“A new type of thinking is essential if mankind is to survive and move toward higher levels.” — Albert Einstein, 1946

The other day I received a call from a doctor in Maine asking to talk to me about the comprehensive pain management programs that I help run here in California. He informed me that he was working with a local hospital to try to set up something comparable, and he wanted to ask me a few questions. It turns out that Maine has recently adopted legislation to slash the use of opioid-based pain medications for recipients of MaineCare, its state-run health care system. In fact, the bill puts a cap on the use of opioids like Oxycontin and Vicodin to only 45 days unless you have cancer or AIDS. What prompted this roguish proclamation on chronic pain treatment was the governor’s need to address Maine’s budget woes. The Portland Press Herald reported that in 2010 almost one-third of MaineCare’s patients received at least one prescription for a narcotic painkiller at a total cost of $7 million, and that addiction treatment costs the state about $100 million annually.

That same day that I got the call from Maine, The New York Times ran a front page story on what the state of Washington has been doing to control how painkillers are prescribed. Washington is not just trying to clamp down on the rise in pain medication abuse and diversion, but legislators, insurance leaders, and some physicians are working to reign in what is perceived to be the over-prescription of opioid-based painkillers to the general population with chronic pain. Citing multiple concerns, including a rise in harmful narcotic side effects, a lack of well-documented long-term efficacy, and an increasing trend of accidental deaths from overdosing, the Times reported that hundreds of thousands of patients nationwide may be on dangerously high dosages of painkillers.

It turns out the question of how to regulate the use of painkillers now has the attention of many states as well as federal agencies. A number of states are trying to come up with ways of curtailing the abuse and diversion of prescription painkillers, and as evidenced by Maine and Washington, some are also taking on the controversial task of trying to provide guidelines on how they can be prescribed for legitimate medical treatment. Then, there is the pill mill disaster that has come to be associated with parts of Florida, where customers can pay cash to get prescriptions for painkillers like Oxycontin and have them filled by an in-house pharmacy at the same time. This has prompted a federal crackdown that included agents recently searching several Florida pharmacies owned by two major chains as well as a large distributor.

How bad is this getting? Earlier this year the CDC called painkiller overdoses “a public health epidemic” and reported these statistics:

• Prescription painkiller overdoses killed nearly 15,000 people in the U.S. in 2008. This is more than three times the 4,000 people killed by these drugs in 1999.

•  In 2010, about 12 million Americans (age 12 or older) reported non-medical use of prescription painkillers in the past year.
•  Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers.
•  Non-medical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.

Where does this mess leave legitimate patients with pain problems that need help and their doctors who genuinely want to help improve their lives? In a nutshell, a doctor who sees a patient with a pain problem likely only has about 15 minutes scheduled to try to understand what is important about that patient’s situation (and I mean medically but also psychologically and socially), provide education, review diagnostic test results, and recommend some type of treatment that will have impact. As we move into the arena of tighter regulation, this also means that visit needs to now be spent doing things like urine drug tests and downloading pharmacy reports to see if the patients are getting prescriptions from other doctors. Let’s not forget to toss in the fact doctors now need to spend time doing their charting in an electronic medical record, which means the annoying sensation that he/she is talking to the computer and not the patient.

If you do the math, there really isn’t enough time to accomplish much of anything other than to fill out new prescriptions. Unless, of course, health plans start to support better alternatives for treating chronic pain, like what my colleague in Maine is hoping to accomplish.

Just like a person having a heart attack needs to be monitored and treated in an ICU, a person suffering from pain needs a place that they can go to get healthy, too. The difference is that it isn’t apparent to most what that place should look like. I think we can see that the traditional medical office setting that leads to more tests, invasive treatments and prescriptions for strong painkillers is not working and may be creating more problems than it is solving. In fact, I discovered years ago that my most successful patients are generally the least dependent on pills, and for that matter, the least dependent on me.

If I was to describe what folks who won their battle against their pain looked like, I would say that they learned how to think and act healthy. In other words, they got the help they needed to learn how to get physically more active, manage stress, become constructive problem solvers that understand the mind/body connection, and communicate better to stay more connected with others. On top of that, they become real picky about what they ingest, whether we are talking about their medications, food, choices of beverages, or tobacco. People feeling overwhelmed by their pain shouldn’t be in line at pill mills or get treated like they are going through airport security. They should have a place to go where they can learn how to overcome what really ails them.

Creating a “cultural transformation” is no small feat, no matter what the subject or the circumstances. Isn’t that a term reserved to describe things like the Maoist revolution in China or text messaging and teenage social behaviors? It means a lot people all of a sudden start doing things in new and different ways with a common objective. Are doctors and pain sufferers up to this task?

Opportunities to fuel this transformation abound, and I think another one recently popped up with little fanfare in the pain management community. A large new study was just published in the journal Obesity showing a significant link between obesity and pain. This study was based on survey results of more than 1 million respondents, and the results suggested that the degree of obesity, based on the Body-Mass Index (BMI), correlated with greater levels of reported pain symptoms. Also of note, the research team showed that the relationship between pain and obesity persisted even after factoring in the effects of other chronic diseases like diabetes. This is by no means the first study to link pain with body size. For example, obesity has previously been shown to correlate with the severity of pain symptoms from arthritic joints, but any time a study comes out with a sample size this large, doctors at the front lines of treating pain should be compelled to take notice.

In no way does a study like this lead to the conclusion that obesity is what is causing the pain. It certainly begs for further discovery about how body weight impacts pain. Questions arise like which came first, the weight gain or the pain. Certainly, some patients report that their pain resulted in inactivity-related weight gain. We also don’t know that if two people sustain the same injury where one is obese and the other is not, whether or not the obese person is predisposed to experience more pain after the injury. It is hard to quantify how much subjective complaints are directly related to the calculated increase in mechanical forces created by excess weight, and we don’t know yet if the suspicious inflammatory mediators released by fat cells can directly affect pain.

Chronic pain is such a complex experience, based on so many different biological and psychosocial variables, that it can be really hard to tease out the impact of one specific factor (like body weight). I decided to crunch a little of my own data by taking a random sample of patients from our practice who are on prescription pain medications to see how many were overweight. This included 28 men and 18 women, and my results showed an average BMI of 30.3 for the males and 28.6 for the females. Based on CDC recommendations, a BMI greater than 25.0 is considered overweight and 30.0 or above is considered obese. In fact, only 12 percent of the men and 22 percent of the women in my sample had body weights within the normal range.

Where does all of this leave us with respect to the appropriately requested cultural transformation for pain management? Well, consider the analogy of where everyone who drank water from a particular lake came down with some type of stomach flu? Initially, we don’t know if it is the lake that is causing the sickness or even if the lake is contaminated with anything harmful; we just know the two events seem to be shared by the same group of people in a particular community. The association between folks drinking the lake water and getting ill could be purely circumstantial. Despite these uncertainties in cause and effect, the logical thing to do would be to alert the citizens about the situation and recommend that they stop drinking water from that particular lake, at least until things become clearer.

The logical thing to do as part of our pain management transformation is to make weight management an inherent part of pain education, treatment and prevention. Consider this an example of why pain treatment needs to shift from a primarily symptom management model, with a focus on things like medications and procedures, to more of a disease management model with measurable outcomes. This can be very hard to do when patients are coming to you because they hurt and want to see results quickly, and making lifestyle changes is a slow evolving process that isn’t expected to provide instantaneous relief. What makes this even more challenging is doctors typically don’t get the resources or the support they would need to actually create meaningful change. Most health systems don’t pay physicians much to spend extra time on nutrition and lifestyle counseling, not to mention all the support needed for things like followup phone calls and educational classes that would be needed to deliver lasting results.

Change can occur when we build accountability and rewards for successful accomplishments into the system. Imagine insurance plans paying doctors for implementing disease management programs to better control the impact of pain on society instead of ignoring these options? Perhaps they offer patients refunds for participating in value-based programs for things like weight management? If this can help pain sufferers feel better in the long run, then surely the insurance world will save money on treatment costs and medication use. In order to start the cultural transformation for pain treatment, we will have to establish benchmark measurements, and equip patients and providers alike with the resources necessary to create lasting results. Unfortunately, if we don’t know where we are going nor have a map to guide us, then we will continue to spin, directionless, while creating bigger and bigger waves.

Unfortunately, this behavior pattern loses its protective benefit once the condition lingers and/or the pain becomes more chronic. In fact, this avoidance behavior is generally believed by many pain experts to significantly contribute to the severity of chronic pain symptoms. The medical term for this is fear-avoidance, and it defines a thought process in which an individual fears the presence or potential exacerbation of pain to the point of avoiding activities. Unlike the acute injury model, developing fear-avoidant behaviors when dealing with chronic conditions becomes maladaptive in that it increases one’s physical disability and contributes to emotional distress.

Let’s go back to the example of the sprained ankle and suppose we stay off of it, not just for a few weeks, but rather for six months. In this scenario avoiding using the injured body part becomes harmful, as opposed to helpful, to the healing process. Staying off of the injured leg for a prolonged period of time can lead to all kinds of physical changes, including a stiffening of the joints, muscle atrophy throughout the whole limb, and scar tissue buildup. Physical changes will start to occur throughout the rest of the body as well, which will cause problems like postural changes and overuse of other parts like the uninjured leg. Once we become fearful of re-engaging our bodies after it is in pain or has been injured, then this avoidance behavior gradually leads to changes that ultimately leave us much more disabled and, sadly, in even more pain.

Inactivity and avoidance should be considered painful. In the example above where we stop using one of our legs for six months, you can imagine that the leg will hurt more and more as it gets weaker and stiffer, and the longer we wait, the more it will hurt when we try to use it. If we continue to over-use our good leg, then it will also start to hurt from the excessive pressure exerted on it. In my experience, disrupted gait patterns eventually lead to lower back pain, too. Now, if we add assistive devices like canes or crutches, then we run the risk of straining our hands, arms and shoulders, too. Before you know it, we are practically hurting all over.

Overcoming fear-avoidance is tricky business, but an important part of winning the battle against pain. Our pain changes the way we think and makes it difficult for us to recognize when we have developed irrational fears or behavior patterns that stand in the way of getting better and feeling better. Most folks need some help seeing past the pain to start believing that moving something that hurts will eventually help make it stronger and less painful. For some, working with experts in movement like high-quality physical therapists, Pilates instructors, or trainers can help get the ball rolling. In other cases, learning tools to better manage anxiety and fear through special techniques like relaxation training and breathing exercises can have a big impact. Achieving just small but steady gains over time can eventually lead to larger triumphs and personal transformations. I routinely see patients come in with walkers, canes, and all sorts of physical limitations that are able to learn how to walk, climb stairs and, in some cases, even jog on a treadmill. Overcoming chronic pain can mean working through some serious fears and misconceptions about your condition, but the rewards make it so worth it.

When we hurt, we tend to shut down physically and even emotionally. It is our natural tendency to protect a part of our body that has been injured or is uncomfortable. If our right leg hurts, then we naturally shift our weight to our left leg. This basic inherent guarded behavior pattern that we possess can be considered protective at times of acute injury. When we first sprain our ankle, staying off of it for a few weeks helps it heal.

Unfortunately, this behavior pattern loses its protective benefit once the condition lingers and/or the pain becomes more chronic. In fact, this avoidance behavior is believed by some pain experts to be a significant contributing factor to the severity of chronic musculoskeletal pain symptoms that many experience. The medical term for this is “fear-avoidance,” and it defines a thought process where an individual fears the presence or potential exacerbation of pain to the point of avoiding activities. Unlike the acute injury model, developing fear-avoidant behaviors when dealing with chronic conditions becomes maladaptive in that it increases one’s physical disability and contributes to emotional distress.

Let’s go back to the example of the sprained ankle and suppose we stay off of it, not just for a few weeks, but rather for six months. In this scenario, avoiding using the injured body part becomes harmful as opposed to helpful with the healing process. Staying off of the injured leg for a prolonged period of time can lead to all kinds of physical changes including a stiffening of the joints, muscle atrophy throughout the whole limb, and scar tissue buildup. Physical changes will start to occur throughout the rest of the body, as well, which will cause problems like postural changes and overuse of other parts like the uninjured leg. Once we become fearful of reengaging our bodies after it is in pain or has been injured, then this avoidance behavior gradually leads to changes that ultimately leave us much more disabled and sadly in even more pain.

Inactivity and avoidance should be considered painful behavior traits. In the example above where we stop using one of our legs for six months, you can imagine that the leg will hurt more and more as it gets weaker and stiffer, and the longer we wait, the more it will hurt when we try to use it. If we continue to overuse our good leg, then it will also start to hurt from the excessive pressure exerted on it. In my experience, disrupted gait patterns eventually lead to lower back pain, too. Now, if we add assistive devices like canes or crutches, then we run the risk of straining our hands, arms and shoulders, too. Before you know it, we are practically hurting all over it. At my center we use a special test, the Tampa Scale for Kinesiophobia, to quantify levels of fear avoidance in patients both before and after treatment.

Overcoming fear-avoidance is tricky business, but an important part of winning the battle against pain. Our pain changes the way we think, and makes it difficult for us to recognize when we have developed irrational fears or behavior patterns that stand in the way of getting better and feeling better. Most folks need some help in seeing past the pain to start believing that moving something that hurts will eventually help make it stronger and less painful. For some, working with experts in movement like high-quality physical therapists, Pilates instructors or trainers, for example, can help get the ball rolling. In other cases, learning tools to better manage anxiety and fear through special techniques like relaxation training and breathing exercises can have a big impact.

Achieving just small but steady gains over time can eventually lead to larger triumphs and personal transformations. One component of overcoming chronic pain can mean working through some serious fears and misconceptions, but the rewards make it so worth it.

I never met my paternal grandfather, who passed away shortly before I was born. When I was growing up, my parents kept a few pictures of him in a special drawer at our house. As a young boy, one of these pictures of my grandfather always haunted me. It was a black and white photograph taken of him in the later years of his life sitting in a chair without any legs. His face was sunken and his body seemed frail, yet his eyes stared at the camera with a look of inner strength despite the limitations of a physical body that could no longer walk. There was a beam of light cast down across his face and body, giving the appearance of a man living in between light and dark, at a crossroad between life and death. My grandfather eventually died of a failing heart in his 80s.

My grandfather was a double amputee because of the effects of advanced peripheral vascular disease. From what I have been told, he smoked (a big fan of the water pipe, no less) and drank a fair amount. He lived on a different continent and in a past era, without the bells and whistles of modern medicine. Medications to thin the blood and lower cholesterol were decades away from becoming common medical treatments.

While I was away at college, my parents called me one evening to let me know that my dad was going to have surgery the next day on his leg because an artery was clogged, but that everything would be fine. My dad had a bypass graft put in his left leg to stop the pain he was getting from walking. The medical term for this is claudication. My dad never smoked, and he didn’t drink. Throughout his life, he had wonderful, caring doctors; and my mom monitored his health closely. His health was carefully managed with the latest and greatest in medications for his heart and vascular system, and his primary care physician was a concierge doctor who was always a phone call away to help with all things health-related.

Despite significant cardiovascular disease, my dad was able to resume his normal activities after the presumably successful bypass surgery in his left leg. Things eventually took a turn for the worse last year when gangrene took hold of his right leg, and because of severe blockage in the blood flow to his leg he was forced to undergo an above-the-knee amputation. I remember getting hysterical calls from my relatives who had known my grandfather, frantic about the notion that my dad would be in the same tragic predicament.

About three months ago, gangrene crept into his remaining leg and he was forced to have an above-the-knee amputation of his left leg. Tragically, my dad didn’t make it out of the hospital, and he passed away due to a failing heart — in his 80s, and without his legs, much the same way his own father died half a century earlier. In those last months, my dad took on that sunken, frail appearance while keeping that steely look in his eyes, creating an eerie resemblance to the image implanted in my brain of my grandfather.

Over the years, I have preached to my patients about the importance that lifestyle and attitude have in improving how we feel. I am a firm believer in optimizing the environment we expose our bodies and our minds to in order to create the quality of life that I think my patients deserve. While I haven’t changed my mind about this, I can’t help but feel bowled over by the sense of finality engraved in my family’s genes. Is it my chromosomes that have been directing my behavior all of these years, and have they already predetermined the time when and manner in which my end will come?

After you hit middle age, you really need to work hard at maintaining good health. Evidence strongly dictates that a key ingredient of putting together a long-term plan for aging well is to comprise a detailed family history and make sure that you and your doctor take it very seriously. For some, that may mean searching through old records like diaries, obituaries, funeral home documents, or military records. If you are adopted and cannot find information about your natural birth parents, consider hunting for information about your ethnic and racial background.

As Shakespeare wrote in his play The Tempest, “What is past is prologue.” Let’s not forget to remind our doctors of that.

According to recent data from the Institute of Medicine, pain cost us between $297 billion and $335 billion in lost productivity in 2010. The leading causes of time missed from work due to pain are headaches, back pain, arthritis and musculoskeletal pain, respectively. A 2006 study by the American Pain Foundation found that 89 percent of Americans with chronic pain choose to go to work rather than stay home, and 46 percent of those working with pain reported that their pain impacted their job performance.

For people who work at typical computer work stations, the most common sore spots are the arms, upper backs/shoulders and neck. Prolonged sitting creates weakness in the legs and tightness in the hips and lower back. I think excessive computer work causes a functional separation between the upper and lower halves of the body. What I mean by that is from the lower back down to the legs, things are pretty quiet while the arms and hands are active and the upper back is straining to support their constant activity.

The body is designed to create its center of support from the core and the legs, yet we don’t engage them when working at our typical work stations. Instead, we shift our support center up to the base of our neck, upper back and tops of our shoulders. This causes a tightening and elevation of these areas. As a result, our shoulder blades get pulled up and apart, as opposed to together and down. This change in the positioning of the shoulder blades causes postural problems, weakness, and upper back and neck pain. Here are some tools to help counteract these painful pitfalls:

• Postural Correction- Use this to offset potentially painful postural changes created by excessive computer work. Slide your shoulder blades down as if into your back pockets and bring them together in the mid-back. While doing this, your chest will open and the curve in your lower back will expand. In order to maximize this motion, your elbows need to rotate inward toward your sides, and your chin should tuck slightly to lift the top of your head. Keep a piece of colored tape or some other reminder at your workstation and do this postural correction ever time you look at it.

• Stand and Extend- This will help create length throughout your spine and joints. Stand with your arms at your side and your palms facing forward. Bring your feet together so they touch and tighten your buttocks so that your pelvis pushes forward. Let your shoulder blades slide down toward your pockets while lifting the top of your head to the sky. Take a several deep breaths.

• Hip Stretch- This will help prevent tightness in the hips and prevent lower back pain. Stand with your back to your chair. Place your right foot on the seat of your chair and either slide your chair backward with your foot or simply just stretch your leg. Consider holding on to your desk for balance. Repeat the same move with your left foot.

• Deep breathing- Use this to help your body relax. Take a moment to concentrate on the slow outward and inward movement of your belly while breathing through your nose. Try closing your eyes to avoid distraction and place a hand on your belly to focus on the breath.

• Chest expansion- This exercise is to prevent pain in the shoulders, neck and upper back. Sit tall at your chair and raise your hands straight up overhead. Now gently pull your arms back toward your ears and press your mid-back against your chair. Keep the shoulder blades down while stretching open your chest and rib cage.

• Wrist Stretch- Overused tendons and muscles in the arms and hands need to be released. Once you get home from work, get down on the floor on your hands and knees. First, rotate your hands so that your fingers now point toward you as opposed to away from you. Slowly lean back toward your heals to stretch the tendons in your forearms. Return to the starting position, but instead of putting your palms down on the floor, bend your wrists toward you and touch the floor with the backs of your hands with your fingers pointing toward you. Again, slowly lean back stretching a different group of tendons in the forearms.

Naturally, if you are following the trial of Dr. Conrad Murray, who is facing charges of involuntary manslaughter in the death of Michael Jackson — and by the way, nobody puts on a better court drama story than the city of Los Angeles, lest we forgot — then the scenario above could easily apply to Mr. Jackson’s untimely ending. Like many of us, he dealt with some chronic pain issues, worked too hard at times, was under a lot of stress, slept poorly, and he also had a documented history of addiction to prescription medications. As a physician who treats these types of problems every day, it is just downright disappointing to me to see someone who lived amidst such abundance to not get the type of medical care that would have improved his health and quality of life as opposed to the exact opposite.

Problems like pain, addiction, stress and insomnia all feed off of each other. It is a vicious cycle, where each one escalates the severity of the other. When such cases end in a premature death, the culprit is often an overdose of a mixture of pain killers and sometimes tranquilizers. According to the Centers for Disease Control and Prevention (CDC), we have 26,000 fatal overdoses a year, at a rate of 7.8 per 100,000 people, and it is the second leading cause of unintentional deaths behind motor vehicle accidents. These types of challenging medical problems involve complex interactions between the brain and the physical body. Overcoming the challenges of pain and addiction come not from fancy pharmacology but through the rewiring of how our bodies and minds communicate with each other and support each other’s well-being.

What may not be obvious is that the seemingly bizarre events surrounding the death of Michael Jackson are an allegory of the current state of the doctor-patient relationship in America. Before we cast too many stones at Michael Jackson’s doctor, let’s recognize the glass house that we are tossing them from. In 2010, the most prescribed medication in the U.S. was the painkiller hydrocodone with acetaminophen, at a whopping 131 million prescriptions, according to an April 2011 report released by the IMS Institute for Healthcare Infomatics. In their list of most prescribed medications by therapeutic category, antidepressants and narcotic-based pain medications came in at number two and number three, respectively, just behind lipid regulators at the top of the list.

At a fundamental level, this data tells us that a primary reason people go see the doctor nowadays is to get a prescription to change the way they feel. Be honest, how many of you can say that you have never gone to the doctor and demanded a prescription at least once, even if it was for antibiotics? As a society, we are still among the wealthiest in the world and certainly, by far, have the most medical resources at our disposal. Yet we don’t use this advantage to create better health for ourselves. Instead, we demand more medications and tests while continuing to drown ourselves in rising health care costs as opposed to seeking lasting solutions that can better our well-being.

It wasn’t vexing medical problems like chronic pain and addiction that killed the King of Pop, but rather the way they were treated. But he isn’t alone, and his story is really our problem to solve. I can only hope that his publicized ending can serve as a powerful wake-up call to help change how and what we seek from our medical providers, and likewise, motivate doctors to reach beyond quick fixes and into the realm of creating greater lasting health.

This brings me to the million dollar question of why? In other words, why is the incidence of chronic pain on the rise and now affecting so many people?

I think we can find some of the answers if we look carefully at the changes that have occurred in our society during this same time period. Such changes, spurred by the evolution of technology, have had a big impact on lifestyle behaviors. For starters, we move less and we move differently than our previous generations. Innovations like cars, computers, and cell phones mean more of us can live and work in a primarily sedentary fashion. As a result, we burn fewer calories each day and we don’t use many of the muscles that we used to need for survival resulting in wholesale changes to our bodies.

Computers were not a regular part of peoples’ lives until the 1990s. Our bodies were not made to sit and work on a keyboard all day long, yet that is precisely what many of us now do. This ultimately has a big impact on the muscles and joints that support our necks, shoulders, and backs, and at the same time requires very little input from our lower halves. This also requires us to be indoors more, which means more of us are now vitamin D deficient (also a risk factor for chronic pain).

Diets have also changed over the last few decades. We eat more processed foods containing products with high-fructose corn syrup and trans fats, while consuming less fruits, vegetables, and whole-grains. Such dietary changes mean consuming more harmful pro-inflammatory food products and an overall increase in calorie consumption compared to past generations.

The end result of all of these changes is that people are getting larger and larger. At one time, the obesity rate in the U.S. was relatively low, but it has recently shot up to 30% and is projected to hit 50% by 2030 according to a recent article in the Lancet. Even small increases in body weight can cause big increases in force exerted onto the spine and knee joints, and that translates into more degeneration and more pain. On top of that, abdominal fat cells have been found to increase the secretion of inflammatory mediators.

A number of recent studies have shown strong correlations between chronic pain and lifestyle factors like obesity and smoking. If people have been smoking for decades, then why would smoking all of a sudden be associated with chronic pain? I think this has to do with our increased longevity. Certain lifestyle habits may not have a big impact on how we feel in middle age, but could have a big impact on our quality of life as we grow older.

As more of us continue to live longer, it becomes imperative that we adopt strategies to diminish the impact pain can have on the quality of our lives. If we want to successfully fight this rise in chronic pain, then we need to look at how technological changes have directly led to lifestyle shifts and find ways to offset or counter-balance these changes so we can all have a better chance of feeling well at any age.

Treating chronic pain is often about creating change. In order to help someone feel better and function better, you have to help them change the way they move, think and even breathe. Overcoming chronic pain is a game of control. Is the pain in control of the patient or is the patient in control of the pain? It is the job of someone like me to help tip this scale in the direction of the patient.

Here are some key ingredients that have helped me create positive change for those overcome by pain and how these same concepts can be used to treat what ails our economy:

Fear: There is a concept in pain management known as the fear-of-re-injury, or fear-avoidance model, where the individual in pain stops moving or using certain injured body parts out of fear. That can mean avoiding using a hand or refusing to stand on one particular leg well beyond the acute injury phase. This is a tricky situation for patients to understand because fear is often seen as a natural defense mechanism and initial attempts at using an overprotected body part can feel uncomfortable. They often need help understanding how the new fear they have developed is holding them back from getting better. Fear can put people in a very small box, but patients overcome their fears very gradually, step-by-step, by building confidence in what they can do.

It seems like there is a pervasive feeling of fear throughout the U.S. and around the world affecting decisions on a bigger scale. This would account for the wide fluctuations in our investment markets each day. You hear talk every day now about the “fear of going back to a recession” and everyone cringes whenever a new economic statistic — like unemployment — is going to be released. I know that my patients stay stagnate and fail to progress when they are controlled by their fears. We need all of our parts moving freely, in both the public and private sectors. Please inspire me with courage, build my confidence and don’t hold me back with fear-mongering.

Independence: An important concept in chronic disease management has to do with returning the locus of control to the patient. When patients initially seek medical care, they are dependent on their health care providers for getting tests, diagnoses and treatments. Successful disease management occurs when the patients start to take on more and more of the responsibility for managing their own conditions.

In the case of diabetes, for example, blood sugar control improves when proper dietary changes happen at home. When my patients develop effective tools to better manage their pain, then they feel better about becoming less dependent on needing my help. This means they have gotten past some of their fears and are more self-confident, which is a sign of sustainable progress.

I would suggest that our leaders put more emphasis on returning the locus of our economic control back home. This always gets discussed during election campaigns but never seems to gain enough traction to get off of the ground. This means tackling problems like our dependence on foreign oil and using our technological innovations to promote a better balance between hiring at home and outsourcing jobs abroad.

Avoid Quick Fixes: Patients often spend years looking for the magical treatment that will eliminate all of their chronic pain and never find it. Those who learn to accept their injuries and focus their energy more on healthy management tools, are more likely to feel happier and fulfilled.

When businesses and governments focus on quarterly profit reports and re-elections, they often fail to achieve meaningful change. There seems to be a general lack of accountability on long-term outcomes.

Environment Matters: Experience has taught me that nothing inspires a patient more than another patient who has successfully overcome similar challenges.

We need to see, hear and read more about what is working and who is having economic success from our media, and read less about whining, complaining and finger pointing. If there is a business doing well on Main Street right now, then we should all learn about it.

Be Careful What You Believe: When patients misinterpret the medical terms that get thrown at them, then they are much more likely to make poor decisions. Degenerating discs on a MRI of the lower back in a middle-aged person can be a typical age-related change of little significance, yet I see many folks interpret this to mean something is “broken” or “cracked” in their backs. Medical information is always more useful when we can put it in the right context and do something with it that is good for our health.

Is it possible that the economic reports that get released have a similar impact on the public as a whole? Do we really understand what these terms and numbers mean and how to use them appropriately? When I vote, buy a house or invest in mutual funds, I do so, not as an expert, but as a regular guy who has come to some sort of emotional decision, based on less than an ideal understanding of whatever I am evaluating. Really being in danger and just thinking you are in danger can have the exact same outcome. In other words, my advice to patients who are concerned about MRI results but can still walk, is to not stop walking.

Growth occurs when we aren’t afraid to fail. Change happens when we are open to it. Sometimes you just have to lead with your heart.

In other words, we know the right answers, but nobody is standing up to deliver them and try to right this ship. With so many millions of lives devastated by such a vexing problem as chronic pain, why do you think this is happening? As is usually the case, there are a lot of special interests influencing what is happening.

First of all, chronic pain is big business. Odds are that if you are in pain, then you are probably helping make somebody a lot of money. I bet you never thought that your pain was the focus of bonuses, corporate takeovers, kickbacks and expensive advertising campaigns, but it absolutely is. The latest data from the Institute of Medicine estimates that more than 100 million Americans experience chronic pain. That is a big target, and one that is desperate for help.

According to IMS Health, a company that tracks sales for drug companies, Vicoden, an opioid-based pain killer, is the most commonly prescribed medication in the country, and almost 20 percent of all doctor visits involve a prescription for opioids. Drug companies know that the prescription of opioid-based pills is “the gift that keeps on giving” because once folks start taking them they won’t stop because of the physical dependence they create. I think it is fair to say that there have been some pretty successful business plans out there!

Shouldn’t the fact that chronic pain sufferers are now getting more access to the strongest pain killers on the planet and at higher dosages mean that we are now doing a better job helping them manage their pain? Guess again. In my 15 years of practice, I have yet to see a scientifically sound study that can show significant benefit from the long-term use of opioid medications for chronic pain in a large patient population.

There are many reasons for this including problems with tolerance, addiction and a newer discovery known as opioid-induced hyperalgesia (OIH) — where opioid medications eventually cause some to get even more sensitive to pain. That would be akin to insulin shots making your glucose go up instead of down. If you have never heard of OIH, then my guess you is will get an earful about it once a drug company comes up with a supposed pill to treat it. Did you ever hear of ED before Viagra? Unfortunately, statistics can’t describe the heartache I see every day from the over-dependence on medications.

Certainly, doctors are up to date on all of this stuff and can put things in the right perspective? When you consider that Wall Street-driven companies sponsor our medical conferences, journals, research and dinners (basically our education) then you can see how jaded the decision making can quickly become. Unfortunately, we are now seeing a sharp rise in abuse and deaths from prescription pain killers. According to the National Institute on Drug Abuse, the abuse of prescription pain medications is the fastest growing type of substance abuse among teens, and it is now the second leading cause of accidental deaths in the U.S.

In no way are the problems with pain management strictly limited to the misguided use of pills. For example, over the last two decades there has been an exponential rise in the use of spine surgery and interventional procedures for the treatment of lower back pain. Rapid growth has taken place in the use of more complex and costly spinal fusion surgeries, and there is cut-throat competition among the manufacturers of the hardware used in these procedures. Medtronic alone makes $3 billion annually off of its spinal device unit. Again, research has consistently shown that such treatments are no more effective for low back pain than much lower cost alternatives such as aggressive rehabilitation. What the data can’t describe is what some patients and their families go through for months and years trying to recover and get their lives back after having these types of surgeries.

For years now, evidence-based medicine and scientific outcome studies have consistently shown that the most effective way to treat chronic pain is through comprehensive interdisciplinary pain programs. In 2006 the American Pain Society’s Journal of Pain published the most comprehensive and thorough review of all chronic pain treatments to date. No matter what criteria they looked at, including improved pain levels, function, return-to-work rates and cost-containment, outcome studies demonstrated that such programs gave the best long-term results. The authors concluded that “the only therapeutic approach that has shown efficacy and cost-effectiveness is a chronic pain program” and “there is unequivocal evidence for chronic pain programs.” Sadly, there are very few of these types of programs out there. Having run this type of treatment for ten years now, I could bore you with the details of all of the challenges I have faced trying to “do the right thing,” but instead let me focus on the rewards.

What does a program like this entail? Interdisciplinary treatment means different specialists (like doctors, physical therapists, psychologists as well as yoga instructors, art therapists and life coaches) working together as a cohesive and well-organized team to teach patients as many tools as possible to help them better manage their pain and improve the quality of their lives. It is really like going to an intensive school for several weeks for patients debilitated by pain to learn how to move, breathe, communicate, process and overcome one of the biggest challenges they have ever faced in their lives. Think about the hit TV show “The Biggest Loser” — but for those suffering from pain, not obesity — taking place at my center every day.

The great news here is that when pain patients learn how to adopt healthy lifestyle habits and start exercising regularly, connect better with others and become less dependent on external resources like heavy medications, then they start to feel a whole lot better. Once you look at the new research being done on the brain in pain, you start to see why this holistic approach works better than drugs and surgeries. The time for doctors, insurance companies and patients to come together and figure out how to make this readily available to the millions of folks out there who seem to need it is long over due. It’s time that we do the right thing for everyone.