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William G. Brose, M.D.
Associate Professor of Anesthesia
Director of Stanford University Medical Center
Pain Management Service

Pain is endemic in our society. Each year millions of Americans are afflicted with chronic pain, including low back pain, headaches, arthritis, and many more uncommon but no less painful medical conditions. The early identification of pain as a symptom by the medical community has led to gross undertreatment of most chronic pain conditions by physicians in modern medical practice. After all, as physicians we don’t treat symptoms; we are taught to treat diseases. The biomedical model that educates physicians and, in fact, has permeated much of the fabric of American society, fosters the undertreatment of pain we currently experience today. As a part of Western scientific method, when one identifies a problem, the first goal in resolving the problem is to identify its cause. Identifying causes for medical problems has led to some tremendous values in health care, including the identification of infectious bacteria, viruses and other organisms which cause disease. The subsequent development of specific antibiotic and vaccine treatments to virtually eradicate such parasitic and infectious diseases is due to that biomedical research. However, while we have had success in some ventures using this search for the cause, in other areas medicine has far too little information and far too little knowledge to impact such a positive outcome. Witness the problems of diabetes, arthritis, cancer, heart disease, all of which afflict millions of patients in the United States every day. In some of these conditions, we understand the underlying pathogenesis and etiology and yet are unable to provide a cure. In others, we as yet do not possess the knowledge to even clearly delineate pathophysiology, let alone the inciting cause.

The failure to be able to "cure" chronic pain is recognized by most physicians and accepted by many patients. However, the problem in chronic pain is all too similar to any other chronic medical condition. Since we do not know how to cure it what can we do? Physicians are taught to view chronic pain as an extension of the acute pain warning system. As such, the pain tells us that something may pose a threat to our lives or the integrity of our bodies. Chronic pain, however, provides no such threat and this awareness should help physicians as well as patients to recognize that chronic pain is a separate disease, which, like other chronic diseases, needs to be appropriately managed. Unlike the quest for the elusive cure of chronic pain, which continues to evade us, by viewing pain as a chronic disease, one can look for successful strategies to help reduce the impact of this disease on a patient’s life.

In the Pain Management Center at Stanford the view of pain as a chronic disease is well supported. For this reason, the orientation of patient care within the Pain Service is that of an outcome-oriented approach helping to individualize the treatments of each patient to achieve the specific outcomes they desire. By assessing the multitude of impacts that chronic pain has had on patients’ lives, interrupting their vocational, social, and recreational pursuits, increasing their reliance on health care resources, as well as contributing to their overall physical and mental health, physician providers can assess areas of greatest need for patients and by working with them, identify the most successful management strategies to reverse the impacts of pain on their lives.

Bob Miller was one such patient who identified himself to me in his first visit in February 1994. Miller had been afflicted with low back pain, intermittently for nearly a year. While initially he had seen a number of specialists, each seeking the "holy grail" of a cure for his pain, time and time again these providers failed to identify the sole causative agent. Their failures were not the failures of individual doctors in treating a single patient, but rather should be recognized as the failures of a symptom-oriented biomedical model failing to provide adequate diagnostic and treatment tools for conditions as complex as Miller’s low back pain. Unfortunately, in the multiple failures that he had experienced with the medical community, the message that was being reinforced was not that his back pain was real, but perhaps too complicated or too multifactorial for the current state of medical knowledge to clearly identify a solid cause. Instead, he was left with the impression that either there must be something sinister accounting for his low back pain that had yet to be identified by any of these skilled practitioners, or that his pain, in fact, was fictitious and presenting itself as a primary manifestation of some underlying mental disorder.

After first going through a series of appropriate steps in medical and psychological evaluation, the providers in the Pain Service attempted to educate Miller that his back pain was not evidence of some sinister, underlying pathology that represented a threat to his life, nor was it evidence of some smoldering mental disorder that would eventually lead to his being diagnosed as "crazy." Instead, we educated him to the multifactorial nature of his low back pain, which included elements of muscular spasm, disk and facet inflammation, as well as super-imposed psychological stressors, all of which combined to make this a chronic pain condition. By identifying the impacts that this chronic painful condition had had on his life, and working with him to specify the areas where he would like to see the most immediate change, we initiated treatments that engaged him, from medical, rehabilitative and psychological perspectives. By having Miller accept the responsibility for measurement and monitoring of his changes with the various medical and non-medical components of treatment, he was quickly able to identify those elements of care which were linked most directly to improvement of outcome.

Once this process was initiated, Bob Miller began his own quest to identify the specific components of non-medical management that would take him to the highest levels of productivity he had seen in his lifetime. After working some months at half-time due to his chronic back pain problem, he was able to return to his demanding career as an attorney and director of a federal government agency regional office. In addition to the demands of his full-time position, he was functioning so well that after extensive study and research in the areas of pain management and alternative medicine, he co-authored this comprehensive book. Moreover after 315 hours of instruction, he became a California Certified Holistic Health Counselor and in this capacity has assisted others in managing their pain.

The success of Miller’s program for managing his low back pain documented in this book should stand as a reassurance to all patients afflicted with chronic painful conditions to help them recognize that if they can engage in the same type of introspective process, they too can learn to manage their chronic back pain. As a secondary benefit of Miller’s involvement in the Pain Management Service at Stanford, this book provides a unique and well-structured presentation of the myriad different non-medical management techniques for chronic pain. By picking up and reviewing this text, not only can patients with chronic low back pain identify and learn from someone who has transcended his problem, but moreover they can use specific instructions and self-help tools provided with book to integrate these same successful management strategies into their own treatment armamentarium.

As a physician I am pleased to see the progress that Bob Miller has been able to make in his personal battle with chronic pain, and moreover I am thankful to him for chronicling and cataloging the treatment he identified for chronic pain, which hopefully will provide similar benefit to back pain sufferers everywhere.

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