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.

Leading Figure Describes Current State of Pain Management

December 16, 2009 | Filed Under: General Information | Comments(0)

John Loeser, M.D., and J.J. Bonica, M.D., are two of the leading figures of chronic non-cancer pain (CNCP) management in the US. Dr. Loeser has been writing, treating, teaching and researching chronic non-cancer pain for the half a century that the field has been trying to make chronic non-cancer pain management better grounded in its own science and, thereby, make it more relevant, accessible, effective, safer and less expensive for patients. The citation is as follows: Loeser, John (2007). “Foreward” in Schatman, Michael E. and Alexandra Campbell, Eds. Chronic pain management: guidelines for multidisciplinary program development. NY/London: Informa Healthcare, p. iii-iv (Pain Management Series, 3)

The idea that chronic pain is a medical problem was born with the pioneering work of John J. Bonica, M.D., at the end of World War II. Chronic pain entered the world of academic medicine when Dr. Bonica was appointed the founding Chairman of Anesthesiology at the University of Washington in 1960. The term, multidisciplinary pain clinic (MPC), was invented by Dr. Bonica, originally to describe an approach to the diagnosis and treatment of chronic pain patients by a group of physicians who interacted with each other as well as with the patients. In the 1960’s, also at the University of Washington, Wilbert Fordyce, a psychologist in the Department of Rehabilitation Medicine, recognized that a behavioral approach to the treatment of chronic pain patients could be more successful than injections, pills or surgery. He started a behavioral pain management service in Rehabilitation Medicine and brought his principles of pain management into the multidisciplinary pain clinic. Other psychologist broadened the Fordyce approach to include cognitive-behavioral strategies and increased its effectiveness. In 1983, Dr. Fordyce and I started a 20-bed inpatient and outpatient multidisciplinary pain clinic that was independent of any single academic department. This served as the prototype for multidisciplinary pain clinics throughout the world, in part because of our active teaching programs and openness to visitors. Physicians of many specialties, psychologists, nurses, physical and occupational therapists and vocational counselors were all integral members of our team.

Many other health care providers also played important roles in the development multidisciplinary pain management; the Commission on Accreditation of Rehabilitation Facilities (CARF) adopted our model as the accreditation standard for multidisciplinary pain clinics. Multidisciplinary pain clinics were developed throughout the world, often with varying content and emphasis to fit the needs of the patients they treated and the providers they had available. In countries with rational health care systems, this form of patient diagnosis and treatment seems to have prospered, as it has been recognized as more effective, less hazardous, and less costly than traditional approaches to treating chronic pain patients. Based squarely upon a biopsychosocial model rather than the prevalent biomedical model, multidisciplinary pain management has been seen as a threat to biomedicine and the industry’s imperative to consume expensive health resources.

In the United States, with a non-system of health care and the dramatic introduction of economic factors into health care decisions, MPCs have not fared as well and the number of programs has decreased steeply in the past ten years. There are many factors that have contributed to the relative demise of MPCs.

First, a labeling issue: Any group of two or more health care providers can call themselves a multidisciplinary pain clinic and is capable of deceiving the public as to what they offer insofar as diagnostic and treatment options. This is a common occurrence and has brought considerable disrepute to bona fide MPCs.

Second, decisions about what forms of health care are to be offered are not made uniquely by doctors and their patients. Instead, insurance companies and large hospitals and academic medical centers ignore both the moral imperatives to treat chronic pain and the available outcomes data on treatment efficacy and often will not fund MPCs. For large, American hospitals, especially those associated with a medical school, revenue generation is the major determinant of what services the institution will offer. MPC is not seen as a value compared to cosmetic surgery.

Third, payment to providers is skewed in favor of procedures and surgeries, putting great economic pressures on those who provide a personal service without a procedural intervention.

Fourth, proceduralists have done a much better job lobbying funding agencies and the public as to the utility of their interventions than have those who run MPCs.

Fifthly, there is no single optimal plan for how to run an MPC and what its content, duration of treatment and team members should be. This has made it difficult for funding agencies to evaluate programs and compare costs and efficacy.

Finally, organized medicine has never accepted the validity of multidisciplinary pain management and there are many impediments to its implementation in the medical community.

This book is designed to combat many of the problems that confront multidisciplinary pain management in the United States today. A stellar group of contributors has addressed the problems of building and maintaining a multidisciplinary pain clinic. The emphasis is upon outcomes, not personal anecdotes. Multidisciplinary pain care is the best treatment we now have for the rehabilitation and relief of suffering of chronic pain patients. Chronic pain patients always have psychosocial factors that influence their disability and suffering; pills and surgery do not address these at all. This volume will be an important tool in the restoration and continued development of multidisciplinary pain management in the United States and the remainder of the developed world.

John D. Loeser, M.D.

Professor of Neurology and Anesthesiology

University of Washington Medical School

Seattle, Washington, U.S.A.

Is Chronic Non-Cancer Pain Complicated, or Are the People Trying to Treat it The Complication?

August 3, 2009 | Filed Under: General Information | Comments(0)

“In the land of the blind, the one-eyed man is king. And, in 5+ level chronic non-cancer pain, whoever can consistently restore functionality according to patients’ priorities, controls chronic pain as we know it.” Grand Rounds, Scripps Memorial Hospital Campus, Schaetzel Conference Center, 2004

 

Around the world, those who study chronic non-cancer pain agree on the following:

That patients with moderate to severe (5+) pain have had their pain, on average, for 7½ years before they find the qualified multidisciplinary treatment that is the gold standard for restoring the functionality that most patients want restored. Furthermore, functionality is a clearly observable, measurable, objective standard, so why do so many studies talk about increased “quality of life” in regards to chronic non-cancer pain? It’s interesting semantics that patients need to understand lest their treatment objectives be changed without their awareness.

Medications are “licensed” by the FDA for specific uses. Therefore, medications intended strictly for cancer pain can only be legitimately marketed to cancer patients. And, the language of cancer pain must be used to stay on the safe side of the FDA, who can be pretty strict about misapplications of a licensed drug. Now, a key outcome in cancer pain is increased “quality of life,” meaning that someone who is facing life and death – and for whom going back to work, socializing, doing housework and getting a higher degree to improve one’s chance of promotion on the job is pretty irrelevant stuff – and is just happy to get an “increased quality of life,” which really means “suffering a bit less from cancer pain.”

However, once the drug is on the market, any physician can choose to use a medication “off license,” or for some other use than the use that was “licensed” by the FDA. Therefore, a drug company wishing to increase use of its cancer drug would be wise not to directly challenge the FDA by changing the wording of its key outcome – or its “improved quality of life” claim – and just put the advertising out there in the right journals and hope that general physicians, who are the majority of those who prescribe “off license,” will think that “improved quality of life” might be what their chronic non-cancer pain patients could benefit from, without worrying about splitting hairs over what cancer and non-cancer pain patients really see as their tangible treatment objective.

Now, since chronic non-cancer pain patients are not dying and do very much want to go back to work, socialize, do housework again and improve their chances of an increased salary and all that future-oriented stuff, the “quality of life” is not what they want as a key outcome of their pain treatment. In fact, in repeated studies with non-cancer pain patients, the tangible, future oriented things are precisely what they want more of, and those really constitute “quantity of life,” which is quite a different bird from “quality of life,” which is just a matter of feeling a bit better about your suffering and, therefore, about your prospects of dying or not, or again, your overall “quality of life.”

What is the implication for chronic non-cancer pain patients? Obviously, keep your eye on the ball. If your treatment objective really is to go back to work and all those good activities that constitute your “functionality” and “ability to function as normally as possible,” then do  NOT allow a physician to mix metaphors on you. If a physician tells you, in offering you a pain medication, that “it should increase your quality of life,” do two things. First, remind her/him that you’re not dying and that you want an observable, measurable, objective measure of improvement relevant to your life, like going back to work and all those other activities you want restored. In other words, you want “increased quantity of life,” in a reliable, predictable manner over the long term, not some vague, subjective “quality of life” that is no different than telling your boss that you want an “improved quality of salary” rather than that you want a “12 percent increase in salary.” And, second, you had better start looking for another physician to prescribe your pain medications, because the one that couldn’t tell the difference between “quantity” and “quality of life,” you really don’t want treating your pain any more.

See the difference? And that’s the difference between effective and ineffective treatment for chronic non-cancer pain, that you can, and must make for yourself… if you want restored ability to function!

Dr. Henry E. Adams

1-IX-2009

The Collapse of American Healthcare and How Pain Patients Can Survive It

July 6, 2009 | Filed Under: General Information | Comments(0)

Dr. Henry Adams, Diplomate in Pain Management, AAPM

“When the world is destroyed, it will be destroyed not by its madmen but by the sanity of its experts and the superior ignorance of its bureaucrats” John Le Carré

SITUATION ANALYSIS

In 2005, when I was directing the outpatient chronic non-cancer pain program on the campus of Scripps Memorial Hospital in La Jolla, CA, I wrote a  draft of a book that was going to be distributed to pain patients in my pain program. Although I had to postpone publication of the book, writing the manuscript forced me to research a lot of government data that, already in 2005, showed that the collapse of American  healthcare was already taking place. The inescapable negative data included the following:

In 2008, healthcare expenditures exceeded $2.4 trillion, were projected to rise to $3.1 trillion by 2012 and, by 2016, to $4.3 trillion. The absolute numbers and the rate of growth were to become even greater as 77 million Baby Boomers would begin entering Medicare between 2011-2030. What those numbers say to anyone with a little  understanding of numbers, is that the healthcare strategy used since Richard Nixon and intended to provide “cost containment” could NOT possibly work because whenever costs continue to climb  regardless of what you do, it means that your basic strategy needs to be thrown out. What incentive does anyone have to pursue a strategy whose numbers tell is absolutely wrong?

– In 2006, America spent 4 times more on healthcare than it did on national defense.

– In 2008, the US spent 17% of every cent it made  – its Gross Domestic Product – on healthcare. That percentage, the estimates are, will climb to 20% by 2017.  Today, the US spends more total and per capita on healthcare than any other country in the world. Not because it wants to, but because there is no will to control the major costs which are “eminently” controllable.

– That fails to take into account the numbers that make it absurd to say that the solution is  that Americans  “buy” health insurance so they can access to health care when needed:  1)  12 -14 million Americans are currently unemployed and have no regular source of income with which to “buy” that insurance;  2) 77 million Baby Boomers are coming into Medicare between 2011 and 2030, will be 65, will be living on a fixed income, and won’t have the money to “buy” the health coverage that will cover the chronic diseases that naturally occur with aging; 3)  70 million Americans who live at or below the poverty level, are disabled, or 75 or older, and all of them can’t work and can’t “buy” health insurance. That adds up to the fact that 1/3 of all Americans cannot “buy” insurance, such that everybody has access to the same quality and quantity of care when and how they need it.

– Most recently, the numbers gathered on primary care physicians charged with caring for the rapidly growing needs of an America burdened with chronic diseases that require more, and more varied care reveal that: 1) the supply of primary care physicians is dropping rapidly as the demand for services for chronic diseases also rises rapidly; 2) the government in its wisdom has cut primary care physicians’ Medicare reimbursement by 21%, which has driven even more to stop providing care to Medicare patients who will need to get more, and more varied care, with the shortage of primary care physicians,  from far more expensive specialists.

Conclusion: 1) we have more people now needing more, and more varied health care due to the economic, demographic, and lifestyle patterns molded by this nation than ever before; 2) we also have less people than ever before,  proportionately, who are able to competently care for those who need it; 3) one third of all Americans do not have the consistent income that will reliably accompany cost of living changes and give them the ability to “buy” healthcare in any ongoing manner such that they will have access to the continuing  standard of care they will need to maintain wellness and optimal functionality, including the return to work; and, 4) the “healthcare-as-market” hypothesis is invalid, unusable and bankrupting individual Americans and the nation, as evidenced by over half a century of total lack of control of healthcare costs.

As Healthcare Eliminates Pain Specialists, Wise Patients Learn to Self-Manage

February 3, 2008 | Filed Under: General Information | Comments(0)

It’s time for Americans with any chronic disease to say “I’m not going to take it any more” for 2 reasons: 1) There is no evidence to support the view that healthcare managed as if it were a market provides better health outcomes and lower costs;  2) Most of what needs managing in chronic disease – chronic lifestyle, proven chronic risk factors, and restoring patients’ ability to function as much as possible again  – is outside physicians’ area of practice. So, frankly, physicians can offer nothing that they can “take to Court” in restoring the lost functionality so typical of all chronic diseases, and so frequently demanded by patients is their treatment goal but not their physician. What the data increasingly show worldwide is that:

– in all chronic diseases, making effective lifestyle changes and reducing chronic risk factors, and doing so consistently is a far more important self-management tool for chronic pain patients than any single or combination of powerful pain drugs, especially over the long term;

– the effective role of drugs is as a “catalyst” to start re-integrating all the highly integrated functions that been disrupted because of the persistent pain. Unfortunately, no “clinical practice guidelines” exist that fit all patients, so physicians will either have to refer to professionals competent in making the subtle modifications in patients’ unique life situation and habits so that restoration of function is obtained, or they can expose themselves to the extensive training and experience that produces those observational and decision skills so they can customize it to each of their patients. Effective changes are highly nuanced and require this specific type of expertise and then knowing how to customize it to the individual patient and their unique life situations. Absent that, patients will not achieve functional restoration;

– the facts also are that a competently coordinated combination of the right drugs  PLUS the type of functionality restoration program that I just described can restore lost functioning, reduce pain and reduce the need for more medical services than just taking powerful pain drugs. AND, pain patients themselves are the most effective change agents of the lifestyle and other chronic risk factors of their pain’s occurrence than any one or any combination of solo medical practitioners. It’s not that physicians don’t know what they’re doing, it’s simply outside of their skill area – no one  really does know everything – and patients know more about their own lifestyle and habits than physicians can competently guide them on without the proven behavior change change skills. I might mention in passing that “encouragement” is not a proven behavior change agent. Furthermore, just because a physician reads an article written by one or more pain experts on how experts treat chronic pain does NOT endow the reader with the nuanced skills needed to effectively implement pain management as if s/he had the education, training and certification to do so. This assumption is simply a matter of common sense because, by just reading an article by Isaac Stern on how he plays the violin,  one does not magically become able to play the violin like Isaac Stern. Commonsense also leads us to the conclusion that reading alone does nothing to produce the nuanced skills to generate effective, safe, long-lasting treatment to people who want their ability to function restored. Regardless of how nice your physician is, if you expect a physician to restore functionality to the point that you can return to work,  the likelihood is that your functionality will decrease, your pain will get much worse, and your need for medical services  be much greater over a longer period than if you were treated with a combination drug and functionality restoration program of the type described above. That’s what pain patients need. Unfortunately, most seem to believe that complaining indefinitely to their doctor about their pain changes the level of their doctor’s skills, when it doesn’t. It doesn’t no more than complaining to me that after reading Isaac Stern’s book about how to play the violin I still cannot play the violin the way Isaac Stern does. Complaining will also not persuade your physician to make a quick and appropriate referral to a credentialed pain specialist. The conditions that I have seen make that happen after 6 months of a general practice doctor “trying” and not making the referral, are: a) a formal complaint drawn up by an attorney to the doctor’s licensing board, and b) an equally formal complaint to the Attorney General that the doctor is violating State Intractable Pain Laws.

How did we get into this mess? By accepting the assumption that “market forces” are the mechanisms of biological, physiological and neurological changes associated with health. And that “market forces” produce healthcare practices that improve pain patients’ quantity of life. There is no data anywhere worldwide to support that assumption. The numbers speak. Fifty years of implementing healthcare based on that assumption shows strong correlations  with uncontrollable increases in costs. That means that the assumption, and the strategy underlying it are wrong, regardless of what “socialist” rhetoric opponents may want to coat it with. The numbers prove it doesn’t work.  Conversely, numbers do prove what does work. Restore patients’ functionality, especially return them to work, and pain and healthcare utilization drops in a statistically significant and reliable manner.

How did this evolve? Our current problems started with the realization after World War II that wounded veterans wanted their ability to function restored and surgery and pills alone did nothing to restore their functionality and their ability to return to work.  We also found out that chronic pain and acute pain are two totally different phenomena. We found this out in 1953 with the publication of J. J. Bonica The Management of Pain (Philadelphia, PA: Lea & Febiger). After seeing hundreds of cases of wounded veterans with neuropathic pain for whom acute care was totally ineffective, JJ Bonica published the first professional work on pain management, which elegantly raised the urgency of the problem and the need for specialty training and certification in pain management, with the  goal of reducing costs by means of providing the appropriate treatment.

1983. Twenty-eight years later, in a monograph published by the National Institutes of Health, the dream Bonica proposed in 1953 was still unattained, even though it was growing more critical as the country aged, got fatter, more insulin resistant and developed more chronic diseases. By this time, Bonica’s words remained prophetic:

“Multidisciplinary pain clinics or centers, often university-based, are emerging as institutions in which new understanding of the nature of pain and pain-related behavior is being developed and applied. Neurologists, orthopedic and neurological surgeons, psychiatrists and psychologists, anesthesiologists, social workers, specialized nurses, physical and occupational therapists, vocational counselors, and others, all may be part of the therapeutic team, but the patient’s own active role in achieving a level of function as nearly normal as possible is central. As part of this process, elimination of all or most analgesic medication is stressed. “(Bonica JJ” Foreword in Lorenz, KY Ng, Editor. New approaches to treatment of chronic pain: a review of multidisciplinary pain clinics and pain centers. Washington, DC: GPO, 1981. (NIDA Research Monograph, 36). The book includes reports of 13 representative multidisciplinary clinics scattered throughout the US. Most were still offering outpatient and inpatient services, with the primary purpose being to eliminate all, or at least most dependence on powerful pain killers and to make the patient as self-sufficient as possible. The editor of the book, Lorenz, K.Y. Ng said: “Collectively, the papers present a picture of the treatment of chronic intractable pain at the major multidisciplinary pain clinics and centers in the United States at the present time. The main focus of the monograph is on chronic non-cancer pain and experience of the centers in the treatment and management of such pain. ”

1990’s: By the late 90s, certified multidisciplinary pain treatment begins to disappear. As the economy began to to leave its steady-state 3% inflation trend per year and began to fluctuate widely, physicians began to make decisions that mirrored the fluctuations of “market forces.” There was no focus on the needs of the growing numbers of aging Americans with chronic diseases. Physicians and the non-existent “healthcare system” – remember, there is not one building in the United States that says “US Government Hospital” – cared a wit what medical and allied health needs the growing population of chronic pain patients were quietly, but ineffectively, demanding. “What’s good for American physicians is good for America” was the reigning sacred cow. But what the data continued to show was that lifestyle and behavioral were more effective than single or combination of drugs. And, the implications were obvious, any pain patient who does not take charge of the lifestyle and behavioral conditions of their pain’s occurrence, are increasingly being, by choice, doomed to progressively more severe, long-lasting chronic incapacitating pain. The most effective treatment was the inpatient integrated functionality restoration program developed at the University of Washington. Around the same time, the Department of Defense (the quintessential example of “socialized medicine” on US soil) developed a similar functionality restoration program aimed at keeping pain drug use at minimal levels. What we all knew by then is that, when pain patients go through a Washington University or Veterans Administration functionality restoration program you not only achieve restored functionality (including return to work), relieved pain and, especially, significant reductions in the use of all types of costly healthcare services, from having to use more doctors, diagnostic procedures, emergency room care, using more and stronger drugs, and being unnecessarily hospitalized “to see if we can rule out some more causes of your pain.”

2000’s: This is the decade when the costs of pretending that we could continue to bury our heads in the sand and pretend that physicians using drugs alone and pretending that there was no need for expert OPERANT behavioral and lifestyle modification that could effectively restore lost functionality was not a solution but a cause of the two major problems of this approach: it is totally inadequate for supplying the needs of an aging, chronic disease laden population, and physicians simply can’t do it… except for the catalytic use of drugs to “kick start” pain rehab, integrated functionality programs, in a solo practitioner America, is simply beyond physicians’ area of expertise, as much as cardiovascular surgery is beyond the expertise of functionality restoration experts..

2008: October 14, 2008. The bank crash and the money crisis it generated has made it abundantly clear that the “feeding trough” is over. Categorically, what is good for American physicians is not good for Americans with chronic disease, including chronic non-cancer pain.

2010: Is there a quick fix? Of course. It’s the same solution JJ Bonica suggested in 1953… that the patient be systematically exposed, by certified pain management and functionality restoration experts how to self-manage the lifestyle conditions of their pain’s occurrence, with the help of competently provided medications. That should be every pain patients’ objective… instead of a patronizing “increased QUALITY of life,” pain patients need to demand first “increased QUANTITY of life,” for the simple reason that “quantity produces its own quality.”  Don’t tell your kids, “I want you to be a ‘good boy.’” Tell them instead, the exact behaviors you want them to engage in. “Quality of life” is, by definition, qualitative, subjective. Demand instead an observable, measurable, behavioral “I want to return to work within 3 months” which meets the quantitative, solidly grounded premises of science. In 2010, 1 in 3 Americans do not have the money to “buy” insurance. The new strategy for the current chaotic conditions healthcare in America is in, is for pain patients to find a physician who is credentialed in pain management or pain medicine to prescribe your pain meds locally, and a provider credentialed in pain management with a proven track record of restoring pain patient functionality via the Internet if necessary, from whatever part of the world, and then self-manage your lifestyle, habits and chronic risk factors yourself. It’s a lot safer and far more effective.

This blog will show you what hundreds of chronic non-cancer pain patients that we studied in a tightly controlled study needed to do achieve outcomes that involved changes in 3 critical areas: 1) the ability to function again as normally as possible; 2) relieve both breakthrough and constant pain significantly relative to their baseline levels of pain; and, 3) significantly reduce the frequency of use of a wide variety of medical services, most of which were a product of doctors unqualified in pain management practicing defensive medicine because they were not able to produce a competent level of skills and, for legal purposes that have nothing to do with patient care, to protect themselves from “frivolous” suits.

The ball is the patients’ court. Patients have to stop allowing doctors not qualified to treat their specific complex pain problem to do so indefinitely and, thereby, reinforce the current state of chaos in the treatment of chronic non-cancer pain, that turns you into a full-time patient and puts you at serious risk  of having to declare healthcare bankruptcy. Right now, locate a physician locally who is credentialed in pain management or pain medicine, and who can competently prescribe your pain drugs, then come back here and further expand your awareness, decision making skills about chronic pain, and get the support all pain patients need to learn how to assertively self manage their pain.

Call me, if you have no other excuses for allowing your pain to be treated inappropriately. Call me for an Online Pain Management Consultation.

Dr. Henry E. Adams, AAPM Diplomate in Pain Management