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.

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