On the Meaning of "Chronic"

The healthcare system is typically quite open about how chronic health conditions are in fact chronic. When first diagnosing heart disease or diabetes, for example, most healthcare providers take care to discuss with their patients that there are no cures for these conditions.

Also, by and large, healthcare providers tend to review with their heart disease or diabetic patients that the most effective things that they can do are not so much medical treatments, but rather things that the patients themselves can do. That is to say, some of the most effective things that patients can do are healthy lifestyle changes. In the case of heart disease, these healthy lifestyle changes are quitting smoking, beginning an exercise routine, eating healthier, weight loss, and stress management. In the case of diabetes, the healthy lifestyle changes are eating healthier, weight loss, beginning an exercise routine, and stress management. This emphasis of care on what the patient can do in terms of coping and healthy lifestyle changes is what’s called self-management. So, the healthcare system tends to be open with patients that chronic health conditions are truly chronic and that there is no pharmacological or procedural cure. They are also quite open with the fact that self-management is one of the most effective ways to manage chronic health condition well.

The one exception in our healthcare system is chronic pain. When patients come to their primary care providers with chronic low back pain, for instance, it’s common for patients to get an order for an MRI and a referral to a clinic that performs interventional or surgical procedures. Once evaluated at these specialty clinics, patients are commonly told that the interventional or surgical recommendations might rid the patient of pain. As such, many chronic pain management specialists tend to refrain from accepting that chronic pain is truly chronic. Moreover, many chronic pain management specialists do not tend to educate their patients that, like other chronic health conditions, self-management is one of the most effective ways to manage chronic pain.

Patients, too, often believe that there must be a cure for their chronic pain and they tend to assume that the cure will come as a result of some type of interventional or surgical procedure.

As a result, it is common for chronic pain patients – and the providers who care for them -- to proceed on a long series of increasingly invasive procedures, which persistently fail to cure their chronic pain.

This state of affairs within the chronic pain management field flies in the face of what science tells us about the nature of chronic pain. Science tells us that chronic pain really is chronic in the sense that there is no pharmacological or procedural cure. Research on the outcomes of interventional and surgical procedures for chronic pain consistently shows that they are largely ineffective or only minimally effective.^{1, 2, 3, 4, 5, 6} 

So, why do specialists in chronic pain management fail to accept that chronic pain is really chronic?

Before answering this question, it should be noted that not all specialists in chronic pain management do so. A traditional type of chronic pain management is chronic pain rehabilitation. The focus of chronic pain rehabilitation is accepting the chronicity of pain and helping patients to learn how to self-manage it. Specialists in chronic pain rehabilitation teach patients how to cope with chronic pain and make it easier to live with. They also show patients how to make healthy lifestyle changes that reduce the level of pain. Chronic pain rehabilitation is typically performed in an interdisciplinary program that lasts for three to four weeks.

While they are not a cure, chronic pain rehabilitation programs are consistently shown in research to be the most effective therapy for chronic pain, particularly when compared to the effectiveness of narcotic pain medications, interventional or surgical procedures.^{7, 8} 

Despite being the most effective therapy for chronic pain, chronic pain rehabilitation programs are typically the last therapy that patients receive. It is common for patients to be referred to such programs only after they have received a series of unsuccessful interventional or surgical procedures.

So, the question again arises, why does the healthcare system fail to accept that chronic pain is really chronic? Why does it tend to promote interventional and surgical procedures as possible cures when they really aren’t? Moreover, why does the healthcare system fail to help patients to accept the chronicity of their pain and subsequently learn the healthy lifestyle changes that most effectively makes coping with chronic pain easier?

The answer is complex. There are likely different reasons for why the healthcare system fails to recognize that there is no cure for chronic pain. Different investigators have reviewed a number of possible reasons: difficulties in disseminating research findings, problems with tradition-based medical education,⁹ and the profit motive.^{10, 11} 

It may also be that chronic pain is so emotionally distressing to experience. Having heart disease or diabetes is just not as emotionally distressing as having chronic pain. Among chronic health conditions, this level of emotional distress is possibly unique to chronic pain. As such, the chronicity of chronic pain may simply be harder to accept than it is with other chronic health conditions.

There is, however, hope – even in the absence of a cure. Chronic pain rehabilitation programs allow patients to learn how to successfully self-manage pain, return to work, and reduce their reliance on the healthcare system -- including eliminating the use of opioid medications for pain. It’s possible to live well despite having chronic pain. Patients just have to learn how and they learn how in chronic pain rehabilitation programs.

The healthcare system has to do a better job at understanding the truly chronic nature of chronic pain. It also has to do a better job at promoting self-management and its healthy lifestyle changes that make living with chronic pain easier. Chronic pain rehabilitation should really be the first treatment option that gets recommended for chronic pain – not the last.

References

1. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012.

2. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

3. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

4. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.

5. Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195.

6. Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

7. 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.

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

9. Haynes, B., & Haines, A. (1998). Barriers and bridges to evidence-based clinical practice. British Medical Journal, 317, 273-276.

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

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

Date of publication: March 25, 2013

Date of last modification: May 28, 2017