How do you treat pain without pills, procedures, and surgeries? Injections and oral steroids are more limited, and the nation is far too well aware of what too many opioids do. Even the most basic, function-oriented, hands-on therapies, such as physical therapy, are stuck in limbo. What happens to the millions of already-anxious, sick patients out there, stuck in the constant fear cycle of stress, disability, and unhealthy lifestyles, who are now told to stay home, not touch anything or anyone, and try to face alone the biggest human stressor of all: the fear of death. Be ready for a tsunami, not just of the sick and dying, but of the worsening chronic pain and mental health disorders out there, of which there was no scarcity in our practices.
There are a million examples of pain and suffering, but when does the treatment we are used to selecting (whether it be pills, procedures, manual therapies, or surgery) become part of “essential” healthcare? Maybe physical therapy, for example, is the “essential” healthcare tool which could prevent the frail from falling and the weak from becoming immobile, and gradually change patients’ views about themselves and their abilities. But was our routine prescription, imaging test, or procedure ever a matter of life or death in pain medicine? We were too comfortable with our tool kit, too confident and assured it would always be there for us forever, driving the way we practiced medicine. We don’t have this pandemic under control. And we never had chronic pain under control. What we always had was the health care industry’s push for more tests, more procedures, more pills, and the never ending chronic pain that fed it.
What tools are left to us outpatient physicians, now on the frontlines before the masses of confused, angry, depressed, and above all, anxious patients suffering out there?
The answer is still what has always empowered us as healers – our message. People come to see us, trust us, and (hopefully) try to listen to us, because we are supposed to have answers for them. We studied hard, learned so much, and swore oaths of goodwill. The way we connect with patients now, and the message we give them, is going to determine everything. As pain psychologist, C. Eccleston stated, “Beliefs about the cause, meaning, and consequence of pain are often at stake in any consultation. The pain doctor is a powerful co-creator of beliefs about pain, which can endure and drive disability behavior.” Whether we give honest and educated, compassionate and empowering messages of healing, or whether we tell them, “There is no treatment at this time,” will make or break our patients on the brink of despair.
We cannot forget the 2.3 million people with opioid use disorder, who will still face a higher death rate than others. I suspect suicides and mental breakdowns will occur more as people lose their livelihoods, comforts, identities, physical connections, and previous work societies. Due to the strange new world of social distancing, every social dynamic and every structure supporting modern society is undergoing a massive online transformation. It is a seismic shift that will take time to fathom. We are all now sensing the same human loss and despair felt by the survivors of hurricane Katrina, the 2019 Mississippi River floods, and the recent horrific fires of California and Australia. Those human disasters did not affect everyone personally the way this disaster is, in such a contagious, insidious, and ubiquitous way. COVID-19 is the greatest equalizer of all. It is the strongest message from our planet that we have ever had to face in our lifetime. We are learning, in so many ways, how deeply connected we are as a human race.
As a spine interventionalist, I had an early sense of moral unease, at times, deep in the pit of my stomach, that maybe it was wrong to keep offering redundant injections as a way to keep the business of pain care going, though they did not seem to help the chronic pain patients too much, who comprise the majority of my practice. But that’s what we were trained for and got paid to do, what we were supposed to do by the business model of healthcare. We will of course return to this model again when the pandemic is over, so I cannot be too dismissive or disparaging of our interventional arsenal against pain, which helps many daily. I know that our prodigious partner industries of biotechnology, diagnostic imaging, health business management, support teams, and on and on in healthcare will ensure that our procedures and elective surgeries for pain will never become obsolete. In fact, they too are only evolving and changing. We will all get through the transformation of hands-on medicine into telemedicine, eventually, and then come back to many of our old ways in the end. But I do think COVID-19 gives us the chance to change pain care delivery, the industry of health care, and our collective conscience about “what is essential medicine,” forever. We will have to rethink how we deliver health care, which is always on our minds, particularly with the looming presidential election. We need to think carefully how to educate and counsel our patients moving forward, and how to keep people well.
We can now start to individually dig more into the psychological and behavioral root causes of suffering, which we in the pain care industry must understand, by now, are not just the degenerative disc disease, arthritis, or soft tissue pathologies read off to us by patients after their umpteenth MRI and failed short-term, symptomatic treatments. I hope I will be strong enough to tell the opioid-demanding pain patient, now in a duel crisis of pandemic and opioid use disorder, that simply providing more opioids won’t truly heal the suffering underlying the pain and substance use, but I will still listen and provide comfort and more adaptive ideas to change the pain experience. I hope I may be able to explain to the elderly, suffering patient, with few close supports and limited understanding of current events, that there may not be a readily available physical therapist at this time to get her back on her feet, but we can still practice Tai chi and home exercises on a computer screen together to restore balance.
I may feel my stress response flaring when encountering that patient with an acutely inflamed disc, causing “10/10” severe lumbar radiculopathy, primed for a procedure I am more than capable of performing but am now unable to give. I may feel the unfairness of it all: the anger, the frustration, the helpless and hopeless negative emotions. These are likely to give me the same types of physical ailments owned by my patients on a chronic basis: headaches and neck pain (we all need screen ergonomics now!), more IBS, insomnia, cold symptoms, and palpitations. But then I must ask myself, does the person really need this injection right now – is it the only way to end the suffering? Is there a way I can encourage the acute pain patient to detach from physical discomfort, or else accept it, and continue to exercise despite the pain? Let the pain go? The mind is capable of this, with support and practice.
Buddha understood, thousands of years ago, that the root of suffering is Attachment. Attachments to physical comforts, behaviors, and our very thoughts constantly telling us how we feel and who we are – are going to be very difficult to let go. There will often be moments we wished we had our old treatments as pain doctors, our familiar, comfortable habits that let us be part of the well-oiled, vigorously churning machine of the medical industry. But let us be compassionate and patient with ourselves. Let us free our minds so we can help others.
We must learn to adapt during this Era of Internet Medicine. We must think glass half-full: There is a new opportunity to change the course of what it means to suffer from pain and how to treat it. To do this, first our computer skills need to adapt and become more completely integrated in every way – not only in the triaging, ordering, documenting, billing, and electronic messaging most of us had already – but now truly in our treatment delivery paradigm. What used to be one of the greatest “burn-out” parts of medicine, screen fatigue, is now our greatest asset and means of economic survival: The giant Telemedicine machine that is part of the rapidly adapting, transforming virtual world. The Internet is our main lifeline now, and health may depend on who has Access and stays connected and who does not. We need to help and support the older generations, the less tech-savvy, and of course those without resources among us to get access, learn, and adapt as well. We may then maximize on the fact that we can reach potentially anyone, anywhere, at a designated time, and from the comfort and security of home. Patients, on their computers or mobile phones, will also quickly experience the great potential benefits of this new health care delivery as well.
In terms of pain management, we can dig deeper into what it means to suffer, and talk with patients about the root of much of their pain: the anger, hopelessness, and fear. The fear of being alone and dying is now all too real. It is the truest fear of all, particularly without the comfort of human touch, which we needed the moment we left the womb. We are currently down to the bare bones of health care and wellness. This always includes a feeling of connection, safety, and self. As a believer in integrative pain care, my work will be to try to transform a once heavily procedure-driven practice into a more mind body educational practice. I will guide patients about how to live well, suffer less, and let go of some of the stress and fear which underlies most chronic, painful, disabling conditions. It is going to be slow – painfully slow — dependent upon how technology-adapted we really are, but maybe, just maybe, our planet has given us an undeniable, revelatory message: We have an opportunity for positive change.
Pain does matter, and it is the most basic reason for a medical visit. But now we can try to better understand it and how our patients feel about it by listening, educating, and engaging –without all the incessant testing, labeling, and procedures. The rise of Internet Medicineis finally taking its truest form, which is scary and new to us all, including me. But in a paradoxical way, once we master that obscuring interface of the computer screen, which used to limit our time and face-to-face communication with patients, we can remove the obstacle by being the screen itself – we will be the screens talking directly to our patients. We can host live educational platforms and group support sessions in addition to our regular office virtual visits. We may now spend more time talking with patients (and hopefully somehow even support our salaries by doing it!), and come to the truth that perhaps the real way to treat chronic pain is through working to change the mind, the most essential part of wellness.
The mind body connection is often crushed in the daily grind of external cures and consumer health care culture. With a more empowering, integrative pain management mindset, this time may be an opportunity to chip away at the real suffering behind chronic pain and the diseases of the mind that feed it. Now, we need the mind body connection, compassion, and the empowering message of self-care more than ever. Let us steer our patients towards hope and healing through mindful practices, real lifestyle change, and a little positive soul searching. Our society is out of balance. This is a turning point for the world, and a turning point for our own identities. I hope we will let the more noble parts of humanity shine through and prevail. I hope the altruistic, kind, and innovative parts of us may guide us in our counsel. Let us depend on what has always healed us throughout time: the mind and spirit.