MEDPAGE TODAY
by Heath McAnally, MD
August 30, 2018
“Do you guys apply whale blubber poultices frozen or heat them up first?”
I’m always asked silly questions like that after my colleagues find out I’m from the last frontier — Alaska. But they might be surprised to learn we actually have SCS, even DRG stim, RFA, Sublocade, and I just prescribed my first CGRP inhibitor for a migraine.
My viewpoints may not reflect those of my subarctic colleagues’ on many issues, but one thing I think we’d all agree on is that up here in the last frontier, we’ve always relied on what works. From our heterogeneous native and immigrant backgrounds, we bring different traditions and adaptations (hopefully proven and evidence-based) for addressing problems of serious importance. (We try not to sweat the small stuff.) But we’re also by necessity open to new ideas and paradigms — as long as they work. If something doesn’t work, we have a low threshold for modifying or abandoning it — survival depends on reliable processes.
If It’s Broke…
We have an issue up here that I gather isn’t unique to Alaska. There’s a growing realization that “business as usual” in chronic pain management isn’t working, with spiraling costs, increasing disability and despair, and the opioid epidemic evidencing the failure.
Physicians don’t get all the credit; nonetheless, we’re the ones folks look to for guidance and help with making sense out of their physical complaints — none of which gets people’s attention quite like pain does. And yet what’s obvious to our thought leaders and government remains mostly unknown to the participants (both providers and patients) in our mainstream pain management industry. That elephant in the exam room is the failure of our overly-somatic-focused, reactive, and passivity-reinforcing treatment approach to benefit either individual patients or our society.
The Institute of Medicine tells us that a third of us suffer from chronic pain. While that may be an exaggeration based on a generous categorical cutoff point applied to a spectrum of ubiquitous human experience, the point is made — we’re talking about a widespread condition garnering growing attention from Washington for a number of reasons. Whether the actual prevalence of chronic pain is increasing (tough to measure without historic and comparable benchmarks), it’s clear that the societal impact is. During the 50 years from 1961 to 2011, the proportion of back pain and other musculoskeletal complaints as the diagnosis conferring social security disability status essentially quadrupled (8.3% to 33.8%) with mental illness and developmental disabilities doubling (9.6% to 19.2%.) Cancer and respiratory illnesses haven’t changed appreciably in terms of their share of the pie, while cardiac, cerebrovascular and neurologic claims have declined proportionately with better treatment perhaps, but certainly in the face of the new majority. At worst in this post-agrarian and increasingly post-industrial society, we’re reinforcing or encouraging pain complaints economically. At best, it’s clear we’re not improving people’s perception of and resilience against their pain.
Other metrics such as the often-quoted figure of over $600 billion costs associated with chronic pain — with the attached mantra of “greater than heart disease, diabetes, and cancer combined” support the notion that we’re not doing things well. It’s no wonder then that leaders in our field (and outside of it) are calling for a revolution in how we go about treating chronic pain. If we don’t change things for the better — and soon — it’s likely not an exaggeration that we’ll bankrupt the healthcare and welfare budget, and the opioid epidemic is probably just the proverbial tip of the iceberg in terms of population-level chemical coping.
The Native Way
Trying to treat pain (or any chronic condition) with an exclusively somatic focus doesn’t work. That realization has permeated at least our ivory towers and conferences, and the National Pain Strategy among other consensus charters acknowledges the need for a biopsychosocial-spiritual approach. But with all due respect to Dr. George Engel and his vastly important rediscovery, most cultures and societies since the dawn of time (not stymied by technological dependence, materialism, Cartesian dualism) have operated on the premise that you can’t separate mind from the heart from the body when it comes to health. The ancient Hebrews, Chinese, Aristotle and our last frontier first peoples knew that.
In our incredibly diverse population (the Anchorage School District boasts over 100 languages spoken in its halls), I’ve had the privilege of working with Inupiaq, Y’upik, Aleut and Aluutiq, Athabascan, Tlingit, and Haida peoples. Among my colleagues are traditional healers whom the Alaska Native Tribal Healthcare Consortium have supported in a long-overdue resurrection of truly holistic healthcare, incorporating counseling, prayer, community fellowship and other culture-specific practices that are met with increasing demand and endorsement. Of note, mirroring the Western/allopathic consensus, the most common presenting complaints involve pain (53% in 2015) followed by behavioral health issues (20%). While I don’t have comparative outcomes data, anecdotally I can attest that those who pursue whole-person wellness thrive more than those who simply react to physical symptoms and seek a quick, unidimensional “fix.”
Getting Ready for Winter
With half the year disproportionately cold, dark and devoid of natural resources, preparation is critical for survival. Granted, McDonald’s and WalMart in our metropoli, such as they are — there are 360,000 in our three biggest cities of Anchorage, Juneau, and Fairbanks — have eroded some of our traditional values in more ways than one, but many still cherish and adhere to a subsistence lifestyle. Respecting and adapting to the land, ocean and atmosphere, the seasons, and the migratory patterns of fauna are essential to life, let alone a good one.
Aligning our pursuits of biopsychosocial-spiritual health and wellness early in the spring and summer of life (even autumn isn’t too late) are key to preventing illness and chronic pain. There’s no other way to say it — if we humans don’t actively prepare, mother nature won’t show mercy. That’s as true of pain as anything in this life.
Pull Your Weight
And that leads me to my final thought in this introductory installation. The frontier favors a self-reliant people. That’s not to say we don’t value community — on the contrary, without a good sled dog team, fishing vessel, or drilling rig crew, we wouldn’t see many winters. But everyone has to contribute.
To appeal to the National Pain Strategy again (and consensus common medical sense for millennia) we need to be instilling a sense of responsibility in prevention, management, and cultivating self-efficacy and internal locus of control. Best practices in life, including healthcare, must respect the individual and their choices (and those choices’ consequences) while not facilitating self-destructiveness. Hydrocodone isn’t the answer for dietary indiscretion and joint pain, nor Ambien for a pot of coffee every day and poor sleep hygiene. And really that aligns with justice, non-maleficence, beneficence … not to mention autonomy. If we’re to benefit the individual and the community, we as providers (just like parents, teachers, coaches, managers) must lead our patients – especially those sidelined and confused by chronic pain – in rediscovering, or learning for the first time that their outcome is directly proportional to their ownership.
We’ve seen all these things work, and I look forward to exploring these topics and more from a pragmatic pain management standpoint with you.
by Heath McAnally, MD > August 30, 2018
Heath McAnally, MD, MSPH, is a board-certified anesthesiologist, pain physician and addictionologist practicing in Alaska (the military sent him there and he decided to stay.) If he wasn’t trying to guide people in improving their own lives, teaching medical students to do the same, or writing about it, he’d probably be outdoors right now slogging up a mountain with a good friend or two.
last updated 08.31.2018