So, What IS Pain Management?

So, What IS Pain Management?

By Dr. David Nagel

David_J_Nagel_MD_2

DR. David Nagel

As many of you have probably been referred for “pain management” defining it is quite important.  The answer, unfortunately, is not as obvious as it would seem.  Even medical professionals struggle to agree with what pain management is, and that creates a big problem.   There is a perception that pain management is all about needles and opioids, a perception that is unfortunately based on what happens in the real world.  Needling and prescribing pay well, managing pain does not, so too often pain patients are needled and drugged in a piecemeal fashion with no attempt to look at the big picture of their lives.  Many patients seem bewildered and disappointed with the process.  What they receive is not what they were promised, that being a cure, and this upsets them.  This creates an agenda crisis, one which threatens the success of treatment.  So, we need to get on the same page.  That is where the challenge begins, and this is my modest attempt to accomplish this lofty goal.  As 100 million Americans are affected by chronic pain, 35 – 40 million with “high impact chronic pain,” this is not a trivial topic when it comes to human lives and dollars.

Before we answer the question, we must first define what we are talking about, as the answer differs depending on what type of pain we are talking about.  The goals of pain management are different for acute, chronic, and end of life (palliative medicine) pain care.  For our discussion, we are talking about chronic pain, which we arbitrarily define as being refractory to tincture of time and our treatments, and having lasted more than 3 months.

The challenge begins with the party line of the medical profession, those who supposedly offer this treatment.  Several years ago, I stood up at a national meeting and asked my colleagues what we mean by pain management.  The reason I asked the question is all that we had talked about for several days is where to put needles, scalpels, electrical stimulators in patients’ (and mouse’s’!) in order to eradicate(?!) their pain.  The proponents proudly referred to themselves as “interventional pain management specialists,” a pronouncement which immediately shot their noses in the air relative to their less invasive colleagues.  They promised such wonderful results.  The shine off their needles blinded them to the reality that the success rate of any of their procedures is really not that great.  It certainly does not even come close to matching the reimbursement potential.  Cure almost never happens.  More often than not patients spend incredible amounts of time and money only to end up right where they started, no better, perhaps worse.

So, the question I posed to my colleagues was important.  They struggled to answer, and there really was no consensus.  Recently I attended another national symposium where the same question was again asked, again with the same lack of consensus.

Last year I attended a meeting to discuss and plan the National Pain Strategy.   Towards the end of the meeting, we broke into groups to separately discuss the six parts of the strategy.  I chose to attend the community advocacy meeting.  In our group, I was one of only two physicians, the other an academician, I, a clinician.  The others in our group shared three things in common.  First, each suffered from some form of chronic pain.  Second, each had been through the medical mill and had come to some form of acceptance of his or her pain and the altered lifestyle so created.  Third, each served as the leader of a community advocacy group.  In sometimes not so subtle ways, in our discussion they provided the definition of pain management that had eluded the supposedly more learned medical experts.

First, pain management is NOT a CURE!  While it may be reasonable to never abandon hope for a better future, one must learn to accept the current reality and adapt as best as possible.  There is no universal understanding of pain, nor a universal solution.  As long as these elude us, cure is not possible.

Second, acceptance is never easy.  Giving up the past creates a sense of loss.  And so, the sufferer grieves.  That is a normal process that entails feelings of denial, guilt, anger, and depression, not in any specific time frame or order.  For one to come to an acceptance, one must go through this process, and it is the role of pain management to assist the sufferer in this process.

Third, chronic pain affects the whole of the person, biologically, psychologically, socially, and spiritually, and it is incumbent on pain management professionals to acknowledge each of these areas of the person’s life in the treatment plan.

Fourth, there is no professional who has cornered the market on an understanding of how pain affects all of these aspects of a person’s life.  Therefore, pain management must be interdisciplinary, meaning pain management requires a team of professionals who work, not in parallel, but together, communicating readily so all are on the same page.  There is no “I” in “team,” and in my experience, it only takes only one individual acting outside the team to sabotage the whole process.  It is crucial all accept that the patient’s best interests are always paramount, not those of any member of the treatment team.  Sometimes the patient will have to hear things he doesn’t want to, but that is the role of tough love.  In this model, interventional pain therapies may be a part of pain management, not the whole.  Therefore, interventional pain treatment, by itself, is not pain management.

Fifth, and related to four, the patient and her family are very important members of the team.  Unlike the more common medical model of “guidance-cooperation,” “mutual-cooperation” is the goal in pain management.  Each member of the team is equally valuable, all have something to contribute, and all should be valued, especially the patient and family.

Sixth, the team is not limited to those in the immediate vicinity of the sufferer.  While we accept the patient, family, various health care professionals, counselors, therapists, vocational planners, etc. as part of the team, the team actually involves all of society, and that is crucial to understand in planning public policy.  Those in the workplace, insurers, government regulators, public policy makers, neighbors, and many others have an incredible ability to help or harm those who suffer.  In my book, Needless Suffering; How Society Fails Those With Chronic Pain, (University Press of New England, July, 2016, http://www.upne.com/1611689624.html) I argue too often these “team members” to often harm more than they help, and that must be addressed in creating public policy to address  crisis of chronic pain.

Seventh, the long term goal of pain management is self-management.  Pain will probably present for the remainder of the patient’s life.  Over time, the role of the treatment team will diminish and that of the patient increase.  The patient must be given the skills to self-manage their problem and those around them given an understanding of how to help, understanding that the extremes of abandonment and enabling are equally un-productive and potentially harmful.  In this model, support groups can be very helpful, in assisting the sufferer.  Empowering the patient in this way is very powerful.

I propose, then, this seven part definition of pain management.  The problem is this complex definition challenges the simple we wish for, but our failing to acknowledge the complexity of pain management is why we fail in our current ministrations.  From a practical standpoint, this model challenges the financial status quo of many of the team members.  I fear that is why such a model fails in practice.  However, at some point, for us to succeed, we must put aside our own needs for the good of others.  Hmmm.  Sounds like the Golden Rule my mom and others taught me in kindergarten.  Some things never change.

Dr. David Nagel is a New Hampshire specialist in physical medicine and rehabilitation, who been practicing pain management for 28 years in private practice in Concord, New Hampshire. His book Needless Suffering: How We Fail to Manage Chronic Pain will be released in 2016.

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Authored by: David Nagel, MD

There are 20 comments for this article
  1. Sheri Lynn at 8:02 pm

    “Thank You” Sir for this Article. I find it to be very true. I have felt useless for so long. My Mom has dementia now, and since the Doctor cut my medicine in half, I have not been able to help my Dad like I used to. This makes me feel horrible. The whole situation is sad. I do want to tell the world that my cousin was cut off of his medications completely, about 2 weeks ago, with NO Weening! He is 56 yrs old. He was going through Withdrawals, tried to take a shower, apparently got sick, and inhaled the vomit. His blood pressure must have went sky-high because he then had a massive stroke. He layed in his bathroom for 2 days before someone found him. He is currently on life support, and if he were to live, he would be a vegetable. The Doctors at the hospital will not acknowledge that is was due to being cut-off his pain medicine without weening. They are insisting that he “only” had a stroke. No Doctors are taking responsible for this Mess with the DEA and Obama. I found out today that they are gonna pull the plug this Friday. So now I find myself “getting my affairs in order” because I keep wondering if my Neurologist is going to do this to me when I see him in June??? This has got to stop. P.S. Pain Patients are treated with NO COMPASSION by anyone.

  2. Robin Birdfeather, BA, MTPT, CFS at 3:41 am

    Having read all the letters so far, I saw no reference to the hands-on tx of people who do trigger point work.
    The best trained of these are called MTPTs, or Myofascial Trigger Point Myotherapists. Active in-practice members can be found in the online directory of our professional organization, .
    We have put up a self-help site: http://myofascialtherapy.org/
    that many have found very useful.
    The ever larger and more diversified professional pain management community can be accessed through national organizations such as the American Academy of Pain Management , the American Pain Society, et al. There are pain researches going on to discover more about the loci of trigger points, the role of and problems with the voluntary nervous system, and many other aspects of the origins and perpetuation of pain.
    A free magazine is available to professionals: that deals with a wide variety of approaches and research.
    I hope these references are of help.
    As a TrPt Myotherapist retired from clinical practice, I am preparing materials and approaches to teaching self help pain management in small groups in Northern CA in a few months. My own limitations are
    a result of multiple years of Chronic Lyme Disease that have left me with Lyme Arthritis (not the Osteo type), that is, for most Lymies, another source of pain that is not very well known about among doctors & other pain management professionals yet. The CDC has recently stated that approximately 300,000 people a year in the U.S. are getting Lyme Disease
    which has so many possible symptoms, up to about 300, that the pain of LD – one of the most frequent of those symptoms – should not be counted out for so many people with pain complaints. Go to to learn more.
    NOTE: you can find a list of Lyme Literate Doctors (LLMD and LLND) there. They are the only ones you really want treating you if you have Lyme.

  3. Richard Oberg M.D. at 12:24 pm

    Bob Shubring – not to say much about Kevorkian, but the notion that ‘nearly one-third, at autopsy, were found not to have had a terminal illness’ is meaningless with regard to chronic pain or other serious clinical issues and you can’t determine whether someone is going to have a terminal illness by autopsy unless they’re already dead from it. Most people with extreme suffering would have no findings at autopsy and areas like the spine are virtually never examined nor would you find much anyway. There is no relationship to ‘pain’ and autopsy determinations – it’s all derived from clinical data.

    I did this for a living and spent two years out of residency also doing forensic work and misconceptions about what an autopsy will or will not reveal is astounding and, not uncommonly, misstated by sources that should know better. Mode, Mechanism, Manner of death all play into this and are determined AFTER someone is dead (or sometimes are – given that only 16 states even have a medical examiner system and even those favor just ‘any’ physician as opposed to a pathologist). In 1600 of 3143 total U.S. counties elected or appointed coroners who may have no qualifications beyond a high school education get the final say. Believe it because it’s true and really bad.

    I say the latter because this is where CDC national statistics about how people died are compiled and is mostly cr*p. Garbage in, garbage out. If someone has trace hydrocodone in their system from a legitimate prescription, it wouldn’t be uncommon to say they died of a prescription drug death (seriously). It’s that bad.

    The numbers of deaths cited by the CDC due to prescription drugs is absolutely false because of this yet they conveniently don’t mention it much. Bootleg fentanyl is easy to make and indistinguishable on drug testing from prescription fentanyl – guess how they get tabulated in prescription drug deaths? Not to mention prescription drug deaths are actually slightly over half of auto accidents every media source misquotes because the CDC misquotes their own data. Look it up. It’s 101 statistics gone wrong. They’ve never exceeded auto accidents yet everyone ‘knows’ it. Right. Just like physicians must script for heroin because it’s always included in the tabulations.

    And no, most heroin users didn’t necessarily start with prescription drugs (nor are they reliable witnesses any more than alcoholics who notoriously confabulate). Yet we’ll deprive the majority of legitimate people of their pain meds over this – more people (including physicians) should be outraged.

    This game is played by quoting some number that seems large to ordinary people (and to physicians who should know better) like ‘100 people died around here due to drugs NOS’ when 100,000 people die every year in Tennessee and 2,500,000 people die every year in the U.S. from all causes. And according to even 19,000 dying from prescription drugs makes it 0.76% of all deaths nationwide meaning 99.24% die of something else. Anyone still impressed with this epidemic and why we can’t get pain meds?

    Most anti-opioid articles still pay lip service to 100,000,000 in pain don’t they? So does the number of deaths sound like a lot compared to the number of scripts written and people in pain?

  4. Barbara Hite at 7:01 pm

    I’m tired of being treated like this. I have pain each and every day. I didn’t ask for it. But God said I should have it. Dr. don’t believe I am in that much pain. I have migraines at least 6 times a month, fibromyalgia, ddd, removed disc, Rod in my back, both knees replaced, upper back with a pinched nerve, diabetic neuropathy, and if I go to the ER I get treated like a drug addiction instead of a person with chronic pain. I see horses, dogs, cats get more pain relief at a vet then I do at a doctors off or at a hospital. Why is this? Why is ketamine a schedule 3 medicine, when it can kill you faster then demerol, which is a schedule I I drug. Please someone with some authority or intelligence tell me, explain to my why I get blamed for being in pain when I didn’t ask for this. I’m not a drug dealer. I’m not an addict, but I sure do get treated like one. Doctors at pain clinics dont even want to schedule an appointment with me, because I’m a difficult patient. I’m allergic to many medications. So what…I didn’t ask to be that way…can someone please help me. …probably not, because I’m a nobody, I m not a millionaire, I don’t work in Congress, my last name isn’t Rockefeller or Clinton. I unfortunately, am a nobody that is quite ill, and in very much pain. And being a nobody means I get very little pain meds and very little care in the medical field.
    I want help for my pain. I may get up every day and put on a fake smile for my family and friends and colleagues but it’s very hard and I’m fed up with it. It’s been 25 years of this charade and I’m fed up with doctors, nurses, pharmacies, pain management doctors, and even people that wait on me at the Walmart pharmacy. It’s sickening!

  5. Robin Melendez at 12:01 pm

    I very much appreciate this article, and the many excellent comments, especially Dr. Oberg’s. I agree with Oberg’s definition of palliative care, and wish this was universally understood. I have been a pain management patient for 15 years, following serious head/neck injuries sustained in a fall from a ladder. Until that awful day in March of 1998 I’d led an uncomplicated, happy, productive life and was completely naive to both the treatment of pain and opiates. Upon my release from hospital I was passed around between neurologists, orthopedic surgeons, physiatrists, physcial therapists, and the inevitable psychiatrist. I had every test, injection, adjustment, and modality of “treatment” imposed upon me. I was made to feel my pain was delusion, “that I wasn’t trying hard enough” when all the above failed – as if the treatments themselves were directly tied to the egos of the providers I’d seen. My exasperated physiatrist finally made a scribbled and hasty referral to a pain management doctor. His offand documentation of this allowed me to get to the anesthesiologist and pain practice that changed my life. After three years of suffering (torture is no exaggeration), unemployment, and near suicidal despair, I was able to get my life back. I was comfortable again. I could think straight again. Within 6 weeks I was working again! I have no doubt that because this MD’s own child was afflicted with MS, he possessed an empathy for his patients and a desire to treat them wholistically. To say this doctor saved my life and the lives of many others is an understatement. Yes, he gave me opiates. My medications are the difference between a functional life and none.

    Since that time I married a military man, and naturally have had to move all over the world. I have encountered esteemed doctors and providers who’ve treated me like a criminal without reviewing a single page of my records. Some refused to look at them at all! I have been told I am delusional. A bad mother! I have been lied to and verbally abused by pharmacists. (Presenting a script for oxycontin is like handing a pharmacist a ticking dirty bomb, or a flaming turd.) I have had my medications reduced for no clinical reason whatsoever. FWIW, I have been on the same dose of meds since 2006 – the spiraling addiction and tolerance I was told would be inevitable ISN’T. I’ve never “lost” medications, needed early refills, or blown off appointments. No E.R. visits. I’ve voluntarily submitted to monthly urine tests, even requested them when they weren’t required. I’ve dutifully kept pain journals. I have abstained from alcohol completely. In short, I have been a model patient. I have been treated by American pain management practices as just another pincushion, and a problem when the treatments fail. Again, a drug-seeking criminal, even with multiple MRI’s, and a wheelbarrow full of records.

    In 2006 the heavens parted and my husband recieved orders to Germany. I imagined the worst would happen once we got there, that I’d be denied pain care or meds altogether. Miraculously, the opposite happened! I was referred by the military to a German “Schmerztherapie Klinikum” and was shocked at what I discovered at appointment #1. After the kindly doctor examined me and asked me questions about every aspect of my life, I was taken to another room which was FILLED with an assortment of providers: a physical therapist, a trainer, a physiatrist, an ortho doc, a pain management nurse, and a psychologist. This group, along with my anesthesiologist took over my case and managed my pain from every angle. What a difference, what a blessing. German pharmacists treated me with the utmost respect from day 1 to the last day I came in, 8 years later. They never raised an eyebrow. This team managed to get my meds down by half. They also helped me process and accept that I probably wasn’t going to get much better physically – but I could ALWAYS improve the way I handle my pain emotionally, intellectually, and spiritually. Just having a team acknowledge that my pain was as real as my injury and that it colored every facet of my life was a huge palliative. Strange, but true. Not having to be defensive or explain yourself goes a long way in terms of relief. How many pain patients lie awake, anxious and terrified their meds will be arbitrarily cut? How many thousands worry every moment that their doc will retire and leave them in the cold to manage pain and withdrawal while continuing to work, parent, drive, and scramble to find another doctor? How many can’t afford yet another 1st visit where they’ll be told to go seek drugs elsewhere? This doesn’t help the pain, FYI. EVERY TIME a pain management patient walks into a doctor’s office, they are in fear for their day-to-day lives, their ability to function, to work, to survive. Will this be the day I am cut off? Reduced? No way to live, much less heal.

    Because of the comprehensive care I recieved there, and the elaborate reports and notes these providers kept, I’ve had very little trouble establishing the same plan of care now that we are stateside. American docs have A LOT to learn from their European counterparts when it comes to treating and managing pain. Indeed it is a societal difference. SOMETHING HAS TO CHANGE.

    Didn’t mean to write a novel. I wish this discussion would continue in doctor’s offices from coast to coast. Opiates are not the devil, and they can be effective with careful and compliant management along with other treatments. I intend to make copies of this post and leave them with my very excellent new doc on base. Thanks.

  6. Terri Lewis PhD at 12:53 am

    I count myself as among the most fortunate of people. To have been blessed with the experiences in this lifetime that have kept me connected to my profession and to humanity. Thank you David for your wisdom, and to each of you responders who help to move this ball down the field. And to you Ed for hanging in there with this important vehicle for discussion. And thanks to my family – my tribe of real people – some of whom have or continue to experience the pain that nobody should have to endure.

    When I get a moment, I want to develop a discussion on models of care – the filters through which pain is characterized, why they block us or facilitate the treatment and care partner processes, and what we can do as professionals and advocates to reset this discussion – even as the stupid stuff is all around us.

  7. Christine at 8:42 pm

    You know when I first heard of pain management I thought great! Finally some help. First they wanted me to enroll in the pain clinic program. I called them and the women asked me questions, then said I don’t need it because I understand my pain and I know how to manage it . Went back and told the doctor and he was like well what do you want me to do? I can’t help you. If you are not going to go to the program. I went home and cried. The doctor was so cold.

    I am in chronic pain all the time fibromyalgia, neuropathy, muscle weakness, back injury etc.

    Switched pain doctors and she told me I should drink kale smoothies for the pain. At least my neurologist and my gp gives me pain meds, but I have to go to the office to pick up the prescription. I don’t drive so it is hard for me to get it sometimes. I have to wait for the hubby to be off work. I realized pain management does really do anything to help. Which is sad. So many people are suffering with chronic pain and no help. What are they there for?

  8. Bob Schubring at 8:36 pm

    Dr Nagel is absolutely correct, in asserting that many people have incredible powers to cause others to thrive or to suffer.

    I witnessed this firsthand, in Michigan, when Dr Jack Kevorkian began “assisting” patient suicides and people began flocking to him to be killed. Of 116 dead, nearly one-third, at autopsy, were found not to have had a terminal illness. They were simply afraid that they might have one. And they were very afraid it was cancer, it would be painful, and no medicine would be able to relieve the pain.

    In short, Kevorkian and his entourage promoted catastrophization of symptoms, instead of pointing people toward genuine relief.

    We need look no further than Kevorkian’s own book, “Prescription: Medicide”, for the motive behind his efforts. In the book, Kevorkian asserts that Society can “increase the health of the public”, by speeding up the deaths of Society’s sickest members…the disabled, the mentally ill, the unwanted.

    By Jack Kevorkian’s definition, everyone who could be tricked into committing suicide, out of fear that they might get a serious illness that left them suffering extreme pain, was a weak link in the social chain, and Society (whoever that is) is better off without them.

    This meets the legal definition of a hate crime. Then tries to draw in anyone who’s presently healthy and cannot see the risk, that once a policy is established that demands killing the weak, someone will always be weaker than someone else, and therefore, will be killed. There’s no way out of this quicksand-like illogic, short of refusing to accept the premise.

    Over the intervening two decades since Kevorkian’s rampage, advances in genetics are revealing the absolute importance of genetic diversity, in no uncertain terms. It is the fact that my genes predispose me to get Disease Q, that make me nearly immune to Disease Z. A “master race” of genetically-identical people, such as German dictator Adolf Hitler wanted to create, would all fall victim to the same fatal disease! Diversity is what enables the human population to utilize empathy as a survival strategy. It’s the twin facts, that 1) we feel bad when someone else is ill and we try to help them, and 2) that we don’t all get the same diseases with equal amounts of damage, that make a community who help their members, the stronger for it.

    We need to promote rational thinking about pain, and that means acknowledging truths, Addiction exists, and addiction is a risk factor for suicide, but not everyone has addictive personality disorder. It’s absurd to withhold lifesaving medical treatment that eliminates the suffering from chronic pain, just to stop addicts from obtaining drugs…just as it is absurd, to withhold lifesaving mental health care from people with addictive personality disorder.

    Abandoning patient’s needs for mental health care, enables and encourages self-destructive behavior. This is precisely the opposite of caring for people who are ill.

    And exactly what we were fighting, two decades ago, when Kevorkian was on the loose.

  9. Steve at 4:36 pm

    After 30 years with fibromyalgia, my pain finally went off the charts two years ago and I sought help. I saw several rheumatologists and recently, a pain managreement and fibromyalgia specialist, at a rehab hospital. She kept telling me ” not to focus on the pain” and do aerobic exercise. I knew she was running my symptoms through algorithms because she told me and, after I failed the last two meds, she said I was “not a medication kind of guy, to not focus on the pain, and to just live my life”. She then threw my chart on the table and walked out, the most arrogant and least caring M.D. In my experience. I was devastated and wrote her a nasty letter which I copied to the hospital CMO. I’m now forced back to my PCP who is empathic but has said I have the worst case of FM he’s seen and he isn’t sure how to be of help. Every day is hell.

  10. joe at 4:04 pm

    I agree wholeheartedly w the comments of dr robert kutzner. The part about self management I totally agree with. Ive been suffering now w 8 herniated discs (4 cerv 2 thor & 2 lumb) spinal stenosis radiculopathy and severe spasms since my MVA in 2012. Being that I have been told only my cervical discs will be operable I have no other choice than PM to manage my chronic pain. I sought out the best PM Dr. In my state and learned alot from him. I also did my own homework on my conditions my medications and my options going forward. Sadly my PM Drs cancer came back from remission in and was forced to sell his sole practice. The new Dr did not take my insurance so I started seeing my PCP for my issues. It saddens me greatly to say I know more about all of it (meds, conditions etc) than he does.. being that he is a nose in the air type this does not make him happy when I must correct him… but I sincerely feel that I could properly prescribe my own medications, tests and then confer w other professionals when need be. More pain patients should be taking a proactive role in their personal care. Im a person who craves knowledge but many out there seem to care less as long as they are receiving their opiod script monthly. Drs def need to push for more patients to take this proactive role and then use role reversal as dr kutzner stated. Im extremely happy to see a Dr. Say this!

  11. Kathy Jamison at 2:22 pm

    Having CRPS /RSD has taught me one thing, you are on your own. I joined the integrated pain cinic, I drove 120 miles round trip only to go in ,be called the wrong name, and the have all my meds reduced, taken away, by a clinical pharmacist that I have never spoken to. I go to physical therapy twice a week on my own accord, just to have my pc tell me that 5 my of oxycodone is all she is able to help me with. It should be a crime against humanity the way chronic pain patients are treated in the good old USA. Who if not your pc should you go to for help? Who if not your pc can you ask for guidance on medical issues. I want some of my life back,I want to play with my grandchildren, I just want health care from someone who actually cares. This is a great article every Dr’s office in America should receive it. Thank you

  12. Robert R. Kutzner MD at 12:41 pm

    Discussion with reference to Dr. Nagel’s numbered items.

    NO CURE (1): We are dealing with Chronic Pain here and by definition, “chronic”, means it is without cure.
    • It needs to be noted that chronicity is a relative term time wise. Most acknowledge that 3 months is a good marker. Others point out that chronic really means any pain the lasts longer than would be expected. Although I use both, I prefer the definition being any pain that lasts longer than anticipated. Think of that the next time you get a simple “charlie horse” or “foot cramp”; a few minutes is one thing but hours or even days, let alone weeks or months, surely is a chronic pain problem.
    • It should also be noted that since chronicity is dependent on the underlying pathology it behooves us to move closer to the definition that chronicity is anything beyond what is expected. With this approach implementation of an integrated multidisciplinary approach as early as possible would open the door to stopping (curing) some forms of chronicity like Post Herpetic Neuralgia, Reflex Sympathetic Dystrophy, etc.. Since examples like these can be cured it should be considered malpractice to allow them to become chronic.

    BEHAVIOR CHANGES (2,3,5): With chronic pain comes behavior adaption.
    • Depression is common especially with suffering. Physiologic changes happen centrally. Opiates depress testosterone levels. Somatization, catastrophizing, anxiety, sleep deprivation, hopelessness, and anger are common.
    • Family, occupational, and social dynamics are impacted and must be addressed.
    • Pain is not suffering. We all live with pain but when it gets so sever or out of control then suffering ensues, i.e. torture. For over 40 years medicine has the ability to prevent suffering from pain. Suffering is without excuse and should be recognized as an abomination.

    MULTIDISCIPLINARY APPROACH (4, 5): No single profession can address all aspects of a chronic pain patient.
    • Integrated care means just that, integration. This cannot be accomplished by fractionating the care through referrals to different specialists outside, or inside, the same building. This cannot be accomplished by providing one type of care followed by another, then another. All care, all treatment, must be provided in concert. This also means that there must be regular meetings to ensure a team approach and that it is working in the same direction for the same goal.
    • To treat the whole patient we must address the biological, psychological, social, and spiritual. This requires multimodal treatments which necessitates practitioners from different disciplines, i.e. a multidisciplinary approach.
    • All the literature over the last 40 years has supported this approach. It is not new but few listen. The CA Div of WC Medical Treatment Utilization Schedule made it law back in 2004 and provided literature reviews every 5 years since. Recently the CDC published the same findings.

    SOCIETY MUST BE VESTED (6): Employers, insurance companies, government, places of worship, corrections, recovery, etc… Society as a whole, all have skin in the game, all have a shared responsibility, all have a vested interest in dealing with chronic pain.
    • In California the WC laws that demand a multidisciplinary approach are not enforced and never followed.
    • Insurances deny and fractionate care making multidisciplinary approach impossible.
    • Providers do not refer pain patients, preferring to band aid symptoms with opiates driving up chronicity, addiction, and overdose. Primary care providers are the biggest abusers.
    • True integrated multidisciplinary clinics struggle to stay open and are not supported.
    • Health care costs are decreased nearly 40% by a multidisciplinary approach.
    • All-Cause mortality is decreased nearly 80% a multidisciplinary approach.

    SELF MANAGEMENT (7): Chronicity means lifelong and as such the patient should become the expert in managing their pain.
    • The point of multidisciplinary is to provide as many effective treatments for the patient to utilize to manage their pain long term. Treatments are provided and those that work become tools for the patient to use to manage their pain. In effect, treatments that help are identified and the patient educated on how to use them. Physical therapy, CBT, even injections become part of the patients armamentarium, part of the patients tool box, they turn to manage their pain. Patients become the experts. Roles are reversed.
    • Early access to the patient is paramount. A diagnosis, prognosis, and treatment plans are developed as soon as possible. When the patient is permanent and stationary, without further improvement, then, and only then, does the patient have the tools to make an informed decision on what tools, treatments, to use and when. Since this is a concentrated effort, a “full court press”, it shouldn’t take much longer than 3 months or so depending on each patients underlying pathology. Think of it; you could have your legs broken, laid on a bed and fed yogurt, and Mother Nature would heal you within 3 months.

    So, Dr. Nagel, I do agree with you in every aspect except I do believe we can come up with a succinct, as possible, definition of pain management. Decades ago I wrote the following but, admittedly, I am not the best at writing. Maybe you, or someone else, may be able to improve it.

    Pain Management is an integrated multimodal approach intended to be implemented, as early as possible, to generate a diagnosis, prognosis, and treatment plan, as soon as possible, for the ultimate purpose of training the patient to take control of their long term care.

  13. Richard Oberg M.D. at 11:45 am

    Dr Nagel – thanks for your post. I wouldn’t be me if I didn’t critique. My apologies for anything you said or implied that I’ve somehow misconstrued.

    Anyone who’d stand up in a room and challenge basic assumptions is my kind of person. Also relating insider knowledge of how poorly things on paper look in actual fact, bring up financial incentives, etc. is a big plus.

    My criticisms would be the following from the perspective of my wife and I as physician/chronic pain patients.

    Palliative care is routinely incorrectly defined – it’s the care of anyone past the point of effective primary disease management of ANY disease and almost always gets skewed into end of life care for terminal cancer. Non-sequitur errors are all too common. All terminal cancer patients are palliative care patients but not all palliative care patients have terminal cancer. A large percentage of chronic pain patients are palliative care patients yet are not seen or treated as such. Hospice is another similarly misused term and often by physicians who don’t seem to know better.

    Next would be the common advice given to chronic pain patients who’ve already done the Kubler-Ross progression and, however much they’ve accepted their condition, get an all-too-common physician ‘no you haven’t’ projection. Physicians are the ones who have trouble accepting their patient’s diagnoses, limitations, and symptoms. None of it really helps any patient but maybe makes physicians feel better – and they get paid for it.

    The interdisciplinary approach is of course correct yet is context-dependent. If it means padding some pain management office it’s generally not useful and patient feedback is generally ignored. Note many of Krissy’s experiences which are typical. Offices act according to whomever’s the top dawg and the algorithm of ‘care’ (whatever that means) flows from the top down.

    You seem very well intended but I can tell you (if you’re an anesthesiologist) many or most of your colleagues aren’t and left the hospital environment due to CRNA’s taking over what most anesthesiologists were trained and reimbursed for decades ago. The pain management thing opened up and was filled by people who never intended to practice in a primary care setting and many do it very poorly. They’re seeing those of us who are seriously ill with conditions they were never trained to understand. Politicians think anyone with an M.D after their name can do anything – quite a myth – and physicians who abdicate care responsibilities want people to believe it too. No one’s buying it.

    We’ve seen FOUR in our area and not a single one came close to either BEING appropriate or providing us with care like that we’ve gotten from internists who were trained to understand disease, care for it, and also understand the palliative care requirements of those patients (like us). Internists are now told they must stop, or, others found it inconvenient in the new paradigm of high-volume reimbursement care schemes to take the time with it.

    A physician cohort tasked with taking care of ALL disease conditions with chronic pain and palliative care would be a challenging task to any but the most elite physicians – yet we end up with people who do ‘interventional’ treatments not appropriate for so many of us who are having to fend for ourselves. If they’re overloaded because internists are being forced to give it up then they asked for it being the ‘experts’ they claim to be. Hyperbaric oxygen chambers, antioxidant diets, etc. should play no role in our seeing a pain management ‘expert’.

    I agree with you – physicians ARE only patient care facilitators but when they fail to perform that role via either education for those who don’t need pain meds or refusing to provide them and try to be pretend-rheumatologists, we have a serious problem.

    I suspect if you could see what ‘pain management experts’ look like in our area you’d cringe and admonish this profession in a stronger way rather than provide patient advice. The ideology of what you propose and the reality that exists for patients are two VERY different things and no one is being held accountable. My wife and I are going to try to make everyone aware of exactly what’s going on.

  14. carol at 10:14 am

    I thought all the comments and Dr David Nagel’s very well written article was informative. I am 71 and until 3 year’s ago was with the same clinic. I have several problems and have severe Fibromyalgia. In 1990 I was asked to attend a Study at the University of Washington, it lasted 6 months. My Dr put me on oxycontin in the early 90’s and it helped a lot. I’ve been on the same dose for all these years. Because of the different areas of pain and the savarity of the pain with no chance of the pain lessening the pain medication is the most affective. I didn’t read where Dr Nagel had pain medication as a part of the answer.

  15. Marian at 9:53 am

    There is nothing about the words “pain management” that implies a cure. I had one “fellow” who used this approach, “you are strong, there is nothing wrong with you, you should enjoy your life, go where you want, do what you want. Goodbye.” So I wrote my pain doc a couple of days later about what he had said and I told him I tried to go line dancing, all a bunch of old people. I got basically thrown out after 20 minutes. No, I cannot go out and do what I want, am getting more and more limited I various ways. I cannot go to events that require walking, even church festivals, etc. I cannot get through a grocery without a cart. Life is not good. At least with pain meds, I had some comfort, for short periods of time. I do wonder what so called pain management doctors are going to do now that their jobs have been reduced. Perhaps they should have fought harder for us.

  16. Dave at 8:55 am

    “Cure almost never happens” Gee, i wonder why. I was “cured” of chronic pain-as have been many people. The fact that there hasnt been a large scale effort to identify and study people who have had pain and are now pain free- leads me to believe there isnt much ingterest in health care industry or government about curing”or preventing chronic pain. In addition you dont see much studies on people who have never had chronic pain and compare them to people who have chronic pain. So its no wonder with the lack of interest in cures and prevention for chronic pain that the author, also lacks interest in such. But promoting an occupational strategy based on conventionalism and a naturalistic fallacy isnt good practice in my opinion.
    There is nothing wrong with someone in chronic pain wanting to be cured of pain and asking the health industry to do ore then manage their pain. Just as their is nothing wrong with someone seeking pain management and Dr Nagel provining pain management. Let the person in pain decide what their goals for pain care are- to do otherwise is despotic.
    My problem also with pain management is what is someone supposed to expect from pain management as an outcome- return to work?, reduction of nrs?, less sequelae? So from where i sit “pain management” is quite a nebulous term- I guess it can mean almost everything but cure pain.
    Also pain care “must” be interdisciplinary? Let the person in pain decide what treatments they wish. Interdisciplinary sounds expensive, time consuming- and from my experience different disciplines dont play well together-theyre way too egotistical and too attached to their way of doing things for that. But, again, if the person in pain wants interdisciplinary care- then i think they should have it.
    If the focus is on the “lifetime pain patient”

  17. Krissy at 7:32 am

    I believe your explanation is helpful, indeed. From a patient’s point of view. my comment is that at the last “true PM team” I went to did not communicate with each other well. They were all in the same, large office building and it was a specialty clinic built just for pain management. My pain doc was one of the more knowledgable docs I had seen before, (on the subject of ME). but he ignored my progressive RA — not even asking if I had a rheumatologist or if that pain was being managed. Then when I was sent over to the psychologist, he couldn’t remember who I was each week and always assumed I was a new patient. I got tired of re-educating him, knowing he had never read my chart and never took a note. In this big, expensive building, “the team” didn’t host a professional for alternative therapy, yet the doc disagreed with my taking opioids.
    They had physical therapy, but by the time I could get an appointment with that, I had already come to a decision to leave. My experience was about 5 years ago or less.

    I agree and always have believed in what you are saying. That approach is key to treatment, especially if you are 1) new to chronic pain, or 2) if you have never experienced a team approach in your treatment and feel you are lacking in care.

    From the clinic side, a team approach requires sharp communications abilities, impeccable organization and a clear understanding for the patient’s reassurance that s/he is being taken care of across the board, with written references to any needed specialists outside the pain management door.

    The first pain clinic I went to was one of the first pain clinics in Minneapolis, perhaps the country. (Abbott-Northwestern Hospital.) They were doing good job for being on the ground floor of that kind of team approach.

    Now one would have a hard time getting me to go that route again because many of us, as senior patients, have just had enough doctoring and too many failed experiences — not to exclude those who need certain docs on a regular schedule for non-pain care. My once-a-month to my PM guy is good, although here’s where I’ll contradict myself: I do wish I could afford to look at eastern medicine, have physical therapy, get involved in some of the modalities one of our people comments about here and see a naturopath and a specialty doc who does extensive blood and DNA testing. Then! I’d go a-doctoring again. However, our healthcare system is not set up for patients to see these types of doctors. Only the rich get that privilege. I believe I could be much more well if I could (have) gone that route too.

    Thanks for your article. It is good to see this and I think a lot of people would love more!

  18. Angel at 7:24 am

    Yes yes and yes. This article points to the many aspects facing patients like me with life altering diagnoses that impact every aspect of ones life. My pain specialist is a DO not MD. I spent 20 years being poked tested and treated but find my DO’s approach is much like this article. He measures my success each month by my ability to function not my pain. He measures the true tests, am I attending church am I able to exercise care for my family etc. these parameters we set up together and the measures have given me much of my life back without any useless extras.

  19. Richard A. Lawhern, Ph.D. at 5:52 am

    Well said, Dr. Nagel. I find much to agree with in your formulation. It is only in your remarks about the roles of society that I have a few reservations. We cannot think about social context as a monolith. Instead it is an aggregate of often-conflicting interests.

    Insurance companies are in business to make money — and too often that occurs by minimizing costs of treatment whether in the interests of the patient or not. Physicians are of necessity also financially or professionally self-interested (they must earn a living to continue in practice). Government healthcare bureaucracies are frequently led by political professionals who have drifted far from the ethics they should have learned in school.

    In one way or another, all of these elements and people play a role in *making* public policy, in a rough and tumble process that has no enforceable rules of fairness. To be effective in influencing public policy, patients must find common consensus where they can, and then be prepared to get their hands dirty in confrontation — even to the point of publicly shaming those who act insensibly to protect their own rice bowls at the expense of others in pain.

    That being said, thanks for being an informed voice of reason.

  20. Jud at 5:31 am

    Good intentions, but nothing new. No “i” in team, but definitely one in pain and in patient. Empowering the patient, bottom line: you’re on your own, suck it up. Millions of dollars and so many years of studies, all for nought. And in the meantime, all these “experts” screaming their heads off about addiction, already proven false for chronic pain patients, and the few medicines that reduce pain levels are so highly restricted, it is criminal torture that way patients are treated, especially when one of the worst conditions, CRPS/RSD, is often the result of stupid medical mistakes.