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

To Overcome Chronic Pain, First Use “Evidence-Based Thinking”

January 31, 2008 | Filed Under: Tips | Comments(0)

Dr. Henry Adams, Dipl. in Pain Management, AAPM, Member/Medical Staff Coalinga State Hospital

Healthcare, it is said, is going through a revolution called “Evidence-based medicine,” which is defined as follows:

Evidence-based medicine (EBM) aims to apply evidence gained from the scientific method to certain parts of medical practice. It seeks to assess the quality of evidence supporting specific treatments (or lack thereof). According to the Centre for Evidence-Based Medicine, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” EBM seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best control possible of outcomes in medical treatment, even as debate about which outcomes are desirable continue. (Wikipedia)

What this means is that, after hundreds of years of medicine being “an art” in which every physician’s personal opinion was equally valid, the complexity of technology and the complexity and cost of treating the chronic diseases currently going around the world, governments and Courts have decided, requires far stricter standardization. That standardization, experts decided, could best be achieved by basing clinical decisions on on something on which everyone can agree, namely that the quantitative bases of the scientific method allow for the establishment of reliability and validity standards that effectively reduce risk in our clinical decisions. Put simply, EBM is simply “good science,” the practical effect of which is that by doing “good science,” one significantly reduces “error” in our decisions which, in turn, decreases risk while increasing the likelihood of positive outcomes for the end-recipient of all these efforts, the patient. What that means in chronic non-cancer pain is that you the patient now have the means of increasing the likelihood of selecting clinicians with a high likelihood of increasing your functional capacity, your ability to return to work and control your pain while decreasing your dependence on costly medical services. Now, clearly, whenever we can make decisions this way, we wind up making much more risk-free decisions, which increases the likelihood of restoring functionality, return to work, decreased pain and decreased costs of – if the “evidence” doesn’t support their use – unnecessary physicians and medical services.

Therefore, what EMB does is to give patients – especially those with complex disorders like chronic non-cancer pain where the risk of error, because of the multiple mechanisms and systems involved, is exponentially greater – with a means of determining when risk is greater or less depending on key elements that clinicians “bring to the party” and weeding out as much “error” as possible in the treatment process.

Below is an example of “good science” that helped our pain patients get optimal care:

1. The management of chronic non-cancer pain is like any other sub-specialty. Sub-specialty education, training, experience, certification and a successful track record is needed to be able to provide “evidence” that can “stand up in Court.” E.g., if we have heart symptoms that seriously disrupt our ability to function, work and enjoy our usual lifestyle, the wise decision is to go to a clinician with the sub-specialty education, training, experience, certification and positive track record of returning heart patients to functionality, work and decreased dependence on cardiologists than when they started. This, clearly then, is a clinician who can take their opinion, behavior and track record to Court and be accepted by a judge as an “expert” capable of providing “expert opinion” and evidence that a gate-keeping judge would allow to be put before the jury. Patients who were able to apply this way of thinking were able to eliminate:

Non-specialty physicians lacking documentable expertise in pain management and CNCP

Non-specialty clinicians working in chronic pain programs lacking documentable expertise in pain management and CNCP

Single modality (drugs only) treatments lacking randomized controlled trials (RCTs) to support them

All treatments not supported by RCTs as being effective for 5+ pain

All non-certified clinicians lacking extensive experience with the full range of CNCP disorders.

What remains is what wise patients try to achieve locally when they screen clinicians:

A physician Board Certified in pain management or pain medicine, experienced in prescribing the full range of pain drugs, including opioids, with a minimum of 5 years experience in CNCP, and who has worked as a member of a team in a functionality restoration program

A psychologist certified in pain management, experienced in the full range of CNCP disorders and approaches, with education, training, experience and a positive track record of restoring functional capacity using operant behavioral modification of habits and lifestyle and responsible for coordinating a team of credentialed clinicians in an integrated functionality restoration program

There are numerous other steps that we will periodically post. In the meantime, this step alone got most of our CNCP patients into treatments that had a high likelihood of restoring their functional capacity, helping them get back to work, and decreasing their pain and their dependence on costly medical services.

Dr. Henry Adams


Death Rates: Oxycontin vs. Other Drugs

January 21, 2008 | Filed Under: Opiods | Comments(0)

Dr. Henry Adams, AAPM Dipl. in Pain Management

Representative data from the Centers for Disease Control & Prevention, in 2004, indicate statistically lower  risk of death by Oxycontin, condemned by the American press, when compared to deaths caused by other controversial drugs:

Death Rates By Different Drugs, 1990-2001(Representative Data From 11 States) 

Drug / Percentage rate

Morphine    23

Cocaine      22

Heroin         16

Alcohol        10

Benzos         9

Oxycontin      7

Methadone   6

Codeine       6


* Extracted from Centers for Disease Control and Prevention (2004). Death rates for unintentional poisonings and undetermined. MMWR, Mar, 53 (11) :233-38.