Murray J. McAllister, PsyD
Murray J. McAllister, PsyD, is the editor and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.
The notion of a neuromatrix of the brain is a theoretical model that explains the nature of pain, including chronic pain. Ronald Melzack, PhD, a psychologist, and one of the founding fathers of the field of pain management as we know it today, developed the theory and published it in a series of papers at the end of the last century.1, 2, 3, 4 Melzack had previously revolutionized the field of pain management in an earlier theory that he had developed and published with his physician colleague, Patrick Wall, in what is known as the gate control theory of pain.5 Few theories in modern science have spawned more empirical research than those of the gate control theory of pain and the neuromatrix of pain. Indeed, while technically theories, the field largely considers these models as accurate explanations of the nature of pain, given the great wealth of empirical evidence that now confirms them. So, what is this notion of the neuromatrix of the brain that explains the nature of pain?
Few topics in healthcare generate more passion than the use of opioid medications for chronic, non-cancer pain. Some, in the debate, lead the charge for greater access to opioids, arguing fervently that these medications are under-prescribed, while others call for more limited access, arguing that opioids are over-prescribed. The central focus for these strong feelings is typically the issue of addiction, but other issues commonly receive attention as well, such as the effectiveness of opioids and humanitarian calls to alleviate suffering.
While it appears that the Affordable Care Act (ACA) may have slowed the rate of annual increases in health insurance premiums, the overall cost of health insurance continues to rise.1, 2, 3 Employers subsequently continue to face the dilemma of either absorbing these annual cost increases and thereby reduce potential profit or passing these costs onto their employees and thereby reduce their potential take-home pay. In other words, do you face the ire of shareholders or workers?
Chronic Pain Rehabilitation Programs
The American Chronic Pain Association provides information on chronic pain rehabilitation programs.
A TED Talk by Tracy Jackson, MD, of Vanderbilt University, on interdisciplinary chronic pain rehabilitation programs (aka, functional restoration programs).
Stigma is a significant and persistent problem for those with chronic pain. Stigma occurs when someone is judged for having a condition that they didn't choose to have, like chronic pain. In other words, stigma is the criticism of being bad in some way for simply having a condition that you didn't choose to have. It can also occur in relationship to how a patient with chronic pain is coping. Stigma thus arises when moral judgments occur not for wrong behavior, which might rightly get criticized, but for simply being who you are, for simply having the health condition that you have, or for how you are dealing with it.
One of the more common sentiments that chronic pain patients express is that that the profit-motive seems to have had too much of an influence on the recommendations that their healthcare providers have made over the years. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried again and again despite having failed to reduce pain at previous clinics, they conclude that the business side of healthcare has played too much of a role in their own care. They are now disappointed, angry, and distrustful of chronic pain management providers.
Patients with chronic pain, their healthcare providers, and society, more generally, are all typically concerned about addiction to opioid pain medications. This concern is well founded. Once commonly thought of as rare,1, 2 it is now generally accepted that the true rate of addiction to such medications is much higher than what was once thought.3, 4 The issue of addiction to prescription opioid pain medications generates considerable debate among the stakeholders in the field of chronic pain management. There are strong voices for the continued use of such medications despite the rate of addiction and strong voices against the continued use of these medications because of the rate of addiction.
Teaching People About Pain
Pain is a normal human experience. Without the ability to experience pain, people would not survive. Living in pain, however, is not normal.1 Pain that lasts beyond the normal healing time of tissues is called chronic or persistent pain. Worldwide, chronic pain is increasing. In the US alone, chronic pain has doubled in the last 15-20 years.2 With this increase, comes increased cost. Within Medicare, a US government-based insurance, epidural steroid (pain) injections have increased 629% in the last five years and the use of opioids (for example, hydrocodone and oxycodone) is up 423%.1 This increase is not isolated to the US and represents a global concern. In the shadow of this growing epidemic, we are faced with serious questions. Why is chronic pain increasing? Why are some of our most heroic treatments (opioids, injections, surgery, amputations, etc.) not working? The answer to these questions is complex and contains a variety of issues.
What is opioid-induced hyperalgesia?
Algesia means pain. Hyper means over or above or heightened. Opioid-induced means caused by opioid pain medication.
We all have normal levels of heightened sensitivity to various stimuli. For example, you may have a favorite smell. Perhaps, it is cigar smoke because it fondly reminds you of your grandfather. A slight whiff of cigar smoke makes you think of your grandfather and gives you pleasant feelings. This experience is in response to a simple smell, which to others, leads to no such connotations. Or, perhaps, you have a favorite song. You may find yourself on an elevator and upon hearing the elevator music, you recognize the song and it feels good. No one else in the elevator even notices the song until you say, "Oh, that’s my favorite song." To take yet another example, you might be able to readily pick out your spouse in a large crowd and subsequently come to feel a sense of warmth and joy at simply your spouse’s presence. To others, however, your spouse may simply be an invisible stranger among others in the crowd. These kinds of normal sensitivity can be present in any and all of the senses, including touch, sight, smell, taste, and hearing.
In chronic pain management, there are different types of pain clinics. Among others, there are two that seem almost diametrically opposed in their treatment of patients – even for patients with the same chronic pain conditions. One type of pain clinic is the chronic opioid management clinic. These types of clinics start chronic pain patients on opioids or take over the prescribing of the medications from other providers and subsequently maintain patients on chronic opioid management indefinitely. The other type of pain clinic is the interdisciplinary chronic pain rehabilitation program. They admit the same kinds of chronic pain patients and, instead of maintaining them on chronic opioid management, they taper opioids while teaching patients how to successfully self-manage pain.
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