By 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.