Murray J. McAllister, PsyD
Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.
One of the more long-standing recommendations of chronic pain rehabilitation is to reduce pain behaviors. It’s one of the ways that people with persistent pain can learn to cope better with pain. Let’s review how to do it.
This past summer, Minnesota Governor Mark Dayton signed into law an omnibus health and human services budget bill and in so doing he marked a significant milestone in the recent history of chronic pain management. The bill contained language, introduced by State Representative Deb Kiel and State Senator Jim Abler, authorizing the trial of a new payment arrangement through Medical Assistance, which makes it possible for state recipients of the public health insurance to receive care within an interdisciplinary chronic pain rehabilitation program.
I am nearing the end of a forty-five minute initial evaluation for our interdisciplinary chronic pain rehabilitation clinic and my patient is an amiable woman in her late forties from the suburbs. She drove a minivan to the clinic and attends the evaluation while her three children are at school for the day. Her primary care provider had referred her to us because of her chronic and disabling low back pain, which over the years had become progressively worse and more widespread.
Opioids, or narcotic pain medications, are commonly thought of as powerful pain relievers. Patients frequently request them and healthcare providers often prescribe them for back pain because they think that opioids are the most effective pain reliving treatment. Popular media and others in society also commonly think that without opioids patients will suffer intolerable or “intractable” back pain. The implication is that, again, opioids are the most powerful and effective pain reliever.
But are they the most effective pain relieving treatment for back pain?
Exercise, of course, is good for you. Activity is good for you too. Both are helpful for those with chronic pain. Yet, they are different. They are not an equal substitute for the other. Let’s explain.
Patients and healthcare providers commonly think of pain as a symptom of an underlying injury or illness. Say, for example, you hurt your low back while lifting. Perhaps, you’ve injured a muscle or ligament, or perhaps it’s an injury to the spine, like a disc bulge or herniation. Either way, you now have pain and the pain is the symptom of the injury. The same might be true for any health condition that causes pain, particularly when it first starts.
The Institute for Chronic Pain is saddened by the recent outbreak of fungal meningitis from tainted steroid used in interventional pain management procedures. As of this writing, over 400 cases have been reported and 29 deaths. Our thoughts and prayers go out to those who are ill and to the families of those who have lost their lives.
Date of last modification: 11/4/2012
Author: Murray J. McAllister, PsyD
Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.
Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.
Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.
It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.
- As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
- As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
- We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
- As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured, as we do with other chronic conditions, such as diabetes or heart disease.
- Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
- As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
- As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
- As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
- As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures which are largely ineffective
The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.
To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.
In short, we need to change the paradigm that underlies chronic pain management.
Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago. In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.
A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. They began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.
Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.
It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.
On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.
On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.
All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking. They have been largely effective in making a profound and beneficial impact on our health.
The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.
It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.
The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:
- We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
- Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
- Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
- We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
- We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.
The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.
The Institute has set out a number of methods for achieving the resolution of these goals.
- We have a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
- We provide this blog through our website.
- We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
- We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
- We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
- We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
- We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
- We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.
Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.
We hope that you will join us in this endeavor. Join our community and be part of this change.
Author: Murray J. McAllister, PsyD
Date of last modification: 10/7/2012
Opioids are certainly in the news. The US Surgeon General recently issued a statement on the relationship between their widespread use for chronic pain and the subsequent epidemics of opioid addiction and accidental overdose (US Surgeon General, 2016). The US National Institute for Drug Abuse and Centers for Disease Control have also issued concerns (see here and here, respectively). Mainstream media reports on the problems of opioids appear almost daily.
The Institute for Chronic Pain is an educational and public policy think tank that produces academic quality information on chronic pain. We aim to provide such information in a manner that’s empirically accurate, yet also approachable to patients, their families, non-specialist healthcare providers, third party payers, and public policy analysts. We do so because the field of chronic pain management needs to change.