This article first appeared in the Winter 2011 edition of Trial Lawyer magazine, the quarterly journal of the Oregon Trial Lawyers Association.
Motivating patients in chronic pain poses a challenging dilemma for most physicians. Pain has become the fifth vital sign and in the day and age of pain management, it is expected that doctors will relieve suffering. It is hard to witness someone’s suffering. If we can relieve it with medication, we feel it imperative to do so.
But perhaps we are looking at chronic pain and incurable conditions all wrong. I’d like to propose another way of looking at suffering and perhaps a way of motivating patients to live their lives to the fullest under any condition. I also suggest we exhaust all options before we relegate patients to managing and coping with their pain.
Sally came to my office accepting the pain from her fibromyalgia and arthritis, that her doctors told her she’d have to cope with the rest of her life. Every change in the weather brought on joint pain, which would be so severe it would wake her up at night. She used a walker for stability and security. She took three doses of 800 mg ofTylenol every day. She was on trazodone for sleep every night.
She told me, “I can’t stop taking this or else the pain will wake me up.” She had a prescription for oxycodone daily as well. And she took prilosec to counteract the inflammation in her gut from all of the pain medications.
I see patients like this every day.They have accepted the pain and dis-ease of their lives. No one has given them a chance for things to be any different.
Changing the mindset about pain management
First, let’s change our mindset for dealing with chronic pain sufferers. Bernie Siegel, M.D., speaks to this directly when he says, “We must realize the pain most people suffer, and redefine our goals. What is healing? Is it a liver transplant or cure of an illness, or is it getting people to have peace of mind and live life to its fullest? One of the most important factors is a patient’s confidence in having the doctor’s undivided attention.”(Siegel, B.S., Love, Medicine and Miracles, New York, NY, Harper and Row Publishers, Inc., 1986)
Naturopathic doctors and acupuncturists tend to spend more time with their patients, listening and witnessing their suffering. Now I know what you are thinking — this is all well and good, but the patient is in extreme pain. I am not suggesting not treating the pain, but this piece of witnessing — being with the person — has been sapped out of current medicine. Many doctors resist such intimacy out of fear of transference.
But as Patch Adams, M.D. writes, “Without intimacy how can healers offset the pain and suffering they are so helpless to cure? Physicians need freedom to cry with patients, to hug them and cradle them in their arms, and to receive the same care in return. Human communication without this exchange of love is phony. It is painful to be a fake.” (Adams, P.,
Gesundheit!, Rochester,VT, Healing Arts Press, 1993)
I think Sally came to my office because she heard me speak at her office and I spoke directly to this point. We are bringing back the doctor patient relationship as a healing modality all of itself. All too often I hear patients complaining they weren’t heard or worse yet, they were told this is as good as they are going to get and they will have to accept their
Kate, a brain injury patient, was just one of those patients. She came to my clinic on anti-depressants, pain medications and searching for another opinion. She was in counseling with her long-term partner after her accident. Her physicians had told her they had done all they could for her. She was left depressed, on oxycontin, medicated and frustrated that after almost two years of therapy she hadn’t really progressed.
Another way of looking at suffering and meaning is presented by Viktor Frankl. He founded the logotherapy school of psychoanalysis. Logotherapy is based on the belief that it is the striving to find a meaning in one’s life that is the primary, most powerful motivating and driving force in humans.This framework is very helpful when dealing with patients in chronic and debilitating pain.
A short introduction to logotherapy is given in Frankl’s most famous book, Man’s Search for Meaning, in which he outlines how his theories helped him to survive his Holocaust experience and how that experience further developed and reinforced his theories. He concludes there are three ways one can discover a meaning to life:
• By creating a work or doing a deed.
• By experiencing something or encountering someone.
• By the attitude we take toward unavoidable suffering.
We are exploring the third potential here, facing a fate that cannot be changed.
Frankl says, “For what matters is to bear witness to the uniquely human potential at its best, which is to transform personal tragedy into a triumph, to turn one’s predicament into a human achievement.” When we are faced with an incurable condition, we are challenged to change ourselves.
Edith Weisskoph-Joelson, a logotherapy practitioner, says, “Our current mental-hygiene philosophy stresses the idea that people ought to be happy, that unhappiness is a symptom of maladjustment. Such a value system might be responsible for the fact that the burden of unavoidable unhappiness is increased by unhappiness about being unhappy.” She goes on to conclude that logotherapy “may help counteract certain unhealthy trends in the present day culture of the United States, where the incurable sufferer is given very little opportunity to be proud of his suffering and to con- sider it ennobling rather than degrading,” so that “he is not only unhappy, but also ashamed of being unhappy.”
More treatment options
So let’s return to our original question: how to motivate patients in chronic pain? First we look to reframe the process, and then we explore whether the condition is really incurable or recalcitrant to treatment. The current western medicine approach is to prescribe heavier and heavier narcotics for the person in chronic pain, and to prescribe pain management classes on how they are to cope with their current situation. These medications often times are highly addictive, which poses its own set of issues.
As a result, patients oftentimes lose hope of improving and are left to suffer. Unfortunately, many physicians and patients themselves don’t realize they have options that have never been explored. We see a lot of chronic pain sufferers improve with our treatments. Often, the options are not known or there is a bias against more natural treatment options.
I often hear physicians telling their patients that there is not enough research to support even trying the options. While I agree there could be more research on all therapies done today (this includes many allopathic treatments as well, as only 12% of western therapies have adequate research), it is still worth trying them, as they MAY be beneficial.
Sally, with her debilitating arthritis, had accepted her path of suffering. Fortunately I had the opportunity to speak with her. I offered to treat her for four visits to see how she would respond to acupuncture. Through a four-day report of findings, I see how someone responds to treatment. In Sally’s case, she got great relief from her pain, more mobility in her joints and better quality sleep. She responded well to acupuncture.
From there we set up a treatment plan in which we used Chinese herbs and enzyme therapy to reduce inflammation naturally and break up fibrinogen adhesions. We also treated her as a whole person, not just a chronic pain patient or someone with fibromyalgia.
Sally is a success story. Two years later she is still pain free, only needing occasional tune-ups.
What’s best for the patient
A lot of times patients think they can’t talk with their medical doctor about their naturopathic doctors. They feel they are “cheating” on the medical doctor. When I hear this, I tell them that my goal is patient-centered care, and their MD’s goal should be the same. Patient-centered care is the best care on the planet, since it involves all health care models working for the patient to get the person the best outcome possible.
I have seen patients with chronic knee pain for 14 years finally try acupuncture, and with a short course, all of their pain was resolved. I have seen patients who suffered needlessly after motor vehicle accidents because all they were given were pain medications and muscle relaxants after their accident.
Twenty years later they come to our office saying, “You know, I’ve never been well since that car accident.” All too often this is the result of under-treatment, and masking of symptoms, without addressing the underlying dysfunction.
I recently saw Kate after about a year of her intensive treatment at the clinic. She remembered how she was when she arrived at our clinic and thanked me for the work we do. She was able to get off all of the drugs she was on. Her pain resolved. She exhibited none of the anxiety or other effects from the brain trauma she had when she first arrived. Her previous team of physicians had all but left her, but she had more healing to do.
Will we be able to help everyone? Of course not. I am a realist and don’t give false hope, but by not trying we are not helping anyone. I always say to patients that we MIGHT be able to help relieve their suffering, and that everyone responds differently to treatment. Everyone arrives at our office with their own genetic background, their own story of trauma.We treat individuals, not pathology.
What we offer with our style of treatment are providers who will not give up on their patients. I have a patient, Amy, for whom we haven’t been able to reach the big breakthrough. We have done several rounds of acupuncture, different pain reducing IV therapies, diet therapy, supplements, medications, manipulations, neurological relief technique and cranio-sacral therapy, to name just a few. She has been struggling from a low impact motor vehicle accident.
The IME called her a liar. She has been in and out of depression. We have been working on reframing her experience with her. Allowing her to have the pain, but also knowing that she can choose what she does with her situation.
For my western medicine counterparts, one of the frustrating things about
naturopaths is that we don’t have set protocols for conditions. I could have ten chronic pain patients in my office and could develop 12 different treatment plans to help resolve their issues.
Multiple treatment plans
The treatments I use include acupuncture, physical medicine such as manipulation and massage, and physiotherapy (use of interferential and ultrasound). Another options is therapeutic injections, which is discussed in more detail later in this article.
The hierarchies of treatments start with the least invasive. We begin with diet therapy (anti-inflammatory in nature), then move on to acupuncture and Chinese herbs, manipulation and massage (to work on nerve communication and regulation of the body, as well as lymphatic/blood flow), nutraceuticals such as turmeric (natural anti-inflammatory), enzymes to change the terrain and fibrous adhesions of inflammation, and essential fatty acids (such as omega-3’s).
All these treatments work on changing the inflammatory cascade. For pain treatment, we begin by working on the diet. That is where the nutrients that flow in the blood come from. If someone is missing the building blocks for their body to heal — whether it’s protein, complex carbohydrates, or essential fatty acids — it doesn’t matter what therapy we use for the individual, they won’t get better. For the first few years of my practice I didn’t address my patients’ diets. Because of that, my patients and I didn’t get the results we are getting today.
Nutrition is crucial to the body’s ability to heal itself. I have seen patients with chronic back pain, whom we adjusted week in and week out with pain returning. When we finally started to work on diet, they were holding their adjustments much longer to the point of total rehabilitation — without any back pain at all.
When addressing diet, I often hear “it’s too hard,” or “I don’t want my diet addressed.” I clearly remember when one of the first patients I saw, Jocelyn, told me she would not give up peanut butter, because it was her favorite food. She also had chronic headaches and back pain.
We did an elimination diet and her symptoms improved, actually went away. She had struggled with these symptoms for 20 years. She was at a party and there was a tray of peanut butter cookies. Of course she had one (well maybe two). When she next came to the clinic she announced she would not be eating peanut butter anymore because the symptoms she experienced were just not worth it!
Results equal motivation
Everyone has choices. I find that when patients remove their obstacles to health and begin to see results, they are very motivated to make changes. Our goal is not to have everyone eat like a monk in Sichuan province. We want to make sustainable and very doable treatment plans. Small steps are all it takes to rule diet out as the root of disease in the patient. Food is ultimately our best medicine.
For pain, Chinese medicine is another front line therapy. The therapies have been well researched, and it is easy to see if it’s beneficial for someone in pain — either they feel different with treatment or they don’t.
Acupuncture works on blood flow. The healing properties of the body travel in the blood. Oxygen, vitamins and nutrients flow into the cell as waste products, and carbon dioxide flows out. Acupuncture works by increasing or decreasing the blood flow to certain areas of body.
When the first steps in pain treatment don’t get results, we move onto trigger point injection therapy and prolotherapy. Trigger point injection therapy works by releasing chronically spasmed muscles.
Janet Travell described the process in her monumental book, The Trigger Point Manual, which she wrote in 1983. Trigger point injections work by getting the muscle spasm to release and relax, taking the spasm off the nerve and thus relieving the pain.
Prolotherapy treatment is useful for many different types of musculoskeletal pain, including arthritis, back pain, neck pain, fibromyalgia, sports injuries, unresolved whiplash injuries, carpal tunnel syndrome, chronic tendonitis, partially torn tendons, ligaments and cartilage, degenerated or herniated discs, TMJ and sciatica. Prolotherapy uses a dextrose (sugar water) solution, which is injected into the ligament or tendon where it attaches to the bone. This causes a localized inflammation in the weak areas, which then increases the blood supply and flow of nutrients, and stimulates the tissue to repair itself.
Working together for results
In my experience, the natural approach coupled with traditional pain management tends to give the best results for patients. While not always resolving the issue, this patient-centered care can help provide a practitioner who will look for and exhaust all options. Naturopathic doctors and Chinese medicine practitioners are caregivers who listen to the patient and use techniques and counseling that can help motivate the patient.