Pain Management in Modern Times:  Does This Sound Familiar?

James Schroeder, PhD
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A little ways back, a close family member of mine saw an orthopedist for chronic hip/knee issues.  He described it as a positive experience.  He was very pleased with the time spent and thoroughness of the physician and staff, both through conversation and scans done to determine what was wrong.  He went in expecting the worst — a joint replacement recommendation — but instead came out with a prescription for advanced pain relief and reassurance that his joints looked much better than expected.  As we talked further, though, he admitted being surprised that there was little conversation around lifestyle issues or other treatment options.  There was a brief exchange regarding exercise, but no talk of stretching, dietary strategies, physical rehabilitation, losing weight, or other behavioral strategies to alleviate his pain and increase functionality.  As someone who admittedly has struggled to eat healthy and with being overweight, as with many, he was surprised that these issues were left for him to discern.

In September, an article was published on HCP Psychiatry Live by Dr. B. Eliot Cole, MD.  Dr. Cole works as a psychiatric hospitalist and has specialized in pain management for more than 30 years.  The title of the article is “It’s the Pain Education Season, but We’re Teaching the Wrong Lessons to Physicians.”  After noting the number of upcoming pain meetings and conventions, he states:

Frankly, I am concerned that there is so much information devoted to opioid prescribing and wonder what happened to the rehabilitative model proposed 40 years ago, and the focus on providing comprehensive care for people who have complex pain problems. Over the past 20 years the field of pain management drifted from comprehensive care involving behavioral methods, rehabilitation, and promotion of wellness, with an emphasis on coping, to monomaniacal care based upon administering a series of injections or a regimen of opioids, with little or no emphasis on rehabilitation, behavioral methods, or anything else. Care has been routinized, standardized, hybridized, but we still rely more on blocks and opioids with or without antidepressants and anticonvulsants for the majority of people seeking treatment for their pain.

He goes on to say about his patients:

I hear about their failed attempts to balance prescription opioids with heroin, alprazolam, lorazepam, clonazepam, and methamphetamine, but they never tell me about their prior use of behavioral therapies, exercise, stretching, physical or occupational therapy, benefit from proper nutrition, or even one attempt to wean from opioids to see if they still need these medications.  As I finish my third decade in pain management/medicine, I am perplexed to see so much illogical care, so much denial of what was clearly shown to work so well in the 70s, 80s, and early 90s. We finally recognize the risks and long-term consequences associated with injections, opioids, or any other form of monomaniacal care, yet we have no national agenda to offer comprehensive care for people who have complex pain conditions.

His article raises grave questions about the direction in which pain management is moving.  It seems both providers and patients are increasingly seeing pain as though it is less about the human condition, and more as a foreign entity that must be exterminated, overtaken, and/or washed clean from the body.

Over the last few hundred years, technology, classification and other factors have also ushered in a distinct focus on perceived categorization of symptoms, including pain.  The number of diagnoses continues to increase as does the methods of imaging, such as MRI and PET scans.   In the process, the individual, idiosyncratic experience of pain has been relegated as less important to its treatment.  As noted by Stanley Reiser (1993),

The goal of evaluating illness has become the classification of people into delimited categories of diseases.  Thus the symptoms that combine patients into populations have become more significant to physicians than the symptoms that separate patients as individuals.

As Joanna Bourke noted in “The Story of Pain”, technologies and other factors have led to an ideological shift that focuses on “treating” (which emphasizes practices that physicians carry out on patients) instead of “healing” (which entails a complex, collaborative interaction between patients and providers).  Many may reasonably argue that in certain areas, such as that of communicable diseases, this shift has led to a significant increase in the efficiency and capacity of providers and organizations in alleviating illnesses.  But when it comes to difficulties that arise within the individual, especially those with complex psychological overlay and lifestyle connections, serious questions exist about the consequences of this ideological shift.  Many questions exist about whether it results in better outcomes, or rather minimization of the entire patient’s experience necessary for true healing to occur.

Regardless, somewhere along the line, we all — providers, patients, payers, and the public as a whole — became enamored with the idea that instant panaceas really do exist.  Some of this consciously occurs in our daily conversations and response to uncomfortable states.  Some of this unconsciously occurs when we see just one more ad about how to make the pain, physical or psychological, go away with little effort required.  And it seems that every day we are realizing what a false promise this is.  So where does the responsibility lie?  Well, of course, it lies with many parties, in more ways than this article has a full scope to describe. At least initially, though, it lies within the pharmaceutical companies who prominently promote pain relief while burying all the risks and responsibilities in fine print and voice overs.  It remains with the patients who understandably demand pain relief, but do not follow-up their prescriptions with daily efforts to improve their lifestyle and address other vital factors.  But ultimately, it must lie with the physicians themselves, who pledge to do no harm first, and are the gatekeepers of the treatments they prescribe.  Pressure persists from all fronts to provide immediate relief for those that we see.  But if we are truly undertaking the art of healing first (and all other professional and personal desires come second), then we cannot prescribe a course of treatment that has the serious potential to not only fail, but even make things worse.  We can’t neglect critical interventions just because they require more time and effort even in the absence of more revenue.

Does this all sound eerily familiar?  Does it remind anyone of the course that much of psychiatric care has taken?  It has made me wonder lately.  The process of many organ transplants has a model that is starting to look very prudent.  Recently, a parent of a close friend of our family received a lung transplant.  But before she could, it was required that she lose a substantial amount of weight and increase her overall health in order to even be eligible to receive a new lung.  It led her son to remark that “mom has never been healthier—unfortunately it took a terminal illness to make it happen.”  Of course, the only way the organ industry gets away with this is for one reason:  the demand significantly outstrips the supply.  Otherwise, there would likely be a public uproar if this approach was utilized in other medical domains.

But what if this approach was adapted to pain management and psychiatric care?  No one can reasonably argue that health and lifestyle does not have a tremendous impact on both.   So what if physicians actually required that patients made noticeable changes to their health (or undertook a specified regiment of physical rehabilitation) before they would prescribe drugs laden with serious potential side effects and adverse consequences?  I am not talking about situations of emergency or acute pain, or those with a terminal illness.  But I am proposing this for the millions of people struggling with chronic conditions clearly linked to modifiable lifestyle factors or behavioral changes.  Recently, a mother in her 20’s acknowledged to me that her smoking and obesity was probably associated with issues related to two serious back surgeries and a plethora of narcotic prescriptions.  But when I asked if she had worked with others closely on more natural methods of recovery and improved lifestyle, the answer was a clear “no.”  Not surprisingly, no healing had occurred.

There is little doubt that the pursuit of convenient cure-alls will continue for pain, both of a psychological and physical nature.  It seems just as likely that this quest will continue to see disappointing results.  But maybe this is all part of a deeper reality, one of which reminds us that nothing in life worth having is really free—free of conscious, dynamic effort to actively pursue the life we desire.  As Dr. Cole noted at the close of his article,

I entered the field of pain management in 1985, naively hoping my lower back pain would be ‘cured’ along the way.  Thirty years later, my back still hurts, but now I also have joint pain, headaches, heartburn/abdominal discomfort, and the realization that as I get older it really does matter what I eat, that I adhere to a regular exercise program, stretch daily, do meditation, receive an occasional deep tissue/myofascial release massage, and get a few acupuncture needles strategically placed.

Maybe our current endorsement of quick fixes also tells us about the way that we suffer, and the value we place on it.  No one wants suffering and pain, but it raises three inevitable questions.  Will we seek to address its root causes, or just focus on eliminating or subduing it?  Will we discern whether suffering suggests a different course needs to be taken, or resign ourselves to the course we are on?  And will we attempt to find ways in which undesirable suffering could be valuable to ourselves and others, or will we cling unceasingly to the belief that it has no value at all?  It appears our current attitudes towards pain demand that healers, and those in search of healing, take these questions more seriously if we are to truly undertake a collaborative, multi-faceted approach in reducing pain.  As Joanna Burke concluded her book,

A painful world is still a world of meaning.  History can help in this process.  By knowing how people in the past have coped with painful ailments, perhaps we can all learn to ‘suffer better.’

* * * * *

References:

Bourke, Joanna.  The Story of Pain (New York:  Oxford University Press, 2014).

Reiser, Stanley Joel, ‘Science, Pedagogy, and the Transformation of Empathy in Medicine’ in Howard M. Spiro, Mary G. McCrea Curmen, Enid Peschel, and Deborah St. John (eds), Empathy and the Practice of Medicine:  Beyond Pills and the Scalpel (New Haven:  Yale University

Press, 1993).

13 COMMENTS

  1. James,

    I always enjoy your posts!

    This is one of my favorite quotes on the subject of suffering, from someone who certainly had experience on the subject in her life:

    “Character cannot be developed in ease and quiet. Only through experience of trial and *suffering* can the soul be strengthened, ambition inspired, and success achieved.” – Helen Keller

    And of course, John Paul II had much to say of the spiritual value of suffering; serving as an example of dying with dignity, while in great pain.

    Duane

  2. The issue of pain management in and of itself is an issue that has overlays with psychiatry because various anti depressants and anti anxiety medication are used to help manage surgical pain. As a pediatric psychologist I am wondering if you have any contact with the orthopedic services and teams that are managing pediatric pain issues. My daughter had a total of four surgeries due to neuro/ortho issue and a hospital based infection. After the final surgery she was concerned she had developed either an emotional or physical dependence on her pain medications. She had PT and OT in hospital but was on her own afterwards and I had to demand a nutrition consult. These are things you and the articles you reference talk about. What is not talked about is her experience of being appropriately concerned about a dependence issue. I was at a loss because I was unfamiliar with dependence issues that come about as a result of pain. She was the one who did internet research and came up with the idea of using a strip for medication which she cut down gradually as she weaned herself off of the medication. This came from a 17 year old high school student. The pain management doc was unaware of a strip form existed for this medication. She still is on an antidepressant for sleep which worries me greatly. It took so much effort and time for her to get off the more “troublesome” drugs that she didn’t have the fight in her to go all the way.
    In not that there only is a good comparison to be made there is also a legitimate issue for it to be taken as a combined problem for pediatric surgical cases and adults.

  3. James

    Good article and good topic to explore.

    I recommend the following brief article that explores the politics and money behind the rise in the use of pain “medications” (drugs) in this country. http://www.thepoisonreview.com/2012/12/16/the-money-and-influence-behind-pain-as-a-fifth-vital-sign/

    In the middle to late 1990’s certain doctors working with the pharmaceutical industry pushed a powerful campaign to make “pain” the so-called fifth vital sign. That is, in addition to heart rate, blood pressure, temperature, and respiratory function, all doctors were being pressured to ask every patient to rate their level of pain from 1-10.

    So-called pain doctors and certain drug companies, of course, had a direct self-interest in getting more people to take prescribed pain drugs. Keep in mind that this is about the time when the powerful drug, oxycontin, hit the market. Part of this campaign pushed the notion that doctors should, in fact, be punished if they ignored the “fifth vital sign” and they did not prescribe pain drugs to someone requesting them.

    All this was the beginning of a major prescription drug epidemic that has led to millions of people becoming addicted to pain drugs and the opening of thousands of pain clinics throughout the country. This has fueled a rash of drug overdose deaths and expanded the heroin epidemic raging throughout our cities and suburbs. And it should be pointed out again and again, that over 30% of all people dying of an opiate overdose have benzos in their system.

    Biological Psychiatry and the pharmaceutical industry have much blood on their hands coming from many places where the medical model has been shaped and distorted to promote their own economic agenda.

    Richard

    • Richard: I love your posts in general and I think you are right for the most point about pharmaceutical companies having a vested interest in the over prescription of pain medication but I think there is enough blame to go around. Individuals, in general are not taking responsibility for their personal health and many patients are doctor shopping for legal prescriptions for ulterior motives. I know from experience that my step son, for years was able to feed his Adderal (clean meth) addiction legally and all of it was paid for by his medical insurance! His Adderal binges became so bad that he had several episodes of psychosis. I fault NAMI and other ADHD ‘support groups’ for creating this great big myth about ADHD and creating covers for people like my step son who want to legally obtain performance enhancing and recreational drugs.

      Because of HIPPA, it was difficult for us concerned family members to intervene by identifying which doctors were over prescribing and take action. Since he was legitimately enrolled at a university and had a diagnosis of adult ADHD, his prescriptions appeared to be above board since he was able to convince his physicians that the adderal was critical for his success in school. I think that pain killer prescriptions are similar. People go into a medical appointment expecting to get a quick fix for everything. Doctors are simply caving to the unreasonable expectations of their patients. I don’t think we should blame it all on doctors.

      My husband is carefully weaning himself from Oxycotin after a hip replacement surgery. His doctor would gladly prescribe him a boatload. For some individuals with legitimate pain, they can be a life saver but the entire family has noticed that he is moody and volatile after a deep Ocycotin induced sleep so we are constantly reminding him of the importance of finding other ways to get through the night. There is clearly a ‘hang over’ effect. The entire family should be involved in decisions to medication for pain when the side effects become apparent.

      • Madmom

        When dealing with an individual person (such as your step-son) who is abusing substances, yes , of course, you educate them about the dangers and then appeal to their sense of individual responsibility to take charge of their lives.

        In all other situations we must target the real criminals in society who are responsible for and make a huge profit from our culture of addiction and the promotion of quick fixes (in the form of pills) as the so-called solution for extreme forms of psychological distress. People are not born lazy or irresponsible; it is a learned process.

        Richard

  4. I happen to suffer from chronic pain and it’s so mcuh easier to get a benzo prescription (or another muscle-relaxing drug or a pain-killer) than to get into physiotherapy. I’d love to get a course of physiotherapy and massage treatments refunded rather than a bunch of pills with very bad long-term side effects (and prescribing them for chronic pain means long-term use). I’ve learnt that I’m better of doing some exercise and taking a pill only on rare occasions but many people are left with popping the pills and wondering why they get even sicker.

  5. How to begin here? First of all, as a person starting at 15 years old, that’s was 1976, getting chronic cluster headaches. Not being able to get anything or any help but (psychiatry) for them, except for asprin or tylenol. Just surround your head with ice in the dark and quiet, until parts go numb and you will see, their is no dignity in suffering. Doctors did nothing, people say your faking and my parents, didn’t know what to do. Followed the doctors advice and I learned biofeedback, Yoga meditations. Stretching and exercise! Therapy for anxiety! On and on. Did nothing. In some ways it made it worse. Of course the next step is Alcohol and other drugs. After not being able to finish high school, did join the Army and somehow, with tears gushing but not crying in pain almost daily, I finished my tour. But you know why I didn’t blow my brains out, Heroin in Italy! By 1987, after an average of 4 days a week with three headaches a day and one cluster lasted 14 months straight everyday with 3 headaches. I ended up in dual diagnosis treatment! I call it a nervous breakdown. Never have done an illicit opiate again, to this day. That’s 30 years. Oh and guess what the doctors gave me for the next 15 years with no exception? Ibuprofen! That’s because of a phony brain disease that only made suicide more of a thought of an option. By 1991, diagnosed with bi-polar disorder, addiction because I did what I had to, to not kill myself! I also blew a disk in my back, arthritis all along my spine. Especially my neck! Bad knees from construction work. torn ligament in chest, partially blind in left eye from that 14 months of headaches. Put on disability! Wasted ankle and sciatic nerve problems. Etc. What was done? They increased the ibuprofen! Then it made me throw up and I learned on my own about rebound headaches. The VA acted like they didn’t know what I was talking about. Like they never heard of rebound headaches. Tried to go back to work, twice and ended up having to quit as the work was either to painful, construction or couldn’t look at computer screens all day as it gave me headaches. So did the florescent lights in all the buildings. Took extra semesters because of the headaches and did get a degree but almost daily headaches. What I am try to say here is their is not dignity in chronic pain. That is just a mental game of ego! Come on, get real! It was almost 25 years without anything that worked for pain or anxiety! Finally, about 2008, I got put on tramadol and .5 mg twice a day of kolonopin. Was able to help put the roof on my house! Then in 2014, both medications were taken had no increase in medications, done cold turkey. When I asked if I did something wrong, “NO” was the answer! I never abused or overtook, saved or sold my medications, however, now I can barely take my dogs without the dignity of pain, so I say to you, with all due respect, “glory is fleeting”! P.S. I wanted to ask here if it is understood that it is now a fact that the majority of the over dose deaths are from the synthetic more powerful illicit fentanyl? It is the killer? it is something like .4% of pain patients ends up with and addiction. A dependency, maybe, but we all have those! Here are two articles you may find interesting! http://journals.lww.com/journaladdictionmedicine/Abstract/publishahead/High_Mortality_Among_Patients_With_Opioid_Use.99558.aspx https://www.ncnp.org/journal-of-medicine/1980-the-cdcs-fictitious-opioid-epidemic-part-2.html This may give some perspective to this situation. One thing I am totally convinced of is that harm reduction is the way to go in both addiction and pain management. Been a cd counselor to and most of the successful people, long term, do harm reduction of their own making anyway! What is safer for the patient, physical pain that other therapies have been tried but were ineffective and and ineffective doses of gabapentin and NSAIDS. With Fentanyl showing up in all the street drugs now too. Or is it safer to relieve pain taking medicine from a doctor? I want to bring up a way of thinking that myself and a few other people like me talk about! ADT’s are actually worse for patients than medications that are not ADTs. Because it is thought of as deterring and not, what if abused as the way to look at this for safety! We are thinking that with all the Fentanyl, the real killer here, and that ADT meds if abused make people feel sicker than the old more close to pure from the poppy stuff, so the withdrawals are worse! (more addictive) not less! Also, as I talk to addicts, so many are mad as hell that pain patients are loosing their pain medications because of them, how else could they feel. “It’s wrong” I hear often! Psychotherapy and changing behaviors? Been doing that for what? 40 years! For me, James Schroeder, PhD. With all due respect to you and any others on here, talking about finding your self worth, “dignity” or anything but pain with snot running down your face on to your shirt and are shaking enough where you piss and or shit yourself in pain and the doctors try to force you to talk, breath, whatever yourself out of the pain. This is kinda insulting. All it is taking with my new doctor out of VA for headaches is .5 mg twice a day and the headaches relent, if I also stay quite limited physically as well! Wonder why the VA doctors that would change quite often and if you do good, they take you off the medication that is allowing you to have less headaches (do good) so I can try the same thing over and over and over again until I get results from it, die, or not listen to the “experts” and find my own way! What you wrote sounds nice, but how long does it take to work? 40 years?