Alternatives to Pain Management | Podcast #1 of 3

Alternatives to Pain Management | Podcast #1 of 3


FS: (MUSIC) The Substance Abuse and Mental
Health Services Administration or SAMHSA created the Wellness Initiative because people with
mental and/or substance use disorders tend to die years earlier than the general population. Studies show this is mostly due to preventable
and treatable conditions, such as diabetes, heart disease and cancer, which can be improved
by healthy eating, increased physical activity and smoking cessation. Focusing on health and wellness is particularly
important for people with or at risk for mental and/or substance use disorders so they can
live long, healthy lives. SAMHSA’s goal is to help individuals, families,
providers and communities improve whole health outcomes. Keep listening to learn more about wellness
and tips you can apply in your life. Cathy: Hello, everyone, my name is Cathy Cave,
I’m Co-Director of SAMHSA’s Program to Achieve Wellness. Welcome to our three-part podcast series on
non-opioid alternative treatments for chronic pain. For the first podcast in our series, we are
joined by Mel Pohl, who’s the Chief Medical Officer of Las Vegas Recovery Center; and
Niki Miller who’s a Senior Research Associate at Advocates for Human Potential. We’re first going to hear from Niki about
her experiences and have an opportunity for her to share her wisdom with us, with more
than 30 years of working with communities and systems to improve the lives of individuals
with multiple vulnerabilities. She was founding Executive Director of New
Hampshire task force on Women in Recovery, nationally recognized advocates for women,
girls, and families dealing with addiction, trauma, and mental health issues. She also served as administrator of Women
Offenders for the state of New Hampshire. Recent projects include developing promising
practice guidelines for medication assisted treatment with justice populations, and writer
for SAMHSA’s online shared decision-making tool. Today she’s going to start off our conversation
on alternatives to pain management talking about the scope of the challenge for individuals
with mental illness. Niki, thank you for coming. Niki: Well, thank you, Cathy, for that terrific
introduction. I’m glad to be here. I’m excited to hear from Dr. Pohl and to talk
to all of you about an issue that is a very serious concern for communities across the
country. I’m delighted to share information and ideas
with you about chronic pain management for individuals with serious mental health disorders. In my work, I specialize in developing practical
tools that help professionals apply research and best practices to the everyday interactions
they have with the people they serve. I have extensive experience with prevention
and treatment of opioid use disorders, and also with approaches that support shared decision-making
in behavioral health and wellness and recovery self-management. I’m also a person in long-term co-occurring
recovery from mental illness and addiction, who happens to also live with chronic pain. A physician who I admire very much once said
something that resonated very deeply with my own experience of chronic pain. He said that, in medicine, is usually a mistake
to attribute a condition to any single cause. That rings true for me. Most days my experience of chronic pain is
kind of like white noise. It’s always in the background, but I’m used
to it. Some days it’s hardly noticeable, but then
there are those difficult days when I might have more than one type of pain going on,
and that’s when something like lack of sleep or the onset of a headache or even a high
pollen count can just sort of push me right over my threshold. On those days, that white noise of chronic
pain becomes so loud that it drowns out everything else in my life. But just as a combination of factors generally
trigger intolerable levels of pain, for me, it usually takes a combination of remedies
to find adequate relief. There is— there are a number of different
approaches that different people respond to when it comes to chronic pain. The more options people have, the better they
are able to discover the things that actually work for them best. Unfortunately, in recent years, an overreliance
on opioid prescribing for chronic pain has contributed to a number of unintended consequences,
as I’m sure you are well aware. Some of these consequences include a very
sharp rise in opioid addiction rates and higher rates of opioid overdose fatalities than have
ever been seen before. There’s been a fourfold increase over the
last 15 years in the prescribing of opioid analgesics or opioid pain killers as they’re
sometimes called. Nationally, overdose fatalities attributed
to the commonly prescribed opioid analgesics exceed heroin overdose fatalities. They’ve been exceeding these heroin overdose
fatalities for a number years. But at the same time, both in demand and the
supply of illicit opioids has increased while prices have dropped and the potency has risen,
often in response to the attempts to rein in the accessibility of their pharmaceutical
counterparts. So, patients who are prescribed opioids for
legitimate medical reasons and take them exactly as directed can and do become physically dependent
on these drugs. Today, an individual who is addicted to opioids
is way more likely to have started out using a prescribed pain medication than to have
started out using an illicit drug of some sort. Now, this is a big departure from decades
of drug use trends in the United States. One recent study of patients in opioid treatment
programs found that more than a third of them reported their reasons for seeking treatment
was related to opioid use for physical pain. For many people taking opioid medications
for pain can be a direct route to physical dependency that quickly developed into an
addiction, especially when they have certain risk factors that increase their susceptibility
to addiction in the first place. Yet, pain management is a very real issue
for many people, including those with mental health issues and people in recovery from
substance abuse. They require information and options that
can improve the quality of life. There is no doubt that opioids are extremely
effective at changing the body and brain’s response to pain. They provide significant relief to untold
numbers of individuals experiencing severe levels of acute pain. However, today we know that the body and brain
are also very efficient at adapting to the presence of opioids in a pretty short period
of time. The result is that the same dose that once
offered relief is no longer effective. Higher doses are required to do the job, but
then it doesn’t take very long for the body and brain to marshal their response when more
opioids are introduced into the system, and the cycle starts again. This phenomenon is known as opioid tolerance. And it is one of the big reasons that long-term
use of opioids to manage chronic pain often creates a situation where there are diminishing
returns and increasingly serious risks. Now, fortunately, in 2016, the Centers for
Disease Control and Prevention released new updated guidelines for prescribing opioids
for chronic pain. And these were based on current research,
which demonstrates that the benefits are pretty limited for long-term use and management of
chronic pain. The new guidelines emphasize the need for
providers to fully advise patients about the risk involved and all the alternative approaches
that are available to them. These practices ensure patients are equipped
to make informed decisions together with their healthcare providers. Now, throughout this entire podcast series,
we’re going to hear more about alternative approaches from highly qualified practitioners
and from some individuals who are recovering from serious mental health disorders, living
with chronic pain, and maintaining a level of wellness that has improved their quality
of life. They’ll share some good information about
the way these two recoveries interact and the variety of options they have discovered
that help them achieve wellness. But before we do, I’d like to discuss a few
compounding risk factors that can affect people with mental illness and elevate the risks
associated with treating chronic pain with opioid medications. One factor that contributes to the development
of a drug or alcohol problem is the reinforcing effects that occur when people use a substance. Now, opioids in and of themselves are one
of the most highly reinforcing drugs anyone can possibly assume. Their euphoric effects can lift up your spirits. Their sedative effects can soothe your nerves. And suddenly things that usually cause you
all kinds of emotional distress, eh, they don’t seem to bother you too much at all anymore. So, people who have never used drugs that
might have a depressive disorder, an anxiety disorder, or any number of mental health symptoms
that cause them distress, tend to be a little more susceptible to developing a problem if
they experience positive effects that powerfully reinforced taking the drug. There’s also a significant number of individuals
with mental health disorders who’ve had a problem in the past with substance abuse
at some point, which might’ve been very mild. It could’ve been severe. It could be undiagnosed. Or it could be in remission. Many people who are in long-term recovery
from substance use disorders also have serious mental health disorders. Pain management is a critical issue for these
individuals. When they do not get that specialized care
that they require, it can contribute to relapse and that can lead to devastating consequences,
including fatality. Now, both types of disorders share some common
risk factors. Studies have documented high rates of childhood
abuse, exposure to violence, and exposure to multiple family stressors among both groups. Heredity’s also been identified as a very
influential risk factor for both mental health and substance use disorders. Research suggests there’s a very complex relationship
between substance abuse, mental health, chronic pain and opioid use. An estimated 29 to 60% of people with opioid
addiction also have chronic pain. A recent study was of 825 people in opioid
treatment programs. And it found that almost half of them reported
severe psychological distress and 37% had attempted suicide. 42% had a history of posttraumatic stress
disorder. And about a third met the criteria for major
depression. Another similar study found the rates of attention
deficit disorder was about 20% and bipolar disorder about 43%. But several of the people that they surveyed
and sampled met the criteria for both ADD and bipolar disorder. And the research on overdose fatalities also
indicates that rates are higher among people with mental health disorders. An overdose risk assessment that was recently
developed and tested using Veterans’ Health Administration data is— the purpose of it
is to identify high-risk medical and behavioral health conditions. So, patients who have these conditions, if
they’re prescribed opioids, they also receive some risk reduction counseling are closely
monitored. Two of the substantially weighted risk factors
on this screening tool are having a bipolar disorder or schizophrenia and current use
of a prescribed antidepressant. All this information’s very important to
consider when discussing the risks and the benefits of the various treatment alternatives
available to people with chronic pain. It’s also tremendously helpful to talk with
people about how their mental health symptoms and pain levels interact. I’ll share a personal example of the just
how beneficial and important this approach can be. I have posttraumatic stress disorder. And at one time my symptoms were really quite
severe. But I am fortunate enough to have recovered
significantly. And I really only have to deal with one symptom
on a regular basis, and that symptom is sleep disturbance. I still have a hard time falling asleep, staying
asleep, and I have difficulty getting enough sleep. Well, when I discussed this with an informed
pain management specialist, she told me that sleep deprivation decreases your pain threshold
and it exacerbates pain. And she also said the effect was more pronounced
among women than men. Now, since that time, I have found through
trial and error that catching up on sleep has a profound effect on my pain levels and
it’s now my first line of defense when pain levels become too high or intolerable or difficult
to deal with. Now, as a person in addiction recovery, I
don’t think I can overstate how important that lifeline she threw me was when she informed
me of this stuff and took the time to work with me on these issues. Well, the next speaker, I’m also really looking
forward to hearing because he’s one of those beacons of light that people like me feel
incredibly fortunate to encounter as we sort of stumbled along our pathway to wellness
looking for solutions, and I’m really looking forward to hearing from him. So, I want to thank you so much for your attention
to this issue and for all you do to help people make wellness a reality. Cathy: Niki, thank you so much for sharing
your wisdom with us today, and really laying the foundation for not only the rest of today’s
conversation but for our future podcasts in the series. Next, we’re going to hear from Mel Pohl,
who’s going to expand upon some of the points that you shared with us already and add his
conversation to really strengthen what we’re going to hear today about chronic pain and
strengthen our understanding about chronic pain. We are pleased to have Dr. Mel Pohl with us
today. As I mentioned, he’s a board certified family
practitioner. He’s the Chief Medical Officer of the Las
Vegas Recovery Center. Dr. Pohl was a major force in developing the
Recovery Center’s chronic pain recovery program. He’s certified by the American Board of
Addiction Medicine. He is author of A Day Without Pain, and The
Pain Antidote: Stop Suffering From Chronic Pain, Avoid Addiction To Painkillers, and
Reclaim Your Life. He recently filmed a show for PBS on chronic
pain, which aired around the country in August of 2016. Mel has substantial expertise that he’s generous
enough to share with us today, really highlighting the role of science in chronic pain management. Mel. Mel: Thank you for the introduction, Cathy,
and for kicking off the conversation, Niki. It was a wonderful opening to this very complex
subject. I’m pleased to be here today and hope that
what we share can help make a difference for providers and the individuals they serve all
around the country. When having this discussion around chronic
pain, it’s important to ask, how have we gone wrong with our treatment of chronic pain? There actually are some fundamental misunderstandings
that have lead us to where we are today, with 2 million Americans dependent on opioids,
thousands dying from overdoses every year and millions more struggling with the suffering
of living with chronic pain. So many of our patients who have serious mental
illness and substance use disorders also suffer from co-occurring chronic pain. So, how did we get here? We are a culture who abhors feeling pain. We avoid it at all costs. We somehow feel we should be free of it. Of course, that’s the first and most problematic
misunderstanding about life. We’ve all heard pain is inevitable. We’ve been told this over and over, but
also that suffering is optional. And it turns out, the more we fight against
or resist pain, the more we suffer with tight muscles and negative attitudes. The biggest problem with our approach to pain,
both patients and clinicians, is that we confuse acute pain with chronic pain. As if chronic pain is just a longer version
of acute pain. If we take the next steps in this ill-conceived
comparison, we ought to be able to find the source of the chronic pain as we can acute
pain, with x-rays, MRIs, CAT scans and the like since the pain was caused by tissue damage. In fact, the more tissue damage, the worse
the pain should be, right? Once we’ve diagnosed the pain, as with acute
pain, we should be able to fix the problem by manipulating or cutting out the damaged
tissue, causing healing and the resolution of the pain. And the final misconception is that if there’s
no evidence of tissue damage, then the pain must not be real. Turns out these basic misunderstandings have
lead us to medicate, operate, and ultimately give up on patients who don’t get better. Tragically, we as clinicians, and often the
patient themselves, aren’t sure the pain is real. So, let’s start with some essential truths
about chronic pain. And the first one is the pain is real. In fact, all pain is real. The nature of chronic pain is different than
acute pain since it’s not related to tissue damage, but rather to changes in the brain
and the nervous system. Rather than just more acute pain, chronic
pain is a totally different process. Acute pain— think of it as an alarm clock
going off. It warns us of actual or potential tissue
damage. It warns us something is wrong. The problem is in the hardware of the nervous
system. This transient activation of nervous system
ends when the cause of the pain ceases. If you have a nail in your finger, removing
the nail eventually causes the pain to go away. Or an infection subsides. Or fractured bones come together and the tissue
heals. Chronic pain, on the other hand, is a problem
with the software of the nervous system, the processing areas of the brain and the spinal
column and the nerves that supply them. It’s as if the alarm clock has gone off
and we are awake, but the clock just keeps buzzing, becoming annoying and frustrating. With chronic pain, as with the buzzing alarm
clock that won’t shut off, the pain is not serving the function it was created for. It is maladaptive and a source of irritation,
but no less real than acute pain. In actual fact, the brain has become more
sensitive to the pain signal coming from other parts of the body. Over time, that signal registers in the person’s
brain and the brain believes that there’s something really wrong. The brain believes that the signal means that
something is physiologically significant. For example, my patient tells me, “my bones
are degenerating” or “my head is exploding.” “I have chronic back pain in and back throbs
from time to time, related to the position that I’m in.” The pain in my back and in the spine of many
people in their head is not necessary to inform us about an anatomical problem, like a broken
bone. Its significance is, however, that it impacts
every aspect of the person’s quality of life on a daily basis. Unfortunately, it is not uncommon for physicians
and other prescribers, families, and even patients themselves to misunderstand the nature
of this chronic pain. Diseases like fibromyalgia and migraine headaches
are often misinterpreted as malingering or “psychosomatic illnesses,” somehow less
real. Patients’ report of pain are not believed. They are judged. And the cost of this disbelief is significant. Essentially, the validity of the patient’s
word is doubted and the patient begins to doubt his or her own experience. And this can be devastating. Pain is a subjective experience, so it can’t
be assessed effectively without input from the patient. We can’t hook the patient up to a pain-o-meter
or a dolorimeter, like a blood pressure machine, and calibrate the experience. So, the patient is what the patient says it
is. The pain is what the patient says it is. And it turns out that some feel more pain
than others. There is good information about the effects
of genetics and trauma on the on the central nervous system and the way certain neurotransmitters
metabolize differently in different people, causing some to be more sensitive to a stimulus
than others. There is a kind of switchboard in our nervous
system that can make the pain bigger or smaller. This switchboard is mediated by an enzyme
called – big word – catechol-o-methyltransferase or COMT. For those of you that have medical backgrounds,
COMT is an enzyme that metabolizes dopamine and adrenaline. Dopamine, many of you know is the neurotransmitter
of well-being. Adrenaline is the neurotransmitter associated
with excitement and alertness. COMT is different in different people. And some people, it causes the pain signal
to get huge and for them to feel more pain. In others, it keeps the signal low and insignificant. Let’s say someone has a variant of COMT
that makes touching him or her lightly with little pressure cause excruciating pain. If this person was sitting here complaining
vehemently about this pain from being touched lightly, what would we say about this person? Perhaps that he or she is a wuss, a wimp? We would judge him or her, we do judge him
or her. And we judge these people who are sensitive
to pain even though, as I’ve just explained, it’s actually related to a physiologic phenomenon
that is a response to a variance of these— this enzyme system. There are two things that influence the type
of COMT and pain sensitivity one experiences. As we mentioned, Niki and I, the first is
genetics. In other words, people are born with sensitivity
to pain just like eye color. The second factor influencing COMT variance
is the experience of trauma. People who have had sexual, emotional, or
physical trauma, or all three, as often is the case, as well as people who have had combat
experience and witnessed horrible things in their lives, like first responders and veterans. These people experience more pain. Living through trauma sets the volume knob
inside the pain center on high. This phenomenon is referred to as central
sensitization, it occurs in the brain and nervous system where the signal intensity
inside mid-brains pain centers called the amygdala, the nucleus accumbens, and the insula,
those signals are turned up. The volume in that part of the brain is turned
up. People with this form of chronic pain are
suffering and frequently present to clinicians seeking treatment in pain relief. They are often alienated from families and
friends, and more importantly, at this point, from the prescriber of their medications. It is said that these patients have a better
relationship with the drug than with the doctor. And this disconnect is a significant element
of the crisis faced today in effectively treating chronic pain with medication. Some people who have chronic pain either shrug
it off and we call them strong and tough, while others suffer more because for them
the suffering is bigger than the pain. Suffering is the human response to the experience
of pain. In order to be effective in our treatment,
rather than judging, we must align with the patient and they must perceive that we are
on their side. In medical school, I remember being taught
that if you have tissue damage, you have pain. And if you don’t have tissue damage, you must
be making it up. That’s simply not the truth. The second truth is that emotions and thoughts
drive the experience of chronic pain. One of the questions that I frequently get
asked by referring clinicians is, is it real pain or emotional pain? And my answer is always the same. The answer is yes. Yes, it’s real, and yes, it’s emotional pain. Because thoughts and emotions drive the experience
of chronic pain. This is where we really do patients an injustice,
it’s as if we judge emotions as not real or legitimate. How many people suffer from depressed feelings
or anxiety or fear or anger? Certainly, with mental illness people do,
but actually, we all do. These are human emotions. And physiology of thoughts and emotions is
well understood, it’s all happening inside our 50 billion brain cells, trillions of connections,
hundreds neurotransmitters, including dopamine, serotonin, and a group of pain relieving chemicals
you all well know, known as endorphins. And they’re all communicating with each
other every moment of every minute of every day. Pain lives in the brain along with these emotions. And there is serious data showing that when
somebody has a broken ankle, a particular part of the brain called the thalamus lights
up on functional MRI scans. When someone has back pain or someone has
chronic headaches or sore neck or shoulder that lasts longer than six months, which is
chronic pain definition, a completely different part of the brain lights up. The part of the brain that lights up with
chronic pain is that where we feel emotion. So, the pain is psychosomatic because it involves
the mind and the body, but it’s legitimate real pain. Patients must deal with the psychological,
emotional, and cognitive aspects of pain if they’re ever going to recover, regardless
of physical and pharmacologic interventions that are undertaken. The chronification of pain refers to the process
of the plastic changeable brain reorganizing around misguided signals. There is an increased up regulation of certain
cells, glial cells, and these are the cells that support the nerve cells or neurons that
are present in our brains. Also, there is a decrease in the body’s ability
to turn down the pain. Furthermore, there are chemical changes with
increases in glutamate and NMDA, which are excitatory to the nervous system. Consequently, there is a decreased threshold
for the pain signal, or an increased sensitivity, which results in light touch feeling more
like a blowtorch. The emotions that arise due to chronic pain
constitute the basis of suffering. The suffering increases because of the desire
for the experience to be different than it is. Actually, fear of the pain is more disabling
than the pain itself. The fear that it will hurt more results in
fear avoidance. Not moving because of the anticipation that
it will hurt worse, resulting in less movement and eventually the inability to move due to
the formation of scar tissue decreased circulation and compression of nerves, which can cause,
for example, a frozen shoulder or other joint that is immobilized. In addition to fear, the pain is stimulated
by anxiety, anger, depression, and guilt. These conditions are worse in people, of course,
with mental illness. Resistance makes pain worse. Trying to escape from the pain versus leaning
in and simply allowing it to be there makes the pain less troublesome. The third fact about chronic pain, going back
to some of Niki’s key points, is that opioids simply aren’t the best treatment of chronic
pain and often make the pain worse. What we use to try to take the pain away,
the opioids, also known as narcotics, actually can increase pain in several ways. These medications have been shown to cause
inflammation in brain tissues, resulting in more pain while on the medicine than off the
medicine. This is called opiate-induced hyperalgesia. It’s not easy to convince patients that
this is occurring. This is a place where therapists and trusted
counselors can impact people you’re working with. Patients say to me, “Doc, I know the opioids
are helping me. Sure, my pain is a 9 out of 10, 90% of the
time and I’m in bed 18 hours per day. I can’t sleep and am generally miserable. But when I don’t take the pills, my pain level
shoots up to the sky. So, if you took my opioids away, I’d be
worse.” The fallacy here is that the opioids are working
to diminish pain, when in fact, the person is physiologically dependent on the opioids
so that stopping the opioid will temporarily make things worse because of withdrawal. Physical dependence and tolerance often result
in a problematic relationship between the patient and the drug. This isn’t necessarily addiction or substance
use disorder, by the way. Substance use disorder involves the pathological
pursuit of reward and/or relief from the drug. I do see some patients caught up in a peculiar
relationship with the medications. As I’ve mentioned before, so that continuing
the drug results in continued problems. Opioids are perceived as pain relievers and
the salience of the effect is often compulsively pursued. Craving for the drug comes in the form of
pain for these patients. The only two pain-free states are death and
general anesthesia. And neither of these is the best treatment
of chronic pain. If we are treating someone, we must consider
the old axiom of measuring benefit versus harm. With opioids for chronic pain, the negatives
outweigh the positives for the most part in most people. There are significant side effects, including
but not limited to, constipation, sleep apnea, hormonal and immune system changes, and cognitive
changes. The dangers of overdose are increased with
higher dose of opioids, particularly when sedatives, like the benzodiazepine drugs including
Valium, Xanax, Klonopin and others, are ingested along with opioids. Chronic opioid efficacy studies are few and
far between. In one long-term study, half of the patients
who had a prescription for opioids discontinued the drug within six months of having prescription. The rest showed modest, if any, benefit for
pain, and the little benefit for improved function. If, on the drugs for six months, the likelihood
of being on them for years is significant. Unfortunately, as prescriptions for opioids
become harder to acquire, some patients are turning to heroin, which is cheaper and more
potent. Overdose deaths from heroin are on the rise. Opioids are not the proper treatment of a
sad, painful life. And they don’t offer good treatment for suffering
since they cause dysregulation in the emotional centers of the brain, affecting dopamine and
other neurotransmitters. People on opioids experience a rollercoaster
of effect and opposite effect. Withdrawal, though usually not life-threatening,
is quite unpleasant, to say the least. Provisions must be made for detoxification
or weaning under medical supervision. The next truth is that the treatment of pain
must involve improving the patient’s function, resulting in a better life. If we’re going to treat pain, we ought to
see evidence of improved function. There isn’t anyone, any patient whose pain
I can’t take away if I give them enough pain medication, say Demerol or morphine. Everybody’s pain would be absolutely gone
and you would all be unconscious. That’s not proper, correct pain treatment. So, instead of asking what’s your pain level,
doctors and other clinicians ought to ask, how is your life? Are you walking? Are you hanging out with your kids and grandchildren? Are you able to work? If the answer is “no, actually, I stopped
working two months ago and I’m in bed because the pain disables me. I’m tired all the time and I’m depressed,”
that’s not proper pain treatment. And yet, when we go to the doctor’s office,
the first question asked is, “what’s your pain score?” If we’re simply going after the pain, again,
we’re missing the boat. And the final truth is that expectations influence
outcome in the course of chronic pain treatment. Our beliefs drive what happens to us, and
that’s the direct result of the power of the mind. Placebos are a good example of this. By simply believing a pill will reduce pain,
20% of those taking it would have decreased pain. This is comparable to some drug effects, which
might have an impact of maybe 30 or 35% versus 25%. These drugs get released on the market and
somebody sells them, doctors prescribe them, and companies make billions, while placebos
are free. We should be capitalizing on this effect. There’s another phenomenon related to the
power of the mind known as nocebo. With a nocebo, the suggestion is negative. For example, take this pill and within 20
minutes your stomach is going to start cramping. Nocebos are effective 90% of the time, so
the power of the negative thought and negative beliefs is much stronger than the positive. That’s a big part of the internal messaging
with chronic pain and the chronic pain syndrome. “I can’t walk, my feet are on fire. My back is killing me.” These are not the truth. But if we expect that they’re not going to
be able to walk, we create that reality for ourselves through our mindset. Pessimists have a more realistic view of life,
perhaps, but optimists live longer, have lower pain scores, and enjoy a better life. So, let’s be optimistic and teach these skills
to our patients. Furthermore, cognitive behavioral therapy
is more effective if the patient believes it will be effective. What we think is going to happen is a lot
more likely to happen because we think it is going to happen. This works in a negative way as well. Anticipating pain causes more pain. This is known as catastrophizing, which essentially
magnifies the negative and makes the situation worse than it is. Catastrophization involves rumination of negative
thoughts. It also involves pessimism, magnification
of pain symptoms, and helplessness. Patients do better when they are engaged and
distracted. Therefore, they are less affected by the pain. Of course, not everybody who has pain is in
trouble. There are people who have chronic pain and
manage their lives and go to work, and function well. Other patients are said to have chronic pain
syndrome, which is a constellation of symptoms and has been defined by the U.S. Commission
on the Evaluation of Pain in 1987. Chronic pain syndrome includes pain for more
than six months, and it also includes experiencing those emotions that we’ve been talking about,
including depression, anger, anxiety, and fear. The pain results in restriction of daily activities,
so people are in bed more than they’re up. This also includes excessive use of medications
and medical services, multiple nonproductive tests, treatments, and surgeries. I can’t tell you how many people come in and
say “I’m getting off my opioids because my surgeon won’t operate on me until I’m
off.” I asked how many surgeries have you had on
your back? And the answer is “four, this will be my
fifth”. Like the fifth is going to cut out the scar
tissue causing the pain and putting in new titanium rods to better fuse spine will improve
the situation. Rods that stabilize the spine by fusing it,
preventing it from bending, are supposed to decrease the pain. Over the long haul, that is rarely the case,
partly because the fix is unrealistic. And secondly, because as we’ve already decided,
the pain is not coming from the back is coming from the brain. Finally, with chronic pain syndrome, there’s
also no clear relationship to the organic disorder. So as I will consider these patients are misunderstood
and not believed. Part of the reason we have so much trouble
assessing pain is that pain is a totally subjective experience. The patient’s pain is his or her own pain. Whatever she or he says it is. Tthere is no way to prove that the pain level
isn’t 8/10 and as we learned, a patient’s subjective experience is different from another’s. So, we can only rely on the person’s self-report,
acknowledging that some people feel more pain than others. Treatment of chronic pain should focus on
improving function, not simply reduction of pain. The problem with opioids is that if we’re
dealing with a broken leg, it makes good sense to take a limited dose of opioids for a short
time as possible. If one breaks their back and two years later
they developed degenerative disc disease and it hurts all the time, one must be very careful
in making a decision to take opioids since the pain is going to last the rest of his
or her life. If the decision is to try them, well then
let’s try them as a clinical trial. Let’s see how they work. How will we know if they work? Are we going to ask how the pain is? Of course, but as important is to ask how
the patient is functioning. If she or he is up and around, going to work,
sleeping better, and having better relationships, then that’s a good trial. We should continually assess that on a regular
basis and if something changes and there is deterioration, like less pain relief or impairment
of function, consider discontinuing these drugs before things get worse. Opioids work and they take the pain away,
or at least decrease it temporarily. But over time, they stop working because of
the development of tolerances Niki mentioned. So, the dose must be increased to get an effect,
which diminishes over time. If the patient wants to stop, he or she will
have trouble because of physical dependence. We ought to have a plan to stop before we
ever start. This is what I tell physicians when I train
them. We need to have an exit strategy for how we
will get people off these drugs if we start them. And we ought to implement that exit strategy
if function is not improving, or worse, still is deteriorating. In other words, we, the system, the medical
system, the therapeutic system, need some overhauling in the way we treat chronic pain. Opioids, as we mentioned have a lot of associated
problems. The worst side effect, as I mentioned, is
constipation. It doesn’t sound that serious, but it is. I treated a woman who was 80 years old and
hurt her back working as a maid. She’d been treated with 80 mg of hydrocodone
per day and her constipation was so severe that the only way she could move her bowels
was to put her hand up in her rectum every 10 days and manually disimpact herself. She was suicidal. We detoxed her off of hydrocodone and by the
end of the 12th day she was free of constipation, free of opioids. Her pain score was reduced by 50%. Now, we all agree that this is a good news
story, but we also can be encouraged that there are two new drugs released to treat
opiate-induced constipation. Is that the solution to this problem? There are people take opioids for their anxiety,
fear, and sleep disturbance. I treated a woman who said, “Doc, since
I started that hydrocodone my marriage is better.” That’s not the proper use of opioids. I’ve already discussed the phenomenon called
opiate-induced hyperalgesia. This basically means that opioids cause more
pain; and more physicians and medical practitioners are finally coming to realize that this is
true. Clinicians can be most helpful to their patients
in reviewing this information and developing a treatment plan consisting of decreasing
or possibly discontinuing opioid medications. Treatments for chronic pain will be covered
in the series, but the key interventions include changing thoughts and feelings using cognitive
behavioral therapies, stress reduction skills, and mindfulness practices. Movement is key. Motion is lotion. So, start slow and developing consistency
with stretching exercise, yoga, Qigong, Pilates, or any number of other activities. Simply getting started with a daily walk would
be terrific. By all means consider avoiding toxic substances,
especially nicotine and tobacco, which are associated with increased pain levels. And finally, giving up the expectation of
being pain-free, and accepting the reality of functioning better, despite having pain,
will enable your patients to live a better life. And isn’t that what this is all about? Cathy: Thank you, Mel, so much for your time
and your insights and truths around treatment of chronic pain. And, Niki, thank you for sharing your experience
with us today. In closing, I’d like to remind everyone
that in our next podcast, in our series, we will continue the conversation about the science
behind alternative pain management strategies, and hear from two individuals to offer alternative
treatments for chronic pain, and they will also share the interaction they had together
as someone provides treatment for chronic pain and someone who receives treatment for
chronic pain. So, our guests next time will be Jeanne Supin
and Teresa Baltzell. Thank you again for joining us today and hope
you can participate in the rest of our series. (END OF TAPE)

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