Chronic Pain Programs Rise from the Ashes: This Was Silly in the '90s and It's Still Silly Today
POSTED ON 8/10/2017 IN Industry News BY Christopher Centeno
Back in the '90s, when I was a young physician, we had many "chronic pain programs" in town. These were made up of an interdisciplinary team of physicians and therapists who would be the court of last resort for patients in pain for whom traditional medicine couldn't help. The problem was that patients would graduate from one of these programs and still be in pain, but they felt a bit better about it. Hence, by 2005 they all went out of business as the insurers had figured out this was a massive waste of lots of money. Now the pain program has been resurrected through a new physical-therapy philosophy and is featured at the Mayo Pain Rehabilitation Center. All of this was silly back in the '90s and it's still silly today, despite the reboot. Let me explain.
The Chronic Pain Programs and Pain Research
Back in the '90s, physicians as a medical profession were awful at treating patients with pain. The surgeries we used didn't work, physical therapy often didn't help, and these patients were just incredibly expensive. Because of that, we saw the emergence of "chronic pain" programs. These pricey three-week outpatient affairs touted that all these patients needed was to learn physical and mental coping skills and they would be fine. The problem was that the basic thesis of the program—that patients were in pain simply because they believed themselves to be and learned bad habits because of those beliefs—was not in keeping with the science on pain as it evolved. In addition, these programs produced patients who were still in pain, but they had a few more coping skills. By the early 2000s, pharma had figured out that there was gold in them thar hills of pain. As a result, hard-core research on pain exploded, and that was aided by new imaging technologies that could "see" pain in the brain. These advances along with dismal results and a better understanding of how to treat pain through interventional spine techniques all caused the demise of the chronic pain program. The few that survived in any fashion morphed into local pill mills doling out and closely monitoring narcotic scripts.
The "Pain in Your Head" Crowd Reinvents Itself
By the early 2000s, the army of medical and therapy providers who believed that chronic pain was more of a mental than a physical phenomenon had a distinct problem. Their main thesis was being proven wrong by study after study that showed that pain was real and could be imaged. In addition, the local interventional spine doctor shooting steroids into the spine via X-ray guidance could usually get better results far more quickly. If the movement and the masses it employed was to survive, it needed a serious reboot. That would come from the very studies that were causing its demise. Pharma's focus in pain was always purely mercenary. Since its medicines could only work on receptors and sites where chemicals act, the focus of those drugs soon became nerves. After all, what is pain without nerves to carry the signals? As a result, the university researchers who follow grants began to get funding to study nerve pain. Their discoveries led to a concept called central "sensitization." This meant that the nerves themselves were "on fire" and could cause pain. While the research killed the "it's in your head" crowd's theories, it eventually managed to launch a reboot. The focus shifted from "it's all in your head" to "it's all in your nerves." However, the shift kept the same concept: pain wasn't a problem that could be treated with expertise—it instead just happened in some patients, and as a result, these patients learned to be afraid of their wonky nerves. Hence, they needed to be taught not to be afraid. The new nerve-pain concept is called pain neuroscience education (PNE) and has spread like wildfire. This is not because we have good research on the topic showing this is an accurate or effective model of disease or therapy, but because it's easy to teach physical therapists and other providers. After all, becoming an expert in manual therapy or advanced rehabilitation or understanding why patients in chronic pain hurt from a mechanical standpoint is tough and takes many years. So anytime someone takes an extremely complex problem and simplifies it to the nth degree, the uneducated medical masses bite, seeking "easy" over "hard."
The Mayo Clinic Pain Program
I see patients with chronic pain from all over the world. Many of those patients will often make a pilgrimage to one or more big universities to try to find out what's wrong and often one of those is the Mayo Clinic. However, since pain management didn't grow up in a university setting, most of these visits are a huge waste of time and money. The patients don't get answers that lead to solutions, and most of the answers they've gotten through the years we've later proven to be incorrect by identifying and solving the problem that was causing the pain. Don't get me wrong, these places would be great if you had a rare type of cancer or a rare heart condition, but they're not great for figuring out how to treat an uncommon pain problem. This past year or so, I've been seeing more patients who have been through a Mayo Clinic reboot of the old chronic pain program format described above. It's basically the same pain program from the '90s, but instead of the messaging being that the pain is all in your head, the messaging is that it's all in your nerves. For example, last week I evaluated an out-of-town patient who had been to the Mayo Pain Rehabilitation Program. They told her that she had central sensitization, and they taught her some simple physical therapy exercises. Was she cured or even substantially better? Not really. She was a bit more functional, but all of the same problems she had before the program she still had after the program. Again, all of this sounded familiar as I had heard the same thing time and time again in the '90s from almost every patient who attended the local chronic pain programs.
The New York Times Piece
I was recently sent a link to a New York Times story written by a former academic physicist and diplomat who attended the Mayo Pain Rehabilitation Program, just like my patient. He was able to get rid of braces and cushions he used because of his chronic pain as a result of attending the Mayo program. While I think that's great, reading the comments on that story will help you separate a single home-run result from the reality we have seen with chronic pain programs since the '90s. Scroll to the bottom of the piece and click the "Comments" in the lower right. It's basically filled with angry patients who know their pain is quite real and were insulted by the premise of the piece and the pain-program reboot. Why the hostility? Because the people who run these programs often report that they work better than the patients that go through them. The upshot? Pain is real, but often complex. It's a neuro-chemical-mechanical problem that can only be understood in terms of understanding each of those pieces and how that relates to the whole body. That's a tough thing to easily teach in a weekend course, so the messaging that pain is an incurable nerve phenomenon that we all should ignore (which leaves out the other two factors) doesn't fit neatly into a weekend-course format. The chronic pain program reboot will fare no better than the chronic pain programs of the '90s. Why? Helping patients in pain takes immense expertise and experience, and while some patients will do fine ignoring their pain and symptoms, many just continue to get worse or don't respond to that approach. They understand something their doctor's don't. That their pain is real and can be understood if they find the right provider.
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