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.

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.

Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

Self-Management

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

Commentaries on the use of opioid medications often exhibit this lack of consideration of self-management as a viable option. For example, it’s common for stakeholders in the field to hold the use of opioids as self-evidently necessary to successfully manage chronic pain. The notion that self-management is a viable option is never even considered. Indeed, the underlying and unspoken assumption is that it is impossible to manage pain well without the use of these medications. (See, for instance, these thought leaders failing to mention self-management as an option in the face of the various crises that beset the practice of opioid management for chronic pain, here and here).

It’s an odd state of affairs for a major specialty within healthcare to persistently fail to consider, let alone promote, self-management as a viable option. Other specialty areas within healthcare don’t fail to consider the role of self-care. Think of how the fields of diabetes care or cardiology or mental health encourage and promote self-management. Such fields go to great lengths to motivate and teach patients to take ownership and responsibility for their health condition, lose weight, start and maintain an exercise program, quit smoking, eat right, manage stress, assertively resolve conflicts or other problems, and so forth.

The field of chronic pain management instead seems to subtly or not so subtly emphasize the need for patients to rely on healthcare providers to manage pain for them. How often do you hear the assertion that patients will suffer without the pain management that the healthcare system provides? With such assertions, we inadvertently proliferate a belief that it is impossible to self-manage pain well. As such, it hardly ever comes up as a viable option among the many different treatments for managing chronic pain.

Why is that?

 

Author: Murray J. McAllister, PsyD

Date of last modification: August 7, 2015

How Stigma Prevents Self-Management

We tend to stigmatize pain because we misunderstand its nature. Specifically, we fail to acknowledge the role that the nervous system plays in producing the experience of pain. If we more fully appreciated this role, we would understand that chronic pain is similar to other health conditions that we don’t stigmatize much, such as high hypertension (i.e., high blood pressure) or type II diabetes.

Stigma of chronic pain defined

Stigma is someone’s negative judgment or criticism of you for having a condition that is not of your choosing. You didn’t choose to have chronic pain, but when getting stigmatized, you are getting blamed for having it or not coping with it well enough. It’s often in the form of a rhetorical question: ‘How could you possibly have so much pain?’ ‘How could you hurt when all I did was hug you?’ ‘Why are you suffering so when others with the same condition don’t suffer as much as you?’ The assumption that leads to these stigmatizing rhetorical questions is that the severity of pain should always correspond to the severity of injury or illness. Small injuries or mild illnesses should cause only mild pain, whereas only large injuries or serious illnesses should cause severe pain. However, more often than not, chronic pain patients don’t fit this mold. Herein lies the rub. Patients with chronic pain seem to have severe pain often beyond what this assumption leads us to believe they should have. Simple movements seem to cause severe pain. Hugs can cause pain. Common conditions like chronic back pain lead to severe suffering in some people. This assumption subsequently leads to stigma. It can’t be the injury or illness that causes such severe pain or suffering. It must be something personal about you that causes such pain or suffering. In other words, you are to blame.

In reaction to stigma, chronic pain patients can often assert that they didn’t choose to have chronic severe pain and, as such, there’s nothing they can do about it. They go on to assert that it is not something about them, but the condition they have. It is inherent to the pain, not something personal about them. Anyone, they assert, would be the same way if they had such pain.

In its blame of the victim, stigma insinuates that you are choosing your suffering. In defense of such blame, you emphasize your lack of choice in either having pain or its subsequent suffering. ‘It’s not me,’ you might say, ‘it’s the pain.’

Control over unchosen events

As described in previous posts on stigma, this defense is problematic in two ways. First, in asserting your lack of choice in the matter, you can easily fall into the trap of asserting that you have no control over the pain. That is to say, in response to stigma, it’s so easy to go from, say, “Don’t blame me. I didn’t choose this…” to “There’s nothing I can do about it.” As such, we tend to equate lack of choice with lack of control. If we don’t have control, we couldn’t have chosen it and if we couldn’t have chosen it, we can’t be blamed for it. While it might be a successful defense against stigma, the argument wins at the cost of coming to see yourself as powerless to pain. (Indeed, many patients with chronic pain often feel this exact way: like they have no control over their pain.) Powerlessness, however, is not a good thing as it leads right to suffering. Those who suffer have no power to affect the problem from which they suffer. Second, it is not factually accurate. It is possible to have some control over our health, including pain levels and how much one suffers. Now, of course, some patients with chronic pain might have to learn how to improve their health or how to gain better control of their pain and to cope better. However, the fact that some may need to learn how to manage pain well is different than the notion that it is impossible.

We thus arrive at a dilemma that chronic pain patients face: either they acknowledge that they have some degree of control over their pain and suffering, and subsequently become the object of blame or criticism if they are not doing a very good job of it, or they deny that they have any degree of control over their pain and suffering, and subsequently see themselves as powerless.

This dilemma can essentially shut down the possibility of learning how to effectively self-manage pain. To learn how to effectively self-manage pain, people with chronic pain have to learn how to acquire control and responsibility over their health, including their pain. This possibility opens the doors to stigma. To prevent the stigma, it is easy to assert that having some degree of control over pain is impossible — buying relief from stigma at the cost of denying the possibility of any meaningful ability to effectively self-manage pain.

The dilemma, however, is a false dilemma. It is based on a failure to understand the true nature of pain. Like stigma itself, the defense against stigma assumes that there are only two possible causes for severe pain: a severe injury or illness on the one hand or some personal weakness on the part of the patient who has pain. Everyone seems to fail to recognize that there may be a third option. Specifically, they fail to take into account the role of the nervous system in producing the experience of pain.  By taking it into account, you can skirt the dilemma of stigma and learn to effectively self-manage pain.

A subjective experience with neural underpinnings

We tend to think of pain as a physical sensation. However, we are only partly correct. It’s also a subjective experience. We can’t divorce the sensation from the perceiving subject – the person who has the sensation. It’s also not just any old sensation. While involving a bodily sensation, the experience of pain also inherently includes a cognitive appraisal of threat, an emotional sense of alarm or distress, and an automatic behavioral reaction to protect, usually through resting and/or guarding. These are the things that differentiate pain from other sensations, say, tickles. We simply don’t perceive a tickle to be threatening or alarming. We cry when in pain, yell out in distress, grimace, and guard the painful area. We laugh and squirm when tickled.

Pain, in this sense, is a danger signal. It signals to us that something is wrong in the area of the body that has the pain. A tickle doesn’t signal to us that there is anything wrong. Pain does. Inherent to the sensation is this sense that it is threatening and alarming. These are the essentially cognitive and emotional aspects of the experience of pain. (See the generally accepted International Association for the Study of Pain’s definition of pain.)

The nervous system is what produces this experience. The nervous system consists of all the nerves in the body, including nerves in limbs, in our bodily organs, as well as the spinal cord and brain. When an injury occurs, nerves in the affected area detect it. They subsequently send an electro-chemical message from the site of injury to the spinal cord and then up the spinal cord to the brain. Multiple areas of the brain become involved to produce the sensation and its inherent cognitive appraisal of threat, the emotional sense of alarm, and the behavioral reflex of guarding and grimacing (Melzack, 1999; Moseley, 2003).

In this way, the nervous system functions like a fire alarm in an office building. With a fire alarm, a smoke detector senses smoke and sets off the entire alarm system. The loud sound of the alarm signals threat. As a result, everyone becomes alarmed at the threat of fire and leaves the building. Fire fighters come to the rescue and put out the fire. The next day everyone is back at work and things return to normal.

Similarly, the nervous system, acting like an alarm system, can detect some bodily disturbance and sets off the alarm of pain. Pain, like the loud sound of a fire alarm, signals the threat. Inherent to the sense of alarm, the person becomes alarmed and reacts reflexively. Like fire fighters coming to the rescue, the person with pain and/or healthcare providers fix what’s wrong or the body naturally heals and the alarm of pain subsides. Things return to normal.

Alarm systems can become set at different levels of sensitivity

Now, with any alarm system, we want its sensitivity to stimuli to be set just right. Imagine if an office building’s fire alarm system was set too high — where it doesn’t detect smoke until the fire is raging. It wouldn’t do us any good, would it? We also wouldn’t want the sensitivity of the alarm system to be set too low — where it goes off, say, every time someone walks by the building smoking a cigarette. Rather, we want our fire alarm systems set at just the right level of sensitivity.

Similarly, we want our nervous system set at just the right level of sensitivity as well. We want to be able to feel pain long before an injury, say, becomes life threatening. Our nervous system wouldn’t be very useful to us in such a case. But, we also don’t want to feel pain in response to stimuli that is typically not painful – such as touch or the light pressure of hugs, normal movements like getting up from a chair or walking, changes in barometric pressure, or emotional stress.

Nonetheless, that is what’s happening in chronic pain. Chronic pain is like what happens with a faulty alarm system – one where the threshold for sounding the alarm is set too low and so it’s getting set off in response to stimuli that is typically not threatening (i.e., painful).

By definition, chronic pain is pain that continues past the normal time of healing. There is no longer a bodily disturbance for the nervous system to detect because the injury has healed. With chronic pain, though, the nervous system remains reactive, detecting normal stimuli as if they are threatening and, as a result, sounding the alarm of pain.

It’s how people can develop pain in the absence of any objective findings of injury. It’s also how people can have pain in response to normal stimuli like touch, mild pressure, simple movements, changes in barometric pressure, or emotional stress.

It’s important for people with chronic pain and the people around them to know that they are not making this pain up. The pain is real. And there is a real explanation for their pain. It’s being produced by the nervous system in much the same way as any other pain. The only difference is that their nervous systems are stuck in a heightened state of reactivity, and so the threshold for sounding the alarm of pain has come to be set too low. It is sounding the alarm bells of pain in response to stimuli that is typically not sufficiently dangerous to elicit the alarms bells of pain – just like an office building’s fire alarm going off when someone walks by outside on the sidewalk smoking a cigarette.

Chronic pain is real pain due to central sensitization – not tissue damage

This heightened state of reactivity of the nervous system is called central sensitization. It’s a real health condition that can be the cause of chronic pain. It maintains pain beyond the normal healing process of an injury or, as commonly occurs, when scans show normal age-related osteoarthritic findings. In such cases, chronic pain is not necessarily due to healed injuries or normal, age-related osteoarthritis in joints or the spine, but rather due to an up-regulated nervous system that is setting off the alarm of pain in response to stimuli that is not typically associated with pain. In other words, central sensitization is what maintains pain on a chronic basis.

Central sensitization is as real as hypertension or type II diabetes. In each of these health conditions, some bodily system or aspect of a bodily system is abnormally elevated – the nervous system having become too reactive in the case of chronic pain, the cardiovascular system becoming regulated too high in the case of hypertension, and heightened levels of blood sugar (an aspect of the neuroendocrine systems) in the case of type II diabetes. All three conditions are common examples of an up-regulation of a bodily system or an aspect of a bodily system that over time has become problematic (i.e., symptomatic).

Why stigmatize pain when we don’t stigmatize hypertension or type II diabetes?

When we understand this role of the nervous system in the production of the experience of pain, we see that chronic pain is real pain that has a real explanation. People make up chronic pain about as often as people make up having hypertension or type II diabetes, which is to say, they don’t make these things up. So, why stigmatize chronic pain?

We typically don’t stigmatize these other conditions because we understand that we don’t choose to have these conditions – at least not in any sense of the word “choose” that we typically use. For instance, no one decides to have hypertension or type II diabetes as if it was a choice between having one of these conditions or not. Choices typically involve having a ready or easy control over a set of options. ‘Would you like coffee or tea?’ – now that is a choice. There is no similar use of the word “choice” that might apply to hypertension or type II diabetes. No one ever faces a decision such as, ‘Would you like to be diabetic or not?’ No, it just doesn’t make sense to use the notion of “choice” with regard to conditions like hypertension or type II diabetes.

Similarly, no one chooses to have chronic pain. Just as we don’t have ready or easy control over our cardiovascular systems or our blood sugars, we don’t have ready or easy control over our nervous systems. It’s not like you can just make a decision and choose to no longer have chronic pain, hypertension or high blood sugar levels. No, it doesn’t work like that.

As such, stigma is misplaced blame. It relies on an overly naïve view of pain as something that one can just make up or will into (or out of) existence. However, as we see, having chronic pain is not the product of a choice or decision.

Chronic pain is not impossible to control

While chronic pain is not the result of a choice, it is possible to control it to some meaningful extent. This control, however, is not readily or easily attained – it’s not like we choose between health and ill health as we choose between coffee and tea. Nonetheless, we can affect change to our health over time and with a concerted effort.

The analogies between chronic pain and hypertension and type II diabetes continues to be helpful here. With a concerted effort over time, we can affect significant and meaningful changes in each of these conditions. It often requires a team effort between medical and health psychology providers and the patient (and possibly even their families). The focus of care is self-management: assisting the patient to make healthy changes over time that will positively affect the condition that the patient has.

In the case of hypertension, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, stress management, achieving a healthy weight, improvements in diet, engaging in an aerobic exercise, cessation of tobacco use, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, hypertensive patients come to down-regulate their cardiovascular system and subsequently lower their blood pressure.

In the case of type II diabetes, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, achieving a healthy weight, improvements in diet, stress management, engaging in an aerobic exercise, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, type II diabetic patients come to down-regulate their blood sugar levels.

Notice that these health behavior changes are difficult to achieve. They take time. They often require coaching and support from medical and health psychology providers, as well as support from family members. However, they are not impossible. That is to say, it is possible to affect significant and meaningful change to conditions like hypertension and type II diabetes. We all recognize that if we were to come to have either of these conditions, we would not be fated to uncontrolled hypertension or type II diabetes. We know that we can affect them. Through a process of learning how and sticking with it over time, we can come to have meaningful control over these conditions.

Chronic pain is the same way. Learning how to manage chronic pain well is possible, but it takes a concerted effort over time. It often also requires a team effort that includes health psychology providers, medical providers, physical therapists, and the patient (and often the patient’s family too). This kind of team is typically found in an interdisciplinary chronic pain rehabilitation program.

It also tends to require an accurate understanding of the role of the nervous system in maintaining pain on a chronic course. Why? It’s because the focus of care is to down-regulate the reactivity of the nervous system through a combination of medical, health psychology, and self-management approaches that we know to be effective. By pursuing these changes over time, patients come to reduce pain and increase the ability to cope with the pain that remains.

These therapeutic approaches consist of, but are not limited to, the following:

  • Effective non-narcotic medication management (particularly anti-epileptics and antidepressants)
  • Cognitive-behavioral therapy involving coping skill training
  • Mild aerobic exercise
  • Relaxation therapies
  • Exposure-based therapies to reduce fear-avoidance
  • Stress management & treatment of any co-occurring depression or anxiety disorders
  • Cognitive-behavioral therapy for insomnia
  • Tapering of opioid medications, if applicable

When patients pursue these therapies and strategies, they learn how to engage in them independently and take over doing them on their own. Over time, they come to affect their nervous systems by down-regulating its reactivity and subsequently have less pain. Because they do it themselves, they come to see that they are no longer powerless to pain and subsequently it is one of the most empowering experiences of their life. For the first time in their life with chronic pain, they have successfully learned how to control their pain at tolerable levels and have proven to themselves that they can do it. Such know-how and empowerment comes to further increase their abilities to cope with pain. As such, they develop a positive cycle of increasing self-management that leads to less pain, which in turn leads to improved empowerment and coping, which subsequently leads to improved self-management.

Notice, though, it takes work. In fact, it takes a lot of work. Successful self-management is the product of a long and concerted effort to make healthy changes over time.

As anyone who has ever attempted to make long-term changes to their health, this sense of control is not an object of stigma, but rather an object of admiration.

References

Melzack, R. (1999). From the gate to the neuromatrix. Pain, S6, S121-S126.

Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-27-2014

An Alternative to Opioids for Chronic Pain

It’s an interesting fact about the field of chronic pain management that there is a safe and effective alternative to the use of opioids for chronic pain, but relatively few people know about it. The alternative to opioids is an interdisciplinary chronic pain rehabilitation program.

Chronic pain rehabilitation programs

Interdisciplinary chronic pain rehabilitation programs are a traditional form of treatment that provides patients with the ability to self-manage pain and return to work, all without the use of opioid medications. They bring about these goals by providing chronic pain patients with the opportunity to 1) make a number of lifestyle changes, which, when done over time, reduce the physiological basis of pain, and 2) learn a number of advanced ways to better cope with the pain that remains chronic. Patients learn both of these two prongs of self-management from a safe and supportive team of chronic pain rehabilitation experts who coach patients on how to do them.

For the motivated patient who is open to learning and wiling to practice these changes and skills, it becomes possible over time to self-manage pain without opioid medications and do it successfully. Many people with chronic pain learn to do it everyday in interdisciplinary chronic pain rehabilitation programs. As such, they are the traditional alternative to opioids for the management of chronic pain.

While currently not as common as other types of pain clinic (such as long-term opioid management clinics or interventional pain clinics), most every major city across the United States, Canada, Western Europe, Australia, and New Zealand has a chronic pain rehabilitation program. Most of the well-known destination healthcare centers through out the world have an interdisciplinary chronic pain rehabilitation program. Many smaller, local clinics have such programs too. Literally, countless numbers of patients go through interdisciplinary chronic pain rehabilitation programs everyday and in doing so they learn how to live well without opioid medications despite having chronic pain.

Interdisciplinary chronic pain rehabilitation programs have high quality research evidence that demonstrate their effectiveness as an alternative to opioids (Chou, et al., 2007; Gatchel & Okifuji, 2006). There are numerous well-designed studies that show patients routinely have considerably less pain once they complete an interdisciplinary chronic pain rehabilitation program. On top of it all, they are no longer taking opioid medications. That is to say, following participation in such a program, they have less pain than when they were taking opioids, but are now no longer on opioids (Becker, et al., 2000; Cosio & Linn, 2014; Crisostomo, et al., 2008; Meineche-Schmidt, Jensen, & Sjogren, 2012; Murphy, Clark, & Banou, 2013; Rush, et al., 2014; Townsend, et al., 2008).

Despite the large number of programs and despite the well-documented evidence supporting their effectiveness, many people with chronic pain who are seeking care, perhaps even a majority, remain unaware of chronic pain rehabilitation programs as an option available to them – let alone know that it is a safe and effective alternative to opioids for chronic pain.

A short history of chronic pain management

It wasn’t always this way. For a few decades prior to the 1990’s people with chronic pain obtained treatment in interdisciplinary chronic pain rehabilitation programs on a much more routine basis. Moreover, there were significantly more interdisciplinary chronic pain rehabilitation programs in existence (Gatchel, et al., 2014; Schatman, 2012). So what changed?

In the decades prior to the 1990’s, it was significantly less common to manage chronic pain with opioids. As such, interdisciplinary chronic pain rehabilitation programs were largely the only type of pain clinic there was. Patients with chronic pain knew of them and tended to seek out care within them.

With the advent of widespread use of opioids in the 1990’s, interdisciplinary chronic pain rehabilitation programs tended to get overshadowed. Some pain clinics offering this traditional model of chronic pain management closed and new pain clinics, offering long-term opioid management, opened in large numbers.

There are many possible reasons for this state of affairs. The newer form of chronic pain management is more lucrative than interdisciplinary chronic pain rehabilitation programs. Long-term opioid management tends to obtain insurance reimbursement easier than interdisciplinary chronic pain rehabilitation programs. The use of opioids also appears to at least temporarily resolve the need for interdisciplinary chronic pain rehabilitation programs. Who wants to go through the hard work of making large-scale lifestyle changes and learn advanced ways of coping to reduce pain if a medication can temporarily reduce it for you? (A similar argument could be made with regard to the widespread use of interventional procedures and spine surgeries beginning in the late 1980’s and into the 1990’s). Moreover, an increasingly common belief among patients, providers and society generally is that it is impossible to manage chronic pain well without opioids – that intolerable suffering would be the inevitable result. When firmly held, this belief subsequently leads to a great deal of skepticism about the wealth of clinical and research evidence that shows interdisciplinary chronic pain rehabilitation programs are a safe and effective alternative to opioids for chronic pain.

An alternative to opioids for pain that few know about

So, we have an odd state of affairs at present in the field of chronic pain management. We know that we have a safe and effective alternative to opioids for chronic pain but few people know of it or take advantage of it, at least relative to the number of people who manage their pain with opioids.

How do you think the field should tell the public about interdisciplinary chronic pain rehabilitation programs? Why do you think they have difficulty getting widely recognized as an effective alternative to opioids for chronic pain? If you find yourself skeptical of the above-noted research, what would convince you to participate in such a program?

References

Becker, N., Sjogren, P., Bech, P., Olson, A. K., & Eriksen, J. (2000). Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: A randomized controlled trial. Pain, 84, 203-211.

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.

Cosio, D. & Linn, E. (2014). Efficacy of an outpatient, multidisciplinary VA pain management clinic: Findings from a one-year outcome study. Journal of Pain, 15(4), S110.

Crisostomo, R. A., Schmidt, J. E., Hooten, W. D., Kerkvliet, J. L., Townsend, C. O., & Bruce, B. K. (2008). Withdrawal of analgesic medication for chronic low-back pain patients: Improvements in outcomes of multidisciplinary rehabilitation regardless of surgical history. American Journal of Physical Medicine & Rehabilitation, 87(7), 527-536. doi: 10.1097/PHM.0b013e31817c124f

Gatchel, R. J., (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130. doi: 10.1037/a0035514

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, 17(11), 779-793.

Meineche-Schmidt, V., Jensen, N., & Sjogren, P. (2012). Long-term outcome of multidisciplinary intervention of chronic non-cancer pain in a private setting. Scandinavian Journal of Pain, 3(2), 99-105.

Murphy, J. L., Clark, M. E., & Banou, E. (2013). Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Journal of Pain, 29(2), 109-117.

Rush, T., Huffman, K., Mathews, M., Sweis, B., Vij, B., Scheman J., & Covington, E. (2014). High dose opioid weaning within the context of a chronic pain rehabilitation program. Journal of Pain, 15(4), S111.

Schatman, M. E. (2012, December). Interdisciplinary chronic pain management: International perspectives. Pain: Clinical Updates, 20(7), 1-5.

Townsend, C. O., Kerkvliet, J. L., Bruce, B. K., Rome, J. D., Hooten, W. D., Luedtke, C. L., & Hodgson, J. E. (2008). A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Pain, 140(1), 177-189.

Author: Murray J. McAllister, PsyD

Date of last modification: 4-20-2013

How People Cope with Pain Really Well: 2

In the last post, we started a discussion about how people cope with chronic pain really well. Specifically, we looked at five attributes and skills that people do when coping well with chronic pain. The point of the discussion was that it is a way to learn how to cope better. Coping with chronic pain is a set of skills like any other set of skills and you learn how to cope with pain just like you learn other skills – like learning how to knit or play the piano or play tennis. If you wanted to learn how to play the piano really well, you would do a number of things (such as take piano lessons), but one of the most important things is that you would study those who are better than you. You would play their recordings and listen and watch how they do it. You would then try to do what they do. The same can be true with learning how to better cope with pain. With this idea in mind, we looked at five attributes and skills that people do when they cope with pain really well.

These five things were the following:

  • Being open to change and learning from others
  • Accepting that chronic pain is chronic
  • Focusing on self-management
  • Engaging in a mild, low-impact aerobic exercise on a regular basis
  • Understanding the relationship between pain and stress, and managing stress well

These are things that people do when coping really well with chronic pain.

Lets look at five more attributes and skills that make for good coping. As we do, remember one more thing from the last post. It was the discussion about how there is no shame in acknowledging that you can learn to cope with pain better. All skills, including the skills of coping, can be seen as on a spectrum for which there is no point at which you are as good as you ever will get. Rather, if you take any skill imaginable, you can always get better at doing it no matter how good you are at it. Any guitar player can get better with learning and practice – even rock and roll superstars. Any tennis player can get better too – even the pros. Similarly, anyone with chronic pain can learn to cope better — no matter how good you are at it. So, there is no shame in acknowledging that you can learn a thing or two. You are in the same boat as everyone else. So, let’s look at five more ways to cope better with chronic pain.

1. People who cope really well don’t react to their chronic pain as if it is acute pain.

If you accidentally stepped into a hole and broke your ankle, the pain of the broken ankle would be considered acute pain. The normal reaction to such an injury would be to become alarmed, seek help, stop using the ankle, stay at home, and rest. With the pain of acute injuries, such as a broken ankle, this set of reactions would not only be normal but largely helpful. Generally, a broken ankle gets put into a brace or cast and we are told to stay off it. By doing these things, we allow the bone fracture to heal. Subsequently, the pain goes away. As such, this set of reactions to acute pain is a good thing.

However, what’s good for acute pain is not good for chronic pain. The normal sense of alarm that goes along with being in pain becomes problematic when occurring on a chronic basis. It can become any number of negative emotions, such as fear, anxiety, irritability, and even depression. The normal reaction of resting becomes problematic too when done on a chronic basis. While resting can help an acute injury, it can make chronic pain worse. Your body is made to move and if you don’t use it for too long you get stiff, achy, and sore. It’s not just you. It’s true for everyone of us. We also get out of shape and gain weight when we are inactive for too long. Becoming de-conditioned in these ways can make pain worse too. Staying home and resting for too long also leads to what healthcare providers call “fear-avoidance.” Fear-avoidance is the cycle of avoiding activities out of concern that the activities will increase pain. Any number of normal activities of daily life can increase pain and so it can become easy to stop doing them out of anticipation that they will cause pain. When done in response to acute pain, it might be helpful. When done on a chronic basis, it’s one of the ways pain can become disabling. Moreover, staying home and not doing your normal daily activities for too long can lead to becoming chronically bored or aimless or depressed. In all these ways, responding to chronic pain as if it is acute pain becomes problematic.

People who cope with pain really well make the transition in their understanding that their pain is no longer acute pain but chronic pain. They know what their chronic pain is and are no longer alarmed by it. They understand that chronic pain is a nervous system condition and not a long-lasting orthopedic injury. They understand that engaging in normal activities won’t make the nervous system condition worse, as it might if it was an acute orthopedic injury, like a bone fracture. Consequently, they no longer become alarmed that they will make the underlying condition worse when they do normal activities of life.

Now, of course, their pain might be worse when they do things, even if it doesn’t make the underlying nervous system condition worse. However, they recognize that not doing things makes their pain worse too. Staying home and resting doesn’t serve a useful purpose when done on a long-term basis. So, people who cope with pain well respond to their pain by saying, “I got to get up and do something!” or “I’ve got to get out of the house or else I’ll go stir-crazy!” That is to say, they react to their chronic pain in ways that are almost opposite to how you normally react to acute pain.

People who cope with pain well have gotten back into the normal activities of their lives despite the pain because the pay off is that it leads to improved coping. They are no longer bored or aimless or depressed. They are getting things done, checking things off their lists, and even having fun on occasion. Because they are doing these things, they feel productive. They feel like they are going somewhere and have a direction again to their life. Their self-esteem is on the rise. In all these ways, they are now coping better and their improved abilities to cope buffer the increased pain they may have from doing these activities.

2. People who cope with pain well pace their activities.

Having gotten back into the normal activities of life, people who cope with pain well are reasonable about how much they do. They do some things, but not everything. They break up a large activity or their entire ‘to do’ list into manageable size chunks. Referring to the story about the tortoise and hare, they might joke that their motto is “slow and steady wins the race.” That is to say, they have overcome any tendencies to engage in what psychologists call “all-or-nothing” approaches to life.

Additionally, they are reasonable about what they do, and not just how much they do. They might not expect to be able to water ski or dirt bike race. Nonetheless, they make it a point to still do a lot of fun things.

3. People who cope well with pain overcome any perfectionist or workaholic tendencies they may have had.

Perfectionists and workaholics get a lot of kudos in our society. They get a lot done and what they do they do very well. Employers love them and reward them for it. So, if you are a perfectionist or workaholic, it may have gotten you far before the onset of chronic pain. However, now that you have chronic pain, perfectionism and workaholism are problematic.

Perfectionism and workaholism are problematic in many ways. First, perfectionists and workaholics engage in “all-or-nothing” thinking and as such tend to struggle with pacing themselves. If they have a good day in terms of their pain level, they clean, not just the kitchen, but the entire house. As they do, they might say to themselves, ‘If you are going to do it, do it right or not at all.’ However, their strict adherence to perfectionistic standards leads to exacerbating their pain through over-activity. Second, their ‘do it right or not at all’ attitude lends itself to the ‘not at all’ side of the equation because they have chronic pain and the pain makes it difficult to ‘do it right.’ Not doing things leads to all the problems described above – getting out of shape, weight gain, aimlessness, and more pain. Third, once they have stopped doing things, they are prone to self-criticism. Their perfectionistic standards are hard taskmasters. When they don’t live up to their standards, they get down on themselves. No one is harder on him- or herself than the perfectionist or workaholic. Such persistent self-criticism can lead to poor self-worth and depression. Fourth, perfectionism and workaholism tend to make people inflexible and poor adapters. We reviewed in our last post that one attribute of a good coper is someone who is flexible and can adapt. The ‘all-or-nothing’ thinking of the perfectionist or workaholic makes it hard to adapt and be flexible. They have difficulty finding the middle ground between their ‘either-or’ thinking. In all these ways, perfectionism and workaholism do not lend themselves to coping well with pain.

People who cope with pain well tend to have worked through their perfectionist and workaholic tendencies. With persistent effort and time, they have broken themselves of the habit of holding themselves accountable to perfectionistic standards. They have come to see that even before the onset of their chronic pain they never really did achieve those standards. Whatever they did, they could always find some fault or room for improvement. There was always something more on the list to do. It never really was a very good recipe for happiness. By overcoming perfectionism, they came to see that what they thought was happiness was really just temporary satisfaction. The feeling associated with a job well done lasted only as long as it took to move on to the next thing on the ‘to do’ list. And there was always more to do on the ‘to do’ list. So, people who cope with pain well have worked through these issues and no longer hold themselves to perfectionistic and workaholic standards.

4. People who cope with pain well maintain a regularly structured day.

Everyone has a routine. We typically go to bed and get up at more or less the same time each day. We typically eat our first meal in the morning, our second meal in the early afternoon, and our third meal in the late afternoon or early evening. We typically shower or bathe shortly after awakening or shortly before bed. Our typical daily chores and activities also follow a routine. We all do better when, more or less, we follow a routine.

Sometimes, of course, it’s fun to break up the routine. When we are on vacation, we enjoy the break in the routine. Right after retirement or obtaining disability, it is nice to have a break in our usual routines and many people have some fun with it.

However, if the break in the usual routine never returns to the normal routine or is never supplanted by a new routine, a couple of problematic things happen that reduce our abilities to function well in life. First, we become aimless. After awhile, we don’t know what to do with ourselves if we don’t have a focus for the day. Without a focus for our concentration and efforts, our attention tends to focus in on the problems of life. For those with chronic pain, our attention gets focused on pain and all the stressful problems associated with living a life in chronic pain. Second, we tend to start napping. Now, an occasional nap is fine, but when it starts happening everyday, it become problematic. It disrupts our nightly bedtime routines. It’s hard to fall asleep because of the nap earlier in the day. Once we start falling asleep later in the evening, we tend to start sleeping in longer and longer in the morning. In turn, this shift pushes the naptime later into the afternoon, which subsequently pushes bedtime later and later. As a result, a shift occurs in your sleep-wake cycle, sleeping more and more into the day and awake more and more at night. Chronic disruption in your sleep-wake cycle is a common cause of social isolation, aimlessness, persistent fatigue, and depression.

I often tell patients that we all need a reason to get up in the morning. We need to have some idea of what we are going to do with ourselves throughout the day. When, on a chronic basis, we don’t have any plans or routine to guide us through the day, then every moment requires a decision – “What am I going to do?” The question can become surprisingly hard to answer! It’s like when you were a kid during the last few weeks of summer vacation and you and the neighborhood kids have done everything you wanted to do; you sit around the house or backyard, staring at each other, asking, “What do you want to do? Oh, I don’t care, what do you want to do?” Back and forth it goes and boredom and aimlessness are the result. Routines serve the function of allowing us not to think so hard. We just know what we are supposed to do from one thing to the next. They keep our minds focused on getting things done, rather than becoming aimless or, worse yet, becoming focused in on all the problems of life while awake in the middle of the night when every one else is sleeping. That’s not what good coping looks like.

5. People who cope with pain well engage in a daily relaxation exercise.

Like mild aerobic exercise, a regular relaxation exercise is an essential component of successful self-management. People who cope with pain really well engage in both on a regular basis.

People commonly misunderstand the role of relaxation in pain management. They tend to think of it as something you do when experiencing a lot of pain in order to get through it. When they try it, it doesn’t work real well and so give up.

While a relaxation exercise can be done in the midst of a pain flare (think, for example, the deep breathing women learn for childbirth), relaxation for this purpose is a very difficult skill to achieve and it takes a lot of practice – more than most people are initially willing to do.

The most important reason a relaxation exercise is an effective treatment for chronic pain is that it is an intervention that targets the nervous system and reduces its reactivity over time. It’s more of a prevention type treatment than something you do in the midst of a pain flare.

Chronic pain is the result of the nervous system being stuck in a persistent state of reactivity that makes nerves highly sensitive to pain. As you know, any normal movement can be painful. Mild pressure like massage or even touch in the painful area of the body can feel painful. Of course, normal movements and massage and touch shouldn’t be painful, but they are because the nerves and the rest of the nervous system are stuck in a persistent state of reactivity, making the nerves in the painful area sensitive. It’s called central sensitization.

A daily relaxation exercise is one of many treatments for this condition. A relaxation exercise targets the nervous and relaxes it for a short period of time. After awhile, the nervous system returns to its high level of reactivity. If you do it again everyday, however, the nervous system begins to return to lower and lower levels of reactivity. As a result, you have less and less pain over time.

You are also more grounded and less stressed. As a result, you also tend to cope better.

A daily relaxation exercise is a two-fer: less pain over time and improved coping over time.

There are literally countless ways to get better at coping with pain. In this post, we reviewed five of them. We reviewed a different five ways in the last post. I intend to periodically review more ways to cope with pain on this blog.

 

Author: Murray J. McAllister, PsyD

Date of last modification: 9-27-2013

3 Healthy Ways to Overcome Stigma

If you have chronic pain, you also have to deal with social stigma. Stigma is the disapproval of others for how you are coping with pain. Friends, loved ones, employers, and even healthcare providers can judge you in any number of ways. They might disapprove when you rest or nap, or if you don’t work, or if you take narcotic pain medications. Such critical judgments from others are stigma.

Of course, it doesn’t happen all the time. Nonetheless, it likely happens enough of the time for you to be aware of it or at least its possibility when interacting with others.

Stigma puts people on the defensive. No one likes to be judged. It can lead to shame and anger. In the last post, we reviewed two ways people with chronic pain find themselves defending against stigma. They were:

  • emphasizing the medical aspects of chronic pain and, as such, emphasizing that you have no control over it
  • insisting that you are coping as well as possible given the condition that you have

While understandable, these ways of responding to stigma ultimately back fire in the end.

Let’s look at some ways to overcome stigma that are healthy and effective. Unfortunately, there are no step-by-step instructions for how to do it. It’s actually hard to describe how people do it. The ability to do it, though, involves at least three factors: coming to terms with the moral luck of your chronic pain; developing ego strength; and understanding that no matter how well you are coping with chronic pain, you can always get better at it.

All three of these factors, however, fall under the category of ‘easier said than done.’

The good news is that it is possible. It is possible to deal with social stigma in healthy and effective ways. Most people have to learn how to do it. It can be hard to learn. It takes a lot of practice. And, like most things that take practice, it takes time. Typically, people learn healthy ways to respond to stigma in one of two different types of therapy: in a chronic pain rehabilitation program or in psychotherapy with a health psychologist.

Let’s take each of these three factors and discuss them one at a time.

Coming to terms with the moral luck of your condition

A common response to stigma among those with chronic pain is to deny responsibility for the pain. Say, for example, that your spouse criticizes you for resting too much and not doing enough around the house. A natural reaction is to remind your spouse that you have a medical condition and there’s nothing you can do about it. You didn’t choose it. It happened to you. It’s out of your control. You are simply doing, you might assert, what everyone else does when having a medical condition: you stay at home and rest.

Your argument is that your spouse shouldn’t judge you because you didn’t choose it and it is out of your control. In effect, you are reminding your spouse of an assumption of moral reasoning that we all hold: we cannot be held responsible for something we didn’t choose or have control over. So, what you are basically arguing is that you can’t be held responsible (i.e., judged) for your pain because you didn’t choose it and you are essentially powerless to change the fact that you have it – i.e. you can’t be responsible for something you don’t have control over.

As we saw in the last post, this position has some problematic consequences. If you have no responsibility, it’s because you have no control over the situation and if you have no control, then you are powerless to do anything about it. You stop the disapproval of your spouse (or anyone else) at the cost of maintaining a viewpoint that you have no control and are therefore powerless to pain. It’s a bad way to understand your situation because it leaves you convinced that you are helpless.

It’s a dilemma: how can you overcome being stigmatized without asserting that you are powerless to your pain and therefore not responsible for its management?

It’s an important question because people who cope with chronic pain well see themselves as responsible for managing their pain, and their overall health, for that matter. They take ownership of their health and self-manage their pain. That is to say, they engage in healthy lifestyle changes and ways of coping that make their chronic pain tolerable enough so that they can move on with the rest of their life, engaging in productive and meaningful activities. That’s what good coping looks like.

It’s the chronic pain version of what we all know we should do when attempting to lead a healthy life – assume responsibility for our health and make healthy lifestyle choices, including healthy ways of coping with whatever life throws at us.

While it’s easier said than done, we all know it. We all know that we should assume responsibility for our health and well-being.

But how do you do it when being stigmatized? How do you overcome stigma while at the same time maintaining responsibility for your health and well-being?

Ancient and modern moral philosophers have studied this dilemma and they can offer some insights that I think are helpful for those with chronic pain. The insights involve the notion of moral luck. It’s the notion that much of what happens to us is beyond our choosing, but nonetheless we are still responsible for dealing with it as we go on with life. For instance, we do not choose the family we are born into and we do not choose much of our childhoods, but nonetheless these events have significant influence on us, an influence that reaches far into adulthood. Indeed, our childhood shapes us in countless ways and its influence extends throughout our lives. Were you born into a poor family or a wealthy one? Were your family relationships healthy or dysfunctional? Did you have one parent in your life or two? Did your parents divorce? Were they ever married? Were there any deaths in your family or did everyone remain healthy? So much of childhood is beyond our choosing and in effect is a matter of luck. It’s a matter of luck whether good things happen to us or bad things happen to us. In many ways, these unchosen events shape how we turn out as adults. Despite our lack of choice in all these childhood influences, we are nonetheless responsible for what we go on to do in adulthood. We are all subject to moral luck.

So, how does all this relate to chronic pain and dealing with stigma? You can use the notion of moral luck to understand your condition. It is true that you didn’t choose to have chronic pain, but nonetheless you are still responsible for how you are going to manage it, now that you have it. This way of understanding your condition is helpful in dealing with stigma. You are not to blame for your chronic pain. The stigma is not true! But, nonetheless, you are still responsible for how you manage your pain. And thank goodness too! For if you are not responsible for it, who would be? You don’t want to see yourself as having no control over your pain and health. For one thing, it is not factually accurate. For another thing, if it were true, it would leave you powerless, which in turn leaves you helpless and ultimately hopeless! So, accept the fact that you can self-manage your chronic pain. You just have to learn how. By understanding your condition with the use of the notion of moral luck, you can know that you are not to blame for your chronic pain, but you also know that you can learn to have some modest, yet meaningful, control over your pain.

The notion of moral luck allows you to side-step the social stigma of chronic pain. At the same time, it makes way for learning how to successfully self-manage pain.

Developing ego strength

When you acknowledge that you are responsible for managing your pain, you open yourself up to the possibility of judgment from others. In this post and the last, we discussed how common it is for people to become defensive when judged or stigmatized. Understandably, they become sensitive and angry. In their anger, they deny their ability to control the pain and therefore deny their responsibility for its management. At other times, they defensively assert that they are coping as well as humanly possible, which is another way to respond to stigmatizing statements that they aren’t coping well enough. These reactions are common.

What if, in either of these situations, you maintained your cool when someone questioned how you are coping with pain? What would that look like? Let’s imagine two different scenarios and review what it would be like if you interacted with the other person while remaining grounded.

In the first scenario, suppose someone critically judges you by accusing you of not coping well enough with your pain. You control your sensitivity and defensive anger, and in response assertively state that you do not appreciate the criticism. You ask the person to stop making such judgments. You do not lose it. You don’t cry or let your anger get out of control. Rather, you maintain your cool. Maybe, you acknowledge that everyone can always get better at dealing with problems, like chronic pain, and it may be true that you could learn to cope better, but the judgmental criticism is not helpful. In doing so, you simply state your peace and walk away.

In the second scenario, a healthcare provider begins to talk to you about participating in a chronic pain rehabilitation program. In describing the program, she states that it would help you to learn how to cope better with your chronic pain. Your immediate reaction is to become a little sensitive and think that she is judging you for not coping well enough. For after all, you’ve had a lot of people stigmatize you over the years and your immediate reaction is that your healthcare provider is doing it too. Before you say anything, though, you contain your immediate reaction and think to yourself, ‘No, she’s not judging me… She just trying to be helpful.’ You then ask about her recommendation and you talk about it without feeling offended. In the course of the conversation, you acknowledge that it would be helpful to learn some new ways to cope with pain and to get better at it. By doing so, you get a little vulnerable with your healthcare provider, but, at the same time, you remain strong, as it were, in your vulnerability. You know that it is okay to get help and you remind yourself before rejecting her recommendation that getting help is why you are seeing your healthcare provider in the first place. You remind yourself that everyone needs help, sometimes, and that it’s a mark of strength to acknowledge that you need help and could benefit from learning how to cope better with pain.

In both these scenarios, you demonstrate that you possess ego strength. Ego strength is a term that captures what in everyday language we might call ‘character strength’ or ‘maturity.’ It’s the ability to acknowledge that you don’t know everything and that you can benefit from learning from others. In short, it’s the ability to be in the student role. You can tolerate getting feedback about yourself without becoming ashamed or defensively angry. You take it in and learn from it.

People demonstrate ego strength when they acknowledge that they were wrong about something when apologizing. Workers demonstrate ego strength when they tolerate feedback from their supervisor when discussing how they could do their job better or during their annual reviews. Patients demonstrate ego strength when they acknowledge that they could do better while talking with their healthcare providers about making healthy lifestyle choices.

Now, of course, such discussions are a two-way street. The other person, whether a friend or work supervisor or a healthcare provider, can be more or less respectful and tactful when talking with you about ways to improve what you do. When the other person is good at communicating such information, it is easier to hear. But, you also have a role in such conversations. It’s the role of tolerating such discussions, and acknowledging that you don’t know everything there is to know about the topic, and can learn and improve.

Developing ego strength is also a way of overcoming stigma. When you know that you have room to grow and change, and are truly okay with it, it doesn’t bother you as much when others point it out. When they do it respectfully, your confidence in yourself allows you to be vulnerable and acknowledge that they are right – that you can stand to benefit from working on getting better at coping with pain. When they don’t do it respectfully, your confidence in yourself allows you to tell them that the way they’re talking to you is not helpful – even if it might be accurate in some way. Ego strength allows you to have the confidence that overcomes stigma.

Traditionally, psychotherapy is the place where people develop ego strength. You do so in a trusting relationship with a healthcare provider who helps you to accept feedback about yourself, learn from it, and grow. When it comes to chronic pain patients, such psychotherapy is done with a health psychologist. Developing ego strength also occurs in chronic pain rehabilitation programs, because they have traditionally been a psychology-driven therapy.

You can always get better at coping

In the course of developing ego strength, it becomes clear that the ability to cope with problems, like chronic pain, occurs along a spectrum. There is no endpoint in the ability to cope. No matter how well you are coping, you can always get better at it. This way of understanding coping allows you to overcome stigma.

We have seen how it is easy to respond to stigmatizing accusations that you are not coping well enough by asserting that you are coping as well as possible given the nature of your condition. Now, of course, the stigmatizing accusation is judgmental, disrespectful, and hurtful. So, it is understandable that you respond in some way. But, is this type of response factually accurate?

Patients commonly tell me that they have an incredibly high pain tolerance or that they don’t want to hear about ways to cope better with pain because they are coping as well humanly possible. These kinds of statements cut off the possibility of stigma, but they also cut off all discussion of the possibility of learning how to cope better too. And are they really factually accurate? Have such persons really reached an endpoint in their ability to tolerate and cope with pain? While their reactions to stigma are understandable, I think it is more factually accurate to see that, no matter how well people tolerate and cope with pain, they can always get better at it. There is always room for improvement.

Moreover, there is no shame in acknowledging in acknowledging where you are at on the coping spectrum. We are all in same boat, as it were. Wherever we are on the spectrum of coping, we can all get better at coping with adversity!

As such, it is most helpful to understand the ability to cope as something that occurs along a spectrum of coping, where there is no ideal endpoint. Wherever you are on the spectrum of coping, you can always get better at it.

The ability to cope with problems is like any skill. People don’t reach an endpoint in their ability to play a musical instrument or play a sport. A musician or athlete can always improve, no matter how good they get. The same is true with the ability to cope with adversity. The more you learn and the more you practice, the better you get at it.

So, what do you do when people disrespectfully accuse you of not coping well enough? Well, let’s review. With the help of your healthcare providers, you have worked through the moral luck of your situation. Over time, you have become confident that you are not to blame for your chronic pain, but you have also accepted ownership of your health and well-being. As such, you have been working with your healthcare providers in learning how to self-manage chronic pain. You have developed the strength to be in the student role with your healthcare providers. You have accepted their feedback and insights about you, and have learned from them, and have grown. You now have the confidence to know that it’s okay to be still learning. You know that you have come to cope better and better, but in reality there is always more to learn. You are now hopeful in ways that you haven’t been in a long, long time: you know that your future is one of continuously getting better and better at self-managing pain, as long as you keep learning and practicing. So, with all this hard work behind you, and with your new-found strength and confidence, you tell the people who disrespectfully judged you something like the following: you say that, while it may be true that we can all get better at coping, it is not right to judge and that they should stop being so judgmental. You then walk away without shame or anger, but with the confidence that you are on the right track.

Author: Murray J. McAllister, PsyD

Date of last modification: April 15, 2013