Putting Pain in Its Place : Medicine Tackles an Age-Old Adversary With Inpatient Clinics--but Not Without Some Controversy

BERNIECE Davis took life at full tilt. She worked. Spent time with her husband and two kids. Enjoyed volunteering at church.

Even when she was exhausted or busy, she admits, she had trouble saying no to anyone who wanted her time. “I tried to be all things to all people,” says the 45-year-old Los Angeles woman.

Then the pain started.

Last October, Davis began feeling discomfort in her abdomen. “In early January,” she recalls with a grimace, “it got worse. I went to nine doctors, but none could figure out what was causing it.”

Within a month, she left her job as a telephone-company service representative and went on disability. “I slept 20 hours a day,” she recalls. “I took Tylenol and codeine, and I was (still) in pain every day.”

Nothing produced relief. Finally, a doctor referred her to the Pain Management Program at Daniel Freeman Marina Hospital in Marina del Rey, an intensive five-week inpatient regimen. And while the pain hasn’t stopped, she’s relying on herself, not drugs or pilgrimages to doctors’ offices, to control it.

Davis, a plump woman who now flashes a ready smile, remembers her turning point clearly. During her second week in the program, Richard Ross, a psychologist and clinical director of the program, asked her to draw a picture of her pain. “The image that came to me was someone driving nails into my upper abdomen,” says Davis. A week later, Ross asked her to repeat the exercise. In the second drawing, Davis recalls, the claws of the hammer were turned up. “One nail had already been removed and the second was almost out,” she says. “The full reality dawned on me--they were not promising the discomfort would go away.” At that point, Davis says, she vowed to learn to manage the pain, to be in control.

Instilling that sense of self-reliance is at the core of the sometimes controversial and often costly inpatient pain programs operating around Southern California. Davis expects two insurance policies to cover most of her hospital bill of $25,000 plus an estimated $1,500 in physician fees. But she can’t put a dollar value on the coping mechanisms she learned.

After her discharge, Davis took a week off to relax, then began working part time, planning to resume full-time work two weeks later. “It’s still not easy (to manage the pain),” Davis says a few weeks after being released, “but it’s possible.”

ONE OF EVERY three Americans--about 86 million people--suffer from chronic pain, according to the American Chronic Pain Assn., a Pittsburgh-based self-help group. Back problems, recurrent headaches and arthritis are the top three causes, though sometimes the source remains a mystery, says Penney Cowan, founder and executive director of the association.

We spend about $70 billion a year on medical costs, lost workdays and compensation for chronic pain, Cowan says.

Traditionally, experts term pain chronic if it lasts six months or more. It’s not the “healthy” pain you feel when you burn your finger on a stove. That sort of “acute pain is adaptive and protective,” explains Dr. Armen Dumas, medical director of the Center for Rehabilitation Medicine at Valley Hospital Medical Center in Van Nuys. “It’s a signal or a warning. In chronic pain, that signal goes awry. It’s like crying wolf, and it’s not serving a protective role anymore.”

Pain--once the symptom-- becomes the disease in chronic-pain patients, some experts say. The pain, whatever its source, is real, not “all in the head,” experts concur, and often represents a cry for help.

Chronic-pain patients will do almost anything for relief. Doctor visits become a way of life for many. Some back patients undergo multiple operations. Other chronic-pain patients try long-term physical therapy as outpatients. Some pour money into “passive” remedies such as ultrasound and massage. Many become dependent on painkillers and tranquilizers. And many feel guilty that they can’t function normally while they may appear perfectly OK.

Some patients, like Davis, end up in inpatient pain-management programs, where directors tell them that they can regain control of their lives--if they’re willing to work hard and to rethink the medical model of physician-as-fixer.

“ ‘Not by medicine alone’ is our theme,” says Harold Gottlieb, a psychologist who directs the Comprehensive Back Services and Pain Related Disorders Program at Casa Colina Centers for Rehabilitation in Pomona. “If patients look to the physician as healer, that simply doesn’t work,” adds Dr. Donald Weir, medical director of the Casa Colina pain program. “We change the approach to one in which they take control. To make that work, the physician has to take a more remote role.”

Treating pain through intensive inpatient programs isn’t a new concept. The first such programs opened more than 25 years ago. Today, experts estimate, about a dozen inpatient pain-management programs operate in Southern California. Seven of them are accredited by the Tucson-based Commission on Accreditation of Rehabilitation Facilities, although several programs lacking that accreditation are reputable, say some physicians who specialize in pain control.

Proponents of the inpatient programs use a team approach, relying on the services of physicians, nurses, psychologists, social workers, and occupational and physical therapists to help patients break out of chronic pain.

The programs aren’t without controversy. Several insurance-company policies won’t cover the programs, which often cost $5,000 a week or more. Pain specialists themselves are divided about the worth of the inpatient programs. Some believe all but a few patients can learn how to deal with their pain effectively as outpatients--for a fraction of the cost.

But advocates of inpatient programs feel strongly that their way is ideal for some people. The protective and educational setting of a hospital--without interference from family members who often contribute, sometimes unwittingly, to the pain problem--provides the optimal environment for enabling some patients to turn their lives around, they maintain.

If they work hard enough, patients who check into the programs can expect to learn how to understand and control their pain, proponents say. It’s like learning to turn down a loud radio, says Dr. Thomas Hedge, the medical director of the Pain Management Program at Northridge Hospital Medical Center in Northridge. “We can (help them) modulate it.”

Patients expecting hotel-like accommodations and a chance to wallow in their problems get a quick dose of reality. “No one wears hospital garb--we emphasize normalcy and de-emphasize the sick role,” says Dr. Colin Stokol, medical director of the Pain Management Program at Centinela Hospital Medical Center in Inglewood. Whenever possible, patients are expected to carry their own cafeteria trays, make their own beds and follow the daily schedule. “This is work,” Stokol tells patients. “It’s the work of getting better.”

While the daily activities at inpatient pain-management programs vary, Centinela’s schedule is fairly typical. Patients must rise in time for a 7:15 a.m. breakfast (though they’re allowed to sleep in until 9 on weekends). The morning walk begins at 8:30 a.m. Next, an occupational therapist teaches patients basic preventive body mechanics, such as the correct way to pick up a dish or a bag of groceries.

At 10 a.m., patients go to physical therapy, where they spend time on exercise bicycles, treadmills, pulleys and weight machines. Chronic-pain patients often have tried passive treatments like massage, heat packs and ultrasound, says Joseph Chan, a physical therapist at Centinela Hospital Medical Center. “They are usually weak, have loss of strength and flexibility and mobility.” And, he says, they emphasize their pain by grinding their teeth, moaning and depending on devices like crutches and canes they may not need.

From 11 to 1, patients practice relaxation skills, have lunch and receive individual counseling from the hospital psychologist. In the afternoon, they participate in more physical therapy and group discussions. Dinner is followed by educational sessions or socializing.

They’re encouraged to get to know patients in the rooms around them. Most inpatient pain-management programs are housed in the hospital’s rehabilitation unit, which may also provide care for those with stroke and other brain injuries, spinal-cord damage and amputations. “It can show patients the pecking order,” Northridge’s Hedge notes.

Coddling is not on the agenda. “We don’t dispute the fact that they have pain,” Stokol says. “What we dispute is that they can’t do anything about it. You could say we are compassionate but relatively uncompromising.”

One of the first things patients are asked to do is to stop making pain the center of their lives.

“They don’t want us to say the ‘P’ word here,” says Robert Laird, only half-joking as he brushes black paint on a doorstop-in-the-making during an occupational therapy session at Daniel Freeman Marina Hospital. A 32-year-old Culver City resident formerly employed as a sheet-metal worker, Laird says he checked into the program after he became addicted to the painkillers he took for his chronic pancreatitis, an inflammation of the pancreas.

Eliminating the word from his vocabulary was difficult, Laird admits: “Pain was a constant thing in my life.” Does he still feel it?

“Oh, yes,” he replies without hesitation, “but it doesn’t seem as bad anymore because I’m learning to deal with it.”

Reducing or eliminating painkillers and tranquilizers is often the next step. And whenever possible, patients are encouraged to give up unnecessary aids such as canes and walkers.

When patients begin to experience some control over the pain, the program coordinators start to talk about the psychology of chronic pain. Although the profile of a chronic pain patient is far from complete, experts do agree on some points. The patients often have a history of a “chaotic life,” says Joseph Dunn, psychological services director at Centinela Hospital Medical Center. They may have been shuttled off to live with relatives as a child, or abused, he says. Later, if they experience divorce, financial problems or other traumas, the stress often manifests itself in physical symptoms such as pain or a worsening of existing physical problems, Dunn finds. “We think stress in life plays a role in how people perceive pain,” he adds. “There is a large psychological component to pain, but that doesn’t mean it’s not real.”

A history of child abuse is pervasive in chronic-pain patients, says Dr. Charles Morgan, the medical director of the Pain Center at Scripps Memorial Hospital in La Jolla, although other pain specialists say that he overstates the problem. In a sample of 300 patients treated at his center, Morgan says 80% disclosed neglect or sexual, physical or verbal abuse as children.

“People treated abusively as kids are rendered vulnerable,” he believes. “If they have an accident or illness down the road, they’re probably not going to do as well as the person who was well-loved as a child.”

Why not? “Unconsciously, these people may have bought a script that they’re not good enough, and an accident or injury is a solution rather than a problem,” he says. It provides a way to help justify failure.

“These people store up an immense amount of anger. The anger may magnify the perception of pain and the disability or limitations accompanying it.

“They have an investment in their disease. It becomes a focus of their lives,” he continues. “If they get better, they’re going to be held responsible for their lives.”

Chronic-pain patients are often prone to depression, say pain specialists, and they may, at least in initial stages, enjoy the pampering provided by family and friends when the pain becomes unbearable.

Obviously, even the best psychotherapy can’t erase years of trauma in a few weeks. So therapists working in inpatient pain management focus on helping their clients change hurtful behavior. Patients are encouraged to reduce stress levels, partly by learning how to say no to people when necessary. They’re encouraged to learn how to manage their time and to relax, to acknowledge physical limitations and to vent their feelings.

Therapy for the families of chronic-pain patients is another integral part of the inpatient programs, experts say, because pain doesn’t affect only the patient. “Sometimes the family revolves around the pain,” says Dunn of Centinela Hospital Medical Center. A spouse may have taken over household chores. The social schedule may hinge on how the patient feels and so be subject to constant juggling.

And family members, manipulated by the chronic-pain patients, may unwittingly encourage them not to change, becoming entrenched in a “pain life style,” experts say. One man, accustomed to injecting his wife with a painkiller every two hours, lost that duty when his wife checked into a pain-management program, recalls one physician. But he wasn’t without the chore for long. During a therapy session, the man announced that the family pet had gotten sick and he was now injecting it.

Once patients and families make progress, patients are allowed a weekend pass. “A weekend pass is not a break from us,” Stokol emphasizes. “Patients go home and function in their own environment and see how they do.”

The four- to six-week pain-management program is a first step to recovery, not a quick fix, proponents stress. Most physicians advise outpatient treatment for several months after discharge.

HOW SUCCESSFUL are the inpatient programs? Evaluating success is difficult, partly because it’s measured subjectively.

The continuum of success is long--ranging from a perception of feeling better to a return to full-time employment. And different criteria are used in different programs.

For example, about 40% of the chronic-pain patients who complete the inpatient program at Centinela Hospital Medical Center return to work, reports Nancy Coker, the hospital’s director of rehabilitation services, and 80% are active again.

In a study published in the journal Pain earlier this year, Gottlieb of Casa Colina and other authors report that 90% of 700 patients with chronic low-back pain improved to some degree.

Six months after discharge, about 70% of patients remain improved, finds Dr. Lawrence Miller, medical director of the Chronic Pain Management Program at Glendale Adventist Medical Center.

Critics of the inpatient programs charge, however, that such improvement is short-lived and that the criteria are too variable.

Success rates may rise because many programs now have stricter admission requirements. “Five years ago, nearly everybody who hurt was admitted,” notes Miller. Not so today. Many programs screen potential participants to find out why they want to enter and to rule out surgical or medical remedies. Some are reluctant to admit patients actively involved in litigation over an accident that led to the pain, although that’s not always practical because of the sheer number of litigating patients. In the Daniel Freeman Marina Hospital program, for example, up to 50% of patients who apply are turned down, according to Grace Millington, a nurse and rehabilitation coordinator.

The best candidates for the inpatient programs, Miller believes, have clear-cut goals: to stop depending on drugs or to return to work, for example. A goal of feeling better is not good enough.

THE JOB OF helping chronic-pain patients--considered by many doctors to be the most demanding and manipulative of patients--is difficult enough. But specialists who direct the inpatient pain-management programs battle simultaneously on other fronts as well.

Misunderstandings with private insurance-company personnel and workers’ compensation adjusters are common, doctors say. Complains one physician: “Many insurance companies call me every week to keep close tabs on the patient.” Other pain specialists say insurers push for outpatient treatment.

Insurance companies are more likely to pay for surgery than for pain-management programs, other doctors complain, and they expect miracles during the brief stays in the programs.

Some insurance-company executives, in turn, maintain that many employers try to contain costs by choosing policies that don’t cover inpatient pain management. But some insurers acknowledge that they, too, prefer outpatient treatment. “We don’t find inpatient confinement medically necessary for this type of evaluation and treatment,” says Dr. Brian Gould, vice president and medical director of Blue Cross of California. “Nor is there at this time any scientific rationale I’m aware of that inpatient (treatment) is more effective. If such evidence should develop, we would reevaluate our position.”

“Pain-management programs are very suspect, even among other physicians,” says Dr. Howard Chew, medical director of the Daniel Freeman Marina Hospital program.

“Few chronic-pain patients need an inpatient program,” charges Alan H. Roberts, a psychologist and director of the behavioral medicine program at the Scripps Clinic and Research Foundation, La Jolla, who is on staff at the clinic’s outpatient Pain Treatment Center. (The Scripps Clinic and Research Foundation and Scripps Memorial Hospitals are not affiliated.) Only two or three of the estimated 150 chronic-pain patients he has treated in the past year needed an inpatient program, Roberts says.

Counters Chew, who believes it unwise to return some patients to an unhealthful home environment at night after outpatient treatment: “You can undo at home what you did during the day.”

For physicians who direct inpatient pain-management programs, there is at least one bright spot: Come budget time, says one expert, most directors don’t have to fight for staff, funds or equipment for their generally profitable programs.

And, for many involved in the inpatient pain-management programs, the rewards of improving someone’s life--even slightly--seem enough. “So many patients come in, housebound and dependent on families and on medications, and then find out there’s a whole new world out there they were letting go by,” says Cathy Lee of Centinela Hospital Medical Center.

Such is the case with Berniece Davis. “My whole world is wonderful again, and I can’t wait to get out there,” she told other chronic-pain patients gathered in a physical-therapy room two days before her discharge from Daniel Freeman Marina Hospital. Dressed in pale pink sneakers and a gray jogging suit, she smiled as audio-visual specialist Tom Tobin began videotaping her to record her progress.

Then she watched as Tobin showed a videotape made during the first week of her stay. “Look at me,” she said mockingly as she watched her “old” self speaking slowly, eyes like those of an abandoned, hungry beagle. “How pitiful!”

Not all patients are as verbal about their progress as Davis. But most pain specialists have come to believe in the old adage that actions speak louder than words. Says Colin Stokol of Centinela Hospital Medical Center: “They may walk out of here saying, ‘Dr. Stokol is such an insensitive swine.’ But they live their life.”