Is It Time to Talk About Managing Pain Without Opioids?

Opioids are certainly in the news. The US Surgeon General recently issued a statement on the relationship between their widespread use for chronic pain and the subsequent epidemics of opioid addiction and accidental overdose (US Surgeon General, 2016). The US National Institute for Drug Abuse and Centers for Disease Control have also issued concerns (see here and here, respectively). Mainstream media reports on the problems of opioids appear almost daily.

After a couple of decades of strong proponents and persistent messaging on the benefits of opioids, the tide of public opinion and the opinion of health experts seems to be turning against the widespread use of opioids for chronic pain.

Among people with chronic pain who use opioids, this change in perspective on the use of opioids can be alarming. For about two decades, people with chronic pain have been encouraged to take opioid medications. Many have subsequently come to rely on them. Some may have even come to believe that it is impossible to manage chronic pain well without the use of opioid medications.

We now face a dilemma in the management of chronic pain. We have strong managing pain without opioidsproponents for the use of opioids and strong proponents against the use opioids. Both sides have valid concerns that lead to their respective positions.

Often, the sides in this dilemma seem to get expressed in untenable ways. It’s as if the stakeholders in the field have to choose between two bad options: either you take opioids on a chronic basis and expose yourself to the risks of addiction and accidental overdose, which are actually occurring to people with chronic pain at epidemic proportions; or don’t take opioids, remain safe from addiction and accidental death, but expose yourself to pain, which may be intolerable. Healthcare providers seem to face a corresponding dilemma: either manage patients on chronic opioids while exposing them to addiction and accidental overdose or refrain from opioid management and expose them to what might be intolerable pain. Whether patient or provider, both options seem bad.

Is there a third option?

There is another way, of course. It’s called chronic pain rehabilitation and it effectively shows people how to successfully self-manage chronic pain without the use of opioid medications. Chronic pain rehabilitation clinics have been around for three to four decades. However, it’s hard to get people to go to them. It’s not because they are ineffective. Research over the last four decades shows clearly that they are effective (Gatchel & Okifuji, 2006; Kamper, et al., 2015).

Managing pain without opioids

People who’ve been managing their pain with opioids are often a little leery of recommendations to go to a chronic pain rehabilitation clinic. The recommendations seem to run counter to much of what’s been previously recommended throughout the long course of care for their chronic condition. After years of recommendation and encouragement to take opioids by some providers, it’s hard to understand why other providers might recommend and encourage the exact opposite. Maybe they are recommending learning to self-manage pain without the use of opioids because:

  • They don’t believe my pain is as bad as it is.
  • They think (wrongly) that I’m addicted to opioid medications.
  • They think my pain is all in my head.
  • They just want to make money off their program that they are recommending.
  • They are ignorant of what’s most effective for chronic pain (i.e., they don’t know what they’re talking about).
  • They are not as compassionate as the previous providers who recommended opioid management.

In all these concerns, people become leery of a recommendation to forego opioids because it’s hard to believe that the recommendation is being made in the best interest of the patient. It seems that relief of pain through the use of opioids is what’s best for the patient and anything that runs counter to that recommendation must be in the best interests of someone else.

Moreover, it’s a sensitive topic. Let’s face it, no one feels especially proud of managing their chronic pain with opioids. Rather, people with chronic pain do it because it seems a necessity – they believe that the pain will be intolerable without opioids. The recommendation and encouragement to take opioids by healthcare providers and by society, more generally, is helpful in this regard. Such encouragement supports the decision to use opioids, one in which there’s always been some ambivalence. Again, no one is exactly proud of taking opioids for chronic pain; upon reflection, there is always some degree of doubt or concern about their use that leads to a sense of vulnerability and sensitivity. It’s helpful to have others, especially healthcare providers, recommend and encourage their use.

When, however, other healthcare providers recommend against opioid use and encourage learning to self-manage pain instead, it can sting because it taps right into the inherent sense of vulnerability and sensitivity that occur when taking opioids.

It’s hard to see a healthcare provider as acting in the best interest of patients when they openly question the issue that can be so sensitive. The recommendation to learn to self-manage pain without the use of opioids shines a direct light onto the inherent sense of vulnerability or shame that so many feel when using opioids for the management of chronic pain.

tapering opioidsThe recommendation inadvertently breaks all the tacit rules that healthcare providers (and pharmaceutical companies) have heretofore been following. The rule up until now has been to reassure patients that it’s okay to take opioids for chronic pain. Over the last two decades, the field has asked patients to trust these assurances that they shouldn’t be ashamed of their need for opioid medications. Now, the field is changing and has begun to question the need for opioids. In so doing, we break the trust of patients who have been on opioids for some time: we expose them to potential pain, but also the shame that heretofore we alleviated with assurances that taking opioids is okay. It’s no wonder that patients are now upset.

In a microcosm, it’s this dynamic that occurs in the offices of chronic pain rehabilitation clinics everyday when, after the initial evaluation and recommendation to participate in the therapies of the clinic occurs, patients leave and refrain from accepting the recommendation to learn to self-manage pain. Such patients are doubtful that it will work and are afraid of the pain that would ensue if it doesn’t. Moreover, though, they tend to leave feeling somewhat ashamed that the provider so openly talked about the fact that they could learn to self-manage pain without the use of opioids. Providers are supposed to provide reassurance that it’s okay to be on opioids, not question their use.

Even when it’s well-informed and done in the best interest of the patient, the recommendation and encouragement to learn to self-manage pain without the use of opioids can be heard as a subtle yet stinging rebuke because of the inherent sensitivity that occurs when taking opioids for chronic pain.

How, then, do we bridge this divide?

The Institute for Chronic Pain has a new content page that may play a small role in such bridge building. When patients come to chronic pain rehabilitation clinics for the first time, they may have never had an experience of a provider talk to them about self-managing pain without the use of opioids. As we’ve seen, it’s a complex and sensitive interaction that occurs under the surface of the words that are spoken. It can be a lot to take in. It can feel like the rules are being broken. As we’ve seen, it can be easy to become angry and accuse the provider of incompetence, ill-will or insensitivity. Oftentimes, people need a little time to reflect on the discussion and talk it over with their loved ones. No one comes lightly to the decision to taper opioids and learn to self-manage pain instead.

The new content page provides assistance with this reflection. The hope is that patients can use the information on the page to further reflect on if and when it may be time to begin learning to self-manage chronic pain. Providers can refer their patients to the page too, ask them to read it, and come back for further discussion.

For countless people over the last four decades, chronic pain rehabilitation has provided hope and a way to take back control of a life with chronic pain. However, it must be approached with sensitivity and compassion. Initially, the idea that one can successfully self-manage chronic pain without the use of opioid medications can be threatening, especially for those who have been managing pain with opioids for some time and for those whose providers have long provided reassurance that it’s okay to take opioids. Nonetheless, if your providers have recently begun to express concerns about the long-term use of opioids or if you yourself have concerns about their long-term use, you might find it helpful to read the new ICP page on the common benefits of learning to self-manage pain without the use of opioid medications.

You can find the new page by clicking on the link here.

References

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Kamper, S. J., Apeldorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ, 350. doi: http://dx.doi.org/10.1136/bmj.h444

Author: Murray J. McAllister, PsyD

Date of last modification: January 23, 2017

About the author: Dr. McAllister is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

 

On Hearing Patient Stories & Building Community

The Institute for Chronic Pain is an educational and public policy think tank that produces academic quality information on chronic pain. We aim to provide such information in a manner that’s empirically accurate, yet also approachable to patients, their families, non-specialist healthcare providers, third party payers, and public policy analysts. We do so because the field of chronic pain management needs to change.

The widespread use of opioid medications for chronic pain in the last two decades have led to epidemic rates of opioid addiction and accidental overdoses (Centers for Disease Control, 2016; National Institute of Drug Abuse, 2016). In the same decades, the rates of spine surgery and interventional procedures have grown exponentially and yet the rate of disability related to chronic pain has similarly risen (Deyo, et al., 2009). Among healthcare providers, patients, and their families, there’s growing recognition that as a field we need to do better.

Dr. Melissa Cady agrees and she’s had the insight that we begin to do better by listening to those who matter most: people who live sharing hopeeveryday with chronic pain. We need to hear the stories of how people live with chronic pain – the stories of those who suffer, to be sure, but also the stories of those who have come to flourish even with persistent pain. Both narratives are important. One of these narratives fosters compassion. The other fosters hope.

Dr. Cady provides the Institute with a new content page on the importance of sharing stories from real people who make real changes in their lives in order to thrive despite continuing to live with pain.

Dr. Melissa Cady is an osteopathic physician with training and dual board certification in anesthesiology and pain medicine. She runs a website that carries stories of real people with chronic pain who have successfully come to self-manage their pain. They each tell their story of how they’ve overcome suffering and have learned to thrive in life despite persistent pain.

The website is Pain Out Loud and I encourage everyone to visit it and listen to the stories of those who have successfully come to self-manage chronic pain. It shows that living a full life is possible once one learns how. It shows that you can learn to do it too. It shows that there is hope.

Please consider sharing your story of how you overcame adversity and learned to successfully self-manage pain. We can all learn from each other. In so doing, we foster hope and empowerment. We build community.

If you think that hearing from the people who have persistent pain is important, please link to Pain Out Loud on your site or post a link to it through your social media.

References

Deyo, R. A., Mirza, S. K. Tuner, J. A., & Martin, B. I. (2009). Overtreting chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-58.

Centers for Disease Control (CDC). (2016). https://www.cdc.gov/drugoverdose/epidemic/

National Institute of Drug Abuse. (2016). https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

Date of last modification: 1-8-2017

Author: Murray J. McAllister, PsyD

Treatment Plan: Do Nothing?

It’s cold and flu season again and we all do the best we can to stay well and avoid catching an all-too-contagious virus. We each have our own go-to plans of how to fight it: vitamin C, zinc or elderberry supplements, gargling with salt water, staying warm, rest and binge-watching Netflix shows. My grandmother swore by anise candy that she made from scratch, while my father prefers a hot toddy to remedy a cold. Washing hands is still the number one way to avoid illness — along with avoiding contact with your face, and keeping your immune system strong. Far too many of us have also taken antibiotics despite the fact that they do nothing for a virus and their overuse has now created resistant strains of bacteria for all humans (Ventola, 2015). You may be tempted to go to the doctor for antibiotics “just in case,” and then the antibiotics are falsely credited for your recovery since you always do eventually recover. Primary care physician and medical director at Chapa-De Indian Health, Dr. Mike Mulligan, says in reference to antibiotics, “If I do nothing I will be doing right by patients most of the time compared to if I prescribe something. If I prescribed antibiotics for everyone who wanted them, I would most often be doing wrong.”

Typically when we go to the doctor we expect someone to do something, yet overtreatment is far more common than under-treatment and the impact causes real harm. Dr. H. Gilbert Welch has investigated how and why this happens for many health problems including heart conditions, headaches, back pain, knee and hip joints, gastrointestinal disorders, and even cancer. In his book Less Medicine, More Health (2015), he examines how early detection hasn’t led to saved or improved lives, which defies logic at first glance. The over-prescription of medications alone is nothing short of epidemic, most glaringly seen with the overuse of opioid pain medications.

Chronic pain is that much more frustrating because of its long duration and frequently leaves people feeling Something More Should Be Done. It seems like Something Else Must Be Wrong if only the doctor could find it. Each specialty department shakes their heads and gives the “good news” of normal or inconclusive scans. Navigating health care systems is not easy to begin with chronic pain rehab programand there are still far too few comprehensive pain management programs that focus on functional rehabilitation. Once in a while the ragged pursuit of Something Else can lead to a more thorough workup or referral to a good treatment program. It depends where the Doing More is directed. Too often, the quest for the Something Else leads to tests and treatments that carry their own risks without relief; often frustrating and distracting to the patient and doctor, resulting in more pain, medical appointment exhaustion, and patients feeling demoralized and hopeless.

Chronic pain has few circumstances where invasive procedures are the best choice. Usually if surgery is warranted it becomes quite clear early on and a 2nd or 3rd opinion will render the same conclusion. The risk of more pain is high with surgery when done because “it might help,” even if the structure has been “fixed.” To a surgeon, fixed means correcting the abnormality. To you as a patient, fixed likely means less pain and improved function. The past 30 years has revealed that abnormal scans of the lumbar spine are common among pain-free individuals and normal scans are common among those who experience pain (Jensen, et al., 1994; Borenstein, et al, 2001). So if the abnormal is normal and abnormal findings do not predict pain, what do we do now?

Last week my daughter’s knee swelled up larger than a softball until she could no longer bend it. We had an x-ray and waited. And waited. The swollen mass grew bigger and her doctor reassured us that ice, elevation and anti-inflammatories were the best treatment. This was hard for me to believe and my mind raced: What caused it? There must be a reason! Why is it so large? Can’t we test the fluid? Can’t we do something to make it go away quickly? I felt like I was Doing Nothing and this felt terrible, but her doctor had ruled-out life and limb-threatening infection and it was the right call. Had I gone to the emergency room, the fluid may have been tapped, risking infection, leading to antibiotics, potential complications and unwanted effects, including more time in bed. An MRI may have revealed an abnormality that was unrelated, which could have led to Doing Too Much. My worst fears were not realized, but it was tempting to buy into the fear that Doing Nothing would lead to a bad result that could have been avoided if I had Done More. What felt like Doing Nothing really was doing something – something at home (elevation, ice, anti-inflammatories, and coping with fear and pain) and Nothing More at the hospital.

The Temptation

It is tempting to assume:
• If there is pain, something is wrong.
• If something is wrong, it can and should be found if we look hard enough.
• Once it is found, it can be fixed.
• If it is fixed, I will feel better.

These assumptions are myths that have been dispelled over time. Sometimes we hurt without any abnormal findings. Sometimes looking harder leads to more problems rather than fixes. Even if the source of pain is found, it may be best to avoid invasive treatments. And the fixing of found abnormalities helps — if you are a car (but even then be cautious of overtreatment!).

But isn’t the pursuit worth the risks? Welch’s data suggests not. One common example is a CT scan – the radiation may increase cancer risk and should be avoided whenever possible. But there also are lesser known risks he calls “incidentalomas” – those incidental findings that appear abnormal on a scan, but do not actually explain or contribute to the symptoms you are experiencing. These red herrings lead to many unnecessary procedures including what I call health-ectomies, or removal of healthy organs in the hopes that it will solve the problem. This is very common in abdominal pain, one of the leading causes of emergency room visits (CDC, 2011). In our highly medicalized society that relies on technology to save us, we can be misled to think that everything can and should be found on a scan or test. However, the search may only distract you from good self-care in the pursuit of an outside fix. Living in the information age leads us to think that more information is better, but more is not always better. “Better information is better,” Welch says (2015). We need useful information to move forward with clarity in medical decisions and health. “At least I would know” does not work if it distracts you from the truth. The truth may be that your disks are degenerating, but it is not typically the cause of your discomfort.

The Frustration

It’s frustrating to be told no, you don’t need that test, that the cause of your do nothingsuffering is unknown, or that there is no cure. “That’s all I can do,” are not words we like to hear. They rank up there with “Could it be depression?” Your doctor may or may not have explained to you why more tests are not recommended. Some people suspect it’s to save money, but most clinics have financial incentives to perform more tests, not fewer. You as the patient may feel more taken care of, more thoroughly examined, but it may not lead at all to better care. Sometimes it is best to Do Nothing, at least nothing at the doctor’s office.

The Fear of Missing Something

The Fear of Missing Something is real and powerful. Any doctor can tell you how terrible it feels when something has been missed. It haunts them for a lifetime. This is a fear of patient and doctor alike, although it is overtreatment that is the common daily occurrence. Most of us feel better Doing Something. Mistakes are made when we are guided by fear rather than facts. We depend on doctors to rule-out anything life-threatening. Afterwards, it can feel devastating when it’s suggested that you “learn to live with it.” But this is not because doctors don’t care enough to do more. Most health care providers really do care, and they care enough to do less. This is where their job ends and yours continues.

Chronic pain is often part of a feedback loop with the central nervous system that becomes sensitized even when the pain signal from body to brain carries no new or useful information about the condition of the body. Inflammation and degeneration are common pain-related issues best treated by lifestyle improvements. A spinal fusion may “fix” the current instability, but create more instability in surrounding areas. It may “fix” the problem, but also severely decrease range of motion. Medication almost always has unwanted effects. Injections have risk and the benefits must outweigh the risks for it to be a good choice for you. Physical therapy may hurt and you swore you would never go back, but finding a physical therapist who specializes in chronic pain is a key part of rehabilitation. Dr. Nobert Boos and colleagues (2000) found that the physical and psychological aspects of a person’s job predicted pain over a 5-year period better than MRI results. If the chronic stress of a tyrant boss or conflict-filled relationships are fueling inflammation in your body, you might consider treatment that targets these root causes of inflammation rather than pursuing a traditional medical fix targeting the wear and tear that’s found on MRI.

Often the body does best when it’s left to its own devices rather than modern medicine interfering at all. You may feel like More Should Be Done, but for chronic and stable conditions or the common cold and flu, wellness is best found at home, not at the doctor. Self-care is a full time job and the goal is to get so good at it, less effort is required over time.

References

Boos, N, Semmer, N, Elfering, A, et al. (2000). Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity. Spine, 25, 1484-1492.

Borenstein G., O’Mara, J. W., Boden S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel S. W. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. Journal of Bone & Joint Surgery, 83, 320-34.

Centers for Disease Control (CDC). (2011). http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. D., Malkasian, N., & Ross, J. S. (1994). MRI imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 369-373.

Schwartz, A. L., Landon, B. E., Elshaug, A. G., Chernew, M. E., & McWilliams, M. (2014). Measuring low-value care in Medicare. JAMA Internal Medicine, 174(7), 1067–1076.

Ventola, C. L. (2015). The antibiotic resistance crisis. Part 1: Causes and threats. Pharmacy and Therapeutics, 40(4), 277–283.

Welch, H. G. (2015). Less medicine more health. Boston, Massachusetts. Beacon Press.

Date of last modification: 12-22-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

What Would You Do If You Had Less Pain? (Part 2)

 

  1. Spend More Time with Loved Ones
  2. Travel
  3. Be More Independent
  4. Enjoy Life More
  5. Be In a Better Mood

6. If you answered Spend More Time with Loved Ones, it is clear that family and friends are a top value for you. You may feel you aren’t doing your part in the relationship. Perhaps, you say, “I don’t want to slow them down” and so you miss out on fun events with them. Or are you used to being the caregiver in your family? Maybe you withdraw from other because you are uncomfortable asking for help.

Solution: Withdrawing from people you love doesn’t usually help with pain in the long run. However, taking self-care breaks or setting healthy boundaries with loved ones is a necessity for a good life even for those without chronic pain. It is tempting to put fun activities or strengthening relationships on hold until pain decreases, but this may result in more strained relationships and cause you more pain in the end. If taking care of others is important to you, pain might be a signal for you to find more balance between taking care of others and your own self-care. Don’t jump back in at full force, but show up when you can and participate in a way that works for you now. As for not slowing them down – they likely value you for who you are, not what you do. You might value yourself the same way and let them decide if they mind being slowed down.

7. If you chose Travel, it is likely you have an adventurous spirit, have traveled before and know the gifts of perspective, beauty, and excitement that travel can bring. Avoiding travel is a common mistake for those with chronic pain. If your condition is stable and chronic (not rapidly worsening, deteriorating, or waiting for surgery), you have likely been given permission by your doctor to travel, but it’s fear of pain that keeps you at home. You wonder what will happen if you have a terrible flare up on vacation and so decide to remain home.

Solution: What would happen if you had a flare-up on vacation? What is the worst thing that could happen? Be aware of how much fear is driving your decision to avoid travel. Pain can be awful and we want the comfort of home, but a flare is a flare. You may be out of your comfort zone experiencing a flare, but this is not something you can know for certain in advance. Our expectation is to feel our best on vacation. The reality is you might not, but don’t let this deter you from doing something you enjoy. You can bring pain with you anywhere — fortunately and unfortunately.

Challenge yourself to set up your trip for success. Thoughtful preparation will help. Be creative using supportive devices like canes, walkers, back supports, ice and heat packs to ease your ride. Work on conditioning yourself, eating right, sleeping well, and minimizing medications before you go. Creatively schedule the details of your trip to pace events such as sight-seeing, hiking, sitting, and build plenty of opportunities for rest and gentle movement into your itinerary. Take more time to go shorter distances. A slow, steady rate may take longer, but you may discover things otherwise missed on the journey.

8. If you said Live More Independently you may be grieving some of the personal losses that go with chronic pain. It is likely that you have been forced to give up some independence such as working, driving, or engaging in projects around your home. Adjustment to these losses certainly takes time and patience. It may be especially challenging if you are used to taking care of others and now you need help taking care of yourself.

Solution: Being truly self-sufficient is more of a myth than a way of life. Wanting to be alone too much may even be a sign of depression. Being interdependent, rather than independent, is how we survive as a group. It is very challenging to let go of control and let others help. Pushing yourself in an attempt to maintain complete independence can lead to misery. Eventually, it negatively impacts your well-being and the well-being of those around you. How do you feel when you help others? Likely, you enjoy it. What would it be like to afford them this same gift?

Chronic pain and limitations can be a catalyst toward recognizing the gifts that come with asking for help and relying on others. When you need help, use your energy to do what you can without fighting against yourself or others. Be realistic about what you can and cannot do and communicate clearly with those around you. All-or-nothing is not the best option. Try picking and choosing those activities you can still do safely on your own.

less pain9. If you chose that without pain you would Enjoy Life More, there seems to be no argument! Agreed, life would be more enjoyable without chronic pain and if that was possible, I would be selling the cure in bulk. But what will life be like for you if you wait to enjoy it only after pain goes away?

Solution: Any wish for suffering is unhealthy. However, pain is already here so we may as well recognize the gifts that can come with it. It can be a great teacher — not just a disciplinarian. It seems like everything would be better without pain, yet some people who have suffered greatly say that suffering was a gift that brought other beautiful things with it. Without the struggle, they would have missed out on the growth. This is not to say that you should start enjoying pain or be grateful for pain…that’s just crazy. Or is it?

Could we dare to be grateful for pain as we lean in to hear what it has to say? Might it have messages reminding us that we are human and to slow down, to prioritize our values, to take better care of ourselves, to lean into discomfort, to forgive, to share, to ask for help, to empathize, to be brave and stare it in the face, move through it rather than away from it — yes, even befriend it? This is the ultimate challenge in your relationship to pain. What would it be like to befriend yourself with pain? What would you lose if you stopped fighting pain?

10. If without pain you would Be In A Better Mood, you likely have insight into how pain and mood can impact each other. You may have noticed how irritable you become, or even that you can lash out at loved ones — and it justifiably bothers you. Pain can certainly take up so much space in our brains that we feel worn out, irritable, and as if one more thing will tip us over the edge. You may have thought, “If only pain would go away, I could be a nice person again!”

Solution: You may have already noticed that your mood is impacted by how your body feels, but did you know that your body also holds emotions in it and that your moods affect pain? Although the brain is the control center for your body and its sensations, emotions also reside in the body. Do you know where you feel frustration in your body? Where do you feel anger physically? What about impatience, fear, helplessness, loneliness, or sadness? Check your body when you are experiencing different emotions to see where you personally hold these feelings. Is it your shoulders, stomach, back, hands, jaw or forehead? Sooth your mood and pain at the same time. Try to move straight through discomfort and other strong emotions. Find small joys and comforts in the ordinary. Search for wellness by asking yourself, “What is right with my body today?” Be loving and patient with yourself and you may find that you are more patient with others as well.

Date of last modification: 10-20-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

What Would You Do If You Had Less Pain?

 

  1. Everything
  2. More of What I am Doing Already
  3. Clean My House
  4. Go Back to Work
  5. Exercise

1. If you chose Everything, you are among a noble, but misguided group of people who are thoroughly frustrated by being slowed down by pain. You have been dedicated to finding a fix for your condition and impatiently waiting to resume moving at the rapid pace you used to run through each day. You lament how much you used to do, continually comparing yourself to your pre-pain self.

Solution: Break down your Everything into tangible bite size pieces. What specifically would you choose to spend your time doing if you felt better? Pain can push us to prioritize what is truly important. Everything cannot be important anymore, so as much as you are tempted to fight it, begin to narrow your focus to what you really care about and allow this value to be at the forefront of each day. This will be a challenge if you are used to doing it all or thinking that you should be able to. Letting go of this old belief will make room for creatively reaching toward what you most value.

2. If you chose More of What I am Already Doing, this is an indication that you are already plugged into those activities that you value, but unsatisfied with the level you are currently participating in them. Your identity may be tightly entwined with your accomplishments.

Solution: Ask yourself, when will it be enough? When will I be satisfied with busy-880800_1920what I accomplish? Do I hold myself to a realistic and flexible standard? Pain does slow us down, but this is not always a negative thing. It can open us up to the beauty of seemingly small everyday things that often go unrecognized until we are brought to the moment. Discomfort can bring us to the moment, but it is up to us to find the beauty contained in that moment.

3. If you chose Clean My House, you may be among the many obsessively clean people or among the multitudes who are overwhelmed with too much stuff.

Solution: Your home may be messier than you prefer because you cannot scrub, stand, reach, or bend as easily as you used to. However, it may improve your daily quality of life to let go of some cleaning ideals and at the same time, simplify your environment. Having too much stuff to maintain makes it harder to navigate your home when you are hurting. Redirect your attention to those items that bring you the most joy – books, favorite heirlooms, artwork – and discard as much clutter as you can. This will free up space and energy for the relationships and activities that matter to you more than a clean house while at the same time tidying things up.

4. If you answered Get Back to Work, this is a good sign that you seek meaningful activities and find purpose in what you do. Many people have found that letting go of what they used to do is like losing part of their identity. On the other hand, dissatisfaction on the job is associated with more pain — so finding ways to enjoy work to some degree is important.

Solution: If you used to do work that would be harmful for you to return to, the harsh reality may be that you will have to reinvent yourself. List your current skills and other skills you may wish to acquire. The fear of failure can be strong, but do not underestimate yourself even with physical limitations. Many activities within a job can be modified, as there are hundreds of thousands of people living and working with chronic pain. At first, many people cannot imagine doing anything other than their previous vocation; however, those open to reinvention sometimes find even more fulfilling work than before.

5. If you said Exercise, you may be among the many people who have given up your favorite sport or exercise routine due to a painful condition. This is frustrating as a sedentary lifestyle can tumble into a myriad of other health problems. Dr. James Levine has said to the Los Angeles Times, “Sitting is more dangerous than smoking, kills more people than HIV and is more treacherous than parachuting. We are sitting ourselves to death.” Americans sit upwards of 13 hours per day between desk work and screen time at home. This does not include the 7-8 hours we spend in bed! But how do we exercise with chronic pain?

Solution: How much are you moving currently? Starting at your actual current aerobic exercisebaseline is the key to beginning a movement routine and gradually, gradually, increase in very small steps. This is the best way to reach your newly revamped realistic movement goals while avoiding major setbacks. You may not be able to do the gym workout you used to, but gentle movements are still movements and movement is essential for chronic pain and the prevention of many illnesses. Americans watch an average of 4 hours of television each day. What would it be like to add 4 minutes of easy movements to each of those 4 hours? That would be 16 minutes of movement in bite size chunks.

Exercise may not look how it used to. Many people with chronic pain find that pool therapy or stationary bikes work best for them. Others find the movements of qi gong or tai chi are easier than yoga or Pilates, and you still get the benefits of increased circulation, improved balance, better mood and deeper sleep. Build your tolerance slowly and then gradually increase the “dose.”

Date of last modification: 9-27-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

How to Get Better When Pain is Chronic

In the last post, we began to introduce a broad definition of coping, as one’s subjective experience, or reaction, to a problem. In this post, let’s expand on this definition and explain how coming to cope better with a problem is a process of coming to experience the problem in a different and better way.

Coping is how we subjectively experience a problem

In our society, when having a problem, we tend to focus on the problem itself, its characteristics and how they do or don’t lend themselves to resolving the problem. In so doing, we put our focus and energy towards fixing or getting rid of the problem. This way of thinking about the problem is all well and good. It likely lends itself to our society’s successes in developing technological solutions to many of the great problems that we have faced.

As an example of this tendency to focus on problems and fixing them, we need only to look to the problem of pain and how we tend to focus on it, and how we try to get rid of it or otherwise reduce it. Knees and hips can now be replaced and we have a large assortment of different medications that can reduce pain and sometimes get rid of it entirely.

However, instead of focusing primarily on the problems itself, we might also coping with painbring our attention to the unique characteristics of each individual with the problem and how they understand it, feel about it, perceive it, and how they behave in regards to it. In effect, we might focus on the characteristics of each person and how these characteristics influence the way individuals experience the problem.

For wherever there is an objective problem in the world, there are also perceiving subjects who have the problem.

We typically call the ways that people experience problems “coping.” It’s something that usually we only direct our attention to when we can’t come up with a solution, or fix, to a problem itself. Nonetheless, it comes in handy in such situations because it offers a way to still get better even if there is no fix to the problem. Namely, we get better at coping with the problem: we can become less distraught by the problem or less impaired by the problem.

In this regard, in returning to our pain example above, we might focus not so much on how to get rid of pain, but how to get better at coping with pain. This change in the approach to getting better may come in handy when pain is truly chronic and you’ve already tried every reasonable procedure and medication without any significant benefit. In such a situation, you focus not so much on how to reduce pain, but on how to increase coping.

In doing so, you can come to learn to tolerate pain that at present is intolerable. You might even get so good at coping that you do more than simply tolerate it – you might get so good at coping that the pain goes from something that is the central focus of your life to something that occurs in the background of your life. It becomes a problem, in other words, that’s not very problematic.

Moreover, you can do such thing without ever reducing pain itself. It can all occur by changing how you experience, or cope with, pain.

It may sound too good to be true.

How coping better makes problems less problematic

It’s important to recognize that people who cope well with a problem tend to experience the problem as less significant or severe than those who don’t cope well with the problem. In other words, when we aren’t coping well, we tend to perceive or judge the problem that we face as more problematic than those who cope well with it. For example, if you had taken a speech class and had actually given many speeches before in the past, you might find the prospect of giving a speech to a packed auditorium as less problematic as someone without your level of expertise and practice. You might find it quite tolerable, in fact possibly even not problematic at all – something in the category of “Well, it was no big deal.” However, another individual, who faces the challenge of giving the exact same speech to the exact same auditorium, might find it overwhelming, paralyzing or intolerable. This individual might judge the problem as one of the hardest things he has ever done in his life.

Objectively, it’s the exact same problem, but the two people subjectively experience it in very different ways. We might say, in such cases, that the differences lie in how well the individuals cope with the problem of giving a speech to a packed auditorium.

How well we cope depends, of course, on how significant the problem is. Big or complicated problems are more difficult to deal with than small or simple problems. Most people will find talking to a group of two or thee people easier than an auditorium of two or three hundred. Nonetheless, how well we cope with problems is also dependent on other things too.

Cope with PainNotably, it’s dependent on certain characteristics of the person who is coping with the problem. If one knows a lot about the problem and is actually an expert on the topic, then typically that person copes better than someone who doesn’t know as much about the problem. Or, if someone has experienced the problem before or expects the problem to occur, then that person often copes better than the individual who has never encountered the problem before or someone who is taken by surprise by the problem. Confidence plays a role here too. Someone who knows a lot about the problem and is well-versed or well-practiced with dealing with the problem tends to be more confident and that confidence aids in coping better. Someone who lacks such confidence tends to be more alarmed or even distraught, which makes for more difficulty in coping. In any of these cases, the subjective experiences of the problem are different for the different people, even if the problem was objectively the same problem.

We could go on indefinitely about the subjective characteristics of the coper, which play a role in how well the individual deals with a problem. We might make a list of subjective characteristics that determine, in part, how well one copes:

  • Degree of knowledge or expertise about the problem
  • How one conceptualizes the problem
  • Degree of accurate information that one has about the problem
  • How much one has practiced overcoming the problem
  • Other attitudes about the problem
  • Degree of confidence in facing the challenge
  • Degree of attention directed on the problem
  • How one feels about the problem
  • What one’s mood is at the time of encountering the problem (e.g., whether one is calm or irritable, depressed or anxious)
  • How much sleep one has had in the past few days prior to encountering the problem
  • How many other problems one is experiencing at the time of encountering a new problem
  • What one goes on to do about the problem (behaviorally)
  • Degree of loving support one has in facing the problem

There are literally countless aspects of the coper that determines, in part, how well one experiences, or copes with, a problem. Some of these characteristics lend themselves to better coping and some lend themselves to worse coping.

Getting better by getting better at coping

So, think about this simple fact: if you have a problem that can’t be entirely fixed, you could still get better by setting out in a concerted effort to get better at coping with it. You could, in effect, obtain training at having the problem and get so good at it that having the problem becomes less and less problematic. It could become, for example, something that occurs in the background of your day-to-day activities, but for the most part you’ve moved on and focus on the meaningful activities of your life. Indeed, there is simply no end to how good one can get in coping with a problem, even a problem that can’t be entirely fixed, like chronic pain.

Here is where true hope lies. Even when your pain is chronic, you can get so Needing Hopegood at coping with it that living with chronic pain is no longer a distressing or impairing problem. Alternatively, you can get so good at coping with it that it no longer requires opioids to manage it and so you can move on with the rest of your life.

Usually, this level of advanced coping requires a concerted effort of training, done over time, and typically with a team of healthcare providers who coach you and support you throughout the process. Traditionally, patients find such support and training in chronic pain rehabilitation clinics. Such clinics are a type of pain clinic that involve an interdisciplinary team of healthcare providers (consisting of at least pain psychologists, medical providers, and physical therapists, but oftentimes other kinds of providers as well) who work with patients over an extended period of time in the pursuit of not so much reducing pain, but improving the patient’s coping. Such clinics are not new, but have been around since at least the early 1970’s and as a result they have about four decades of published research proving their effectiveness (see, for example, these meta-analytic studies and literature reviews: Chou, et al., 2007; Flor, Frydrich, & Turk,1992; Gatchel & Okifuji, 2006; Neusch, et al., 2013; Turk, 2002).

When talk of the possibility of coping better feels like a criticism

Sometimes, when healthcare providers like me talk in these ways, it feels to patients with chronic pain like a judgment. It feels like blame. It feels like you’re being told there’s something wrong with you — that you aren’t coping well enough.

Oftentimes, when patients have people in their lives who judge them or stigmatize them for how they have been coping, they can come to hear their healthcare provider talking about the benefits of learning to cope better as a similar criticism.

In such cases, patients can come to refuse the recommendation to participate in chronic pain rehabilitation. The hopeful message that there is a traditional and scientifically proven treatment that helps patients to learn to cope better with pain can be met with quick and sometimes sharp rebuttals. Common examples are the following:

  • The provider must be insensitive.
  • The provider must not know what he or she is talking about (i.e. the provider is incompetent).
  • The provider doesn’t (or won’t) recognize that I’m coping as well as humanly possible given the amount of pain I have.
  • The provider must not have chronic pain or otherwise he or she would understand.
  • The provider must not believe me that I have real pain.
  • The provider is just out to make money and so wants me to go to yet another treatment from which he or she will profit.
  • The provider just wants me to get off opioid medications.

Obviously, talk of how to learn to cope better is a sensitive topic. It’s as if the same words can engender almost two opposite interpretations. The healthcare provider intends it to be a hopeful message – you can get better by undergoing extensive training over time and as a result come to cope better with a condition that is incurable. The patient, however, can hear it as an insensitive criticism of how the patient isn’t coping well right now.

Importance of trusting your healthcare provider

In such situations, what can make the difference is having a good, therapeutic relationship with your healthcare provider. If you know your provider and trust him or her, then you know that your provider isn’t just being mean or insensitive or ignorant of what’s it like to have pain or out to make money off you. Instead, you know that your provider has your best interest at heart.

Your thoughts

Have you ever had a healthcare provider talk to you about chronic pain rehabilitation or learning how to cope better with pain? What were your reactions? Have you ever attended a chronic pain rehabilitation program? Why or why not?

[Please note our comment publishing policies. All participants in the discussion will appreciate your cooperation with this policy.]

References

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Flor, H. & Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Author: Murray J. McAllister, PsyD

Date of last modification: September 11, 2016

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Can you experience the same pain differently?

A major tenet of chronic pain rehabilitation is that the way you experience pain is not the only possible way to experience pain. In other words, the experience of pain differs across individuals and can even differ in the same individual across time. As such, it’s possible to have a different experience of pain than the experience that you have today, even if your pain remains on a chronic course.

This point isn’t necessarily controversial. Patients commonly make a similar point themselves. For instance, patients sometimes express that pain is a subjective experience that only they can feel.

The rub, though, lies in the consequences we draw from such a point. We can draw different consequences.

Patients often make the point about the subjective nature of pain as a means to defend against stigma. It’s a way to say that others shouldn’t judge if their experience of pain differs from the patient’s experience of pain. While it’s a good point that no one should ever stigmatize patients for how they experience pain, we might draw an altogether different inference from the point that pain is a subjective experience. This inference has nothing to do with the issue of stigma and it is often drawn by healthcare providers, particularly pain psychologists and others who work in chronic pain rehabilitation. This additional inference is that you can come to experience pain differently.

In other words, the subjective nature of pain is such that different people can have different experiences of pain and what this shows is that it is possible to experience pain differently than how you experience it today. You can learn, in other words, how to have pain in other ways. It’s a hopeful message. It’s the foundation for what pain psychologists do everyday – help people come to experience their pain differently, in ways that are better than how they presently experience it.

Coping with pain as changing how you experience pain

In effect, what’s happening is that, with the help of pain psychology and chronic pain rehabilitation, people come to cope better with pain. They literally experience their pain in new and different ways. They experience pain in ways that are better than they had experienced it previously.

They know, for instance, that their pain isn’t a sign of a fragile injury, which is experience painabout to get worse at any point in time. Subsequently, they are not alarmed by pain and do not understand it as some thing for which they must stay home and rest. Instead, they tend to see pain as akin to white noise, something that is there, but remains in the background of their attention. They remain grounded and focused on their activities, which they continue to do. They go to work and go to their children’s activities and go to the neighborhood potlucks. They do all these things with pain.

Now, that’s what coping really well with pain looks like.

When people cope well with pain, they literally experience it differently than someone who isn’t coping well – the individual, for instance, who is alarmed by pain, sees it as a function of a deteriorating disease that is inevitably going to get worse, and so subsequently believes the best course of action is to avoid the activities of daily life and instead stay home and rest, out of concern for not making their condition worse.

What would it be like to cope so well with pain that you literally experience it in the manner I previously described above – as something that remains present, but something that nonetheless doesn’t deserve a lot of day-to-day attention and emotional energy and so remains in the background of your daily activities like white noise?

There are countless lessons to learn that can be helpful when learning how to do it. The pain psychologists of a chronic pain rehabilitation clinic or program can help you to learn them. We have discussed a number of them in the posts of this blog (see, for example, posts on catastrophizing, all-or-nothing thinking, mind-reading, perfectionism, among others).

In our next post, we’ll review yet another important cognitive distortion that adversely affects how people experience pain. It occurs when people understand pain as something that always signals harm. It can happen, for instance, when people with back or neck pain understand their pain as solely the result of a fragile, degenerative condition of the spine. In large measure, this cognitive distortion is a consequence of how certain parts of the healthcare system understand back and neck pain as the symptom of degenerative disc disease. It’s therefore a complicated issue as it plays out in both patients and some healthcare providers.

It’s also, though, an important issue. Every rehabilitation provider tends to encourage patients to exercise, move and get back into life, within some reasonable limits. However, people don’t tend to do these things when they see their pain as signaling harm. Instead, what people tend to do when understanding their pain as indicative of a fragile injury is to become mildly alarmed, stay home and rest.

It’s therefore important to learn when pain is a sign of injury (for which you should become alarmed, stop what you are doing and seek care) and when pain is not a sign of injury (for which you try to stay grounded, redirect your attention elsewhere and remain engaged in the activities of your life). In other words, sometimes pain has a psychobiological function of signaling injury or illness and sometimes pain continues even though it has lost this function. It’s important to know the difference. In the former case, you take heed. In the latter case, you try to tune it out as white noise.

Will discuss more in the next post!

Date of last modification: 8-29-2016

Author: Murray J. McAllister, PsyD

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Relearning to Sleep: How to Cope with Pain Series

Many people with chronic pain have trouble getting regular, restful sleep. To improve sleep, it helps to understand how the 24-hour circadian rhythm works and to grasp other biological rhythms that affect sleep-wake cycles. In other words, what we do during the day impacts our ability to sleep well at night and visa versa.

Everything alive has a biological rhythm, an internal clock. We are aware of some rhythms and less aware of others: the earth’s rotation, the tides, flowers blooming, insects hatching, and our own biological rhythms such as digestion, hormones, body temperature, neurotransmitters and many other patterns that fluctuate on a schedule.

What do biological rhythms have to do with sleep?

Poor sleep affects our health and our health and habits affect our sleep. Disrupted sleep or insufficient slow wave (deep) sleep affects mood, the ability to think clearly, appetite regulation, immune system functioning, growth hormone release, and glucose regulation, among others. Poor sleep can cause poor wound healing, high blood pressure, mental errors, weight gain, depression, anxiety, and, of course, fatigue.

Each organ, in fact each cell, behaves according to a rhythm and depends on cues from its environment to start or stop its cycle. We may think of our genetic code as a set code we cannot control, but various environmental cues may trigger a gene or set of genes to express themselves – to start or stop their function. So called “clock genes” are triggered at night to initiate and maintain sleep while other parts of the brain are notified to inhibit wakefulness.

You feel your best when a biological cycle starts and stops at the optimal, or Sleep Patternintended, time. When we talk about wanting to sleep better, what we really want is to be more awake during the day and logically assume the best way to feel more awake is to get better sleep. But the circadian rhythm is not isolated. Rather, it’s interdependent with many other cycles. A part of the brain, called the suprachiasmatic nucleus of the hypothalamus, is the sleep engine that can operate somewhat independently to cause sleep. However, many other factors keep us asleep and set the stage for the quality of sleep we have.

Many naturally occurring hormones such as glucocorticoids and catecholamines fluctuate related to circadian rhythms. Cortisol is a glucocorticoid, sometimes referred to as a stress hormone, and has a daily rhythm that increases in the early morning to help us feel awake and then decreases throughout the daytime hours into nighttime to allow sleep. This diurnal pattern of cortisol can flatten out leaving you feeling tired all day and still unable to sleep well at night.

Melatonin is another naturally occurring hormone that assists with sleep. It is regulated by light and would ideally be low during the day and high at night for optimum sleep. Putting light, activity, and food into the proper times of each day to establish a routine helps hormones like cortisol and melatonin do their jobs.

What is deep sleep and how do I get more of it?

We all go through various stages of sleep approximately every 90 minutes or so. This includes shallow sleep, deep sleep, and rapid eye movement (REM) sleep, which is best known for when we dream. It is not uncommon to wake briefly in between 90-minute cycles. The most common issue arising for people with chronic pain is not often a lack of REM sleep or shallow sleep, but insufficient deep sleep. Deep sleep is dominated by delta waves, which are slow brain waves. It is the most restful type of sleep that helps you feel refreshed. Eight hours of shallow sleep will likely cause you to feel worse than fewer hours, which includes deep sleep.

There are many things that can rob us of deep sleep. Common culprits are:

  • Daytime habits involving light, activity, & food (LAF)
  • Oversleeping the day before or “catching up”
  • Doing other things in bed
  • Anxiety
  • Medications
  • Alcohol
  • Caffeine
  • Temperature
  • Noise

What can I do during the day to help me sleep at night?

Separate Day from Night: LAF

  • Light is the most obvious indicator for the body that day is separate from night. Be awake with the sun and asleep with the moon. Of course, this pattern has been altered artificially with the invention of electricity and with the flip of a switch. In other words, we can have bright lights all night. Natural light in the morning will signal melatonin to stop being released, while darkness at night will help signal for melatonin to be released.
  • Activity during the day will help increase deep sleep, as long as the activity is not too close to bedtime. Movement indicates it is daytime. Movement also signals to the body and brain that we are using energy and will be tired later.

If you don’t move enough during the day, deep sleep will be reduced. It can be a frustrating dilemma for many people with physical limitations or chronic pain. Moving may hurt, but restless sleep does no favors either. For the sake of improving sleep, movement can come in many forms. Some people find swimming or water movement is best for them. Others do chair exercises, chair dancing, or simple bike pedals they use from an easy chair. Regular aerobic exercise is a good way to increase delta wave sleep.

  • Food is key because you when you eat, you release other hormones like ghrelin, leptin, and glucose. Breakfast is still the most important meal of the day, as we “break the fast” of the nighttime hibernation, if you will. If you frequently skip or delay breakfast, try starting with small amounts of easy to digest food within an hour after waking.

As far as eating at night, you may have heard of tryptophan, a naturally occurring amino acid, found in certain foods. While turkey meat has a little tryptophan, dairy products have more and grandma may have been onto something with the glass of warm milk before bed. However, before you pour the milk or scoop a bowl of ice cream, remember that we are trying to signal to the brain-body that it is nighttime. If it has digesting to do, it signals to the body to be awake and would like to burn these calories. Since the energy consumed is not being utilized, it goes into storage — as fat.

Plant-based diets are gaining more and more support for improving energy, reducing risk of many diseases, and their anti-inflammatory properties are good for pain and healing as well. Fats take a lot of work to digest while carbohydrates and sugar signal quick energy is needed. It makes good sense to avoid eating several hours before bedtime. If you are used to late night feedings, it may take a few nights for your body and brain to adjust to skipping the last calorie boost, but you will sleep better for it.

What can I do at night to improve sleep?

  • Keep a regular wake time. You may not be able to control when exactly you fall asleep, but you have more control over when you wake up and also how long you stay in bed awake. You can use these two things to your advantage. Set your wake-up time to be the same time every single day, even if it means waking up earlier than you need to on certain days. This anchors one part of the 24-hour cycle so circadian rhythms know what to expect tomorrow around the same time. The other anchors are built in already: light, activity, and food.
  • Give up the fight to force yourself to fall sleep. Avoid going to bed until you are sleepy so you minimize the time you spend trying to fall asleep. (This includes giving up the idea that you need 8 hours of sleep). Yes, try less rather than harder to sleep and simply wait until you are sleepy. However, do not allow yourself to doze on the couch. Dozing starts a sleep cycle and then you wake, crawl into bed, possibly now wide-awake.

Use the 20-minute rule. If you snuggle into bed and lie awake for more than 20 minutes, get up, go back to the chair or couch, use a low reading light to read, do needle work, or something else relaxing until you are drowsy again. This will likely be at least an hour later. Then go to bed and you will begin a new 90-minute sleep cycle. If you wake later in the night and are awake for more than 20 minutes, get up and wait until you are sleepy again before you get back into bed.

  • Avoid oversleeping. Sorry, no more sleeping in. People often ask, “Can I catch up on sleep?” Short-term, yes, but it is only helpful for a day or so. Oversleeping is a common mistake that reduces deep sleep. It happens when we sleep in, go to bed early, and take long naps. This “catching up” on sleep may feel good temporarily, but the brain tracks the amount of sleep you have gotten for that 24-hour period and then will likely not allow you to get a good night sleep the next night. This often leads to restless shallow sleep, staying up late, more sleeping in, and before you know it, your brain wants to sleep during the day and cannot at night. The more you try to “catch up” the worse sleep quality and insomnia may become.
  • Create a sacred space for sleep. The antidote to insomnia is relearning to sleep. It is important to keep sleep only for bed and bed only for sleep. This pairing of bed and sleep is an example of classical conditioning similar to toilet training. We put toddlers on the toilet and wait for them to learn what physiological sensation goes with it. They eventually learn that these two things go together. We want the brain and body to learn that sleep and bed go together. Bed and sleep, sleep and bed. When we do other things in bed like watch TV, work, think or just be awake, we are teaching the brain that the bed is a place to be awake. If we then move to the couch to fall asleep, we are teaching the brain that the couch and sleep go together. We want to untangle this pattern and re-teach the brain that sleep and our bed are the two things that go together best. If you are awake for more than 20 minutes or so, get up and be awake somewhere other than your bed. Once your brain is ready to start a new 90-minute sleep cycle, you will feel sleepy and can crawl back into bed.

What is the #1 thing that keeps people from sleeping?

In a word: worry. Stinking thinking. Monkey Mind. Anxiety, fear, and ruminative thinking are the most common things that keep us awake at night. Humans are the only species known to replay regrets and worry about the future. Sometimes even the anxiety about not sleeping can keep you awake and it becomes a vicious cycle.

There are many techniques to help with these problems, including diaphragmatic breathing, mindfulness practice, biofeedback skills, relaxation, and meditation. These techniques are best practiced during the daytime without falling asleep, and then applied at nighttime with the intention of total relaxation in bed, followed by sleep. The daytime practice trains the brain to stay present and focused. Let go of worry and allow sleep at night and leave problem-solving for the daytime. Designate a worry place for scheduled worry time during the day in a place other than the bedroom.

Other Factors that Influence Sleep

Sleep and Pain Medications: Many medications may affect sleep. Two of the most troublesome are benzodiazepines (sleep and anxiety pills) and opioids (pain medication), which are often prescribed to help with sleep and pain. However, because the body naturally defends against long-term use of them, a natural tolerance builds when they are used frequently and they become less effective. Both benzodiazepines and opioids affect the breathing centers in the brain stem by slowing respiration. The brain may protect against this by reducing the amount of deep sleep, eventually not allowing any deep sleep at all. Some people have tried taking more medication or combining medications with alcohol. This practice is risky and can lead to slowed breathing and death.

Alcohol: Alcohol may seem to help with sleep, but it reduces good quality deep sleep. Having a drink with dinner may be better than a drink near bedtime; however, alcohol may be best avoided until you are sleeping well. Alcohol does not mix safely with most medications, especially benzodiazepines and opioids.

Caffeine: Caffeine is a stimulant that prevents sleep for most people. Moderate amounts of coffee unadulterated by too much sugar and cream in the morning may be fine for you and even have some health benefits. Since caffeine can stay in your system for up to 10 hours, if you drink more than a couple of cups in the morning or drink it afternoon, it may affect your sleep. Overall, keep the use of caffeine in moderation. Consume it only in the morning. Try to keep it “clean,” which means minimize processed ingredients.

Temperature: Being too warm can prevent sleep. The body cools at night as metabolism slows and you will be more comfortable at a lower temperature. A warm bath before bed may still be helpful as long as there is enough time for the cooling system of the body to kick in. A fan might provide white noise and keep you cool as well.

Noise: Intermittent noise and light of the TV, although possibly mind-numbing and comforting, actually tells your brain to avoid deep-sleep. If other noises keep you awake, it may be worth investing in a pair of custom made earplugs. There are many types of earplugs on the market, as well as white noise and sound machines. However, if you want to be able to hear things because you are a parent or caregiver, you will have to choose between allowing deep-sleep or staying more alert in shallow sleep. You cannot have both at the same time. Caregivers, military, and firefighters often train themselves to sleep shallowly so they can quickly be awake and alert in a moment’s notice. This practice is not a sustainable way to sleep and eventually will have health consequences.

Am I supposed to get 8 hours of sleep?

Eight hours of sleep is an average, but oversleeping and spending time in bed trying to sleep decreases deep sleep and disrupts the 24-hour circadian rhythm. For poor sleepers, less may be more. If a chronic pain condition prevents you from sleeping for too many consecutive hours, you may choose to sleep in chunks (e.g, from 10pm-1am and again 3am-6am). For now, let go of the 8-hour idea and focus on getting better quality sleep until you are sleeping better. Once you relearn how to sleep through the night for shorter amounts of time, such as in 3-hour chunks, try going to bed a little bit earlier (15 minutes) each night until you find what works for you. If you decide that chunking sleep into 2 separate parts works better, just be sure to keep the same schedule each night for the chunks and continue to avoid oversleeping.

In summary, do your best during the daytime to engage in daytime activities (LAF) even when you are tired. Do not try to force sleep. Accept when you are awake and find something pleasant to do somewhere else until you are sleepy. Practice letting go and surrender to the sleep gods so you can keep calm and sleep on.

Date of last modification: August 1, 2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

Developing an Observational Self: How to Cope with Pain Series

From the time before Socrates in ancient Greece there stood a temple built upon a spring at a location the Greeks would have considered the center of the world. Inscribed on the walls of this holy temple was the simple phrase, “Know Thyself”.

This simple phrase inspired Socrates to a life of learning and teaching, and, from him, Plato learned to be a philosopher and later came to teach Aristotle. Subsequently, Western civilization, in large measure, began.

This maxim – “Know thyself” — and others similar to it were not uncommon in the ancient world. Indeed, a few thousand years previously, early Hindus and later Buddhists practiced a form of moment-to-moment self-knowledge, later coming to be called mindfulness.

The directive inherent to this maxim has two components. The first is to pay attention. In observational selfother words, slow down and observe what’s happening. In today’s language, we might express the maxim as something like, “Get out of your head and notice what’s going on around you.” When we carry out such a dictum, we become observant and reflective. We see or otherwise perceive things that we might not have heretofore noticed. We subsequently create opportunity to consider what it is we observe.

Good things happen when we do. We see good things and become appreciative. We stop and smell the roses because we were observant enough to even notice them as we walked by and as a result we are able to appreciate their visual and olfactory beauty. Whereas in one moment our kid might be bugging us because of her need for attention is interrupting our apparent need to make a phone call or put dinner on the table, in the next moment, once we get out of our head, we recognize just how funny or cute the kid is and we subsequently are overwhelmed by how much love we have for her.

So much of life goes unnoticed because we are simply and persistently reacting to whatever thoughts, feelings and needs that pop into our attention. Whatever pops into our heads tends to have a sense of immediacy to which we react impulsively, without thinking in the sense of thoughtful consideration. It’s just a never-ending chain reaction of stimulus and response, like billiard balls knocking into each other. Notice that when we live life as if we are a player in a video game that goes on in our head, simply and persistently reacting to whatever momentary thought, feeling, or need that pops into our head, so much of what goes on around us gets missed.

We don’t see how cute our kid is in that moment. We don’t notice that our spouse made coffee for us before leaving for work. We don’t smell the fresh air. We don’t taste our lunch. We don’t fully appreciate how funny it was when our coworker or neighbor made that comment yesterday.

Instead, we were busying ourselves with the immediacy of whatever popped into our head at the time.

Notice too all the things we could have done in those moments but didn’t do simply because it never occurred to us. When we react to whatever thought, feeling or need that pops into awareness at any given time, it’s as if the reaction that we have is the only possible thing to do at the time. We might even justify the reaction, if anyone ever were to ask us about what we did, by saying ‘Oh, I had to,’ as if the thing we did was the only possible thing that could have been done. However, it’s not really true, and this point brings us to the second good thing that happens when we get out of our heads and start to observe what in actuality is happening in any given moment.

Namely, we become liberated from being a passive recipient of what happens to us to an active decision-maker of a well-informed life. By observing what in actuality is happening in life, and by considering the various possible ways we might respond, we exercise choice. No longer is our life dominated by the apparent ‘must’ and ‘have to’ and ‘got to’, but rather we are free to choose. When we pay attention, we recognize that we do not have to simply endure things happening to us. We are not victims. We have the power to choose among a number of different options as long as we slow down enough to recognize and consider the options that are available to us.

The simple maxim – Know thyself”, then, is a truth that sets us free. It’s freedom from a determinism of automatic reactions to whatever life gives us. We no longer ‘have to’ do this, that, or the other thing, but are free to choose how we live our life. We no longer ‘can’t’ do anything but the reaction that we have automatically done countless times in the past and are now free to choose how we might respond and move forward. From moment to moment, we are free to choose how to respond even to the things in life that we do not choose – like bad things that happen to us. We still are free to choose how we react to them and the perspective by which we see them.

In sum, the second good thing that happens when we observe what’s happening is that we become intentional about what we do, how we react to things, and even how we perceive the things around us.

This ability to observe life and intentionally choose how to respond to the things that come up from moment to moment is the main goal of psychotherapy. Freud called this ability the development of an ‘observing ego’ and considered analysis a way to develop this ability. In more recent psychotherapies, we call it an ‘observational self’. It’s the ability, as described, to step out of any given moment, consider what’s happening, and intentionally choose how to react. Of course, in this day and age, we also call it ‘mindfulness’.

What does developing an observational self have to do with pain?

The development of the ability to step out of the moment and reflect on how to react to pain is the initial and most important thing to do in pain management. Everything else in pain management follows from this skill.

Pain has a sense of immediacy about it. It’s a sensation that is inherently emotionally alarming and to which we automatically react with avoidance behaviors – we stop what we’re doing, pull away and guard. This sensory, emotional and behavioral experience happens all at once, of course, and it happens automatically. We don’t typically choose any of it. The sensation just is alarming and we pull away and guard without ever intending to do so.

For example, if you were out hiking in the woods and, without looking, you stepped in a hole and twisted your ankle, you’d have pain. That is to say, you would have a sensation that was emotionally alarming and to which you would stop walking and guard your ankle in some manner. The whole experience would be almost instantaneous. It would also be automatic, in a sense. The alarming sensation and behavioral avoidance would occur without any intentional decision-making on your part.

However, if you had chronic pain, and you set out to pay attention to the pain that occurred with activities, you could learn to make the whole experience more intentional. You would do so in a multiple step process. You would first simply pay attention to the pain that occurs and not be taken by surprise by it. Chronic pain often has a degree of predictability that the pain of an acute injury doesn’t have. So, by paying attention, you could practice the skill of not being taken aback by the pain. Just as importantly, you could recall that you have chronic pain and that you’ve had it for some time and you know what it is. In most cases, chronic pain is the result of the nervous system having become highly reactive to the stimuli of activities that are normally not painful to do – like walking, sitting, standing up, laying. You could consider that, even though it is painful, these activities are safe to do– that you are not injuring yourself even though it is painful. In this manner, you start to control the sense of emotional alarm that you have with pain. You set out to intentionally remain emotionally grounded in the presence of pain. To this end, you also practice taking deep, diaphragmatic breaths to assist you in remaining calm. From this new-found perspective, you can also choose how to behaviorally react. You intentionally choose to engage in the activity and have the sensation while practicing remaining calm.

Suppose, for example, every time an individual with pain sits down she knows she’ll experience pain. More often than not, however, she doesn’t keep this fact in mind and she goes about her day, like most of us, simply reacting to whatever pops into her attention. She does this and then that, checking things off her to do list. Each time she sits down, she lets out a soft groan, grabs whatever is within reach in order to brace herself, and becomes, for an instant or two, emotionally and physically tense. The pain is severe and it takes her breath away.

She could, though, with some proper coaching from a psychologist at her pain clinic, set out to learn and practice the ability to step out of the moment and pay more attention to her actions. She could then practice slowing down the process of experiencing pain. In doing so, she pays attention to what she does and predicts the severe pain prior to sitting down. In this way, she isn’t taken by surprise each time. With knowing that it’ll hurt, she takes some deep diaphragmatic breaths as she works and reminds herself that even though it is painful she isn’t injuring herself every time she sits down. She intentionally recognizes that it is safe to sit down even though it hurts badly. In these ways, she practices remaining grounded while having pain. With her budding abilities to remain calm in the presence of pain, she intentionally sets out to control her pain avoidance behaviors. She makes the decision to stop letting out the groan because she’s predicted the pain and isn’t taken aback by it as she sits down. She intentionally stops her tendency to abruptly reach out for something to hold on to while she sits, reassuring herself that it is safe to sit down. She also tries to refrain from grabbing her back and instead sets out to remain as calm as she can be in the presence of her pain, even severe pain. She intentionally does all things, moreover, on a repetitive basis through the course of her day, day after day. She discusses her strategies with her psychologist each week, and her psychologist gives her pointers, which she tries at home. Over time and with practice, she gets better and better at it. By developing her abilities to pay attention, observe herself and engage in intentional decision-making, she comes to be able to control, in part, her experience of pain. She comes, in other words, to be able to control the alarming and behavioral aspects of pain and subsequently becomes able to remain grounded and productive in the course of her day, even though she continues to have severe pain.

This description is what good coping looks like. Good coping is not getting rid of pain, but getting so good at reacting to pain that it is no longer as problematic as it once was. It requires the development of an observational self from which you can have pain, remain aware of how you are reacting to it, and intentionally attempting to remain grounded and active while having pain.

From the river Ganges to the temple at Delphi and all the way through to the modern pain clinic, the dictum to know thyself travels through time because good things happen when we follow it. The ability to pay attention and engage in intentional decision-making when having pain is the initial and most important skill to develop in pain management.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-19-2016

Irritable Bowel Syndrome: A New ICP Content Page

The Institute for Chronic Pain (ICP) is an educational and public policy think tank that brings together thought leaders from around the world to provide scientifically accurate information about chronic pain and its most effective treatments. We endeavor to provide academic-quality information that is easy to read and as such we serve as a scientifically accurate resource to patients and their families, generalist healthcare providers, third-party payers, and public policy analysts.

Our aim is to change the culture of how pain is managed — to foster a culture in which the field of pain management more readily provides treatments with demonstrated effectiveness. We imagine a day in which healthcare providers deliver and patients regularly demand empirically-supported therapies for chronic pain. To bring this goal to fruition, stakeholders in the field must have a scientifically accurate source of information on the nature of pain and what most effectively treats it.

What drives pain management today?

Patients and their families are often surprised to learn that not everything that healthcare providers do is effective. Antibiotics for earache and arthroscopic knee surgery are two commonly cited examples of treatments that are routinely provided, but are no better than placebo (which is a common measure of effectiveness). Despite their demonstrated ineffectiveness, these kinds of procedures and therapies continue to be commonly delivered by healthcare providers and demanded by the public for a complex array of reasons.

  • Discipline-specific practice: Most healthcare providers do not practice within interdisciplinary teams and so become ignorant of advances made by other disciplines.
  • Tradition-bound practice: Healthcare providers tend to practice as they were taught, even if it has been many years since their initial education; keeping up with advances in the field is solely the responsibility of the individual provider and fulfilling this responsibility competes with many other demands on the time of the provider.
  • There are few sources of objectively neutral continuing education: Presently, continuing education is predominantly provided by pharmaceutical and medical technology companies, both of which have vested interests in teaching advances that only relate to the sale of their products.
  • The profit-motive: In the U.S., the healthcare system is capitalistic and so relies on providers selling a service, under the auspices of making treatment recommendations, and many ineffective procedures and therapies are highly profitable.
  • The predominance of the use of placebo-controlled trials of new medications: To come to market, new medications do not have to be more effective than already existing medications for a given condition, but only better than a placebo; as such, with the right marketing strategy, a new medication for a given condition can become a top selling blockbuster, and supplant the use of an already existing medication that happens to be more effective; in other words, the new, but less effective, medication can become more widely prescribed than a more effective older medication that lacks a good marketing strategy.
  • A common understanding of a condition that was initially developed based on common-sense considerations can easily remain as a widely-held understanding in society even though empirical research has shown the understanding to be wrong; the reason is that there is no entity responsible for making the more scientifically accurate understanding of the condition more widely known in society.

For any and all these reasons, the healthcare system can continue to provide care that is ineffective or less effective than other therapies and more effective therapies can come to be less commonly used.

Mission of the ICP

Many of the above-noted problems occur because there is no entity that assumes responsibility for both providing up-to-date, scientifically accurate information about health conditions and proliferating this education on a wide scale basis. The goals of the ICP are to engage in these endeavors for issues related to chronic pain. Without any vested professional or financial self-interest, we seek to educate the public and healthcare professionals alike on a) scientifically accurate conceptualizations of the nature of chronic pain conditions and b) how to most effectively treat these conditions.

Irritable Bowel Syndrome

To this end, we announce the publication of a new content page on our website. Written by Jessica Del Pozo, PhD, it provides approachable, yet scientifically accurate, information on irritable bowel syndrome (IBS). IBS is a particularly good example of a condition that society, including many healthcare providers, often misunderstands. Specifically, the commonly held understanding of IBS as a digestive condition isn’t accurate to what we know from science; as a result, in our society, we do not tend to treat it as effectively as we could.

irritable bowel syndromeAs Dr. Del Pozo indicates, IBS is not primarily a gastrointestinal condition, but rather primarily a nervous system condition. Nonetheless, treatment recommendations are commonly based on the inaccurate understanding of the condition as a gastrointestinal condition. These recommendations fail to be effective and yet they are more commonly pursued. They are even more commonly pursued than therapies focused on the nervous system, which science tells us are more effective.

Our hope is that Dr. Del Pozo’s piece on IBS can be one way for society to have access to approachable, yet scientifically accurate, information on the condition. Through this site and our social media, we’ll try to proliferate this information.

Your help in this regard would also be greatly appreciated. If IBS is important to you, please link to it on your site or post a link to it through your social media.

Dr. Del Pozo is an expert in the field of chronic pain rehabilitation and in the treatment of IBS in particular. She is the co-author of The Gut Solution, a book for families with IBS utilizing a biopsychosocial approach (www.thegutsolution.com).

Dr. Del Pozo is also the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). In addition, for the last six years, she has been involved in an interdisciplinary chronic pain rehabilitation program at Kaiser Permanente, where she helps people with chronic pain learn to manage their pain without the use of opioid medications.

We appreciate Dr. Del Pozo’s expertise and contribution to the ICP. Please read her important piece on irritable bowel syndrome on the ICP website.

Author: Murray J. McAllister, PsyD

Date of last modification: May 5, 2016