1. Attend our pain management/education group at least twice monthly. We complete pain diaries during the group along with measures of the severity and type of pain.
2. Engage in body/movement therapy of some type at least once weekly. This can be physical therapy, yoga, t'ai chi, chi gong, or supervised exercise.
3. Be willing to try non-opiate medications which can reduce reliance on opiates.
4. Undertake counseling with someone knowledgeable of pain for at least two sessions per month, either within our practice or outside of it.
Patients are often skeptical about being asked to move, but studies confirm that this is helpful for back pain. For example, Dr. Claus Manniche and colleagues at the University of Copenhagen9 studied the effect of 30 sessions of intensive dynamic back extensor exercises for patients with chronic low back pain over 3-months. They divided their 105 patients into 3 groups: a treatment group, an alternative group which underwent 20% of the treatment group's exercise program, and an alternative group in which treatment consisted of heat, massage and mild exercise. The exercises worked as long as one year afterwards. Irrespective of sex, age, duration and degree of severity of back trouble, or of pre-existing sciatica or abnormal findings upon X-ray of the spine, patients obtained a favorable result from the training program. No one got worse as a result of the program.
I am willing to increase opiate medication if pain increases, but only when that increase can be justified by a documentable improvement in function on some important level (work, activities of daily living, ability to care for others, etc.). Otherwise I can only increase opiate doses with the support of a consultation from an established pain clinic physician who agrees that an increase in opiates is warranted. I have found that rarely does the pain clinic at Dartmouth University, which is the one closest to me, recommend opiate therapy in a patient who is not taking these drugs, when the condition is not life-threatening and shows no definite likelihood of quick resolution. Nevertheless, I like patients to hear this for themselves. I use Dartmouth to prevent me from seeming like the bad guy who's standing in their way of relief. This is because the road to relief is not an opiate freeway but a rather bumpy, narrow country road with deep ruts and pot holes. Like Old County Road near my friends in Stamford, Vermont, it may have been abandoned by the County 20 years ago and will only cause your axle to break should you try to drive on it.
Lost prescriptions are not refilled, so I recommend keeping opiates under lock and only carrying a small amount on one's person. If this is a problem, we can prescribe lower quantities -- either one week at a time or two weeks at a time. Keep these pills away from dogs, toilets, sinks, and microwave ovens.
For all these reasons, I believe we need to work together to create communities of pain sufferers, to change their brains through social interaction (the social brain hypothesis) and to help each other to live better lives with or without pain. I'm all for anything that works, but not for harm or for approaches in which the risks may outweigh the benefits.
1. Urban BJ, France RD, Steinberger EK, Scott DL, Maltbie AA. Long-term use of narcotic/antidepressant medication in the management of phantom limb pain. Pain 1986; 24:191-6.
