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11 Articles in Volume 14, Issue #5
DEA and Doctors Working Together
Working With Law Enforcement and DEA
Demystifying CRPS: What Clinicians Need to Know
Glial Cell Activation and Neuroinflammation: How They Cause Centralized Pain
History of Pain: The Treatment of Pain
Spirituality Assessments and Interventions In Pain Medicine
The Stanford Opioid Management Model
We Need More “Tolerance” in Medical Pain Management
Treating Rebound or Chronic Daily Headaches
Buprenorphine With Naloxone for Chronic Pain
More on Nitrous Oxide and Meperidine in Pain Care

History of Pain: The Treatment of Pain

Editor’s Note: This is the fifth installment in Dr. Olson’s series on the History of Pain. The first four installments addressed early pioneers in pain management, the nature of pain, and the psychosocial assessment of pain. This issue will review, in a broad stroke, all the elements of successful pain management programs—medical management, interventions, and psychosocial coping strategies.

“The stronger person is not the one making the most noise but the one who can quietly direct the conversation toward defining and solving problems.”

—Aaron T. Beck, MD (1921- ), Founder of Cognitive Behavioral Therapy

I have a strong conviction that the best treatment of chronic pain encompasses a multidisciplinary approach—not an either/or option. Clinicians should not treat chronic pain just medically and then only refer the patient for psychological treatment if medical treatment fails. This is the worst-case scenario for the patient because the patient will interpret that scenario to mean, “my pain must be all in my head.”

This conviction evolved over my 25 years of practice, during which time I have been fortunate to work with excellent surgeons and pain management physicians.1-4 Twenty years ago, I was invited to join a small, select group of spine surgeons to form a website. At that time, the World Wide Web was just beginning and we had no idea where this endeavor would go. Today, SpineUniverse.com, a sister website to Practical Pain Management, has over 200 distinguished faculty members as contributing editors and receives over 5 million visits per year.

My experience as a pain psychologist at the Oregon Health & Science University (OHSU) Multidisciplinary Pain Program also taught me to appreciate how various disciplines can work together to provide optimal pain treatment. While at OHSU, I was appointed to sit on the Institutional Review Board (IRB) for 6 years. Because the IRB is responsible for evaluating and approving every research protocol involving human subjects within the medical school, this experience was extremely valuable in honing my critical thinking skills needed to evaluate research methodologies. And perhaps most importantly, I have acquired critical knowledge from my many patients as to what treatments have been helpful. These experiences inspire me to share my thoughts and opinions on the treatment of pain.

The Scope of Pain Treatment

Because the scope of pain treatment is so extensive, I have divided this review into 2 major sections:

I have omitted many adjunctive and alternative therapies that are equally important in the overall treatment of pain. The most notable omissions are physical and occupational therapies. The value of both of these therapies from a multidisciplinary approach is well documented and I highly recommend them.

When I discuss treatment options with patients, I use the metaphor of a toolbox. I explain that each provider will offer pain management tools for the patient’s toolbox. These tools are not mutually exclusive; they are additive. The more tools in your toolbox, the more effective you will be in managing your pain. Some tools may be invasive, pharmacological, or behavioral, and they all are equally important. I point out that there are no “silver bullets.” These therapies are not necessarily curative, but if the patient is willing to work hard, they will achieve more control over their chronic pain and an improved quality of life.

Pharmacological Approaches

We begin with the World Health Organization (WHO) pain ladder, which was first published in 1986 (Figure 1).5 This widely accepted approach to medication management has 3 successive rungs (steps), from Step 1 to Step 3. The ladder describes pain in terms of intensity and recommends that an analgesic be prescribed starting at Step 1 (non-opioid analgesics including non-steroidal anti-inflammatory drugs [NSAIDS] and aspirin). If the pain persists or worsens, the physician should prescribe analgesics from Step 2, including “weak” opioids, including schedule II opioids such as codeine, with or without a nonopioid or adjuvant therapy. Step 3, reserved for patients with moderate to severe pain, calls for the use of “strong” opioids.

Prescription practices vary depending on physician location, nature of practice, insurance coverage, and training levels. The efficacy or analgesia achieved is further compounded by patient variables including compliance issues, tolerance, and adverse reactions.

In my opinion, pharmacological approaches to pain treatment can be appropriate adjunctive tools if the prescribing physician is familiar with the patient’s history of pain, type of pain, pain medications, and contraindications related to the patient’s pathology.

I have worked with many prescribing pain physicians who feel that schedule III opioids are not appropriate for long-term care. One pain physician I work with requires a psychosocial evaluation before prescribing opioids long-term. As a practicing pain psychologist who provides adjunctive behavioral treatment, the requirement of a psychosocial assessment appears prudent, but it is not a universally accepted approach. From a practical treatment approach, it makes sense if you know your patient’s psychological profile before you enter into a long-term relationship of opioid prescribing. On the other hand, it may not be feasible in rural areas where pain psychologists are scarce. As pain psychology matures and more pain psychologists become available, I can foresee a requirement of a psychosocial evaluation becoming the rule and not the exception.

Nonopioid Analgesics

Aspirin (salicylate), acetaminophen (Tylenol, others), and NSAIDS are the most common analgesics represented in Step 1 of the WHO analgesic ladder. NSAIDs yield pain relief by reducing the excitation of the peripheral nociceptors by reducing synthesis of prostaglandins, chemical lipid mediators associated with cell membranes that are synthesized in most tissues. According to Marchand, “the reduction of postaglandin synthesis will decrease the inflammatory response by blocking the accumulation of substances such as bradykinin and histamine which activate or sensitize the peripheral nociceptors.”6

Therefore, NSAIDs work directly at the site of a lesion. Unfortunately, there are well-documented adverse reactions associated with the use of NSAIDs. They may cause gastrointestinal upset, bleeding issues, and neurological problems. Some patients may experience an allergic response, and these risks increase in the elderly population. If the forgoing risks are an issue, then the use of acetaminophen is a safer alternative because it does not have an anti-inflammatory effect, although at higher doses it can impact the liver.

Cyclooxygenase (COX)-2 inhibitors (coxibs) were introduced to the market as safer alternatives to NSAIDs. Because coxibs do not inhibit COX-1, a theoretical advantage of these agents was fewer GI adverse events compared with nonselective NSAIDS with similar analgesic efficacy.6 Celecoxib (Celebrex, others), is the only commercially available coxib, carries a boxed warning regarding an increased risk for serious cardiovascular and GI events. Given these risks, the FDA encourages practitioners to use the lowest effective dose of celecoxib for the shortest duration consistent with the treatment goals of the individual patient.

Anticonvulsants

Anticonvulsants, or membrane-
stabilizing drugs, were originally developed to control seizures or epilepsy. The drugs in this class usually are indicated for neuropathic pain because epilepsy and neuropathic pain both are associated with changes in the sodium and calcium channels. According to Marchand, “the analgesic effect of membrane stabilizers is found in their regulation of neuronal excitability in the central nervous system [CNS] by increasing inhibition or reducing excitability.”6 They further stabilize the activity of sodium or potassium by increasing the activity of g-amino butyric acid (GABA), an amino acid neurotransmitter whose main function is to inhibit neuronal firing.6 Even though this class of medicines is relatively safe, there are reported reactions associated with its central effects, such as sedation, fatigue, dizziness, and balance and vision problems.

Antidepressants

When we discussed the nature of pain,3 I emphasized the importance of antidepressant medicine in the pain management toolbox. Because most pain patients are clinically depressed, this class of medicine has a dual purpose of improving mood and enhancing analgesic effects. My experience has substantiated the value of the older tricyclic antidepressants (TCAs), especially the shorter-acting TCAs such as desipramine (Norpramin, others) and imipramine (Tofranil, others). These agents produce fewer negative side effects and do not alter sleep architecture or suppress rapid eye movement sleep. There is a growing body of research supporting the use of TCAs for the following pain conditions: post-herpetic neuralgia, diabetic neuropathy, headache, rheumatoid arthritis, chronic low back pain, fibromyalgia, and cancer pain.7

An advantage of TCAs is their relatively low costs; however, they are not without adverse effects. They can produce central effects, such as fatigue and impaired alertness, as well as anticholinergic effects, such as dry mouth, vision problems, constipation, and tremors.

The newer dual-acting antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs), are effective alternatives to TCAs. The SNRI antidepressants that have been shown to be effective for chronic pain include venlafaxine (Effexor, others), duloxetine (Cymbalta, others), and milnacipran (Savella). Venlafaxine was the initial agent in this drug class and was primarily developed for the treatment of depression. Studies with duloxetine have focused on its use as a primary treatment of chronic musculoskelatal pain, neuropathic pain, and fibromyalgia, while milnacipran has been studied in the treatment of fibromyalgia.

Opioids

First isolated from the opium poppy during the 19th century, morphine provides pain relief by inhibiting nociceptive signals within the CNS and activating the descending inhibitory system. Opioids exert their analgesic effect by acting as agonists at the opioid receptors—primarily the mu receptor.8,9 Opioid receptors are found throughout the nervous system including the periphery and within the spine.10 Most opioids exhibit selectivity for the mu opioid receptor. However, as the dose increases, selectivity can be lost and other opioid receptors (eg, kappa and delta) can be affected, increasing certain side effects, such as sedation, respiratory depression, and euphoria. In addition to central nervous effects, peripheral adverse effects include nausea, constipation, increased pressure on the bile ducts, itching, histamine release, and urinary retention.6

One of the most common issues associated with long-term use of opioid therapy is tolerance to the analgesic effects of opioids. This presents a unique problem for the prescribing pain provider, especially at higher dose levels. I recommend Scott Fishman’s Responsible Opioid Prescribing Guide for a more in-depth discussion regarding this topic.11 Recent research indicates that continuous infusion of morphine directly into the epidural space or cerebrospinal fluid provides direct pain relief at a lower dose.12

Methadone is a synthetic opioid agent that was initially introduced in the United States as an analgesic in 1947.13,14 In the 1960s, methadone became a popular treatment for opioid addiction. It works like the opioids but with different emphasis on the receptor subtypes. According to Chou, methadone is appropriate in the treatment of chronic non-cancer pain because of its potent analgesic effects and its relatively low cost, but it does have substantial risks.15 According to a literature review by Webster, methadone represented less than 5% of all opioids prescribed during the study period of 1999 to 2009, but it was responsible for one-third of the opioid-related deaths during that time.16 Because of methadone’s long half-life, proper titration can be difficult. Therefore, methadone should be prescribed only by clinicians who are familiar with its use.

Since the nature of opioid therapy presents so many potential negative outcomes, including potential addiction or dependency issues and inappropriate patient use, special considerations must be employed. The first is a provider-patient agreement or contract for long-term opioid therapy. All the pain providers with whom I have worked require some form of agreement before initiating treatment. According to Fishman, 6 basic elements of a patient’s care should be documented in writing; 1) assessment, 2) education, 3) treatment agreement and informed consent, 4) action plans, 5) outcomes, and 6) monitoring.11

As mentioned earlier, there is a growing awareness within the pain medicine field of the need for a psychosocial evaluation before long-term opioid therapy is initiated. It makes clinical sense because the provider should be fully informed of potential risks before initiating treatment rather than after, when it is too late.

For a more comprehensive treatment of long-term opioid therapy, I recommend an excellent book on this topic published by the International Association for the Study of Pain entitled The Pharmacology of Pain.7

Non-Pharmaceutical Approaches

Invasive Treatments

The theory supporting surgical treatment is fairly straightforward. It is based on the idea that if you interrupt the nociceptive pathway by surgical section, the pain will disappear. Even though surgical techniques and approaches have improved, chronic pain has persisted and, in some cases, has become worse. Deductive reasoning then postulated that chronic pain must be of central origin, as in the example of post-amputation phantom limb pain.17

My recent clinical experience in working with patients who have gone through an ablative procedure leads me to believe that some well-selected patients will experience pain relief from surgery. The length of pain relief can be highly variable, from no relief to relief lasting months. Even during radical surgical procedures, such as posterior radicotomy, cordotomy, or sympathectomy, the pain signal is rarely extinguished completely. Any surgical intervention to “cure” pain is controversial at best. Spine surgery can be helpful for some patients, but, on average, approximately 50% of patients experience some pain relief, with moderate improvement in functional ability. About 25% of patients have no relief at all.18

Failed back surgery syndrome is not well understood or accepted. It usually is a diagnosis of exclusion when a patient has experienced a poor outcome from spinal surgery. There are a number of reasons why back or spinal surgery fails. According to Oaklander and North, the most common reason is poor psychosocial status at the time of surgery.19 This conclusion reinforces the value of a psychosocial evaluation prior to surgery. For a more complete discussion on this topic, I highly recommend the Psychology of Spine Surgery by Block et al.18

Acupuncture and Trigger Point Injections

Acupuncture and trigger point injections are well-established pain interventions. The origins of acupuncture are based in eastern medicine, on the belief that pain is the result of a disconnection between 2 poles of energy (yin and yang). The goal of acupuncture is to reconnect or balance the 2 poles of energy. Within the practice of acupuncture, there exist differences of opinion regarding the placement of needles. Research findings are mixed with respect to the points to be stimulated.20 Reports from patients who have undergone acupuncture treatment suggest that the degree of relief and the length of relief are highly variable (Figure 2).

Trigger point injections (TPIs) using a local anesthetic can be a useful tool if paired with physical therapy. The role of the physical therapist is to work with the patient immediately after the TPI, when the trigger point is not active. The goal of the therapist is to stretch the target area while it is less painful or reactive. According to Travell, trigger points vacillate between active and latent states and can persist for years.21

The pain relief from trigger point therapy also is highly variable and usually subsides as the anesthetic effect wears off. If the pain provider can convince the patient to use heat and stretch on a regular basis, longer lasting relief can be obtained. I also feel that deep massage or acupressure can complement the relief obtained from TPI therapy as well.

The neurophysiology of trigger points is not well understood. Melzack found an interesting 70% correlation between the location of a trigger point and the location of an acupuncture point.22 For a more in-depth discussion, I recommend an excellent review by Simmons.23

Implantable Pain Technology

Spinal cord stimulation (SCS) was introduced in 1967 by C. Norman Shealy to help control cancer pain. Since that time, there have been notable improvements in hardware and selection criteria.18 The theory behind SCS was based on the Gate Control Theory. Simply stated, SCS is based on the idea that electrical stimulation of the A-beta pain fibers inhibits the A-delta and C fibers and, theoretically, closes the pain gate. The technique is fairly straightforward in that an electrode is placed in the epidural space using a hollow needle. The placement of the electrode is based on the patient’s pain presentation. Before initiating SCS, the patient will undergo psychosocial evaluation to rule out risk factors that may interfere with a successful outcome.18 If the patient is an appropriate candidate, the next step is a trial period during which the patient goes home and tries out the SCS. The trial period can vary depending on the implanting physician, but it usually lasts from 5 to 7 days. At the end of the trial period, the patient will meet with the implanting physician to determine if the trial was a success. The criteria for success will vary with each implanting physician.

Sometimes the results of the trial are mixed. The patient may experience relief in certain places, but it may not cover all of the painful areas. In this case, the patient and the implanting physician have to consider the benefits of partial pain relief before proceeding to final implantation. Outcome research is mixed, with published reports indicating 50% to 75% relief for patients proceeding to permanent implantation.

The other major form of implantable pain technology is direct infusion or neuraxial drug administration (eg, intrathecal pain therapy). This form of therapy initially was approved for cancer pain but now is appr

oved for benign or non-cancer pain. It allows opioid-based medicines to be administered directly to opioid receptors by passing the blood-brain barrier. This form of administration allows for a smaller amount of medicine to achieve similar or improved results, without the systemic side effects associated with oral administration.24

Noninvasive Treatments

Transcutaneous electrical nerve stimulation (TENS) is a widely used noninvasive treatment. TENS is based on the Gate Control model of pain since it inhibits the pain signal through the stimulation of non-nociceptive pain fibers. In practical clinical terms, the theory is based on the assumption that electrical peripheral stimulation of a specific region produces a localized analgesic effect. Keep in mind that this also is the basis for muscle stimulation techniques, so I will not include additional discussion of this procedure. TENS approaches can be grouped into 2 categories: conventional TENS, which is based on stimulating non-painful nerve fibers; and acupuncture-like TENS, which is based on stimulating painful nerve fibers.

Conventional TENS uses high-frequency, low-intensity stimulation to produce paresthesia without producing pain. Research supporting the clinical use of TENS is mixed.25-27 My clinical experience with patients suggests that for some patients it can be a useful tool and, therefore, it is worth a trial.

One caveat pointed out by Marchand is that caffeine appears to block the optimal effect of TENS, even at low doses. Therefore, it is important to limit coffee, caffeine-based teas, chocolate, and colas in patients undergoing TENS.28 In addition, there is evidence suggesting that opioid-based medicine may produce a cross-tolerance to acupuncture-like TENS but not conventional TENS.29

Behavioral Treatments

In my own clinical practice, I include the use of relaxation therapy, if it is appropriate. I have found that not all pain patients will respond to relaxation therapy, so it takes some flexibility on the part of the provider to determine if relaxation therapy is appropriate. If the patient agrees to actively pursue relaxation therapy, I will augment this training with the use of biofeedback. I consider the use of relaxation therapy and biofeedback to be an active form of therapy, but I also include passive techniques.

If sympathetic reactivity appears to be contributing to the patient’s pain experience, I initially instruct the patient in the technique of deep breathing or breathing from the diaphragm. It is best if the patient is wearing loose-fitting clothing and, if they are wearing a belt, they should unbuckle it. I start by asking the patient to take a deep breath through the nose, expand their chest, hold their breath for a few seconds, then exhale through the mouth and emptying their lungs. I have them practice a couple of breaths with their eyes closed and repeating a mantra to themselves as they exhale.

I let them pick their own mantra. The one I use is “relax.” I explain that when they are under stress or experiencing a pain episode, most patients will revert to shallow breathing or holding their breath completely. At this point, I may add visualization techniques such as telling the patient to imagine their pain is Swiss cheese and to breathe through the pain as you would breathe through the holes in the Swiss cheese. To enhance the emptying of the lungs on exhale, I suggest another visualization of blowing up a balloon, and blowing their pain, stress, and worries into the balloon. I then instruct them to let the balloon float up into the sky until it disappears. It is important to caution the patient to be well-supported when they practice this technique, since they will sometimes feel lightheaded due to the change of CO2 in their blood stream.

Once the patient has mastered the deep breathing technique, I introduce progressive relaxation. I should mention that not every patient is appropriate for progressive relaxation, since it is a technique based on isometric contraction of a muscle group. I also will caution the patient not to contract muscle groups if it produces pain, since we do not want to trigger a muscle spasm.

Introduced in the 1920s by Edmund Jacobson, progressive relaxation is sometimes referred to as the Jacobson Technique.30 Jacobson’s premise was that if he could relax your muscles, your brain would then relax. As you relax your muscles, sympathetic arousal will also decrease, thereby lowering your pain levels. Early in my career, I would personally talk the patient through the various muscle groups. Today, I use professionally made CDs that are available. My favorite CDs are produced by Miller and Halpern.31

I enhance the relaxation response by adding deep breathing to coincide with the tensing of the muscle groups. I accomplish this by instructing the patient to take a deep breath as they tense the muscle and then exhale as they relax the muscle, letting the tension float away.

I augment the relaxation experience with the use of a temperature thermistor biofeedback device, which patients can take with them and practice in their own homes. Most patients can increase their skin temperature a couple of degrees after 20 to 30 minutes with the above approach. The use of temperature feedback reinforces the mind-body connection and provides a simple method of demonstrating sympathetic reactivity. Progressive relaxation is a fairly straightforward technique that I have used for patients ranging from children to older adults.

Before I progress to the next stage of relaxation training, I assess the patient’s openness to more abstract techniques. I have found Auke Tellegen’s Absorption Scale to be helpful in selecting patients for more suggestive therapies such as autogenics and self-hypnosis.32 Additionally, I will ask the patient 2 questions that are from the Harvard Hypnotic Scales.33 The first is to ascertain whether they can dictate their dream activity and the second to determine whether they can set their internal clock to awaken them at a certain time without the use of an external clock?

If the patient can answer yes to at least one of these questions, my experience tells me they are probably good candidates for suggestive relaxation techniques. In addition, I highly recommend the book by Herbert Benson, MD, The Relaxation Response, to complement the patient’s knowledge base.34 It is very readable and explains in basic terms the importance of controlling your physiological arousal by mastering the relaxation response.

If the patient does well with progressive relaxation and they are open and motivated to learn a more abstract and powerful technique, I introduce Autogenic Therapy. Autogenics was introduced by Luthe and is based on self-phrasing and visualization.35 Based on my clinical experience, I have found it difficult for the patient to initiate autogenics without some experience with relaxation or meditation training. In practical terms, autogenics is more effective if the patient can quiet their sympathetic arousal before initiating the self-phrasing technique. I share with the patient that, as we relax, our brain becomes more open or absorbent to our own suggestions. It enhances concentration and narrows focus.

I consider autogenic therapy to be a form of initial self-hypnosis. If the patient is progressing at this point in therapy, I encourage the use of positive self-affirmations, a form of self-hypnotic suggestion. In other words, when you give yourself a positive self-affirmation in a deeply relaxed state, it increases the probability that it will become a self-fulfilling prophecy.

The next step in my clinical algorithm is the addition of a self-hypnotic induction procedure to achieve a deeper state of relaxation. The induction procedure I use the most is the image of an elevator (the old fashioned type, not the high-speed ones we have now, which would be counterproductive). When in a relaxed state, I ask the patient to imagine standing in front of an elevator door, usually on the tenth floor. The door opens, they get on alone, the door closes and they push the down button. They focus on the floor indicator hand that, like a clock, moves down as the elevator descends slowly floor by floor. As each floor passes they take a deep breath and as they exhale, repeat to themselves a mantra or the word “relax.” When they reach the ground floor, the door opens and they walk out in a deeply relaxed state.

A variation on the induction procedure that I have found helpful in promoting deeper and more restful sleep is to imagine your bed waiting for you when the door opens, and as you crawl into bed, say the following affirmation, “I will have a deep and restful sleep” repeating this affirmation as you drop off to sleep. If the patient awakes during the night, they can repeat the procedure to help fall asleep faster and achieve deeper sleep. Personally, I do not recommend traditional hypnosis because my treatment philosophy is based on giving the patient skills or tools they can take with them without fostering a dependence on me to guide them. If the reader is interested in hypnosis as a treatment tool, I recommend Mark Jensen’s book Hypnosis for Chronic Pain Management.36

Cognitive Behavioral Therapy (CBT)

Early behavior therapy is founded in operant learning theory that assumes our behavior is shaped by the consequences we experience in our environment. When Fordyce introduced the term “pain behavior,” it was a logical extension of operant learning theory. I still use operant learning techniques in my practice. According to Keefe and Lefebvre, operant learning processes are likely to play an important role in shaping and maintaining pain behaviors that are maladaptive.37

The ABCs, or circular model of pain behavior, is based on operant learning principles. First there is the antecedent or trigger (A) that leads to the pain behavior (B) and then the consequent results (C).

My doctoral dissertation examined the role of self-monitoring; does charting a behavior modify or influence a behavior? The results of my research indicated that the act of keeping track of behavior is a reinforcing event that will modify behavior. Using this finding, I encourage pain patients to monitor their ABCs on a daily basis and, if they are willing to take this data a step further, to chart this information in the form of a graph.

I ask the patient to post this information somewhere the entire family or support system can see it (eg, on the refrigerator). This act of public disclosure adds additional power or therapeutic effect to the entire self-monitoring exercise. I also ask the patient to bring their data or graph to each session so that we can troubleshoot and discuss treatment options.

In the 1970s, Beck introduced the idea that a person’s thoughts or cognitions can exert a significant impact on their mood, behavior, and physiology.38 This idea was a logical next step in the evolution of behavior therapy that led to what we now call cognitive behavioral therapy (CBT). CBT techniques help patients modify or change negative thought patterns that contribute to pain behavior and depression.39

CBT techniques also are designed to promote positive coping strategies as they relate to pain. Specific techniques can include cognitive restructuring or reframing, problem solving, distraction, and relapse prevention. There is a growing body of empirical research that supports the use of CBT for a variety of pain conditions and has established CBT as the behavioral therapy of choice.40

Summary

It is a difficult task to review all treatments for chronic pain; therefore, I have focused on treatments that are supported by empirical research. The intent of this article was to cover a variety of treatment options that are complementary from a multidisciplinary approach. I have included some of my personal approaches and techniques that have evolved out of many years as a pain provider. I have also omitted newer alternative treatments that sound promising but are not yet well supported by empirical data. Finally, if the reader is interested in more specific techniques mentioned in this article, I would highly recommend the workbook by Margaret Caudill, MD, PhD, Managing Pain Before it Manages You.41

Last updated on: May 19, 2015
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