People with moderate-to-severe, persistent pain often come to a pain rehabilitation program because they want more out of life. It is not so much that they are looking for outright pain relief, since they’ve had pain for so long they know it isn't going away altogether. What they are looking for instead is to be able to get back into life and do activities that they no longer do.
Last year, I served on a committee looking into reasons for resistance by the healthcare community to adopt opioid prescribing guidelines. At first blush, this reluctance was perplexing.
The Institute for Chronic Pain (ICP) recently published a content piece on the roles that shame play in the experience of pain, particularly in persistent pain. It’s an under-reported topic in the field of pain management. In fact, we don’t tend to talk about it at all.
I recently was at a meeting on designing a model of pain care delivery. The meeting was filled with clinical and operational experts. In the course of the meeting, one healthcare provider made the case that high quality pain care starts with “finding the pain generator.” By this phrase, he meant that the delivery system should support the use of scans and diagnostic injections to identify the orthopedic structure(s) responsible for any given patient’s pain. From there, he insisted that a foundation could be laid for establishing successful treatment plans to resolve the identified pain generator, presumably through interventional and/or surgical means.
Once having made his case, another provider spoke up and asked how he’d square the care delivery model he proposed with the fact that so-called “pain generators” lack any significant correlation with pain. She cited common evidence showing that findings on MRI scans do not correlate with pain, and that diagnostic injections lack reliability and validity (cf., Vagaska, et., 2019; Kreiner, et al., 2020). In so doing, she used science to challenge the whole foundation on which the previous speaker had advocated for his model of pain care delivery.
In reaction, it was apparent that the original speaker didn’t quite know how to respond. The challenge seemed to catch him by surprise. He seemed unaware of the common research findings she referenced.
Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.
The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers.
Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.
Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution.
The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose.
Commonly, patients and providers assume that pain is the result of an injury or illness, or at least some type of condition in the body. So, for example, when pain in the low back occurs, it’s common to think of it as the result of some type of tweak or mild injury that must have occurred. When it goes on for some time, it’s also is common to want an MRI scan to see “what’s going on” in the back. Such scans often reveal some type of degenerative condition of the spine, which is subsequently considered the cause of the back pain.
As a result, people with pain tend to seek therapies that target the condition in the body by means of physical therapy that strengthens the core, or undergo steroid injections, or even surgery.
The same would be true if the onset of pain occurred in the shoulder or knee or hip. We’d tend to think of the pain as a sign that something is wrong in these joints, something orthopedic in nature, such as arthritis or a problem with a ligament or muscle. We’d tend to seek a scan to help in diagnosis followed by physical therapy, an injection or surgery,
The purpose of these types of assessment and therapies would be to treat the condition that is assumed to be the cause of pain. While doing so, we might take pain medications that act on the brain.
The single most important concern in public policy debates related to the use of opioids for persistent, or chronic, pain is what happens to people with persistent pain when they reduce or taper the use of opioids.
It is often helpful to use analogies and metaphors when explaining complex health topics to patients and their families. This statement is no less true when explaining the complexities of successful pain management. There are many helpful metaphors and analogies, and we have discussed a number of them previously in this blog, such as in the different ways to relate to pain or even experience pain. Another helpful analogy to explain the nature and goals of successful pain management is with the analogy to successful weight management.
It is helpful to liken pain management to weight management because weight management is often better understood by patients and their families. So, let’s review and learn about what it takes to successfully self-manage pain by looking at how it’s similar to successful weight management.
Just this morning, a primary care provider came to consult with me, looking for pain rehabilitation options for her patient with a complex set of needs. Emphasizing the legitimacy of the patient’s pain complaints, the provider detailed a long history of an active substance use disorder. The patient has had multiple urine drug screens positive for both opioids, which weren’t prescribed to the patient, and illegal substances. The provider recounts that the patient has been asked to leave multiple pain clinics for similar aberrant prescription drug use behaviors, all of which are indicative of an inability to control the use of opioids. Given the patient's history, she is at high risk of further exacerbating her addiction and/or death, if opioids continue to be prescribed. Nevertheless, the provider feels as if she has to prescribe opioids to the patient because, "she has legitimate medical conditions with real pain."
Living among the COVID-19 pandemic, with its loss of life and livelihood, and our need to maintain physical distancing to protect ourselves and our communities, we face the dual burdens of stress and boredom. It’s a difficult combination because persistent stress leads to lack of focus and feeling scattered. This distractibility leads to aimlessness and inactivity, which further leads to boredom. In boredom, we have nothing to distract attention away from all the stressors in our lives. Thus, stress can lead to boredom and boredom leads back to stress.
The COVID-19 pandemic continues to impact the world with deaths in the hundreds of thousands and countless more having become ill. To reduce the risk of contagion and death, areas around the world maintain self-quarantining practices and have been doing so now for multiple months.
Sheltering-in-place, or self- quarantining, presents both challenges and opportunities for everyone, including those with persistent, or chronic, pain.
A giant in the field of pain management passed away the other day. It was December 22, 2019, and, to be exact, he was the father of pain management. It is no overestimation to say that he brought pain management into modernity. Ron Melzack, PhD, was 90 years old.