Pain Specialists Urge Stronger Use of Holistic Therapies

They believe that such therapies should replace prescription opiates as the dominant method of treatment
The Lund Report

August 16, 2011 -- Pain specialists think a paradigm shift in the way chronic pain is treated is needed in Oregon, strongly advocating that holistic therapies replace prescription opiates as the dominant method of treatment.

Prescription opiates such as methadone, oxycodone and morphine have become the most widely used method to treat chronic pain. According to Dartmouth Medicine magazine, there’s been a 347 percent increase of these opiates between 1997 and 2006.

But pain specialists, researchers, and physical therapists argue that prescription opiates are a costly and ineffective method of treating chronic pain. “[It] causes us all a lot of angst,” said Kathryn Hahn, pharmacy manager at the Springfield Bi-Mart, who chairs the state’s Pain Management Commission, at a presentation she gave to the Oregon Health Plan medical directors in June.

According to the National Center for Health Statistics, approximately 26 percent of Americans experience pain that lasts longer than 24 hours. If that statistic holds true for Oregon, then around 940,000 Oregonians suffer from chronic pain. And according to the American Pain Foundation, $100 billion is lost each year due to medical expenses, lost job wages and decreased productivity.

“We need to change our system,” Hahn said. “We're not getting good outcomes.”

Oregon is the only state with a pain commission. In June, the state’s new Prescription Drug Monitoring Program began, requiring pharmacies to report the opiate prescriptions they fill.

But for Oregon to decrease prescription opiate use and increase other therapies, Hahn and others think primary care providers need to be better educated about the effect of opiates, and insurance companies must cover other treatment options.

Chronic pain drastically affects a person’s life

Chronic pain, said Beth Darnall, a pain psychologist at Oregon Health & Science University’s Pain Clinic, lasts longer than three months after the injury is expected to heal. There’s no test that can identify how much pain a particular patient is feeling. In that sense, she said, pain is subjective. “Ultimately, pain is something that the person feels,” Darnall said.

Chronic pain can dramatically alter a person’s life and habits. People may not be able to work, mow their lawn, play with their children, or do other activities. Chronic pain can also cause irritability, depression and anxiety.

Prescription opiates are often prescribed, but can be ineffective

Prescription opiates have become popular because they are an easy solution for physicians, who can simply prescribe them to patients who seek a quick fix for their pain.

Released over time, prescription opiates relieve pain by essentially dulling the nervous system. People are relieved of pain for a short while. But the pain isn’t cured. “Most of the people who come to the pain clinic say it takes the edge off, but it doesn’t take the pain away,” Darnall said.

Anxiety and stress are also reduced because of the drug’s effect on the nervous system. But that has negative consequences. “It makes people reliant on the medication to manage stress, anxiety and other factors in their life,” Darnall said.

Over time, a tolerance develops. “They start working less and less well,” Darnall said. “In a few months, someone is suddenly desperate for stronger medications.”

Opiates are highly addictive, and Hahn said there’s an increasing culture of sharing opiates and people stealing them from family member’s medicine cabinets. “We have prescription drug abuse that’s looming bigger and bigger,” she said.

Side effects of long-term use of prescription opiates are include disruption to sleep patterns, endocrine deficiencies, hyperalgesia (increased sensitivity to pain) and suppression of the immune system, said Catriona Buist, clinical director of rehabilitation clinic Progressive Rehabilitation Associates.

The main concern, Buist said, is that increased use of opiates doesn’t improve a person’s function—which should be the main goal of treating chronic pain.

Pain treatment should increase a patient’s function and quality of life

The paradigm shift Hahn wants to see is from an “analgesia alone” approach to one that’s function-based. Because chronic pain never goes away, as Hahn and others emphasize, treatment should help people manage and learn to live with pain.

“It's about not really curing it, but bringing quality of life back,” said Namita Gandhi, clinical exercise physiologist and founder of the Integrative Movement Clinic, Inc.

Increasing a person’s function can mean enabling them to move, go to work, play with their children, and pursue other activities they did before becoming injured. “Your pain may not go away, but if you can ride your bike with your children or go to the grocery store, then your quality of life has improved,” Darnall said.

The treatment focus is “on improving the patient’s life rather than eliminating their pain,” Hahn said. 

There are multiple ways of treating chronic pain. Patients can pursue physical and occupational therapy; stress management; self-hypnosis; relaxation exercises; acupuncture, chiropractic and movement therapy that strengthens and stretches injured muscles, and lifestyle changes in diet and exercise.

Hahn said such treatment methods create objective and verifiable goals, whereas the only standard existing with prescription opiates is whether they relieve pain for short periods of time. Gandhi describes the treatment as more “holistic.”

Integrative Movement Clinic offers a 10-week program offering movement programs, integrated with different stress management techniques, such as reading and relaxation. “Movement can only take you so far,” Gandhi said. “It’s not what you do, but how you do it.”

Insurance doesn’t pay for alternative types of care

Buist said a major obstacle to expanding access of these treatments is insurance companies, which typically don’t pay for integrative treatments and only cover prescription opiates. “There are many times when the only thing covered for a patient is a kind of drug therapy,” Hahn said.

The Oregon Health Plan is limited in what it covers--acupuncture for treating back and pelvic pain during pregnancy, as well as for migraine headaches. And, of course, methadone and prescription opiates.

She faults the Oregon Health Plan for only providing coverage for methadone and other opiates. “For Medicaid patients, there are almost no services complimentary to prescription opiates, or alternatives to them,” she said. “All they have available is methadone.”

During Hahn’s presentation at the medical directors meeting, Mike Shirtcliff, president and director of Advantage Dental, admitted “we have more work to do in this area.”

But many medical directors became defensive. “This is a problem because of physicians” and not necessarily the drugs, said Dr. Chris Kirk, medical director of Mid-Valley IPA. “I think doctors would tell you that patients are there, asking for them, demanding.”

Dr. John Sattenspiel, senior medical director of Agate Healthcare, worried that if providers began selectively prescribing opiates to patients, and routing others to other types of therapy, the move would “put our license in jeopardy because we aren’t adequately addressing pain. It takes one disgruntled patient to complain to the Medical Board of Examiners.” 

The Division of Medical Assistance Programs (DMAP) is currently reviewing the coverage of chronic pain treatment. A report will be submitted during the 2012 legislation session in February.

Increasing the level of education providers have about prescription opiates and their effects is critical, Hahn said. “We want [prescription opiates] to stay; we just want more education on how to use it.”

Providers can fail to properly assess patients, assess risk for drug abuse, notice aberrant patient behavior, identify goals of therapy and not check in with patients.

The National Pain Care Policy Act, part of the federal Affordable Care Act, will improve training for healthcare professionals, by increasing research funding for pain and improving access to pain care.

Many hope the Prescription Drug Monitoring Program will help stop people from abusing prescription opiates, and increase awareness about how they’re being used. “It remains to be seen,” Darnall said.

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Comments

I agree that "a paradigm shift in the way chronic pain is treated is needed." But, I believe that the main bottle neck that needs to be addressed is the lack of insurance coverage for alternative therapies. All the education in the world will not make these effective alternative therapies available to the masses until the coverage is there and people can afford to take advantage of them. Yes, education for the health care provider is very important. But, not only education about the opiates and their effects, but education about alternative methods of dealing with pain. And the patient, also, needs to have available to them educational material about the alternative pain management options, as well as information about drug therapy and their possible negative effects. I understand Dr. Sattenspiel's concerns about “putting our license in jeopardy because we aren’t adequately addressing pain. It takes one disgruntled patient to complain to the Medical Board of Examiners.” I see the solution to this, again, as one of education and of offering choices to a patient. Alternative pain management does not need to be perscribed by a health care providers. It is a choice, available to anyone. Only drugs need a perscription. An educated health care provider can inform their patients and offer them options to manage their pain without side effects. The patient is always free to return to the health care provider for drug thearpy if they are not seeing the desired results from alternative pain management therapy. Carolyn J. Richardson Boulder, Colorado

I disagree that chronic pain isnt curable-this is an excuse by the health care industry that hides their longstanding neglect of people in pain. The fact is people do overcome fibromyalgia, migraine,low back pain etc-but modern medicine which is more focused on doing whatever they want instead of helping people in pain. Dr Atul Gawande has said that doctors dont like people in pain-and doctors are trained to ignore pain in medical school- only 5 states require doctors to have any education in pain care- despite pain being the most common medical complaint. Doctors need to be required by law to take several courses in being humane toward people in pain-failing that we can expect to see a continuous escalation of failure in pain care. With 116 million people in chronic pain-costing over $660 billion-you think congres or state government would take some action-but they are bought and paid for by the health care industry that continues to fiddle whilst people in pain burn

Doctors really dont care about people in pain and until government enforces by law a right to adequate pain care we are unlikely to see real progress. Most doctors just excuse the poor pain care they provide or call people in pain "catastrophizers" They fiddle while people in pain burn

I'll probably regret posting this. Doctors do care about people in pain. Doctors, however, have been "used" many many times and therefore are often very weary of prescribing opiates. Neither right or wrong, but it's the truth. Alternative treatments might be of help but like other therapies, they'll not be a cure all. It's finding the right combination of all available therapies. Long acting opiates have very little abuse potential and do provide some improvement chronically for patients with actual pain...as opposed to having "pain" as a manifestation of functional issues looking for an opiate induced escape from those issues. For these, perhaps medical marijuana would be of value. enough...now will come the flaming

The United States now consumes 80% of the world's opioid pain medications and 99% of the world's hydrocodone. http://www.guardian.co.uk/commentisfree/cifamerica/2011/jun/10/prescription-drug-abuse And yet, pain is inadequately treated in the USA. What nonsense.

I am glad we are talking about this issue and would like to add an addendum to a couple of items in the article attributed to me. First, I do feel as if opioids can be helpful for a select group of people to improve function. The concern lies if there is dose escalation of opioids, without an improvement in function. Additionally, a select group of insurance companies have recognized the benefit of investing in coordinated interdisciplinary treatment, and reimbursement for these programs is worth expanding given the improvement in outcomes for patients with chronic pain. Catriona Buist, Psy.D.

The first part of this post is reasonable: "...opioids can be helpful for a select group of people to improve function." The last sentence seems like a supportive statement/commercial for a pain clinic. Briefly, the proof in the value of "coordinated interdisciplinary treatment" is in the long term result for the patient. I encourage readers to take the time, do the research for outcome studies, not from providers but more objective sources of patient outcome data. Treatment of chronic pain is a complicated matter. No singular or one type of integrative approach fits all. Pain treatment needs to be tailored to the needs of each individual. Pain treatment professionals practicing individually or within a larger organizational setting need to bear this in mind. Fit your treatment to suit your patient not the other way around. It is best to reduce reliance on pain medications as much as possible. Practitioners in the behavioral health and interdisciplinary treatment arena must not forget that PAIN is still a real phenomenon felt by the patient every day. "Feel good" exercises don't make it go away. Psychological coping (distraction, rationalization) mechanisms, increased activity, just help the person divert thier attention from the moments of pain. There is value to these approaches but let's not over sell them. Joel Seres seemed to say it best in comments attributed to him by a former patient. I want behavioral health professionals and interdisciplinary pain treatment staff to connect themselves to devices producing an electric shock. Keep it connected throughout a day shocking you at random then use your "techniques" to reduce the pain. Try your own medicine. I am not saying what you recommend can't help. It will for many BUT pain is pain. Patients know opioids just dull the pain but what alternatives do thay have? Finally, for those in practice in private pain clinics, be honest with your patients and your referral sources. Makse sure you are focused on your patient not just the cash they bring in. People with chonic pain are largely stuck with it and they know it. They have the same goals as the treatment pros do for them: to be more comfortable.

The more recent, peer-reviewed literature does not support the broad generalization that "prescription opiates are a costly and ineffective method of treating chronic pain," as stated at the beginning of this article. A large fraction of those treated with opiates for chronic non-malignant pain have improved function, at stable doses, without signs and behaviors of addiction. That's a different picture than most of us older physicians recall from 20+ years ago, before the recent literature was published. Second, the alternative treatments advocated here do help some patients, but there is great variability in which treatments, and which patients, show those benefits; so alternatives should not be oversold, nor should the reasons they are viewed with skepticism by those making payment policies for insurance (other people's money) be trivialized. There is, and should continue to be, ongoing research on the effectiveness and value of alternative treatments, and we should be open to the peer-reviewed, published results and guidelines that follow---just as we should be accountable to make ourselves familiar with recent publications about appropriate use of opioids. The Federation of State Medical Boards has a concise and inexpensive monograph titled "Responsible Opiate Prescribing: a Phyisician's Guide." It's an excellent way to begin getting up to date, if one has not yet seen it.

I think some of the comments here indicate that it's not just health care providers who need education. So do patients. There are now more deaths from methadone than there are from heroin. (And not all methadone is used for treatment of heroin addicts.) The US does use the vast majority of the world's opioids. Why? I don't think doctors are the sole parties to blame.

There are very few studies on "integrative care." There is no commonly agreed upon definition for this term. I have seen acute patients turned into chronic patients by "alternative" as well as traditional practitioners. The medical term for this is "iatrogenic disability," and it is facilitated by an unreasonably extensive search for the physical source of pain, the pathoanatomic needle in the haystack. I am seeing more patients on opiates seeking chiropractic services. These people often do not respond well. It seems their pain perception is completely out of proportion to the physical pain stimulus. There is evidence for the benefits of certain nonpharmaceutical interventions for chronic pain patients, but who you see is as important as what you get. Does the provider use an evidence-informed model of care or take an anything-goes approach? Any type of treatment carries the risk of perpetuating chronic pain. It is critical to consider psychological and social factors, not just physical ones, in the treatment of chronic pain (the biopsychosocial model). (from a D.C.)

As a physical therapist clinical specialist in pain, I would say that the fundamental need in working with pain is in both the practitioner, AND the patient having an understanding of pain as a product of the brain. This is really the paradigm shift, that the problem is not in the tissues, it's biopsychosocial. Following that understanding, we can think about a number of treatments that address the biopsychosocial issues in an integrated way. That can include the way that the physician initially talks with the patients, as well as various ways of working with the patient to get back to moving, and overcoming the fear avoidance and other brain processes that are perpetuating the pain. Nora Stern, MS PT

I find it rather disturbing that clinicians and other health care administrators are sending the message that the pain these people are experiencing is subjective to alternative therapies. When I was fifteen years old, I was run over by a 1969 3/4 ton 4x4 International pickup truck. I broke my back in four places, my pelvis was shattered and I fractured both hips, not to mention multiple lacerations over my entire body and the internal injuries I sustained. I am currently 54 years old and have had twenty-two surgeries in the past 40 years. I have total hip implants on right and left sides, have had my gallbladder removed, and multiple back surgeries. I thought it was normal to wake each morning and not be able to get myself out of bed at the ripe old age of 16. The only therapy that was available was narcotic pain therapy. My point is this: After all of the surgeries, the time spent in recovery (roughly about a 1/3 of my life), and the alternative therapies that I have participated in over the years, I can honestly say that acupuncture did not work, pain counseling was a joke, and medications such as Lyrica and Nuerontin were not the answer. These medications caused extremely dark and depressive thoughts of suicide and pain management classes were reduced to nothing more than informing the patient that "the pain is all in your head" and that an individual "just needs to work through it" in order to feel better. I find it disrespectful that doctors and other clinicians feel they have the inalienable right to invalidate what an individual is experiencing, especially when it comes to pain. After all, isn't pain subjective? I have literally had doctors tell me that what I was experiencing was "all in my head." Theoretically, however, they are right, since all pain is first perceived in the brain. Thanks doc, for that earth-shattering news. I have tried holistic therapies to no avail. I am not able to count the times I have listened to someone in a group therapy setting sharing about how "my doctor will not prescribe me anything," and I am at my wits end," and other comments such as "where's the compassion and mercy?" Since when did the medical community of the United States decide it was up to "them" to decide what is best for the patient. If a patient needs opiates to maintain a quality of life they are accustomed to, then let them have the medication. I'd like to put some of these so-called doctors to the test and let them "feel" what its like to try and live a normal, productive life while wracked with pain so intense that you can't think to even talk. No. I cry foul. Tell them that it's all in their heads and you will hear them sing a different song. And when did it become such a concern for the insurance companies. They are posturing themselves to be the eyes and ears of the healthcare professions, informing patients of not only when they may have a specific medication, but also how much they may have, and when a prescription may be filled. I have a right to pain medication and I don't give shit about some pompous, self-absorbed, arrogant, asshole doctor that has never experienced what I have been through telling me that he "thinks I have a pain medication problem" and would rather see me suffer while diligently protecting his/her precious medical license than provide me with relief. No doc, I have a pain problem. Who are these people, and who gave them the right to say what is and what isn't effective relief? Sorry folks. I'm not buying it for one second. I can not endorse your "Holistic" approach to pain management. I've tried absolutely everything in the last 40 plus years and in my personal experience I have not tried anything that works as well as opiates. Call me an addict if you like. I don't care. I don't have a problem telling these doctors to take a fucking hike. One other medication I tried is medical cannabis. I've never slept so good in my life. No. I think that it is time to educate the educated. As patients, we need to let them know in no uncertain terms that until something more effective than talk therapy, acupuncture, NSAIDS, (Non-steroidal anti-inflammatory drugs) which destroy precious organs like the liver, kidneys, spleen and pancreas while at the same time creating havoc in the digestive system, and others like lyrica and nuerontin, which have been proven unsafe alternatives for nerve and other chronic pain issues, are not the drugs of choice. The problem is that these medications, while effective in treating some forms of pain, do not work for all types of pain, and are ineffective in 63% of patients that are prescribed them. If it sounds as though I'm frustrated, I am. For over forty years I have been in pain. I have had 22 surgeries, including total bi-lateral hip replacements. I was a park ranger working in Oregon. The state told me that I could no longer perform the functions that my job required and let me go. I went back to college, educated myself and gained an entirely different perspective on pain, and what you are proposing will not work. I have always been of the persuasion that "if it isn't broken, don't fix it." Currently, I am on disability and hate, I repeat, hate that there is this talk of a "more holistic approach" to treating chronic pain. I've tried them and I'm here to tell you that they do not work. Good luck on your endeavor at convincing those of us that suffer chronic, intractable pain that you have a better idea for us, and that you know better what is best for us than we, the actual patient does. Perhaps before you embark on this quest, you should hold a clinic or seminar and allow those of us that have tried your methods our day in court. I guarantee, the findings will alarm you. People in pain do not wish to be trifled with. Their world is already turned upside down simply by virtue of what they are experiencing. Your approach is just a little on the heavy handed side. It would be better if you simply admitted that you don't have any real proof your methods work rather than to force those of us that want nothing to do with them to accept them as solid evidence that they do. People in pain don't want your sympathy. We just want to feel better. I didn't ask for what happened to me. The only clue I had that this singular event would effect my entire life was when my family physician told it would. Even then, I had no idea. Now, however, I do. My name is Daniel Carrick and I can be reached for comment at dbdinportlandia@comcast.net.

My personal experience as an acute and chronic pain patient in Oregon is not that doctors dispense opiates (even long-acting opiates) willy-nilly. It is the opposite: that pain is undertreated. I suffer from one of the most painful diseases one can experience: trigeminal neuralgia. It is unbearable face pain caused by a spasming nerve in the brain. It is known as "the suicide disease" because something like 25% of people with TN kill themselves within the first years of onset because of the severity of the pain (regardless of prior history of any mental health problems). Surgical outcomes to fix it are a mixed bag (many have a history of making the pain worse, and many risk such things as deafness or blindness). Non-opiate treatments only work for some people. I was lucky to be referred to a compassionate pain doctor who treated me with opiates when the alternatives failed. I have no doubt I would be a statistic rather than a soon to be graduate student if I hadn't had that relief. When I am not on opiates, the pain is so bad I am not able to brush my teeth or talk. My dose of long acting opiates has been steady for 3 years. They have brought me out of blackness. Cranial sacral therapy has helped, but if I forget to take my medication, I get electric shock like jolts from my cheek to the back of my skull. To the physical therapist who says that chronic pain is always "biopsychosocial," check your able bodied privilege. My chronic pain would exist in any "psychosocial" environment. It is caused by a loose nerve inside my brain which I have decided not to pursue surgery for because of the risks. Opiates are a necessary evil. No amount of pain counseling (though I have gotten therapy for adjusting to my condition) or physical therapy (which seems pretty silly in my case) would allow me to live with the amount of pain I'm in without medication. It's either surgery (with unacceptable risks, which might leave me less functional) or opiates (which allow me to function without surgery). Opiates do not forestall chronic pain patients from seeking holistic treatments. Trust me -- if you have intractable pain, you have tried everything, including things your insurance does not reimburse. If I were denied medication, I would be forced to consider surgery, which would be a worse outcome. This article was poorly written and did not consider patients' POV or the POV of doctors who advocate and destigmatize opiate therapy for chronic pain. These are just tired old prejudices.

There is little new under the chronic pain sun. I have since 1969 experienced daily chronic pain from adhesive arachnoiditis caused by multiple oil-based myelograms and several failed back surgeries. In 1974, I was an in-patient at what was, I believe, Oregon's first chronic pain clinic, affiliated with Emanuel Hospital and run by neurosurgeon Joel Seres. The clinic was interdisciplinary and employed the very "holistic approach" urged in the article on which this blog is based. That approach equipped me to manage my pain employing each and every day the three core teachings of that pain clinic's interdisciplinary approach. First, you will experience pain each and every day for the rest of your life. Don't waste energy and time striving to be pain-free because it will never be. Second, each and every pain medication, whether OTC or prescription, has over time damaging side-effects. For a chronic pain condition, seek to minimize reliance on pain medications, and reserve their use for periods of significant exacerbation. Third, since you will experience pain whether you do something or do nothing, choose to be as active as you reasonably can tolerate. While this holistic approach has served me well for 37 years, I acknowledge that it may not work for all. It does, however, improve the quality of life for some, and probably many. I consequently applaud the renewed interest in a holistic approach, and moving away from reliance on every-more powerful pain meds as the dominant mode of treating chronic pain.

Reading through all the comments posted here, I find some value and merit in each. Professional opinion and personal experiences tell the whole story. I became the most sensitized to the needs and plight of those dealing with chronic pain when I worked as a Counselor at Progressive Rehabilitation Associates in Portland. One clarification, this is not a commercial for PRA. This is an open statement to the community about a truly remarkable program offering specialized treatment of chronic pain. It is just one of their many highly effective services aimed at helping people make significant changes in their lives. PRA is a provider that those who suffer from chonic pain should check into. What makes PRA a recommended treatment partner? The time proven quality of the program content and all the well trained, experienced professional staff who truly DO care. The staff because of who they are by personality make a sincere connection with each person. I saw a lot of clients come and go. There were very few who didn't benefit in great measure from their participation in the program. They left feeling a greater sense of happiness in thier life. They benefitted from all the interventions: psychology, PT, OT and medical. Thier reliance on opiods pain medications was in most cases significantly reduced. Overall psychological and physical functioning was increased much to their surprise and delight. PRA is a good model for others to follow. Steve Sorlien, LCSW Tualatin, OR