When I began practicing pain medicine in the 1990s, spinal surgery was really taking off. Armed with new diagnostic tools, implantable devices and surgical techniques, surgeons often operated on patients who had very complicated problems: long-standing chronic pain, associated difficulties such as depression or anxiety, addiction to pain medicines or other substances, work injuries, economic hardship caused by an inability to work, and more. Surprisingly, all of these problems were addressed anatomically. That is, the doctors used MRIs and other diagnostic tools to find some physical anomaly in the body that might be causing the problem—like a bulging disc—then tried to fix it. It’s kind of like examining a person suffering from diabetes, finding elevated blood sugar, treating it with insulin, and believing you’ve cured the disease. Yet all you’ve really done is brought the blood sugar level down to normal temporarily; the underlying disease process continues.
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Unfortunately, with this approach, most chronic pain patients left the hospital with more pain and greater anxiety, taking stronger medicines, and finding themselves less able to return to work or reengage in other meaningful life activities. I often saw patients for the first time at this point, after they had been thoroughly disappointed by standard medical care. Why did standard treatment fail so often? Because chronic pain is not just a “body problem” triggered by a bulging disc, hairline fracture, strained muscle, or some other physical malady that refuses to heal. Chronic pain is an interconnected body-brainproblem. It starts with a body issue, but soon causes physical changes to the brain that quite literally turn a healthy brain into a “pain brain.” Just like an errant immune system that attacks the body in the form of rheumatoid arthritis or lupus, the “pain brain” perversely floods the body with pain signals. And while the pain itself is bad enough, over time it leads to additional problems, including depression, forgetfulness, anxiety, fear, problems with work and relationships, and much more. Think of the “pain brain” as the accumulation of all of the changes that have taken place within your central nervous system that perpetuate your pain experience. It is the remodeling of the brain into an irritated, sensitive, inflamed, and beaten-down version of itself that must be overcome so that you can successfully conquer your chronic pain. We will dive deep into the latest science discoveries about the “pain brain” in the next chapter.
In the early days of my practice, I did what everyone expected of me, managing pain with the latest medications and procedures. But after I had seen many patients over the course of years, it became clear to me that while standard treatments could often reduce pain over the short run, they were not very good at decreasing it over the long haul, or eliminating it entirely. They were “quick fixes,” not lasting solutions. Dismayed, I began delving into the scientific literature, “studying the studies” as it were. And two things quickly became apparent.
First, the overwhelming majority of studies on pain patients were flawed because they didn’t follow the patients for a sufficient length of time. They showed good results over the course of days, weeks, or several months, but they didn’t look at what happened after many months or years.
Second, even a casual look at the “pain numbers” made it clear that the health system was failing its pain patients. The numbers were frightening back then and today they’re even worse. In 2011, the Institute of Medicine, which is part of the National Academies of Sciences, Engineering, and Medicine, reported that:
• At least 100 million American adults (one-third of the U.S. population) suffer from chronic pain —more than the combined total of people suffering from cancer, heart disease, and diabetes.
• Chronic pain costs the nation between $560 billion and $635 billion every single year to cover the costs of medical treatment and lost productivity. (This does not factor in the cost of human suffering, which is incalculable.)
• Caring for chronic pain patients places an enormous strain on the nation’s medical resources, taking time and resources away from the treatment of other ailments.
When one-third of the population continues to suffer from the same disease, there is clearly a problem with the treatment being offered. More than that, as you will see, the entire system for dealing with chronic pain is seriously flawed. Despite more and more powerful drugs and cutting-edge diagnostic tools, flashy high-tech procedures and surgeries, and huge amounts of money spent on the problem, more people are suffering from more serious chronic pain than ever before. And the problem is only growing worse.
That’s why the authors of the Institute of Medicine study called for a “cultural transformation in the way pain is viewed and treated.” Unfortunately, they did not offer a blueprint for that transformation. While everyone seems to agree that the problem is daunting, finding the best approach is a difficult task. We now know that medicating patients heavily isn’t the answer. Yet the primary focus of pain therapy continues to be how best to distribute pain medications. This is not acceptable! It is time we offer chronic pain sufferers paths to true and meaningful change. Medicine must stop being part of the problem and become part of the solution. For a major transformation to take place, chronic pain treatment must stop revolving around unnecessary surgeries and how many pills to give or take away. We must develop a deeper understanding of pain, the true goals of treatment, and ways to promote sustainable recovery.