Pain Management in Modern Times: Does This Sound Familiar?

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

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

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

He goes on to say about his patients:

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

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

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

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

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

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

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

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

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

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

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

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

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