). Epidural injections for spinal pain: A systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. Anesthesiology, 119(4), 907-931. doi: 10.1097/ALN.0b013e31829c2ddd

Carette, S., Leclaire, R., Marcoux, S., Morin, F., Blaise, G. A., St. Pierre, A., Truchon, R., Parent, F., Levesque, J., Bergeron, V., Montminy, P., & Blanchette, C. (1997). Epidural corticosteroid injections for sciatica for herniated nucleus pulposus. New England Journal of Medicine, 336, 1634-1640. doi: 10.1056/NEJM199706053362303

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Friedly, J., Chan, L., & Deyo, R. (2007). Increases in lumbosacral injections in the Medicare population: 1994-2001. Spine, 32, 1754-1760.

Iverson, T., Solberg, T. K., Romner, B., Wilsgaard, T., Twisk, J., Anke, A., Nygaard, O., Hasvold, T., & Ingebrigtsen, T. (2011). Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: Multicentre, blinded, randomized controlled trial. BMJ, 343, d5278. doi: 10.1136/bmj.d5278

Manchikanti, Pampati, V., Falco, F., & Hirsch, J. A. (2013). Growth of spinal interventional pain management techniques: Analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine, 38(2), 157-168. doi: 1097/BRS.0b013e318267f463

Quraishi, N. A. (2012). Transforaminal injection of corticosteroids for lumbar radiculopathy: Systematic review and meta-analysis. European Spine Journal, 21(2), 214-219. doi: 10.1007/s00586-011-2008-y

Schofferman, J. (2006). Interventional pain medicine: Financial success and ethical practice: An oxymoron? Pain Medicine, 7, 5, 457-460.

Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (2008). Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews, 3(3). doi: 10.1002/14651858.CD001824.pub3

Taylor, M. L. (2011). The impact of the “business” of pain medicine on patient care. Pain Medicine, 12, 5, 763-772.

AUTHOR: Murray J. McAllister, PsyD

DATE OF LAST MODIFICATION: 5-4-2014

Is Degenerative Disc Disease Inevitably Degenerative?

It’s common to be upset when you’ve been told that you have degenerative disc disease. It’s an awful sounding diagnosis. It sounds like you have a disease that is deteriorating your spine. And on top of it all, it doesn’t sound like there’s much you can do about it. The spine, it seems, is inevitably degenerating.

Patients commonly express the belief that their chronic back or neck pain is a progressive condition that will unavoidably lead to greater and greater pain and disability. They’ve been told that they have degenerative disc disease and that it is the cause of their pain. It was found on their MRI scan of the spine. Since the cause of their pain is called ‘degenerative,’ they understandably believe that it’s inevitable that they are going to get worse. Their future, it seems, holds nothing but increasing pain and impairment.

Sometimes, healthcare providers believe that degenerative disc disease is inevitably degenerative too. Commonly, patients tell me that they’ve been told by their healthcare provider that they will end up in a wheelchair someday or that the provider is surprised the patient can walk upright given the extent of the findings of degenerative disc disease that’s evident on the MRI scan. Such comments by healthcare providers seem to indicate that they too believe that degenerative disc disease is inevitably degenerative, progressively leading to a worsening of pain and disability.

What is the natural course of degenerative disc disease?

How confident should we be in this belief that degenerative disc disease is inevitably degenerative? What does science tell us about what happens to so-called degenerative changes of the spine over time? In healthcare, studies of what happens to health conditions over time when left untreated are called ‘natural history’ studies. Such studies simply track a condition over time to see what its natural trajectory is– whether the condition tends to get better or worse. It would be helpful to look at natural history studies of the conditions that fall under the category of degenerative disc disease. We’d then know what the natural trajectory is for such conditions.

Degenerative disc disease is a catchall phrase for a number of conditions of the spine. These conditions are typically evident on CT and MRI scans. They are a loss of disc height, disc bulges and herniations, annular tears, endplate changes, osteophyte complexes, neuroforaminal stenosis, and central canal stenosis, among others.

Let’s look at what happens to these conditions over time. Many chronic back or neck pain patients have such degenerative changes in their spine as evidenced by MRI or CT scans and it will be helpful to know something about what typically happens to them if you have them. Contrary to popular belief, we will find that the changes to the spine that we call degenerative disc disease are not inevitably degenerative.

When I review this research with patients, they are a little surprised. They have long thought of their condition as inevitably progressive and it can take a little bit of time to get used to the idea that their condition is not as degenerative as they had thought it to be. Moreover, they are frequently a little skeptical. One of the most common exceptions to the review of this research goes something like, ‘Well, Doc, I’ve been told that my degenerative disc disease is very severe… Severe or advanced degenerative disc disease is going to get worse. How could it not?’ That is to say, a common belief about degenerative disc disease is not only that it is inevitably degenerative, but that the more advanced it is the more progressive it will be. Another way to put it is the belief that the worst or most advanced stages of degenerative disc disease will always tend to lead to the most severe pain and disability. So, let’s review what science tells us about what happens to the most advanced or worst degenerative changes over time too.

Specifically, with our review of natural history studies of degenerative disc disease, we want to determine the answers to two questions:

  • Do degenerative changes to the spine inevitably worsen?
  • What happens to the most severe degenerative changes?

 Natural history studies of degenerative disc disease

Symmons, et al., (1991) were some of the first investigators to look at these questions. They took X-rays of 742 women aged 45 or older and then repeated the X-rays 8 to 11 years later. They broke women into two groups, those with back pain and those without back pain. They found degenerative changes in both groups. They also found that degenerative disc disease progressed most often in those with back pain. Over the study period, they found that almost 60% of women with back pain had a progression of their degenerative disc disease; whereas, a little more than 30% of women without back pain had a progression of their degenerative disc disease. Notice, however, that progression of degenerative disc disease is not inevitable. The remaining 40% of those with back pain had degenerative disc disease that did not get worse. The remaining 70% of the women without back pain had degenerative disc disease that did not get worse.

This study relied on X-rays, rather than more accurate CT or MRI scans. Is there evidence of the same findings with CT or MRI scans?

Using MRI scans on a repeated basis, Matsubara, et al., (1995) followed 32 patients with herniated discs in their lumbar spine over the course of a year. They found that 62% of the disc herniations spontaneously reduced in size and the remaining 38% of herniations did not get worse. In this study, we see a significant degenerative disc problem – herniations – tending to get better the majority of the time. Even when disc herniations failed to get better, they did not tend to get worse. Here, we find that the disc herniations are not inevitably degenerative.

These researchers also found data that pertains to the severity of disc herniations. Contrary to the popular belief that the worst problems tend to become more problematic, they found that the larger the disc herniation, the more it reduced.

Another spinal condition that falls under the category of degenerative disc disease are endplate changes. Hutton, et al., (2011) reviewed two groups of patients with lumbar-related endplate changes who had had MRI’s repeated over time. The first group was 36 patients with a minimal level of endplate changes. The second group was 22 patients with a more advanced stage of such changes. Of the first group with less significant endplate changes, half remained the same; a little less than half got worse; and two patients reversed back to normal. Of the second group with the more advanced changes, most remained the same; some got better and none got worse.

Here again, we see two important facts about this specific type of degenerative change. First, in its least advanced stage, sometime it does get worse, but only less than half the time. Thus, we really can’t say it is inevitable that it gets worse. Second, contrary to the notion that the more severe spine problems always lead to more severe consequences, we see that the advanced stages of endplate changes generally stay the same. Sometimes it gets better, but they don’t tend to get worse.

Park, et al., (2013) found in a sample of 27 cervical spondylolisthesis patients that only three had a progressive worsening of their condition over a 2-7 year follow-up period. None of the three experienced any significant neurological injury or an increase in their symptoms as a result.

Humphreys, et al., (1998) looked at still other conditions of the spine, which are associated with degenerative disc disease. They found that foraminal stenosis did in fact narrow with age but found no progression of disc height, lordosis, or central canal stenosis. So, here again, we find that degenerative changes of the spine are far from inevitably degenerative.

Regarding the latter, Karadimas, et al., (2013) reviewed the literature on cervical spondyltic myelopathy, or a degenerative narrowing of the spinal cord in the area of the neck, and found that the condition naturally worsened in 20-60% of the cases. Again, we see a significant degenerative condition can get worse, but does not always get worse. Indeed, depending on the study, 40-80% of the time it does not get worse.

Some might counter with a subtle variation of the second question we have been attempting to review, namely that the most advanced degenerative disc disease tends to be more degenerative. They might acknowledge that degenerative disc disease itself may not inevitably become worse. They might even acknowledge that the most advanced stages of such changes don’t tend to inevitably get worse. However, they might argue that the most severe degenerative changes to the spine do in fact lead to greater pain and/or a greater decline in functioning. In other words, those with the most severe degenerative disc disease will inevitably experience the greatest pain and disability.

A recent study by Berg, et al., (2013) inadvertently sheds light on this point. They were interested in looking at whether degenerative disc disease correlates with pain and disability in a sample of 170 low back pain patients who had been recommended for disc replacement surgery at either of the two lowest disc levels of the lumbar spine (i.e., L4-5 & L5-S1). Presumably, the degenerative disc disease evident at these two levels was severe enough to have the surgery recommended to them. Interestingly, they found no significant correlation at all between degenerative disc disease and either pain or disability. Even among a subgroup of people with the most severe degenerative changes (the severest of the severe), they still found no correlation. They subsequently added findings of facet arthropathy, another degenerative condition, and with the combination of degenerative disc and facet changes they still found no correlation between such changes and either pain or disability. In other words, neither more severe findings of degenerative disc disease nor a greater amount of such degenerative conditions lead to a worsening of pain or impairment. (This study highlights another interesting question to which we tend to all assume we know the answer – to what extent does degenerative disc disease explain chronic back or neck pain. This question will be taken up in our next blog post).

Concluding remarks

To summarize, we set out to determine the truth of certain common beliefs that patients have about degenerative disc disease. These beliefs are that degenerative disc disease is inevitably going to worsen, or at the very least the most severe degenerative changes are always going to get worse. By reviewing what the science tells us about degenerative disc disease, we see that neither of these beliefs are true. While degenerative changes do sometimes get worse, they very often either remain the same or get better. Also, we see evidence that the worse the degenerative condition is, the more it tends to either stay the same or get better.

Has your healthcare provider ever told you or implied that degenerative disc disease was inevitably going to get worse? Why do you think that this belief continues to be common when the scientific literature doesn’t support it?

References

Berg, L., Hellum, C., Gjertsen, O., Neckelmann, G., Johnsen, L. G., Storheim, K., Brox, J. I., Eide, G. E., & Espeland, A. (2013). Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis. Skeletal Radiology, 42(11), 1593-1602.

Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23, 2180-2184.

Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.

Karadimas, S. K., Erwin, W. M., Ely, C. G., Dettori, J. R., & Fehlings, M. G. (2013). Pathophysiology and natural history of cervical spondyltic myelopathy. Spine, 38(22S), S21-S36. doi: 10.1097/BRS.0b013e318a7f2c3

Matsubara, Y., Kato, F., Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.

Park, M. S., Moon, S. H. Lee. H. M., Kim, S. W., Kim, T. H., Suh, B. K., & Riew, K. D. (2013). The natural history of degenerative spondylolisthesis of the cervical spine with 2-7year follow-up. Spine, 38(4), E205-E210. doi: 10.1097/BRS.0b013e1827de4fd

Symmons, D. P., van Hemert, A. M., Vandenbroucke, J. P., & Valkenburg, H. A. (1991). A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings. Annals of the Rheumatic Diseases, 50, 162-166.

Author: Murray J. McAllister, PsyD

Date of last modification: 3-10-2014

September is Pain Awareness Month

September is Pain Awareness Month! It is a special month for us at the Institute for Chronic Pain (ICP). The theme of the month is one of the central goals of our mission. Specifically, our mission is to change the culture of how chronic pain is treated by promoting the theory and practice of chronic pain rehabilitation.

We raise awareness of the numerous personal, systemic, and societal issues related to chronic pain with the long-term goal of making the management of chronic pain more effective and cost-effective.

It’s no small task. Indeed, a critic might charge that we are pie-in-the-sky dreamers. However, the status quo is not acceptable.

And what is the status quo when it comes to chronic pain management? Consider these facts about the current state of affairs in the U.S.

  • The U. S. consumes 80% of all opioid medications prescribed in the world (Manchikanti & Singh, 2008).
  • The rate of spine surgery has been steadily and significantly increasing  over the last thirty years (Nilasena, Vaughn, Mori, & Lyon, 1995; Rajaee, Bae, Kanim, & Delamarter, 2012; Weinstein, et al., 2006).
  • The increase in the rate of interventional pain procedures has been described as “explosive” over the first decade of this century (Manchikanti, Pampati, Falco, & Hirsch, 2008).
  • Pain-related conditions remain the most common reason for disability and the rate of disability continues to increase (CDC, 2011).

Obviously, all this pharmacological, surgical, and interventional care is not helping.

Maybe, it is because as a society we are treating chronic pain in the wrong way. What if even the ways we think about the nature of chronic pain are wrong?

The ICP was founded and developed to resolve these issues. We attempt to foster consensus among the patients, providers, third-party payers, and public policy makers as to how to most accurately conceptualize chronic pain and how to most effectively treat it. We aim for everyone to more accurately understand that the nature of chronic pain is a biopsychosocial condition.

The leading scientific research clearly shows us that chronic pain is a nervous system condition that is biopsychosocial in nature, not an orthopedic condition (see, for examples, Apkarian, Baliki, & Geha, 2009; Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Meeus & Nijs, 2007; Woolf, 2011; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007).

Moreover, a large number of studies over multiple decades show consistent findings that chronic pain rehabilitation, an interdisciplinary therapy that focuses on down-regulating the nervous system, is the most effective form of chronic pain management (see, for examples, Flor, Frydrich, & Turk, 1992; Gatchel & Okifuji, 2006; Guzman, et al., 2001; Hoffman, Papas, Chatkoff, & Kerns, 2007; Turk, 2002).

At the ICP, we aim to tell the story of both these facts and do so in a way that’s credible and understandable to everyone. Thanks for supporting us!

References

Apkarian, A. V., Baliki, M. N., & Geha, P. Y. (2009). Towards a theory of chronic pain. Progress in Neurobiology, 87, (2), 81-97.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Center for Disease Control. (June 21, 2011). 47.5 million U. S. adults report a disability; arthritis remains most common cause. Retrieved September 22, 2013, from http://www.cdc.gov/features/dsadultdisabilitycauses/.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S. (2006). Central hypersensitivity in chronic pain: Mechanisms and clinical implications. Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Frydrich, T., & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49(2), 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.

Guzman, J., Esmail, R., Karjalainen, K., Malmivaara, A., Irvin, E., & Bombardier, C. (2001). Multidisciplinary rehabilitation for chronic low back pain: Systematic review. BMJ, 322(7301), 1511-1516.

Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26(1), 1-9. doi: 10.1037/0278-6133.26.1.1.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Manchikanti, L., Pampati, V., Falco, F. J., & Hirsch, J. A. (2013). Growth of spinal interventional pain management techniques: Analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine, 38(2), 157-168.

Manchikanti, L., & Singh, A. (2008). Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician, 11(2suppl), S63-S88.

Nilasena, D. S., Vaughn, R. J., Mori, M. & Lyon, J. L. (1995). Surgical trends in the treatment of diseases of the lumbar spine in Utah’s Medicare population, 1984-1990. Medical Care, 33(6), 585-597.

Rajaee, S. S., Bae, H. W., Kanim, L. E., & Delamarter, R. B. (2012). Spinal fusion in the United States: Analysis of trends from 1998 to 2008. Spine, 37(1), 67-76. doi: 10.1097/BRS.0b013e31820cccfb.

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

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Date of last update: September 23, 2013

Author: Murray J. McAllister, PsyD

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

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