Editor’s note: This is the second of a two-part article. Part One (Vol. 19, Issue 3) introduced the concept of chronic pain and issues common in correctional settings.

It only takes an evening of watching television to pick up the powerful message of the drug companies. “You shouldn’t have to suffer pain. Our drug will stop it. Ask your doctor!” The message is followed by appallingly graphic symptoms you might get as a replacement for your pain.

The message that gets through, though, is that you deserve a pain-free existence through chemicals—swallowed, rubbed in or inhaled.

No one is completely immune to this message. The concept of entitlement particularly appeals to inmates, especially since they are entitled to relatively little else. At the University of Washington Pain Center, an outraged patient once told me, “I came into this world with no pain, and by damn, I’m going out with no pain!!!”

A Patient Right
The Joint Commission on Accreditation of Healthcare Organizations has established pain management standards for hospitals stating that “pain management is a right for all patients.” The standards also call for providing patients with “pain reduction education” and “continuity of care for pain management.” Similar standards don’t exist for nonhospitalized patients.

We don’t want our inmates to suffer needlessly, however, so prisons can, and should, meet these standards. But correctional physicians need not be concerned if their states do not allow the prescribing of opioids to inmates. Nothing in JCAHO standards says that the pain management has to involve opioids. There are many other strategies and interventions besides medications.

Pain reduction education and self-management techniques for chronic pain should be part of our treatment plans. “Continuity of care for pain management” means follow-up with inmates who report pain problems. Pain management may or may not include medications, but merely prescribing drugs—whether NSAIDS or opioids—is a disservice to our patients. I’ve yet to hear one of our physicians express alarm that we are not providing pain reduction education for inmates.

Providers have had little training in pain management. Medical training teaches elaborate methods, procedures and tests for tracking down the “cause” of the pain. But with chronic pain (longer than three months), the original cause is not what is maintaining the present pain. Tissue damage, strains and sprains have resolved. Even if the original cause is found, it is seldom something that can be “fixed” far out from the onset.

This is a confusing concept to doctors, not to mention the patient who is hurting. Entire medical careers have been built on diagnostic investigations that may, perhaps, lead to a diagnosis but seldom a resolution of the patient’s pain problem.

Minimize the Impact
Chronic pain is part of the human condition. Eventually, everybody has one or more chronic pain problems. The difference between people is how they react to the experience. Culture, family influences and personal experiences cause some people to see the doctor for virtually any symptom, while others avoid seeking professional care under any circumstances. These and all responses in between occur in inmates.

It is tempting to attribute an inmate complaint of pain at sick call to manipulation or to drug seeking. That may make it easy for the provider to decide how to deal with the complaint. But you don’t want to ignore a legitimate pain problem that deserves your efforts to help minimize its impact on the individual’s life, functioning and mood. Patients, whether inmates or in the community, deserve your help. They also are entitled to you acting in their best interests in the long term.

Armed with more than a prescription pad, you can help inmates in an invaluable way, far beyond the immediate problem. You can begin to model for them a different way to interact with their doctors and nurses, to teach them about self-management of pain and other health matters. Real cognitive changes in an inmate’s perspective can occur.

This is an outcome with far greater impact than further “medicalizing” the pain by handing out a pill. Medications can be part of the plan. But never the whole plan.

You and the patient are partners in developing pain management strategies that work. Because there are multiple contributors to maintaining chronic pain, there must be multiple treatment regimens for the patient to be successful. All pain has social, emotional, physical and environmental consequences. In order to develop an effective approach to managing pain, all aspects must have their own protocols developed in conjunction with the inmate, who knows his circumstances best.

Establish a Foundation for Change
Unless beliefs change, behavior will not change, and the outcome will be the same.

1. Stop looking for the “cause.” Shift from the medical model to the rehabilitative model. Pain is analogous to essential hypertension. Who knows why their blood pressure is high? You treat what you have.
   This is often the case with muscular- skeletal pain (95% of chronic pain problems). When doctors persist in exploring the etiology of the pain, the patient continues to be concerned that something bad is “wrong” and could be set right if only it were discovered.
   In the pain clinic, we often discovered that it was harder for doctors to give up looking for a cause than it was for patients. For patients, it is often a relief to start rehabilitation efforts. When we told one patient that he would probably always have some degree of pain, he expressed relief that he could move on with his life and not feel that, somehow, he should still be looking for an answer.

2. Normalize the experience of pain for the patient. Chronic pain is not abnormal nor is it a sign that something is wrong. Cite the statistics for the huge incidence of chronic pain (Part 1). Empathize with the suffering, but communicate the need to move beyond it. Reducing the fear and anxiety associated with worry about a serious medical problem will allow the inmate to participate in treatment.

3. Explain the goals of pain management. The goal is not to eliminate pain, but to minimize the impact it has on the individual’s daily functioning. Minimizing pain along the way, if that happens, is a bonus.

4. Communicate that you will work with the patient in rehabilitation efforts. Patients may believe you will lose interest in them if they don’t have a “real” medical problem. Schedule regular brief meetings with them to review progress (not pain!).

5. Reactivation will be painful, but not damaging. Hurt does not equal harm, in chronic pain.

Treatment Plans
Giving inmates the perspective above will allow the following type of treatment to work.

1. Treat any coexisting depression (commonly found) or sleep disturbance with minimal and appropriate medication. Pain and depression have been shown to follow similar pathways in the brain, and treatment for one helps reduce the other.

2. Begin a physical reactivation and reconditioning program. This is the key to managing chronic pain. Even in the absence of medication, research shows that moderate depression and all degrees of chronic pain respond positively to a gradual, staged reactivation (stretching and strengthening). There is undoubtedly some physiological basis for this change, as well as the psychological increase in self-confidence and self-efficacy that comes from taking control.
   An initial visit and exercise “prescription” from a physical therapist will provide the inmate with the confidence that she is not harming herself. This can be done in a group setting, especially when there are many low back pain patients, for example. There are standard back exercises. Inmates can do them in their cells. There is no need for special equipment for most exercises.

3. If you decide to use medications, try NSAIDs (along with antidepressants if indicated). There are more than 26 nonsteroidals in five categories that each work differently. If one doesn’t work, another will. A major study recently showed ibuprofen has the best efficacy and the lowest incidence of side effects. Use NSAIDs only in conjunction with the exercise program. These nonsteroidal anti-inflammatories have been demonstrated to have pain reduction effects beyond reducing inflammation (UW Pain Center).

4. If your state allows the prescribing of opioids, you can consider them, with all the caveats associated with giving dependency-producing drugs to previously chemically dependent inmates. If you use them, a time limit of 10 to 20 days might be reasonable with the understanding that significant progress in strengthening and reconditioning goals be met or the drugs “are not doing you any good” and should be discontinued. Inmates should know from the beginning that an increase in pain at the end of the drug trial will not merit a return to these drugs.
   Keep in mind that when the inmates are released from prison, they are unlikely to be prime candidates for long-term opioids prescribed by a community physician. Setting them up for failure when they get out is counterproductive.

5. Give inmates an activity diary in which they record their exercises and daily activities such as walks. You will review this at visits. Do not have them record their pain levels! This reinforces their focus on pain rather than on progress. A sheet of paper divided into sections for each hour of the day will enable them to keep track of physical activity.

6. Schedule time-contingent, not symptom-contingent, follow-up appointments. Seeing a doctor or a nurse is a reward. Make sure you are rewarding that which you want to see increased. For chronic pain inmates, it will take you less time if you schedule 15-minute appointments every few weeks than if you “require” them to have exacerbation of pain to see you. You do not see them between visits for the pain.

7. At appointments, review with the inmate her progress. Compliment her ability to do exercises under difficult circumstances. It should be clear to the inmate that her efforts “earn” her appointment times. Chat with the inmate and make it pleasant.

8. Provide cognitive behavioral group sessions on improving functioning and increasing activity levels. Sessions for patients with pain problems will aid their continuing progress. The sessions should be run by a psychologist, who will make sure that they don’t turn into “my pain is worse than your pain” sessions.

9. Provide psychoeducational and physical education group classes. Structured classes can be taught by a nurse, doctor, psychologist or counselor using a standard curriculum that focuses on coping and managing pain.

The goal of these treatment plans is to implement self-management techniques supplemented by coaching from the provider. Skills will be learned, attitudes will be changed and the inmate will leave your care more prepared to be responsible for his own health needs.