The Full Circle Pain Program was featured in a couple of articles in 2008 in the Eureka Reporter:

Locals with chronic pain don’t gain as another practice closes: Part 1

By

CAROL HARRISON, The Eureka Reporter
Published: Apr 1 2008, 10:56 PM · Updated: Apr 1 2008, 11:28 PM
Topic: Health

The county’s only multidisciplinary chronic pain clinic closed Tuesday when Dr. Connie Basch officially shut the doors of her Arcata practice.

Basch’s decision to return to teaching cuts by 10 percent the number of obstetric and gynecologic physicians available in Humboldt and Del Norte counties.

While the remaining nine specialists will shoulder the OB-GYN overflow, Basch’s approximately 100 pain patients have a tougher row to hoe. Therapist Len Wolff and social work intern Jenny Silverstein will continue the groups with a McLean Foundation grant good for a year, but without a physician at the top of the pyramid, they lose the medication part of the equation. Basch tried to find a replacement, but no one has committed to picking up the chronic pain clinic she introduced in 2005.

“There’s a definite disdain,” Basch said of the desire to treat the chronic pain of those who suffer from fibromyalgia, low back pain, degenerative or rheumatoid arthritis, and a variety of other ailments. “There’s always the question: Is it addiction or is it pain?”

“We have a very high rate of drug overdoses in this county and 30 percent are related to prescription drugs,” said Dr. Ann Lindsay, the county’s chief public health officer.

Telling the difference between those who need medication to get high and those who need it for quality of life is not an easy assessment.

“Sometimes doctors know and sometimes they don’t — that’s what we’ve learned,” Lindsay said.

From Basch’s perspective, erring on the side of helping those facing a lifetime of misery is the choice, personally and professionally.

“Pain is inevitable; suffering is not,” she said. “Doctors are worried about inappropriate prescribing and a loss of their license, but undertreatment is inappropriate. The Medical Board of California specifically identifies failure to manage pain adequately as ‘inappropriate prescribing.’”

She also points to the Pain Patient Bill of Rights, passed by the California Legislature in 1997. The pertinent passage: “(a) patient suffering from chronic intractable pain has the option to request or reject the use of any or all modalities to relieve his or her severe chronic intractable pain.”

“Assessing pain is inherently subjective,” Basch said. “There’s the feeling that there’s no way people could need the pain medication they’re being prescribed. Narcotics and the tolerance associated with them frightens doctors. If I took one-tenth of the medication some of my patients are taking, I’d die.”

“Everybody with chronic pain has psychological issues and that’s an important part of managing chronic care,” Lindsay said. “Making sure they get the psychological evaluation and support helps the quality of life and to sort out issues between addiction and medication.”

But it takes times. Basch’s clinic begins with a 60-minute introductory meeting with each patient. Basch and a therapist then took eight to 10 participants per group through two-hour meetings every two weeks for 14 sessions. After the seven-month program, clients moved to monthly follow-up sessions.

“This has been the closest thing to a cure yet,” wrote Susie L., who’s dealt with chronic pain for a decade. “I still have bad days, of course. But I also have the group to look forward to, and in between I usually remember how to cope and turn that day around.”

“Being with other people who understand what it is to live with constant pain that has no end in sight and sharing our experiences in a safe environment has ended my feeling of isolation,” wrote another in the grant request to the McLean Foundation. “I take pain medication and not only didn’t want to use more, I was tired of using any medication.”

The fear of addiction scares patients as well as physicians. Basch thinks both overemphasize the risk of addiction while underplaying the risks of other drugs they freely diagnose or take.

“Our criteria for treating chronic pain with opioids has been that aggressive treatment of pain is appropriate as long as function is improved — meaning a person is more able to complete the activities of daily living and interact with family,” Basch said. “When function deteriorates or there’s a loss of control, we taper the medications.”

Tomorrow: A multidisciplinary approach to chronic pain management and the patients who used it.

Clinic used mind-body strategies to make a difference

By CAROL HARRISON, The Eureka Reporter

Published: Apr 2 2008, 9:45 PM · Updated: Apr 2 2008, 11:52 PM

Category: Local News

“I am a success story,” Suzanne Avola said.

After 15 years of pain related to a 1991 diagnosis of fibromyalgia, Avola has been pain-free for 18 months. She credits the turnaround to the multidisciplinary approach offered through the chronic pain clinic offered as part of Dr. Connie Basch’s practice.

Basch’s practice, the Full Circle Center for Integrative Medicine, officially closed its doors Tuesday.

“It’s a big loss — for her patients and future patients she might have had,” Avola said.

A woman identified only as Marilyn is another success. She worked in a community clinic for 13 years, long enough to learn that “chronic care patients are looked down upon” by the medical profession and the general public. In late January, she wrote a letter seeking grant support to keep the clinic going.

“While society is caring and motivated to help people with acute problems, people with problems that cannot be solved do not receive the same understanding, even though they may be in more need of it,” she stated. “This is especially true for those of us that must take morphine or other ‘drugs’ to manage.”

Marilyn noted a genetic disorder that can’t be cured led her to “the most excruciating pain I had ever experienced.” Disability and isolation followed. So did morphine.

“I felt that I had to hide the fact that I had been put on morphine so people would not consider me a ‘drug addict,’” she stated. “Within days, I went from being a respected, normal citizen to being literally shut away from the rest of society and locked alone into a terrible world of extreme pain.”

After 18 months with the group, Marilyn said her morphine dose is half of what it was a year ago. As of a month ago, Avola was drug-free.

“I’ve regained all the weight I’d lost, and my pain is well-controlled,” Marilyn said. “This group has shown me and all my fellow group members the way back to a positive life.”

The clinic instructed participants about medications and side effects and addressed the stress and psychosocial dysfunction created by experiencing chronic pain and disability. It also tackled the underlying physical pathology creating and maintaining pain and sought to give clients alternative tools for dealing with pain.

After an introductory individual meeting with Basch, groups of 8-10 clients met for two hours every other week over a seven-month period. Monthly meetings followed.

The groups learned how to evoke a relaxation response through abdominal breathing, imagery, chair yoga and mindfulness meditation. Cognitive behavioral therapy introduced other stress management, communication and goal setting skills while discussion and reading broadened the understanding of the roles of medications, nutrition, exercise, sleep and herbal therapies in managing pain.

“Your unconscious mind can trick your conscious mind,” Avola said. “Connie helped me to understand the connection between the mind and the body. You can have a lot of emotional pain in your life and if you don’t attend to it and just stuff it in, it can come out in physical pain. Learning about that is what helped me to put it together.”

Avola said she had all but given up when Basch started the pain clinic in 2005.

“I was skeptical of anything and I didn’t see how going to a group and talking about it was going to make anything different,” she said. “I was in extreme pain and couldn’t function. I’d had it for so long and tried so many things. I couldn’t take care of myself.”

Avola said she was on “a lot” of different medications and couldn’t physically keep up with the jobs she’d get.

“That was the worst part,” she recalled. “When you can’t take care of yourself, pay your own bills and have to go on disability, your self-esteem takes a beating. It’s hard — really hard.”

It’s also hard on primary care physicians.

“Our traditional biomedical model falls particularly short in chronic pain,” Basch said. She called it a complex problem that can create “needy” patients who are difficult to serve in the rushed visits now common in traditional office settings.

“All of the primary care doctors in this community are challenged by giving good care to people with chronic pain,” said Dr. Ann Lindsay, the chief public health officer for the county.

Contributing to their concern: the subjective nature of pain assessment and the county’s high rate of drug overdoses — 30 percent of which Lindsay said were attributable to prescription drugs.

A few years ago, Lindsay said she was part of a feasibility study for a pain clinic even more comprehensive than Basch’s.

“We got to the point where we put together a directory of non-prescription methods for dealing with chronic pain and it’s posted on the medical society Web page,” she said of the feasibility effort funded by the Humboldt Area Foundation.

But when it came time to make it fly, Lindsay said, “It had to be run by a federally qualified health center because of the opportunity for enhanced reimbursement. It may be on Open Door’s list of things to do, but they’re scrambling for providers which tends to make expansion into other areas challenging.”

Frank Anderson, director of Open Door’s Telehealth and Visiting Specialist Center in Eureka, said a group from San Mateo is looking to do pilot studies on pain management through telehealth.

He called himself “cautiously optimistic” about the project and expects to know more after meeting with the San Mateo group this spring.

“A mantra, yoga, tai chi, guided imagery — it’s amazing how profound the impact (of the clinic was),” Basch said. “This isn’t about people getting loaded and high. It’s about trying to decrease pain and improve the quality of people’s lives.”

“I don’t understand how we have become a society where we separate the head from the body,” Avola said. “Without your head, the body couldn’t function. You can’t feel pain unless it goes through the head first. What does that say about us? You have to integrate this or people won’t get better. Maybe that’s why people aren’t getting better.”

Colleen Sullivan is better. She arrived at Basch’s clinic after the cancer doctors who had ”been quite kind during treatment” were unwilling to follow up with the extensive pain, exhaustion and depression she later experienced.

“My primary care physician was bewildered at what to do,” Sullivan wrote in a letter for her group.

She absorbed the suggestion that she head to San Francisco for a pain clinic “because nothing was available in our little community.”

“The use of long-acting opioids in intractable pain is considered the standard of care elsewhere,” Basch said. “Patients I have spoken to who have moved out of the area have found much less resistance to this sort of management in Oakland, Portland and other cities than here in Humboldt.”

Sullivan described her group as “shattered by the effects of pain.” Old and young, working and disabled, many had suffered longer than her two years.

The group became a “means of problem-solving and emotional and psychological support. All of this was done with a selfless consideration for the fact that the majority of us are poorly insured, if at all, and lacking in the kind of deep pockets necessary to get needed treatment.”

Basch said there is “a ton of data” that supports a multidisciplinary approach.

“People with chronic pain have all sorts of complaints and go to see doctors,” she said. “Eighty-five percent of patients who go through multidisciplinary programs see their quality of life improve. Their pain scores drop. Their emotional distress drops. It leads to less health care expenditures. Coping strategies save money.”

A 62-year-old retired nurse practitioner who did not want to be identified talking about her battle with pain called the loss of Basch “huge.” The retiree said she went from feeling useful to useless after an accident that left her disabled and in pain, but she’s hopeful for the future.

“I’ve learned that even though my life is completely different, it’s far from over,” she said of her time with Basch and Len Wolff, a therapist Basch teamed with. “I’m rarely depressed now. I have a small business designing and making clothing for babies and toddlers. I’ve learned that I have value.”

Wolff is teaming with social work intern Jenny Silverstein an the McLean Foundation to keep an altered form of the clinic going. Without a physician, the reimbursement and prescription medication challenges make the endeavor more difficult. Patients will have to work through their own primary care providers.

“We met with Open Door last week and they’re excited to continue to have a place to refer,” Wolff said.

A sliding payment scale and outreach to the medical and therapy community are his immediate plans. That’s good news for the approximately 100 pain patients served by Basch who hope the pain clinic can find a more permanent home in the year the McLean Foundation grant lasts.

“Desperate people do desperate things and people in pain are desperate,” Sullivan wrote.

To contact Wolff for information, phone 707-826-7338.

 Seed money helps pair to fill hole in chronic pain management
By CAROL HARRISON, The Eureka Reporter
Published: Aug 26 2008, 11:44 PM · Updated: Aug 26 2008, 11:54 PM
Topics: Health, Health

There’s no group physician and no medication, but starting in October, chronic pain sufferers and their doctors will have a complementary healing alternative offered by marriage and family therapist Len Wolff and social worker Jenni Silverstein. 

The pair hope physicians looking for holistic approaches to treating the needs of patients suffering with chronic pain will refer patients to the two-hour group sessions to be offered once per week for 14 weeks.

Equally important: that the referred patients embrace a program Wolff said is loosely based on the Mind Body Medicine Institute at Harvard and the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School.

It is similar to what they offered when they affiliated with Dr. Connie Basch and the Full Circle Center for Integrative Medicine, which closed in April.

“We lost something when Connie left,” Wolff said. “There are a lot of people in pain in this community.”

Wolff went to the McLean Foundation and Humboldt Area Foundation for $11,000 in seed money to try to plug the hole in the system made by Basch’s exit.

“These kinds of groups have been proven in multiple studies to help people reduce suffering and improve overall quality of life,” Wolff said. “Physicians can refer them, but clients still have to come.”

“There’s a lot of evidence that shows pain causes depression, and depression and anxiety make pain worse,” Silverstein said.

Wolff cited a study in which almost 90 percent of the clients were better able to manage the pain associated with fibromyalgia, lower back ailments, degenerative and rheumatoid arthritis, and other chronic conditions if they had gone through multi-disciplinary programs.

“We help clients learn how to restructure the negative thoughts that interfere with their coping abilities, to recognize the distinction between the pain and the depression and anxiety that often accompany it, and to appreciate the small things that can make their lives more manageable,” Wolff said.

Skeptics abound. Suzanne Avola was one.

“I didn’t see how going to a group and talking about it was going to make anything different,” she said last spring. “I was in extreme pain and couldn’t function. I’d had it for so long and tried so many things, I couldn’t take care of myself.”

She’d been on “a lot” of medications since being diagnosed with fibromyalgia in 1991. But she said the multi-disciplinary approach used by Silverstein, Wolff and the now-departed Basch left her pain-free and drug-free.

Hydesville’s Linda Shapeero said the program led to a 70 percent reduction in her use of pain medication and opened the door to volunteering at the Multiple Assistance Center, Redwood Memorial Hospital and her granddaughter’s school.

“Way back in 1992, doctors made me feel like it was all in my head, that I was imagining the pain,” she said. “I was like, wow, what if this is all in my mind?

“It affects your outlook. It became depressing. This group is not so much about counseling; it’s about everybody in the same boat working together and trying to heal.”

Wolff and Silverstein emphasize that the October therapist-only groups do not provide medication. Yoga, tai-chi, ortho-bionomy, cognitive behavioral therapy, guided imagery and a sound-sleep method are some of the techniques they utilize.

“This is not a medical program,” Wolff said. “It’s therapeutic and psycho-educational. We are willing to work with prescribing doctors to best help clients heal holistically.”

Physicians can choose, or not, to link with Wolff and Silverstein.

“There are some who see the value of what we do,” Wolff said. “Those seeking drugs aren’t likely to stay in sessions.”

“No one wants to be dependent on pain medication, but to have to live with that pain all the time is a living nightmare,” Shapeero said. “Some doctors lose sight of the patient.”

Pain is a controversial topic in medicine. Physicians struggle to identify those who need medication for high quality of life from those who need medication to get high or sell on the street.

“Sometimes doctors know and sometimes they don’t. That’s what we’ve learned,” said Dr. Ann Lindsay, the county’s public health officer, in the aftermath of Basch’s closure of a clinic that served 100 people since 2005. “We have a very high rate of drug overdoses in this county and 30 percent are related to prescription drugs.”

Basch called pain assessment tricky, especially since it requires time most primary care practitioners don’t have for patients she said are often seen as “needy.”

The seed money enables Wolff and Silverstein to spend time teaching and bonding with clients while establishing multiple links with physicians. Because of the arcane nature of medical reimbursement, a physician running the clinic as Basch did allows for better insurance reimbursement, but that still wasn’t enough to cover the group costs.

“Doctors manage symptoms. They don’t treat the whole patient by dealing with the therapeutic issues around losing mobility, your identity as a worker in a job you no longer have, or friendships. We work a lot with helping people to change their attitudes, but we don’t have a magic pill,” Wolff said.

The complete 14-week session is available on a sliding scale of $140 to $540.

“If you are a physician, I can act as a middleman and you can see patients less often,” Wolff said. “They don’t take up as much of the physician’s time and physicians get some assurance that someone going through a weekly program isn’t an addict. It’s a win-win.”

Referrals and questions should be directed to 707-826-7338. Wolff and Silverstein practice at 1062 G St., Suite F, in Arcata.

(Carol Harrison can be reached at charrison@eurekareporter.com or 707-269-7435.)