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Peripheral Neuropathy Symptoms|Symptoms of Peripheral Neuropathy https://instituteforchronicpain.org Sun, 29 Jan 2023 15:24:17 +0000 Joomla! - Open Source Content Management en-gb When Good Things Become Bad Things https://instituteforchronicpain.org/blog/item/203-when-good-things-become-bad-things https://instituteforchronicpain.org/blog/item/203-when-good-things-become-bad-things

I am nearing the end of a forty-five minute initial evaluation for our interdisciplinary chronic pain rehabilitation clinic and my patient is an amiable woman in her late forties from the suburbs. She drove a minivan to the clinic and attends the evaluation while her three children are at school for the day. Her primary care provider had referred her to us because of her chronic and disabling low back pain, which over the years had become progressively worse and more widespread.

On a daily basis, she has back and right leg pain, she tells me, but on some days, she has pain all over. She has undergone two lumbar spine surgeries, which she expresses were successful even though her pain continued and in fact worsened over time. She explains the discrepancy by stating that the “degenerative disease in my spine keeps getting worse.” She has undergone various series of epidural steroid injections, which, when she first starting getting them, were helpful in that they produced about a week’s long reduction in pain, but she states now, “They don’t work anymore.” She reports also having had a neuroablation procedure that unfortunately “made things a bit worse.”

My patient tells me that her low back pain began during the second pregnancy of her three children. At first, it came and went, but over time it came to stay. She began to seek healthcare for it eight years ago with her primary care provider. At the time, the provider prescribed a short-acting opioid two times daily and recommended that she walk for about twenty to thirty minutes, four times a week. She indicated that her primary also reassured her that her pain would dissipate as it had in the past. After her third refill request, her provider re-evaluated her and ordered an MRI scan with subsequent referral to a spine surgeon. Her first lumbar surgery, an L5-S1 fusion, reduced the pain initially, but after having returned to full-time work for a few months the pain worsened. With an increased dose of opioids, she attempted to return to work yet again, but eventually she stopped working altogether. Her burgeoning career had ended. Since having given up attempts to return to work, she underwent another fusion. She repeats to me today that this secind surgery was successful, but it’s unclear to me how it’s been successful. She has remained distressed and disabled by pain and it continues to require the use of opioid medication that’s been increasing in dose over time. I decide against asking further about the topic and move on with the evaluation.

Understandably, the loss of her career has been a persistent source of grief and loss for her. To make things worse, with some individuals of her extended family, this loss of work has been a source of stigma too. She professes a number of times she loved her job. She implies, with an endearing sense of humility, that she was good at what she did. Between the lines, it seems clear that her self-esteem seemed grounded in her highly adept multi-tasking abilities to raise three children, be a loving and helpful spouse, and work a 40+ hour professional position in a career for which she had gone to college. By all accounts, she was really good at all of it and she was rising through the ranks of her organization. Until, her pain became too much.

But then, she became caught between either maintaining the career she loved with increasing back pain or reducing her back pain and acquiring a persistent grief and stigma over giving up her beloved career.

Again, I don’t challenge her reported history and the dilemma she experiences. I have no reason to do so, as her experience is so understandably common. In the interview, I repetitively try to empathize with her and show her that I understand and do not judge.

Nonetheless, throughout the interview, in what seems like anticipation of potential criticism from me, she recurrently stresses that she has tried everything in order to remain at work – multiple surgeries, numerous interventional procedures, multiple physical therapies, occupational therapy, and increasing levels of opioids. She persistently expresses to me how much she loved her work. She says a number of times that she would return to work in a heartbeat if she could find something that would reduce her pain.

The only thing that she identifies as at all helpful is her “pain medicine,” by which she means opioids. She acknowledges that the opioids haven’t helped her return to work, but stresses that it’s because her pain is just too great. She volunteers often in the interview that the opioids “take the edge off” and that they “allow me to function enough to get my kids off to school and keep the house running.”

Like the fact that she’s not working, my patient seems vulnerable about her use of opioids. She acknowledges that she’s becoming quite tolerant – she’s now on moderately high doses of both long-acting and short-acting opioids for pain. Nonetheless, she recurrently stresses how bad her pain would be without them. She also asserts a number of times that she’d give them up in a minute if there was something that would get rid of her pain, but as her treatment history demonstrates, she’s tried many procedures and therapies and nothing has worked. So, she’s caught in yet another dilemma: she has to take something that she doesn’t want to take.

My patient offers these repetitive assertions without any prompts or inquiries from me. Throughout the evaluation, I never challenge her reported inability to work or the necessity of her use of opioids. Rather, I maintain a friendly, neutral, and non-judgmental demeanor.

We near the end of the evaluation and it is customary at this time to discuss a proposed treatment recommendation as well as other potential treatment options from which she can compare and contrast the proposed recommendation. Other than my experience of having performed this kind of evaluation countless times before, I have no indication that the ensuing discussion will be anything but collaborative. For indeed, because of her repetitive expressions of distress about both her job loss and the necessity of having to take of opioids, I might have every reason to believe that she’ll welcome my recommendation to transfer her care to our clinic, as we specialize in the things that she finds most distressing: her persistent intolerable pain, her resultant disability from work, and the fact that at this time she needs opioid pain medications to manage her pain. What we can offer her, in other words, is the opportunity to have a team of supportive, non-judgmental experts help her to gradually acquire the abilities to self-manage pain without opioids and return to work in some meaningful capacity – both of which are things that no other pain clinic that she’s previously seen has offered her. So, given her repetitive assertions that she’s tried everything and so must remain on opioids, I can offer her hope that we have a therapy that she hasn’t yet tried, which allows her the opportunity to learn how to manage pain without opioids.

Given my past experiences, however, I approach the recommendation in a gentle manner. I review with her my understanding of the dilemmas she has faced and empathize again with how anyonechuttersnap 193778 compressor would find such problems difficult. I want her to know that I understand – that I get it. I then talk about her treatment history – the different types of surgical, interventional and opioid management that she has had. I want to demonstrate that I’ve been listening and know the many different procedures and therapies she has had. I review that none of them were unreasonable, and in fact that they all have had their time and place. I then change the focus of the conversation to the fact that there has always been another type of pain clinic, called chronic pain rehabilitation, which pursues care differently, just as a surgeon is different from an interventional pain physician, we are yet again different from either, though we treat the same conditions. I review that in our healthcare system often times patients tend to get referred to our type of pain clinic after the other types of treatment have been tried and failed, which seems the case for her.

I review with her that, while we don’t typically cure people of their pain, we have an interdisciplinary team of providers who essentially serve as her coaches and we slowly and gradually teach folks just like her how to self-manage pain so successfully that they no longer require opioid medications to manage their chronic pain. I stress that it takes time and effort, but with the right kind of coaching, it’s possible to learn to self-manage pain without opioids. We also help people find some type of meaningful, structured activity to pursue, such as work, school or volunteering, which helps folks just like her get back on a track in life that they feel good about again. I review that she may or may not be able to return to her previous position, but through a combination of creatively coming up with options we might be able to identify some type of meaningful work that she could strive to obtain.

I also share with her that we have been maintaining outcomes on our program for years and that what we find is that our patients have a more than 90% reduction in opioid use and over 50% of our patients return to work, volunteering, or job retraining/school. I add at the end of my gentle and hopeful message that on average our patients report 20% less pain then when they started, even after they’ve achieved these other gains. In other words, on average, our patients have 20% less pain even though they are no longer taking opioids and have significantly increased their daily activities, by returning to work or school.

From my chair in the consulting room, this message can be heard as a beacon of hope – that she does not have to settle for the life she currently has; with hard work, coaching, and learning, she can get better. She will, of course, continue to have pain, but she will likely have less pain, be off her opioids and engaged in some type of regular, meaningful activity that allows her to feel proud of herself again. It’s a hopeful message that details a way to get better while grounded in the realism that she truly has a chronic – lifelong—pain condition.

As I near the end of this feedback and recommendation, I can tell, however, that from her chair, my message is not a beacon of hope at all. It began when her legs started to fidget. Then, tears began to well up in her eyes. By the time I finished, she had become intensely vulnerable and subsequently very angry.

I could tell that the good things our clinic has to offer had become bad things.

Now, the patient that I describe in this encounter is not an actual person. I made her up. She’s not, though, no one. She could be most any one of my patients. She could be a man in his thirties or a man in his fifties or a woman in her sixties. He might have recurrent migraine. She might have had persistent neck pain.

The point here is not the details of the individual’s presenting problem, or their gender, or whether the individual has children in school or not. The point is how an individual hears and tolerates feedback about themselves and the recommendations they receive. It’s also about one’s capacity for hope – that hope often lies in the eye of the beholder.

Because we are a clinic that specializes in people with persistent pain who are disabled by pain and/or reliant on opioids, we tend to see a lot of patients who fit these descriptions. Sometimes, we see patients who welcome the help we can provide. Nonetheless, we often see patients who become threatened by the help we provide.

It all tends to boil down to two things: one, the degree of shame, or vulnerability, that patients have for finding themselves in the position that they are in, whether it be reliant on opioids or unable to work or both; and two, the degree to which they can openly acknowledge this shame in some constructive manner.

When people have high degrees of shame and significant difficulty acknowledging it, they tend to experience stigma when others broach the sensitive topic even when no stigma was ever intended. As a result, they tend to shun open discussion of their role in their health, and instead engage in discussions of how there's nothing more to do, but what they are doing. This impassable stance thus comes to justify the sense of vulnerability, or shame, they feel for taking opioids or being disabled or both. I didn't choose this; I have to do this.  

From this perspective, my patient might make any number of counter-arguments:

  • My surgeon told me that there’s nothing more that can be done.
  • My doctor told me that I’d probably have to be on these medications for the rest of my life.
  • I have a degenerating disc disease. It’s just going to keep getting worse. You‘re not going to cure that!
  • If pain rehabilitation programs are as successful as you say they are, why wouldn’t my doctor have referred me earlier?
  • Look, I’ve done everything humanly possible to get back to work. If it’s as easy as you say it is, then you aren’t seeing people like me.
  • I have the highest pain tolerance of anyone I know and my pain would be intolerable without pain medicines.
  • I don’t know who you’re seeing in your program, but I’ve got real pain!
  • Every doctor I’ve ever seen has reassured me that it’s okay to be taking pain medicines (i.e., opioids) and to be on disability, why are you questioning it now? You talk to me all calm and gentle like, but you’re actually the meanest doctor I think I’ve ever seen!
  • You think I want to be this way? I can’t believe I’m sitting here listening to this.
  • Are you in pain? I know you’re not, because if you were you wouldn’t be saying the things you’re saying.
  • You don’t have my pain! You have no idea how bad it is. How dare you say that I can learn to cope with it. If you had my pain, you’d know I'm coping better than anyone possibly can under the circumstances!

Such responses and more are common reactions to a recommendation to participate in a chronic pain rehabilitation program where patients learn how to self-manage pain and return to work. The recommendation, of course, is meant as a good thing, a beacon of hope, that with hard work, openness and motivation, they can achieve these goals. Implied in these responses to the recommendation, however, is the rejection of the notion that patients can't do anything about their pain. The above reactions imply that patients have done all that can be done; they’ve learned all that they can learn. They've done everything humanly possible and so are beset with having to be on opioids and/or disability. The reactions are all versions of these implications -- dare not question the conclusion that remaining on opioids and/or disability is the only possible things left, because I didn't choose this -- I have to do this.

It is, however, these very conclusions that come into question with a recommendation to participate in a chronic pain rehabilitation program. The recommendation is indeed an affirmation of the pssibility of change for the better -- that, with effort over time, they can come to cope better with pain -- so good, in fact, that one wil be able to self-manage pain without opioids and return to some meaningful, structured activity, such as work. One might think that this message is a good thing – there is still more to be done and so therefore there is still hope!

Why shun, then, this possibility of hope? Why shun the possibility of having a greater sense of control – even a potential control that one doesn’t yet have?

Shame and pain

It is shame. It's the sense of shame that comes when people recognize that they have a role in their health and in the conditions in which they find themselves. This shame is threatening. In some ways, it's safer to view oneself as powerless. Acknowledgement of power – even the power to get better – cuts both ways.

Is it a good thing or bad thing? It depends on the perspective. Good things can easily become bad things.

In early psychoanalytic thinking, Freud (1943) called it resistance and considered it one of the hallmarks of a mental health, as opposed to a physical health, condition. Cancer patients, for instance, don’t tend to resist the recommendations of their oncologist, but will rather readily do most anything to beat their cancer. Later Kleinians (cf. Ogden, 1990) focused on patients’ sense of vulnerability and the shame that underlies it. They recognized that any one of us, with whatever health condition we have, can move fluidly in and out of perspectives that we take when interacting with others. Sometimes, we interact in strong and mature ways and so accept feedback as constructive, while other times we become vulnerable and so hear the very same feedback as shaming. As a result of the latter, we can become defensively angry or offended. In such  scenarios, we tend to resist the feedback, come to see the person who is providing it as being judgmental or incompetent or mean. In more contemporary times, Miller & Rollnick (2013), for example, call it ambivalence. Ambivalence captures the fluidity of perspectives that we can all take: we all might recognize the experience of wanting to start an exercise routine and not wanting to at the same time or getting feedback from a healthcare provider about the need to lose weight as a realistic observation or as a criticizing judgment to which one responds with resistance. These common perspectives can be taken with most any health condition. It’s one of the reasons that we might advocate to no longer split up health conditions between mental and physical health, but rather recognize that all health conditions are biopsychosocial in nature.

Nonetheless, we don’t have to use complicated conceptualizations to describe what occurred between my patient and myself when giving her feedback and a recommendation. We might just call it the experience of when good things become bad things. 

References

Freud, S. (1943). A general introduction to psycho-analysis. Garden City, New York: Garden City Publishing.

Miller, S. & Rollnick, W. R. (2013). Motivational interviewing: Helping people change, 3rd edition. New York, New York: Guilfard Press.

Ogden, T. H. (1990). Matrix of the mind: Object relations and the psychoanalytic dialogue. Oxford, UK: Jason Aronson.

 

Date of publication: August 28, 2017

Date of last modification: December 7, 2019

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Mon, 28 Aug 2017 12:32:05 +0000
Are Opioids the Most Powerful Pain Reliever for Low Back Pain? https://instituteforchronicpain.org/blog/item/202-are-opioids-the-most-powerful-pain-reliever-for-low-back-pain https://instituteforchronicpain.org/blog/item/202-are-opioids-the-most-powerful-pain-reliever-for-low-back-pain Are Opioids the Most Effective Pain Reliever?

Opioids, or narcotic pain medications, are commonly thought of as powerful pain relievers. Patients frequently request them and healthcare providers often prescribe them for back pain because they think that opioids are the most effective pain reliving treatment. Popular media and others in society also commonly think that without opioids patients will suffer intolerable or “intractable” back pain. The implication is that, again, opioids are the most powerful and effective pain reliever.

But are they the most effective pain relieving treatment for back pain?

 The American College of Physicians (Qaseem, et al., 2017) recently published guidelines for the treatment of acute low back pain (i.e., back pain lasting less than three months) and chronic low back pain (i.e., pain lasting longer than three months). Experts in the field of low back pain from within their group developed the guidelines. The experts reviewed all the available scientific evidence on what works and what doesn’t work for low back pain. Specifically, they reviewed the evidence for the effectiveness of medications and non-medication therapies, with the exception of surgeries and other interventional procedures, such as spinal injections.

Here’s what they found:

  • Many therapies have more evidence in support of their effectiveness than opioids
  • A number of non-medication therapies were more effective than any medication, including opioids
  • For low back pain lasting less than three months long (i.e., acute low back pain), the therapies that have more evidence to support their effectiveness are anti-inflammatory medications, heat, exercise, spinal manipulation (i.e., chiropractic) and possibly acupuncture
  • For low back pain lasting longer than three months (i.e., chronic low back pain), these therapies are largely considered to be more effective than opioid pain medications: interdisciplinary pain rehabilitation programs, cognitive behavioral therapy, exercise, mindfulness based stress reduction, and to a lesser extent acupuncture, tai chi, and yoga.
  • Of the medications used for chronic low back pain, anti-inflammatories and duloxetine have greater support for their effectiveness than opioid medications.
  • Opioid pain medications, while having less scientific evidence supporting their effectiveness, were associated with increased risk of harm, including addiction and death.

Perhaps it’s time to start dispelling the myth that opioid pain medications are always the most effective pain relieving treatment. There are conditions, like low back pain, for which other treatments are more effective. On top of it all, these more effective treatments aren’t associated with high rates of addiction and death.

References

Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530.

Author: Murray J. McAllister, PsyD

Date of last modification: July 5, 2017

About the author: Dr. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. 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. 

The views contained in this post are solely those of the author and do not represent Courage Kenny Rehabilitation Institute or Allina Health.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Opioids Tue, 04 Jul 2017 13:14:56 +0000
Activity versus Exercise: Coping with Pain Series https://instituteforchronicpain.org/blog/item/201-activity-versus-exercise-how-to-cope-with-pain-series https://instituteforchronicpain.org/blog/item/201-activity-versus-exercise-how-to-cope-with-pain-series Activity versus Exercise: Coping with Pain Series

Exercise, of course, is good for you. Activity is good for you too. Both are helpful for those with chronic pain. Yet, they are different. They are not an equal substitute for the other. Let’s explain.

Activity

Patients often come to providers and, upon evaluation, respond affirmatively after being asked whether they engage in any regular exercise. When asked to describe their exercise routine, some folks go on to report various activities that they pursue through the course of their day. Still other times, they suggest that they get a lot of exercise because their employment involves being on their feet all day, such as with a retail sales associate, or engaged in other activities, such as the case of a carpenter or machinist.

Engaging in activities on a daily basis is important when self-managing chronic pain. It’s important because it fosters improved coping. The following list describes some of the numerous ways that remaining active helps people to cope with chronic pain:

  • It provides a meaningful focus away from pain and focuses attention on other pursuits that have value in life
  • Provides sources of self-esteem, as we tend to feel good about ourselves when we are productive in some way
  • Provides sources of self-definition, as we often define ourselves by our occupation, hobbies, roles in the family
  • Brings a sense of happiness and fulfillment when we pursue activities that we value
  • Dispels the belief that chronic pain is a sign of injury and frailty, and instead reinforces a sense of confidence that remaining active despite pain is appropriate and healthy

The list isn’t exhaustive of all possible benefits of remaining active while living with chronic pain. However, these benefits, along with others like them, stand to reason. Who would argue that chronic rest and inactivity, along with its resultant lack of stimulation, boredom and lack of direction to one’s life, is good for anyone?

Empirical research backs up our rationally derived conclusions about the benefits of activity. Physical activity, along with its concomitant psychological stimulation, seems to change how the brain and spinal cord process signals from nerves in the body that could ordinarily be turned into pain (Naugle, et al., 2017). Those who maintain regular, stimulating physical activity tend to have less pain than those who remain passively inactive.

In another study, Pinto, et al., (2014) similarly found that higher levels of moderate-to-vigorous, leisure time activities were associated with reduced pain and perceived disability 12 months later. In other words, regular activity, rather than persistent rest, inactivity and lack of stimulation, is associated with less pain and improved coping.

Both common sense and science thus determines the truth of a standard maxim in chronic pain rehabilitation: that if you want to cope well with chronic pain, you must get up off the couch and go do something that’s stimulating, pleasurable or meaningful in some way, and preferably outside the house with other people.

Can we, or better yet, should we, count engaging in activities, such as most forms of work and play, as exercise?

Exercise

By exercise, we might define as repetitive bodily movements for the purposes of improving health, or physical and emotional well-being (Cf. Howley, 2001). Common types of exercise are stretching, core strengthening and aerobic exercise. Stretching involves the extension of various muscle groups, whereas core strengthening exercises attempt to increase control of abdominal and trunk muscles over the pelvis, with the goal of stabilizing the position of the spine (Hodges & Richardson, 1996). Aerobic exercise involves continuous use of large muscle groups that increases heart and breath rates (Pollock, et al., 1998).

Of course, everyone should follow the recommendations of their own healthcare providers, as each person’s health conditions can be different. However, a common form of exercise that is typically important for the management of chronic pain is mild, low-impact aerobic exercise.

Examples of gentle, low-impact aerobic exercise are walking, biking on land or on a stationary bike, use of an arm bike, and walking or swimming in a pool. These exercises are typically mild on the joints of the ankles, knees, hips and low back. So, in this sense, they are not rigorous and so most people with chronic pain can begin engaging in one of these types of exercises for at least a limited amount of time. Nonetheless, these exercises elevate the heart rate, which is what’s important and what makes them aerobic in nature. It’s also what makes these activities into a form of exercise.

With typical daily activities, we don’t elevate our heart rate for a continuous amount of time, which is what we do when engaging in aerobic exercise. When walking on land or in a pool or when riding a bicycle, our heart rate increases and continues at this elevated pace until we stop the exercise. This continuous elevated heart rate is what makes exercise an exercise and it’s what makes the difference between activities and exercise. Activities are meaningful and stimulating and engages attention away from pain, which is all well and good, but most activities don’t elevate heart rate in the manner that exercise does.

As such, activities are not exercise.

Some form of aerobic exercise is essential for successfully self-managing pain. When done on a regular basis, it reduces pain (Hauser, et al., 2010; Kroll, 2015; Meng & Yue, 2015). Likely, it does so by the effect that aerobic exercise has on the nervous system.

When we get a good, aerobic workout, our nervous system produces feel-good chemicals that produce a mild sense of euphoria and reduce our reactivity to stimuli that might typicaly affect us. For a period of time following the exercise, we have a sense of feeling mellow and things that normally bug us don’t bug us as much. The same goes for things that might typically cause pain. They don't cause as much pain as they usually do. In this relaxed state, our nervous system is simply less reactive or sensitive. Runners call this experience a runner’s high. However, you don’t have to run to get it. Simply walking or biking or engaging in pool exercises can also do it.

When done on a repetitive basis, you lower the reactivity of the nervous system and thereby the things that used to cause pain don’t cause as much pain or come to cease causing pain all together. The less reactive nervous system simply doesn’t react to produce pain as it once did. In so doing, you can increase the threshold for what elicits pain through the intervention on the nervous system, which we call mild, aerobic exercise. In other words, you can reduce the degree of pain you have.

There’s a couple of important things to keep in mind.

One, the mild aerobic exercise must be done on a regular basis over time. It doesn’t have the described effect if you just do it once or twice, or if you do it only once in a while. There’s no exact number to quote, but a rough rule of thumb would be to engage in some type of mild aerobic exercise three to four times weekly on a continuous basis and after a number of weeks you’ll come to see some difference in pain levels. It won’t happen, in other words, over night in a dramatic manner. It occurs in a subtle manner over time. You might not even notice it at first, but at some point you'll have a realization that your pain isn’t as bad as it once was.

Second, when starting out, you can easily do too much and as a result flare up your pain. This experience can be unpleasant and it can come to perform double duty as the perfect rationalization to stop your attempt to begin an exercise routine. It’s common for people to say in clinic that they tried to start an exercise routine, but that it hurt too much so they stopped exercising altogether. In beginning an exercise routine, then, it pays to start out slow and with a limited amount of time for each instance of walking or biking or pool exercise. Again, there’s no hard and fast rule to follow, but a combination of consultation with your healthcare providers and common sense can go a long way. Talk with your pain rehabilitation providers and come up with a modest beginning point and slowly, over time increase the length of time that you engage in the exercise. Perhaps, at first, it’s quite modest, so modest that you might not expect much pain relief. However, you’ve got a starting point from which you can slowly increase the time or rigor of the exercise as you get into shape. Over time, you increase the exercise to a point of rigor that really does provide benefit. So, it pays to consult with your pain rehabilitation providers to find a form of mild, aerobic exercise that works for you and to be patient in getting to a point that will really help you.

As we’ve said, engaging in some type of mild, aerobic exercise on a frequent and regular basis is essential for most people to self-manage chronic pain well.

Summary

In this post, we discussed two important things that most people with chronic pain do if they want to self-manage it well. They engage in meaningful and stimulating activities and they engage in a mild, aerobic exercise on a frequent and repetitive basis. We reviewed that activities and exercise are not the same. They each provide benefit in different ways. We described these benefits and reviewed some basics to get started. We also discussed the importance of seeking consultation with your pain rehabilitation providers when getting started. Along the way, we hopefully also motivated you to do both meaningful activities and some form of mild exercise.

References

Hauser, W., Klose, P., Langhorst, J., Moradi, B., Steinbach, M., Schiltenwolf, M., & Busch, A. (2010). Efficacy of different types of aerobic exercise in fibromyalgia syndrome: A systematic review and meta-analysis of randomized controlled trials. Arthritis Research & Therapy, 12, R79.

Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the spine associated with low back pain: A motor control evaluation of the transversus abdominis. Spine, 21(22), 2640-2650.

Howley, E. T. (2001). Type of activity: Resistance, aerobic and leisure versus occupational physical activity. Medicine & Science in Sports & Exercise, 33, S364-S369.

Kroll, H. R. (2015). Exercise therapy for chronic pain. Physical Medicine & Rehabilitation Clinics of North America, 26, 263-281.

Meng, X. G. & Yue, S. W. (2015). Efficacy of aerobic exercise for treatment of low back pain: A meta-analysis. American Journal of Physical Medicine & Rehabilitation, 94(5), 358-365.

Naugle, K. M., Ohlman, T., Naugle, K. E., Riley, Z. A., & Keith, N. R. (2017). Physical activity behavior predicts modulation in older adults. Pain, 158(3), 383-390. doi: 10.1097/j.pain.0000000000000769

Pinto, R. Z., Ferreira, P. H., Kongsted, A., Ferreira, M. L., Maher, C. G., & Kent, P. (2014). Self-reported moderate-to-vigorous leisure time physical activity predicts less pain and disability over 12 months in chronic and persistent low back pain. European Journal of Pain, 18(8), 1190-1198. doi: 10.1002/j.1532-2149.2014.004688

Pollock, M. L., Gaesser, G. A., Butcher, J. D., Despres, J. P., Dishman, R. K., Franklin, B. A., & Garber, C. E. (1998). ACSM position stand on the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medicine & Science: Sports & Exercise, 30(6), 975-991. 

Author: Murray J. McAllister, PsyD

Date of publication: June 25, 2017

Date of last modification: June 25, 2017

About the author: Dr. McAllister is a pain psychologist and the 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. 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 25 Jun 2017 13:31:39 +0000
What is Chronic Pain? https://instituteforchronicpain.org/common-conditions/neuropathy/peripheral/item/200-what-is-chronic-pain https://instituteforchronicpain.org/common-conditions/neuropathy/peripheral/item/200-what-is-chronic-pain What is Chronic Pain?

Patients and healthcare providers commonly think of pain as a symptom of an underlying injury or illness. Say, for example, you hurt your low back while lifting. Perhaps, you’ve injured a muscle or ligament, or perhaps it’s an injury to the spine, like a disc bulge or herniation. Either way, you now have pain and the pain is the symptom of the injury. The same might be true for any health condition that causes pain, particularly when it first starts.

Acute pain defined

We call this type of pain acute pain.  Acute pain has two characteristics. First, just as described, acute pain is a symptom of an underlying health condition. Second, its duration is

Patients and healthcare providers commonly think of pain as a symptom of an underlying injury or illness. Say, for example, you hurt your low back while lifting. Perhaps, you’ve injured a muscle or ligament, or perhaps it’s an injury to the spine, like a disc bulge or herniation. Either way, you now have pain and the pain is the symptom of the injury. The same might be true for any health condition that causes pain, particularly when it first starts.

Chronic pain is not long-lasting acute pain

Sometimes pain doesn’t go away. It can last for longer than six months. In fact, it can last for years. In these situations, there is a tendency among patients and some healthcare providers to continue to see the pain as a symptom of the underlying health condition that started it. They think of chronic pain as simply the long-lasting pain of an injury or illness that hasn’t yet healed.

This line of thinking leads to getting a lot of healthcare. Surgeries, injections, and other interventional procedures are common attempts to reduce pain by focusing on the underlying condition that started the pain. The typical chronic pain patient has had any number of such procedures and therapies.

These procedures and therapies aren’t very effective. At best, they tend to provide temporary reductions in pain. Studies of healthcare expenditures show that in the last twenty years the rates of pain-related surgeries, injections and narcotic pain medications are at an all time high. At the same time, applications for pain-related disability are also at an all time high.1 Obviously, these procedures and therapies don’t work so well.

The truth is, once pain is chronic, it’s pretty hard to stop, particularly if the focus of care is to try to fix the underlying injury or illness that started it all.

The reason is that chronic pain is something more than the pain of a health condition that hasn’t healed. The importance of this point is hard to underestimate.

Chronic pain defined

Chronic pain has two characteristics that are different from acute pain. First, chronic pain lasts longer than six months. Second, and most importantly, chronic pain is pain that occurs in addition to the pain of the original health condition. In fact, the original, underlying condition may or may not have healed. It doesn’t really matter. Chronic pain is pain that has become independent of the underlying injury or illness that started it all.

Once pain has become chronic, attempts to fix the underlying injury or illness that started it tend to fail to reduce pain. The mistake that patients and some healthcare providers make is to think that chronic pain is just a long-lasting version of acute pain. However, chronic pain is pain that has taken on a life of its own. Chronic pain is pain that is occurring over and above any pain that may or may not occur from the underlying injury or illness that started it. As such, attempts to cure the original health condition commonly miss the mark.

Cause of chronic pain

What then is the cause of chronic pain? To answer this question, we need to understand some facts about the nervous system.

Whatever its initial cause, pain is a function of the nervous system. Say you injure your low back. Nerves around the site of the injury detect it and sends signals that travel on a highway of nerves from the injury to the spinal cord and up to the brain. Once they get to the brain, the brain processes the signals and they register as pain in the low back. The whole highway, from the nerves in the low back to the brain, is the nervous system.

At the same time as the signals travel from the injury to the brain, the whole nervous system becomes reactive. Like a fire detector in a building sounding the alarm in response to fire, the nervous system sets off the alarm bells when in pain. Our muscles become tense. We guard and grimace. We cry and are emotionally alarmed. The nervous system controls all these reactions. We can think of it as the whole nervous system going into red alert.

This reactivity of the nervous system is all well and good when it comes to acute pain. It helps us to know that something is wrong. Becoming alarmed, we protect against further injury and seek help. Once the original injury or illness heals, everything about the nervous system usually comes back to normal.

In some people, however, the nervous system can stay in a persistent state of reactivity even upon healing of the original acute injury or illness. The whole nervous system becomes more and more reactive in a process called wind-up. This reactivity of the nervous system comes to maintain pain in a vicious cycle, over and above the pain of the original condition that started it all. The end state of this process is a highly reactive nervous system called central sensitization.

The hallmarks of central sensitization are increasingly widespread pain and increasingly intense pain. Suppose you have an injury to your neck and come to have chronic neck pain. In this process, central sensitization develops independdnelty of whether the initial injury heals.  Subsequently, you develop pain in your shoulders and upper back as well as tension headaches in adition to neck pain. The pain may become so intense that even touch can hurt.

Other problems occur as well with central sensitization. Since the nervous system also controls our emotional lives, a highly reactive nervous system leads to anxiety and irritability, poor sleep, fatigue, and eventually depression. These psychological problems are secondarily stressful. The stress adds to the reactivity of the nervous system, making the pain worse.

The upshot of it all is that chronic pain develops from acute pain but becomes an altogether different type of pain, which we call chronic pain, by way of central sensitization and is not the result of a long-lasting injury or illness.

Central sensitization can occur with all acute pain conditions. It can occur with spine-related acute injuries, whiplash injuries, tension headaches, migraine headaches, rheumatoid arthritis, osteoarthritis, and endometriosis. It can occur with injuries from a motor vehicle accident or following surgeries.

The importance of treating the nervous system in chronic pain

Chronic pain is thus categorically different from acute pain. It’s not just that it lasts longer. It’s that the whole nervous system is involved, maintaining the chronicity of the pain, over and above whatever pain that might continue, if any, from the original health condition that started it.

Earlier, we commented on the frequent failure of surgeries, injections, and other interventional procedures to permanently reduce pain. From here, we can see why. They are attempts to fix the injury or condition that started it all. The original condition, however, is typically not what’s responsible for maintaining pain on a chronic course. That is to say, the treatments fail because none of them address the most important cause of chronic pain – central sensitization.

The only treatment that fully addresses central sensitization is chronic pain rehabilitation.

References

1. Brook, M. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., & Sullivan S. D. (2008). Expenditures and health status among adults with back and neck problems. Journal of the American Medical Association, 299, 656-664.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) What is Chronic Pain Thu, 20 Apr 2017 16:47:15 +0000
Thoughts & Prayers https://instituteforchronicpain.org/blog/item/199-2thoughts-prayers https://instituteforchronicpain.org/blog/item/199-2thoughts-prayers

The Institute for Chronic Pain is saddened by the recent outbreak of fungal meningitis from tainted steroid used in interventional pain management procedures.  As of this writing, over 400 cases have been reported and 29 deaths. Our thoughts and prayers go out to those who are ill and to the families of those who have lost their lives.

Date of last modification: 11/4/2012

Author: Murray J. McAllister, PsyD

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Sun, 04 Nov 2012 00:33:53 +0000
Institute for Chronic Pain Blog: Introductions https://instituteforchronicpain.org/blog/item/177-0institute-for-chronic-pain-blog-introductions https://instituteforchronicpain.org/blog/item/177-0institute-for-chronic-pain-blog-introductions

Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.

Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.

Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.

It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.

  • As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
  • As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
  • We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
  • As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured, as we do with other chronic conditions, such as diabetes or heart disease.
  • Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
  • As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
  • As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
  • As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
  • As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures which are largely ineffective

The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.

To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.

In short, we need to change the paradigm that underlies chronic pain management.

* *

Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago. In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.

A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. They began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.

Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.

It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.

On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.

On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.

All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking.  They have been largely effective in making a profound and beneficial impact on our health.

The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.

It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.

The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:

  • We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
  • Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
  • Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
  • We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
  • We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.

The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.

The Institute has set out a number of methods for achieving the resolution of these goals.

  • We have a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
  • We provide this blog through our website.
  • We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
  • We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
  • We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
  • We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
  • We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
  • We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.

Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.

We hope that you will join us in this endeavor. Join our community and be part of this change.

 

Author: Murray J. McAllister, PsyD

Date of last modification: 10/7/2012

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Introduction Sun, 07 Oct 2012 13:39:07 +0000
Is It Time to Talk About Managing Pain Without Opioids? https://instituteforchronicpain.org/blog/item/176-79is-it-time-to-talk-about-managing-pain-without-opioids https://instituteforchronicpain.org/blog/item/176-79is-it-time-to-talk-about-managing-pain-without-opioids Is It Time to Talk About Managing Pain Without Opioids?

Opioids are certainly in the news. The US Surgeon General recently issued a statement on the relationship between their widespread use for chronic pain and the subsequent epidemics of opioid addiction and accidental overdose (US Surgeon General, 2016). The US National Institute for Drug Abuse and Centers for Disease Control have also issued concerns (see here and here, respectively). Mainstream media reports on the problems of opioids appear almost daily.

After a couple of decades of strong proponents and persistent messaging on the benefits of opioids, the tide of public opinion and the opinion of health experts seems to be turning against the widespread use of opioids for chronic pain.

Among people with chronic pain who use opioids, this change in perspective on the use of opioids can be alarming. For about two decades, people with chronic pain have been encouraged to take opioid medications. Many have subsequently come to rely on them. Some may have even come to believe that it is impossible to manage chronic pain well without the use of opioid medications.

We now face a dilemma in the management of chronic pain. We have strong proponents for the use of opioids and strong proponents against the use opioids. Both sides have valid concerns that lead to their respective positions.

Often, the sides in this dilemma seem to get expressed in untenable ways. It’s as if the stakeholders in the field have to choose between two bad options: either you take opioids on a chronic basis and expose yourself to the risks of addiction and accidental overdose, which are actually occurring to people with chronic pain at epidemic proportions; or don’t take opioids, remain safe from addiction and accidental death, but expose yourself to pain, which may be intolerable. Healthcare providers seem to face a corresponding dilemma: either manage patients on chronic opioids while exposing them to addiction and accidental overdose or refrain from opioid management and expose them to what might be intolerable pain. Whether patient or provider, both options seem bad.

Is there a third option?

There is another way, of course. It’s called chronic pain rehabilitation and it effectively shows people how to successfully self-manage chronic pain without the use of opioid medications. Chronic pain rehabilitation clinics have been around for three to four decades. However, it’s hard to get people to go to them. It’s not because they are ineffective. Research over the last four decades shows clearly that they are effective (Gatchel & Okifuji, 2006; Kamper, et al., 2015).

Managing pain without opioids

People who’ve been managing their pain with opioids are often a little leery of recommendations to go to a chronic pain rehabilitation clinic. The recommendations seem to run counter to much of what’s been previously recommended throughout the long course of care for their chronic condition. After years of recommendation and encouragement to take opioids by some providers, it’s hard to understand why other providers might recommend and encourage the exact opposite. Maybe they are recommending learning to self-manage pain without the use of opioids because:

  • They don’t believe my pain is as bad as it is.
  • They think (wrongly) that I’m addicted to opioid medications.
  • They think my pain is all in my head.
  • They just want to make money off their program that they are recommending.
  • They are ignorant of what’s most effective for chronic pain (i.e., they don’t know what they’re talking about).
  • They are not as compassionate as the previous providers who recommended opioid management.

In all these concerns, people become leery of a recommendation to forego opioids because it’s hard to believe that the recommendation is being made in the best interest of the patient. It seems that relief of pain through the use of opioids is what’s best for the patient and anything that runs counter to that recommendation must be in the best interests of someone else.

Moreover, it’s a sensitive topic. Let’s face it, no one feels especially proud of managing their chronic pain with opioids. Rather, people with chronic pain do it because it seems a necessity – they believe that the pain will be intolerable without opioids. The recommendation and encouragement to take opioids by healthcare providers and by society, more generally, is helpful in this regard. Such encouragement supports the decision to use opioids, one in which there’s always been some ambivalence. Again, no one is exactly proud of taking opioids for chronic pain; upon reflection, there is always some degree of doubt or concern about their use that leads to a sense of vulnerability and sensitivity. It’s helpful to have others, especially healthcare providers, recommend and encourage their use.

When, however, other healthcare providers recommend against opioid use and encourage learning to self-manage pain instead, it can sting because it taps right into the inherent sense of vulnerability and sensitivity that occur when taking opioids.

It’s hard to see a healthcare provider as acting in the best interest of patients when they openly question the issue that can be so sensitive. The recommendation to learn to self-manage pain without the use of opioids shines a direct light onto the inherent sense of vulnerability or shame that so many feel when using opioids for the management of chronic pain. 

Photo by Erwan HesryUnsplash 450x300The recommendation inadvertently breaks all the tacit rules that healthcare providers (and pharmaceutical companies) have heretofore been following. The rule up until now has been to reassure patients that it’s okay to take opioids for chronic pain. Over the last two decades, the field has asked patients to trust these assurances that they shouldn’t be ashamed of their need for opioid medications. Now, the field is changing and has begun to question the need for opioids. In so doing, we break the trust of patients who have been on opioids for some time: we expose them to potential pain, but also the shame that heretofore we alleviated with assurances that taking opioids is okay. It’s no wonder that patients are now upset.

In a microcosm, it’s this dynamic that occurs in the offices of chronic pain rehabilitation clinics everyday when, after the initial evaluation and recommendation to participate in the therapies of the clinic occurs, patients leave and refrain from accepting the recommendation to learn to self-manage pain. Such patients are doubtful that it will work and are afraid of the pain that would ensue if it doesn’t. Moreover, though, they tend to leave feeling somewhat ashamed that the provider so openly talked about the fact that they could learn to self-manage pain without the use of opioids. Providers are supposed to provide reassurance that it’s okay to be on opioids, not question their use.

Even when it’s well-informed and done in the best interest of the patient, the recommendation and encouragement to learn to self-manage pain without the use of opioids can be heard as a subtle yet stinging rebuke because of the inherent sensitivity that occurs when taking opioids for chronic pain.

How, then, do we bridge this divide?

The Institute for Chronic Pain has a new content page that may play a small role in such bridge building. When patients come to chronic pain rehabilitation clinics for the first time, they may have never had an experience of a provider talk to them about self-managing pain without the use of opioids. As we’ve seen, it’s a complex and sensitive interaction that occurs under the surface of the words that are spoken. It can be a lot to take in. It can feel like the rules are being broken. As we’ve seen, it can be easy to become angry and accuse the provider of incompetence, ill-will or insensitivity. Oftentimes, people need a little time to reflect on the discussion and talk it over with their loved ones. No one comes lightly to the decision to taper opioids and learn to self-manage pain instead.

The new content page provides assistance with this reflection. The hope is that patients can use the information on the page to further reflect on if and when it may be time to begin learning to self-manage chronic pain. Providers can refer their patients to the page too, ask them to read it, and come back for further discussion.

For countless people over the last four decades, chronic pain rehabilitation has provided hope and a way to take back control of a life with chronic pain. However, it must be approached with sensitivity and compassion. Initially, the idea that one can successfully self-manage chronic pain without the use of opioid medications can be threatening, especially for those who have been managing pain with opioids for some time and for those whose providers have long provided reassurance that it's okay to take opioids. Nonetheless, if your providers have recently begun to express concerns about the long-term use of opioids or if you yourself have concerns about their long-term use, you might find it helpful to read the new ICP page on the common benefits of learning to self-manage pain without the use of opioid medications.

You can find the new page by clicking on the link here.

References

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Kamper, S. J., Apeldorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ, 350. doi: http://dx.doi.org/10.1136/bmj.h444

 

Author: Murray J. McAllister, PsyD

Date of publication: 12-1-2016

Date of last modification: October 5, 2019

About the author: Dr. McAllister is the editor at 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. 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Self-management Sun, 29 Jan 2017 13:49:15 +0000
On Hearing Patient Stories & Building Community https://instituteforchronicpain.org/blog/item/175-78on-hearing-patient-stories-building-community https://instituteforchronicpain.org/blog/item/175-78on-hearing-patient-stories-building-community On Hearing Patient Stories & Building Community

The Institute for Chronic Pain is an educational and public policy think tank that produces academic quality information on chronic pain. We aim to provide such information in a manner that’s empirically accurate, yet also approachable to patients, their families, non-specialist healthcare providers, third party payers, and public policy analysts. We do so because the field of chronic pain management needs to change.

The widespread use of opioid medications for chronic pain in the last two decades have led to epidemic rates of opioid addiction and accidental overdoses (Centers for Disease Control, 2016; National Institute of Drug Abuse, 2016). In the same decades, the rates of spine surgery and interventional procedures have grown exponentially and yet the rate of disability related to chronic pain has similarly risen (Deyo, et al., 2009). Among healthcare providers, patients, and their families, there’s growing recognition that as a field we need to do better.

Dr. Melissa Cady agrees and she’s had the insight that we begin to do better by listening to those who matter most: people who live everyday with chronic pain. We need to hear the stories of how people live with chronic pain – the stories of those who suffer, to be sure, but also the stories of those who have come to flourish even with persistent pain. Both narratives are important. One of these narratives fosters compassion. The other fosters hope.

Dr. Cady provides the Institute with a new content page on the importance of sharing stories from real people who make real changes in their lives in order to thrive despite continuing to live with pain.

Dr. Melissa Cady is an osteopathic physician with training and dual board certification in anesthesiology and pain medicine. She runs a website that carries stories of real people with chronic pain who have successfully come to self-manage their pain. They each tell their story of how they’ve overcome suffering and have learned to thrive in life despite persistent pain.

The website is Pain Out Loud and I encourage everyone to visit it and listen to the stories of those who have successfully come to self-manage chronic pain. It shows that living a full life is possible once one learns how. It shows that you can learn to do it too. It shows that there is hope.

Please consider sharing your story of how you overcame adversity and learned to successfully self-manage pain. We can all learn from each other. In so doing, we foster hope and empowerment. We build community.

If you think that hearing from the people who have persistent pain is important, please link to Pain Out Loud on your site or post a link to it through your social media.

References

Deyo, R. A., Mirza, S. K. Tuner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-58.

Centers for Disease Control (CDC). (2016). https://www.cdc.gov/drugoverdose/epidemic/

National Institute of Drug Abuse. (2016). https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

Author: Murray J. McAllister

Date of last modification: 1-8-2017

About the author: Dr. McAllister is the editor at 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. 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 08 Jan 2017 18:55:22 +0000
How to Get Better When Pain is Chronic https://instituteforchronicpain.org/blog/item/171-74how-to-get-better-when-pain-is-chronic https://instituteforchronicpain.org/blog/item/171-74how-to-get-better-when-pain-is-chronic How to Get Better When Pain is Chronic

In the last post, we began to introduce a broad definition of coping, as one’s subjective experience, or reaction, to a problem. In this post, let’s expand on this definition and explain how coming to cope better with a problem is a process of coming to experience the problem in a different and better way.

Coping is how we subjectively experience a problem

In our society, when having a problem, we tend to focus on the problem itself, its characteristics and how they do or don’t lend themselves to resolving the problem. In so doing, we put our focus and energy towards fixing or getting rid of the problem. This way of thinking about the problem is all well and good. It likely lends itself to our society’s successes in developing technological solutions to many of the great problems that we have faced.

As an example of this tendency to focus on problems and fixing them, we need only to look to the problem of pain and how we tend to focus on it, and how we try to get rid of it or otherwise reduce it. Knees and hips can now be replaced and we have a large assortment of different medications that can reduce pain and sometimes get rid of it entirely.

However, instead of focusing primarily on the problems itself, we might also bring our attention to the unique characteristics of each individual with the problem and how they understand it, feel about it, perceive it, and how they behave in regards to it. In effect, we might focus on the characteristics of each person and how these characteristics influence the way individuals experience the problem.

For wherever there is an objective problem in the world, there are also perceiving subjects who have the problem.

We typically call the ways that people experience problems “coping.” It’s something that usually we only direct our attention to when we can’t come up with a solution, or fix, to a problem itself. Nonetheless, it comes in handy in such situations because it offers a way to still get better even if there is no fix to the problem. Namely, we get better at coping with the problem: we can become less distraught by the problem or less impaired by the problem.

In this regard, in returning to our pain example above, we might focus not so much on how to get rid of pain, but how to get better at coping with pain. This change in the approach to getting better may come in handy when pain is truly chronic and you’ve already tried every reasonable procedure and medication without any significant benefit. In such a situation, you focus not so much on how to reduce pain, but on how to increase coping.

In doing so, you can come to learn to tolerate pain that at present is intolerable. You might even get so good at coping that you do more than simply tolerate it – you might get so good at coping that the pain goes from something that is the central focus of your life to something that occurs in the background of your life. It becomes a problem, in other words, that’s not very problematic.

Moreover, you can do such a thing without ever reducing pain itself. It can all occur by changing how you experience, or cope with, pain.

It may sound too good to be true.

How coping better makes problems less problematic

It’s important to recognize that people who cope well with a problem tend to experience the problem as less significant or severe than those who don’t cope well with the problem. In other words, when we aren’t coping well, we tend to perceive or judge the problem that we face as more problematic than those who cope well with it. For example, if you had taken a speech class and had actually given many speeches before in the past, you might find the prospect of giving a speech to a packed auditorium as less problematic than someone without your level of expertise and practice. You might find it quite tolerable, in fact possibly even not problematic at all – something in the category of “Well, it was no big deal.” However, another individual, who faces the challenge of giving the exact same speech to the exact same auditorium, might find it overwhelming, paralyzing or intolerable. This individual might judge the problem as one of the hardest things he has ever done in his life.

Objectively, it’s the exact same problem, but the two people subjectively experience it in very different ways. We might say, in such cases, that the differences lie in how well the individuals cope with the problem of giving a speech to a packed auditorium.

How well we cope depends, of course, on how significant the problem is. Big or complicated problems are more difficult to deal with than small or simple problems. Most people will find talking to a group of two or thee people easier than an auditorium of two or three hundred. Nonetheless, how well we cope with problems is also dependent on other things too.

Notably, it’s dependent on certain characteristics of the person who is coping with the problem. If one knows a lot about the problem and is actually an expert on the topic, then typically that person copes better than someone who doesn’t know as much about the problem. Or, if someone has experienced the problem before or expects the problem to occur, then that person often copes better than the individual who has never encountered the problem before or someone who is taken by surprise by the problem. Confidence plays a role here too. Someone who knows a lot about the problem and is well-versed or well-practiced with dealing with the problem tends to be more confident and that confidence aids in coping better. Someone who lacks such confidence tends to be more alarmed or even distraught, which makes for more difficulty in coping. In any of these cases, the subjective experiences of the problem are different for the different people, even if the problem was objectively the same problem.

We could go on indefinitely about the subjective characteristics of the coper, which play a role in how well the individual deals with a problem. We might make a list of subjective characteristics that determine, in part, how well one copes:

  • Degree of knowledge or expertise about the problem
  • How one conceptualizes the problem
  • Degree of accurate information that one has about the problem
  • How much one has practiced overcoming the problem
  • Other attitudes about the problem
  • Degree of confidence in facing the challenge
  • Degree of attention directed on the problem
  • How one feels about the problem
  • What one’s mood is at the time of encountering the problem (e.g., whether one is calm or irritable, depressed or anxious)
  • How much sleep one has had in the past few days prior to encountering the problem
  • How many other problems one is experiencing at the time of encountering a new problem
  • What one goes on to do about the problem (behaviorally)
  • Degree of loving support one has in facing the problem

There are literally countless aspects of the coper that determines, in part, how well one experiences, or copes with, a problem. Some of these characteristics lend themselves to better coping and some lend themselves to worse coping.

Getting better by getting better at coping

So, think about this simple fact: if you have a problem that can’t be entirely fixed, you could still get better by setting out in a concerted effort to get better at coping with it. You could, in effect, obtain training at having the problem and get so good at it that having the problem becomes less and less problematic. It could become, for example, something that occurs in the background of your day-to-day activities, but for the most part you’ve moved on and focus on the meaningful activities of your life. Indeed, there is simply no end to how good one can get in coping with a problem, even a problem that can’t be entirely fixed, like chronic pain.

Photo by Tim Marshall 450x300Here is where true hope lies. Even when your pain is chronic, you can get so good at coping with it that living with chronic pain is no longer a distressing or impairing problem. Alternatively, you can get so good at coping with it that it no longer requires opioids to manage it and so you can move on with the rest of your life.

Usually, this level of advanced coping requires a concerted effort of training, done over time, and typically with a team of healthcare providers who coach you and support you throughout the process. Traditionally, patients find such support and training in chronic pain rehabilitation clinics. Such clinics are a type of pain clinic that involve an interdisciplinary team of healthcare providers (consisting of at least pain psychologists, medical providers, and physical therapists, but oftentimes other kinds of providers as well) who work with patients over an extended period of time in the pursuit of not so much reducing pain, but improving the patient’s coping. Such clinics are not new, but have been around since at least the early 1970’s and as a result they have about four decades of published research proving their effectiveness (see, for example, these meta-analytic studies and literature reviews: Chou, et al., 2007; Flor, Frydrich, & Turk,1992; Gatchel & Okifuji, 2006; Neusch, et al., 2013; Turk, 2002).

When talk of the possibility of coping better feels like a criticism

Sometimes, when healthcare providers like me talk in these ways, it feels to patients with chronic pain like a judgment. It feels like blame. It feels like you’re being told there’s something wrong with you -- that you aren’t coping well enough.

Oftentimes, when patients have people in their lives who judge them or stigmatize them for how they have been coping, they can come to hear their healthcare provider talking about the benefits of learning to cope better as a similar criticism.

In such cases, patients can come to refuse the recommendation to participate in chronic pain rehabilitation. The hopeful message that there is a traditional and scientifically proven treatment that helps patients to learn to cope better with pain can be met with quick and sometimes sharp rebuttals. Common examples are the following:

  • The provider must be insensitive.
  • The provider must not know what he or she is talking about (i.e. the provider is incompetent).
  • The provider doesn’t (or won’t) recognize that I’m coping as well as humanly possible given the amount of pain I have.
  • The provider must not have chronic pain or otherwise he or she would understand.
  • The provider must not believe me that I have real pain.
  • The provider is just out to make money and so wants me to go to yet another treatment from which he or she will profit.
  • The provider just wants me to get off opioid medications.

Obviously, talk of how to learn to cope better is a sensitive topic. It’s as if the same words can engender almost two opposite interpretations. The healthcare provider intends it to be a hopeful message – you can get better by undergoing extensive training over time and as a result come to cope better with a condition that is incurable. The patient, however, can hear it as an insensitive criticism of how the patient isn’t coping well right now.

Importance of trusting your healthcare provider

In such situations, what can make the difference is having a good, therapeutic relationship with your healthcare provider. If you know your provider and trust him or her, then you know that your provider isn’t just being mean or insensitive or ignorant of what’s it like to have pain or out to make money off you. Instead, you know that your provider has your best interest at heart.

References

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Flor, H. & Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962

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

Author: Murray J. McAllister, PsyD

Date of last modification: September 11, 2016

About the author: Dr. McAllister is the editor 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.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 11 Sep 2016 17:52:53 +0000
Can you experience your pain differently? https://instituteforchronicpain.org/blog/item/170-73can-you-experience-the-same-pain-differently https://instituteforchronicpain.org/blog/item/170-73can-you-experience-the-same-pain-differently Can you experience your pain differently?

A major tenet of chronic pain rehabilitation is that the way you experience pain is not the only possible way to experience pain. In other words, the experience of pain differs across individuals and can even differ in the same individual across time. As such, it's possible to have a different experience of pain than the experience that you have today, even if your pain remains on a chronic course.

This point isn’t necessarily controversial. Patients commonly make a similar point themselves. For instance, patients sometimes express that pain is a subjective experience that only they can feel.

The rub, though, lies in the consequences we draw from such a point. We can draw different consequences.

Patients often make the point about the subjective nature of pain as a means to defend against stigma. It's a way to say that others shouldn’t judge if their experience of pain differs from the patient’s experience of pain. While it’s a good point that no one should ever stigmatize patients for how they experience pain, we might draw an altogether different inference from the point that pain is a subjective experience. This inference has nothing to do with the issue of stigma and it is often drawn by healthcare providers, particularly pain psychologists and others who work in chronic pain rehabilitation. This additional inference is that you yourself can come to experience pain differently.

In other words, the subjective nature of pain is such that different people can have different experiences of pain and what this shows is that it is possible to experience pain differently than how you experience it today. You can learn, in other words, how to have pain in other ways. It’s a hopeful message. It’s the foundation for what pain psychologists do everyday – help people come to experience their pain differently, in ways that are better than how they presently experience it.

Coping with pain as changing how you experience pain

In effect, what’s happening is that, with the help of pain psychology and chronic pain rehabilitation, people come to cope better with pain. They literally experience their pain in new and different ways. They experience pain in ways that are better than they had experienced it previously.

They know, for instance, that their pain isn’t a sign of a fragile injury, which is about to get worse at any point in time. Subsequently, they are not alarmed by pain and do not understand it as some thing for which they must stay home and rest. Instead, they tend to see pain as akin to white noise, something that is there, but remains in the background of their attention. They remain grounded and focused on their activities, which they continue to do. They go to work and go to their children’s activities and go to the neighborhood potlucks. They do all these things with pain.

Now, that’s what coping really well with pain looks like.

When people cope well with pain, they literally experience it differently than someone who isn’t coping well – the individual, for instance, who is alarmed by pain, sees it as a function of a deteriorating disease that is inevitably going to get worse, and so subsequently believes the best course of action is to avoid the activities of daily life and instead stay home and rest, out of concern for not making their condition worse.

What would it be like to cope so well with pain that you literally experience it in the manner I previously described above – as something that remains present, but something that nonetheless doesn’t deserve a lot of day-to-day attention and emotional energy and so remains in the background of your daily activities like white noise?

There are countless lessons to learn that can be helpful when learning how to do it. The pain psychologists of a chronic pain rehabilitation clinic or program can help you to learn them. We have discussed a number of them in the posts of this blog (see, for example, posts on catastrophizing, all-or-nothing thinking, mind-reading, perfectionism, among others).

In our next post, we’ll review yet another important cognitive distortion that adversely affects how people experience pain. It occurs when people understand pain as something that always signals harm. It can happen, for instance, when people with back or neck pain understand their pain as solely the result of a fragile, degenerative condition of the spine. In large measure, this cognitive distortion is a consequence of how certain parts of the healthcare system understand back and neck pain as the symptom of degenerative disc disease. It’s therefore a complicated issue as it plays out in both patients and some healthcare providers.

It’s also, though, an important issue. Every rehabilitation provider tends to encourage patients to exercise, move and get back into life, within some reasonable limits. However, people don’t tend to do these things when they see their pain as signaling harm. Instead, what people tend to do when understanding their pain as indicative of a fragile injury is to become mildly alarmed, stay home and rest.

It’s therefore important to learn when pain is a sign of injury (for which you should become alarmed, stop what you are doing and seek care) and when pain is not a sign of injury (for which you try to stay grounded, redirect your attention elsewhere and remain engaged in the activities of your life). In other words, sometimes pain has a psychobiological function of signaling injury or illness and sometimes pain continues even though it has lost this function. It’s important to know the difference. In the former case, you take heed. In the latter case, you try to tune it out as white noise.

Will discuss more in the next post!

Author: Murray J. McAllister, PsyD

Date of publication: 8-29-2016

Date of last modification: 8-29-2016

About the author: Dr. McAllister is a pain psychologist and the editor and founder of the Institute for Chronic Pain (ICP). 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Mon, 29 Aug 2016 19:38:38 +0000