Introduction

My passion for helping people take control of their pain has led me in a variety of directions—all with the common destination of helping those in pain. I am a licensed clinical psychologist and president of Pain Assessment Resources, a company that assists health care professionals who work with people who have chronic pain. I have extensive training—and, more importantly, a great deal of experience—in the application of psychological principles to problems in medicine.

Early in my professional career, I was extremely fortunate to be trained and mentored by Dr. Richard Kroening, former director of the Pain Management Program at the University of California, Los Angeles. He was the first to show me the therapeutic value of a team approach in working with people suffering from chronic pain and the first to introduce the importance of understanding pain as a biopsychosocial experience.

Since completing my Ph.D. in 1990 at the University of Nevada, I have worked exclusively with people suffering from chronic medical and pain conditions. While I was director of the behavioral medicine department for a pain management program in Nevada, the program achieved the highest level of accreditation from the Commission on Accreditation of Rehabilitation Facilities. In addition to my clinical, administrative, and legal experience working with chronic pain sufferers, I have conducted, presented, and published original scientific research in the area of chronic pain at conferences throughout the world.

All of my experience has been poured into the development of a pain assessment tool, the Behavioral Assessment of Pain Questionnaire, which is used in pain management programs worldwide. The BAP has become the cornerstone of my clinical work, and it will help guide you along your pain management journey.

Why I Wrote This Book

One of the greatest needs in the field of chronic pain management is teaching people how to manage their pain using a self-directed, self-help approach. The Chronic Pain Care Workbook offers just that, allowing you to answer specific questions about your unique pain experience. These questions address everything from counterproductive ideas and beliefs about pain to depression, anger, and anxiety; from sleep disturbance to activity avoidance. Answering all these questions will lead you to a personalized pain management profile that outlines your personal strengths in coping with pain and gives you specific treatment recommendations.

The Chronic Pain Care Workbook provides a simple program for you to regain control of your life by taking control of your pain. But unlike too many self-help books on pain management, this book is not about quick fixes, fads, or platitudes. This workbook was developed from my two decades of experience in pain management, and the recommended treatments are based on the latest clinical research in the field of pain management. The book incorporates real-world data and scientific expertise to offer you a powerful new lease on life.

Before we get started, take a moment to think about your goals. How do you want to be different? What do you want to change? Here is a list of goals I had in mind when I wrote the book. Let’s see if we are a good match.

The Chronic Pain Care Workbook will help you:

·        learn more about what influences your pain

·        improve the quality of your life

·        get back in the driver’s seat of life, not the backseat

·        sleep better and wake feeling more refreshed and alive

·        improve your relationships with family, friends, and coworkers

·        be in a better mood

·        return to productive work and meaningful play

·        get real about the negative impact of your pain

·        understand the relationship between stress, psychological factors, and physical symptoms

·        increase your ability to exercise

·        increase your physical activity

·        increase your ability to care for yourself

·        develop basic relaxation skills to improve pain management

·        reduce how often you complain about pain

·        learn thinking skills to deal with pain

·        learn to divert your attention away from pain

·        decrease the amount of pity and attention you get from family and friends

·        improve sexual functioning

·        find ways to meet your emotional needs

·        learn to be more assertive

·        feel less helpless

·        learn to recognize improvements and accomplishments

·        recognize the impact that your behavior has on others

·        become more active and less dependent on others

In the end, the number one reason I wrote this book is to encourage positive change. While I can’t simulate one-on-one care, I hope to make this a personal journey toward a better and more active life. A self-management strategy that monitors improvement (through exercises, graphs, and writing) is the most efficient and beneficial program I have found, one that lends itself quite well to the workbook format.

How to Use This Book

Not all chronic pain is curable, but all chronic pain is manageable. The Chronic Pain Care Workbook will help you decrease the effect of pain on your day-to-day life. Throughout this book, I will act as your partner and validating collaborator. But I’m not the expert here. You are the expert. Nobody knows your pain like you do. I’ll share what I have learned from my education and training and from people who suffer from chronic pain. If I can help you look at your pain differently, develop some new tools, and perhaps sharpen some existing ones, I will have accomplished my goal. But only you can choose what to build with those tools.

Working through this book is a journey of discovery. This book seeks to help you find out which factors do and do not work in the management of your pain. In the end, you will have a unique self-management plan unlike anyone else’s.

Vince Lombardi, Hall of Fame football coach for the Green Bay Packers, once said that the only place you find success before work is in the dictionary. Pain management takes work, so you need to be up for the challenge. Self-management is an active process, so you can’t sit on the sidelines if you want to feel better. No one else is going to take charge of managing your pain, because no one else is experiencing what you are experiencing. But while you may be alone in your experience of your pain, you are not alone in your quest for a better quality of life. We will work together through this workbook to help you take charge of your experience, your pain, your life.

The self-management approach is powerful for two simple reasons:

·        You are the expert. You know the nuances and evolution of your pain. You can tell subtle changes, for better or worse.

·        Participating actively in changing your pain experience helps you attribute success to your own competence and not to external authority. It makes you more motivated. Rather than relying on outside forces to improve your lot, you can take charge and know you are capable of managing your own experience.

While this book will explore a variety of factors that can increase your pain (such as physical tissue damage, inactivity, thoughts, poor sleep, mood problems, the way you do things, the reactions of others, and your responses to pain), no one thing is likely to be causing all of your pain problems. Understanding your pain is like doing a jigsaw puzzle. First you look at all the pieces to make sure you’re not missing any. Then you start experimenting with how the pieces fit together. Finally, you can see the big picture. You may not have all the pieces today, since modern medicine can bring wonderful advances, but by starting the process you can begin to see what emerges.

The big picture of pain management is made up of information and skills you can find in this book. With these tools, you can build a new, better life.

How This Book Is Organized

You’ll begin your journey of taking control of your pain by learning to understand your pain, including where it comes from and how you react. In part 1, I cover the basics of pain.

Part 2 takes a close look at how you have dealt with chronic pain and its impact on your life. You’ll assess how the biological, psychological, and social domains influence your pain, and you’ll learn tools for better managing your pain experience. Your response to the questions will reveal your personal strengths for coping with pain and also those areas that may need more attention.

While there are a variety of programs to help you manage your pain, changing how you behave and changing how you think are at the heart of the most effective. Research shows that the most effective pain management approaches share the following characteristics:

·        increasing your physical activity through graduated movement and exercise

·        altering the ways you do things, while avoiding extremes

·        learning fatigue management techniques (including good sleep habits)

·        challenging unproductive thoughts and ideas about pain

·        learning assertiveness skills

·        learning relaxation skills

All of these skills will be discussed or taught in this book.

Part 3 focuses on handling setbacks and maintaining your treatment gains.

Part 4 includes your Pain Scorecard. As you complete the exercises in each chapter, you will transfer your results to the Pain Scorecard so that you can see the big picture. The Pain Scorecard can tell you what specific areas you need to work on and what areas you are handling well. You can then focus on the areas of concern and spend your energy where it will do the most good.

The Pain Scorecard is also set up to show any changes you have made. By answering the questions once more after you have started to make changes in your life, you will be able to see your progress. The differences between your “before” and “after” scores will show you the distance you have come.

The Pain Scorecard can also be a helpful document to share with physicians, psychologists, physical therapists, family members—anyone who is part of your pain management team. This way you can all start from the same place, and all work toward the same goal, with full knowledge of your particular pain management strengths and struggles.

Resources for pain management—such as how to find a therapist or physician, obtain answers to medical questions, and locate support groups—are included at the end of the book.

Self-Monitoring Is a Key to Pain Relief and Management

As you work through this book, I hope that you will see real-life evidence that the self-management approach is improving your quality of life. This evidence will make it easier for you to continue. Managing pain can be hard work, and you are more likely to persevere if you remind yourself why you are learning and practicing new skills. Keep your goals (which you’ll list in chapter 4) handy—put a copy in your wallet, use it as a bookmark, tack it up on the fridge. While you don’t need to dwell on the negatives of chronic pain, do keep in mind that your pain interferes with a variety of factors in your life: sleep, participation in valued activities, mood. Reviewing these negative effects—along with the benefits of self-management—helps you stay motivated.

Adding consequences to your goals will only strengthen your resolve. In many ways, we humans are simple creatures. We respond well to rewards. As you go through your self-management program, remember to build rewards into your system. For example, allow yourself to relax after exercise, treat yourself to a nice warm bath at the end of a hard day, and pat yourself on the back when you accomplish even the smallest of gains. This will help you maintain your self-management practice.

Creating Your Unique Pain Profile

If chronic pain is like a puzzle, it often feels as if many of the pieces are missing. We are going to start by finding some of the pieces and getting them in place, just as you might group all the straight-edged pieces in a jigsaw puzzle before putting them together. Throughout this book, you will answer questions that will help define pieces of that puzzle. These very same questions have been asked of more than a thousand other people suffering from chronic pain. Their answers have given a normal or typical range for responses, and they serve as a baseline by which to judge your experience.

Chronic pain, however, is not a constant, consistent experience. Fluctuations, variations, and deviations are all part of the picture. Your pain may be worse on some days and better on others. At various times (of the day, night, or week), you may answer questions differently, and that is okay. When you respond to the questions with your average or typical experience, you will get the most accurate pieces to your particular puzzle.

Your responses to the questions will help you measure your progress as you continue with this program. Yes, it will take time—just as it takes time to create a productive garden or a fine wine—but it will be time well spent. These questions were developed through years of study and analysis in order to help you discover your unique pain profile and help you find your optimal approach to taking control of your pain and thereby your life.

Getting Further Help

While you can use the advice and strategies offered in this book on your own, The Chronic Pain Care Workbook does not ignore the benefits offered by medical and psychological professionals. To find professionals in your area with expertise in pain management, go to my Web site (www.PainCareWorkbook.com) or see “Resources” at the end of this book.

What Is Chronic Pain?

Chances are, if you have picked up this book, you are familiar with pain. You have probably been struggling with pain for months or even years. Normally, pain is temporary. We can be thankful for that. But if you have been experiencing pain for more than three months, you have chronic pain.

The common denominator for people who experience chronic pain is suffering. Your quality of life and ability to function has likely been dramatically affected by your pain. You have probably seen a number of doctors and therapists who have tried their best to solve your pain problem. They have likely administered numerous medications, tests, and procedures, but your suffering continues. You may even feel that the medical system has failed you.

I want to present to you what I have learned over the past twenty-three years of working in the field of pain management as a behavioral psychologist. I hope that after reading The Chronic Pain Care Workbook, you will be armed with new ideas, information, and strategies to reduce your suffering and return to a higher level of physical functioning. I hope you feel better.

Chronic Pain Care Basics

Put simply, chronic pain is any pain that lasts more than three months. If you are suffering from chronic pain, you are not alone. A variety of studies have looked at the effects of pain on individuals and society. Key among these is a 1999 study by Elliott and colleagues. Some of their findings include:

·        Over 50 million people in the United States suffer from chronic pain, yet most medical students don’t take a single course focused on treating pain.

·        At least 45 percent of Americans will seek care or treatment for persistent pain at some point in their lives.

·        A recent poll showed three out of four people surveyed either suffered from pain themselves or had a close family member or friend who was suffering.

·        Pain is the most common reason Americans seek medical care and is a leading cause of disability in the United States.

·        Chronic pain takes a greater toll on the United States economy in health insurance claims than any other chronic condition, including heart disease, hypertension, and diabetes.

·        Pain is the leading cause of lost productivity and costs employers over $80 billion a year.

·        As the baby boomers continue to age, the problem will only get worse.

There is a huge variety of chronic pain problems. The most common types of chronic pain I see in my practice are low back pain, fibromyalgia, myofascial pain, complex regional pain syndrome, neuropathic pain, chronic headaches (including tension, migraine, and cluster headaches), arthritis, and temporomandibular disorders.

If you have persistent pain, you undoubtedly want to feel better. You want to break free from the hold that pain has on your life. Breaking free from the control pain wields over you is even more important than breaking free of the pain itself. You can live with pain, but only if you can modify its impact upon your life. This book is all about regaining your life. If you realize that you have reached an impasse in effectively coping with pain, and you want to find better ways to manage it, this book is written especially for you.

Acute and Chronic Pain

A key element in pain management is the distinction between acute and chronic pain. Acute pain lasts from the moment of injury to about twelve weeks. Chronic pain lasts longer than twelve weeks. Acute pain can be mild to severe, similar to chronic pain, but acute pain conditions are easily diagnosable, meaning the source of the pain can be discovered. This is not typically the case with chronic pain. Each type of pain needs to be treated differently. Problems occur when health care providers treat chronic pain as if it were an acute pain problem. In fact, mistreatment can inadvertently perpetuate the pain.

Acute pain can be useful as a warning signal. It is an alarm system that alerts the body to respond quickly to threats. People who are born with congenital analgesia, a condition in which they feel no pain, actually suffer shorter life spans. They can’t feel when they have broken bones or acquired infections. They don’t have the warning systems that alert most people to seek medical help.

Resting and protecting a painful area following an acute injury is adaptive; it eventually increases your ability to live your life, in this case by allowing your body to heal. However, reliance on rest in the case of chronic pain is often maladaptive; it eventually decreases your ability to live your life. Acute pain goes away, so the rest period has an end in sight. When the pain doesn’t go away, you need to find a way to live with it. So do the people around you. The social component of chronic pain can be huge.

Causes and Effects of Chronic Pain

When you consider the causes of chronic pain, you probably think about the beginning, an injury, trauma, or accident—the biological factors. And biological factors are definitely important. Some types of pain are neuropathic, that is, caused by injury or damage to nerve tissue or by malfunctioning nerve signals. This is typically felt as burning, shooting, and stabbing pain; examples include sciatica or a pinched nerve. Other types of pain are nociceptive, or caused by inflammation, disease, or injury to certain tissues such as muscles, tendons, or ligaments. Knowing the difference is important because each type of pain can react to different treatments. But it’s also important to examine the emotional, social, and psychological aftershocks of chronic pain—the impact on not only the person in pain, but also the people around that person. Family, friends, and coworkers may all be affected by your chronic pain.

Research has shown that pain can be modified to reduce the associated misery. This is the good news. You have the power to make significant changes in your experience of chronic pain. In this book, you will look beyond the physical problems that have led up to your life with chronic pain; you will consider all the parts of your life that have been affected by your chronic pain. We are going to examine those factors that are contributing to, maintaining, and exacerbating your pain experience. We will also look at different strategies to put you back in the driver’s seat of your life. For the millions of people suffering from chronic pain, a new focus on self-management of pain is long overdue.

Exercise 1.1: Do You Have Chronic Pain?

Answer the following questions to see if your pain is truly chronic.

Have you had pain for more than three months?                                                 yes       no

Has your pain interfered with your daily life?                                                      yes       no

Is your quality of life unacceptable to you due to your pain?                               yes       no

Are you unable to be active and function at an acceptable level due to your pain?           yes       no

If you answered yes to these questions, chronic pain is a real problem in your life, and this book can help.

Pain Myths and Fallacies

The myths involved with chronic pain could fill a book all on their own. Partners for Understanding Pain, a consortium of more than fifty organizations that have an interest in pain and its effects, commissioned a telephone survey of 1,000 adult Americans which revealed that many held beliefs contrary to established facts about pain and pain management (American Chronic Pain Association 2002). Although pain is the primary cause of disability in the United States, almost two-thirds of those surveyed thought disability claims were caused by other medical conditions, not pain. Even though most physicians have very little training in pain management, the vast majority of people surveyed believed strongly that their primary care physician could effectively diagnose and treat any pain problem they encountered. Although 80 percent of people who have chronic pain are between twenty-four and sixty-four, most of those surveyed thought the typical chronic pain patient was sixty-five or older. And even though most pain medications rarely cause addiction, over three-quarters of the respondents expressed concern about addiction from prescribed pain medications.

Every day I hear people’s ideas and beliefs about living with pain. Some people tell me at the beginning of my interview that they don’t know why they are seeing a psychologist for their pain. They have real pain, and they just need to find the right doctor or combination of treatments. But there are a few common ideas and beliefs about pain that are simply wrong. Here are my top four.

Rest is best.  Rest is best—but for acute pain, not chronic pain. With acute pain, such as pain caused by a pulled muscle, rest is what allows the injury to heal. But rest is definitely not best for chronic pain.

Rest is best is a belief people build from their real experiences dealing with acute injuries and pain. But if your pain is going to be with you for years, maybe the rest of your life, are you really prepared to spend most of your time on the couch? When it comes to chronic pain, feeling discomfort with exertion is not a reliable sign that you should stop all activity and movement. Being active can speed recovery. Unless your activity is excessive, your discomfort may have more to do with reduced muscle flexibility, strength, and endurance than with your original injury or source of pain.

In the case of chronic pain, rest can become atrophy (wasting away of the muscles). But that doesn’t mean you should never rest. The key is balance. Contingent rest—resting after motion—is fine. Try looking at rest as a reward for doing good work, not a punishment for getting hurt or ill.

No pain, no gain.  This is the old football coach approach to life. It’s right up there with Walk it off. You tell yourself (or someone tells you) to be tough, to work through the pain, to push yourself. But where you often end up pushing yourself is into a pain flare-up.

No pain, no gain is the opposite of Rest is best, but it can be just as bad for you. In some cases, there is absolutely nothing to be gained from pain. Let me give you an example from my own life. To put it mildly, I don’t like to go to the dentist, let alone get a shot from the dentist. I don’t like needles. So you can imagine how happy I was to hear I needed a dental procedure that usually involves several shots. I decided I could muscle through without novocaine. Bad idea. The dentist was uptight because he could see he was hurting me. And as he worked, the vibrations reverberated against my nerves. They kept reverberating for five days. It was a very long five days.

Several years later, I needed to have the same procedure on another tooth. This time I chose the novocaine. I still didn’t like getting needles stuck in my mouth, but I was happy to not feel the procedure. And the next day, I was fine. I gained plenty by choosing the no-pain option.

You must have a pain-prone personality. There is no such thing as a pain-prone personality, an innate propensity to have chronic illness and pain. Researchers have tried for years to find evidence of such a personality but have always come up short. Some people may view the world in ways that cause them more suffering, but that’s not the same as being born with a personality that attracts chronic pain. Part 2 of this book, particularly chapter 8, will help you discover what thoughts, ideas, and behaviors you may be engaging in that are exacerbating and even maintaining your pain problem.

It’s all in your head.  Your pain is all in your head in that the brain is the central processing unit of your pain experience. But the Cartesian model of pain (that the degree of pain should be directly tied to the degree of injury) is as outdated as the idea of a flat earth. Pain is much more complicated than René Descartes thought. (See chapter 2 for more about the different models of pain.) Just because a physician can’t find a cause for your pain does not mean your pain is imagined. And even a physician who can find a cause does not know your pain. All the X-rays, MRIs, and blood tests in the world can’t tell a physician what you feel. Important as it is, a diagnosis is only one piece of a complex puzzle.

The fact that your pain changes also does not mean that your pain is all in your head. If you start getting better without medication or treatment by a physician, that does not mean the pain wasn’t real. It means something you are doing is working. Understanding what you did to cause the improvement may be more useful than getting a diagnosis. A diagnosis is very important, but it is not critical to improving your pain experience.

To Sum Up

The basics of chronic pain are not difficult to understand. But the fact that they are relatively simple does not mean they are unimportant. Quite the contrary. After reading this chapter, you should have a better idea of what constitutes chronic pain, how it differs from acute pain (and why that distinction is important), some of the causes of chronic pain, why self-management is important to your quality of life, and some of the myths and fallacies that can get in the way.

Chapter 2 will continue down this road of education as you learn about various models for understanding chronic pain and take a more comprehensive look at your particular pain.