By Mark Farris Pirtle, D.P.T., CSCS, COMT
Associate Director of the Pain Management Program at Sierra Tucson

I gave a couple of talks recently in Chicago, where many people came to hear me propose how pain patients could learn to reset the “tone” of their nervous systems and work through painful or otherwise stressful experiences without using drugs. I presented the latest scientific evidence to bolster my claims and taught the audience a meditation method that provides an experiential understanding of the power of such practices. By the end, participants seemed convinced and ready to go home and put these techniques to work. That’s the way it seemed to me, anyway.

The good news about these types of self-care practices are that those who learn them overwhelmingly report they like them and they work. The bad news is few people go on to put enough effort into practicing self-care for substantial and long-term benefits to take hold. Why is this? Maybe because it is easier to take a pill to manage life’s discomforts than to learn to work through them. If you really think about it, you know that’s the reason; we’re a quick-fix society. Unfortunately, in the case of chronic pain, taking the easy way out often turns into an unintended, torturous, and downward spiraling cycle of pain and addiction.

Our society, medical system, pharmaceutical and legal industries, and patients themselves must all shoulder some of the responsibility for creating this pain/addiction crisis. Although opiate-based medication prescriptions began to increase during the 90’s, this trend got an unwitting boost when, in 2000, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) made pain the “5th vital sign.” These standards intended that pain is to be assessed at every patient contact. This was a great step forward for those patients who had their pain undertreated in the past. Now patients with malignant cancers and those experiencing pain after surgery get the relief they need. But, as we are now discovering, this positive change brought with it the unintended and negative consequence of reinforcing medical prescriber trends and the “take the easy way” approach.

The JCAHO standards implemented what is now the familiar 0 to 10 Point Pain Scale, where 0 means “absolutely no pain,” and 10 means “excruciating pain with a complete inability to cope or function.” It may not be obvious to readers, but pain is a very hard thing to measure, even for the one experiencing the pain. All over the country, doctors and hospitals began measuring pain as best they could. Predictably, different treatment protocols began cropping up in different parts of the country. Drug companies seized on this confusion and increasingly recommended their opiate-based medicines for more pain diagnoses without solid evidence for their appropriateness. After a few high-profile lawsuits where patients successfully sued their doctors for under-treatment of pain, the scales tipped in favor of treating all sorts of chronic pain conditions using opiate medications. It used to be that receiving an opiate-based prescription was rare; nowadays, most patients expect their pain to be treated using these powerful drugs. If this expectation is not satisfied, patients can complain to hospital administrators and medical boards. Savvy patients have learned if they merely rate their pain 8/10 on the pain scale, they are more likely to get opiates from their doctor.

What Are the Risks?

What patients don’t know is that these drugs are very dangerous; just because they are frequently and inappropriately prescribed does not change that fact. Dependency, meaning becoming abnormally tolerant to and dependent on something that is psychologically and physically habit-forming, happens very quickly with these drugs, sometimes after taking only a few doses. The risk of pulmonary edema and death comes with opioids as well. This risk increases if opiates are taken with alcohol or sedatives, which they frequently are. Opiates obviously can lead to intense cravings in vulnerable persons (people in recovery) and are associated with very uncomfortable withdrawal symptoms. Reexposure to opiates even years later can trigger relapse in persons demonstrating previously addictive behaviors.

What is the right way to use these medications?

As I mentioned, if a patient has malignant cancer pain, the risk of the above mentioned side effects is moderated by the benefit of providing comfort to a dying patient in his/her last months. Additionally, if a patient has just had a major surgery, five days of opiate medication is appropriate, as long as the patient is switched to non-opiate-based medications soon thereafter.

The reality is, treating chronic pain with opiates often causes more problems than it’s worth, especially in an at risk population. Persons at risk include those with a history of alcohol and chemical dependency, including cigarette smokers. Teens, patients with a family history of alcohol and chemical dependency, and depressed individuals also should avoid these medicines if at all possible. If these drugs are taken for an extended period, even persons who do not meet the above criteria can get into trouble. It’s been reported that up to 20% of all patients are at risk for abuse when exposed to opioids. Because of this statistic alone, the benefits of opioid use for chronic pain do not seem to be justified. Even worse, we’re learning that opiate medication does not even help some of the conditions it’s prescribed for, like fibromyalgia, for example. Our doctors need to help us understand that there are better choices.

There’s a bigger issue here that often goes unrecognized. What pain patients (and their doctors) don’t often realize is that pain sensations generate related and simultaneous emotional reactions. Emotions like sadness, fear, and anger intensify pain sensations. If a person lives with pain for an extended period of time, these core feelings can deepen and turn into depression, anxiety, and rage, respectively. When this happens and a pain patient is asked to rate his/her pain on a 0 to 10 scale, they often rate the pain higher, because to them the whole experience feels overwhelming.

Negative self-talk and images in the mind, and uncomfortable emotional sensations in the body accompany chronic pain sensations in such a way that the pain experience itself begins to wear a patient down. In a despondent state, the patient often lacks the energy and motivation for self-care, which sets up and perpetuates the cycle of chemical dependency. When a patient has fallen into this hole, often the only way out is a multidisciplinary pain program. There are not many of these programs in the country, but there are some and, thankfully, new ones are cropping up all the time. A chronic pain patient with opiate dependency should look for a program that treats both his pain and chemical dependency at the same time. Pain science gives the nod to programs that are based on patient education. When patients learn about their condition, they are more apt to manage it skillfully and, therefore, achieve more positive outcomes.

Moving Toward a Solution

Movement therapy and exercise are also a big part of recovery. Pain patients often have a history of withdrawing from activities in which they previously engaged. As a result, their bodies become deconditioned and sensitive. Movement and exercise, although sometimes initially difficult, has been proven to increase patients’ functional abilities and lower their reports of pain. Addiction-free pain management and psychological denial patterns (ways of thinking that keep us stuck in our problems) are also something to look for in a pain program. Mind-body practices like meditation, yoga, and breathing techniques teach pain patients to manage each pain experience better and, thus, they learn not to make the pain they have worse than it is. The difficulty lies in the fact that healing using self-care techniques is not easy. But as we’ve seen, relying on opiate medications is no solution either. When a pain experience is “on-board,” sometimes the only appropriate thing to do is to learn to sit through it by practicing healthy, self-soothing mind-body techniques. I realize that this “don’t make it worse” approach may sound unbelievable and extreme to those raised in a society that supports instant relief.

But learning to sit courageously with pain, not making it any worse by practicing self-soothing techniques sets up a pattern of increasing distress tolerance that calms the nervous system. And that is just what pain patients need: to calm themselves. Just as nervous systems change to become sensitive, with effort, practice, awareness, and composure, a nervous system can and will reset itself to a more normal tone. Yes, it’s easy to say and hard to do, but what other choice is there?

Reprinted with permission from California Together Newspaper.