Does Your Pain Clinic Teach Coping?

As we’ve discussed in an earlier post, not all pain clinics are alike. To be sure, all pain clinics provide therapies aimed at reducing pain. Some, however, don’t stop there. They set out to systematically coach patients to cope better with pain that remains chronic.

Types of Pain Clinics

Despite the fact that they all operate under the name ‘pain clinic’, there are at least four different types of clinics.

• Interventional pain clinics
• Long-term opioid management clinics
• Orthopedic or spinal surgery clinics
• Chronic pain rehabilitation clinics

Interventional pain clinics:  Interventional pain clinics tend to focus on minimally invasive procedures, or ‘interventions’, which aim to reduce pain. To be fair, most interventional pain providers would assert that they also aim to improve functioning, which means increasing a patient’s ability to engage in the activities of life, such as being able to perform household chores or return to work. However, interventional pain clinics primarily aim to increase functioning by attempting to reduce pain, under the assumption that people will be able to do more when their pain is reduced (i.e., in an inverse relationship that as pain reduces functioning increases).

Examples of minimally invasive procedures that one might obtain at an interventional pain clinic are epidural steroid injections, nerve blocks, radiofrequency neuroablations, spinal cord stimulator implants and intrathecal drug delivery device implants.

Notice that nowhere within this list is there specific time and resources set aside to teach patients how to cope better with pain that remains despite the use of the afore-mentioned procedures. While certainly individual clinics and/or providers might vary, most interventional pain clinics concentrate on providing procedures, not providing groups or classes or even one-to-one time to coach people on how to live well with pain that remains refractory to procedures.

The observation is not a complaint. It’s just not what they do, just as bankers typically don’t provide legal advice, even though in some areas of the respective fields there is some overlap.

Long-term opioid management clinics: Long-term opioid management clinics tend to provide access to the long-term use of narcotic pain medications. The aim of this type of clinic is to reduce pain and secondarily increase functioning. Akin to the interventional pain management aims, the assumption is that when pain is reduced, patients with pain will be able to do more and thereby their functioning increases.

Long-term opioid management clinics typically provide access to opioid, or narcotic, medications on an indefinite basis. Usually, patients see the healthcare providers on some regular interval to obtain a prescription of medications that lasts only until their next appointment. Oftentimes, this interval of time is monthly, though sometimes it’s shorter or longer in duration. Typically, the two main reasons such care comes to an end is when patients abuse the medications, in which case the patient is potentially referred to a substance dependence treatment program, or when patients become too tolerant to the medications and the medications are therefore no longer effective, in which case the patients are referred to another type of pain clinic.

Often, in long-term opioid management clinics, there might be a little bit more emphasis on coping with pain than in interventional pain clinics. So, providers might encourage exercise, staying active, the use of diaphragmatic breathing, or the use of more traditionally passive coping strategies, such as ice, heat, home traction units, or TENS units.

However, the primary focus of long-term opioid management clinics typically remains on providing access to opioid medications. Of course, there might be some exceptions, but for the most part the care in such clinics aim to reduce pain through the use of opioids and the elementary basics of coping that they teach are intended to complement opioids, not substitute for their use.

Orthopedic and surgery clinics:  Orthopedic and surgery clinics provide invasive procedures aimed to reduce pain. Surgery clinics make the same assumption about functioning as the previous two clinics do -- that the primary purpose of the procedures is pain reduction and secondarily to increase function. How this assumption typically plays out in surgery clinics is that patients commonly remain off work prior to and immediately after obtaining a surgical procedure and, once a procedure reduces pain, patients go back to work.

Examples of procedures that surgery clinics perform are arthroscopic surgeries of various joints, joint replacement surgeries, and spine surgeries, such as laminectomies, discectomies, and fusions.

Chronic pain rehabilitation clinics: Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care that aim to reduce pain, but primarily increase function. In this way, chronic pain rehabilitation clinics are different. Chronic pain rehabilitation clinics point to clinical and scientific evidence that pain is one of many factors that determine a patient’s functioning – one’s ability to remain engaged in the activities of life, such as work. What clinical experience and science tells us, in other words, is that how one responds to adversity, such as pain, is as important as how significant the adversity is – especially in terms of how one goes on to live with the adversity.

The importance of this observation cannot be overerestimated. It elevates the importance of increasing coping to the same degree of importance that reducing pain has. So, to take an example, if we want to help people with chronic pain return to work, then we can approach this problem in two different ways: 1) we can focus on reducing pain, under the above-noted assumption that when pain is reduced people can subsequently return to work; or 2) we can teach people with chronic pain to respond more effectively to the pain so that they know how to cope with pain so well that the pain is no longer as problematic, or disabling, as it once was and subsequently they learn how to return to work even with pain.

Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care, which means it’s care that focuses on what the patient can do to reduce pain and live better despite having pain. Patients learn to engage in various lifestyle changes, which, when done over time, reduce pain. More importantly, because chronic pain is typically chronic and cannot be entirely cured, patients also learn how to change the ways they react to pain so that they can still do things in life, such as return to work and engage in other daily activities of life, even though they continue to have pain. In other words, chronic pain rehabilitation clinics provide systematic education on how to remain functional in life despite having pain.

In this way, chronic pain rehabilitation clinics teach coping in a way that no other pain clinic does. In fact, they tend to emphasize coping over pain reduction because they base their approach on acceptance of the fact that chronic pain is really chronic. There tends to be no misleading anyone, as typically, chronic pain can only be reduced so much in whatever clinic one seeks care. Rather than repetitively trying to cure an incurable, or chronic, condition, chronic pain rehabilitation aims to increase patients’ abilities to cope with pain and help them to get so good at dealing with it that pain is no longer the showstopper that it once was. Patients come to learn, in other words, to accept pain, remain grounded in the presence of pain, and make an intentional choice to go to work and remain at work (or some other similar activity of life) despite having pain. With practice and expert coaching from the staff of the chronic pain rehabilitation clinic, pain becomes no longer the central focus of life, but rather is something that is just a side issue, with work, family and other activities being the most central aspects of life.

Coping with pain

Sometimes, patients with chronic pain won’t believe that such progress is possible. They might be sensitive to the possibility that one could have chronic pain and remain at work, and so tend to assert that it is impossible. They might also fear the sting of stigma if they acknowledge that they might be able to learn a thing or two about how to cope better with pain. Instead, they might assert that they already know how to cope with pain and that they cope better than anyone else could, who might find themselves in a similar situation.

In these ways, some people can have difficulty with openly acknowledging that they don’t cope as well as they’d like or could.

However, the possibility of getting better through learning to cope better doesn’t have to be perceived in this way. Most people would say that there is nothing wrong with you if you don’t know how to read very well, or don’t know how to change a tire on your car, or don’t know how to speak a foreign language, or don’t know how to play basketball very well. It’s okay to not know how to do certain things really well.

In fact, most people think learning new things is good. It’s admirable to learn something really well. In learning, the person who learns has to acknowledge and be okay with the fact that they don’t know everything already. In most situations of learning, no one ever has a problem with this aspect of learning.

If you are okay with learning how to cope with pain really well, then chronic pain rehabilitation clinics might be very helpful to you. Everyday, people with moderate to severe chronic pain learn how to cope so well with pain that they become much more functional in life. They go back to work. They attend family functions again. They do household chores and do fun things again with friends and family. In other words, they get back into life. Of course, in order to learn how, you’d have to be okay with being in a student role. But, again, most of the time, we think that learning is a good and admirable thing to do. The same can be true of learning how to cope better with pain.

Author: Murray J. McAllister, PsyD

Date of publication: March 23, 2016

Date of last modification: March 23, 2016

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate 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.