For many Americans, near constant daily pain is a way of life. Our grandparents learned to accept their pain as a part of the aging process, but it limited their ability to enjoy their later years and in some cases even shortened their lifespan. Then, beginning in the 1990s, a significant shift in chronic pain treatment occurred, thanks to aggressive pharmaceutical marketing that pushed opioids as a way to make life pain free.
As addiction to opioid-based pain medication has skyrocketed worldwide, the medical community has come to accept that that approach was deeply flawed. Today, pain-management physicians are taking a different tack, helping chronic-pain patients avoid opioids in favor of a range of treatment options designed to address pain at its root cause.
At HealthPartners’ four pain clinics, in Bloomington, Coon Rapids, St. Louis Park and St. Paul, providers take a multidisciplinary approach to the management of chronic pain, offering a wide range of treatments, including physical therapy, pain psychiatry, medication management, addiction medicine and integrative therapies like acupuncture and massage.
I talked to Peter Stiles, M.D., medical director of the four-year-old pain program at TRIA Orthopedic Clinic in Bloomington. He develops individual treatment programs for patients, with a focus on avoiding addictive pharmaceuticals whenever possible. The clinics are busy, with a steady stream of patients seeking treatment for pain that is disrupting their lives.
“For a variety of factors, a lot of people are in pain in our country,” Stiles told me. “And it’s just getting worse. Some of it is an aging population. Some of it is the fact that people are working at more dangerous occupations. And some people have experienced childhood trauma or are under extreme stress, which can also be a source of chronic pain.”
He said that moving away from the old approach of offering drugs that provide false promises to erase chronic pain is key to slowing the national addiction crisis. Many physicians agree, he said, and this is a positive sign.
“More people are talking about the dangers of opioid-based pain medication. The unfortunate thing is it took a narcotic crisis with 115 people a day dying from overdose to think that we needed to change our approach. I think it will take a generation of doctors to fully make this happen.”
MinnPost: Can you explain the difference between acute pain and chronic pain?
Peter Stiles: It’s important to differentiate between acute and chronic pain. They are two very different processes. Acute pain comes from something like a broken leg. It hurts, but it is temporary. Real chronic pain is pain that lasts for a much longer time, usually somewhere between three to six months. I focus on the chronic-pain population, a group of people with no quick fix for their pain.
MP: Opioid-based pain medications are commonly prescribed for chronic pain. Do you think they work well for that purpose?
PS: Opioid-based pain medication is best indicated for pain management after major surgery or injury. The length of time that someone should be on these medications is much shorter than we thought a few years ago. We are learning more and more that they are not useful for pain relief after a certain amount of time, so they are not suited for treating chronic pain.
MP: What’s the preferred approach to treating chronic pain?
PS: When it comes to treating chronic pain I think you have to look at the person rather than at their pain. This represents a major shift away from what has been taught for about 20 years. Chronic pain patients are often seen as some of the most difficult patients to treat. They are in some ways marginalized by a system that is geared toward helping the people that are easier to help. Doctors are trained to help their patients feel better; when they can’t do that it’s frustrating and overwhelming. That’s why chronic-pain patients are so often overlooked and underserved.
MP: Since chronic-pain patients are so hard to treat, have you developed a new strategy?
PS: I believe we have to look at pain as the disease itself — rather than as a symptom that can be cured. Chronic pain is a disease. Seeing it that way requires a change in thinking. Once you understand that reality, you can begin to see why it is more difficult to treat. You wouldn’t tell someone with Type 1 diabetes to take a couple of pills and it will all be good. You have to manage that disease over a lifetime with a variety of resources. It’s the same with chronic pain: It is a chronic disease that should be treated with a constellation of appropriate management techniques.
Chronic pain merits a global approach.
MP: Tell me more about this global approach.
PS: I believe there are four — actually five — legs in a responsible pain management program. The legs are, in no particular order of importance:
1) A pain management doctor;
2) A functional therapy program that includes physical therapy or occupational therapy;
3) Behavioral care from a supportive pain psychologist;
4) Addiction management; and
4.5) Integrative therapies.
MP: Tell me more about the role of the pain-management doctor.
PS: The pain doctor, even though I called it the first leg, is probably the least important. That’s what I do. I build a plan, sitting down with a patient and coming up with a tailored treatment strategy that works for them.
I view the role of a pain-management physician much like a quarterback. Sometimes we come up with a medication strategy that is responsible and sustainable, something that won’t overmedicate and check the patient out of life. Another part of my job is putting needles in funny places or implanting a stimulator in a person’s spine. These are important parts of supporting a treatment plan, but they cannot be the whole plan.
MP: Your second leg is functional therapy. What’s that?
PS: For most people, functional therapy is physical therapy. With chronic pain, physical therapy takes a commitment from a patient to improve how they live their life. The focus should be on a goal, not just physical therapy. Different physical therapists have different specialties: Some are good at helping a person get back to a marathon after a broken ankle. But you also need physical therapists who understand chronic pain to have a truly comprehensive pain program.
MP: Your third leg is behavioral care. Is that another word for therapy?
PS: Yes. Behavioral care acknowledges that living with chronic pain impacts you as a person. It affects your sleep, your mood, your relationships, your motivation. Pain-management clinics need to address this reality head on, to recognize that living with chronic pain will look different for different people. This is best done under the direction of a pain psychologist.
If I think a patient needs behavioral support I will suggest that they meet with the psychologist. Part of that visit is going to focus on what options may be most helpful for the patient. That may be conventional approaches like psychiatric medication. That may be biofeedback or EMDR. There are a number of different kinds of approaches. The goal is to fill the patient’s toolkit with strategies so they can learn to help themselves in a more constructive way.
Pain often comes along with depression, anxiety, PTSD. Sometimes there are things underlying the chronic pain, like childhood abuse and chronic stress that has turned up the volume on a patient’s nervous system. If you only treat the pain without treating co-occurring depression and anxiety, you are not going to get anywhere, but if you acknowledge that patients, like everyone else, are a complex mixture, you may get somewhere in addressing their underlying chronic pain.
MP: Some of the medications prescribed for pain are addictive. How can an addiction management specialist help a person with chronic pain?
PS: This fourth leg of the table is important. I hope that someday our problem with opioid addiction goes away, but the reality right now is that one-fourth of the patients who suffer from chronic pain are already on opioids. This is not to say that they are all addicted, but having someone with addiction training is an important part of any pain program.
MP: Why is integrative care leg 4.5?
PS: It’s as equally important as any of the other legs, but it often gets ignored. Tables don’t usually have five legs. I like to say that integrative care is thinking outside the box. It is a broad category that includes mindfulness techniques, meditation, gentle yoga, healing touch, energy work like Reiki, hypnosis, aromatherapy and acupuncture. The downside with this category is that except for acupuncture, most of these services are not usually supported by any kind of reimbursement. But they are certainly safer and at least as effective as most narcotics.
MP: How did you get interested in this specialty?
PS: I’m an anesthesiologist by training. One thing that I found when I was working in the OR full time was that I missed developing a relationship with patients. I’d see a patient, and within 20 minutes they’d be unconscious. If I did my job really well they wouldn’t remember me at all. But pain management it is a hybrid. I’m implanting spinal-cord stimulators. I’m doing some anesthesia work. And I get to work closely with patients as we come up with a plan and carry that plan forward over a number of months or years.
MP: Can you take your patients’ pain away?
PS: I tell my patients that the goal of pain management is not a lack of pain — which is a hard sell at first. I feel like I have succeeded if we improve their function and their quality of life. Ultimately that should be the goal of all pain management. If your pain comes from arthritis, for instance, you’re never going to get that pain to zero. I don’t usually tell my patients that the first time I see them; I want them to buy into an overall care plan first. The goal of pain management is function and quality of life — rather than the absence of pain.
MP: Accepting that definition might require some people to completely change their way of thinking. Not so long ago, the promise of opioid-based medications was that they could make pain disappear forever.
PS: The explosion of opioids has a lot of complicated underpinnings. We are a society that expects a quick fix to basically anything. You see people advertising painless surgery: There is really no such thing as a painless surgery. That mindset only makes us hold out for an unachievable goal.
When I work with a patient, my goal is to shift them on the spectrum of pain, to turn down the sensitivity of their nervous system. That will be a long-lasting improvement, a goal that feels worthwhile.