In the United States, chronic pain is often poorly treated at an exceedingly high cost. The use of the biomedical model to manage pain is frequently ineffective, and evidence suggests that the biopsychosocial (BPS) model is a better choice. A problem with the BPS model is that it has not been operationalized in terms of patient behavior. This commentary addresses that issue by suggesting that people with chronic pain and illness participate daily in four self-management health behaviors: socialize, work, exercise, and meditation, and discusses evidence that supports these recommendations. These self-management behaviors may decrease pain and thus reduce the need for pain medications and other medical interventions. Additional topics include patient adherence and health coaching.
Collen Method, Sacramento, CA The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this letter.
At the end of 2013, the Medical Licensing Board of Indiana adopted emergency rules that require physicians to have a segment of their patients sign a treatment agreement and submit to drug testing.1 This applies only to nonterminal patients who, for at least 3 months, have been prescribed more than 60 opioidcontaining pills per month or a morphine equivalent dose of more than 15 mg per day.1 On January 8, 2014, the American Civil Liberties Union (ACLU) filed a lawsuit that “. . . seeks a court order prohibiting the Medical Licensing Board from requiring the drug testing when that testing is not medically indicated and from requiring that patients sign a treatment agreement consenting to the testing.”2 The ACLU contends that mandatory drug testing violates the Fourth Amendment, which prohibits unreasonable searches and seizures.2 When is drug testing medically indicated? Considering that there remains insufficient evidence of efficacy for both pain contracts and drug testing,3 their use should be questioned in any application. Regardless, numerous professional pain associations recommend or suggest utilizing these adherence monitoring tools4−6 and there is little opposition. I oppose their use and have written about contracts and drug testing in the literature.7−10 I consider treatment agreements to be unconscionable adhesion contracts and drug tests as suspicionless and warrantless searches. I believe their use increases costs and may harm the patient/physician relationship, resulting in negative health outcomes. Now that the ACLU is suing to stop the use of agreements and drug testing, it may be time for pain managers to begin a discussion and seek alternatives that are less paternalistic and more patient centered.
Human animals have evolved with the primary missions of survival and reproduction and these natural drives may impact behavior whether humans are aware of them or not. The author offers evidence in support of the idea that injury and resulting acute or chronic pain may trigger the unconscious human primate brain to believe there is a threat to survival. This perceived threat may be exacerbated or mitigated by the pain manager, both of which may impact health outcomes in a negative or positive way, respectively. The commentary argues the patient-health care provider relationship is of paramount importance for those with chronic pain and illness and should be nurtured for the best possible outcomes.
Neuropathic pain affects between 5% and 10% of the US population and can be refractory to treatment. Opioids may be recommended as a second-line pharmacotherapy but have risks including overdose and death. Cannabis has been shown to be effective for treating nerve pain without the risk of fatal poisoning. The author suggests that physicians who treat neuropathic pain with opioids should evaluate their patients for a trial of cannabis and prescribe it when appropriate prior to using opioids. This harm reduction strategy may reduce the morbidity and mortality rates associated with prescription pain medications.
Green represents life and growth while depression in black smothers it. Depression often accompanies chronic pain and may worsen suffering and increase health care costs. Physicians should consistently evaluate their patients’ mental health and treat comorbid depression. The art is mixed media measuring 40 inches long × 30 inches wide. It will soon appear on PainExhibit.com. PainExhibit.com is an online exhibit from artists with chronic pain and was created by Journal Editorial Board member Mark Collen. The full exhibit can be viewed at: PainExhibit. com.
Random drug testing of people being treated for chronic pain has become more common. Physicians may drug test patients on opioid therapy as a result of concerns over prosecution, drug misuse, addiction, and overdose. However, profit motive has remained unexplored. This article suggests profits also drive physician drug-testing behavior and evidence is offered, including an exploration of Medicare reimbursement incentives and kickbacks for drug testing.
As the author of the paper (1) that helped to prompt the editorial entitled “Urine Drug Screens: A Double Edged Sword,” which appeared in this journal last June (2), I am pleased that the journal's...
It is common for physicians who prescribe opioids for chronic pain to drug test their patients. This practice may soon be mandated by the State of Washington as a result of passage of their new law ESHB 2876. Random drug testing of people simply because they seek treatment for chronic pain arguably constitutes a suspicionless and warrantless search that violates both the Fourth and Fourteenth Amendments. Issues discussed include consent, circumstantial coercion, and “special needs” searches.
Controlled substance management agreements (contracts) are widely used by pain specialists in the United States, but what do they contain? This survey analysis answers that question by taking a thorough look at 41 controlled substance medication management agreements from physicians in private practice.
The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment.
To the Editor: I recently developed an educational brochure entitled, "So You’ve Got Chronic Pain . . . What’s Next?" Steven Feinberg, MD, the brochure’s editor, is an adjunct professor at Stanford University and a physiatrist in private practice. The brochure is designed for patients new to chronic pain, but everyone who interacts with persons who have chronic pain may benefit from it. The brochure provides tested and true strategies for living a high quality life with pain and helps persons with pain to manage their expectations. PAIN Exhibit art is used throughout the brochure to elucidate important points. The brochure was developed over a three-year period and markettested at 25 clinics nationwide. Feedback from both clinicians and patients was integral in its creation. The brochure is reproduced below. Complimentary brochures are available by sending a request to Mark Collen at Mark@PainExhibit.com.
This commentary suggests that pain, insomnia, and depression might be considered as a symptom cluster in chronic nonmalignant pain and that it might be called Pain Insomnia Depression Syndrome, or PIDS. Evidence is provided in support of the designation. The author suggests acceptance of PIDS would increase awareness of the pain comorbidities insomnia and depression, and this might lead to improved symptom management and better clinical outcomes.
A commentary on the problem of tolerance to opioids is presented from the perspective of a person with chronic nonmalignant pain. The writer challenges the position of many clinicians and professional societies that tolerance to opioid analgesia usually is not a barrier to effective pain management. Implications for clinicians are presented.
