I recently was at a meeting on designing a model of pain care delivery. The meeting was filled with clinical and operational experts. In the course of the meeting, one healthcare provider made the case that high quality pain care starts with “finding the pain generator.” By this phrase, he meant that the delivery system should support the use of scans and diagnostic injections to identify the orthopedic structure(s) responsible for any given patient’s pain. From there, he insisted that a foundation could be laid for establishing successful treatment plans to resolve the identified pain generator, presumably through interventional and/or surgical means.
Once having made his case, another provider spoke up and asked how he’d square the care delivery model he proposed with the fact that so-called “pain generators” lack any significant correlation with pain. She cited common evidence showing that findings on MRI scans do not correlate with pain, and that diagnostic injections lack reliability and validity (cf., Vagaska, et., 2019; Kreiner, et al., 2020). In so doing, she used science to challenge the whole foundation on which the previous speaker had advocated for his model of pain care delivery.
In reaction, it was apparent that the original speaker didn’t quite know how to respond. The challenge seemed to catch him by surprise. He seemed unaware of the common research findings she referenced.
It was one of those awkward moments that sometimes happens in meetings when someone says something patently untrue, but doesn’t know it, and when called out on it, they don’t know what to do, and so you end up feeling bad for them, despite knowing that they shouldn’t have said it in the first place.
In all, what the second speaker did was to make public the fact that the initial speaker had failed to keep up with scientifically-based progress in our understanding of pain and its causes.
This simple anecdote puts in a nutshell the current state of affairs within the field of pain management. It is not uncommon for providers practicing in the field to base their practice on models that are unsupported by current scientific research. Indeed, large swaths of pain management lack sufficient evidence to consider them empirically supported.
Moreover, people seeking pain care commonly don't know about this unfortunate state of affairs within the field of pain management. It seems reasonable to assume when seeking care that your healthcare provider is up to date on latest scientific findings and that any therapies the provider recommends has been scientifically shown to be effective. However, it is not always the case. In fact, it is not always the case, all too often.
This central problem within pain management is the reason for the Institute for Chronic Pain. Everyone wants to make pain care more
effective. As such, it would seem a worthy endeavor to put more time, attention and money towards advancing our scientific understanding of pain and how to best treat it. However, it would also be insufficient, as the above anecdote illustrates. We also need to more widely proliferate scientific understanding to patients and provider communities. Healthcare providers need to know what to recommend and patients need to know that they can trust the recommendations they receive. A greater understanding of pain, its causes, and treatments, in other words, is also needed.
To this end, the Institute for Chronic Pain provides academic-quality information on pain and pain care, but in a manner that is approachable to all. Our hope is that you will find it useful.
Our latest webpage attempts to clarify in everyday language the generally accepted definition of pain that comes from the International Association for the Study of Pain (IASP). The IASP is the world’s largest interdisciplinary professional organization devoted to pain science and pain care. They recently updated the definition and we attempt to break it down for you.
You can access the article with the following link: What is Pain?
Kreiner, D. S., Matz, P., Bono, C. M… & Yahiro, A. M. (2020). Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of low back pain. The Spine Journal, 20(7), 998-1024. doi: 10.1016/j.spine.2020.04.006
Vagaska, e. Litacova, A. Srotova, I., Vickova, E., Kerkovsky, M., Jarkovsky, J., Bednarik, J., & Adamova, B. (2019). Do lumbar magnetic resonance imaging changes predict neuropathic pain in patients with chronic non-specific low back pain? Medicine, 98(17), e15377. doi: 10.1097/MD.0000000000015377
Date of publication: October 16, 2021
Date of last modification: October 17, 2021
About the author: Dr. Murray J. McAllister is the founder and publisher at the Institute for Chronic Pain (ICP).
Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.
The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers.
Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.
Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution.
The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose.
Commonly, patients and providers assume that pain is the result of an injury or illness, or at least some type of condition in the body. So, for example, when pain in the low back occurs, it’s common to think of it as the result of some type of tweak or mild injury that must have occurred. When it goes on for some time, it’s also is common to want an MRI scan to see “what’s going on” in the back. Such scans often reveal some type of degenerative condition of the spine, which is subsequently considered the cause of the back pain.
As a result, people with pain tend to seek therapies that target the condition in the body by means of physical therapy that strengthens the core, or undergo steroid injections, or even surgery.
The same would be true if the onset of pain occurred in the shoulder or knee or hip. We’d tend to think of the pain as a sign that something is wrong in these joints, something orthopedic in nature, such as arthritis or a problem with a ligament or muscle. We’d tend to seek a scan to help in diagnosis followed by physical therapy, an injection or surgery,
The purpose of these types of assessment and therapies would be to treat the condition that is assumed to be the cause of pain. While doing so, we might take pain medications that act on the brain.
The single most important concern in public policy debates related to the use of opioids for persistent, or chronic, pain is what happens to people with persistent pain when they reduce or taper the use of opioids.
It is often helpful to use analogies and metaphors when explaining complex health topics to patients and their families. This statement is no less true when explaining the complexities of successful pain management. There are many helpful metaphors and analogies, and we have discussed a number of them previously in this blog, such as in the different ways to relate to pain or even experience pain. Another helpful analogy to explain the nature and goals of successful pain management is with the analogy to successful weight management.
It is helpful to liken pain management to weight management because weight management is often better understood by patients and their families. So, let’s review and learn about what it takes to successfully self-manage pain by looking at how it’s similar to successful weight management.
Just this morning, a primary care provider came to consult with me, looking for pain rehabilitation options for her patient with a complex set of needs. Emphasizing the legitimacy of the patient’s pain complaints, the provider detailed a long history of an active substance use disorder. The patient has had multiple urine drug screens positive for both opioids, which weren’t prescribed to the patient, and illegal substances. The provider recounts that the patient has been asked to leave multiple pain clinics for similar aberrant prescription drug use behaviors, all of which are indicative of an inability to control the use of opioids. Given the patient's history, she is at high risk of further exacerbating her addiction and/or death, if opioids continue to be prescribed. Nevertheless, the provider feels as if she has to prescribe opioids to the patient because, "she has legitimate medical conditions with real pain."
Living among the COVID-19 pandemic, with its loss of life and livelihood, and our need to maintain physical distancing to protect ourselves and our communities, we face the dual burdens of stress and boredom. It’s a difficult combination because persistent stress leads to lack of focus and feeling scattered. This distractibility leads to aimlessness and inactivity, which further leads to boredom. In boredom, we have nothing to distract attention away from all the stressors in our lives. Thus, stress can lead to boredom and boredom leads back to stress.
The COVID-19 pandemic continues to impact the world with deaths in the hundreds of thousands and countless more having become ill. To reduce the risk of contagion and death, areas around the world maintain self-quarantining practices and have been doing so now for multiple months.
Sheltering-in-place, or self- quarantining, presents both challenges and opportunities for everyone, including those with persistent, or chronic, pain.
A giant in the field of pain management passed away the other day. It was December 22, 2019, and, to be exact, he was the father of pain management. It is no overestimation to say that he brought pain management into modernity. Ron Melzack, PhD, was 90 years old.
Readers of the Institute for Chronic Pain website recognize it as a source of trusted and transparent information. The Institute for Chronic Pain aims to bring scientifically accurate information on pain and make it approachable to everyone. In so doing, the findings of scientific research is translated to provide understandable and hopefully helpful information to those with persistent pain and their families.
Chronic pain rehabilitation programs are a traditional and effective treatment for chronic pain. Such programs are based on cognitive-behavioral principles that aim to change how you experience pain. By doing so, chronic pain rehabilitation programs help you to a) reduce pain and b) return to meaningful life activities even though some level of pain may persist. In other words, by participating in chronic pain rehabilitation, you change your relationship to chronic pain. You no longer perceive pain as an alarming and disabling condition, but develop the know-how to understand your pain as a benign condition that no longer needs to disrupt or prevent your daily life activities.
Wouldn’t it be good to become so competent at dealing with persistent pain that you no longer are disabled by it?