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Pain is Not a Disease: A Look at Agostino Villani's Book on a Timely and Costly Topic PDF Print E-mail
Written by John Weeks   

Pain is Not a Disease: A Look at Agostino Villani's Book on a Timely and Costly Topic

Summary: Agostino "Tino" Villani has trafficked in pain for 30 years as a managed care executive and as a chiropractor. The two stakeholders, as he writes, are part of a huge industry that has grown up as we moved, culturally, from bearing pain to muting it. But Villani attributes his greatest learning about the subject to the period when he was leaving his practice and seeking to empower his patient to take more charge on their own. His book, Pain is Not a Disease, is a very approachable read which is a great device for re-thinking our relationship to pain. It is laced throughout with quotes that deepen reflection and help in Villani's goal of transforming our relationship to pain. I conclude this review with some thoughts stimulated by the book regarding two recent experiences with pain prescriptions. 
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To order Pain is Not a Disease, click here.

An approach to pain as an insight into health reform

ImageThe back cover of Pain is Not a Disease, by Agostino Villani, presents a fascinating coupling. Two individuals are quoted in rave endorsement of this book. One is an individual well-known to the integrative practice community:
Christiane Northrup, MD, author and former president of the American Holistic Medical Association. Northrup credits the book with being "full of brilliant insights and practical solutions."

The other quote is from the retired executive chairman of Pitney Bowes, a multinational corporation which is known internationally for its advanced, values-based approach to health and productivity management. Pitney Bowes leader during this period, Michael Critelli, suggests that Villani's approach is not only "insightful" but that "his in-depth discussion of our flawed approach to pain management has much broader lessons for fundamental healthcare reform."

Major employers and holistic medical leaders don't often meet, face-to-face or even on covers of books. That Villani, CEO with former Integrator sponsor Triad Healthcare, and a longtime leader of his profession of chiropractic has convened them on his book cover attests to the potency of Villani's message.

An unusual book

This is an unusual book in a variety of ways. The format has the primary narrative on only the right page. Each racing page on the left has a single quotation relative to the theme.  These are selected from a broad array of sources. Included are Donald Berwick, Socrates, book authors, Emerson, Jerome Groopman, news reporters, HMO leader George Halvorson, and scores of others. The quotes invite the reader to meditate more deeply on the subject. My sense is that the format might be a boost to the cognitive restructuring Villani and his collaborator Hillary Davis seek in order to transform our relationship to pain. I found the quotes compelling.

Villani warns readers early that he will "skate" over many things that could be treated in greater depth. While I was comfortable generally with this approach, I can only imagine the offense some would take when reference to Chinese medicine approaches are relegated to two short paragraphs and
a single herb is the only mention relative to Native Americans efforts to control pain.

Where the skate through history slows into his core theme is the transition, in the last century, from a social view that pain is something a person learns to bear, and the modern perspective that it is something to treat. And do we ever. Writes Villani: "We have developed a thriving commercial environment based on treating pain as a disease - when it is not." Why do we do this? Villani is direct, speaking to all of pain's stakeholders: "What we have collectively done is to put all of our needs ahead of the patients needs."

Author Villani: practitioner and managed care executive, gores all oxes

Author Antonio Villani
With a national healthcare costs bloated with harmful waste by at least 33% ($800-billion a year), it stands to reason that any valuable contribution will gore a few oxes. Villani's tone is one of understanding. He has participated in creating what he criticizes. But what is unusually refreshing is how willingly Villani gores the oxes on which he rides.

"We might want to recognize and admit that inherent in all of us is a blindness created by our professional training and our personal needs ... My point of view comes from asking questions that require answers that may not be fit for public consumption, politically correct, or professionally aligned, but all yield a certain truth and reality about exactly what is happening."
Long-time Integrator readers may recall Villani's straight talk in prior Integrator discussions of problematic outcomes insurance reimbursement had on chiropractic. (See Insurance Coverage and Development of CAM Professions: Perspective of Triad's Tino Villani, DC, June 25, 2006.) Villani directly challenged both his profession, for the course it had taken relative to insurance, and his business of insurance/managed care which had helped wreak the damage.

Now in Pain is Not a Disease, Villani begins by noting that his insight into pain came less from his 20 years as a practitioner but rather from what he learned in weaning from his clinical practice. He attributes his best learning to the "few short years of experience passing on the care of patients to themselves and to other doctors." It's the passing on of care to patients that promotes a radical restructuring.

Keys to a Better Approach to Pain

Villani's refrain throughout is stated in the book's title. He leads off the last chapter, "A Better Approach," with 5 summary points:
  1. Accepts that pain is not a disease and the goal is to empower the patient.
  2. Establishes a truthful doctor-patient relationship.
  3. Accepts there is no cure.
  4. Quality is clinical outcomes-driven.
  5. Doctors are free to balance science and art to the needs of the individual patient.
Villani believes that a "cure" will one day be found in the laboratory. "Right now," Villani writes, "there is a mad race to treat. There is mad political pressure to find answers. There is mad competition." He proposes the common sense of his "Better Approach" as a bridge to that future.

Personal Reflections

Since the Joint Commission on Accreditation of Health Care Organizations passed its pain standards a decade ago, the pain industry has soared. In my recent personal encounters wiht the medical system relative to throat cancer, I repeatedly was told that it would be best to take medications preventively, before the first sign of pain. If I didn't, I was warned I would get "behind" and it would be hard to get on top of it. There was a strong trust me on this message which came from doctors and nurses. They'd rehearsed the party line. I was immediately prescribed a large bottle of a sibling drug to heroin.

During the time of my treatment, my brother-in-law tore his Achilles tendon in a skiing accident. He too was urged to drug the pain at or before the first sign. When his spouse went to pick up the prescribed pain medications - also the same very strong heroin sibling - she was surprised to discover what a grueling recovery was anticipated. Her spouse was given pain meds to cover 21 days of pain control. She had no idea that he would be suffering so severely for so long.

As it turned out, he didn't much listen to his doctors. He took the medications for one day. But imagine if he'd "gotten ahead of the pain" and stayed ahead through the 21 days. They gave me a prescription for 21 days for a reason, didn't they?

I, for whatever reasons, never had to use mine. My brother-in-law and I each felt some pain, but decided it didn't warrant the use of the medications as prescribed. Had we each listened to our physicians and pledged to "stay ahead of the pain," we would have had experienced bowel issues, prescriptions for constipation, mental un-clarity, messed-up functionality and work, possible adverse effects of prescriptions for constipation, dependence, withdrawal, and who knows what all else in the typical adverse effect profile of a heroin-sibling substance.

I thought of this while reading Villani on our cultural shift from living with pain, to treating it, this past century. These experiences in 2009 are at the far-end of the pendulum swing. The approach, and that of my brother-in-law's physician, precisely dis-empower the patient. By urging use prior to any pain coming on, the approach keeps us from the choice of bearing what just might be better to be bourne, rather than buried. My brother-in-law and I escaped the mental and bodily pain which would have been caused by the pain meds themselves. Where is above all do no harm? Part of a "truthful doctor-patient relationship" may be an affirmation that life includes pain.

There are places where I disagree with Villani, particularly about his belief in a coming "cure." That said, Pain is Not a Disease is a very approachable read which is a great reflective device for re-thinking our relationship to pain. The trick will be dealing with the perception of pain that stems from excising from pharma, hospitals, specialty clinics and practitioners of all sorts real chunks of their livelihood.

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