Five Myths and Five Insights about Chronic Pain

By Dr. Mitchell A. Cohn

1. In “acute” pain (caused by a recent injury), the pain signals tissue damage. In ‘chronic’ pain (pain which has lasted after the tissue has healed) the pain is a sort of “ghost”. It no longer indicates ongoing injury.
   1. Most doctors are taught that this is true. Because of this belief, they keep looking to the brain and spinal cord for ways to stop the “pain signal”.
   2. Truth: In the vast majority of cases, although the tissue APPEARS to have healed, residual tissue injury, inflammation, tension, deformation and disrupted nerve function, blood flow and lymph flow – not visible to most technological testing – still persists. Therefore, in the vast majority of such cases, chronic pain STILL signals ongoing injury.

2. All doctors understand of chronic pain and how to treat it.
   1. Just … NO. Virtually all doctors are schooled in the treatment of acute injury and pain.
   2. Most doctors, however, have little to no training in the finer science and art of diagnosis or treatment of persistent pain .The majority turn to narcotics when NSAIDS (aspirin, ibuprofen, naproxen, etc.) fail to control the pain.
   3. This is a significant contributor to the so-called “Opioid Epidemic”.

3. One of the most common causes of chronic back and neck pain is arthritis. As a result, if spinal arthritis is seen on X-ray or MRI in a patient with chronic, unremitting or recurring low back pain or neck pain, and that pain is non-responsive to medications and steroid injections, the next and most effective – and usually definitive – step is surgery to deal with the arthritis.
   1. First, spinal arthritis, though present in most adults, is actually a relatively RARE cause of chronic pain. The reason I see many “arthritis patients” is because they’ve already had their arthritis treated with oral pain medicines, steroid injections, and even surgery … but the pain persists.
   2. The primary problem is that spinal arthritis is actually often a very painless or even pain-FREE condition. It may result in lack of mobility of the spine, but often has no pain-causing effect.
   3. As seen from (1) and (2), above, neck and low back pain “associated with arthritis” often benefit little, if at all, from medication, steroid injections, or surgeries such as laminectomies and fusion.
   4. The reason I put pain “associated with arthritis” in quotations is that arthritis is often seen in regions of pain. That is an “association” better thought of as a “coincidence”. Since most adults have varying degrees of arthritis yet have no symptoms, the presents of arthritis at or near an area of the neck or back spine does NOT imply the arthritis is the cause of the pain.  In scientific terms, the presence of two entities – pain and arthritis – in the same place at the same time implies “correlation” – not causation.
   5. There are many other conditions in and around the spine that are much more likely to be the direct or indirect cause of low back or neck pain than the generic term “arthritis”. Treating these more subtle but less easily visible causes of pain, especially if the cause is precisely determined through history and CAREFUL hands-on PHYSICAL EXAMINATION, is far more likely to result in removal of pain than the standard but haphazard treatment modern medical models and protocols offer.
   6. In other words, arthritis does NOT equal pain! There are many other causes of pain in these regions (tendon or ligament injury, inflamed nerves, dysfunctional vertebral sections, and more). The problem is that most doctors, even pain management specialists, don’t know how to separate out the various causes and determine that the arthritis they can see is just a coincidence and not the cause of the pain.

4. Pain management specialists have very specific protocols they use to both determine the cause of chronic pain and other specific protocols to follow which allow for a stepwise approach to ensure safe, adequate pain relief.
   1. Uh, NO. They may have protocols, but they vary considerably from hospital to hospital and practice to practice. If a surgeon sees you first, it’s likely to be deemed a surgical problem. If an anesthesiology-trained pain specialist sees you first, it’s likely to be considered a medicinally-treatable or injection-treatable problem. If you start at a “multidisciplinary pain clinic” the problem is likely to be deemed “multifactorial” and will be treated with multiple modalities from physical therapy, chiropractic, and acupuncture to medicines, to injections, psychiatry and psychology, “pain school”, and ultimately, may be treated with surgery.
   2. Bluntly, to these doctors, it’s very frequently just guesswork.

5. The so-called “opioid epidemic” or “opioid crisis” is the result of patients abusing properly prescribed pain medications. Some of them get a “high” from their medications and, as such, have an “addictive” personality. As a result, when these medications are decreased or withdrawn, the patients will seek illegal drugs like “street fentanyl” or heroin’ to keep feeling good and getting high.

1. 1. In any group, there will always be those who have a genetic or psychological predisposition to mind-altering drugs from heroin, to opiates, to alcohol. Once these. People have experienced the‘high or pleasurable experiences they associate with use of these chemicals (or others) their addictive and often psychologically escapist-prone personalities will seek further highs and escapism from everyday pain.
2. Truth:
   1. In actuality, a patient who receives a proper amount of pain medication during a critical time in pain development does NOT tend to develop a psychological high. Most of the effect of a narcotic in a patient with appropriately severe pain is actually pain relief and a CLEARER, not clouded mind These people can function safely at their jobs and pursue activities of daily living with little problem.
3. Truth behind the truth:
   1. Most primary care doctors, scared by the possible effects of opioid addiction, poor training, and threats from the Federal Government (DEA – Drug Enforcement Agency) tend to prescribe too little medication for moderate to severe pain. In fact, to stay away from narcotics, they often prescribe NSAIDS (Non-Steroidal Anti-Inflammatory Drugs) which are excellent at reducing pain in many cases Unfortunately, most physicians don’t realize the NSAIDs, far from being innocuous, actually reduce the pain at the expense of healing. Narcotics don’t interfere with tissue repair, but NSAIDs do.  This latter approach actually LEADS to DEVELOPMENT of CHRONIC PAIN!
   2. Other doctors, poorly trained in the use of narcotics for acute and chronic pain relief, make multiple errors in choosing the appropriate narcotic based on its strength and duration of action … and proceed to either underprescribe for pain relief or over prescribe.
      1. Under-prescription – meaning prescribing a pain reliever which is too weak to provide substantial relief of pain or prescribing for too short a period – leads to “pseudo drug-seeking behavior”. his behavior, asking for more pain medications, leads doctors to actually cut the patient off from pain medications altogether, or to try unnecessary different types of medications to replace the ones which had been more or less working.
      2. Over-prescription of opioid pain relievers – the big scare foisted on our society, recently – is now being blamed for over-availability of opioids, getting high from prescription drugs, drug dependency, and seeking of illegal drugs.
   3. The answer:
      1. Understand that doctors need better training in the prescription of pain medications
      2. Under-prescription of drugs is more dangerous than over-prescription. People who feel failed by the system have a higher propensity to seek alternatives such as illegal and dangerous versions of pain relievers like fentanyl and heroin – because they WORK. Unfortunately, the actual medicine content of whatever is purchased off the street and its composition have no regulatory control and frequently result in death.
         1. A side point: more people who fail to receive adequate treatment for chronic pain are not only prone to depression, but to death by suicide than those who are properly treated.

• Over-prescription doesn’t usually mean the number of pills prescribed is too many. It means the strength of the opioid is more than is necessary to control the patient’s pain. The EXCESS – the amount of drug in a person’s system that isn’t needed for pain control can lead to a pleasurable high that becomes addicting. Hence drug-seeking behavior will often follow.

1. If doctors understood the causes of pain, how to diagnose them, and how to treat them with minimal to no medications, the above problems could be avoided.
2. Final work: physician education is the answer. Legally restricting a well-trained physician from using his/her proper judgment by legislation is foolish, burdensome, and NEVER in the patients’ best interest.

Five Insights about Chronic Pain

Let’s keep these simple:

1. What your doctors don’t know WILL ultimately hurt you.

2. If you feel pain, it is NEVER “ALL IN YOUR HEAD”. If you are told that or are led to believe that, it is a reflection of the physician’s inability to diagnose the cause(s) of your pain. You’re not crazy.

3. Corporate interests and government fear (in the grip of corporate interests) have surreptitiously taken control of medical education to the detriment of chronic pain sufferers.
   1. It’s easier to shape the vulnerable mind of a learning medical student to believe that high-tech imaging, dangerous surgeries, and medications for every condition from mild to deadly are more valuable than the time-honored and well-proven disciplines of deep history-taking through precise questioning, LISTENING to your patient without preconceptions, thorough hands-on physical examination, and development of a real, human, humane relationship and bond between a doctor and patient.

4. REAL Diagnosis of the cause(s) of chronic pain – time that must be spent with a highly skilled physician – cannot be done in a 5-12 minute visit. A thorough history alone takes more time than that. These short visits are forced by corporate interests such as insurance companies that limit the income of doctors by limiting what the companies will pay for patient services. This, in turn, forces a dependence by the doctor on technological tests which will often miss crucial details.

5. If you have litigation over chronic pain issues, there is NO SUCH THING AS AN ‘IME’ (independent medical examination). The IME doctor is always hired by the insurance company. His/her job is to find nothing wrong with you so the company is off the hook. Counter this by never going into such a visit without an advocate – either a nurse well familiar with all of the above – or at least a medically knowledgeable friend or family member, and a video or tape recorder. If the doctor refuses to be videoed or taped … LEAVE.

6. The average chiropractor, while adding a dimension to your diagnosis and treatment that may otherwise be missing, is still unable to see the entire picture. While chiropractors often provide great comfort, the biggest complaint I get is that the treatments don’t last long, and virtually never result in permanent cure. There are simply issues for which chiropractors have no solution, despite claims to the contrary. Treatment often becomes life-long – and that is simply not necessary for most patients with chronic pain.

7. The cause of chronic pain may be so subtle that only someone with very specialized knowledge – different from and beyond that of the current average pain specialist (usually with anesthesia training), orthopedic surgeon, neurologist, physical therapist, or even chiropractor – can find the truth. Seek out these doctors if you ever wish to resume a normal, pain-free life without dependence on continuous treatment.

Dr. Mitchell A. Cohn, America’s Pain Detective, is a doctor who suffered chronic back pain for years. He has been an Osteopathic Doctor for several decades and has helped his patients move from managing their pain to curing it altogether.

Dr. Cohn joined the Born Preventive Health Clinic in April, 2012. He received his undergraduate degree from the University of Michigan, Ann Arbor in 1981. In 1986, he received his Doctor of Osteopathic Medicine degree from the University of Osteopathic Medicine and Health Sciences in Des Moines, Iowa. Dr. Cohn went on to do a traditional osteopathic internship at the Community Health Center of Branch County, Coldwater, Michigan – a Michigan State University-affiliated program. He subsequently received post-graduate training in Family Medicine and Biomechanics/Osteopathic Manipulative Medicine through programs at Michigan State University, as well.