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Abdominal Pain https://instituteforchronicpain.org Sun, 29 Jan 2023 16:21:04 +0000 Joomla! - Open Source Content Management en-gb Continued Use Despite Harm: The Under-Utilized Criterion for an Opioid Use Disorder Diagnosis https://instituteforchronicpain.org/blog/item/237-continued-use-despite-harm-the-under-utilization-criterion-for-opioid-use-disorder-diagnosis https://instituteforchronicpain.org/blog/item/237-continued-use-despite-harm-the-under-utilization-criterion-for-opioid-use-disorder-diagnosis

Over the last few years, I have argued that we need to rethink the nature of opioid use disorder in the population of people who take opioids as prescribed for moderate-to-severe persistent pain. I’ve done so in various formats, including in presentations as well as here at the Institute for Chronic Pain, in both web pages (Should the Definition of Opioid Addiction Change? and Opioid Dependency & the Intolerability of Pain) and blog posts (The Central Dilemma in the Opioid Management Debate and Dreaded or Embraced? Opioid Tapering in Chronic Pain Management). 

I do so because I think that the fields of both pain management and addiction are overly focused on loss of control as the primary indicator of when a person on long-term opioids for pain management crosses the line into the problematic state of an opioid use disorder (OUD). The argument these fields tend to use goes something like the following: 

  • Physiological dependence on opioids, in the population of people who use prescription opioids on a daily basis for the management of pain, is largely considered as a condition that is both expected and benign when compared with the condition of an OUD. Physiological dependence, in other words, doesn’t necessarily rise to the level of alarm unless someone on such medications begins to evidence a loss of control over their use. 
  • Loss of control is largely considered a compulsive condition, which is neither expected nor benign, since it leads to distress and/or functional impairment, or even death by means of accidental overdose. 
    • Examples of loss of control tend to be readily observable: repetitive self-escalation of the use of opioids, leading to early refill requests; obtaining opioids from multiple providers at the same time or from friends or relatives or other illegal sources; use of opioids that aren’t prescribed; etc. 
  • At the current time, we tend to reserve the term “misuse” to refer to those instances of use which fail to be in accordance with how the medication is prescribed1; when done repetitively, misuse can cross the line into compulsive use, which is indicative of loss of control, and thus come to exhibit some degree of an OUD. 
  • Repetitive misuse and loss of control tend to go hand in hand and are seen as in contrast with those who may be physiologically dependent, but take opioids as prescribed. 

This line of reasoning has taken hold in the fields of pain management and addiction. In common practice, what it means is that the typical Image by Ahmed Zayan courtesy of Unsplash litmus test for whether someone on prescribed opioids for pain is addicted or not is whether they are taking their medications as prescribed or not. If they are taking their medications as prescribed, they may be physiologically dependent, but not addicted. If not, they are identified as both physiological dependent and addicted, since they have crossed the line into compulsive use behaviors and as such have lost control of their use. 

Misuse and loss of control are admittedly the clearest indicators of problematic use of prescription opioids. Typical examples, as already noted, tend to be readily observable. There’s relatively little doubt, for instance, when an opioid that isn’t prescribed shows up on a urine drug screen. Nonetheless, the fields of pain management and addiction have historically indicated an additional criterion for OUD, which is continued use despite harm.2, 3 This criterion tends to get short shrift in clinical practice. Perhaps, it is because it is not as clearly recognizable as what has come to be recognized as loss of control – the misuse of opioids or taking them in an unprescribed manner. Perhaps too, it is because it can occur in the absence of such misuse. In other words, continued use despite harm can occur when patients take opioids exactly as prescribed, and as such they aren’t as readily identified as addicted. 

Moreover, another reason that those in clinical practice tend to fail to recognize continued use despite harm is that the matter can be confused with patient-reported high pain levels and what constitutes a reasonable response to such pain levels. To put succinctly, it can be difficult to differentiate between continued use despite harm and appropriate medical decision-making in response to moderate-to-severe pain.

Let’s explain each of these two difficult-to-recognize aspects of opioid use disorder one at a time.

Addiction to opioids when taking opioids as prescribed

As the phrase continued use despite harm suggests, the criterion of OUD under consideration occurs when a patient on prescription opioids for pain management insists on their continued use even if it places the patient in danger, such as risk of accidental overdose or exacerbating a co-occurring life-threatening condition. 

The criterion is most clear when it occurs in the context of illegal use of opioids, such as those that are bought off the streets or other non-medical sources. The problematic nature of insisting on the use of opioids when having no knowledge or assurance of their true nature is clear. In some ways, it is a variant of impaired control: you use what you are told are hydrocodone pills, for instance, but you actually have no knowledge of whether they are truly hydrocodone; they may be hydrocodone, but they might also be illegally manufactured fentanyl; as such, the use of these pills place you at considerable risk of harm (e.g., accidental overdose, since fentanyl is exponentially more potent); a more reasonable decision in response to this lack of knowledge would be to forgo their use; one who continues to insist on their use is acting with impaired control. 

But what of the use of this criterion for OUD in a population of people who are taking legally obtained, prescribed opioids for the management of pain?

Say, for example, a person who takes high-dose daily opioids for moderate-to-severe persistent pain also has severe sleep apnea. He reports that he is intolerant to the use of a C-PAP and so his continued use of high-dose opioids places him at significant risk of accidental overdose. His healthcare providers have cautioned against continued use of opioids, especially at his current high dose levels, and have gone so far as to encourage him to reduce his current opioid dose, but he remains adamantly against it and refuses. 

Now, to be clear in our example, the patient is using opioids as prescribed and he takes only those opioids prescribed to him. As such, he is not misusing them and so most providers and patients in this scenario don’t tend to consider use of prescription opioids of this kind as meeting criterion for having lost control. As such, most wouldn’t consider him to have an OUD.

Nonetheless, it is a problematic scenario. He is refusing, so to speak, to come off the ledge of a dangerous precipice. He might die with hisImage by Loic Leray courtesy of Unsplash current use, but nevertheless refuses to change his current use. 

Suppose further that his healthcare providers have cautioned him against continued use at the high dosing schedule and have supportively encouraged him to reduce many times. Maybe his spouse or family have joined in on the encouragement to reduce his dose. He subsequently knows that his continued use may cause him harm, if not death. Were it not for the fact that the substance in question is a prescribed opioid for pain, it would be clear to all that he suffers from impaired use. For instance, suppose in this example the substance wasn’t opioids but alcohol: he continued to consume alcohol after having been told in similar circumstances and by similar people that a pre-existing liver condition is increasingly made worse and so continued use poses considerable risk of harm, if not death. The two instances of impaired control are essentially similar. It’s just that when opioids are used in these ways under the auspices of a prescribing provider it seems to cloud the recognition of an OUD.

This example is not an uncommon scenario in the field of pain management. Day-to-day clinical experience is replete with additional examples of those who continue to insist on using opioids in high risk scenarios: 

  • patients who take exceptionally high doses because of the tolerance that has developed over years of taking opioids on a daily basis as prescribed
  • patients on moderate (or high) doses of opioids who have taken them for years as prescribed and are increasing in age, thus their current dose is increasingly dangerous with each passing year
  • patients on moderate (or high) doses who also take benzodiazepine medications or sedative hypnotic medications
  • obese patients on moderate (or high) doses, with or without sleep apnea, who also take such latter medications
  • elderly patients on opioids who continue to use opioids following a fall or following the onset of cognitive impairment as a side effect of opioids
  • patients with a history of addiction who take long-term, daily opioids as prescribed
  • patients who continue to use opioids following an accidental overdose.

The list could go on.

It’s rare for providers in actual clinical practice of pain management to recognize these behaviors as an OUD.

Through the course of my career, I have found it uncommon among my addiction medicine colleagues as well. Consults related to patients like those described above tend to come back that the patients are using their medication as prescribed and so do not have an OUD. At best, the consult comes back with a recommendation to the prescribing provider to reduce the opioids, but even this helpful recommendation obscurs the fact that it is the patient, not the provider, who is refusing to reduce their opioid dosing and thereby their risk.

Succinctly, the fields of pain management and addiction medicine need to change their perspective on the criterion that we ourselves have advocated for using when diagnosing an OUD. Continued use despite harm can occur even when patients are using opioids as prescribed.

These examples of continued use despite harm are indicative of impaired control over the use of opioids. It is because of the addictive nature of opioids that such patients insist on their continued use under high-risk circumstances.

Suppose, for example, someone with a severe depression develops serotonin syndrome due to the use of antidepressants and the healthcare providers’ recommendation is to stop the use of the medications. We’d be hard pressed to imagine a scenario in which the patient becomes so sensitive and threatened by the recommendation that he or she becomes argumentative and insistent on the continued use of the medications that cause such risk. While all things are possible, such a scenario is not common. In most scenarios of this kind, the patient is open to the recommendation to reduce the use of antidepressants and open to pursuing alternative therapies for depression. 

It is much more common, though, in the population of those with persistent pain who have been taking moderate to high daily doses of opioids despite the above risk of adverse events.

Suppose, to take another example, the long-term use of a proton pump inhibitor is now thought to be contributing to certain health risks and the recommendation is to stop the use of the medication and seek alternatives. It would be uncommon for patients in this scenario to become argumentatively insistent on its continued use despite the associated risks.

Again, it is common in the population of those taking long-term opioids for pain with concomitant risk factors.

Suppose, to take one last example, someone develops a GI bleed from the long-term use of an anti-inflammatory for moderate-to-severe arthritis pain and as a consequence the recommendation from healthcare providers is to discontinue the use of an anti-inflammatory and seek alternative therapies for the management of pain. While it may be common to have misgivings in this scenario, it would be uncommon for individuals to become so threatened by the loss of the medication that they are argumentatively insistent on its continued use despite the GI bleed. 

As has been mentioned, it is fairly common in similar high-risk scenarios when taking long-term opioids.

The difference, of course, between all these examples and that of opioids is that opioids are highly addictive. With repetitive exposure to addictive substances, brain changes occur that lead to compulsive use even in high risk scenarios. In the absence of such brain changes, people maintain the ability to control their behavior, making more or less rational decisions, in response to risk. Antidepressants, proton pump inhibitors, and anti-inflammatories simply do not foster such changes to the brain and so these capacities for rational decision-making are maintained. Opioids, however, do foster such changes to the brain, thus leading to impaired decision-making, or control, and continued use despite associated risks is the result.

Continued use despite harm & confusion with appropriate responses to high pain levels

Patients who insist on the continued use of opioids under conditions of risk to their life commonly maintain that pain relief is more important than life itself. They argue that without pain relief their life would be insufferable and so, when compared to a life of intolerable pain, the risk of catastrophic events such as death through accidental overdose or relapse of a prior addiction (for those on opioids with a prior history of addiction) is preferable.

On countless occasions in clinical encounters or public forums, such as in public policy debates, patients on long-term opioids, who have a history of taking opioids exactly as prescribed, maintain such sentiments: life with their level of pain wouldn’t be worth living were it not for opioid medication management. In other words, opioids are literally their lifeline.

Indeed, such sentiments are often perceived as immediately and obviously true: living a life of moderate-to-severe daily pain seems an intolerable prospect without opioids, and so their use along with their associated risks, seems the preferable option. Any expression of doubt by others is met with affront and accusations of stigmatizing those who have the unchosen life circumstances of living with moderate-to-severe persistent pain. The common litmus test for understanding is living under such circumstances or not: “If you had my level of pain, you’d understand!” The litmus test shuts down the possibility of managing pain well without opioids.

To make clear, the implied corollary to this assertion is that managing moderate-to-severe pain is impossible without the use of opioids. Some pain, in other words, simply requires opioids. There is no other choice between the use of opioids and intolerable pain and suffering. (“You think I like taking opioids?!? There’s nothing I’d like better than to not have to take them!”) Self-management of certain pain levels seems just not possible.

Healthcare providers who prescribe long-term opioids often make a similar calculation: reduction of pain with opioids is a greater value than any of the afore-mentioned catastrophic adverse events. Moreover, such providers typically never think twice about the calculation, perceiving it similarly as their pain patients – the risk-benefit ratio seems to immediately and obviously fall on the side of the ledger involving use of opioids. (See, How Important is Pain Reduction with Opioids?)

Indeed, the reader of this article may have been saying something similar when I used the analogy to someone who continues to use alcohol despite a life-threatening liver condition. It’s easy to argue that the two scenarios are different because the patient using opioids is using opioids for pain, while the patient using alcohol is not using alcohol for a legitimate medical condition. In this context, we might observe the almost countless frequency of people who use alcohol despite high risks because they are using alcohol to medicate latent depression or past trauma. The reader might counter that while depression and trauma are legitimate health conditions, the use of alcohol to medicate them are not legitimate medical responses to them. True, but that is exactly what is at question: Is the use of opioids despite the risk of catastrophic harm, such as death or the exacerbation of a pre-existing addiction, an appropriate response to moderate-to-severe pain?

With the empathy and compassion of those who care for people with the unchosen life circumstance of living with moderate-to-severe pain, it is time to question whether this risk-benefit calculation is warranted. We know, for instance, that most people in the general population with moderate-to-severe pain do not take opioids for pain.4, 5 This fact is the norm. The norm is not the continued use of opioids despite risk of harm. 

Indeed, it is time to even take it a step further: the unquestioning, steadfast belief that some pain is simply so great that no other choice is possible but for to take opioids at the risk to life is indicative of a problematic state of addiction, even if the use of opioids is exactly as prescribed. The perception that pain is so severe that it is prima facie intolerable without opioids in people taking daily opioids for years is a function of neuroplastic changes to the brain induced by repetitive exposure to opioids. The personal affront with which other peoples’ doubts of these unquestioning perceptions are met is the shame-based defensiveness that so often accompanies addiction. When those suffering from an addiction are initially approached about their addiction by others, the common response is denial and affront.

Again, most people with moderate-to-severe persistent pain do not take opioids for pain, let alone do so despite life-threatening risks. They do not perceive moderate-to-severe pain as insufferably intolerable. Without repetitive exposure to opioids, they haven’t undergone neuroplastic changes to their brains that influence their perceptions and abilities to make rational decisions in response to pain. They do not feel compelled to take opioids in response to moderate-to-severe pain despite life-threatening risks. In other words, they do not have an OUD. 

Continued use despite harm has long been advocated for use in the identification of those with an OUD by the fields of pain management and addiction. It has, however, been long under-utilized in the population of people who take long-term opioids as prescribed for the management of persistent pain. For the welfare of those for whom we care in these fields, it is time for this under-utilization to change.

References

1. Volkow, N. D., Jones, E. B., Einstein, E. B., & Wargo, E. M. (2019). Prevention and treatment of opioid misuse and addiction: A review. JAMA Psychiatry, 76(2), 208-216. doi: 10.1001/jamapsychiatry.2018.3126

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

3. American Academy of Pain Medicine, American Pain Society & American Society of Addiction Medicine. (2001). Definitions related to the use of opioids for the treatment of pain: Consensus statement of the American Academy of Pain Medicine, American Pain Society & American Society of Addiction Medicine. Wisconsin Medical Journal, 100(5), 28-29.

4. Nahin, R. L., Sayer, B., Stussman, B. J., & Feinberg, T. M. (2019). Eighteen-year trends in the prevalence of, and health care use for, non cancer pain in the United States: Data from the Medical Expenditure Survey. Journal of Pain, 20(7), P796-809. doi: 10.1016/j.pain.2019.01.003

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

Date of publication: 10-17-2022

Date of last modification: 10-17-2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Opioids Sun, 16 Oct 2022 15:01:47 +0000
When Topics are Off Limits to Talk About in Pain Management https://instituteforchronicpain.org/blog/item/233-when-topics-are-off-limits-to-talk-about-in-pain-management https://instituteforchronicpain.org/blog/item/233-when-topics-are-off-limits-to-talk-about-in-pain-management

The Institute for Chronic Pain (ICP) recently published a content piece on the roles that shame play in the experience of pain, particularly in persistent pain. It’s an under-reported topic in the field of pain management. In fact, we don’t tend to talk about it at all.

There are actually a number of topics that we don’t tend to talk about with each other — whether it’s between professionals in the healthcare community or between healthcare professionals and their patients. While no means a conclusive list, topics that remain off limits to talk about in pain management, and the subsequent alternative topics that we tend to talk about instead, are the following:

  • The role that fear-avoidance plays in pain and disability from pain.
    • It’s often easier, for example, to talk as if stress and mental health problems are solely the consequence of pain.
  • The role that coping has in determining whether someone uses opioids for the long-term management of pain or the role that coping has in whether one experiences pain as intolerable and therefore disabling or not.
    • It’s often easier to talk about how to surgically respond to objective findings, such as on MRI, than the obesity and sedentary lifestyle, for example, that can also contribute to low back or joint pain.

These topics are difficult to discuss. They often sound like blaming the patient for the pain that patients have or its problematic impact that painImage by Gene Gallin courtesy of Unsplash has on their life. Topics related to the bi-directional relationship between pain, on the one hand, and stress, mental health, coping, lifestyle or health behaviors, on the other hand, all imply that patients have some, if only modest, degree of control. That is to say, if patients are not entirely powerless and helpless to affect their pain and overall well-being, then choices, health behavior, and lifestyle have a role in the onset and maintenance of pain, disability and the use of opioid medications. 

This conversation can be had in a productive and hopeful manner — for who doesn’t want to at least potentially, if not actually, have some control over one’s health, including pain, disability and use of opioids? Such control is, after all, a good thing, given the alternative of having no ability to affect one’s health and well-being. Nonetheless, these conversations are sensitive, and can come across as blaming. For after all, if we do in fact have some degree of control over our health and well-being, including pain, disability and use of opioids, then we must be responsible, at least in part, for our health and well-being. If we find ourselves in rough shape, then, are we not, at least in part, responsible for it? Might there not always be in the background an implied criticism of ‘why haven’t you already done something about it?’ If you haven’t, the implied criticism, lurking out there, is ‘maybe, you just want to be in pain [or on disability or on opioids].’ Thus, the acknowledgement that patients may have some degree of control over their health and well-being can take a turn of perspectives in the course of a healthcare visit and come to be seen as a blaming and stigmatizing.

Given the potential for these conversations to go poorly, it is often easier to just not have them and instead focus on those aspects of pain, such as objective findings on exam, that presumably patients have no control over. The focus of office visits thus becomes, not the sedentary lifestyle, or obesity, or ineffective coping responses, but rather the osteoarthritic changes in the joint. Thus, patients leave with only part of the story. The account of the pain, impairment or need for opioid medications as solely the inevitable consequence of a physical ailment is reassuring in its incompleteness. There’s no potential for blame because there’s no capacity for patients to feel, be or do otherwise.

Shame is the underlying factor in these topics that are off limits to talk about. It’s also the driving force in providers and patients finding something else to talk about instead. Shame is the most off limits topic of all the off limits topics. 

The Institute for Chronic Pain has a long history of discussing sensitive topics in as approachable ways as we can achieve. We do so with every effort to share and explain information in thoughtful and inclusive ways. We anticipate when topics can be taken in the wrong way and are careful to explain the non-judgmental perspective from which the reader might more accurately understand. We recognize the persistent role of stigma and write about it frequently, as we also write about ways to overcome stigma

We do so with the intent to educate the pain community — patients, family, and providers — on topics related to pain management and pain rehabilitation. We provide scientifically accurate health information that is approachable to all. Our hope is that the information shared on this site is approachable in two ways: one, that it translates scientifically complex material into information that is readily understandable by all; two, that the information is provided in a sensitive manner, which allows us to talk openly about topics that we need to discuss as a pain community, but that we do so without judgement, criticism or stigma.

We hope that the new content piece on Shame & Pain is helpful to you.

Date of Publication: January 30, 2022

Date of Last Modification: January 30, 2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Blog Wed, 26 Jan 2022 01:15:37 +0000
What the Opioid Epidemic has to Do with Algae Blooms in the Gulf of Mexico https://instituteforchronicpain.org/blog/item/229-what-the-opioid-epidemic-has-to-do-with-algae-blooms-in-the-gulf-of-mexico https://instituteforchronicpain.org/blog/item/229-what-the-opioid-epidemic-has-to-do-with-algae-blooms-in-the-gulf-of-mexico

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. 

Prescription Opioid Use & Addiction

The corresponding rise of both opioid prescriptions and subsequent opioid addiction and overdose is well-documented. Life-time prevalence rates of opioid addiction among patients engaged in long-term opioid management for persistent pain are as high as 40% (Boscarino, Hoffman & Han, 2015). Use of prescription opioids is a common vehicle to subsequent use of illicit opioids (Cicero, et al., 2014; Lankenau, et al., 2015; Monico & Mitchell, 2018). Since 1999, over 800,000 people have died of a drug overdose, with the majority of these involving opioids (CDC, 2021).

It would be fair to say that no one intentionally sets out to become addicted to opioids when using prescription opioids for the management of pain. It would also be fair to say that no prescribing provider intends for their patients to become addicted or die when prescribing opioids. Nevertheless, it does happen.

Much attention in recent years has been on the long-term use of opioids for persistent pain, but new long-term use of opioids also occurs following surgery as well (Hah, et al., 2017). Whatever the clinical indication for the use of opioids, the trajectory of prescription opioid use leading to addiction and/or overdose follows a common pathway involving multiple prescribing providers over time.

Typically, these days, it is uncommon for patients to be intentionally started on long-term use of opioids. Rather, patients tend to drift into it. A provider prescribes opioids to a patient to manage, say, acute or post-surgical pain and everyone expects it to be a brief duration. The pain, they assume, will subside on its own and the use of opioids will come to an end. When the pain, however, fails to subside, a second, third, fourth and fifth prescriptions come to occur. After awhile, the initial prescribing provider comes to refer the patient out to a different prvider after becoming concerned about the length of time the patient has been taking opioids. Or, Image by Nickolas Nikolic, courtesy of Unsplashperhaps, the initial prescribing provider becomes concerned with behaviors on the part of the patient, such as using more pills than were prescribed and subsequent early refill requests. In either scenario, patients commonly protest against the provider's concerns with denials that they are addicted and that they need the medication to manage their pain. In turn, the initial prescribing provider refers the patient to another provider, such as at a pain clinic, where the process over time repeats. Indeed, this process of concern about the patient’s use and subsequent referral to another provider can occur a number of times before any real sense of acceptance that opioid addiction has become an issue.

Opioid addiction thus only becomes apparent downstream in time and space. The initial prescribing provider may never know the eventual outcome of the patients that they start on opioids. The same may be true of the second and third provider in the process. They too may never know of the overdose death that occurs far from the time that they had delivered their care. 

Like the algae bloom in the Gulf of Mexico that is caused by unintentional behavior of farmers in the Midwest, the contributors to the opioid epidemic are both unwitting and separated in time and space from the consequences of their actions.

So, who takes responsibility for the opioid epidemic? It is easy to blame the addicted and the dead, for each of them are the one constant in their individual and often long, complicated trajectory of opioid addiction and overdose. They are, however, not the only responsible party. It’s easy to fail to fully appreciate this fact. 

To resolve the opioid epidemic, everyone in the healthcare system needs to take responsibility. Changes in prescribing practices are necessary, particularly in the difficult-to-predict-for transition period from early use to chronic use. Providers, patients and insurers continue to require education on alternatives to opioids for pain. We also need to de-stigmatize opioid dependency and addiction: while some of us are more prone than others, all of us will become dependent given sufficient exposure to opioids. We also need to educate providers, patients and insurers on pain — how to best treat it when able, and how and when to accept it, and acquire the abilities to self-manage it when necessary.

The Institute for Chronic Pain aims to do its part in achieving all these goals. We provide academic information on pain related topics that is approachable to all. 

References

Bloch, S. (2021). Gulf fishers brace for a “dead zone” the size of Connecticut and Delaware. Retrieved from: https://thecounter.org/gulf-of-mexico-fishers-dead-zone-climate-change-algal-blooms/

Boscarino, J. A., Hoffman, S. N., & Han, J. J. (2015). Opioid use disorder among patients on long-term opioid therapy: Impact on final DSM-5 diagnostic criteria on prevalence and correlates. Substance Abuse and Rehabilitation, 6, 83-91. doi: 10.2147/SAR.S85667

Center for Disease Control (CDC). (March 25, 2021). The drug overdose epidemic: Behind the numbers. Retrieved from: https://www.cdc.gov/opioids/data/index.html

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the last 50 years. JAMA Psychiatry, 71(7), 821-826. doi: 10.1001/jamapsychiatry.2014

Hah, J. M., Bateman, B. T., Ratliff, J., Curtain, C., & Sun, E. (2017). Chronic opioid use after surgery: Implications for preoperative management in the face of the opioid epidemic. Anethesia and Analgesia, 125(5), 1733-1740. doi: 10.1213/ANE.0000000000002458

Lankenau, S. E., Teti, M., Silva, K., Jackson, J. Haracopos, A., & Treese, M. (2012). Initiation into prescription opioid misuse among young injection drug users. International Journal of Drug Policy, 23(1), 37-44. doi: 10.1016/j.drugpo.2011.05.014

Monico, L. B & Mitchell, S. G. (2018). Patient perspectives of transitioning from prescription opioids to heroin and the role of route administration. Substance Abuse Treatment, Prevention, and Policy, 13(4). doi.org/10.1186/s13011-017-0137-y

Date of publication: September 20, 2021

Date of last modification: September 20, 2021

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Opioids Mon, 20 Sep 2021 21:07:19 +0000
How Pain Management is like Weight Management https://instituteforchronicpain.org/blog/item/223-how-pain-management-is-like-weight-management https://instituteforchronicpain.org/blog/item/223-how-pain-management-is-like-weight-management

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.

Quick fixes typically don’t work

Understandably, people with persistent pain want to get rid of it. They want it to go away like any of the countless other health conditions that they have had in their lives. In the past, they’ve become ill or injured, experienced symptoms such as pain, but with time the symptoms tended to subside. Oftentimes, in these situations, people sought healthcare and underwent various therapies, and subsequently their symptoms went away. As a result, they were able to get on with their lives. These past experiences subsequently inform how they think they should approach their persistent pain. Namely, they approach their persistent pain with the idea that they need to find the right specialist, with the right medicine or therapy or procedure, as a result it should all go away. Just as every other health condition was cured in the past, it seems to make all the sense in the world to seek a cure for the current condition of persistent pain.

A similar approach is commonly taken in weight management. People find themselves overweight or obese and, having come to a decision to do something about it, they begin the search for a cure for what ails them. Of course, there is no shortage of potential approaches in the current healthcare market: over-the-counter and prescription medications, and countless diets to follow and the ubiquitous best-selling books about each of those diets.

Now, the thing is, many of these approaches can work -- if, that is, the goal is to lose weight. By following these methods, people can tend to lose 5, 10, 15 or 20 kilograms (or pounds) relatively quickly, in a matter of weeks to months. It all seems good when it happens: mission accomplished. With the loss of weight, they also experience relief, satisfaction and a renewed spirit of getting on with their lives.

But then the weight comes back. It turns out that weight loss is relatively easy. What’s hard is keeping the weight off. It’s like the classic joke about smoking cessation: “Quitting smoking is easy. I’ve done it many times.” Rapid weight loss is common, and for a fortunate few, it can work and work for good. However, most of the time, people tend to gain the weight back and they find themselves where they started.

Having regained weight, they also have the added emotional distress that comes along with it. They are upset, experiencing failure, frustration and anger. The future no longer seems so bright.

Like rapid weight loss, rapid pain reduction can sometimes work, but it doesn’t usually last. There are a number of approaches within the healthcare market place that commonly provide dramatic, if temporary, relief from pain. Opioid medications seem to produce significant pain reduction initially, but clinical trials show that over time they have little effect on reported pain levels (Busse, et al., 2018; Krebs, et al., 2018; Veiga, et al., 2019). Likely due to tolerance, opioids lose their effectiveness over time. Clinical trials of interventional pain procedures, such as epidural steroid injections, show temporary, but not lasting pain reduction (Peul, et al., 2007). Spine surgery for disc herniation has been shown to produce early results when compared to other therapies, such as physical therapy, but by one-year out there’s no difference in terms of the symptoms between those who have had surgery and those who haven’t had surgery. Clinical trials of longer duration continue to show no clinically significant added value to having had surgery (Lurie, et al., 2014; Weinstein, et al., 2006; Weinstein, et al., 2008).

Patients, too, commonly report histories of their pain care that involve repetitive trials of therapies, procedures and medications, which initially showed promise, but failed to make any permanent dramatic reduction in their pain. Hope and their initial cause for optimism fade with each occasion of failed pain reduction, often leaving patients reporting a history of an emotional roller coaster ride: it tends to end with bottoming out in frustration, anger or even depression.

The lesson here is that, like with weight management, there is no quick fix when it comes to pain management, at least not in most situations.

Successful pain management aims for incremental change in pain levels

Weight loss and maintaining a healthy weight is possible, but it involves a commitment to lifestyle interventions that become, well, your lifestyle: whole food choices, portion control, exercise, stress management, mindfulness training, and so on. Maintaining a healthy weight is not, in other words, the product of a solitary intervention, with a beginning, middle and an end, like being on a diet, or taking a medication for a certain time, or even a bariatric surgery. Rather, it is about engaging in multiple interventions over time, most of which involve healthy lifestyle changes and making them your new normal.

Photo by Kari Shea courtesy of UnsplashIn this regard, successful weight management is usually the product of slow change over time. On any given day, weight may fluctuate. Sometimes it is up a bit and sometimes it is down a bit. With time, lifestyle interventions bring down the average level of weight.

This gentle loss of weight serves as a useful and scientifically accurate model for successful pain management. Like with weight loss, pain can fluctuate up or down on any given day, but the goal for successful pain management is for the average level of pain to gently come down over time.

Moreover, this gradual reduction in pain is most effectively achieved by multiple lifestyle interventions pursued on an indefinite basis. Pain rehabilitation is the field of pain management that teaches and shows patients how to successfully engage in pain-related lifestyle management that can produce the most successful results. Pain rehabilitation helps patients to put all of the following into daily use: cognitive-behavioral therapies, mild aerobic exercise, contemplative practices such as mindfulness or tai chi or yoga, whole food anti-inflammatory food choices, the use of anti-inflammatory or antidepressant medications, and so on. When combined and pursued over time, these pain rehabilitation approaches down-regulate the nervous system and thereby reduce pain. They are not a quick fix, but they do tend to be effective at reducing pain. It’s just that they work gradually.

Successful pain management is not all about pain reduction

With weight management, it is not all about weight loss. It is about achieving and maintaining a healthy weight that emphasizes well-being over a singular focus on weight loss. It is a subtle, yet important distinction.

Sometimes, with weight management, the focus on weight loss can become too important – in one of those proverbial occasions of losing sight of the forest by overly focusing on the trees. A singular focus on weight loss can lead to an over-reliance on weight loss products and remedies, such as diet sodas, low-fat food products, diet fads, medications and surgery. Each one of these approaches have been shown to be ineffective when used solely by themselves, in the absence of making other healthy changes in life. They tend to promote binge-and-bust cycles of weight loss followed by weight gain.

A singular focus on weight loss can be a product of a persistent cognitive distortion, which might be called, ‘I’ll be better when…’ Cognitive distortions are an identifiable way of approaching life, involving ways of thinking, feeling and behaviors. We have explored many of them in this blog (for instance, catastrophizing, and all-or-nothing thinking). The ‘I’ll be better when…” type of cognitive distortion occurs in many areas of life, of course, and not just in weight management, and it’s typically a set-up for persistent frustration. When the good life, however defined, is conditional on a future state of obtaining some thing, it almost always fails. The good life tends to remain allusive, even if the condition is met. For after all, weight loss, in and of itself, does not produce well-being, just as no other single thing does (such as a six-figure salary, a three-car garage, quitting smoking, resolving a stressor). Any one thing is just insufficient to bring about the good life, and so well-being remains unobtained, which is to say, a persistent state of frustration remains.

A change in the focus from losing weight to maintaining a healthy weight, or even maintaining well-being, de-emphasizes the importance of losing weight, per se, and paradoxically may increase the likelihood of maintaining a healthy weight. The latter involves, of course, weight loss, but much more. It involves the slow processes of making a new normal – incremental changes that are done with the intention of doing them in one fashion or another for the rest of one’s life:

  • re-introducing the cooking of whole foods on a more consistent basis
  • reducing the consumption of soda to the status of an occasional treat rather than a daily staple
  • starting to walk for exercise on a regular basis, no matter how short or slow you go when first starting to make this change
  • using small sandwich plates for all meals, including dinner, to reduce portion size
  • making a point of eating together with those whom you live and turning off all screens while doing so
  • beginning a stress management schedule of behaviors, such as meditation, diaphragmatic breathing or gentle yoga.

Any of these behaviors, and more, are done with the intention to make a permanent change, making a new normal. All of these behaviors have other positive aspects, which subsequently add value to life. They promote overall health and well-being, and in so doing, de-emphasize weight loss as the central focus of what will produce the good life. At the same time, though, they also promote the likelihood of successfully maintaining weight loss by re-focusing attention and efforts onto promoting well-being.

Similarly, it can be helpful to de-emphasize the focus and goal of pain reduction. Indeed, in some circumstances, it is imperative to see that pain reduction is not the only way to get better when living with persistent pain.

The pursuit of pain reduction can be taken too far. Of course, this statement is not a judgment and it is not meant to stigmatize anyone, but rather it is a compassionate reminder that there are times in life in which there can be too much of a good thing. It is not uncommon in pain clinics to see folks who are on too high of doses of opioids – not in the sense that they are misusing them, but that they have been on them for so long that they need very high doses to get any pain relief. They come to clinic reporting that they are managing well, but despite their own subjective assessment of themselves they appear sedated and report engaging in little of life’s activities. It is hard to tell what part of their impairment is from pain or from opioids. It is also not uncommon to see patients who report histories of having had numerous failed spine surgeries, which may now be in part the cause of their pain and impairment. People can also report that they have stopped many, if not all, meaningful life activities in the pursuit of reducing pain. They buy pain relief, in other words, at the cost of guilt and social isolation over foregoing family activities and social activities.

In any of these situations, the pursuit of pain relief has gone too far. It has become too important. They are paying a price for pain reduction that one might reasonably wonder is too high – higher than the experience of pain itself.

It can be easy to fall into this predicament when engaging in the cognitive distortion of ‘It’ll be better when…’ From this perspective, it can seem that life can only start once pain is reduced. Thus, pain reduction becomes the primary or most important value in life. It must be achieved before anything else can be achieved.

Like with weight management, it can be helpful to de-emphasize the importance of pain reduction. It is not to do away with the pursuit entirely, but rather to recognize that there are other valid ways to successfully manage pain.

Referrences

Busse, J. W., Wang, L., Kamaleldin, M. et al. (2018). Opioids for Chronic Noncancer Pain: A systematic review and meta-analysis. JAMA, 320(23), 2448-2460. doi: 10.1001/jama.2018.18472 Video: https://www.youtube.com/watch?v=qWADk7lr6wA

Krebs, E. E., Gravely, A., Nugent, S., et al. (2018). Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or osteoarthritis knee pain: The SPACE randomized clinical trial. JAMA, 319(9), 872-882. doi: 10.1001/jama.2018.0899

Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Zhao, W., Morgan, T. S., Abdu, W. A., Herkowitz, H. & Weinstein, J. N. (2014). Surgical versus nonoperative treatment for lumbar disk herniation: Eight-year results for the spine patient outcomes research trial. Spine, 39(1), 3-16. doi: 10.1097/BRS.0000000000000088

Peul, W. C., et al. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245-2256.

Veiga, D. R., Montenero- Soares, M., Mendonca, L., Castro-Lopes, J. M., & Azevedo, L. F. (2019). Effectiveness of Opioids for Chronic Noncancer Pain: A two-year multicenter prospective cohort study with propensity score matching. The Journal of Pain, 20(6), 706-715.

Weinstein, J. N., Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Blood, E., Abdu, W. A., Herkowitz, H., Hilibrand, A. S., Albert, T., & Fischgrung, J. (2008). Surgical versus non-operative treatment for lumbar disk herniation: Four-year results for the Spine Patient Outcomes Research Trial (SPORT)Spine, 33(25), 2789-2800. doi: 10.1097/BRS.0b013e318ed8f4

Weinstein, J. N., Tosteson, T. D., Lurie, J. D., Tosteson, A. N., Hanscom, B., Sinner, J. S., Abdu, W. A., Hilibrand, A. S., Boden, S. D., & Deyo, R. A. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA, 296(20), 2441-2450. doi: 10.1001/jama.296.20.2441

Date of publication: January 19, 2021

Date of last modification: January 19, 2021

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Self-management Mon, 18 Jan 2021 01:42:40 +0000
Self-Management https://instituteforchronicpain.org/blog/item/162-65self-management https://instituteforchronicpain.org/blog/item/162-65self-management Self-Management

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

Commentaries on the use of opioid medications often exhibit this lack of consideration of self-management as a viable option. For example, it’s common for stakeholders in the field to hold the use of opioids as self-evidently necessary to successfully manage chronic pain. The notion that self-management is a viable option is never even considered. Indeed, the underlying and unspoken assumption is that it is impossible to manage pain well without the use of these medications. (See, for instance, these thought leaders failing to mention self-management as an option in the face of the various crises that beset the practice of opioid management for chronic pain, here and here).

It’s an odd state of affairs for a major specialty within healthcare to persistently fail to consider, let alone promote, self-management as a viable option. Other specialty areas within healthcare don’t fail to consider the role of self-care. Think of how the fields of diabetes care or cardiology or mental health encourage and promote self-management. Such fields go to great lengths to motivate and teach patients to take ownership and responsibility for their health condition, lose weight, start and maintain an exercise program, quit smoking, eat right, manage stress, assertively resolve conflicts or other problems, and so forth.

The field of chronic pain management instead seems to subtly or not so subtly emphasize the need for patients to rely on healthcare providers to manage pain for them. How often do you hear the assertion that patients will suffer without the pain management that the healthcare system provides? With such assertions, we inadvertently proliferate a belief that it is impossible to self-manage pain well. As such, it hardly ever comes up as a viable option among the many different treatments for managing chronic pain.

Why is that?  

Date of publication: August 7, 2015

Date of last modification: August 7, 2015

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Self-management Fri, 07 Aug 2015 14:43:42 +0000
Stress and Chronic Pain https://instituteforchronicpain.org/blog/item/123-26stress-and-chronic-pain https://instituteforchronicpain.org/blog/item/123-26stress-and-chronic-pain

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another.

It goes something like the following: ‘I’m hear to talk about my pain and what we can do about it, but you ask me about all these things that are unrelated to pain, like whether I worry, whether the worry keeps me up at night, what’s going on at home, whether my spouse believes me that I hurt as much as I do. In effect, I’m here to talk about my pain but you want to know how stressed I am. Why?’

It’s true. Providers who specialize in chronic pain rehabilitation always evaluate the patient’s pain, of course, but they also always assess the stressful problems that the patient experiences. To the list above, we might add such stressors as depression, anxiety, past trauma, sleep problems, persistent problems with concentration and short-term memory, financial problems, loss of the role in your occupation or family, the loss of sexual and emotional intimacy in your relationship, and the list could go on. All these problems cause stress, which is why we call them stressors. Why is it important to deal with stressors when having chronic pain?

There are a number of reasons why it is important, but let’s review two today:

  • If you can’t fix the pain, you might as well work on reducing the problems that occur because of the pain.
  • To successfully self-manage chronic pain, you have to manage your stress.

Let’s look at these reasons one at a time.

Stress caused by pain

Understandably, patients with chronic pain want to focus on how to reduce pain. To some extent, this focus is helpful. There are indeed a number of lifestyle changes, such as mild aerobic exercise and regular relaxation exercises, which, when done over time, can reduce pain. There are some medications, such as tricyclic antidepressants and antiepileptics, which have been shown to reduce pain too. However, these treatments are only so effective. We really don’t have any treatments that are super effective for chronic pain. (Procedures, such as injection therapies and spine surgeries, are known to be largely ineffective, despite how often they are pursued.) At the end of the day, chronic pain is chronic. It’s not ultimately fixable. While some of things that can be done to reduce chronic pain are helpful, they are only mildly so.

Given this fact, if you can’t fix the pain, then you might as well work on the problems that occur as a result of the pain. It’s possible to have chronic pain and not have it disrupt your life. It’s possible to have chronic pain and not be depressed about it. It’s possible to have chronic pain and sleep well at night. It’s possible to have chronic pain and work full-time. It’s possible to have chronic pain and have a fulfilling and intimate relationship.

Now, many people have to learn how. But, if they are open to learning, they can learn to self-manage pain well enough to be able to overcome these secondary problems. Such learning can take time and practice. It also takes a certain amount of devotion to maintain lifestyle changes, once you learn how to do them. Nonetheless, it is possible.

What patients learn could be called stress management and it involves cognitive behavioral therapies.

Good self-management of chronic pain involves stress management. When you overcome depression, even if chronic pain remains, it’s still a win for you. When you come to sleep well at night, after a period of chronic insomnia, life gets better, even if you continue to have chronic pain. When the strain in your relationships subside, your marriage and family life deepen, making life more meaningful and fulfilling, despite having chronic pain.

Overcoming the stressors in life, even when they occur as a result of chronic pain, is a way to get better when there is no cure for the pain itself. Patients with chronic pain might initially wonder why chronic pain rehabilitation providers want to focus on the stressors in their life, but from here we can see why. It’s a way to get better when there is no cure. If you can’t fix the pain, focus on overcoming the stressful consequences of living with pain. By doing so, you make life easier and better.

You also make the chronic pain more tolerable by coping better with it. By overcoming your depression or anxiety, everything in life gets easier to deal with – pain included. It becomes more tolerable. When you sleep reasonably well, on most nights, you deal with everything better – pain included. It becomes more tolerable. The same is true with any of the stressful problems that go along with living with chronic pain. When you overcome them, you cope better with the pain itself. By focusing on reducing stress, you come to cope better and pain can go from what was once intolerable to what is now tolerable.

Chronic pain rehabilitation is the form of chronic pain management that most focuses on helping patients to overcome the stress of living with chronic pain and thereby cope better with pain. The other forms of chronic pain management – spine surgery clinics, interventional pain management clinics, medication management clinics—focus mostly on reducing pain, and not on the stressors that occur as a result of pain. Chronic pain rehabilitation programs focus on both. They provide empirically proven methods to reduce pain, while also providing therapies to overcome depression, anxiety, insomnia, cognitive deficits, relationship problems, and disability.

Stress management and chronic pain management

We just saw how overcoming stressors related to pain makes life easier and better, even though you continue to have chronic pain. We also saw how overcoming stressors can lead to better coping, which, in turn, makes chronic pain more tolerable. Doing so, however, is important for another reason: managing stress well also reduces pain itself.

We all know that stress makes chronic pain worse (Alexander, et al., 2009; Flor, Turk, & Birbaumer, 1985). No matter what the original cause of your pain, stress exacerbates the pain. You have probably noticed this fact.

Whether it’s from depression, insomnia, relationship or financial problems, stress affects us by its effect on the nervous system. Stress makes us tense and nervous – literally. Our muscles becomes tight, particularly in certain areas of the body – the low back, mid and upper back, shoulders, neck, head, forehead, and jaw are the most common areas (we also feel it in our gut, by the way, with upset stomachs, reflux, diarrhea, among other things). Over time, the chronically tense muscles can ache and spasm. In other words, the persistent stress that results from chronic pain can cause chronic muscle tension, which, is painful.

Chronic pain causes more pain! It does so through the stress that it causes, which subsequently activates the nervous system and the persistently stressed nervous system leads to chronic muscle tension, which becomes painful in and of itself.

When understanding the role of stress from this perspective, most every chronic pain patient readily understands it because they live it. They see how stress affects their pain levels from their own experience.

Stress and its effect on the nervous system can exacerbate pain through more direct routes too. It's not just the effect that stress has on muscle tension. It’s harder to see from your own personal experience, however, and so you'll have to rely on a more textbook-like explanation. Stress, particularly the persistent stress of problems that occur as a result of chronic pain, causes changes to the nervous system itself. These changes occur in the spinal cord and brain and they result in changes in how sensory information is processed. An example of sensory information is pain signals that travel from nerves in the body, through the spinal cord, and up to the brain; the brain subsequently processes this information and the experience of pain results. As a result of persistent stress to this system, the brain comes to process such information with greater and greater sensitivity and as a result less and less stimuli (i.e., sensory information) is required to experience pain (Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Imbe, Iwai-Liao, & Senba, 2006; Kuehl, et al., 2010; Rivat, et al., 2010).

It’s generally accepted that by overcoming the persistently stressful problems that occur as a result of living with chronic pain – such as insomnia, depression, anxiety, you can make some headway in reversing these changes. You might not be able to change them entirely, but enough to reduce the pain itself. Indeed, most providers would concur that to adequately manage chronic pain these kinds of stressors must be addressed (Asmundson & Katz, 2009; Kroenke, et al., 2011; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009).

Concluding remarks

In all, good stress management is essential when it comes to successfully self-managing chronic pain. There is only so much that can be done to reduce pain when you have chronic pain. The most effective therapies we have for chronic pain are at best only mildly or modestly helpful at reducing pain. There is, however, no end to how well you can get at managing the stressors that result from chronic pain. It’s possible to overcome depression or anxiety or insomnia or relationship problems or any other stressor, even if you continue to have chronic pain. Now, these problems are not easily overcome. They take work and motivation and perseverance. Nonetheless, it is possible. By doing so, you get better. Pain becomes more tolerable too. In fact, by reducing the amount of stress in your life, you also reduce pain itself.

It’s for all these reasons that your healthcare providers keep wanting to focus on the stress in your life, in addition to the chronic pain in your life.

References

Alexander, J. K., DeVries, A. C., Kigerl, K. A., Dahlman, J. M., & Popovich, P. G. (2009). Stress exacerbates neuropathic pain via glucorticoid and NMDA receptor activation. Brain, Behavior, and Immunity, 23(6), 851-860. doi: 10.1016/j.bbi.2009.04.001.

Asmundson G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26(10), 888-901.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Castillo, R. C., Wegener, S. T. , Heins, S. E., Haythornwaite, J. C., MacKenzie, E. J., & Bosse, M. J. (2013). Longitudinal relationships between anxiety, depression, and pain: Results from a two-year cohort of lower extremity trauma patients. Pain, 30. doi: 10.1016/j.pain.2013.08.025.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S.  (2006).  Central hypersensitivity in chronic pain:  Mechanisms and clinical implications.  Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Turk, D. C., & Birbaumer, N. (1985). Assessment of stress-related psychophysiological reactions in chronic back pain patients. Journal of Clinical and Consulting Psychology, 53(3), 354-364. doi: 10.1037.0022-006X.53.3.354.

Imbe, H., Iwai-Liao, Y., & Senba, E.  (2006).  Stress-induced hyperalgesia:  Animal models and putative mechanisms.  Frontiers in Bioscience, 11, 2179-2192.

Kroenke, K., Wu, J., Bair, M. J., Krebs, E. E., Damush, T. M., & Tu, W. (2011). Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain, 12(9), 964-973. doi: 10.1016/j.jpain.2011.03.003.

Kuehl, L.  K., Michaux, G.  P., Richter, S., Schachinger, H., & Anton F.  (2010).  Increased basal mechanical sensitivity but decreased perceptual wind-up in a human model of relative hypocortisolism.  Pain, 194, 539-546.

Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J.  (2010).  Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long-lasting anxiety-induced hyperalgesia.  Pain, 150, 358-368.

Vachon-Presseau, E., Roy, M., Martel, M., Caron, E., Marin, M., Chen, J., Albouy, G., Plante, I., Sullivan, M. J., Lupien, S. J., & Rainville, P. (2013). The stress model of chronic pain: Evidence from basal cortisol and hippocampal structure and function in humans. Brain, 136, 815-837. doi: 10.1093/brain/aws371.

Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 5(4), 355.

Author: Murray J. McAllister, PsyD

Date of last publication: 11-4-2013

Date of last modification: 2-18-2018

About the author: Dr. McAllister is a pain psychologist, and founder and publisher 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 consults to pain clinics and health systems on redesigning pain care deliver in order to make it more empirically supported and cost effective. He is also a frequenter presenter on pain, addiction, and redesigning healthcare.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stress Mon, 04 Nov 2013 20:06:49 +0000
Profit-Motive and Pain Management https://instituteforchronicpain.org/providers-and-payers/profit-motive-and-pain-management https://instituteforchronicpain.org/providers-and-payers/profit-motive-and-pain-management Profit-Motive and Pain Management

One of the more common sentiments that chronic pain patients express is that that the profit-motive seems to have had too much of an influence on the recommendations that their healthcare providers have made over the years. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried again and again despite having failed to reduce pain at previous clinics, they conclude that the business side of healthcare has played too much of a role in their own care. They are now disappointed, angry, and distrustful of chronic pain management providers.

Sometimes, they express this sentiment when they first come to accept that their chronic pain is really chronic. They wonder why previously no one ever sat them down and talked with them about how their pain is actually chronic. What they got instead, they say, were healthcare providers who kept recommending procedure after procedure that were described as if they might make a substantial benefit, but which were actually vain attempts to cure something that the providers should have acknowledged was a chronic condition. It must have been for the money, patients tend to conclude.

Sometimes, the sentiment comes after patients learn how ineffective some common surgical and interventional procedures are. They subsequently wonder why, if it’s not for the money, healthcare providers recommend treatments that well-designed studies have shown to be ineffective.

Sometimes, too, they come to wonder about the role of money once they have participated in a chronic pain rehabilitation program. After being on opioid medications for many years, they go through a program and come to learn how to self-manage pain without the medications. Once they get over their initial surprise that they really can manage pain without opioids, they begin to wonder aloud, “Why didn’t anyone ever refer me to a program like this before?” Then, they start wondering about the role that money might have played in continuing them on opioids for many years without ever having referred them to a program that could have shown them how to live well without the medications.

However the sentiment arises, patients with chronic pain express it fairly often: money has an undue influence on pain management recommendations.

So, is it true that money plays a role in the recommendations that pain management providers make? I think that most of us would quietly acknowledge that it can have some role. Indeed, a number of commentators in the field have publicly announced it. 1, 2, 3 

Like most things in life, though, the issue is complicated. The question of whether the profit-motive influences pain management recommendations doesn’t lend itself very well to a simple ‘yes or no’ response. Let’s look at some of these complications so that we can appreciate how complicated the issue really is.

It’s important to have an accurate understanding and appreciation for the issue, because, after all, it’s not true that all of what we do is bad even if things like the profit-motive sneak into it and influences it on occasion. Society needs the field of pain management. It’s too simple and likely not good for any of us to get so mad at its imperfections that we become jaded and forego it. We shouldn’t throw the baby out with the bath water, as the old saying goes. Rather, we can acknowledge imperfections of our field and take them into account in order to make clear-headed decisions about the recommendations we make as healthcare providers or those that we receive as patients.

Fee-for-service reimbursement influences healthcare recommendations

In countries where healthcare delivery is a for-profit industry, financial incentives can influence recommendations. To see how, we need to provide a quick review of how financial reimbursement works in a for-profit health care industry.

In the U. S., for example, most hospitals, clinics, and individual providers get paid a set amount of money per patient they see and per procedure or test they provide. This reimbursement system is called fee-for-service. Individual providers are commonly akin to independent contractors with their practice being their business and their livelihood dependent on how many patients they see and how many procedures and tests they provide. In addition, administrators of hospitals and clinics track and evaluate providers’ performance based on productivity (i.e., how many patients that are seen and how many procedures and tests that are provided).

Notice the subtle value system at work. Healthcare providers make more money when they see more patients and perform more procedures and tests. Their administrators will subsequently see those providers with the highest productivity as most favorable. Administrators promote or lay off healthcare providers in part based on productivity. In all these ways, fee-for-service reimbursement creates incentives to provide more rather than less care.

Now, we all know that incentives influence behavior. It’s true in all walks of life and it is similarly true in for-profit healthcare. Fee-for-service incentives influence the type and amount of recommendations that patients receive from their providers, clinics and hospitals. It stands to reason that such influence occurs. Sales people are rarely salaried employees. Rather, they are paid on commission because it influences them to be more productive in the amount of sales they produce – the more they sell, the more they are paid and the more their positions remain safe from being laid off. It’s the same with most healthcare providers – the more patients they see and the more procedures and tests they recommend and subsequently provide, the more they get paid and the more their administrators value their position.

There are actual studies that demonstrate the influence of such incentives on productivity in healthcare. For example, Hickson, Altmeier, and Perrin4 compared salaried physicians to fee-for-service physicians. Both groups were the same type of physician and saw the same types of patients. The fee-for-service physicians saw more patients than the salaried physicians. Likewise, Strope, et al.5 studied a recent trend for providers to build their own ambulatory surgery centers and subsequently change the site where they perform procedures, from the hospital or clinic, to the ambulatory surgery center that they own. The advantage of performing procedures at an ambulatory surgery center that the provider owns is that the provider will make more money. Specifically, they get to bill at a higher rate than in the clinic, even if it is for the same procedure. Specifically, they get to keep the money that ordinarily would have gone to the hospital for the use of the hospital facilities. So, what did Strope, et al., find in their study of this recent trend? Once providers could bill at higher rates of reimbursement and subsequently collect more money, the rate of procedures significantly increased, including the most profitable procedures. It’s hard to argue, in such circumstances, that the need for such procedures dramatically changed once providers came to own their own surgery centers. Similarly, providers who own their own imaging devices (e.g., X-ray, CT or MRI scans) are upwards of eight times more likely to order scans than those who don’t own their own imaging devices, even when the latter providers are from the same specialty and are seeing the same type of patients with the same types of health problems.6 Again, it’s hard to argue that those providers who own their own imaging devices have somehow tapped into an unmet need of patients (see, for example, Fisher & Welch7).

Rather, it stands to reason that such incentives to make more money lead to healthcare providers seeing more patients and providing more recommendations to undergo procedures and tests. As such, incentives to make more money can influence what and what doesn’t get recommended.

The concern, here, of course, is that money influences recommendations in such a way that it leads to unnecessary or ineffective care. As seen above, healthcare providers who own their own facilities or equipment have dramatically higher rates of procedures and tests than the same type of healthcare providers who don’t own their own facilities or equipment. Are the dramatically higher numbers of procedures and tests necessary? If they are unnecessary, they likely do not add value to the diagnosis or treatment of the condition patients have. In other words, under these circumstances, they are ineffective for the particular needs of patients.

It’s hard to argue that this kind of pressure doesn’t lead to unnecessary and therefore ineffective treatments and tests in the management of chronic pain. It’s common to see patients who have a history of obtaining multiple series of the same surgical or interventional procedure at different clinics, even though the first series turned out to be ineffective for their particular pain condition. Why did the subsequent providers think that repeating the same series of interventional procedures or re-doing the spine surgery was a good idea when previously the procedures were ineffective?

How money influences clinical decision-making

Let’s see how the profit-motive might influence pain management recommendations. Imagine, for example, that you are the provider in the following scenario. You have a patient who has chronic pain and is in some degree of distress about it. You’ve learned that the patient has already had a series of interventional procedures, say, and the procedures were unhelpful in reducing pain. However, you are an interventional pain provider and interventional procedures are what you do. The patient is there, at your clinic, and wants you to do something. Might you not reason to yourself, ‘well, there’s a chance that it might work, even if it’s unlikely to work, and the patient wants me to try something; rather than sending the patient away without doing anything and making him or her dissatisfied, let’s at least give it a try.’ We could call this type of clinical decision-making the ‘we might as well give it a try’ decision.

At first blush, it doesn’t seem like the fact that you will personally profit from the procedure has anything to do with the decision. Indeed, the decision seems to be able to stand on its own, as it were. The patient is in pain and is upset about it. The patient wants you to do something. It just so happens that what you do is something that has already been tried and failed in the past. However, there’s still a chance that today it might work. If it works, the patient will be happy. If it doesn’t work, you can say that at least you tried. If you don’t do anything and send the patient away, they’ll likely be more upset than they are now. So, you ‘might as well give it a try.’ The argument seems to stand on its own without needing to reference the fact that you will personally profit from the procedure. As such, the profit-motive may never enter the awareness of the provider when coming to decide on the recommendation.

Nonetheless, the profit-motive remains in the background and can assert a subtle influence. To see how, let’s take this scenario and change nothing about it but the reimbursement system in which it occurs.

Suppose, for instance, that, rather than a fee-for-service system where you profit directly from delivering the care, you work within a capitated system of reimbursement where the profit lies in providing the least and most effective care possible. In a capitated system, providers are not given a fee each time they see a patient or perform a procedure. Instead, they are given a set amount of money for the entire care of a patient for a certain time frame, such as a year. The set amount of money will cover all the care that the patient needs for the given time frame. The incentive in a capitated system is to keep people healthy and out of the doctor’s office so that they don’t use up the set amount of money with frequent visits, procedures, and tests. It also incentivizes providing the care that’s most likely to be effective, and minimizing any ineffective or unnecessary care – again, for the same reason, so that the patients don’t use up the set amount of money that was previously given for their care over the year. Capitated systems of reimbursement are not very common these days, though they were the heart of the HMO system back in the 1970-80’s in America. They may, however, return in the near future if current changes in healthcare, emanating from the Affordable Care Act, continue.

Nonetheless, suppose that, as the interventional provider in our scenario, you are now working under such a system of reimbursement. Under this system, would you be as inclined to come to the same decision to repeat a series of interventions that had previously failed– the ‘we might as well give it a try’ decision? Providing the interventional procedures are going to hurt, rather than help, your bottom line. You are still charged to care for the patient who is in pain and distress, but would you use up the set amount of money that you were given by performing procedures that have already been done and have already been demonstrated to be ineffective? Might it not be the case that you would reason against it now? In this scenario, the fact that the series of interventions has already been tried and failed seems to take on greater importance. You would weigh the previously failed treatment more heavily in your decision-making process. In your clinical decision-making process, you might reason, ‘well, why repeat a failed treatment?’

At first blush, it seems like a perfectly reasonable decision. If your car wouldn’t start and you had already paid one mechanic to fix it and the repair didn’t work, you wouldn’t take it to another mechanic and pay for the exact same repair. Rather, you’d want to pursue a different approach when attempting to fix it. Similarly, as the interventional provider, your decision to refrain from pursuing the same procedure that previously had not worked seems sound.

But, let’s step back for a second, and take stock of our two different, albeit reasonable, decisions.

It’s the same patient with the same condition, but you’ve come to two contradictory treatment recommendations. The only difference that accounts for the different treatment recommendations is how you will get reimbursed. Notice how subtly money influences your decision-making.

It’s an uncomfortable fact that the system of reimbursement in healthcare can influence clinical decision-making.

Concluding remarks

It’s a commonplace these days to advocate for the greater effectiveness of pain management by adhering to empirical-based practices. Such advocacy tends to focus on changing practice patterns through provider education as to what therapies are and what therapies are not empirically supported (i.e., have scientifically demonstrated efectiveness). In their provider education, these admirable efforts would do well to include additional lessons designed to raise awareness of an all-too-common obstacle to increasing the effectiveness of care: the delivery of unnecessary care that derives from the profit-motive. Such consciousness-raising may be uncomfortable for us chronic pain providers, but it may not only increase the effectiveness of what we do, it may also improve our credibility and rapport with the patients we serve.

References

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

2. Perret, D. & Rosen, C. (2011). A physician driven solution – The association for medical ethics, the physician payment sunshine act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

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

4. Hickson, G. B., Altmeier, W. A., & Perrin, J. M. (1987) Physicians reimbursement by salary or fee-for-service: Effect on physician practice behavior in a randomized prospective study. Pediatrics, 80(3), 344-350.

5. Strope, S. A., Daignault, S., Hollingsworth, J. M., Ze. Z., Wei, J. T., & Hollenbeck, B. T. (2009) Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the state of Florida. Medical Care, 47(4), 403-410.

6. Kouri, B. E., Parsons, R. G, & Alpert, H. R. (2002). Physician self-referral for diagnostic imaging: Review of the empiric literature. American Journal of Roentgenology, 179(4), 843-850.

7. Fisher, E. S. & Welch, H. G. (1999). Avoiding the unintended consequences of growth in medical care: How might more be worse? Journal of the American Medical Association, 281(5), 446-453.

Date of publication: 8-23-2014

Date of last modification: 10-5-2019

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Providers and Payers Sat, 23 Aug 2014 15:20:22 +0000
What is Pain Management https://instituteforchronicpain.org/treating-common-pain/what-is-pain-management https://instituteforchronicpain.org/treating-common-pain/what-is-pain-management

Pain management is a catchall phrase used to describe multiple types of healthcare services for pain. Pain management can include the following types of services:

  • Acute care for injuries and illness
  • Post-surgical pain care
  • End of life, or palliative, care
  • Burn unit services
  • Wound care
  • Chronic pain management

These different types of care are usually considered to fall into three broad categories:

  • Acute pain management
  • Terminal, or palliative, care
  • Chronic pain management

The goal of each type of pain management is the control of pain. However, each type differs in what the control of pain looks like.

In acute pain care, the goal is typically to control pain while also trying to cure the underlying condition that is causing pain.  Sometimes, it is intended to reduce pain until the underlying condition naturally heals. In palliative care, the goal of pain management is to keep the patient as comfortable as possible until the end of life. In chronic pain management, the goal of care is to maintain pain at a tolerable level while assisting the patient to return to work or other important life activities.

As patients, it’s important to understand the condition that one has and whether it is:

  • An acute condition, for which a cure or healing can be expected
  • A terminal condition, which has no cure and will bring about the end of life
  • A chronic pain condition, which typicaly has no cure but will not bring about death; patients have chronic conditions throughout the course of their natural life

In general, the type of condition a patient has determines the type of pain management the patient receives.

Typically, pain management employs an interdisciplinary model of care. Interdisciplinary care involves the services from multiple types of providers. Common types of providers that work in pain management are the following:

  • Physicians and surgeons
  • Psychologists
  • Physical therapists
  • Occupational therapists
  • Nurses
  • Social workers

Pain management usually involves some combination of these different types of providers. They work together as a team to provide the best overall care.

In the current healthcare system, chronic pain management itself is pursued in four different ways:

Most of the time, each of these different types of services involves interdisciplinary care.

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Fri, 27 Apr 2012 14:00:34 +0000