Opioid Tolerance

When engaging in long-term opioid management for chronic pain, should healthcare providers discuss with patients that typically the medications won’t remain effective for the rest of their life? That is to say, should healthcare providers fully review the implications of opioid tolerance prior to beginning long-term opioid management for patients who have chronic pain, but who are neither elderly nor sick with a terminal illness? If you have chronic pain and are on long-term use of opioids, and are middle-aged or younger, did your healthcare provider discuss the implications of opioid tolerance with you? The Institute for Chronic Pain website has a new content page that tackles this important yet complex issue.

While the issue of addiction tends to dominate debates over opioid management for chronic pain, the field remains largely silent about another important issue with regard to the long-term use of opioids. It is the issue of opioid tolerance. Tolerance is a phenomenon that occurs when an individual over time requires greater amounts of a drug to continue to obtain the original degree of its desired, therapeutic effect (Savage, et al., 2003). Tolerance to a medication becomes problematic when, on the one hand, patients taking the medication have many years yet to live and, on the other hand, it is not feasible to expect that they can continue to periodically increase the dose of the medication indefinitely. As such, this problem is particularly applicable to chronic pain patients on long-term opioid management who have a reasonably long life expectancy – another twenty or thirty or forty more years to live.

It leads to the inevitable question: What will chronic pain patients do when, after years of periodically increasing the dose whenever their opioid medication started to become less effective, they find themselves on the highest dose of an opioid and even this level of the medication no longer effectively reduces their pain? In other words, what happens when patients become opioid tolerant to the highest doses of the medication and still have many years yet to live?

The field of chronic pain management has now had patients on the long-term use of opioids for almost two decades and as a result it is increasingly common to see opioid tolerant patients in clinic – patients who have been on these medications for many years and are finding that the medications are no longer very effective even when they are on the conventionally agreed upon highest doses.

This increasingly common clinical problem is chockfull of ethical implications:

  • What now is our shared responsibility for the care of such patients?
  • Should the field have done better at predicting this problem, given what historically we knew about tolerance to drugs and medications?
  • Are we as a field routinely providing informed consent by discussing with our patients the long-term consequences of opioid tolerance with our current patients?
  • How much are we helping patients if we allow them to become opioid tolerant to the highest doses of the medications when they have many years yet to live?
  • How are we going to treat such patients in the future if they have an altogether different painful injury or illness? How will we manage the opioid tolerant patient’s pain if, for instance, the patient later in life develops a terminal cancer or falls and breaks a hip and requires surgery when elderly?
  • Should we continue the practice of long-term opioid management for patients who are neither elderly nor terminally ill (i.e., people with chronic pain for whom we might reasonably expect to live more than a decade or two)?
  • Should we continue to engage in long-term opioid management for such patients when we know we have an empirically supported, effective alternative to opioids for people with chronic pain – the interdisciplinary chronic pain rehabilitation program?

Despite our persistent failure to discuss it, the topic of opioid tolerance demands of us to openly acknowledge it. It is an increasingly common clinical problem for chronic pain patients and their providers alike. Moreover, it leads to a slew of ethical problems that require resolution.

For a more in depth discussion of these issues, please read Tolerance to Opioid Pain Medications on the Institute for Chronic Pain website.

References

Savage, S. R., Joranson, D. E., Covington, E. C., Schnoll, S. H., Heit, H. A., & Gilson, A. M. (2003). Definitions related to the medical use of opioids: Evolution towards universal agreement. Journal of Pain and Symptom Management, 26(1), 655-667.

Author: Murray J. McAllister, PsyD

Date of last modification: 7-18-2014

An Alternative to Opioids for Chronic Pain

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

Chronic pain rehabilitation programs

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

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

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

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

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

A short history of chronic pain management

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

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

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

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

An alternative to opioids for pain that few know about

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Author: Murray J. McAllister, PsyD

Date of last modification: 4-20-2013

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.

Weinstein, J. N., Lurie, J. D., Olson, P., Bronner, K. K., Fisher, E. S., & Morgan, T. S. (2006). United States trends and regional variations in lumbar spine surgery: 1992-2003. Spine, 31(23), 2707-2714. doi: 10:1097/01.brs.0000246132.15231.fe.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152 (3 Suppl), S2-15.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

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

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