Notice: Undefined offset: 1 in /home/inst1tut3/public_html/plugins/system/k2/k2.php on line 702
PRIVACY / DISCLAIMER https://www.instituteforchronicpain.org Mon, 30 Jan 2023 18:58:38 +0000 Joomla! - Open Source Content Management en-gb Arthritis https://www.instituteforchronicpain.org/common-conditions/arthritis https://www.instituteforchronicpain.org/common-conditions/arthritis

What is arthritis?

Arthritis is a common pain condition marked by inflammation of the joints. The inflammation causes pain, swelling, and stiffness. Arthritis can occur at any joint of the body.

There are different types of arthritis. The two most common are osteoarthritis and rheumatoid arthritis.

Osteoarthritis might best be considered the result of general wear and tear. It can occur from traumatic injuries, overuse, and age. It results from a loss of cartilage. Cartilage provides cushioning for the bones in the joints. The loss of cartilage causes inflammation when the joint is used. In turn, the inflammation leads to pain, tenderness, swelling, and stiffness. While it can occur any joint, osteoarthritis most commonly occurs in the hips, knees, ankles and feet.

Rheumatoid arthritis is the result of the immune system mistaking healthy cartilage for being diseased, and consequently it attacks the cartilage of the joints. Over time, the immune system erodes the cartilage. The subsequent loss of cartilage causes inflammation when the joints are used. In turn, the inflammation causes pain, joint stiffness, and swelling. In advanced stages, the joints become deformed. Rheumatoid arthritis most commonly occurs in the hands and fingers.

Central sensitization can occur in both types of arthritis.1, 2 Central sensitization is a highly reactive state of the central nervous system, which amplifies pain. It also can cause sensitivity to touch and mild pressure, fatigue, poor sleep, anxiety, and depression. It can occur with any pain disorder, including arthritis. Central sensitization is a complication of the pain associated with arthritis. It is important to address in treatment. 

Is there a cure for arthritis?

Arthritis is a chronic condition. Typically, chronic health conditions are also conditions that have no cure and last indefinitely.

Therapies & Procedures for arthritis

Common treatments for osteoarthritis are anti-inflammatory medications, physical therapy, cortisone injections, arthroscopic and joint replacement surgeries, and chronic pain rehabilitation programs.

Common treatments for rheumatoid arthritis are anti-inflammatory medications, chemotherapies, physical therapy, and chronic pain rehabilitation programs.

Chronic pain rehabilitation programs focus on reducing the central sensitization associated with any type of chronic pain condition, including arthritis. It is an intensive, interdisciplinary approach that combines lifestyle changes, coping skills training, and medication management. The overall goal of these treatment approaches is to reduce central sensitization by down-regulating the nervous system. The arthritic changes to the joints remain the same. However, by reducing central sensitization, pain is reduced to tolerable levels. Additionally, with less central sensitization, patients also have less fatigue, sleep problems and emotional distress.  As a result, they are more able to cope with the pain that remains. They are also more able to engage in the activities of life. 

References

1. Arendt-Nielsen, L., Nie, H., Laursen M. B., Laursen, B. S., Madeleine P., Simonson O. H., & Graven-Nielsen, T. (2010). Sensitization in patients with painful knee osteoarthritis. Pain, 149, 573-581.

2. Meeus M., Vervisch, S., De Clerck, L. S., Moorkens, G., Hans, G., & Nijs, J. (2012). Central sensitization in patients with rheumatoid arthritis: A systematic literature review. Seminars in Arthritis & Rheumatism, 41, 556-567.

Date of publication: April 27, 2012

Date of last modification: February 19, 2015

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Arthritis Fri, 27 Apr 2012 13:35:24 +0000
Arachnoiditis https://www.instituteforchronicpain.org/common-conditions/arachnoiditis https://www.instituteforchronicpain.org/common-conditions/arachnoiditis

What is arachnoiditis?

Arachnoiditis is a rare neurological condition marked by inflammation of the arachnoid. The arachnoid is a lining that surrounds the central nervous system. The central nervous system consists of the brain and spinal cord. In most cases, patients seeking pain management services for arachnoiditis have the condition along the spinal cord.

Arachnoiditis is one of many causes of chronic back pain. It can also cause other symptoms such as numbness and tingling. In extreme cases, it can cause loss of bowel or bladder functions.

Causes of arachnoiditis are rare complications from spine surgeries and epidural steroid injections. Infection of the arachnoid can also cause arachnoiditis. In the past, certain oil-based contrast dyes used in CT scans also caused arachnoiditis in rare circumstances. However, these dyes are typically no longer used and have been substituted with water-based dyes.

Is there a cure for arachnoiditis?

Generally, arachnoiditis is a chronic condition. As such, the focus of care are typical rehabilitation goals: reduce the symptoms of arachnoiditis as much as possible through lifestyle changes and increase the ability to cope with the condition. The overall goal of rehabilitation is to live well despite having the condition.

Therapies & Procedures for arachnoiditis

Typical treatments for arachnoiditis are chronic pain rehabilitation and medications. Most chronic pain rehabilitation programs include medication management as part of their overall therapies.

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:35:10 +0000
Abdominal Pain https://www.instituteforchronicpain.org/common-conditions/abdominal-pain https://www.instituteforchronicpain.org/common-conditions/abdominal-pain

What is chronic abdominal pain?

Abdominal pain is common and occurs to most people on occasion. It usually occurs for a brief period of time and can have many benign causes, such as indigestion, stress and anxiety. Sometimes, such as when having appendicitis, it is serious and requires the attention of a healthcare provider. Abdominal pain can also become chronic. Healthcare providers consider it chronic when it last longer than six months.

Is there a cure for chronic abdominal pain?

Chronic abdominal pain is often identified as a problem in the gastrointestinal, endocrine, or reproductive systems of the body. However, chronic abdominal pain commonly has no identifiable cause. An example is chronic pancreatitis. Healthcare providers are able to identify that the pancreas is involved, but are often unable to understand why it is happening. Conditions, like chronic pancreatitis, that have no identifiable cause are called idiopathic.

Most patients with idiopathic chronic abdominal pain have had numerous tests and procedures. Common tests are the following:

  • MRI scans
  • CT scans
  • Endoscopies
  • Colonoscopies
  • Blood, urine and fecal tests
  • Endoscopic retrograde cholangiopancreatographies (ERCP’s)
  • Magnetic resonance cholangiopancreatographies (MRCP’s)
  • Ultrasound

These tests are ways to assess the health and functioning of the different bodily systems that lie in the abdomen, such as the gastrointestinal and reproductive systems. It is important to rule-out potential causes of pain in these systems, such as cancers, endometriosis, Crohn’s disease, irritable bowel syndrome, among others. Oftentimes, however, as stated above, the cause of chronic abdominal pain remains unknown.

Therapies & Procedures for chronic abdominal pain

Similarly, patients with idiopathic chronic abdominal pain often have had numerous procedures that fail to cure the condition. When a cause is not readily identifiable, recommendations for therapies and procedures tend to get made on a trial-and-error basis. Patients with chronic abdominal pain commonly have had multiple procedures and surgeries. Examples are the following:

  • Appendectomies
  • Cholecystectomies (i.e., removal of the gall bladder)
  • Oopherectomies (i.e., removal of the ovaries)
  • Hysterectomies
  • Ablations
  • Stent insertions
  • Biliary and pancreatic sphincterectomies
  • Scar tissue removal
  • Exploratory surgeries

Pursuit of these procedures assumes that the primary cause of pain is some problem in the gastrointestinal, endocrine, or reproductive system. Patients and their healthcare providers tend to try one procedure after another in attempt to cure the pain condition. These procedures are often worth trying, particularly in the acute phases of having abdominal pain. However, they are often unsuccessful once pain has become chronic.

It is well-established that central sensitization is a factor in chronic abdominal pain.1, 2, 3 Central sensitization is a highly reactive state of the nervous system, which causes pain. It can occur with any pain disorder, including chronic abdominal pain. It is not known whether central sensitization can be an initial cause of abdominal pain or whether it is a secondary cause, which maintains abdominal pain on a chronic course. Either way, it is important to address in treatment.

Chronic pain rehabilitation programs focus on reducing the central sensitization associated with any type of chronic pain condition, including chronic abdominal pain. They are an intensive, interdisciplinary approach that combines lifestyle changes, coping skills training, and medication management. The overall goal of these treatment approaches is to reduce central sensitization by down-regulating the nervous system. The original problem in the gastrointestinal or reproductive system that initially caused the pain may remain unresolved or unknown. However, by reducing central sensitization, pain is reduced to tolerable levels.

There is hope even if the original cause of pain remains unknown. There is hope even if there is no cure.

References

1. Dengler-Crish, C. M., Bruehl, S., & Walker, L. S. (2011). Increased wind-up to heat pain in women with a childhood history of functional abdominal pain. Pain, 152, 802-808.

2. Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152, S2-S15.

3. Mayer, E. A., & Tillisch, K. (2011). The brain-gut axis in abdominal pain syndromes. Annual Review of Medicine, 62. doi: 10.1146/annurev-med-012309-103958.

Date of publication: April 27, 2012

Date of last modification: October 13, 2018

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:34:36 +0000
Common Conditions https://www.instituteforchronicpain.org/privacy-policy/item/19-common-conditions https://www.instituteforchronicpain.org/privacy-policy/item/19-common-conditions

Common Conditions

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:34:17 +0000
Why Healthcare Providers Deliver Ineffective Care https://www.instituteforchronicpain.org/providers-and-payers/ineffective-treatment https://www.instituteforchronicpain.org/providers-and-payers/ineffective-treatment

People outside the healthcare industry, such as the typical consumers of healthcare, are often surprised to find out that some of the most common healthcare procedures and therapies are largely ineffective on average. It can sometimes even border on disbelief. When seeking healthcare, most people assume that the treatments healthcare providers recommend are effective. This assumption forms a basic trust in our healthcare providers – that they know what they are doing and that they wouldn’t recommend something that they know is ineffective. So, it seems hard to believe that a provider might ever recommend treatments that have been shown to be ineffective on average.

In the popular press, the oft-cited example in this regard is antibiotics for simple earache.1 Most people assume that antibiotics are effective for the treatment of earache. Anyone with children has brought them to a clinic for an earache and has come out with a prescription for an antibiotic. It’s what we do in our society. However, on average, antibiotics are not very effective for earache. They often seem like it, but it’s only because earaches naturally tend to clear up on the third or fourth day, which is typically just a day or two after starting the medication. The sequence of events makes it seem that there is a cause and effect going on, though in all but a small minority of cases there actually isn’t.

The field of chronic pain management has an abundance of examples of commonly delivered procedures and therapies that are known to be fairly ineffective. The most notable of them are spine surgeries, spinal injections, and long-term narcotic pain medication use. Numerous clinical trials, naturalistic studies, healthcare utilization studies, and epidemiological data all point to the fact that the widespread use of these procedures and therapies are largely ineffective on average for people with back or neck pain.2, 3, 4, 5, 6, 7, 8, 9, 10 Some can even reduce the chances of actually going back to work or can increase utilization of healthcare services.11, 12, 13, 14 Despite this lack of empirical support, spine surgeries, spinal injections and the long-term use of narcotic pain medications are among the most commonly delivered treatments for chronic back or neck pain. Indeed, over the last few decades, their use has grown exponentially.15 

The delivery of ineffective care occurs in many areas of healthcare. In fact, the list of common procedures and therapies that are ineffective is rather lengthy. From antibiotics for acute bronchitis to PSA screening for prostrate cancer to the use of vitamin D supplementation to prevent bone fractures, people in our society routinely undergo care that is known to be ineffective.

So, how did it get this way?

Causes of delivering ineffective healthcare

The delivery of ineffective care can occur in many ways. To be clear, though, it’s not because healthcare providers are intentionally swindling unsuspecting, vulnerable patients like the snake oil salesman of yesteryear. By and large, healthcare providers are typically trustworthy. Nonetheless, a lot of care gets delivered that is not, on average, very effective. It can happen in various ways.

Problems with disseminating research findings

The traditional specializations of healthcare disciplines can sometimes interfere with the dissemination of research data that show what’s most effective. Healthcare providers tend to remain within their traditional discipline when interacting with other providers. For instance, within the field of chronic pain management, surgeons tend to go to surgical conferences; interventional pain physicians tend to go to interventional pain conferences; rehabilitation providers, like pain psychologists, tend to go to rehabilitation conferences. In this way, by and large, we don’t tend to cross over to other disciplines. We also don’t tend to read each other’s professional journals. Moreover, all healthcare providers, like any other field, tend to do what we were taught and, of course, we were taught by providers from within our own field. Still further, providers tend to seek out continuing education within their respective disciplines. This state of affairs can remain largely harmless until one field comes to have a procedure or therapy that is shown to be effective for a particular condition or more effective than therapies from the other disciplines. These other disciplines can tend to remain ignorant of the innovation or ignorant of the scientific research that supports it. Their practice patterns, in other words, continue as before, providing procedures and therapies that are less effective relative to those that have been found to be more effective.

Even within a traditional specialization, dissemination of empirically-supported treatments remains agonizingly slow. The Institute of Medicine16 estimated that it takes between fifteen and twenty years before an effective treatment (as demonstrated by research) is in common use. This fact points to an unfortunate gap in our healthcare system between researchers and practitioners. Researchers tend to reside in academic or corporate settings and practitioners tend to reside in clinics and hospitals. There is little opportunity for interaction between the two settings. Moreover, practitioners have numerous competing demands on their time besides the task of keeping up with the latest scientific research findings. Indeed, healthcare providers do not have specific time set aside in their clinic schedules for the purpose of keeping abreast of the latest research. Instead, on their own time, they rely on reading professional journals and attending conferences – the two main traditional vehicles for disseminating scientific research findings to practitioners. Given the Institute of Medicine’s findings, these vehicles are obviously inefficient.

Sometimes, of course, dissemination of research findings occur much faster. It happens when corporations innovate and they subsequently disseminate their findings with well-funded marketing strategies. Such strategies tend to be direct-to-provider marketing, with sales representatives persuading practitioners to recommend or prescribe their product, or direct-to-consumer marketing with television and magazine advertisements, persuading patients to ask for their products.

When, however, innovation occurs outside the corporate world, dissemination of the more effective treatment occurs much more slowly because they have no well-funded marketing strategy. As a result, they must rely on the much more slow and more traditional dissemination vehicles, professional journals and conferences. Take, for example, rehabilitation strategies for chronic disease management. Examples are interdisciplinary cardiac rehabilitation, diabetes education, and chronic pain rehabilitation. Such care focuses on teaching patients to make healthy lifestyle changes, which beneficially affects their disease and their ability to cope with their disease. Research consistently shows that these therapies are some of the most effective treatments available for chronic disease. And yet you might not ever see a television commercial extolling their benefits. You also wouldn’t see sales representatives in, say, your cardiologist’s office talking to the providers about why they should more often recommend interdisciplinary cardiac rehabilitation to patients. As a result, demand for such effective therapies remains low and what tends to get recommended are the less effective single modality treatments – medications alone without the health behavior change coaching – in part because it’s the medications that have the marketing strategies.

No vehicle to educate the public on research findings

Consumer demand is another avenue that leads to the delivery of ineffective care. Just like healthcare providers, society in general takes time to catch up to what research shows is most effective. As we've seen, there are widespread societal beliefs about the effectiveness of various procedures and therapies (such as the use of antibiotics for earache or spine surgery for back pain), even when those procedures and therapies are not effective. It's understandable that these beliefs continue. Who is responsible for correcting them? What would be needed is something on the order of a mass marketing campaign, something akin to what was used to change our previous societal beliefs about tobacco use. The campaign to educate the public that smoking is bad for one's health took time and a significant amount of capital. There is no designated entity that is responsible for securing such capital or carrying out such edu-marketing campaigns.

Even when healthcare providers are knowledgeable about the research, they might not have enough time to explain why societal expectations are wrong. The typical allotted time of about fifteen minutes per patient is simply not enough to explain why antibiotics for an earache or narcotic pain medication for back ache is not in the best interests of a patient. Such discussions run the risk of not going over well and dissatisfied patients can subsequently take even more time. Many in the field quietly acknowledge that sometimes it’s just easier to do what’s expected of them.

This scenario between provider and patient can play itself out not only when research comes to identify a new treatment as effective, but, more importantly, also when research shows that a traditional treatment is in fact ineffective. It may be surprising to learn that many treatments in healthcare enter into the armamentarium of therapies before systematic research determines them to be effective. It happens in many ways, such as when a medication comes to be used on an ‘off label’ basis – for a condition that it was not initially intended to treat. For instance, a provider might find that a medication inadvertently helps a different condition than the one for which the medication was originally prescribed and so the provider begins to use it for this additional condition with other patients. Other providers catch on and also begin using it for the other condition. In this manner, an 'off label' use of a medication can become common. Surgical procedures too are often introduced before there is systematic research showing their effectiveness. Procedures are developed because conceptually it makes sense that they should work. In any of these cases, some patients of course benefit. Most any treatment will yield benefit to some people. In actual clinical practice, these successes can influence the decision-making of providers and reinforce the continued 'off label' use of the medication or procedure. At some point, researchers take up the treatment, garner funding, and perform a large scale, difficult to undertake, clinical trial of the medication or procedure and come to find that it’s no better than placebo – that, yes indeed, some people benefit, but the treatment provides no additional benefit over and above the placebo benefit. This process of research can take many years. By this time, the treatment or procedure may have become a traditional treatment that both providers and patients expect should work. As such, the medication or procedure may continue to be used despite its proven lack of effectiveness.

Once demonstrated, the research findings face the further hurdle of getting disseminated on a widespread basis. Since negative findings (i.e., the demonstration that a treatment is ineffective) never have a marketing team behind them, their dissemination must rely on the slower, traditional vehicles of professional journal publications and conference lectures. As we’ve seen, the time it takes to disseminate such findings is lengthy, more than a decade. Meanwhile, ineffective treatments continue in common practice until the findings are disseminated and accepted on a wide-scale basis.

Perhaps, it is in these ways that we currently continue to provide antibiotics for simple earache and spinal surgeries for back and neck pain. If so, we might consider their use as occurring within this in-between period: the studies have been published but widespread practice has not yet assimilated them and consequently practice patterns have not yet changed.

Profit-motive

The profit-motive may also play a role in the persistent delivery of healthcare that is ineffective. We have a capitalistic system that incentivizes the delivery of procedures and therapies. The more care a provider or provider organization delivers, the more money they make. There is very little incentive to not treat someone or send them to another provider who might deliver a more effective therapy. Rather then sending a sick or hurting patient away empty handed, healthcare providers tend to provide something along with the referral to the more effective care. However, the treatment that patients leave with is often not very effective.

Incentivizing the delivery of care also tends to lower the bar for when care should be delivered. In a capitalistic system, it is easy to justify a treatment recommendation on the basis that the treatment might work. That is to say, any procedure or therapy might help someone, even if, on average, the therapy does not help most people. So, it is not untrue or misleading to think that any given treatment might work for a particular patient. Now, if providers are at the same time incentivized to provide care, then the justification that ‘it might work’ can become good enough to give the procedure or therapy a try. That is to say, in our current capitalistic system, there’s no incentive to only provide care that has a higher level of justification, such as only providing treatment that is likely to work. As such, healthcare providers can maintain a good conscience when providing care that, on average, is not very effective. The justification is that it might help and it’s not untrue or misleading. The rub is that many procedures and therapies, as we have seen, are just not likely to help.

While we have already discussed its role in the dissemination of research, marketing can also influence the delivery of care towards providing ineffective therapies in yet another way. For example, new FDA-approved medications often come with great fanfare – television commercials, glossy magazine ads, witty internet videos, and sales representatives who sell healthcare providers on the idea of prescribing the medication. Sometimes, these medications are not as effective as older medications. It’s important to know, in this regard, that FDA approval for widespread use of a medication only means that the medication is better than a placebo and that it has passed tests of safety. FDA approval does not mean that the medication is better than medications that are already on the market for the same condition.17 As such, when a new medication has a lot of marketing behind it, it tends to get prescribed more than older medications for the same condition, even if the older medications are more effective. As a result, less effective care gets delivered.

Society's tendency to externalize responsibility for health

Lastly, society overall tends to view healthcare as something we rely on to make us better. In doing so, we subtly externalize responsibility for our own health. This shift in responsibility is all well and good if the healthcare system actually has a cure for what ails us. It seems, for instance, eminently advisable to give up responsibility for my well-being to an acute care surgeon when I have appendicitis. By doing so, I get better by relying on the surgical procedure and the surgeon who provides it. This shift in responsibility is more problematic though in cases of chronic disease – chronic pain, heart disease, diabetes, obesity and the like. The acute medical model of care has no cure for these conditions. Nevertheless, having externalized responsibility, we tend as a society to continue to rely on procedures, therapies and medications, as if such acute care is the most effective. The rub is that they aren’t the most effective.

As indicated above, what is most effective for chronic health conditions are rehabilitation therapies. Such care focuses on teaching and motivating patients to take back responsibility for their health and engage in lifestyle changes that make them healthier. However, health behavior change – the most effective therapy for chronic health conditions – is notoriously difficult to engage patients in doing and is often the last thing that healthcare providers recommend or the last thing that patients are willing to do – after they have trialed and failed the less effective acute care procedures and therapies.

Conclusions

No doubt there are many reasons why we continue to deliver ineffective healthcare. The list above is not exhaustive. Nonetheless, it can serve as a starting point for a discussion. To be sure, it is an uncomfortable discussion. No one, whether provider or patient, likes to acknowledge when the things we do aren’t working. It’s like airing our dirty laundry.

Despite our discomfort, it’s an important discussion to have. It’s important morally and pragmatically. As healthcare professionals, we should not remain complacent with the status quo. We have an obligation to help people and that obligation requires providing the most effective care on a more routine basis. We should not remain in ignorance of the effectiveness of our care. We need to develop better and more efficient ways to know what is effective. Would any other industry take fifteen to twenty years between the time of innovation and its widespread implementation? While reducing the delivery of ineffective care is the right thing to do, it is also something that will reduce costs for all of us. Whether we get ineffective care or not, we all collectively pay for it through our annual health insurance premiums. It’s time for developing a means to educate, not only providers, but also the public as to what care is effective and what is not. At this time, we have no such vehicle for disseminating this information.

References

1. Newman, D. H. (2008). Hippocrates shadow: Secrets from the house of medicine. New York: Scribner.

2. 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

3. Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

4. 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

5. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin. D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146,116-127.

6. 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

7. van Middelkoop, M., Rubinstein, S. M., Ostelo, R., van Tulder, M. W., Peul, W., Koes, B. W., & Verhagen, A. P. (2012). Surgery versus conservative care for neck pain: A systematic review. European Spine Journal, 22(1), 87-95. doi: 10.1007/s00586-012-2553-z

8. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment modalities in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

9. Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296, 2441-2450.

10. Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

11. Braden, J. B., Russo, J., Fan, M. Y., Edlund, M. J., Martin, B. C., DeVries, A., & Sullivan, M. D. (2010). Emergency department visits among recipients of chronic opioid therapy. Archives of Internal Medicine, 170, 16, 1425-1432.

12. Eriksen, J., Sjorgen, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain, 125, 172-179.

13. Turunen, J., Mantyselka, P., Kumpusalo, E., & Ahonen, R. (2005). Frequent analgesic use at population level: Prevalence and patterns of use. Pain, 115, 374-381.

14. Wisniewski, A. M., Purdy, C. H., & Blondell, R. D. (2008). The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits. Journal of Addictive Disorders, 27(1), 1-11.

15. 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

16. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press.

17. Brownlee, S. (2007). Overtreated: Why too much medicine is making us sicker and poorer. New York: Bloomsbury.

Date of publication: September 20, 2015

Date of last modification: November 21, 2020

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Providers and Payers Fri, 27 Apr 2012 13:17:33 +0000
Coping with Pain https://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/coping-with-pain https://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/coping-with-pain Coping with Pain

When it comes to the management of chronic pain, good coping is quite possibly the most powerful intervention we have to be able to reduce pain and improve function. It’s typically what accounts for the ability to manage pain without opioid medications or remain at work full-time despite having pain. In short, it can make tolerable what was once intolerable pain.

Oftentimes, however, people won’t believe it.

Disbelief

While such disbelief may be due to a number of reasons, stigma is chief among them. In our healthcare system, stigma makes us emphasize the limits of an individual patient’s abilities to cope. In so doing, we tend to imply that, in general, coping well with pain really isn’t possible. Let’s explain.

No one wants to be judged as not coping well and so often patients with chronic pain tend to deny that they are coping poorly. Instead, Copingthey assert, for instance, that they cope exceptionally well under the circumstances, even when by most measures they may not be. By doing so, they emphasize the limits of coping: they assert having a high pain tolerance even though, say, they remain on daily use of opioids and are disabled from pain; so, they imply that there really is no point in discussing coping any further. The implication is that learning to cope better is not such a powerful intervention since they remain in rough shape despite coping exceptionally well. Notice what happens here. The individual’s experience of coping gets generalized to coping in general – to what’s possible with coping.

This way of perceiving oneself really comes out of stigma and the understandable response to it of not wanting to be judged for coping poorly. But is this understandable response to stigma really true of coping in general – that coping only gets you so far when it comes to managing pain?

Healthcare providers too tend to emphasize an individual’s limits to coping and generalize it to what’s possible with coping. When patients aren’t doing well and so present for care, healthcare providers of course don’t want to make them feel worse, but better. So, providers tend to avoid recommendations to learn how to cope better, because such recommendations are hard to hear for many patients. In other words, recommendations to learn to cope better imply a judgment that patients aren’t coping very well at the present time. Patients can feel stigmatized in response to such recommendations to learn to cope better. So, healthcare providers tend to instead respond with reassuring statements, such as ‘You’ve suffered long enough, let’s try this procedure…’ or ‘You should’ve come in sooner.’ These kinds of reassurance, while resolving the problem of stigma, emphasize individuals’ limits of their coping in language that implies coping only gets you so far. It’s as if to say, ‘Don’t try to continue doing this on your own… You’re at a point at which you now really have to rely on medical care.’

In these circumstances, healthcare providers aren’t being disingenuous. It’s safe to assume that for the most part they really believe that typical cases of chronic pain are impossible to cope with successfully and so patients must instead rely on interventional and surgical procedures or certain medications, such as opioids.

So, when chronic pain rehabilitation providers come along and make a statement about the power of coping, that it’s apt to be the most powerful intervention that we have, it’s not commonly believed, at least, until we review the following explanations.

Reminders of what we already know

Wittgenstein,1 arguably the most influential philosopher of the twentieth century, liked to point out our tendency for getting caught up in a line of reasoning that subsequently leads to denying something we actually know is true. Philosophy, it turns out, is full of such lines of thought (e.g., the so-called problem of ‘other minds’). In such situations, he’d admonish us to remind ourselves of what we really already know.2 

Now, philosophy is not the only area in life in which we can get caught up in a line of reasoning that actually leads to a confusion. An example in healthcare might be the afore-mentioned conclusion that the levels of coping, which patients exhibit, are the actual limit of what’s possible for coping with pain – that we can’t get much beyond a certain level of coping because chronic pain is simply intolerable.

Let’s step back a bit, then, and remind ourselves of what we already know. We know that chronic pain is common. Epidemiological studies put the prevalence of chronic pain between 20-30% of the general population. But, then again, we don’t need studies to tell us. Almost everyone either has chronic pain themselves or knows someone who does. We might also notice that only some of these people are taking opioids for their pain or are disabled. Still others self-manage their pain without opioids and remain at work. In other words, they cope well.

Now, the differences don’t lie in the severity of the injury associated with the pain or even in the severity of pain itself. The majority of people with pain who rate their pain as moderate to severe do not manage their pain with opioids.3, 4, 5 The same is true for those who remain at work.6, 7, 8, 9 So, even people with moderate to severe chronic pain can cope well with it.

Now notice that we run right into the problem of stigma when we talk like this. By noticing these differences, are we saying that one group of people are better than the other group? By simply observing a difference between people, it seems as if we are critically judging one group against the other, or stigmatizing one group but not the other.

The point, here, though, is not to judge, but just show what’s possible.

Let’s remind ourselves of a few more things that we already know. To be sure, sometimes some people do make note of these differences and do it in a way that is highly judgmental or stigmatizing. But, the acknowledgment of these differences doesn’t have to be done in a judgmental way.

There are times and places in which everyone of us can acknowledge the fact that some people cope better than others in all facets of life and we never mean it in a judgmental or critical way.

Suppose there are two different people who each have a flat tire on a stretch of interstate highway in which there’s hardly any room on the shoulder and there are a lot of semi-trucks driving by at 75 miles per hour. This kind of experience isn’t pleasant for anyone, including the two people in our example. Now, suppose one of these individuals is a relatively new driver who has never had a flat tire and who has never changed a tire before. When the tire blew, it gave him quite a start. His heart started pounding, his hands got clammy, and he didn’t quite know what to do after pulling over. We might imagine him fumbling around for the spare and the tools, but lacking self-confidence to proceed, he starts to try to change the tire, but then stops, only to start again, becoming doubtful of his abilities and then stopping again. Meanwhile, the semi-trucks keep racing by and the whole experience leaves him rattled. He decides to simply call for a tow truck. The other person, who is also a new driver, grew up with a parent who tinkered with cars and so she was taught from a fairly young age how to make simple repairs herself. In this process, she was shown how to change a tire and had actually rotated the tires of her parent’s car a number of times. When the tire blew, she was a little surprised, but not startled. She pulled over and, rather than having a fear-based reaction of becoming rattled, she had the response of it being an inconvenience for her. She got out and, while the semi-trucks raced by her, she proceeded to change the tire. Once done, she kept on driving.

Notice the differences in how each coped with the same adversity. Now notice that we don’t typically judge one person as better than the other in such situations. Of course, the first person didn’t cope as well, but we don’t think of him as a worse person. In fact, we might even have empathy for him, as every one of us has had some experience in which we met our match and didn’t cope very well.

Notice too that the differences in coping between each respective person lie in what one has learned or not. That is to say, coping is the product of a learning process. The first individual in our example had never learned to change a tire and had never had the opportunity to practice it. As such, he didn’t know what to do, was frightened and overwhelmed, and needed to rely on others. In other words, he found the problem of having a flat tire intolerable. The other individual had been taught what to do and had had the opportunity to practice it many times before. She found the experience tolerable and was able to move on from it all by herself.

The lesson here is that, if we taught the first person in this example how to change a tire and provided him with opportunities to practice with a little coaching along the way, he too would find that such experiences are tolerable and would be able to manage it by himself and subsequently move on from it.

That is to say, the same problem would go from intolerable to tolerable. The problem would remain the same. The only difference that accounts for the problem becoming tolerable and manageable independently is that one learns how to cope with it.

Herein lies the power of coping. It’s what makes the intolerable into something that is tolerable. It’s what makes the unmanageable into the manageable. It’s what allows people to go from being stuck in life to being able to move on with the rest of their life.

Now, we don’t have to make up fictional examples to demonstrate how a process of learning can lead to making problems in life go from intolerable to tolerable. Think of the training that soldiers go through when they first join the armed services. It’s often called ‘boot camp’. Its rigorous and demanding, but it’s essentially a course in which people learn how to tolerate the adversities of war and learn that they can do it. In other words, they learn how to cope with problems that they once would have found intolerable and gain the confidence that they really can do it.

What if there was a boot camp for chronic pain? Well, there is.

Chronic pain rehabilitation programs

Every day people around the world go through a process of learning how to tolerate adversities that they had previously found intolerable. The process of learning involves multiple experts from different disciplines teaching them and providing them with opportunities to practice, giving them supportive coaching along the way. In the process, they get so good at dealing with these adversities that they become able to  manage them so well that they can move on with the rest of their life.

The people are patients in chronic pain rehabilitation programs and their adversities are moderate to severe chronic pain along with the numerous common problems associated with such pain – reliance on opioids, disability, insomnia, depression, anxiety, strained relationships, loneliness, lack of meaningful activities for their daily lives, and so on.

With a willingness to learn, an openness to feedback, motivation and perseverance, they proceed through the program and they learn how to cope with pain so well that their once intolerable pain becomes now tolerable and manageable. As a result, they can begin to move on with the rest of their life and subsequently they no longer have the associated problems that had once come along with their pain.

They no longer have to rely on opioid pain medications. They go back to work. They are no longer depressed or anxious because of pain. They go to family functions and they fulfill their family obligations. Their relationships are no longer strained. In other words, they are engaged in life.

They still have pain, though. To be sure, it is typically less.10, 11 However, it’s not the reduction in pain levels that accounts for the differences described above. It’s the changes in their levels of coping that accounts for the difference. They have learned to cope with pain well -- really well. 

They’ve gone through a course of learning that makes what was once intolerable pain become tolerable. Chronic pain rehabilitation programs are a bridge that leads back into life.

It’s in this way that learning to cope with pain and getting really good at it is one of the most powerful interventions that we have for the management of chronic pain.

References

1. Wittgenstein, L. (1953). Philosophical Investigations. New York: MacMillan.

2. Despite the apparent logic of the argument, how can we conclude, for example, in the problem of ‘other minds’, that we cannot know another’s subjective experience or ‘mind’, when we get up in the morning with our spouse and have breakfast together everyday, talking about our respective plans for the day?

3. Breivek, H., Collett, B., Ventafridda, V., Cohen R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.

4. Fredheim, A. M., Mahic, M., Skurtveit, S., Dale, O., Romundstadt, P., & Borchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian Prescription Database and the Nord-Trondelag Health Study. Pain, 155, 1213-1221.

5. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

6. Cassidy, J. D., Carroll, L., & Cote, P. (1998). The Saskatchewan health and back pain survey: The prevalence of low back pain and related disability in Saskatchewan adults. Spine, 23, 1860-1866.

7. Cote, P., Cassidy, J. D., & Carroll, L. (1998). The Saskatchewan health and back pain survey: The prevalence of neck pain and related disability in Saskatchewan adults. Spine, 23, 1689-1698.

8. Linton, S. J., & Buer, N. (1995). Working despite pain: Factors associated with work attendance versus dysfunction. International Journal of Behavior Medicine, 2, 252-262.

9. Von Korff, M., Dworkin, S. F., & La Resche, L. (1990). Graded chronic pain status: An epidemiologic evaluation. Pain, 40, 279-291.

10. 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.

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

Date of publication: October 23, 2015

Date of last modification: March 25, 2021

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Fri, 27 Apr 2012 13:17:09 +0000
On the Meaning of "Chronic" https://www.instituteforchronicpain.org/understanding-chronic-pain/healthcare-system-failings/the-meaning-of-chronic https://www.instituteforchronicpain.org/understanding-chronic-pain/healthcare-system-failings/the-meaning-of-chronic

The meaning of "chronic" and why the healthcare system refuses to accept the chronicity of chronic pain

We live in an age of chronic illness. Conditions like heart disease, diabetes, asthma and chronic pain are common. All these health conditions are chronic. The term chronic means that a condition has no cure and so will last indefinitely.

The healthcare system is typically quite open about how chronic health conditions are in fact chronic. When first diagnosing heart disease or diabetes, for example, most healthcare providers take care to discuss with their patients that there are no cures for these conditions.

Also, by and large, healthcare providers tend to review with their heart disease or diabetic patients that the most effective things that they can do are not so much medical treatments, but rather things that the patients themselves can do. That is to say, some of the most effective things that patients can do are healthy lifestyle changes. In the case of heart disease, these healthy lifestyle changes are quitting smoking, beginning an exercise routine, eating healthier, weight loss, and stress management. In the case of diabetes, the healthy lifestyle changes are eating healthier, weight loss, beginning an exercise routine, and stress management. This emphasis of care on what the patient can do in terms of coping and healthy lifestyle changes is what’s called self-management. So, the healthcare system tends to be open with patients that chronic health conditions are truly chronic and that there is no pharmacological or procedural cure. They are also quite open with the fact that self-management is one of the most effective ways to manage chronic health condition well.

The one exception in our healthcare system is chronic pain. When patients come to their primary care providers with chronic low back pain, for instance, it’s common for patients to get an order for an MRI and a referral to a clinic that performs interventional or surgical procedures. Once evaluated at these specialty clinics, patients are commonly told that the interventional or surgical recommendations might rid the patient of pain. As such, many chronic pain management specialists tend to refrain from accepting that chronic pain is truly chronic. Moreover, many chronic pain management specialists do not tend to educate their patients that, like other chronic health conditions, self-management is one of the most effective ways to manage chronic pain.

Patients, too, often believe that there must be a cure for their chronic pain and they tend to assume that the cure will come as a result of some type of interventional or surgical procedure.

As a result, it is common for chronic pain patients – and the providers who care for them -- to proceed on a long series of increasingly invasive procedures, which persistently fail to cure their chronic pain.

This state of affairs within the chronic pain management field flies in the face of what science tells us about the nature of chronic pain. Science tells us that chronic pain really is chronic in the sense that there is no pharmacological or procedural cure. Research on the outcomes of interventional and surgical procedures for chronic pain consistently shows that they are largely ineffective or only minimally effective.1, 2, 3, 4, 5, 6 

So, why do specialists in chronic pain management fail to accept that chronic pain is really chronic?

Before answering this question, it should be noted that not all specialists in chronic pain management do so. A traditional type of chronic pain management is chronic pain rehabilitation. The focus of chronic pain rehabilitation is accepting the chronicity of pain and helping patients to learn how to self-manage it. Specialists in chronic pain rehabilitation teach patients how to cope with chronic pain and make it easier to live with. They also show patients how to make healthy lifestyle changes that reduce the level of pain. Chronic pain rehabilitation is typically performed in an interdisciplinary program that lasts for three to four weeks.

While they are not a cure, chronic pain rehabilitation programs are consistently shown in research to be the most effective therapy for chronic pain, particularly when compared to the effectiveness of narcotic pain medications, interventional or surgical procedures.7, 8 

Despite being the most effective therapy for chronic pain, chronic pain rehabilitation programs are typically the last therapy that patients receive. It is common for patients to be referred to such programs only after they have received a series of unsuccessful interventional or surgical procedures.

So, the question again arises, why does the healthcare system fail to accept that chronic pain is really chronic? Why does it tend to promote interventional and surgical procedures as possible cures when they really aren’t? Moreover, why does the healthcare system fail to help patients to accept the chronicity of their pain and subsequently learn the healthy lifestyle changes that most effectively makes coping with chronic pain easier?

The answer is complex. There are likely different reasons for why the healthcare system fails to recognize that there is no cure for chronic pain. Different investigators have reviewed a number of possible reasons: difficulties in disseminating research findings, problems with tradition-based medical education,9 and the profit motive.10, 11 

It may also be that chronic pain is so emotionally distressing to experience. Having heart disease or diabetes is just not as emotionally distressing as having chronic pain. Among chronic health conditions, this level of emotional distress is possibly unique to chronic pain. As such, the chronicity of chronic pain may simply be harder to accept than it is with other chronic health conditions.

There is, however, hope – even in the absence of a cure. Chronic pain rehabilitation programs allow patients to learn how to successfully self-manage pain, return to work, and reduce their reliance on the healthcare system -- including eliminating the use of opioid medications for pain. It’s possible to live well despite having chronic pain. Patients just have to learn how and they learn how in chronic pain rehabilitation programs.

The healthcare system has to do a better job at understanding the truly chronic nature of chronic pain. It also has to do a better job at promoting self-management and its healthy lifestyle changes that make living with chronic pain easier. Chronic pain rehabilitation should really be the first treatment option that gets recommended for chronic pain – not the last.

References

1. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012.

2. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

3. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

4. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.

5. Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195.

6. Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

7. 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.

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

9. Haynes, B., & Haines, A. (1998). Barriers and bridges to evidence-based clinical practice. British Medical Journal, 317, 273-276.

10. Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

11. Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Date of publication: March 25, 2013

Date of last modification: May 28, 2017

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Healthcare System Failings Fri, 27 Apr 2012 13:16:46 +0000
Healthcare System Failings https://www.instituteforchronicpain.org/understanding-chronic-pain/healthcare-system-failings https://www.instituteforchronicpain.org/understanding-chronic-pain/healthcare-system-failings

It’s common to complain about healthcare and our healthcare system. We complain about our health insurance and we also complain about reforms to the health insurance industry. We complain about the long wait times to see a provider. We also complain about the short amount of time that we actually get once we see a provider. We complain about how much money we pay for healthcare. We also complain about how much money certain providers and insurance executives get paid. With our healthcare system so large and complex, most anyone can find something to complain about.

A complaint may be quite justifiable, but it remains only a way to vent frustration if not followed by an action plan to resolve the problem that led to the complaint in the first place. We frequently join together in parties of two or three or more and complain about any number of things. Seldom, though, do we join together around an action plan.

At the Institute for Chronic Pain, we aim to bring together scholars, clinicians, third party payers, patients, and the rest of the lay public around a common complaint. The complaint is the problem of chronic pain and how poorly it is treated. It involves a number of issues:

  • A long-standing and still commonly held view, even among some providers, that chronic pain is the result of a long-lasting acute injury, usually conceived as an orthopedic condition
  • A lack of understanding of the role of central sensitization in chronic pain
  • Healthcare provider recommendations that commonly do not follow established clinical guidelines
  • A resulting odd state of affairs within the healthcare system that the typical chronic pain patient obtains the least effective treatments first and obtains the most effective care last
  • Third-party reimbursement policies that make the least effective treatments the most profitable to provide and the most effective treatments the least profitable to provide (which may in part lead to the odd state of affairs that patients typically obtain the least effective treatments first)

For these reasons, chronic pain remains a poorly treated condition. A number of studies show that the use of spinal surgeries, interventional procedures, and opioid medications have steadily increased over the last decade to an all-time high. Despite patients obtaining these unprecedented numbers of procedures and medications, applications for chronic pain related disability have steadily increased in a corresponding manner over the same decade.1 Obviously, these treatments are not working. Chronic pain remains a poorly treated condition.

The mission of the Institute for Chronic Pain both identifies the complaint and an action plan for resolving it. We aim to resolve the problem of poor treatment of chronic pain by grounding chronic pain management on the principles of empirical based healthcare. We aim to see a day when the field of chronic pain management routinely provides what science tells us is the most effective care. The method we use to obtain this goal is to educate the stakeholders in the field. The stakeholders in the field of chronic pain management are healthcare providers, patients, third-party payers, policy analysts, and the public who eventually pay, in part, for all of our healthcare services. By educating these stakeholders, we eventually lead to a greater demand for more effective chronic pain management.

In terms of supply-and-demand, other organizations aim to change the healthcare system by focusing on the supply side of the system. They focus on changing provider practice patterns, or the policies of third party payers, or government funding patterns. The Institute for Chronic Pain aims to change the demand side of the supply-and-demand equation. We aim to provide high quality health information to inform all stakeholders. We envision a day when everyone knows that chronic pain is a nervous system problem, not necessarily an orthopedic problem, and demand treatments that are appropriate for the nervous system problem that they have. When they do so, they will pursue and obtain the most effective treatments that we have for chronic pain.

At this time, the most effective treatment for chronic pain syndromes is chronic pain rehabilitation.2, 3 All the components of a chronic pain rehabilitation program focus on down-regulating the chronic reactivity of the nervous system that is maintaining pain on a chronic course. However, this treatment is typically the last treatment that chronic pain patients obtain. In part, this fact is due to the continuing widespread belief that chronic pain is the result of a long-lasting acute injury, usually conceived as an orthopedic injury. This conceptualization leads providers and patients to pursue spinal surgeries, interventional procedures, and opioid management, all of which are largely ineffective in reducing pain or increasing functioning.

By focusing on educating all stakeholders in chronic pain management, we change how the public conceives of chronic pain and how they want to treat it. Third-party payers will then follow suit. They will subsequently make it easier for patients to obtain effective treatments and limit reimbursement for ineffective treatments. Once third-party payers change their reimbursement patterns, healthcare providers will recommend ineffective treatments less often. In terms of supply-and-demand, we change the demand side, which then changes the supply side.

In so doing, we also ground the field of chronic pain management on the principles of empirical based healthcare. The field will begin to routinely recommend and provide treatments that science tells us are most effective. With the routine use of more effective treatment, chronic pain will no longer be such a poorly treated condition.

References

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

2. 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.

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

Date of publication: March 25, 2013

Date of last modification: March 25, 2013

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Healthcare System Failings Fri, 27 Apr 2012 13:16:30 +0000
Opioid Dependance and Addiction https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/opioid-dependence-and-addiction https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/opioid-dependence-and-addiction Opioid Addiction

Opioid, or narcotic, pain medications are beneficial in a number of ways. Terminal cancer patients, for instance, benefit from their use. The short-term use of opioid pain medications is beneficial, especially while recovering from an acute injury or a surgery. However, the long-term use of opioid medications for chronic, noncancer, pain remains controversial. While a number of issues contribute to this controversy, the main reason for the controversy is addiction. Opioid pain medications are addictive.

This controversy makes opioid pain medications a highly sensitive issue for patients who take them.

In the 1990’s and early 2000’s, it was common for some healthcare providers to believe that addiction to opioid pain medications didn’t necessarily occur, especially if patients appropriately used their medications to manage pain. The belief was that as long as patients used the medications for pain (as opposed to some other reason, such as to get high) they simply wouldn’t get addicted. It was as if to say that as long as a patient has pain and as long as the intention is to take the medications for pain, then these two factors would disqualify someone from getting addicted. Patients too tended to embrace this sentiment. It was, of course, hugely reassuring. Patients could take the medications and healthcare providers could prescribe them without any alarming concerns.

It’s now well-known that people can have chronic pain and get addicted to opioid pain medications at the same time. It is not an either-or issue. It’s also known that addiction can occur in unintended ways. Intentions don’t really matter. No one ever intends on becoming addicted to anything, opioid pain medications included. Addiction to opioid pain medications can happen, even if patients set out to take them only for pain. So, patients should be concerned about it.

The following attempts to set aside the sensitivity of the issue of addiction and simply explain key concepts of addiction when it comes to the use of opioid pain medications, especially in the context of their long-term use for a chronic pain condition. The key concepts are physiological dependence, psychological dependence, and addiction.

Physiological dependence

When taking opioid medications on a daily basis over a long period of time, patients become physiologically dependent. The body becomes adjusted to having the medication in its system. As a result, two things happen. First, patients become tolerant to the medication. Tolerance is when the body becomes adjusted to the use of opioid medications and as a result the medications lose their effectiveness over time. Second, patients experience withdrawal symptoms if the medication is abruptly stopped. All patients develop physiological dependence when taking opioid medications over time.

Patients frequently mistake physiological dependence for addiction. It’s understandable. With any other drug, people consider physiological dependence as part and parcel of addiction. Take, for example, an individual who experiences tolerance and withdrawal from the use of alcohol. Most would consider the individual an alcoholic. It’s understandable, then, that most would consider the chronic pain patient an addict when they develop tolerance to their medication and experience withdrawal if they abruptly stopped the use of the medication.

However, the use of opioid medications for chronic pain is a unique situation, when compared to the use of other addictive drugs, like alcohol. When people use alcohol (or any of the illegal drugs) to the point of tolerance and withdrawal, most people would consider that they are doing something wrong. When chronic pain patients use opioid medications on a daily basis to the point of tolerance and withdrawal, they are doing just what their healthcare provider told them to do. If patients use their medications exactly as prescribed, they inevitably become tolerant and could experience withdrawal. Notice that they are not doing anything wrong. It’s what makes the situation unique from the use of other addictive drugs.

The American Academy of Pain Medicine and the American Pain Society noticed this difference too. A number of years ago, they decided to team up and define a difference between physiological dependence and addiction. They defined addiction to opioid medications using two criteria: a loss of control over the use of the medication or continued use of the medication despite real or potential harm.1 These criteria are more fully explored in the section on addiction.

While its important to acknowledge the difference between physiological dependence and addiction, it’s also important to acknowledge that tolerance and withdrawal are not benign issues. Even if they are not addiction, many patients are rightfully concerned about them.

Tolerance makes it unfeasible to continue to use opioid medications for pain on an indefinite basis. Patients and their healthcare providers commonly do not consider this problem until it is too late. Patients who have been on opioid medications for a few years become tolerant to even the highest doses of opioid medications. The medications no longer work and yet the patients have the rest of their lives to live. They may need opioid medications for other injuries or surgeries in the future and yet they are now tolerant to the medications. It is a problem for many patients.

The possibility of withdrawal is also a concern for many patients. They simply don’t like their dependency on the medication or their dependency on the healthcare provider who prescribes them. There might be many situations in which patients inadvertently do not have access to their medication or to their provider. This dependency produces a sense of vulnerability. Many patients just don’t like this sense of dependency and vulnerability.

Psychological dependence

When patients use opioid pain medications on a long-term basis, they tend to develop subtle yet strongly held beliefs that lead to a loss of confidence in their own abilities to cope with pain. As such, they come to believe that it is impossible to successfully manage pain without the use of opioid medications. Moreover, they become unwilling to entertain alternative options to their use. As a consequence, patients come to overly rely on the medications long after they are no longer helpful. In other words, opioid medications foster psychological dependence.

This issue is difficult to talk about. It’s difficult because these beliefs are subtle and don’t really come to the foreground unless actually named. It’s also difficult to talk about because it’s a sensitive issue. It can evoke strong emotional reactions.

Patients who are psychologically dependent on opioids are often intolerant of the notion that it is possible to manage pain well without opioids. They might see it as ridiculous. When a healthcare provider raises the notion, they take it that the healthcare provider is incompetent. At other times, patients see it as evidence that the healthcare provider doesn’t understand what it’s like to have chronic pain. They can also see the notion that it is possible to manage pain well without opioids as invalidating the legitimacy of their pain. In any of these ways, patients can get dismissive or angry. As described, it is a sensitive issue. However, the sensitivity is also indicative of psychological dependence.

Patients who are psychologically dependent on opioid medications are often unwilling to entertain different treatments for their pain, even when those treatments might be more effective. For example, numerous studies and reviews2, 3 have shown that chronic pain rehabilitation programs are more effective than long-term use of opioid medications. The psychologically dependent patient tends to forego recommendations to participate in such programs, even though they are more effective. It’s hard to come up with any analogous situation in healthcare. Cancer patients typically don’t insist on using one type of chemotherapy drug when their oncologists recommend using a more effective type. Most patients wouldn’t insist on using an antibiotic that has been consistently shown to be less effective than another medication or treatment. This kind of situation, though, commonly happens when it comes to the use of opioid medications for chronic pain. The difference is that opioid medications have the capacity to foster psychological dependence in the patients who take them. As such, they insist on using opioid medications even when there are other, more effective options for the management of pain.

Patients who are psychologically dependent on opioids rely on the medications long after they cease to be helpful. They tend to demonstrate tolerance to the medication, describing their pain as severe despite taking high doses of opioids. They may also remain disabled by pain, despite the use of opioid medications. Nonetheless, they swear that the medications are helpful. This disconnect between their subjective belief that the medications are helpful and the objective evidence of their reports of continued high levels of pain and disability is an indication of psychological dependence.

It bears remembering that most people with chronic pain do not manage their pain with opioid medications. In an epidemiological study, Toblin, et al., found that a quarter of the population has chronic pain; but among people with chronic pain, they found only 15% using prescription opioids to manage their pain.4 Now, it might be argued that the majority of people with chronic pain should be on opioids and that in fact it’s inhumane that in this day and age the majority of people with chronic pain are still being denied the use of such medications. But, that’s not what these researchers found when they asked people with chronic pain in the study. They found that the vast majority – 80% of them – were satisfied with their pain management. So, it’s true that the majority of patients with chronic pain manage their pain without opioid medications.

Patients who are psychologically dependent on opioid medications tend to believe that it is impossible. They are sensitive to the notion that it is in fact possible and can get emotional when it is brought up. They lack an openness to treatment options that might be more effective than opioid medications. Lastly, they maintain the belief that the medications are helpful and necessary despite their continued reports of high levels of pain and despite the fact that they remain disabled.

Addiction

As indicated earlier, the conventional definition of addiction to opioid medications has two criteria, when their use is in the context of chronic pain management.

  • Loss of control over use of the medication
  • Continued use despite harm

Loss of control occurs when patients do not use the medications as prescribed or in accordance with the agreement that they make with their healthcare providers. In other words, they do not control their use of the medications. Continued use despite harm occurs when patients continue to use the medications even though their use is harming their relationships with others or putting them at physical or legal risk. When patients demonstrate a pattern of behaviors that are indicative of either of these criteria or both, healthcare providers diagnose addiction.

Some examples of a loss of control are the following behaviors:

  • Taking more of the medication than prescribed
  • Early refill requests
  • Multiple reports of lost or stolen medications
  • Repetitive emergency room visits to obtain medications
  • Use of multiple healthcare providers at the same time to obtain medications
  • Use of a friend’s or relative’s medications
  • Breaking the long-acting nature of a medication and ingesting it
  • Buying medications from people who are not healthcare providers
  • Buying medications off the internet

Some of these behaviors are more significant than others. Most healthcare providers would require a pattern of behaviors for the less significant ones. For example, a patient may have a legitimate reason for an early refill request. One instance of this behavior may not be concerning. However, a pattern of such requests almost every month for a number of months does become concerning. Healthcare providers tend to consider such a pattern as indicative of addiction. Other behaviors on the list are more significant. Most healthcare providers become concerned about addiction after even one instance of some of these behaviors. For examples, there are no legitimate reasons to break the long-acting nature of a medication or to buy medications off the streets. When healthcare providers learn about a patient engaged in these types of behaviors, even if it was only once, it is concerning. In fact, it is an indicator of addiction to opioid medications.

Some examples of continued use despite harm are the following behaviors.

  • Pressuring, manipulating, belittling, or threatening a healthcare provider into prescribing opioids
  • Refusing to participate in therapies other than opioid medication management
  • Firing an otherwise competent healthcare provider because of disagreements over whether to prescribe opioid medications
  • Continued use of opioid medications despite expressed concerns about addiction from friends, relatives and healthcare providers
  • Using such high doses of medications that the patient becomes incoherent or falls asleep while engaged in activities
  • Using a false identity to obtain opioid medications
  • Stealing medications from others
  • Altering a prescription

These behaviors also exhibit a loss of control, but the emphasis is on the fact that they are done despite some type of harm to the patient. The loss of control has not been perceived as ‘a wake-up call’ and so the behaviors have crossed a threshold of jeopardizing the patient in some manner. Some of these behaviors harm the relationships that the patient has – relationships with healthcare providers, friends or relatives. Some of these behaviors place the patient or others at risk of physical harm. An example is using medications at such high doses that a patient falls asleep while engaged in a wakeful activity or otherwise is unable to fully track or pay attention to the activity. Other behaviors place the patient at risk of legal harm. Examples are using a false identity or stealing medications or altering a prescription. These activities are, of course, illegal and yet the addicted patient might still do them. In all these examples, the loss of control is evident to others but the patient might not see it or might make excuses for it because obtaining the medication has become more important than the risks. All these behaviors are indicative of addiction.

How often does addiction occur in chronic pain patients?

In the context of chronic pain management, addiction is a significant problem. In their literature review, Hojsted & Sjogren5 cited studies that showed rates of a wide range of addictive behaviors, varying from 0% to 50%. In their meta-analysis published in the same year, Martell, et al.,6 found that 5-24% of patients on opioid pain medications demonstrate the above-mentioned problematic behaviors, depending on the behavior.

In more recent studies, Hojsted, et al.,7 used two different methods for diagnosing addiction. Depending on the method, they found either 14.4% or 19.3% of chronic pain patients meeting criteria for addiction to opioid medications. Within the context of a larger study, Skurtveit, et al.,8 had 686 chronic pain patients who regularly used opioid medications and they identified 191 of them as engaged in problematic behaviors indicative of addiction. The percentage is about 28%. In their study of people prescribed opioids across multiple Western countries, Morley, et al.,9 found a range of misuse and abuse from 8 to 22%. These rates rose considerably when patients were also prescribed benzodiazepines or were taking illegal drugs.

Risk factors for addiction to opioid medications

A number of research studies have looked at risk factors among chronic pain patients that make it more likely for them to be identified as engaged in addictive behaviors.

In the study cited above, Skurtveit, et al.,8 observed that new users of opioids as a group have a considerably smaller chance of becoming addicted than regular users as a group. Sullivan, et al.,10 found that having a history of substance dependence, high daily use of opioids, being young and having multiple pain complaints were risk factors. Hojsted, et al.,7 found that high daily use of opioids, use of benzodiazepine medications, use of alcohol, and anxiety and depression were risk factors for addiction. As indicated above, Morley, et al., found rates of misuse and abuse rose significantly amoung those who also take benzodiazepine medications (sedatives, which are also addictive) and/or illegal drugs.9

For more information

For cutting edge thougts on the distinction between physiological dependence to opioids and opioid addiction, please see our page, Should the Definition of Opioid Addiction Change?

References

1. American Academy of Pain Medicine and the American Pain Society. (1997). The use of opioids for the treatment of chronic pain: A consensus statement. The Clinical Journal of Pain, 13, 6-8.

2. 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.

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

4. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

5. Hojsted, J. & Sjogren, P. (2007). Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 11, 490-518.

6. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

7. Hojsted, J., Nielsen, P. R., Guldstrand, S. K., Frich, L., & Sjogren, P. (2010). Classification and identification of opioid addiction in chronic pain patients. European Journal of Pain, 14, 1014-1020.

8. Skurtveit, S., Furu, K., Borchgrevink, P., Handal, M., & Fredheim, O. (2011). To what extent does a cohort of new users of weak opioid develop persistent or probable problematic opioid use? Pain, 152, 1555-1561.

9. Morley, K. I., Ferris, J. A., Winstock, A. R., & Lynskey, M. T. (2017). Polysubstance use and misuse or abuse of prescription opioid analgesics: A multi-level analysis of international data. Pain, 158, 1138-1144.

10. Sullivan, M. D., Edlund, M. J., Fan, M., DeVries, A., Braden, J. B., & Martin, B. C. (2010). Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and Medicaid insurance plans: The TROUP Study. Pain, 150, 332-339.

Date of publication: March 25, 2013

Date of last modification: October 5, 2019

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Complications Fri, 27 Apr 2012 13:15:50 +0000
Trauma https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/trauma https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/trauma Trauma

What is trauma?

Trauma is the psychological and bodily response to experiencing an overwhelmingly terrible event. Some examples of events that can lead to trauma are the following:

  • Combat
  • Domestic violence
  • Sexual assault
  • Natural disaster
  • Terrorism
  • Physical or sexual abuse in childhood

These events are not run-of-the-mill bad things that happen in life. Rather, events are typically considered traumatic when they threaten the life or bodily integrity of the individual who experiences them.1 Also, traumatic events tend to overwhelm a normal person’s ability to cope with them.

After experiencing events like the above, people tend to develop certain predictable reactions. Examples are the following:

  • Persistent and unwanted thoughts, memories, or dreams of the event
  • Heightened physiological arousal, such as tension, nervousness, irritability, startling easily, poor concentration, or poor sleep
  • Avoidance of places or things or events that are reminiscent of the traumatic event

All these reactions are related to anxiety. The persistent, unwanted thoughts and memories produce fear and anxiety. The arousal reactions are the physical manifestations of this anxiety. It’s the nervous system in action – tense and nervous. Avoidance is a common coping strategy for things that are anxiety provoking. It’s a way of not getting reminded of the event.

Relationship between trauma and anxiety

Whether due to trauma or other causes, anxiety in general is a state of the nervous system. When anxious, people are literally nervous. They are nervous in their feelings, their body, their thinking and in their behavior. With anxiety, the nervous system is stuck in a state of alarm, as if some scary thing were actually happening.

Psychologists have dubbed this state of alarm the fight-or-flight response. It prepares people to respond to danger by making the body ready to fight or flee from danger. The nervous system gets kicked into high gear, as it were, and it responds with feelings of being alarmed, with physical changes of the body that increase the capacity for action, with an increased cognitive focus on the danger, and avoidance behaviors.

In actual dangerous situations, this fight-or-flight response of the nervous system is a helpful thing. It’s the body’s natural overdrive system and it helps people to survive dangerous situations.

Anxiety is the result of the nervous system going into fight-or-flight in the absence of a real or actual danger. It’s anxiety when the nervous system kicks into fight-or-flight at the mere thought that something dangerous might happen. Such thoughts are called worry – thinking something bad is going to happen and consequently becoming nervous.

The anxiety reactions that occur as a result of trauma are similar. Whether it was an assault, violence or a natural disaster, the original traumatic event was actually dangerous. The person who experienced it had a nervous system that went into fight-or-flight. It was likely helpful at the time. After the event has come and gone, though, the thought of the traumatic event or a memory of it can still kick the nervous system into fight-or-flight as if the event is happening now. It leads to anxiety, increased arousal and avoidance behaviors, as described above.

This reaction is considered a form of anxiety because the event is not actually happening. Instead, the reactions are brought on by the thought or memory of the event.

High rates of trauma in people with chronic pain

As a group, people with chronic pain tend to report much higher rates of having experienced trauma in their past, when compared to people without chronic pain. It is a common and consistent finding in the research.

Upwards of 90% of women with fibromyalgia syndrome report trauma in either their childhood or adulthood and 60% of those with arthritis report such a trauma history.2 With or without back surgery, upwards of 76% of patients with chronic low back pain report having had at least one trauma in their past.3 Sixty-six percent of women with chronic headache report a past history of physical or sexual abuse.4 Among men and women, fifty-eight percent of those with migraines report histories of childhood physical or sexual abuse, or neglect.5 Women with chronic pelvic pain also report high rates of sexual abuse in their past, upwards of 56%.6 

As a point of comparison, rates in the general population for physical abuse in childhood are 22% for males and 19% for females; rates in the general population for self-reported childhood sexual abuse are 14% for males and 32% for females.7 Rates of adult sexual assault in the general population are 22% for women and about 4% for men.8 Domestic violence is upwards of 21% in the general population.9 

As is evident, when compared to the general population, people with chronic pain tend to have at least double the rates of trauma in their past.

The relationship between trauma and chronic pain

What accounts for this high rate of trauma in patients with chronic pain?

To be clear, these statistics do not prove that trauma causes chronic pain in any wide scale sense. Of course, traumas, such as injuries sustained in combat or assaults, could lead to chronic pain, but most of the time the onset of chronic pain is independent of the prior history of trauma. Indeed, many people with chronic pain have no history of trauma in their background. So, trauma doesn’t typically cause chronic pain in a direct way.

Nonetheless, the high rate of trauma in people with chronic pain suggests that it might have some relationship to the development of chronic pain.10

The relationship might be the following: a history of trauma might make a person more prone to develop chronic pain once an injury occurs. Let’s explain.

The nervous system & the transition from acute injury to chronic pain

Assume, for the most part, that painful accidents, injuries or illnesses occur on a random basis. Everyone has an accident or gets injured or gets ill on occasion. The vast majority of the time people get better and the pain goes away. Sometimes, though, they don’t. They transition from an acute injury or illness to chronic pain. Most experts agree that the process that accounts for this transition from acute injury or illness to chronic pain is central sensitization.11, 12

Central sensitization is condition associated with chronic pain in which the nervous system becomes stuck in a state of heightened reactivity. In central sensitization, the sensations of pain can become more intense and things that are not normally painful, like touch or massage, can also become painful. Central sensitization maintains pain even after the initial injury or illness heals.

So, here is the relationship between chronic pain and trauma. Trauma and its resultant anxiety is also a condition of the nervous system being in a persistent state of reactivity. As described above, trauma leads to anxiety, physiological arousal, and avoidance behaviors. These reactions to trauma are all indicators of a persistently aroused or reactive nervous system. As such, when patients with a history of trauma get injured or become ill, their nervous system is already in a state of persistent reactivity.

Might it be the case that such persons are more prone to develop central sensitization and transition from an acute injury or illness to chronic pain?

Many experts think so.13, 14, 15, 16 There is research that supports this hypothesis. Young Casey, et al.,17 showed that past traumatic events (along with depression) predicted continued pain and disability three months after onset of back or neck pain. In a prospective study, Jones, et al.,18 found that childhood adversities significantly raised the risk of developing chronic widespread pain by mid-life. Chronic widespread pain is an indicator of central sensitization. McBeth, et al.,19 found that altered levels of a stress hormone prospectively predicted the development of chronic widespread pain. Scarinci, et al., found that patients with histories of trauma tend to have lower pain thresholds.20 Lowered pain thresholds is another characteristic of central sensitization.

The common denominator between chronic pain and trauma is thus the nervous system. Trauma can make the nervous system persistently reactive. Once an acute painful injury or illness occurs, people with an already reactive nervous system are more prone to develop chronic pain.

Of course, a history of trauma is not necessary to develop chronic pain. Many people without a history of trauma can also develop chronic pain.  There are likely multiple routes to the development of central sensitization. Nonetheless, a history of trauma and its resultant anxiety are likely one route.

Treatment for chronic pain

Chronic pain rehabilitation programs are the only form of chronic pain management that makes it a point to also focus on psychological factors that can complicate chronic pain. Such programs routinely focus on helping patients to acquire the abilities to self-manage pain and return to work. However, they also focus on treating anxiety, depression, sleep problems, and also, importantly, anxiety related to trauma.

References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, test revision. Washington DC: American Psychiatric Association.

2. Walker, E. A., Keegan, D., Gardner, G., Sullivan, M., Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II Sexual, physical, and emotional abuse and neglect. Psychosomatic Medicine, 59, 572-577.

3. Schofferman, J., Anderson, D., Hines, R., Smith, G., & Keane, G. (1993). Childhood psychological trauma and chronic refractory low-back pain. The Clinical Journal of Pain, 9, 260-265.

4. Domino, J. V., & Haber, J. D. (1987). Prior physical and sexual abuse in women with chronic headache: Clinical correlates. The Journal of Head and Face Pain, 27, 310-314.

5. Tietjen, G. E., Brandes, J. L., Peterlin, B. L., et al. (2010). Childhood maltreatment and migraine (part I). Prevalence and adult revictimization: A multicenter headache clinic survey. Headache, 50, 20-31.

6. Walling, M. K., Reiter, R. C., O’Hara, M. W., Milburn, A. K., Lilly, G., & Vincent, S. D. (1994). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics & Gynecology, 84, 193-199.

7. Briere, J. & Elliott, D. M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27, 1205-1222.

8. Elliott, D. M., Mok, D. S., & Briere, J. (2004). Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress, 17, 203-211.

9. Schafer, J., Caetano, R., & Clark, C. L. (1998). Rates of intimate partner violence in the United States. American Journal of Public Health, 88, 1702-1704.

10. Nicol, A. L., Sieberg, C. B., Cauw, D. J., Hassett, A. L., Moser, S. E., & Brummett, C. M. (2016). The association between a history of lifetime traumatic events and pain severity, physicacl function, and affective distress in patient with chronic pain. Pain, 17(12), 1334-138.

11. Apkerian, A. V. (2011). The brain in chronic pain: Clinical implications. Pain Management, 1, 577-586.

13. Arendt-Nielsen, L. & Graven-Nielsen, T. (2003). Central sensitization in fibromyalgia and other musculoskeletal disorders. Current Pain & Headache Reports, 7, 355-361.

14. Macfarlane, A. C. (2007). Stress-related musculoskeletal pain. Best Practice & Research Clinical Rheumatology, 21, 549-565.

15. Basser, D. S. (2012). Chronic pain: A neuroscientific understanding. Medical Hypotheses, 78, 79-85.

16. Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1-35.

17. Young Casey, C., Greenberg, M. A., Nicassio, P. M., Harpin, R. E., & Hubbard, D. (2008). Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors. Pain, 134, 69-79.

18. Jones, G. T., Power, C., & Macfarlane, G. J. (2009). Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain, 143, 92-96.

19. McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

20. Scarinci, I. C., McDonald-Haile, J., Bradley, L. A., & Richter, J. E. (1994). Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: A preliminary study. The American Journal of Medicine, 97, 108-118.

Date of publication: April 27, 2012

Date of last modification: August 7, 2017

]]>
joemcallister4@gmail.com (Murray J. McAllister, PsyD) Complications Fri, 27 Apr 2012 13:15:07 +0000