I just left a group of pain clients at Las Vegas Recovery Center (LVRC). I have the same experience on a daily basis — that of being amazed at the process of Pain Recovery that clients experience while they are in treatment. Over the last five years, I have had the privilege of working with hundreds of people with drug dependence and many different chronic pain conditions. This article will review some of the lessons I learned from my best teachers — my clients.
All Pain Is Real
For so many people with chronic pain, the “validity” of the pain is suspect. Since the experience of pain is subjective, the only way to assess pain is by asking the person who has pain (unless you own a functional MRI machine). No one can know what another person’s pain level is. Often pain is labeled as psychosomatic, implying that the pain is psychologically driven (i.e., psychological processes lead to pain). Is such pain less important or less real than physical pain based on sensory input from the nervous system? Can we separate the two?
Clients at LVRC have reported: “My pain ratchets up when I’m mad, afraid, frustrated, anxious and depressed.” And, “I took my pain pills so I didn’t have to feel…anything.”
Research on emotions suggests there are, in fact, feedback loops between psychological processes and physical arousal. In the case of pain, chronic physical arousal is seen as threatening and fear-producing. When you help a person with chronic pain to better understand his or her condition, he or she will feel better, even though the sensory signal of pain hasn’t changed.
The client’s pain score (one through 10 on a 10-point scale) varies with conditions specific to the day, time, circumstances, thoughts and feelings. The experience is always changing.
Emotions Drive the Experience of Pain
According to Jane Ballantyne, MD, pain specialist at University of Washington, “suffering is the tension we feel within us between the way things really are and the way we think things ought to be.”
Many of people I see in treatment are medicating emotional pain that they perceive as physical pain. They feel anxious and their back starts to hurt, so they take a Vicodin. They’re not making it up. Anxiety causes you to hurt more. Using pain medications to treat emotional pain is a common phenomenon known as “chemical coping.” It occurs in many of the people who develop problems with these medications.
If you sum up a description of chronic pain, 20 percent is sensory and the rest, the other 80 percent, is emotional. People have anxiety about pain and about their loss of identity. Fear, anger and frustration drive their experience of pain much more than the physical/sensory aspect of pain.
People with chronic pain are often sedentary because they’re afraid they’ll have an even worse injury if they stretch or exercise. This is called “fear-avoidance.” Or they’re angry with the person who drove the car that injured them or with the doctor who messed up their surgery or got them hooked on drugs in the first place. Or they feel guilty they’re not at their kid’s soccer game, again. The pain gets worse with all of these thoughts and feelings, pointing to the fact that emotions drive chronic pain. This doesn’t make the pain any less real.
Emotions influence pain through the neurocircuitry of the brain. The limbic system, the emotional center of the midbrain, is integrally and intimately associated with the parts of the brain and its function associated with rewards and pleasure, as well as avoidance of danger and pain (physical and emotional). The neurotransmitters associated with mood and emotions are also associated with the experience of pain (dopamine, serotonin, endorphins).
Successful treatment of chronic pain involves surrendering the quest for being pain-free and accepting pain reduction and increased function as goals. This can be facilitated by using awareness of the body without judgment about what is occurring. The book Full Catastrophe Living by John Kabot-Zinn talks about developing mindfulness and relaxed attention to and awareness of all body sensations. Pain can be best described as an “intense sensation” without judgment or interpretation about what this sensation means. Finding positive and meaningful directions in life through values clarification and goal-setting using techniques such as Acceptance Commitment Therapy translates into a more meaningful life and less pain.
Research has shown that feeling out of control, paying attention to pain, and fear are modulating factors that increase pain and contribute to a loss of function. If patients feel like they’re in control of their pain, they experience less pain. When distracted, patients don’t feel as much pain. When a patient is afraid of injury or of causing more pain, an overall fear of movement develops, causing the patient to decrease normal activities, move less and become deconditioned. Prolonged fear of movement may cause a patient to become kinesiaphobic(afraid of movement). Yet the best treatment for acute back pain is to get up and move. Treatment of chronic pain is the same.
Alternative measures are also effective for the treatment of chronic pain. These include, but are not limited to, acupuncture, physical therapy, chiropractic, massage, yoga, Reiki, meditation, mindfulness practices and cognitive-behavioral therapies.
Opioids Don’t Always Make Chronic Pain Better — They May Make Pain Worse
One of my clients said, “What relieved my pain became my pain.” Others have said:
“I have less pain not taking opioids than when I was taking them.” And, “The thing I was most afraid of happened yesterday: My migraine headache was up to an eight out of 10, but I didn’t take any opioids and I was able to sleep. Today I don’t have a headache. When I was taking opioids, I used more and more and would be out of commission for a week.”
I believe that the primary cause of the prescription drug epidemic is an intense desire to avoid or relieve feelings — physical sensations and emotional experiences. Prescribers write a legal prescription and the insurance companies pay for the medication. The efforts to expand the market for opioid painkillers have been very successful in terms of financial gain for pharmaceutical companies, but not for quality of care or improvement in patients’ lives. The system promotes futile attempts to eradicate these experiences in an unrealistic and relatively unsuccessful manner. It’s the patient and his or her family who suffer.
In many ways, we are missing the boat in the medical treatment of chronic pain. Finding the right drug is unlikely to be successful. With opioids, tolerance develops and eventually, physical dependence, which requires increased doses or medically managed withdrawal.
Many physicians, possibly the majority, think that if a patient is in pain — not just if he or she is terminally ill, but simply in chronic pain — then the patient is entitled to take opioids to relieve the pain. We made a big error when we started to use powerful opioids for people with chronic, noncancer pain with no end in sight. The other group of doctors — and this is strictly my school of thought — believes that opioids are not working for most people. An FDA panel convened a group of experts at the end of May 2012 to try to address this problem.
Studies of long-term opioid use for chronic pain are virtually nonexistent, but experts have estimated that opioids result in perhaps a 30-percent reduction in pain. Certainly for acute pain, such as occurs, say, with a broken leg, opioids are appropriate as a short-term treatment of pain over a limited and finite time period.
But if someone experiences chronic headaches or backaches or bowel disease or fibromyalgia, this pain is not going away. Patients and their physicians should have a plan for how their opioid use might look over the course of six months, six years or longer. Because of tolerance and physical dependence, in addition to side effects and long-term complications of opioid use, the picture is often bleak. Increasing doses, increasing pain, decreased function and inability to discontinue the drugs without significant discomfort lead to misery and despair.
Doctors are paying more attention to pain in an attempt to be compassionate, but this has catastrophically backfired. Between 1991 and 2010, prescriptions for opioid analgesics rose to 209 million — from 75 million.
In 2009, more people in the U.S. died from prescription medication overdoses than from motor vehicle accidents. Furthermore, there are more deaths from prescription pill overdose than cocaine and heroin combined. According to the CDC, in 2010, enough opioids were prescribed to treat every person in the U.S. with Vicodin 5 mg every four hours for a month! And treatment episodes have increased by 430 percent for prescription opioid drugs from 1999 to 2009.
The U.S. Senate Committee on Finance has opened a wide-ranging investigation into questionable financial relationships between companies that make narcotic painkillers and various nonprofit organizations that advocate for the treatment of pain. The action of the U.S. Senate to investigate the relationships between pharmaceutical companies and organizations advocating for the proper treatment of chronic pain comes as a welcome opportunity to scrutinize the relationships between medical practitioners and their incentives. I do not believe that physicians who have promoted higher doses of opioids for life have nefarious motives, but are simply misguided in their attempts to offer relief to those in pain, which inadvertently cause more problems for our patients and society. In the words of one of my patients: “Why didn’t my doctor warn me that these drugs were addictive? If I knew then what I know now, I never would have taken them in the first place!”
Treat to Improve Function
It is a certainty that any prescriber can give a patient enough medication to temporarily alleviate pain, but the patient would be left unconscious. This is not the proper goal of the treatment of chronic pain.
I have found that when some patients are off opioids, they have a sense of getting their lives back, waking up from a fog and are able to tolerate the pain by dealing with their thoughts, emotions and bodies.
The primary goal of pain management is to control, if not eliminate, pain. Pain management involves prescribing pain medications and physical interventions. Sometimes, using opioids actually causes more pain — a phenomenon known as opioid-induced hyperalgesia. This often affects people with chronic pain who take opioids for long periods of time. The only effective treatment for this condition is to stop these medications so the brain can “reset” and eliminate the hyperalgesic effect of the opioids.
Pain management is about the quick fix and the desire for that very short-term improvement in everything. Initially, people’s fear, depression and anger abate when they take their medications, but the long-term effect of that is the worsening of depression, fear and anger, as well as mobility. So treating pain needs to take into consideration improvement of function, and traditional pain management does not necessarily do that. Finally, with most chronic pain conditions, the goal of eliminating pain altogether is simply not realistic.
The goal of pain recovery is to learn ways to accept and live in coexistence with pain, rather than to “kill” it. Pain Recovery is about finding balance with thoughts, feelings, body sensations and spirituality. It is based in abstinence from reward-inducing drugs, and involves looking at pain differently.
Expectations Influence Outcome
We can’t fix our state of being with a pill; that’s absurd. But the mind is a different thing. I have seen people make so many changes with their minds, by harnessing the power of their minds. The answers to many of the problems that plague those with chronic pain lie in the powers of their minds.
There are many studies that prove that believing a treatment will work results in a significant percentage of subjects having an effect. For example, when we give a person a placebo,rather than an active drug, usually 20 percent or more have an effect — from an inert substance. What creates this effect? It is the belief that there will be an effect. This belief causes significant changes in the brain and body, which translate into a different experience.
We should be harnessing this effect rather than relying on potentially toxic substances to give relief in as few as 40 percent of people. Instead, we dismiss significant effects of the mind’s power as “placebo effect” with no further study and tout the efficacy of the drug as “indicated.”
Meditation decreases pain levels by increasing the function of the parasympathetic nervous system, which is present in everyone, to counteract the stimulated effects of the sympathetic nervous system (think adrenaline).
In the case of chronic pain, we can use the client’s power of his or her own mind to cause pain reduction, mood improvement and improvement in function. But pharmaceutical companies won’t be studying the power of this effect because their studies are designed to report effects of the drugs that are favorable to their sales goals and bottom lines.
In the groups that I run with clients at Las Vegas Recovery Center, I am repeatedly amazed by the stalwart energy of the human spirit and its ability to help people to recover and flourish even with chronic pain. In fact, it is not uncommon for patients to find meaning in their pain and thrive in their ability to connect with others suffering same or similar conditions. Like twelve-step recovery, this spiritual connection with something “greater than ME” results in remarkable transformations.
In conclusion, the real pain that people experience is heavily influenced by their interpretation of the pain, which can lead to more suffering. Opioids are a large part of the problem for many living with chronic pain. This article has described the scope of the problem and presents some solutions.