NEW ENGLAND JOURNAL OF MEDICINE TALKS CHRONIC PAIN

PRESTIGIOUS MEDICAL JOURNAL TAKES ON
STANDARDS OF CARE FOR DEALING WITH CHRONIC PAIN

"I moderate a group of back pain sufferers. Nearly all are on heavy medication. Nearly all have tried EVERYTHING else first, including up to 17 different surgeries on 1 person.  The doctors must accept some of the blame for this one. Physical Therapy, acupuncture, OTC herbs, remedies, pain meds, braces, heat creams, spinal injections, pain pumps, spinal cord stimulators, etc. I am the moderator because I am well enough to post and keep track of the others in the group. I call them when they aren't active, I stay up at night to talk them through dark suicidal nights. Chronic pain is not a small thing that people can simply bear. And whether it is in a part of the body or a part of the brain that translates signals from the body into pain is material ONLY in choosing an appropriate treatment. I have had my sciatic nerve poked during steroid injections many times--I suspect you have NO idea what this feels like--but it is a tiny fraction of the pain I feel most of the time--and please keep in mind that I suffer the LEAST of anyone in my group."    Gail Fiorini commenting on the article being discussed today

"During the late 1980s and early 1990s, it was argued, largely on moral grounds, that opioids should be available for treating chronic pain, and physicians were persuaded that addiction to opioid treatment would be rare.  The correct dose of an opioid was whatever dose provided pain relief, as measured by a pain-intensity scale....   A focus on pain-intensity scores has had unfortunate and harmful consequences."  From the study being discussed today

I recently ran across a fascinating article from the November 26, 2015 issue of the New England Journal of Medicine, called Intensity of Chronic Pain — The Wrong Metric?  The authors (Jane C. Ballantyne, M.D., and Mark D. Sullivan, M.D., Ph.D.) are both anesthesiologists / professors at the University of Washington in Seattle with a special interest in Chronic Pain.   Some of the article's comments (many by medical professionals) included....

• "Only an idiot might conclude that one can dismiss the effects of living with a healthcare problem that reminds you of its' presence with every move you make."
  

• "It seems the current agenda is chronic pain suffers need only accept & learn to live w/pain all would be well. If we lived in Never Never Land it might be true."
  
• "The authors would like us to believe that NPS initiatives are in place, reducing suffering and brain-seizing pain, when they ask the ludicrous question, “But is a reduction in pain intensity the right goal for the treatment of chronic pain?” I guess that life-altering and debilitating chronic pain must not be such a burden after all."
• "People are dying because they can't get treated. Great job. I will be going into the coffin business thanks to these believers that people should suck it up.   How NEJM even recognizes these people as doctors and not quacks is beyond me."
• "With heart disease we treat the heart, with lung disease we treat the lungs, with kidney disease we treat the kidney. Why with chronic pain disease would we not treat the pain?"
• "Their assertion that increased use of opioids for chronic pain has produced “no demonstrable reduction in the burden of chronic pain” is not supported by the source they cited, and is clearly a statement of the authors’ opinions – not a statement of fact."
• "ANYBODY THAT AGREES WITH THESE AUTHORS CAN NOT BE DOCTORS. THEY ARE BOTH PAID A LOT OF MONEY FROM RPOP AND PHOENIX HOUSE. IF THEY WORKED FOR PERDUE PHARM, THEY WOULD SAY OXYCONTIN IS A GODSEND. THEY ARE THE WRONG PEOPLE TO LISTEN TO."
• "This is an object lesson in the shambles that invariably result when the government declares a 'war' on something. That result is human misery on a massive scale. Taking away the very thing that helps a person cope with the unrelenting never ending pain is grotesque and may well lead to a surge in the number of suicides."
• "If you wouldn't take insulin from a diabetic because it is a proven treatment and just tell them to suck it up and eat right why would you take pain medication from a chronic pain patient?"
• "You say that patients need to accept their pain and involve themselves in activities that render better quality of life despite the pain, just deal with it; Really?  What kind of quality of life can one expect to have if they are having thoughts of suicide because every moment every thought is spent in agony and the individual is consumed body and mind by this pain."

• "Chronic pain patients are worse off now because many doctors refuse to treat them; one result of unintended consequences from recent opioid abuse deterrent policies."

These were only a few comments from the first page (there were three more pages).  As you might guess, the authors were addressing AMERICA'S EPIDEMIC OF OPIOID ADDICTION.  Because INFLAMMATION is the root of most Chronic Pain, it's not surprising that some estimates put the number of Chronic Pain sufferers in our country at over 100 million. It's why we have been referred to by many medical experts as "INFLAMMATION NATION".   How did we get here from there?

It's tough to argue that our government has its hands in all sorts of things it was never intended to have its hand in (HERE, HERE, and HERE are examples) --- things that seem to backfire and blow up in its face.  Let me show you another.  About the time I was in Chiropractic College (1988-1991), our government began creating an emphasis (most would today argue an overemphasis) on "Pain Scales" --- you know; the number line from zero to ten, with 10 being the worst pain ever, and zero being no pain (the VAS or Visual Analogue Scale is the most well known of dozens).  This emphasis on pain was so huge that many clinics / hospitals started referring to it as "the 5th vital sign" (the other "vitals" are TEMPERATURE, pulse, respiration, and BLOOD PRESSURE).

Medical Standards of Care dictate that if something is out of range as far as vital signs go, it must be dealt with ASAP.  By putting PAIN on the same level of importance as other vital signs, this forced  doctors to do something about it --- even if the results were temporary at best.  What was the result of this policy?  Something that has been headlining in the news for the past year -- a national epidemic of Opioid Addiction.  Even though prescription drug addiction was already a significant problem (HERE), these new Medical Standards allowed it to take on epic proportions.

Being dubbed "Pharmageddon" in the press, CDC statistics tell us that in 2014, the medical community wrote 260 million prescriptions for opioids.  These same stats reveal that overdoses leading to death increased by nearly 15% from 2013.  In a recent article (The Attack of Opioids), Dr. JC Smith put it this way....

"Increases in opioid prescription painkillers are the biggest driver of the drug overdose epidemic. There were over 47,055 overdose deaths reported in 2014, which equates to 128 deaths each day. According to the CDC’s data published in CDC’s Morbidity and Mortality Weekly Report, from 2000 to 2014 nearly half a million Americans died from drug overdoses. In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes."

Despite the crazy numbers of addiction to prescription and non-prescription opioids, has this policy done anything to help those in pain --- particularly Chronic Pain?  Although the commenters at the top would argue the affirmative, NEJM says (probably correctly) not.  "For three decades, there has been hope that more liberal use of opioids would help reduce the number of Americans with unrelieved chronic pain. Instead, it produced what has been termed an epidemic of prescription-opioid abuse, overdoses, and deaths — and no demonstrable reduction in the burden of chronic pain."  Which itself begs the question of what these authors recommend for pain.  Glad you asked.

Not surprisingly, the authors of the NEJM study recommend, an "evidence-based multimodal approach" that includes things like (cherry-picked), "self-management and interdisciplinary treatments, coping and acceptance strategies, engagement in valued life activities, behavioral, physical, and integrated medical approaches, conversation between a patient and a clinician, empathy, encouragement, mentorship, hope" and ultimately, "a willingness to accept the pain".  I know what you're thinking and I totally agree --- most of this is touchy feely mumbo jumbo that still fails to address pain's underlying causes.

The hard reality is that sometimes --- especially once you understand TYPE III PAIN --- it is virtually impossible to fix these sorts of problems because the pain can become locked into the brain, playing it's unholy loop over and over and over again.  For THESE PATIENTS, I have only two recommendations.  Firstly, do whatever it takes to cut Inflammation out of your life (HERE are some steps for doing so).  Secondly, go see someone who understands the brain. 

I realize that you've already been to half a dozen neurologists.  Medical neurologists understand one thing --- gross pathology.  That is why I would suggest you see a Functional Neurologist trained by TED CARRICK.    For those of you dealing with an obvious (or sometimes not-so-obvious) musculoskeletal problem ("tissue damage") caused by underlying FASCIAL ADHESIONS (often times I refer to this in my clinic as SCAR TISSUE, although FIBROSIS or DENSIFICATION might be more accurate), pay attention and listen to what the good doctors tell us.

"But is a reduction in pain intensity the right goal for the treatment of chronic pain?  Pain-intensity ratings aren't necessarily a reflection of tissue damage or sensation intensity in patients with chronic pain. The intensity of chronic pain can't be reliably predicted from the extent or severity of tissue damage, since chronic pain is not determined primarily by nociception. Functional neuroimaging studies and other prospective clinical studies have shown that what feels like the same pain is initially associated with the classic sensory “pain matrix” brain regions but is later associated with brain regions involved in emotion and reward. Thus, over time, pain intensity becomes linked less with nociception and more with emotional and psychosocial factors."

Part of the problem is that "tissue damage" is frequently overlooked by standard medical imaging techniques such as MRI (HERE).   And now we're being told that pain reduction might not even be the goal ---- that it's a pipe dream. 

Having previously dealt with nearly a decade of Chronic Pain myself (HERE), I believe that relief of (or at least diminishment of) pain must be the goal!  If you have tried the diet and lifestyle changes I mention earlier without solid results, it might be in your best interest to try Tissue Remodeling.  Despite it's INTENSITY (or may because of it) it gives you at least a chance of getting to the bottom of things and solving certain types of PAIN SYNDROMES.  Although I see plenty of people that "Scar Tissue" is not their chief problem, I see LOTS OF PEOPLE that it is.