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  1. #1
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    Managing Chronic Pain

    Managing Chronic Pain
    by Alex Lickerman, M.D., in Psychology Today
    April 17, 2011

    A surprising treatment for chronic pain

    I have a small cohort of patients who suffer chronic pain so intense and unremitting it prevents them from living normally. They often don't work, shop, go to restaurants or movies, leave their homes or sometimes even their beds except to visit doctors, or have meaningful relationships outside their immediate family, who often struggle to live with and care for them.

    One patient in particular has pain that's so severe she's become wheelchair bound, chronically depressed, and regularly experiences times where she contemplates suicide on a daily basis. Most primary care physicians, I've observed, are woefully undertrained in chronic pain management, often more concerned about painkiller addiction and drug-seeking behavior than quelling excruciating pain they don't feel themselves (studies show such concerns are generally overrated in these patients). But even physicians who find themselves comfortable treating chronic pain aggressively with all the tools we currently have available sometimes find those tools inadequate. Most people outside the medical profession don't routinely encounter people whose lives have been ravaged by chronic pain so don't realize they even exist, much less grasp how awful their lives typically are. But such people do indeed live among us.

    CAREGIVER'S ATTITUDES
    I remember the first time I met my patient. She described in clear yet clinically unemotional detail not just the quality and severity of her pain but its impact on her life. I found myself moved by all the losses she'd suffered at the hands of it: days to weeks of time absent from work, periods she desperately wanted to but couldn't play with her children in her neighborhood playground, and the strain on her marriage that eventually shattered it. I told her I would do everything in my power to help her and that I would not abandon her. Strangely, her response to my saying that, in contrast to the way she'd described the ruin of her life from pain, was to choke up with tears (which she tried, heartrendingly, to hide). She thanked me for my commitment in hoarse tones.

    Only several years later did I come to understand her reaction. Other providers before me, when they too had tried to help her and failed—not for lack of trying and through no fault of their own—had appeared to her to lose all interest in her, gradually coming to return her phone calls sluggishly or not at all, to resist filling prescriptions for her, and even to become irritated when she would report her pain had increased (as it sometimes did for no discernible reason). They had all seemed to care when they'd first met her, she told me, but all failed to stick it out with her in the long run. She knew medicine's ability to help her was limited, but what she wanted more than anything besides pain relief, she told me at that first visit, was someone who would simply stick by her even if that was the full extent of what they could do.
    Ironically, this proved itself even more difficult for her previous providers than finding effective ways to treat her pain. Though I never said so, I well understood why. They hadn't abandoned her out of indifference or lack of caring but, I believed, from frustration—not with her or her pain but rather their own impotence. Perhaps as a result of a psychological coping mechanism, as a group, doctors tend to ignore what they can't fix.

    I, too, have felt inclined to ignore patients I can't help. And, after a time, I began to feel it with her too after proving no more adept at controlling her pain than the doctors who'd tried before me. But she'd warned me well. By calling attention to what her previous doctors had done, she forced me to reflect on their behavior and on my tendency to mimic it. By making me acutely aware of the temptation to turn my back on her, she predisposed me to resolve not to.

    And stick with her I have, for the last ten years. And not abandoning her, I've come to realize, is the best treatment for her pain that I've had to offer. Not that it's been adequate, by any means. But it has been helpful. At least, that's what she says.

    WHAT CAN BE DONE
    Pain is a fascinating subject when one isn't experiencing it oneself. It may feel to us like a single unified experience but in fact is generated in our brains in a series of sequential steps. Counterintuitively, the physical sensation of pain registers in a different part of the brain than does its aversive quality. We know this because of patients who've had damage to the latter portion, the insula, develop a syndrome called pain asymbolia wherein they feel the raw sensation of pain but not its aversiveness. That is, they feel pain but not its painfulness. If that seems hard to understand, it's because to those of us with an intact brain who are incapable of experiencing them as separate things, it is.

    But it raises an interesting possibility: might not there be methods we can employ that exploit this hidden duality? Rather than attack chronic pain at the trigger point (i.e., an injured tissue or even the misfiring of the peripheral nervous system itself), perhaps we could attack it where it actually lives, in the brain itself. If we can't do much to alleviate the source of chronic pain, can we in some way reduce its aversiveness?

    The answer, at least to a limited degree, seems to be yes. A number of studies have explored ways to do this. A recent article in U.S. News reported the results of a small study in which "healthy medical students attended four 20-minute sessions to train them in 'mindfulness meditation', based on techniques such as focusing on breathing and banishing of distracting thoughts. Before and after the training, participants underwent brain scans with a pad heated to a painful 120 degrees attached to the back of their leg. They reported a 40 percent decrease in pain intensity and a 57 percent reduction in pain unpleasantness following their training. Morphine and similar drugs typically reduce pain by about 25 percent." If validated by other, larger studies, this represents an astounding result. When considered in combination with the results of another study in which viewing a loved—one's picture had pain—attenuating effects, we might hypothesize that the degree of aversiveness of pain is at least partly determined by how much attention we give it. If so distraction—though by no means a cure for chronic debilitating pain—may be an effective treatment.

    The problem with pain, of course, is that it's designed not to be ignored. Normally, acute pain indicates something is wrong in our bodies that needs our attention. But in many chronic pain syndromes this isn't the case. Rather, the pain itself becomes the disease, often centered in an "overactive" nervous system response rather than chronically injured tissue (though the latter is certainly common as well). Distracting oneself from such chronic pain requires consistent effort that's difficult to sustain. But the study above gives me hope that though we don't yet have the technology to relieve all chronic pain sufferers of their experience of pain, they themselves may be able to surmount their pain's aversiveness in a way that enables them to reclaim at least parts of their lives. It's not a good solution, I readily admit. But it's better than nothing.

    Though how we subjectively experience pain is undoubtedly influenced by many other variables, just the notion that we have more influence over our experience of pain than previously thought is encouraging. Though I've suggested to my patient, based on the study above and others, that she begin a program of meditation, she hasn't yet. "How could it hurt?" I ask her. "What else do you have to try?" She acknowledges my logic and promises to start. In the meantime, I continue to do what I've done: stand by her and care.

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    Re: Managing Chronic Pain

    I went to an opthomologist yesterday who dispensed a prescription of eye drops to me because my corneas are scarred. He asked me if my eyes had caused me any pain and when I replied, "No," he responded with, "Well, of course you don't [feel pain] because you are on [pain medication]." I sat back a bit in my chair then because even through near-sighted, bleary (but painfree) eyes, I could see that the doctor had just exposed himself to me.

    Not even trained medical practioners understand the treatment for chronic pain. Did he really think that if, say, I stubbed my toe I wouldn't trot out some colorful, surprised language? Managing chronic pain with appropriate medication is a battle with sufferers losing the war--especially when the medical community itself fails to stave off preconceptions about what chronic pain is and what effective treatment for it means. And after my next appointment, when I plan to tell this doctor the effect that those words had on my perception of him, I will take me and my apparently high-flying eyes elsewhere.

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    Re: Managing Chronic Pain

    Excellent insights. I have severe spinal stenosis, moderate to severe disk degeneration, and a torn right rotator cuff. My left shoulder got fixed last year, so at least I no longer have that pain as well.

    When I moved to Toronto I couldn't get a family doctor at all. I was taking break-through morphine up to 15 mg in a day, so every clinic turned me down. They did this because I had no answers as to why I was in pain. I was told I had psychogenic pain, but no diagnostic tests had ever been ordered. I was just prescribed the morphine to treat the alleged psychogenic stuff. The doctor who prescribed the morphine without screening me first, finally got suspended by the College of Physicians and Surgeons.

    Anyway, with no explanation for my pain, the doctor's in Toronto insisted I must agree to a drug withdrawal program or agree to being screened to enter the methadone program. I wouldn't do it. Their attitudes felt inhumane and rather dismissive.

    I finally found a new doctor in the form of a Resident who worked at a local hospital. I was never allowed to meet the main (full-fledged) doctor, even though I requested it.

    The Resident did, however, order diagnostic tests. That's how I finally got an answer as to why I am in pain all the time.

    The left shoulder was badly torn and it has since been surgically fixed. The right shoulder is badly torn and I'm on the waiting list to get it fixed to.

    The Resident referred me to a neurosurgeon to have the severe spinal stenosis and disc degeneration also fixed, but the referral was flat out denied. Apparently the waiting list is too long and because I'm not bedridden yet, I'm not considered a surgical candidate.

    The Resident then sent me to a pain specialist. The pain specialist determined that I did not need cognitive behavior therapy. I just needed to get the surgeries done. He recommended I take the pain patch; the one that has now hit crisis status in the news.

    I've been on it for a year and I'm still on the lowest dose possible. When it was recommended that I increase the dose about 4 months ago, I said I didn't want it. I was prescribed short-acting morphine instead. Now I have a choice.

    When the pain increases I take Advil first. If that doesn't work, I get busy and try to distract myself. If that doesn't work I take a 25 mg tablet of morphine. At the end of the day if the pain is still high, I will take a second one. That usually breaks the pain cycle.

    Overall I was taking less narcotics and managing the pain quite nicely. I thought it was a winning solution.

    Well, with the drug crisis for the patch well established, new rules have been imposed on the clinic where the Resident worked. I was suddenly limited to only seeing only the one Resident. I couldn't see any other doctor, not even the one assigned to cover for my Resident when she's away. I was also limited to seeing her for just one appointment per month.

    All of a sudden my other health issues, and I have many, couldn't be addressed. I was advised by a friend to seek a new, full-fledged doctor that could provide continuity of care and be available more often. I agreed this suggestion made sense so I found a doctor who was taking on new patients. I made one appointment; one I expected would be a meet-and-greet. The appointment wasn't long enough, so I made a followup appointment. I also signed a consent form to release my medical files to the new doctor.

    Little did I know that, before I got an answer about whether the doctor would take my case on and carry forward the current prescriptions I had been on, until I could be re-evaluated, the Resident closed my file.

    I now know the new full-fledged doctor won't carry forward the other treatments. The morphine has been cut off.

    He won't increase the dose of the patch either even though he now has my chart and can read that I turned the increased patch down in favor of using Advil and less narcotics. He said he will be cutting the pain patch off altogether soon too. I hope he will order the surgery instead, but I don't know that yet.

    I'm beside myself with pain because I finally ran out of morphine. I'm taking the maximum dose of Advil I can take I a day. I am using heat. I am alternating it with cold. I am using Voltaran, I am distracting myself, and it's not working.

    I feel abandoned. I'm in so much pain I couldn't sleep last night. I cannot move to transfer even out of my wheelchair or get a meal. For the first time in my life I am thinking that I will have to request the doctor assisted suicide.

    I don't have the guts, desire, or ability, to try killing myself because I'm too afraid of failing and making matters worse. I don't need to add stigma of a mental illness to this mess as well.

    This is cruel.

    This story also supports your observation. You are right when you say we all want to be listened to, to be accepted, and to not be abandoned or doubted. I am forced to suffer because new rules to avert a drug-abuse crisis tied the hands of my doctor and limited her ability to properly treat me.

    An addicted person can't go from 50 mg of morphine per day to zero overnight without withdrawal symptoms. I did. I went from 50 mg to zero overnight. The only symptom I have is a massive increase in pain. I can't move to get dressed, get a meal, or do anything to look after myself without having the severe pain shoot down my legs. Thank God I can push a lever (my joystick) and wheel into the bus. I plan to go out to my volunteer job, despite the pain and lack of sleep, because I'm hoping the distraction with get my mind off the pain.

    I just pray the pain will soon pass on it's own. Both legs are cold and in agonizing pain from, what I now know, is caused by the severe spinal stenosis.

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    Re: Managing Chronic Pain

    I'm outraged at what is happening to you, Wheelchairdemon. Did you find out if the emergency room might be able to help you?

    I really hope you can find a way to get helped with this, even if it perhaps involves talking to the media or an advocacy group or something?? Hope you will let us know what is happening.....?

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    Re: Managing Chronic Pain

    You know, I think I just learned a lesson. "Read the whole thread before you give your opinion." Bings, I think we would all be shocked if we knew how little training our Doctors really get in a lot of areas regarding the Health and Welfare of human life. Maybe we should call it Wealth and Hellfare. How long is Medical School? Is that 4 years, followed by an Internship and a Residency? Is there an additional year for Specialization? Someone once told me that the average Doctor gets one, 3 hour lecture on the harmful effects of alcohol abuse. If they miss the lecture, oh well.

    WCDemon, seems like you are getting a run-around. You mention Advil and I don't think I'm allowed to recommend anything on this forum, but there is another over-the-counter, pain medication that is a non-inflammatory, originally used for severe headache. Guess you have to read labels. As muscle tissue tightens it clamps down on nerves and a non-inflammatory reverses the process.

    Going back to a previous post, there is a definite attempt by the medical profession to decrease the amount of pain medication used and I think it is based on fear from the Governments and the Insurance Companies. It's all about bean counters. I believe Doctors are questioned about what they prescribe. Chronic pain leads to possible drug addiction which leads to treatment needs. The whole thing is about money. In the USA, Medical Marijuana use is spreading and there has been a tremendous increase in heroin use. Which I think will be interesting to see what happens if President Trump does build a wall on the Southern border. It will definitely force the prices of street drugs, up.

    This comes back to the need for the surgery, WCDemon. You are not one that appears to want to be on pain medication. Yes, your best option is to push for the surgery, but as you mentioned that seems to be hard to get. You are in Ontario, is that Canada? Is it Socialized medicine there? I'm not certain how that system works. In the USA it seems that money talks.

  6. #6
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    Re: Managing Chronic Pain

    Several weeks have passed since the pain medications were cut down. The pain is fully out-of-control, my blood pressure is averaging 185/90, and I can't stop crying.

    I can't tolerate lying down for any longer than 4 hours and I can't stay sitting up for very long either.

    I still try to go out, but I can't tolerate the pain when the bus hits a bump. I can't even think clearly anymore.

    I've been back to see the new doctor 3 times now. The parish nurse will no longer attend with me (she has other commitments), so the doctor said he won't talk to me anymore. He just asks questions, takes notes, and says he will answer my questions when "I find a responsible adult to take with me to the next appointment I have with him.

    I am outraged. I'm also very, very, trapped.

    In the first two visits he talked to me (and the parish nurse) and he laid out all kinds of plans for follow up care, rehab, and the like. I was so happy. I thought, finally, some continuity of care.... I can't even begin to imagine why he won't talk to me. Is it the wheelchair? Is it the fact I have pain and I was being treated with powerful pain medication? Is my name flagged? It shouldn't be. I've never abused drugs and I'm not an addict.

    All I know is I can't go to another doctor for a second opinion. That is called Drug seeking behaviour. I might be able to ask for a new examination of my spine, but the newest MRI report is under a year old and my new doctor has it. The answer I was given by an after-hours clinic is that "no doctor would neglect a known condition." Great assumption, eh?.... NOT.

    The only other thing this new doctor has said is, "he must "be really tough on me and break me of my [so called] dependence on pain medication."

    He's made it clear he will not refer me to a Physiatrist after-all. He won't refer me to a Pain Clinic either. He said, "if I wanted that, I know the routine."

    I have no idea what he's talking about. All I know is I'm in big do-dos. It basically feels like I no longer have a doctor.

    To make matters worse, I found out I was being misinformed by the receptionist for my former doctor. There was no need to move on to a full-fledged doctor at all.

    I've written to the "boss" of my former medical clinic explaining how I was misinformed and was even denied an appointment to treat a severe bladder infection; that that's why I felt I had no choice but to find a new doctor. Now I have to wait.

    If I'm lucky that "boss" from my former clinic will investigate and then reverse the wrong-headed decision by that receptionist to close my file (with my former doctor) without my permission.

    I sure hope I can bail myself out of this one.

    I did nothing wrong. I've even got MRI results that can prove I have severe spinal stenosis, severe cervical disc degeneration, and impinged nerves in C5-C7. I don't get it.

    Im still persevering though.

    I just want to ask, is it normal to treat back pain or was I just lucky that my doctor used to treat it? Someone told me that that was the problem; that most people learn to ignore pain and just get on with their life. If this is the case, where do I get help to learn how to ignore this? My blood pressure is 169/92 at rest because of the pain. It's the high blood pressure that scares me too.

    I literally don't know if this treatment is standard protocol or highly unusual.

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    Re: Managing Chronic Pain

    "I find a responsible adult to take with me to the next appointment I have with him."

    That seems an odd statement to make although I have had some very strange things said to me by doctors. I am a very quiet person so I write down the questions/issues I want to speak with the doctor about. My present doctor does not have a lot of patience with this. Like MHealthJo I am outraged at the treatment/non-treatment you are receiving. Patience and persistence and more persistence.

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    Re: Managing Chronic Pain

    Thanks. I just wish I knew what to do. I am beside myself with pain, I'm too stubborn to give up moving (the pain is worse when I stay home alone), and now the pain can't be hidden.

    I have volunteer jobs which I love and I don't want to stop doing, and yet if I go and people see me squirming or my tears begin to flow again, I get the people around me upset. If they get upset I then have to find the words to explain why I'm in so much pain and yet I'm not being treated. I try to rationalize it and not come across as blaming the doctors and I explain how all the doctors are afraid of prescribing pain medication, but it still upsets people.

    I just wish I had a strong person who knows me well and would come to the doctor with me and say, "this woman is strong, determined, dedicated to taking care of her health, has worked hard at losing weight, still gets exercise, and continues to volunteer despite the pain, but I can see it; the pain is debilitating to her. It's not normal to see her crying so much"

    If just one person in my life had the guts to say that - they say it to my face all the time - I would likely not get dismissed like this.

    Well, my coping tool for today is to go to the museum to volunteer. I have four hours of shifts. For the first 2 hours I will direct people to various exhibits. For the second two hours I will be in the Blue Whale exhibit at the Royal Ontario Museum and answering questions related specifically to the ecological benefits of Whale poop and what scientists hope to learn when it unravels it's DNA. That should help to distract me for awhile. It will be a lot better than staying at home alone where I'll notice the pain a lot more.

  9. #9
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    Re: Managing Chronic Pain

    WCDemon, there is a documentary that is available called "Dr. Feelgood." It features the medical practice of Dr. William E. Hurwitz of Virginia (USA.) It discusses most of the aspects of the treatment of chronic pain and the hesitancy of Doctors to prescribe pain medication. The film doesn't take a side nor pass judgement. I believe you may find it rewarding in helping you to understand what may to be happening in your own situation. It is available on DVD at Amazon.

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