Monday, June 13, 2011
Guest Blogger: Managing Chronic Pain
by Guest Blogger, David Schwartz, Ph.D.
One of the few advantages of getting older is the ability to say “”I remember when…”
In 1982 when I did my first clinical placement in pain management, the “state of the art” was that focusing on the patient’s self-report of pain was worthless. Research showed that 0-10 pain scales varied widely between individuals, had little relationship to pathophysiology, and were highly dependent on psychosocial factors. The emphasis in the field was on the measurement and change of pain behavior i.e. measures of function such as uptime, days off work, walking tolerance, etc. A parallel theme was that the use of opiates and aggressive medical interventions such as nerve destruction surgery and nerve blocks for chronic pain management were ineffective and counterproductive. Use of opiates led to decreased function, and withdrawing patients from opiates in the context of a psychological/physical re-activation model (A pain rehabilitation program) consistently increased function. These pain programs remain today as the most effective documented intervention to improve overall life functioning for individuals who had become disabled due to pain.
Fast forward to 2011. These structured pain rehab programs are essentially extinct, starved to death by insurers who saw them as too costly. A patient coming to a pain clinic will almost always be placed on opiates, and receive multiple interventional treatments. The cost of pain treatment has skyrocketed, yet outcomes are worse. Prescription opiates are now the most commonly abused drugs, and many states (including Ohio) are launching expensive initiatives to get the ”drug problem” under control. Worst of all, when the patient returns for a follow-up visit, the only question they are asked is “how is your pain”?
I recently attempted to survey the literature as to whether there was any new evidence that opiates improved function in chronic pain. What I found was- NOTHING! It was exceedingly rare to find a study that even measured function whatsoever! (Keep in mind that many studies have shown that patient self-report of function is both reliable and valid, and there are many brief instruments that assess function with documented validity). The studies employed NONE of them. The few studies I did find showed that opiates produced decreases in self-reported PAIN, but no change in FUNCTION.
“The emperor has no clothes”- remember the fable? Is it possible that the multi-billion dollar pain management industry is a sham? That we are doing worse than we were 30 years ago?
What can we do today? To me, the crucial thing is to go back to function as the core measure when we deal with pain. Always ask- what are doing that you weren’t doing last session? Are you on your feet, talking to people, cleaning the house more, etc? If opiates are used, are increases in function observed?
I tell a joke in talks about pain- the punchline is that the patient had pain that was 10 of 10 and lays on the couch in misery all day. His doctor puts him on OxyContin- he comes back and says “it’s a miracle! My pain is 1-2 out of 10! My life is so much better!” When asked what he now does, he says, “Well, I’m so stoned on the medication I lay on the couch all day…”
Online Pain Resources:
Bio: Dr. David Schwartz earned his Ph.D. from
in 1982, specializing in behavioral medicine, and was an intern and post-doctoral fellow at the University of Virginia Medical Center. He has had medical school appointments at the Vanderbilt University University of Virginia, Vanderbilt University, and the . He has published and presented extensively in pain management and behavioral medicine. He has been in private practice since 1995 and is currently a partner in Hamilton Health Associates, a multi-specialty practice focused on industrial injury. He is a consultant to the Freiberg Spine Institute and a member of the Disability Evaluation Panel for the Ohio Bureau of Worker’s Compensation (BWC). He presently serves as the Ohio Psychological Association (OPA) representative on the BWC’s Health Care Quality Assurance Advisory Committee and chairs the OPA Task Force on Workers Compensation Reform. University of Cincinnati