There has been a media explosion these days about pain and treatment methods due to the new CDC guidelines on opioid prescriptions, and some of it cites the connection between pain meds and psychological states like anxiety or depression. Mainstream press always simplifies and people without chronic pain get the impression that a bunch of neurotic people get addicted to opioids because they don’t want to deal with their stuff. This does all of us a disservice, because pain is a very complex issue that does have psychological and physical aspects, but it is not as simple as “it’s all in your head”.
I have been reading voraciously in the pain studies literature, to try to figure out where they are going with this. (And also looking for any avenues that might help relieve my pain.) My fear, as someone who has pain for multiple reasons, is that they are going to decide that what I need is psychological counseling rather than pain medicine or physical therapy. I am a retired mental health therapist, and I know that psychological counseling is very helpful if done right. But it is a long, complicated process, and to have it suddenly crop up “coincidentally” with guidelines to restrict or withdraw opioid pain meds is concerning. In fact, it is now a nonnegotiable part of the opioid medicine contract in my clinic that I must attend two sessions with a behavioral health therapist each year — and I can’t help seeing that as an attempt to build evidence that my need for pain medication is not legitimate. The fact that the contract also requires me to “admit” that “opioids do no better than ibuprofen for chronic pain” contributes to my suspicions!
My pain comes primarily from severe arthritic degeneration of the spine, and has been ongoing at least since my 20’s (that’s when I discovered chiropractic treatments.) I’ve lost track of the number of times that I injured my back or neck, but for most of my life I’ve had no insurance and so it did not get treated. Finally in my 50’s it became disabling and I received Disability and had to learn a new life path. In 2013, I had my right hip replaced and they botched the job so badly it had to be done a second time after it dislocated 10 times. It is never really healed and that pain is ongoing also. And now I have interstitial cystitis, which creates bladder pain with many kinds of food and also stress – it is not something they have a cure for. Some literature states that chronic pain can actually bring on IC, but so can taking antibiotics.
So my pain has a physical basis, and yet I keep reading that the medical world wants to place a lot of chronic lower back pain and IC pain in the realm of “psychological”. One of the confusing parts of this scramble to get away from opioid medication is that indeed there are psychological treatments for pain and they can help significantly, if they are used correctly.
how pain signals us
Pain is a complex experience – it creates an emotional response and that emotional response in turn can affect the physical transmission of pain. Dr. Caudill1 describes two types of sensor nerve fibers that carry the majority of pain messages to the spinal cords, at different speeds – that is one reason we can use something like a TENS unit to interrupt the pain message. There is a complex process within the spinal cord for modulating the pain signal before it gets to the brain, where the signal can be dampened or enhanced, and meaning is assigned to the pain. We almost never have a pain without in some way deciding what it “is.” And it does affect the sensation of pain if we decide it is a minor problem, like knocking a shin against the table, versus a possible major one like a heart attack. This process is healthy – we need to decide if we have to get to the doctor fast (like last month when I stepped on a rusty nail and my foot suddenly ballooned – that was not a “nothing” pain.)
when we’re told pain all in our heads
It is helpful to discuss the meaning we give our pain, if the doctor works with us honestly. Where I have trouble is when the doctor wants to assure me that it is “all in my head” without adequate investigation, either because investigation cost money or because it takes too much time. (Here’s one study example2: The fear-avoidance model describes how the belief that pain is a sign of damage leads to pain-related fear and avoidance. But other beliefs may also trigger the fear and avoidance responses described by the model. Experts have called for the next generation of fear avoidance research to explore what beliefs underlie pain-related fear and how they evolve. – NO mention of whether the pain IS damage-related!)
The implications can be devastating – currently, I am not able to get even a follow-up x-ray, let alone an MRI, for my lower back because the “new thinking” is that chronic lower back pain is not actually related to what’s going on in the back! This is due to some studies of surgery for lower back pain that did not help X percent of the patients – but that still leaves X percent that it did help! Too often, it seems that generalizations are being made for everybody without getting evidence of the individual situation. I believe this is the result of an increasingly corporate medical system. My doctor tells me that there’s no point doing another x-ray unless we plan to have surgery – but it’s also convenient because it gives me no evidence that my condition is deteriorating. And in a rural setting, I do not have the option of finding another doctor. Oh, and I get 5 chiropractic visits and 3 to 4 physical therapy visits per year.
is pain RELIEF linked to patient’s relationship with doctor?
A study on attachment and pain3 apparently found that one of the critical aspects of resolving chronic pain problems is a good relationship with your doctor – however, that study attributes it to childhood attachment issues. I see no reason to go back that far – it clearly helps the emotional aspects of chronic, unremitting pain to believe that one’s doctor is working hard to find a solution. Why is that anything other than totally normal? And when a doctor doesn’t seem to be listening, or isn’t spending more than 10 minutes with you, pounding on a keyboard the whole time, or when you bring more information about your problem to the appointment than your doctor has, why is it neurotic to be concerned that a solution is being hindered by lack of attention? But this is the way studies are trending.
who decides if we “deserve” pain-killer meds, and how?
And now the CDC guidelines give us another worry: that medical practice will be dictated by people who have never seen us in person, who know nothing of our symptoms, and who are making these decisions based on statistics that are admittedly incomplete and maybe even faulty.4 If you’ve been following the news, you’ll see a huge debate in government and the medical associations as to whether doctors should be required to “learn how to give opioids”, whether patients should be required to “exhaust other treatment options first”, and whether prescriptions for pain have “caused” the current “opioid overdose epidemic”.
Most of the coverage recites the same “facts” without citing the statistics to back them up – and there is a startling reason: the CDC admits that there are zero studies done4 on the long-term benefits of opioid pain medicine for chronic pain. None. Zero. [This is recently been confirmed to me by a doctor who specializes in pain, who says “the studies you’re looking for have not yet received funding.”] And yet they have created guidelines for long-term treatment of chronic pain that state there is no significantly increased benefit of opioids versus over-the-counter drugs like ibuprofen and Tylenol. There are half a dozen studies about the side effects of long-term opioid treatment of chronic pain (do you sense a bias?), but they admit that the quality of those studies is “low”. And now these guidelines are being put in place as rules by many state and corporate medical systems. How is this supposed to give us confidence in our medical treatment??
WHAT IS THE RESEARCH ON PEOPLE WHO SUFFER PAIN?
Both media and corporate medical system are trying to simplify a complex problem. I was surprised to see how many decades they have been studying pain, and how confident they were at every moment that they would solve the conundrum and provide effective pain relief (and it hasn’t happened yet).
One book from 19695 reported that people from different cultures responded to pain. (This is important, especially when newer studies claim that emotional responses to pain suggest psychological problems.) Other studies looked at patients’ Minnesota Multiphasic Personality Inventory (MMPI) profiles and found “psychological vulnerabilities” 6 — until another study uncovered the fact that those pain sufferers had normal MMPI scales before their pain hit – meaning, the pain created the anxiety, depression and “neurosis”, not the other way around! None of that is a surprise to those of us who suffer from pain every day. Other studies found no relationship7.
And that is one of the major cautions about these studies – correlation is not causality. There may be an increased risk of developing chronic pain if someone has suffered early childhood trauma, for example, but to say that therefore their pain is purely psychological, part of some PTSD-type response, is jumping to unjustified conclusions. In fact some studies are showing that early trauma and difficulties in attachment to parents can create hyperarousal in the parts of the brain that either increase or dampen the pain signal. This is a physical change – not a fleeting emotional response controlled by willpower. Thus, when the pain is experienced, it is a completely real pain, and needs to be treated as such. It is possible that the pain is better treated within the brain rather than at the identified source, like hip or back, but those treatments need to be robust, with follow-up until they are effective. Five sessions with a cognitive behavioral therapist is not going to do it for most people.
what type of psychology therapy might help?
And this is where it gets dangerous for us: because psychological interventions are much harder to measure than physical ones, it is all too easy for the medical system to blame the patient for not cooperating when the relief does not happen. (Of course, they do that with pain already – if it does not respond to treatment, they are more than ready to jump in and call it psychological.) The patient is left with no solution and now also has the burden of hopelessness. Also, the mental health system is even more poorly funded than the medical system, the therapists are being paid pitiful wages and many of them fresh out of college. The one thing I have always felt we need are support groups run by someone who has chronic pain themselves – rather like the need for war veterans support groups to be run by vets. It is very much a case of “if you haven’t been there, you don’t know.” Theory is great, but nothing substitutes for having to live with pain constantly for a period of months or years.
I think that some of the psychological studies can empower us to look into ways that we can address the chronic stress that comes with being chronically in pain (or any other disability) and we can take an active role in providing ourselves with whatever soothing, reassuring, supportive actions that are in our repertoire, and we can expand that repertoire. I do not believe that these should at all be a substitute for medical pain relief when it is needed, nor should it be a new euphemism for an old stigma.
NON-DRUG TECHNIQUES can HELP MANAGE PAIN
This has already become long, but I don’t want to stop without mentioning some of the techniques that those with chronic pain have found helpful. They include meditation, acupuncture, chiropractic, massage, physical therapy, art therapy, music therapy, being in nature, keeping a food diary to find out if some foods increase pain, learning to pace oneself and rest when pain increases, using humor – for instance watching funny videos or reading funny books, and getting the support of family and friends or a community of others like this one. We can honor our intuitive body knowledge and discover what works for us, while continuing to advocate for a more responsive medical treatment system.
lit cited and resources for further information
- “Managing Pain Before It Manages You” by Margaret A Caudill, The Guilford Press, ISBN 978-1-4625-2277-4
- www.painresearchforum.org/...
- “Attachment and Pain”, David J Anderson and Robert H Hines, Psychological Vulnerability to Chronic Pain, ISBN 0-8261-8070-1
- CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, Pg 9: “For KQ[Key Question]1, no study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for chronic pain evaluated long-term (≥1 year) outcomes related to pain, function, or
quality of life. Most placebo-controlled randomized clinical
trials were ≤6 weeks in duration. Thus, the body of evidence
for KQ1 is rated as insufficient (0 studies contributing)” [my bolding]
- People in pain. Mark Zborowski, 1969
- Medication usage, emotional disturbance, and pain behavior in chronic low back pain patients. McCreary C, Colman A. J Clin Psychol. 1984 Jan;40(1):15-9.” Group 4 patients scored significantly higher on the Hypochondriasis and Hysteria scales than the others, whereas Group 3 patients scored higher on the PD (acting out) scale. Group 4 patients reported more intense pain and chose more affective terms (punishing/ terrorizing /sickening) in describing their pain than the other three groups.
- “The MMPI and chronic pain: The diagnosis of psychogenic pain” Gary B. Cox, C. Richard Chapman, Richard G. Black. Journal of Behavioral Medicine December 1978, Volume 1, Issue 4, pp 437-443. “..This procedure did not yield any group of patients who could be identified as having chronic pain of psychogenic origin. These results suggest that the MMPI is not a reliable tool for the differential diagnosis of chronic pain…”
- uspainfoundation.org
- www.painresearchforum.org
- nationalpainreport.com
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