Immediate First Aid for Chronic Pain Relief

February 24, 2010 | Filed Under: Tips | Comments(0)

If you still aren’t being treated with a combination drug/life style/habit modification program, you can use the following First Aid to help you begin to mold some control of the conditions of your pain’s occurrence.

1. If you have medication that has helped in the past, use it. Do not try to “Bear it.” It doesn’t work. Pain physicians in our program always tell patients that medication should not be taken as needed, because “you can’t chase pain – you’ll always be too late to catch pain before it goes over the top.” So our pain physicians recommend using a dose that would be in the background, not that makes you drowsy, but gives you the ability to function better than if you had taken no medication. Don’t forget, in a qualified pain program , the aim is to restore as much of your functionality as soon as possible so you can get back to working and leading as normal a life as possible.

2. Find a credentialed pain specialist fast:

(a) In larger cities, look up university hospitals; they often have pain programs.
(b) If not, look up Physicians, Anesthesiologists in your local area phone book and start calling until you find one who is Board Certified in pain management.
(c) If that fails, go to the American Board of Pain Medicine website and click on Diplomates. Type in your State, then click Specialty of Origin, and Anesthesiology. Then start calling them.
(d) As another option, go to the American Board of Anesthesiology website, and click on Verify a Physician’s Certification. Then type your City and State and click Search. Start calling them.

3. An assertive attitude is critical in this type of pain, so start working on it.  First stop the panic, it doesn’t help. I know the desperation one can feel when this pain starts climbing, I’m a chronic pain survivor. But panic just makes it worse. If you have no medications that help, then do what’s needed, go the Emergency Room. Take any medical records that you have that deal with your pain. If you don’t, you may be dealt with like an addict, especially depending on the extent of your state of panic. Next, do not go helpless. Your Body needs you, so take charge and get it the best help you can find. Helplessness adds other symptoms that you don’t need. You have take charge. Finally, if you’ve been seeing the same doctor for more than 3 months and you’ve gotten no noticeable increase in your functionality, you have to muster the courage to fire him and find one that is, first of all, qualified and will pursue your goal rather than your doctor’s personal goal. Just being polite with your doctor is not effective treatment for your pain. You need to be assertive (meaning, calming stating what you want, several times if needed, but calmly).  And, if a doctor who has been treating you for more than 3 months insults you or accuses you of being an addict and that doctor lacks any qualifications in pain management don’t be afraid to report him to his Medical Board for practicing outside of his area of practice for more than 3 months and not making an appropriate referral to a qualified pain doctor or pain rehab clinic.

4. Commonsense is also critical in any chronic disorder, use it. If you have a chronic low-back pain syndrome and sit for hours at your computer and your back hurts afterward,  get the point that your body is telling you, “Don’t allow yourself to be immobile for the amount of minutes that it takes for you to begin to feel the first signs of discomfort.” If you have to sit for long periods of time, be sure to have a gel-pack ready when you get back home. Prop up in a comfortable chair, put the gel-pack directly on the skin; it’s a bit painful at first, but in 5 minutes it’s wonderful, cheap, effective analgesia. Use it no more than 15 minutes. And, if you have burning pain, don’t use ice, it can make possible nerve pain worse.

5. Trial and success works; trial and error does not. Remember the details of what worked for you. You are the one who knows best what works for your specific pain, as it happens under specific conditions in your unique life situation, not a doctor, a spouse or a well-intentioned neighbor. Focus on conditions of your pain’s occurrence and what real-world conditions you have to create to get even a little bit of relief on a consistent basis. Don’t forget to screen your current doctor before you start going to just any doctor who says they’ll “try” to help you. Screen your doctor first. What you want is someone credentialed in pain management or pain medicine and who has extensive experience treating chronic non-cancer pain patients on an outpatient basis, and are not “interventionalists,” who put in the morphine pumps and the spinal column stimulators. Both of these treatments, including surgery, are strictly last resorts. If your goal is recuperating as much of your ability to function as possible, even pain doctors have to do more for you than just prescribe pain drugs to help you restore your ability to function, especially get back to work. Pain relieved by drugs alone does not guarantee restoration of function. So identify your goal, find a credentialed pain specialist and start screening them for demonstrated competence in chronic non-cancer pain. If you only have access to a doctor of general medicine, you must someone who is qualified to treat this type of pain. If you don’t, data indicate that your pain will get worse, and create an even broader range of problems for you than just pain. First Aid is what it is, an effort to relieve a crisis. And, for everything, however minor, that works, reinforce yourself with a, “Good job!”

6. Those who have experienced serious CNCP give the best advice. Talk to people with the same type of CNCP you have. Especially those whose break-through pain is very infrequent. Over years of trial-and-success, these types of pain patients will usually have good tips to give you. If your functionality, and pain relief, haven’t moved in 3 months, make an appointment with me for personal advice on an Online Pain Management Consultation.

Dr. Henry E. Adams

AAPM Diplomate in Pain Management

Welcome to a website devoted exclusively to complex pain.

February 21, 2010 | Filed Under: Welcome Info | Comments(3)

COMPLEX PAIN – DEFINITION

This is a very special type of pain. It’s pain that …

– is not caused by cancer, diagnosable tissue or structural damage and it responds poorly to all sorts of medical treatment;

– has lasted for more than a year;

– is not mild or intermittent but rather it occurs daily and the pain is moderate to severe (5+ on a 10-point scale);

– is pain that physicians you’ve seen haven’t been able to get you back to work or functioning normally again;

– all of your diagnostic tests produce “negative” findings and your physicians tell you that “you have nothing,” yet you continue to have moderate to severe pain and you can’t work and you can’t lead a normal life;

– is pain that the medications that have been prescribed for you for pain have not only not helped but more often than not they’ve made your pain more severe, more frequent, and more long-lasting;

– it’s very likely you’ve never been evaluated and treated by a doctor who was Board Certified or credentialed in pain management;

– it’s pain not caused by nerve damage as determined by a Nerve Conduction Study (NCS) and examination by a qualified neurologist;

– it’s complex pain that has led your doctors to tell you, “That’s all we can do for you. Learn to live with it;”

– it’s complex pain that is becoming increasingly difficult to have carriers pay for the integrated, interdisciplinary treatment that works best; and,

– it’s pain you had better learn to self manage because: (a) the teams of qualified doctors needed to treat it are extremely difficult to find; (b) the carriers aren’t paying for either the drugs or the effective treatment; and, (c) pain patients who follow a qualified program do learn how to self-manage pretty well without physicians and much fewer of the wrong drugs.

HOW DID WE GET HERE?

We’re at this state of chaos because this is pain that fell between the cracks of conventional, acute-minded, acute-treated solo practice medicine. That means, urgent care type medicine provided by a single doctor for as little time as possible. Why? Because that’s all that healthcare will provide. Healthcare is broke. It can’t be afforded any more. Where before it used to cost $200 a month for all medical services and medications, today it’s the equivalent of a salary, or a quarter or more of your take-home pay.

OUT-OF-SYNC ACUTE-MINDED MEDICINE GOT US HERE

Today’s chronic pain doesn’t fit the acute (urgent care) treatment model that worked well from about 1850-1950 when the average age was 25 and the major concern was communicable diseases (like TB, influenza, cholera, smallpox, sexually transmitted diseases, measles, malaria and everything we could pick up from viruses, bacteria and little animals that get under our skin and into our body). It’s great that experimental medicine met the challenge and developed, through experiment and skills learned by doing, a consistent way of identifying a single cause of an illness, isolating the presumed cause in the laboratory, then finding a specific agent that would kill it, then giving the agent to the patient in certain doses over a specific time frame and then watching the patient’s symptoms disappear and the patient’s ability to function return. That’s what happened when the average age of the population was 25, communicable disease was the problem, and acute-minded treatment “fit” the need.

THE CURRENT SITUATION

Conditions drive the type of medicine needed. The problem is that an average age of 25 no longer exists. And communicable diseases are no longer a problem. And urgent care is no longer what is needed. The current condition is that the average age everywhere is increasing, right around 45 when people develop chronic (non-communicable) diseases with multiple causes affecting multiple systems that no solo practitioner with one view of the world – the acute one – can treat effectively. What are we doing treating diseases that have multiple causes with methods that assume that diseases have single causes? What are we doing treating anything chronic, like chronic pain, as if it had a single cause when research around the world indicates chronic pain has multiple causes? Worse. By what magic do primary care physicians develop the skills needed to treat chronic pain effectively when virtually none have ever taken a single course, continuing education credit or completed a pain residency, nor much less ever completed the supervised proctorships that produce the “demonstrable competence” that ethical principles require? By what sense of illogic can someone who is not qualified in chronic pain prescribe “off license” medications for a disorder they are not qualified to treat? In what other sub-specialty besides chronic pain can a physician accept to treat a patient and then say “I don’t feel comfortable prescribing opioids for you” and prescribe a medication that winds up under-treating and/or inappropriately treating  the disorder and then makes the condition worse? Since when does when does the Hippocratic Oath require that a doctor – rather than the patient – “feel comfortable?” Since when does “I will never do harm to anyone” in the Hippocratic Oath now come last, and personally “feeling comfortable” come first? When you’re not qualified to treat, do what the Hippocratic Oath tells you to do:”I will leave this operation to be performed by practitioners, specialists in this art.” Evidence-based medicine is increasingly showing that the outcomes physicians get who are not qualified to treat chronic pain are essentially random, meaning that general physicians efforts at treating chronic pain are worse than a roll of the dice. In a controlled study that we did for 6 years on the Scripps Memorial Hospital campus pain program, pain patients who were left to the “usual care” provided by their primary care physicians got 25% worse in 90 days compared to their counterparts who got the right medications from a Board Certified pain management anesthesiologist, or who got the integrated interdisciplinary reference standard for complex chronic pain. It’s too bad that health care left to its own devices hasn’t worked. It would have been nice to let doctors practice at their convenience, and that they could “feel comfortable” rather than having started addressing 25 years ago the predictable need to deal with the shift of the population towards chronic disease that we knew would cost 8 times what treating acute disease costs. But we didn’t and here we are, pretending that it’s ok fir physicians with no demonstrable competence to treat chronic pain “because it’s expedient.” It’s not so and there is no way that a bunch of overworked general practitioners are going to learn the skills fast enough to meet the need. The further fact is that  there simply aren’t enough qualified pain specialists to treat the 100+ million plus Americans afflicted with complex pain. Do you doubt that number? Don’t, because when 70% of the population has the risk factors for insulin resistance and diabetes, that means that 70% of the population has the risk factors for chronic pain. So what do pain patients do?

RIGHT! PATIENT, HEAL THYSELF

Pain today is the most frequent reason that patients give for going to doctors. Yet, acute-minded medicine that was designed to identify the single causes of symptoms doesn’t work. It’s been proven over and over again in every chronic disease. Acute-minded medicine is out of sync with the times and the chronic diseases afflicting us at this point in time. Acute thinking doesn’t meet the need. So why are we still insisting on using an outdated decision process, because there is no evidence that supports its use for any chronic disease. Acute-minded medicine, unless some readers have missed the point, does not address the lifestyle factors that all chronic diseases are caused by, and there’s no demonstrable evidence that the “usual care” general physicians give chronic pain patients helps patients get back to work or back to functioning optimally the way they used to. Single cause medicine, and treatment by solo practitioners, has proven useless with chronic pain because chronic pain requires a different decision process because chronic pain is a product of a combination of things that, over time produce diseases of wear and tear the symptoms of which acute treatment, does it need repeating, is useless at reversing.

The problem is that the world has changed significantly from the time acute-minded medicine met the challenges of communicable disease 100 years ago. The challenge now is chronic, multi-factor diseases that acute-minded, acute-trained physicians who try to force a round peg in a square hole, despite their persistence at trying, will fail to achieve.  And that’s not a debating point. It’s evidence-based, and the numbers demonstrate it around the world. Urgent care thinking is not working, people are suffering, and our current acute-minded physicians are unable to say, “I don’t know.” And, either primary care docs should do the ethical thing and refer out to a qualified person, or consider trying simple solutions, rather than make the life of patients miserable with shots in the dark that have no evidence base for being used by doctors unqualified in the field in which they are using them.  What we’re going through right now in the treatment of chronic pain is no different from what was happening shortly after the internal combustion engine was invented. Lots of folks were still trying to repair Model Ts using horse-and-buggy methods. We have medicine and physicians that are acute-minded and that are convinced that all health problems are caused by single agents, and they go ahead and treat our chronic diseases as if acute-minded medicine had an evidence base to stand on when the evidence shows their efforts to be wrong. The environment, the times, the lifestyle and the out-of-date medicine for the chronic need is the mix that has created the conditions that people with chronic pain will have to line up their priorities and decide whether they’re “sick and tired and I’m not going to let it happen anymore.” In the current situation, pain patients have to keep one thing in mind: Abuse is what I permit. And, then, don’t permit it. Don’t yell and scream – mainly because it’s useless – just walk. Walk away from the unqualified and do what you can to get into the right hands, as quickly as possible. Otherwise, you’re the only one responsible for the abuse.

WHY DO WE GET CHRONIC PAIN?

The pain implications of an older average age in a wealthier more indulgent times is simple, our bodies will predictably be exposed to more wear and tear and develop more “systemic” diseases that disrupt multiple systems. Just on the physical side, over time we are exposed to more bangs and whacks from vehicles made of plastic that we drive at speeds at which our unprotected bodies were not meant to travel. We use sports equipment designed for professional athletes, and therefore we can predict before they even put on the equipment that non-professionals will get injured and will likely wind up suffering persistent pain for many years, possibly until they die because they couldn’t not respond to the aspirational advertising. Our industrial environment has also changed. We now sit or stand or use specific body parts in unnatural ways for periods of time that the human body was also not designed to do. We were designed to be mobile, not immobile, and to use certain body parts up to a certain point and then to stop. But we don’t now because making a salary forces us to push the body beyond the tolerances of human physiology. Or we go to wars where every day brave men go beyond the tolerance limits of the human body. So disuse and overuse pain syndromes, especially of the low-back now dominate the headlines. Finally, even when we try to entertain ourselves, we engage in single activities like jogging or weight-lifting thousands and thousands of times, most of the time with above-average levels of resistance, that lead to repetitive strain disorders. In sum, we live in an era when we are reinforced for exceeding the tolerances of human physiology. And then we wonder why we have persistent pain that has been produced by a combination of conditions affecting multiple systems in the body and we fail to ask Why can’t my acute-minded doctor not “fix’ this problem right now? Of course, we too are acute-minded so that explains the demand for “right now.”

FIRST THINK, DON’T JUST WALK OFF THE CLIFF

Go back to the bullet points at the top. If you meet the criteria, you probably have pain that is out of sync with acute-minded, urgent care medicine that may have worked for communicable diseases but that medicine has not yet redone itself, from top to bottom as it did last century, to deal with a new challenge, the noncommunicable diseases or what the World Health Organization now calls NCDs. And that means that you are going to have to become responsible, accountable and liable for your the conditions of your own pain’s occurrence. You will have to decide whether you allow yourself to continue going to a physician who is not qualified to treat chronic pain, and you continue to think that s/he is “my pain doctor,” just because s/he prescribes some pain medications that have never worked for you, but have made your doctor “comfortable.” You will have to decide after letting your doctor treat a treatment for 3 months and it fails to get you functioning again how vigorous an action you will take, either with their medical board or with your State’s Intractable Pain Laws. Or, you will learn how to treat the part of your pain that you are more qualified than your physician: the lifestyle, habits and attitudes that are totally beyond your doctor’s area of practice and expertise. They know nothing about effective functional changes where you, with some guidance, can make changes that will modulate your pain. You will also have to decide how to think the way the Body does, with the KISS formula (Keep It Simple Silly). That’s learnable, and actionable, and it modulates pain.

MY AIM IS TO SHOW YOU WHERE THE MINE FIELD IS AND HOW TO GET THROUGH IT

This website deals with pain that meets criteria as a non-communicable disease. That is, chronic pain that is a product of a combination of factors, not the single causes of acute-minded medicine and acute-minded diagnostic techniques. This website also deals with the reality that – international surveys tell us – 98% of chronic pain patients will never see, nor will they ever be treated by a qualified pain specialist. The economics of healthcare make that a predictable impossibility for anybody but the richest chronic pain patients. Qualified, credentialed, board certified continuing care for chronic pain patients is dead. You’re on your own. You have to learn the skills for effectively self-managing the conditions of your pain’s occurrence and extracting whatever helps your particular type of pain from existing healthcare and that is likely the best that you will be able to get for your pain until you die. Moaning and groaning about “the healthcare system” hasn’t changed a thing in half a century. The money isn’t there to deal with any disease that is chronic because the numbers indicate that treating chronic diseases costs 8 times what it costs to deal with acute disease. They’re trying to force a round chronic peg in an acute square hole. And, from your own experience, you know it’s not working.

So, the goal of this website is to provide the attitudes, habits, and lifestyle skills that the pain that has been described above requires. I have chronic pain. I had pain for a period of 5 years where my teeth and my hair hurt. That’s a level of pain that the whole body is humming and there isn’t a moment of piece. I followed my own program, as have hundreds of my patients, and based on controlled studies with hundreds of patients I worked with on Scripps Memorial Hospital campus, with restoration of optimal functioning as the single-minded goal, optimal functioning can be restored in over 90% of our patients. There is an important role for the right pain medications. The reason is that, also from data from our patients, all patients who met the above criteria had to kick-start their rehab with the right pain medications, prescribed by qualified, board certified or credentialed pain management physicians, had to start taking pain medications in order to start their structured approach to rehabilitating their ability to function optimally. Today I take no medications but I am a fanatic about what I have to do to self-manage the conditions of my pain’s occurrence. That’s the goal of this website. It is a website where talk and reading books does nothing for you. You have to do pain self-management or it doesn’t work. Healthcare is what it is right now. Join me if you want help in overcoming chronic pain in a way that it frees you up to again functioning optimally under your own control.

We had 8+ pain and we overcame it,

Dr. Henry Adams

Chicago Tribune: The Oreo, Obesity and Us

December 22, 2009 | Filed Under: Latest News | Comments(2)

Pain patients should read this to be aware of how major food manufacturers make decisions about what to put to the market. Click here to download the article (PDF, 2.2MB)

Dr. Adams’ 100 Pain Mantras

December 22, 2009 | Filed Under: General Information | Comments(0)

(Collected during chronic pain support groups 2000-2006)

1.     There is no greater love or admiration than that felt for the person who can show you how to reliably relieve your pain.

2.     In self-managing your pain, you got to be careful if you don’t know where you’re going because you might not get there.  (Adapted from saying by Yogi Berra)

3.     Blessed are those who, having no personal experience to draw on about CNCP, just can’t stop giving us abundant evidence of that fact.

4.     “Do. No try.” (Yoda, in The Empire Strikes Back)  [Large poster hung in the pain support group room]

5.     If you’re going through Hell, at least be as effective and consistent as you can so you can get out as quick as possible and with least burns.

6.     To those who demand “outcome studies” before taking action on pain, as Einstein said, “Not everything that can be counted counts, and not everything that counts can be counted”

7.     In helping CNCP patients overcome pain, the average doctor does “what I can,” genius makes pain control happen.

8.     If you can do the common things in science in an uncommon way, you will command the attention of the world.

9.     Breakthrough pain is that unpleasant jolt you get when you get distracted from doing things wisely, consistently and correctly enough to remain functional.

10.  Not only is there no God, try getting authorization for a refill for a pain med on a Sunday.

11.  Want to make an enemy? Tell your GP, who thinks he’s doing pain management, that he really doesn’t know what he’s doing.

12.  A bad pain doctor is one of those people who would be greatly improved by Death.

13.  If you still haven’t learned that you have to go to pain specialists to get effective pain management, for sure you’ll find a non-specialist who will tell you, “Let’s try this.”

14.  Do legislators really believe that it is an insurance card that causes severe unremitting pain, and that the time for treatment is when the insurance company tires of sending you denials?

15.  Few things are harder on surgeons’ Egos than to have a patient tell them they still have pain after the surgery.

16.  If Life were as error free as surgeons would have us believe, we’d all still be living in Paradise.

17.  If you don’t believe what we say about the risk of going to non-specialists, the best way to test their effectiveness is to do exactly as they say and in 3 months count how often you now go to work compared to when you started.

18.  Happiness is chronic pain at a level 4 when for 15 years it was at a level 8.

19.  When you have chronic pain, a real friend never asks you, “How’s your pain today?

20.  With doctors who are not qualified in pain management, you can get more with a polite request for pain relief and a gun than you can with just a polite request for pain relief.

21.  In response to a colleague suggesting I get an assistant to help me conduct the pain workshops:  “I guess it is time I stepped down and let a less-experienced doctor who never had chronic pain take over.”

22.  There are some experiences in Life that should not be expected twice of any human being. One of them is listening to doctors who aren’t certified in pain management pontificate about how their pain patients’ pain is “all in their heads.”

23.  “It’s time,” the Walrus said, “for chronic pain patients to stop begging for qualified pain management that restores their ability to enjoy as normal a Quantity of Life as possible.”

24.  Today, expect insurance carriers to only behave compassionately once they’ve first exhausted all other alternatives.

25.  There are two laws for success in the politics of health care: to win votes, disregard the data and talk all the nonsense you can; to lose votes, try to do the right thing for a deserving constituency.

26.  In America today, if a clinician is effective and compassionate, we have to ask, Are we in the right country?

27.  Today, anyone can become a businessman, doctor or thief. The problem is how many doctors insist on trying to be all three.

28.  Since 2000, molecular research showed that chronic pain alters DNA. In 2010, any physician who still says that “chronic pain has no function,” has met the diagnostic criteria for Mental Retardation.

29.  Functionality increases, and pain decreases, in direct proportion to the consistency with which we self-manage the conditions of our pain’s occurrence.

30.  Chronic pain patients do not need improved Quality of Life” but “more Quantity of Life.” The first is for terminal cancer patients, the second is for empowered pain patients.

31.  A pain-loser sees the difficulty in every opportunity; a pain-winner sees the opportunity in every difficulty.

32.  The only thing necessary for pain to become severe and unending is for the pain sufferer to either do nothing, or to do whatever they do inconsistently.

33.  Chronic pain can be both exhausting and depressing. The winner’s answer is:  “I’ll do what I have to, to start doing what’s normal for me… you take the antidepressant, doctor.”

34.  Losers chase magic bullets their whole life and achieve no long-term pain relief.  Winners change their lifestyle and bad habits the way they have to in 3 months and wind up enjoying manageable pain the rest of their lives.

35.  A chronic pain survivor is nothing without consistency and, as in everything else, the consistency is nothing without hard work.

36.  Never stay in bed if you’re in serious pain.  After 24 hrs, muscles will tell you, “You don’t want my services?  Bye, I’m taking a vacation, and I may never come back again.”

37.  Overheard at Workshop 1: “I don’t know why my anesthesiologist prescribed Dr. Adams’ pain program, but I’m pretty sure it’s not because he’s convinced drugs and injections are the answer.”

38.  A procrastinator is a device for turning manageable pain into irreversible pain.

39.  I’m in favor of keeping weapons of mass destruction out of the hands of fools. Let’s start with keeping pain drugs out of the hands of those doctors who think they’re “magic bullets” so they can avoid making a referral to a pain specialist.

40.  Dr. Adams, Workshop 2: “Once you eliminate the contribution lifestyle, bad habits and chronic risk factors make to pain, what remains is ’eminently manageable.'”

41.  Comment from a workshop participant: “By taking Dr. Adams’ chronic pain program, I found it can be extremely empowering to try what I thought was impossible.”

42.  In America, the true measure of a great physician is how he treats someone with no health insurance.

43.  In American medicine today, the current approach to treating chronic pain is evidence that there is more stupidity than there is hydrogen in the universe.

44.  The Law of Failed Back Surgery: “Once is coincidence, twice is a pattern, three times means you’d better run because they’re trying to kill you.”

45.  To listen to your Body as you would a best friend is the first step towards experiencing less pain.

46.  Reassurance, encouragement and support – the fundamental tenets of clinical medicine – have nothing to do with the mechanisms of behavior-change that are needed to make chronic pain more tolerable.

47.  Overhead from a workshop participant:  “As a technique for dealing with people who are being a pain-in-the-neck about my pain, I’ve heard about changing the subject, but never just excusing myself to go to the toilet.” (Recommended in the workshops as the single best way to change the subject)

48.  If you gaze long enough into Pain, Pain will tell you what the conditions are of your pain’s occurrence and, changing those conditions, Pain will leave you alone to enjoy the Quantity of Life that you earned.

49.  Every CNCP patient learns basic ways to overcome their pain over time. Those who are more successful at keeping their pain at tolerable limits simply have a greater sense of commitment to their efforts.

50.  Obsessive-compulsive: a person more interested in being personally responsible for doing whatever reduces their pain than in talking about wanting others to be responsible for their pain.

51.  Will and consistency are guarantees of pain reduction.

52.  In the self-management of CNCP, the wise do a lot and talk little, while fools talk a lot and do little.

53.  The only clinician who can make valid statements about the treatment of CNCP is the one with the track record of effectively reversing it. All others are talking off the top of their head or protecting a fragile Ego. Seek out and stick with the first and run from the second.

54.  Beware! He who cannot tell you what CNCP is in words you can understand will likely have similar problems communicating with your pain.

55.  Dctors who don’t know CNCP are always “trying” this or that. If you hear, “Why don’t we try this,” get your sneakers on, politely thank the doctor for his efforts. and run out the hell out of his office. Chances are your pain will improve more from running than from returning to that “Why-don’t-we-try-this” doctor’s office.

56.  When non-pain doctors’ single-minded approaches to pain fail, a few lifestyle, habit and risk factor  changes  can go a long way to reducing pain.

57.  To transform serious pain to tolerable pain: 1) stabilize the pain or make a referral to a specialist who can; 2) get your patient into a qualified pain program that restores their ability to function, uses just-enough pain meds to enhance their rehab; 3) empower the patient – make them responsible for the conditions of their pain’s occurrence ; and, 4) make yourself useless as soon as possible.

58.  Overheard at a meeting of the Scripps Pain Committe: “The more excuses patients give about why they’re not starting the pain program, the lower their functionality, the more their use of pain meds, and the more frequent their use of medical services. And the more likely you will get sued or the patient will commit suicide.”

59.  Overheard between Dr. Adams and a non-pain doctor: “You’re too old to be trying to treat a chronic disorder alone. You should know by now what you need to do as part of a team to relieve chronic pain that doesn’t respond to conventional treatment.”

60.  Over 25 years ago, Dr. Norman Cousins, in his book Anatomy of an Illness, described how watching Marx Brother movies 3 times a day helped him overcome an illness diagnosed as fatal. Cousins made it a point to enjoy a hearty belly laugh every chance he got… and, his chronic disease remitted. Comments?

61.  Hope, purpose and determination are not merely mental states. They are translated into patterned behaviors that translate into brain circuitry that comes back as molecular events, which directly affect pain and every integrated system of which pain is a function.

62.  A brain – to modify the famous metaphor of Socrates – should be the delivery room for the birth of actions that relieve pain — a place where environment, action and physiology come together and relief becomes a reality.

63.  Action is like a piece of rope; it takes on meaning only in connection with all the things it holds together and that, over time, as it did 4.5 million years ago continue to give us relief from pain.

64.  Death is not the greatest loss in life. The greatest loss is what dies inside us when we live in persistent pain and, particularly, that we permit be done to us by doctors who never had pain, never studied pain and never effectively created the conditions that reduced the suffering of our patients.

65.  For want of a consistent combination program for pain relief, a life was lost.

66.  “A routine, a routine, my kingdom for a routine of pain control that works.”

67.  Regular belly laughs – and the conditions of their occurrence – is the single best means of producing the world’s best pain killers… your own endorphins… and of keeping use of the synthetic stuff to its effective minimum. Don’t forget, your own painkillers produce no side effects, no liver damage and need to even think of lawyers.

68.  Pain is not the enemy; living in constant fear of it, and not living, is.

69.  Don’t defy the diagnosis; try to defy the excuses you’ll come up with to not do what you need to  dis-confirm it.

70.  If a smile comes to another person’s lips because of you, then you have created the conditions for less pain.

71.  Try to use the word “wonderful” in response to all the things that surround you, and your pain will become noticeably less.

72.  Is it possible that love, faith, laughter, confidence, consistency and a fighting spirit can reduce pain even though physicians can find “no objective findings” to confirm them? Of course it can!

73.  It is not necessary to go off on a tour of great cathedrals in order to find Deity. Look within. But, you have to be able to sit and let go a bit to be able to achieve that state.

74.  It makes little difference how many university courses or degrees a person may have.  If they cannot take positive steps to help someone who is in pain, all that education was for naught.

75.  Life is an adventure in forgiveness. Forgive yourself for the stupid things you did to subject your body to persistent pain. Now do the things you have to, to finally give your body the habits and lifestyle patterns it needs to enjoy less pain.

76.  Laughter may or may not activate endorphins, reduce blood pressure and enhance the immune system.  What is  clear, though, is that laughter is good medicine for pain. There are no adverse reactions, no long-term side effects and it’s the cheapest medication on the market. The more you laugh, the less the pain, the better you function and the greater the Quantity of Life you thought you had lost.

77.  Pain Mantra:  The more severe my pain, the more important it that I use all my resources – the right meds, awareness of the uniqueness of my pain and the conditions of its occurrence, my Anti-Inflammatory Way of Eating, and what are the right habits and lifestyle for me – and I will reduce the conditions of my pain’s occurrence.

78.  I became aware that to increase my ability to function and reduce my pain, I would have to be more than a passive recipient of care from a doctor with no specialty training in pain and no personal experience with chronic pain. My many excuses for not doing what I had to had to end or the pain would clearly end me. (Ankylosing spondylitis patient, Workshop 2)

79.  The assumption that the patient should take charge of their own pain management is the single most salient characteristic of pain survivors. It is the cornerstone of the best multidisciplinary treatment approach there is.

80.  Pain Patient Heal Thyself!

81.  Pain Patient Beware The Generalist Who Swears That Your Pain Will Get Better If You Will “Just Try This!”

82.  Pain patient; run rapidly from “Let’s Try This” doctors, for they know not what they do.

83.  The single best solution to ineffective medical care for your pain is in your feet. Run, Don’t Walk!

84.  Aqua-therapy patient: “88 to 92-degree water! Plus pushing against resistance. The closest thing to heaven!”

85.  Hate your pain. In fact, hate it so much that you feel driven to avoid all the conditions of its occurrence. Then you can again begin to have a Life.

86.  Do the Chronic Pain Diet consistently for 6 months; along with all the other consistent things you’re supposed to do. Then talk to me about pain, if a level 3 pain is really “pain” relative to what you had gotten used to.

87.  Keep a log of all the things you could NOT do before you started our program. It will help you appreciate better, 6 weeks into the program, how much better you’re really doing. And, that’s science rather than empty claims.

88.  Let thy food be thy medicine, and thy medicine be thy food. (Hippocrates, Father of Medicine)

89.  No illness that can be treated by diet should be treated by any other means. (Moses Moimonides (12th Century physician)

90.  Unless the doctors of today become the nutritionists of tomorrow, the nutritionists of today will become the doctors of tomorrow. (Alexis Carrel, M.D. (1900)

91.  The doctor of the future will give no medicine, but will interest the patient in the care of the human frame, in diet and in the cause and prevention of disease. (Thomas Edison)

92.  There are no incurable diseases, only incurable people.  (Dr. John Christopher)

93.  Getting well is easy. It’s getting sick that takes years of dedicated hard work. (Dr. Richard Schultze)

94.  All truth goes through 3 stages. First it is ridiculed. Then it is violently opposed. Finally, it is accepted as self-evident fact. (Schopenhauer)

95.  If the only tool you have is a hammer, you tend to see every problem as a nail. (Abraham Maslow)

96. Never mistake good intentions for effectively and quickly restored functionality.

97. If the person treating your pain is unable to deliver observable, measurable, objective results in 3 months, do not walk out of their office, RUN.

98. The devil is in the details in restoring functionality. The daunting task is in converting dime-a-dozen reassurance, advice and support into demonstrable, long-lasting control of the conditions of your pain’s occurrence.

99. Beware of Interventional Pain Management before its time. It’s a last rather than a first resort.

100.  Like it or not, the likelihood is that anyone with 5+ pain will have to take the right pain meds to kick-start their functionality restoration program. And the likelihood also is that the “right pain meds” will not be provided by someone who is not credentialed in pain management or pain medicine, and does not have extensive experience in actually restoring the functionality of chronic pain patients.

Paineurope: Issue 4, 2004. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Researchers at University College London used functional MRI (fMRI) to understand how humans learn to predict conditions that lead to aversive stimulation and pain. Subjects were presented with a series of abstract pictures followed by a 1 second electric shock. While they could not recall the sequence of the images, the imaging indicated that volunteers had learned how to predict the pain-producing conditions. The study concludes that: “The subconscious interpretation of environmental cues, leading to the avoidance of aversive stimuli, may be to the disadvantage (sic) of the persistent pain sufferer.” Dr. Adams Implications: The study conclusions are the just the opposite of what commonsense and casual observation indicate has survival value for any living organism. That is, the ability of lliving organisms to learn to avoid, escpae or terminate the conditions of pain’s occurrence, by effectively modifying the conditions of its occurrence. Clearly this ability provides evolutionary advantage rather than disadvantage to the living organism that learns to manipulate its environment to terminate aversive stimulation. The critical application of this evolutionary skill for CNCP patients is that the ability to effectively escape, avoid or terminate aversive stimulation, technically, is a positive reinforcer and, biochemically, that means systematic release of endorphins. In our program, CNCP patients learn how to avoid aversive stimulation, reinstate release of endorphins, and thereby, as endorphin release is returned to steady state (pre-injury) levels, systematically reduce pain long term.
  • A recent European telephone survey of nearly 6,000 respondents with musculoskeletal pain (MP) and almost 1500 primary care physicians revealed that: (a) the majority of the physicians said they were trying to “improve quality of life” and that they were “aware” of the risks of NSAIDs; while (b) ¼ of the respondents had not sought medical help … those who did often waited for several months before doing so … ¾ had constant or daily pain … just over ½ received a prescription for their pain … however, most felt poorly informed. In 5 of the study countries, only ½ of the respondents “were aware of potential side effects.”  Another survey of 662 patients with peripheral neuropathy conducted by the Neuropathy Trust (UK) revealed that up to ¼ of patients waited at least one year before being referred to a specialist, and 2/3 of the sample “felt they were not being kept under review.” In the UK, there are some 1.4 million people with peripheral neuropathy and around ¾ of these are unable to work because of pain. The article concludes that delays “in assessment and diagnosis can be avoided if primary care practitioners are given advice about recognising and treating neuropathic pain.” Dr. Adams Implications:  Possibly in Europe, if primary care physicians are “given advice about recognizing and treating neuropathic pain,” they will translate it into the action that is needed to expertly care for the 1.4 million Brits with neuropathic pain who are unable to work so that they can return to work and the National Health System can realize the cost savings that this change in practice would bring about. However, based on the US experience, changes in how physicians practice is not driven by “advice” but economics. In the US, even mandated continuing medical education (CME) has not achieved this change in practice. Practitioners of all stripes, since the publication of Bonica’s The management of pain in 1953, continue to practice driven mainly by economic self interest rather than “the right thing to do,” what they are “advised to do” nor, most recently, by what their professional organizations mandate them to do in re. CNCP. In one study – Sohn W, Ismail Al, Tellez M (2004). “Efficacy of educational interventions targeting primary care providers’ practice behaviors: an overview of published systematic reviews” J Public Health Dent, 64(3):164-72 – the authors conclude that “evidence from the included systematic reviews showed that formal continuing medical education (CME) and distributing educational materials did not effectively change primary care providers’ behaviors.” Given the history of inaction on CNCP on both side of the Atlantic, the solution is for CNCP patients to take individual action such as: (1) stop patronizing (read “reinforcing”) non-specialists, (2) put together your own multidisciplinary specialty team, (3) pursue a “restoration of maximum functionality” objective, and (4) if you cannot get the rehabilitative support you need from one doctor, fire that doctor and find another one who will. A half century of inaction is an answer:, and that answer is, “No, we’re not going to do anything about chronic intractable pain.” The best thing CNCP patients can do is get the message and start implementing the 4 steps proposed above. If sufficient numbers of CNCP patients do so, consistent withdrawal of reinforcement, science tells us, will predictably extinguish the undesirable behavior.

Paineurope: Issue 2, 2005. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Drawing on a survey of some 30,000 people, about 17 million Japanese suffer from chronic pain. The prevalence of chronic pain was 13.4%, in ¾ of whom pain is perceived to be poorly controlled. Despite this, almost 90% of patients were satisfied by the treatment provided by their physician. Half of those surveyed believed that their pain would last forever.
  • A Medical Research Council team in the UK has outlined an effective strategy for managing low-back pain. A large study compared standard primary care support with either physiotherapy or spinal manipulation. A third group received both interventions to support treatment from their general practitioner and reported the greatest improvement. Although benefits were modest, the prevalence of back pain is such that the combined approach is likely to be cost effective.
  • According to a study published in the Journal of Neuroscience (2004; 24:10410-15), chronic pain may cause loss of brain tissue, which may be irreversible. Using MRI data, US researchers studied 26 patients with low-back pain and 26 matched controls. Those with pain were divided into groups with neuropathic or non-neuropathic pain. Patients with neuropathic pain demonstrated shrinkage of neocortical areas (prefrontal cortex and thalamus) by as much as 11%, equivalent to grey matter loss occurring with 10-20 years of normal aging. Amount of tissue loss correlated with the length of time patients had had their pain.  The findings agree with other imaging studies that show decreased brain activity – and apparent atrophy – of the affected areas.

Paineurope: Issue 1, 2005. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Self-help advice may be enough to treat back pain: Researchers in Warwick and Oxford in the UK suggests that traditional physiotherapy, alone, may be no more useful for treating back pain than appropriate advice about self-management and modifying beliefs and behavior (http://bmj.com/cgi/content/full/329/7468/708). The study concluded that a single advice session from a physiotherapist was as effective as traditional physiotherapy treatments. Researchers stress that since there is no magical cure for back pain, the need is for better symptom self-management. Dr. Adams Implications:  Our data fully supports that effective pain treatment is multidisciplinary.
  • Also in the UK, researchers have shown that topical anti-inflammatory drugs used for the treatment of osteoarthritis have little benefit if used beyond 2 weeks. Osteoarthritis is a long-term, usually lifelong problem and sufferers need drugs that demonstrate sustainable efficacy. Dr. Adams Implications: at the present time, all pain drugs lack the longitudinal research that supports their use for the average 7 years that the majority of CNCP patients have had their pain. Therefore, CNCP patients should know the side-effect profile of each of their medications, and take personal responsibility for discontinuing problematic ones any time personally risky symptoms arise.
  • European pain specialists have organized to help improve their CNCP knowledge and skills.  The Pan European Pain Specialist  (PEPS) program met in The Netherlands, Sweden and Switzerland during 2004. The purpose was to enable pain specialists to meet, share ideas and experience clinical practice within a variety of European countries. Each meeting has a multi-country delegation of about 20 pain specialists, and consists of a 3-day program of seminars and tours of local pain clinics. The meetings have offered many pain specialists a unique insight into pain management around Europe and provided them with an opportunity to visit some of the world’s leading institutions. Dr. Adams Implications: clearly how pain treatment takes place depends on the healthcare conditions of which it is a function. The impact that the solo practitioner mindset (personal self interest) to treating pain in the US, vs. the national health system mindset (system-wide reduction of costs) in Europe is apparent. Europeans are far ahead of the US in organizing against pain and using the multidisciplinary interventions that have proven more effective for treating CNCP. Two simple factors seem to account for this: self interest is systematically less reinforced in Europe, and the reduction of costs is more reinforced.

Eisenberg, Elon (2004). New online resource for physicians. Paineurope, 4:1

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

“The Opioids and Pain European Network of Minds (OPENMinds), formerly the European Expert Group for the Appropriate Use of Opioids in Pain Management (EEG), have officially launched a European pain and opioids website, www.openmindsonline.org,” coinciding with the European Week Against Pain. “The website aims to assist healthcare professionals in learning about the role of opioids in managing persistent pain and hopes to improve the shared knowledge base on the use of opioids in pain management.” The website “provides visitors with access to in-depth wide-ranging information on the general principles of opioid use in persistent pain management and information on best practice. It also covers various patient subgroups, side-effects, dependence, tolerance (and problem drug users), as well as regulatory and legal issues such as differences in prescribing regulations across Europe. There is also an opportunity for visitors to provide comments and feedback, as well as to ask the OPENMinds group for their expert opinion on key opioid- and pain management-related issues. Healthcare professionals are invited to register for free use of this important new resource at www.openmindsonline.org and are reminded to watch out for updates in paineurope, the official publication of OPENMinds.” Dr. Adams Implications: Offers evidence of the lack of interest in the US of government, the professions and business to take concerted action on chronic pain.

Niv, David (2004). Global experts unite in the fight against pain. Paineurope, 4:1

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Exceptional gathering of the European community of pain specialists with the purpose of taking concerted action on reducing the problem of unrelieved pain. “The European Week Against Pain started in earnest on 11 October with the resounding success of the second Global Day Against Pain. The meeting, held in Geneva on October 11, 2004, was a joint effort between the International Association for the Study of Pain (IASP) and the European Federation of IASP Chapters (EFIC) and was endorsed by the World Health Organization (WHO). “The global focus of the meeting was reinforced… by a live worldwide web-cast, timed so that every continent could view the proceedings first hand. The afternoon sessions covered pain as a global concern, innovation in research and treatment, pain and quality of life and major pain problems in low-income countries.” Dr. Adams Implications: The event contrasts sharply with (1) the minimal efforts being taken in the US to implement national-level action about reducing chronic pain, and (2) why it’s so important that individual CNCP patients get the message that no action probably ever will take place in the US from either government, the medical community, individual physicians or insurance carriers and that every pain patient should get the message and learn to create the conditions that allow them to self manage their pain more effectively, and long term rather than short term.

Puig, Margarita (2005). Drug combinations in pain management. Paineurope, 1:4-5

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Discusses “multi-modal therapy” – combining 2 or more analgesics with different mechanisms in an effort to improve treatment efficacy while minimizing adverse events. Explains decision logic needed to produce drug interactions with additive, synergistic or antagonistic effects. Shows how isobolograms guide drug interaction decision making. Yet, notes that while in cancer pain, the combination of opioids and NSAIDs “slightly improves analgesia,” in CNCP – the subspecialty pain of interest here – “there are insufficient data demonstrating the advantages of analgesic drug combinations,” because “there are less inflammatory components and the pain mechanism of each case should be investigated to find the correct drug combination.” Dr. Adams Implications: This makes the use of multiple drugs a dead issue in chronic non-cancer pain since, “in chronic musculoskeletal pain… monotherapy is often the rule” and, our CNCP patients with neuropathic pain stated that the addition of “antidepressants, anticonvulsants and other adjuvants” simply complicated treatment by: (1) delaying restoration of function, (2) complicating the management of side effects and (3) creating risk of “paradoxical pain,” where random increases in pain amplitude and frequency have been seen in cancer patients on opioids. Our data clearly show that the more medications that are used, especially at the start of treatment, the greater the risk of “paradoxical pain.”