Is Integrated Pain Care an Answer to the Opioid Issue?

Is Integrated Pain Care an Answer to the Opioid Issue?

By Ed Coghlan.

A generation ago, pain was treated in an integrated manner.

Dr. Bob Twillman is trying to turn back the calendar.

Bob Twillman, PhD

Twillman is the executive director of the Academy of Integrative Pain Management (formerly the American Academy of Pain Management) which promotes an integrative approach to managing pain.

He was a featured speaker at the 2017 Pain Summit organized by For Grace—a Los Angeles-based non-profit that is working to increase awareness and promote education of the gender disparity women experience in the assessment and treatment of their pain.

Twillman was promoting the importance of implementing the National Pain Strategy, which was adopted early last year but has not been implemented in any meaningful way.

“People have not recognized the importance of it, particularly in contrast to the issue of prescription opioid abuse,” said Twillman. “The government is throwing billions of dollars at the opioid abuse issue – if they would invest the money in treating pain the right way, we would be able to prevent people from any addiction problem.”

Part of what has happened is that insurance companies and the government health plans aren’t covering many therapies that can help people address their chronic pain.

Twillman’s group is trying to change that.

“Oregon Medicaid is now paying for massage, acupuncture and chiropractic for lower back pain. California now covers acupuncture as an essential health benefit in California Medicaid,” said Twillman. “We can look in a year or two and see how effective these benefits have been in improving outcomes.”

Twillman also believes that providers should be paid for performance – and reimburse them only when they achieve a good outcome for their patients.

“We’ve been pushing people at CMS and at Insurance companies to make more demonstration projects,” he said.

They are being urged to try alternative therapies with a group of 100 patients – see if they improve outcomes and reduce costs and then adopt those therapies as covered benefits.

The Academy will continue to concentrate its work on making sure there’s coverage for more pain therapies.

In the meantime, he believes that the voice of the pain patient must be heard.

He urged pain patient advocacy organizations to keep telling the story of what is happening to people in pain. Taking the data and telling the story of what happens to people in real life is the recipe for change.

“They need to tell real life stories to elected leaders and government bureaucrats of what happens when patients are denied their medications and provided no alternative,” he said.

Twillman was willing to give those decision makers the benefit of the doubt.

“I don’t think policy makers are unsympathetic, they just haven’t thought through the complexities of it.”

He added that he knows some people make decisions by thinking through things, looking at data – others make it on emotion.

“The pain patient story needs to have both of those elements,” he said.


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Authored by: Ed Coghlan

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Quote from above article.“The government is throwing billions of dollars at the opioid abuse issue – if they would invest the money in treating pain the right way, we would be able to prevent people from any addiction problem.” I agree absolutely. IF there really are any pain addicts then that will be because they get seen once, maybe twice pa in the clinic by their pain doctors: that is not frequently enough to supervise complex combinations of medications including opiods or otherwise. Waiting too long in pain/relapse for their next visit I have seen online one or two patients say they take an extra tablet (or two). IM SORRY THIS IS THE MEDICAL ESTABLISHMENT NOT PROVIDING ENOUGH CARE AVAILABILITY TO SUPERVISE PATIENTS SAFELY…..and then punishing them them by removing their opioids!! In the UK where I live integrated pain management is the universal model for those lucky enough to get into the few programs available. However I have managed my pain in this way for 12 years now and it has not prevented the need for me to take large numbers of different pain medications (6 simultaneously) including three containing opiods. I seriously do not believe integrated management is a replacement for medication for the majority of patients, but a compulsory part of it. I also have massage, trauma counselling and cranio sacral therapy, chiropractic, as well as practicing the pacing, sleep hygiene, dietary, stress avoidance, household help, paid carers, postural and lifestyle management elements ie. almost everything that comprises Integrated Pain Management as well as heat and cold and acupuncture plasters (self administered over painful areas), The few things I have tried and failed recommended as elements of an Integrated Management Plan work for some others eg. acupuncture, visualisation, yoga (my wrists won’t take my body weight), meditation (makes me very alone and low), and mindfulness. Please be warned about the mindfulness craze 15% of people get SEVERE PSYCHIATRIC SIDE EFFECTS from it ie. it is not harmless. I have had training in Integrated Management from some of the best pain management doctors there are and leaving out medication has just never been done successfully that I have heard of. . The ONLY THING THAT WORKS in terms of reducing my global pain levels by 3 points for about 3 months is two weeks floating in the geothermal close to zero gravity waters in Iceland. That is not cheap but it also rebalances the hormones that pain unbalances so I feel a lot better in myself for those 3 months. Otherwise there are procedures such as Pulsed Radio Frequency Nerve Ablation which has worked well for my neuropathic leg pain – down 3 points for 9 months each time. This is one tough condition to live with and most people have no idea how very very expensive it is just to survive when one needs all this. Then ignorant medics and so called health professionals, untrained in pain, actually criminally abuse me (not libel) for being on the… Read more »

TYVM Maureen. Hopefully we will get a voice with poor
Dr. Tennants treatment by the DEA!
With luck, this news should go global and put pressure on our “government”.

I hear you. It’s like being held up without a gun.

Praying for you…hang in there. Please. We care about you and the fat lady hasn’t sung yet! Still have faith this mess IS going to turn around!

i’m what i call a real chronic pain patient,what i mean since breaking my neck and damaging my left arm followed by my first neck fusion,i’ve had pain i’ve haven’t or doctor’s haven’t learn to stop,very great every second of time since,i’d had 3 doctor’s mri’s,and medical paper’s staten that to be a fact,in 2015 after over 10 yrs of injection,operation’s,and all other treatments the doctor’s were given me 3-30mg’s of oxycontin aday,plus nerve medication’s four times aday after 10 yrs of suffering i had at least half my very great pain gone and i felt like a new person,that last for a year,i was told my pain doctor wife had a baby and he was taking some time off and would be back in a few month’s i went to another pain doctor and until last did found out why he cut my mg’s and amount’s of rx pain medicine down so low they didn’t hardly work,i found out that someone believed the pain doctor was given out too much medication and the doctor stoped seeing pain patients,also i learn that the patient’s who went to him were look at as doing something wrong which i didn’t and we were even told,it felt like being place in prison without being arrested or even being charged for the crime,well its 2017 all my mri’s medical record’s and treatment are not helping at all,i have c4,c5,c6,c7 fused and the dic’s above and below are now bad i can’t turn my neck at all without pain shooting up my head and down my lower arm’s and body,i don’t have an life anymore even as an disabled person,you’d have to be able to move to live,my past time now is prayer every second of the day that the pain doesn’t become so bad that killing myself become the answer to end the pain that so great its all that’s i can do at the end of the day is not kill myself,sorry but that the truth,most of my real chronic pain patient’s are not here,they couldn’t take the very great pain and killed themself,or it was listed they died from something,really they pain like my became so great they couldn’t move and their health got worst and worst till they die could we get addict to an medicine that only releved half our very very great pain,they are murdering us wake up america real chronic pain patient’s.

Maureen Mollico

@SheWolf, My heart breaks for you. your post struck me hard.
I’m so tired of reading all that we warriors are going through. Its all so very sad, insane and wrong.
While I do still get some medication (low dose and hardly touches my pain though!) I can understand your pain levels and frustrations. My life remains so limited and without support.
Also, I come from a family of Sheriff’s Officers and so I can understand your deepest disappointments in your career and personal losses!! I am so very sorry.
I wish I could wipe it all away and make it all better for you.
I send you hugs, strength, prayers and courage. Hang in there!! Maureen


There is no opioid issue! It is a HEROIN CRISIS.
1% of intractable pain patients become addicted.
MS, multiple spine diseases, amputee, cluster headaches…cut off cold turkey 14 mos ago, 180 mg daily Oxycodone. Took 4-5 yrs of mandatory step therapy before trying opiates, which by no fault of mine, actually worked. Now, 40 #’s overweight, severely depressed, uncontrollable bp (202/107 latest), can’t walk, shower, cook, clean without crying, and have gastritis & gastric ulcers from otc garbage taken for few hours of sleep, get to bathroom, etc.
I graduated top of my Sheriff’s Deputy class while on my meds. Nothing but a mean bitchy hermit contemplating a finally pain free afterlife!
Govt knows exactly what they’re doing…medical genocide!

Maureen Mollico

In my opinion…certainly NOT! We chronic pain folks suffer from a huge array of pain issues/diagnoses.
Once again, treatment is surely not a one size fits all treatment.
Once again, the professionals need to start talking with US, THE SUFFERERS for the answers! Why Is that not common sense?!!
We long time pain Warriors (and we are called Warriors for a reason!) have truly tried it all. We 110% know what works and what does not work.
And for most…it’s our medications. Please hear us speak!

first i had my nerve medication’s taken away that i took because my pain doctor said that the cdc,and dea said that too many people had died from,i was gaven them for 14yrs took as doctor and not only helped my nerve condition but also my great chronic pain,he said either i gave them up or he’d have stop my rx pain medication,next i have found and no one talking about this that either chronic pain patient’s or all patients rx opioid pain medication’s either been reduced or so much narco beening added that they barely do anything for pain i know i’m disabled but it’s caused me too have to let my live go,just because i’m disabled doesn’t mean i have to enduer all my pain that i have since 2004 its a nightmare and no one cares just as long as the addict’s they say don’t get them,this is crazy thinking,if they would do this to another illness they have the hole country against them,and america been lied too i’ve taken my rx opioid pain medicine since 2004 because all the operation’s and other treatment’s helped my broken body,but did very little or nothing for my very great pain,other thing i wanted to say is no one talking or reporting on the chronic pain patient’s who didn’t o.d or use the pain medicines to kill themself because they kill themself because the opioid pain medication have been limited and reduced so much and they couldn’t take the amount of very great pain and had nothing else that would help,you say you’d have to be crazy to kill your self,well hold your hand under a fire for a while and think if you had that kind of pain all the time and every one knew it but told you we can’t help or we will gave you a banaid so we don’t have to hear you cry,because we want to stop addiction,you tell i’ve taken opioid’s for over 10yrs with out problem’s of addiction for i needed them to stop up to half of my very great pain so i could live somewhat a live as a disabled person,i know of over 100 chronic pain patients in my state who have killed themself becaused their opioid rx pain medication were reduced,now i talked to their family who had too watch and care for them knowing they did nothing wrong,the family said they talked to their doctors and those in the state who could have done something but wouldn’t,they said they were told that too save this chronic pain patient’s would mean they would be arrested,how would you like it if your mother was taken to the hospital and the doctor told you i would like to save her live,but if i do i’m going to be arrest,and they are calling us the one’s with an problem,when america started letting patient’s die that could have been helped with their medication ‘s given in the right amount,they have no excuse,only lies,and… Read more »


Why should the pain patients be listened to if the “therapies” that this guy advocates (Acupuncture, chiropractor, etc.) have been on the “been there, done that” list of BS measures that may work for someone like himself, or someone who is young, but I’ve got injuries going back to Vietnam (1969) along with enough failed surgeries that all Doctors want to do is replace, replace replace what they destroyed to begin with, and with no pain meds to boot for recovery.
What a lame report.

Connie Asimakopoulos

I have FM and have done the integrated disciplinary approach re trying meditation, physio etc
So now I have my stretches and exercise bike but have I used it eeeh no cause the pain is debilitating and I’ve no energy even being off codeine now
So now what??


I’m a chronic pain patient with arthritis. Since the lashing out of pain meds I have suffered tremendously! Those who have issues that can’t be fixed by other treatments should not be left out in the field of suffering!

Wendy P.

First my doctor prescribed myofacial trigger release therapy. Every treatment resulted in a tremendous flare up of pain. Finally I was reevaluated and they determined what I had been telling them all along – that the therapy was causing more harm than good. That represented three months of complete agony that could have and should have been avoided. Next I tried a chiropractor. The treatments resulted in more pain and unexpected autoimmune responses. The co-pays clobbered me financially and I am still recovering from the absolute financial wipeout. Next was hydrotherapy. The water was way too cold and my nonstop shivering resulted in a tremendous flare up. I am all for whatever works and willing to try. The past year has been pure misery. Because politics, propaganda and hysteria has interfered with my healthcare, I take Kratom. I don’t know how I will be able to afford my next batch. Medical marijuana is cost prohibitive for me as well. I am dismayed that my choices have boiled down to affording basic expenses on a limited fixed disability income… or pain management… but I cannot afford both living expenses and pain management. If this is the direction that our government, insurance companies, and doctors are forcing us to take – then these entities better pull together and make medical marijuana and Kratom truly legal, accessible, and affordable. Hmm… $4 opiate prescription at WalMart… or $300 for Kratom and marijuana… On $1k/month income. It is crazy that while alternative therapies are promoted, that they seem to be ineffective, inaccessible, inappropriate, and unaffordably expensive. For some of us, even having to travel somewhere for “treatment” adds to the physical agony, whether we are transported or drive ourselves. I think that most of us have accepted that we will never be completely free of pain. Chronic pain patients need and deserve to have quality of life, functioning, and effective pain management.


I 100% agree with Bob Schubring. There are those of us who’ve tried many different treatment modalities and meds etc. What helps are Opioids. There are those of us who’ve been in the same dose for years, never more. This is limiting our choices for one thing. We live in the USA, what happened to freedom of choice for our own care and medical treatment ? I don’t personally want to take medical marijuana and I should NOT be forced that because they’re taking away Opioids! I’ve tried so many meds & I was allergic or got deathly ill! I also have a heart condition & an immunodeficiency that makes it difficult for me to do any of the invasive surgeries (that should not be FORCED upon anyone either!)
What’s happening is terrible and horrible to say the least! If I could “think” my pain away with these integrated treatments, then we’d all be cured and no problems! I don’t believe in Acupuncture and if I did, I don’t like needles. With an illness that’s sensitive to touch, acupuncture & acupressure aren’t something we want to do. I should not have to do what I don’t want to do, what I don’t believe in! It’s not right! Also a chiropractor caused a back surgery for a friend of mine! She went straight to ER following a chiropractor appointment! Then straight to spinal fusion and a lifetime of back pain now!! No way! No thank you! No chiropractor for me, thank you! Besides, if you have Degenerative Disc Disease and other back issues and pain issues; going to a chiropractor would be torturous!!
Let us choose what we feel works for us! Let us continue what has been working for us!
It’s inhumane to not allow a patient to stay on a course of treatment that has no side effects and the treatment is working for them for over 5,10 + Years!
Stop pushing Cannabis, I never smoked or drank and I don’t want to smoke pot, eat pot gummy bears or stick a pot oil suppository where the sun doesn’t shine! This is so crazy, what’s happening to pain patients!!! The yoga, meditation, “thinking your pain away” or as PROP’s evil Ballantyne says we can just “learn to accept our pain”…we’ll everyone can stick all of that junk in the same place the suppositories go!! It might work for a stubbed toe or light headache but it DOESNT WORK FOR The very painful EDS or CRPS etc!! Someone please help us!!??


Mr Coghlan, I agree with you for the most part. Great article and I like the way you are leaning here.

I think partly, the diagnostic/treatment/social work modalities should all be intertwined.

To just go to a pain doctor can be problematic.

My pain has increased but the trials of having constant pain and illness has shifted. My Doctors know I am fused and laminated from cx-2 to t-3 and l5-6. The later post laminectomy syndrome. But I also have digestive issues and my blood pressure has recently popped up to 217/97 at its highest last weekend. It is cycling at very high levels and some tests indicate possible kidney involvement.

So a pain specialist doesn’t track other aspects of pain. That is very problematic. They can be treating pain that is not caused by what they thought.

A more rounded approach is needed.

Two items that I have not seen discussed in regards to opiods being lowered and/or denied or even being pulled from a patient already on them are, some of which is my story:

1. A patient is typically asked during their doctor’s visit by the nurse checking them in if they have any thoughts of harming themselves (along with – what’s your pain level today and are you allergic to anything) and

2. The significance of normal range blood pressure being lost and turned into significant sustained high blood pressure.

In the first scenario of self harming, we’ve learned to never speak of such feelings EVER, because that’s a quick route to getting even more pain relieving medicine taken away, or much needed effective dose ever being given, or they can also report you and have you committed. So as much as one might truly need to vent, talk out an emotion or let the doctor know how this opiod-doctor-media-loss of pain relief is affecting them, the one thing we should be able to do, WE CAN’T. At least not many of us.

The second scenario of high blood pressure with more and more increased pain, which mine has skyrocketed from MY usual of 108/63 almost faithfully, to 192/110 or higher. Faithfully. To me that’s unacceptable, yet I have only one Medical practice I can go to and not allowed to switch doctors, and I walked out after finishing my appointment scratching my head thinking – as nice as this doctor appears, she doesn’t give a damn about me or my well being. Here I am on SS Disability for severe physical anxiety attacks (the kind that come out of nowhere – from a sound sleep, etc. , and make the skin on my upper body turn fire engine red and untouchable, and I’ve been in a car accident 8 years ago that started my chronic back pain, and now hip, buttocks, leg, ankle and foot chronic pain, and not only was my blood pressure ignored, my increasing pain ignored, but she pulled my Diazepam completely. No taper of even that. So now I am screwed with a capital S.

And there are no words to describe the severity of my back pain and this nightmare anxiety. And being treated like they would NEVER TREAT ONE OF THEIR FAMILY MEMBERS.

Bob Schubring

The basic problem with implementing the National Pain Strategy, is that the majority of musculoskeletal pain involves excessive muscle tension that’s modulated by anxiety. Less anxiety results in less pain.

There are three choices of anxiety-reducing agents. Nicotine achieves the result but raises the blood pressure and is addictive. Benzodiazepines are less-addictive but the effective ones are controlled substances. Cannabis reduces anxiety but we’ve got a hodgepodge of laws prohibiting most people from using it safely and effectively. Since 62% of voters want the hodgepodge of cannabis laws fixed, by nationwide legalization of cannabis, sensibly many doctors want to look at incorporating cannabis-derived drugs into pain treatment.

Because the initial pain of a muscle injury is serious, opioids are required for a few days.

This sets up the other dimension of the political problem. Some of those pro-cannabis voters, especially the ones most active in promoting cannabis, don’t grasp the fact that opioids are still necessary for pain control. By casting the political issue as Opioids versus Cannabis, mistakenly blaming drug companies for all their problems, and ignoring the political role of for-profit prisons and for-profit “drug rehabilitation” businesses in lobbying to maintain an irrational hodgepodge of laws prohibiting and controlling all of the drugs that work, the misguided cannabis activists are sabotaging their own cause without knowing it.

Just last week, Gov Chris Christie came out openly opposing cannabis legalization. Again. Christie hinted that legal cannabis could be as big a problem as opioids are. Cannabis activists need to pay attention, because if one studies the degree to which prescribed medicines have not caused the epidemic of deaths from illegally-manufactured fentanyl, but have been mis-reported by the media to be at fault, one can easily see the same blame game played again with cannabis, just in time for the next election. Imagine how much money those for-profit prisons and for-profit rehabs will make, by inventing an epidemic of Cannabis Use Disorder and forcing people to spend 5 weeks in rehab…and then choose a response wisely, fellow activists.


And what about those of us who tried all the options first and for whom those “therapies” didn’t work? Are we to be left to rot?


Whereas I appreciate Dr. Tillman sensitivity to the pain patients ploy, but with all due respect, …I still don’t think you understand that despite doing everything ‘right’ some cases DONT get better. Pls don’t SHAME those of us with intractable pain just because we don’t respond to treatment.
By rewarding those cases for swift pain resolution you just might overlook those whom have difficult pathologies and ‘inadvertently’ blame patients for no fault of there own!