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Temporomandibular Joint Disorder Sat, 04 Feb 2023 03:14:56 +0000 Joomla! - Open Source Content Management en-gb COVID-19 and Chronic Pain: Challenges and Opportunities

The COVID-19 pandemic continues to impact the world with deaths in the hundreds of thousands and countless more having become ill. To reduce the risk of contagion and death, areas around the world maintain self-quarantining practices and have been doing so now for multiple months.

Sheltering-in-place, or self- quarantining, presents both challenges and opportunities for everyone, including those with persistent, or chronic, pain.


While the COVID-19 pandemic presents multiple challenges to everyone, one of the most important of these challenges to those with chronic pain are the potential for vulnerabilities to developing serious complications if becoming ill with COVID-19. The coronavirus, which is the virus that causes COVID-19, leads to a wide range of symptoms for those who become infected. Some people don’t have any symptoms at all. Still others have mild to moderate degrees of symptoms. Still others have critical, life-threatening symptoms. These latter people with COVID-19 tend to become hospitalized and may even die.

The Centers for Disease Control (CDC) keep statistics on cases of COVID-19 worldwide and initially found that those who are most prone to Photo by Allie Smith courtesy of Unsplashdeveloping critical, life-threatening forms of the illness are the elderly and those with certain pre-existing health conditions (April 3, 2020). Health conditions that are present at the time when another, unrelated health condition develops are called comorbid conditions. These conditions are high blood pressure (otherwise known as hypertension), high cholesterol (otherwise known as hyperlipidemia), diabetes, and chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD) and asthma.

In the United States, the CDC later found that African-Americans also have a greater risk of developing serious, life-threatening illness from COVID-19 (April 14, 2020). Indeed, in some states the majority of those who have died from COVID-19 are African-Americans, even though this group of people only makes up a minority of the population. While the cause(s) for this discrepancy is unknown at present, speculation is that the above-mentioned comorbidities as well as social and economic causes of poor health are the most likely culprits (Yancy, 2020).

It’s noteworthy that chronic pain syndromes are not one of the comorbidities that make people prone to critical, life-threatening progressions of COVID-19. With that said, however, the comorbidities listed above can occur in those with persistent pain. As such, it is important to take the threat of COVID-19 infection seriously for anyone with persistent pain whose health is additionally compromised by conditions such as heart disease, diabetes, COPD or asthma.

To reduce your risk of infection, it is important to follow the common guidelines advocated widely by governmental and healthcare institutions. Most everyone knows of them by now, but they bear repetition.

  • Stay home as much as possible.
  • Engage in distancing at least six feet, or 2 meters, (or more) from others, particularly when in public.
  • Wear a mask when out in public or at home if you’re ill.
  • Wear a mask if you are taking care of someone who is ill with COVID-19.
  • Wash your hands often and for at least 20 seconds with soapy water, or use a hand sanitizer that is made up of at least 60% alcohol.
  • Cover your cough or sneeze with your arm or a tissue.
  • Don’t touch your eyes or face.
  • Wash and disinfect common surfaces.

The CDC has a good webpage with more information here on this topic.


It may also be an opportunity for all of us to do what we can to become as healthy as possible. It’s all too easy for anyone of us to focus on the dangers of the illness, the disruptions of sheltering-in-place, and the economic stresses that are occurring as well. With all these problems, it’s easy to seek comfort in comfort foods, sleeping in late and staying up late, binge-watching TV, web surfing aimlessly for hours, or drinking alcohol (or using other drugs) more than you should. It’s all understandable, of course, so we shouldn’t judge ourselves or others when engaging in these behaviors, but when we do them we end up becoming unhealthier at a time when we need to be as healthy as possible.

Most of us while sheltering-in-place tend to have extra time on our hands and we could use this time to start a healthy behavior that we’ve always known we probably should do, but have never really gotten around to doing. As such, we could spend our extra time on ways to foster our health and overall well-being.

Maybe we could work at cooking from scratch more often, looking up some recipes and spending more time in the kitchen. We may come to enjoy cooking when done for pleasure as a pastime. We would also subsequently eat less processed foods and likely more fruits and vegetables. In doing so, we might even lose a bit of weight. In all, we might develop an enjoyable past time that is safe to do because we are also at home, while also eating healthier and possibly even losing some weight.

We could also start a gentle exercise routine.* Initially, it could be something quite modest, without rigor. You could use the motto of 'anything is better than nothing’ and so perhaps it is just walking a circle or two in your house or down to your mailbox and back. With time, you could extend it to walks outside each day or every other day. You could use the same approach if you have access to a treadmill, stationary bike, or other similar equipment. Notice it is gentle, yet something more than just stretching. It’s something that gets your heart rate up. It's a gentle or mild aerobic exercise and it makes us healthier when done over time.

We could get outside more often (while maintaining social distance) and spend time in green spaces.* Many parks remain open. Our grandmothers used to tell us to ‘go outside’ when we were kids because they knew it was good for us and they were right. Being among rocks and trees, with birds and scurrying little critters, and breathing fresh air improves our well-being. This link is a nice article that reviews the science proving that our grandmothers were right all along.

We could also do a stress management technique for a few minutes each day, such as diaphragmatic breathing, progressive muscle relaxation,Photo by Madison Lavern courtesy of Unsplash meditation, yoga, or tai chi. Any of these contemplative practices are ways to develop the skill sets of calming yourself down and focusing your attention. We don’t tend to think of the abilities to calm yourself down and stay focused on things as skills that can be learned, but they are. They are like learning to play a sport or a musical instrument – the more you practice, the better you get at them. Simlarly, a contemplative practice like those listed above take practice to get good at them. With practice, however, you won’t have to resign yourself to being stressed and scattered. Instead, you could get good at becoming calm and focused. These skills sets can positively affect our health and well-being.

Any of these healthy behaviors bring about a greater sense of well-being, but are also apt to reduce factors associated with many of the comorbid conditions listed above that are associated with severity of COVID-19. They help to reduce blood pressure, lower cholesterol, reduce inflammation, lose weight, and lower blood sugars. They may even improve the functioning of the immune system.


Living and staying safe in the time of COVID-19 with its resultant economic uncertainties presents many challenges. It’s normal to be scared in the presence of danger. Sheltering-in-place, or self-quarantining, can also lead to persistent boredom and aimlessness. In response, it is common to seek comfort that temporarily provides relief, but in the end is actually unhealthy.

Now is the time, when we need to be as healthy as we can to fight off potential infection, to take active steps to improve our health. It’s a time to reset our priorities and stop putting off doing those things that we always knew we should do, but haven’t gotten around to it. Now, more than ever, is the time to become as healthy as possible.

*Please always follow the advice of your healthcare providers when starting a gentle exercise routine or going outside. Their recommendations should always supercede the informational content of this site. You may have unique aspects to your health that cannot be represented accurately with general, educational information as found on this site. Please also see Terms and Conditions of Use.


Centers for Disease Control (CDC), (April 3, 2020). Retrieved on April 20, 2020, from

Centers for Disease Control (CDC), (April 14, 2020). Retrieved on April 20, 2020, from

Guan, W., Liang, W., Zhao, Y., et al. (2020). Comorbidity and its impact on 1590 patients with COVID-19 in China: A nationwide analysis. European Respiratory Journal, 55(4), 2000547. doi: 10.1138/139930003.00547-2020

Yancy, C. W. (2020). COVID-19 and African-Americans. JAMA, published online. doi: 10.1001/jama.2020.6548

Date of publication: April 23, 2020

Date of last modification: April 23, 2020

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) News & Recent Events Wed, 22 Apr 2020 18:35:03 +0000
The Passing of Ron Melzack, PhD

A giant in the field of pain management passed away the other day. It was December 22, 2019, and, to be exact, he was the father of pain management. It is no overestimation to say that he brought pain management into modernity. Ron Melzack, PhD, was 90 years old.

A native of Montreal, Melzack earned his PhD in psychology at McGill University in 1954. While earning his degree, he became interested in pain and in so doing he began his life-long career of its study. He taught psychology at Massachusetts Institute of Technology (MIT), among other universities, but for most of his career he was back at McGill University.

While at MIT, however, Melzack met Patrick Wall, MD, (1925-2001), and together they published their novel ideas on what came to be known as the gate control theory of pain.1 This ground-Ron Melzackbreaking work challenged centuries-long Cartesian notions that pain is highly correlated with, and indeed caused by, bodily pathologies, such as injuries or tumors. They dared to notice that pain isn’t as correlated with bodily pathology as the Cartesian notions have long had us expect. Just as often as people experience severe pain when having a severe injury, they noticed that people also experience mild or moderate pain to such injuries. Similarly, many people experience excruciating pain when having mild injuries or no injuries at all (think: tension headaches or fibromyalgia). In response to such commonplace observations, Melzack & Wall posited that the spinal cord and brain must play a role in the production of pain. Moreover, they further posited that the spinal cord and brain are not static entities from birth, but are modifiable by past and present learning and circumstances, all of which go on to influence how the spinal cord and brain produce pain. Thus, in their gate-control theory of pain, Melzack & Wall acknowledged the inherent subjectivity of pain as a product of multiple inputs, including from the body, and the spinal cord and brain, the latter of which exert their influence on the production of pain in accordance with the past and present life circumstances of the individual who experiences pain.

This non-Cartesian model of pain initiated an expansive body of clinical and basic science research into how and why self-management based therapies, such as cognitive-behavioral therapy, mindful meditation, therapeutic neuroscience education, and the like, are effective at reducing pain when they do not target bodily pathologies. In so doing, the gate control theory of pain provided an academic justification for the development and growth of interdisciplinary pain rehabilitation programs and other forms of interdisciplinary pain clinics that today routinely include pain physicians, pain psychologists, nurses, and physical therapists, among other disciplines.

Over the decades, Melzack expanded on the gate control theory of pain to develop what is now known as the neuromatrix model of pain. Basic pain science has now well-established that different parts of the brain, or neuromatrix, lend themselves to the production of the various aspects of pain – sensory, emotional, cognitive-evaluative, behavioral, and social affiliative.

Melzack was a prolific researcher and author who spawned others to follow suit. He also developed the McGill Pain Questionnaire, received a number of academic awards, and co-developed the first interdisciplinary pain clinic in Canada.

When, in 2009, Melzack was inducted into the Canadian Medical Hall of Fame, it was said of him, “What Einstein did for physics, [Melzack] has done for pain research and management.”2

While Melzack’s impressive legacy is well regarded by all in the field, a full appreciation of the extent of the consequences of his work remains unachieved. In many ways, the field of pain management and the general public remain swayed by the Cartesian model of pain and its emphasis on understanding pain as the direct, if not sole, result of bodily pathologies. It’s as if we are only part way through the paradigmatic scientific revolution that Melzack initiated.

On the one hand, the gate control theory and now the neuromatrix model of pain are established and required reading in medical and psychology schools. Basic science researchers and academics take his work as the assumed given, from which they now pursue their own work. Clinically, pain psychologists, physical therapists, relaxation practitioners (such as meditation, tai chi, and yoga) are all commonplace providers in pain clinics and no reputable pain clinic would be without them. Indeed, clinical practice guidelines developed by multiple professional organizations over the last decade call for these therapies to be first line treatments for common conditions, such as low back pain. There even seems to be a general trend towards increasing acceptance of these therapies for common pain complaints.

On the other hand, though, the field of pain management continues to have pockets of deep investment in therapies that target bodily pathologies despite the poor to non-existent correlation that bodily pathologies have to pain levels. Despite years of clinical guidelines advocating for their reduction, scans of orthopedic structures, and interventional and surgical procedures remain highly utilized – even over-utilized. The general public too remains largely influenced by the Cartesian model of pain, when, for instance, the default understanding of backache is that it must be the result of an injury and that the default understanding of conditions like fibromyalgia is that it ‘must be all in their heads’.

Thus, despite Melzack’s unparalleled achievements that have brought pain management into the modern era, more still needs to be achieved.

In light of his passing, we might honor the legacy of Dr. Ron Melzack by continuing his work and striving ourselves to complete the paradigmatic scientific revolution that he started.


1. Melzack, R. & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.

2. Canadian Medical Hall of Fame. (2019). Retrieved from:

Date of publication: December 31, 2019

Date of last modification: December 31, 2019

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) News & Recent Events Tue, 31 Dec 2019 00:41:27 +0000
Should the Definition of Opioid Addiction Change?

Twenty some odd years ago, the American Academy of Pain Medicine and the American Pain Society, two large pain-related professional organizations, teamed up to agree upon what it means to have both chronic pain and be addicted to opioid pain medications at the same time.1 They did it because addiction to opioid medications when patients are prescribed them for legitimate health reasons seems different than addiction to other substances like alcohol, cannabis, cocaine, or even illegally obtained opioid medications when not used for pain. The difference involves the phenomena of tolerance, physical dependence, and withdrawal, which in part serve as criteria for the diagnosis of addiction when it comes to all other substances.

The professional organizations recognized that patients with persistent pain who take opioids as prescribed on a consistent basis will inevitably develop tolerance and physical dependence, and will go into withdrawal if the medications are abruptly stopped.

Now, when it comes to all other substances of abuse, the occurrence of these phenomena are considered to be important aspects of what it means to be addicted to a substance. So, for example, if someone who had been consuming alcohol on a consistent basis over a period of time develops tolerance and physical dependence, and goes into withdrawal upon ceasing use of alcohol, most would consider such phenomena as indicative of alcoholism, or what’s now called an alcohol use disorder.2

However, the occurrence of these phenomena in a person who takes opioids for pain seems uniquely different when occurring in the context of a healthcare setting in which the opioids are prescribed by a provider and the medications are taken as prescribed for the pain of an identified health condition. Tolerance and physical dependence seem an inevitable result of taking the medications exactly as prescribed. As a result, tolerance, physical dependence, and the potential for withdrawal seem an artifact of the treatment, not of addiction. Because of this difference, the professional organizations cited above conventionally agreed to consider pain patients in such contexts as physically dependent, not addicted. Additionally, they re-defined the criteria for addiction to prescription opioids in this context as the occurrence of certain behavioral phenomena. Notably, they advocated that patients should be considered addicted to prescription opioids when patients exhibit behaviors indicative of having lost control over the use of the medications (e.g., no longer using them as prescribed) and/or using them despite harm to oneself (e.g., continuing to use high doses despite past accidental overdoses, or engaging in illegal activities in order to obtain opioid medications). These behaviors thus became, according to the conventional agreement by the professional organizations, the criteria for when a patient is addicted -- not tolerance, physical dependence and withdrawal.

Changes in the significance of physical dependence, tolerance and withdrawal

In the time since this distinction was made, providers and patients alike have also come to change the overall significance of tolerance, physical dependence and withdrawal, on the one hand, and addiction, on the other. Tolerance, physical dependence and the potential for withdrawal have come to be understood as largely benign artifacts of long-term opioid management. In other words, their occurrence is no longer to be considered alarming, but rather expected. Alarm came to be reserved only for when patients break opioid agreements by losing control over their use or continue to use opioids despite harm. In large measure, physical dependence and addiction thus became categorically different, the former became benign and expected, and the latter dangerous and alarming.

The history of this development in how we have come to think of addiction to opioid pain medications is documented in both the professional and popular literature. For instance, a second Photo by Mitchell Hollander Courtesy of Unsplashconsensus statement3 between the American Academy of Pain Medicine, American Pain Society and the American Society of Addiction Medicine, published in 2001, asserted outright that physical dependence and tolerance are not symptoms of addiction when it comes to opioid pain medications when used for pain. Moreover, they added that their nature should be considered as benign. Comparing opioid-related physical dependence and tolerance to the physical dependence that can occur with high blood pressure medications and antidepressant medications, this consensus statement provided reassurance that physical dependence and tolerance are the “normal responses that often occur with the persistent use of certain medications.”

The concern, of course, about physical dependence and tolerance is that they are indications that the body (particularly the brain) has changed in response to persistent exposure to certain drugs and that this change can lead to addictive behaviors when the drugs are no longer readily accessible and are thus withdrawn from use. The comparison with high blood pressure and antidepressant medications makes it seem that such a possibility is rare – for who loses control of the use of high blood pressure and antidepressant medications when abrupt cessation of use occurs? This reassurance notwithstanding, the consensus statement does in all fairness acknowledge that losing control may be more likely with opioid pain medications, but subsequently doubled down with a bold, comforting position: “A patient who is physically dependent on opioids may sometimes continue to use these [sic opioid medications] despite resolution of pain only to avoid withdrawal. Such use does not necessarily reflect addiction.” Use of opioids to avoid withdrawal, even if pain is no longer present, is thus to be considered benign, because it is associated with the benign conditions of physical dependence, tolerance, and withdrawal.

The 2001 consensus statement by the American Academy of Pain Medicine, American Pain Society and the American Society of Addiction Medicine is not the only or last such reassurance that physical dependence, tolerance and withdrawal are largely benign and not to be associated with addiction. In 2006, leading figures in the fields of pain and addiction, including one who is now the head of the National Institute on Drug Abuse, similarly argued that tolerance, physical dependence and withdrawal upon cessation of use are categorically different from losing control over the use of opioids, or addiction. In their editorial published in American Journal of Psychiatry, they asserted that physical dependence and withdrawal are “expected pharmacological response[s]” and that they are “quite distinct from compulsive drug-seeking behavior.”4 They go on to argue that clinicians should refrain from becoming alarmed by the occurrence of tolerance, physical dependence and withdrawal and caution against stopping the use of opioids when they occur. In other words, they advocate that tolerance, physical dependence and withdrawal are expected and benign.

This sentiment has been adopted wholesale and it is now almost unquestioned by the professional healthcare community and the lay public. A quick internet search yields countless professional and patient-related hits providing reassuring explanations that tolerance, physical dependence and withdrawal are:

  • different from addiction
  • expected and benign artifacts of opioid treatment
  • shouldn’t result in the cessation of opioid prescriptions or use.

The chair of the Council on Addiction for the American Psychiatric Association, Andrew Saxon, MD, cites these views even as late as last year in an interview on a popular patient-focused health internet site. He’s quoted as cautioning against confusing “physical dependence, which any patient would have if taking opioids repeatedly for chronic pain, with the full syndrome of addiction.”5

Do the facts match this conventional distinction?

In the time since these developments in our conceptual distinctions of physical dependence and addiction have occurred, we have also come to witness the development of epidemics of opioid-related addiction and accidental overdose.6 Initially, the problem of overdoses was predominantly related to prescription opioids, but in recent years deaths due to taking illegal forms of opioids, like heroin and illegally manufactured fentanyl, have come to modestly surpass deaths related to prescription opioids. Deaths due to both kinds of opioids now occur about 130 times each day.

Addiction to opioids is apt to account for the majority of these deaths. Estimates vary, but at any given time over the last few decades upwards of 20-30% of people taking prescription opioids exhibit behaviors of losing control and about 10% do so to the extent that they could be diagnosed with addiction.7 It’s also well-established that the vast majority of those who use illegal forms of opioids started their habit by taking prescription opioids.8

It’s important to recognize in this regard that some portion of those currently addicted, likely the majority, had started by taking prescription opioids for pain and for some period of time were taking them as prescribed on a repetitive basis, thus having become physically dependent prior to becoming addicted, assuming the conventionally determined definition of addiction described above.9, 10

Let’s therefore be specific. We know that most people who become addicted to opioids started the use of opioids by taking prescription opioids. In other words, few people who are now addicted came to their addiction by starting with heroin or illegal forms of fentanyl (though this minority percentage has been growing in recent years). Thus, the taking of opioids prescribed by a healthcare provider, presumably for an identified health condition, is the typical route taken by those who subsequently become addicted. It’s reasonable to acknowledge that for some period of time during the course of this trajectory a large percentage, if not the majority, of these patients were taking opioids as prescribed and becoming tolerant and physically dependent. While certainly an expected state of affairs for those who are taking opioids on a consistent basis over time, is it really accurate to say that physical dependence, tolerance, and the potential for withdrawal are benign?

At the very least, we should acknowledge that the development of tolerance and physical dependence in someone who is repetitively exposed to opioids by taking them as prescribed on a regular basis raises the risk for developing addiction. It would be hard to argue against the notion that duration of repetitive exposure to opioids, like any other addictive substance, is an independent risk factor for losing control over the use of opioids. Indeed, we’ve known that it is for some time.11, 12, 13

Problematic nature of physical dependence and tolerance

Physical dependence and tolerance to opioids have a neural substrate. In other words, they are indicators of changes to the brain that have occurred due to consistent exposure of the brain to opioids, such as what occurs when patients with identified health conditions take prescription opioids as directed on a consistent basis over time. Abrupt cessation of opioid use initiates withdrawal due to these changes to the brain.

Withdrawal from opioids is a highly distressing experience to which patients become correspondingly averse. The experience of withdrawal involves, among other things, compulsive urges to return to the use of opioids. Resumption of opioids readily comes to be experienced, at least in part, as relieving and welcoming, despite any degree of ambivalence that patients might have for remaining physically dependent on them. These experiences are directly related to the degree of physical dependence that consistent use of prescription opioids causes.

Clinicians in pain management commonly see patients who are so averse to the experience of opioid withdrawal that they resist or otherwise forego any discussions of changes to their treatment plan, even when it might be in their interest to do so. This aversion and resistance to withdrawal can occur without patients ever engaging in aberrant drug use behaviors that are indicative of loss of control or continued use despite harm. Rather, patients commonly express such aversion and resistance even when they take opioids exactly as prescribed. As such, they would be considered physically dependent, not addicted, and thus historically over the last few decades their physical dependence would be considered unproblematic. But, is it really?

Long-term duration of consistent opioid use, such as what we have seen in the common practice of long-term opioid management, leads to physical dependence that fosters an experience of opioid withdrawal, or even the potential for opioid withdrawal, as so aversive that it can come to independently maintain opioid use. This state of affairs behaviorally leads patients to become increasingly intolerant of opioid reduction discussions or treatment plans. In other words, it seems duration of physical dependence on opioids is directly correlated with difficulty in perceiving the possibility of a life of managing pain well without opioids.

Consider the problematic nature of this physical dependence. There are no aberrant behaviors indicative of impaired control, and yet this non-behaviorally aberrant dependence is not benign.

There are any number of patients who might fit this category of non-behaviorally aberrant dependency:

  • Patients who adamantly maintain that opioids are helpful even though their pain remains at moderate to severe levels or remains disabling (“If my pain is as bad as it is now, just think what it would be like without opioids?”).
  • Patients who remain fearfully avoidant of opioid reduction despite their own ambivalence or misgivings about being physically dependent on them.
  • Patients who are referred to pain rehabilitation programs, which have long been known to have superior outcomes to opioid management, but forego recommendations to participate because one of the goals is to learn to self-manage pain and taper from opioid use.
  • Patients with comorbid health conditions that are known to be problematic with the use of opioids, such as sleep apnea, who remain intolerant of opioid reduction or tapering discussions and thus remain on opioids.
  • Patients with concomitant use of certain medications that are contraindicated with opioids, such as benzodiazepines, but who remain intolerant of opioid reduction or tapering discussions and thus remain on opioids.
  • Patients who are so tolerant that they require doses that have come to be identified as having high risk for accidental overdose, but remain on opioids because the potential for reducing opioids is so averse.

All these patients may be taking opioids exactly as prescribed, adhering to their opioid agreements with their prescribing provider, and so would not be considered addicted, but rather physically dependent, and yet this type of dependency is problematic to varying degrees. In other words, their evident physical dependence, tolerance, and potential for withdrawal are not benign.

Moreover, clinically, what makes physical dependence with its potential for withdrawal especially problematic is that patients who develop these conditions increasingly lose their capacity for choice in whether to take opioids or not. Has any provider ever seen a long-term opioid management patient who is physically dependent and tolerant to opioids exhibit a causal, take-it-or-leave attitude to the use of opioids? Rather, what clinicians experience are patients who are significantly emotionally invested in maintaining their use, fearfully avoidant of reducing opioids to the point of being averse to the idea, and insistent that a life without opioids would be nothing but a life of intolerable pain and suffering, despite evidence to the contrary. Discussions with such patients about the need to taper or reduce opioids are also commonly wrought with shame, tears, anger, accusations, or defensiveness.

Patients in this state of affairs might be considered psychologically dependent. The choice of whether to remain on opioids is no longer the result of an entirely rationally derived cost-benefit ratio. Because the potential for opioid withdrawal that comes along with being physically dependent is so aversive, the possibility of coming to manage pain well without the use of opioids, which is typically seen as a good thing, is perceived by the patient as threatening. As so often occurs in the consulting room with such patients, it is cause for either fearful or angry avoidance. As such, patients no longer possess full capacity for reasoned consideration of their choices, but are rather automatically reacting to threat. In other words, physical dependence leads to diminished capacity for self-observant, reflective, rational choice.

From this light, even in such cases where there are no aberrant behaviors indicative of addiction, how did the field of pain management ever come to hold that physical dependence, tolerance, and the potential for withdrawal are unproblematic? No doubt, non-normal neural substrate changes underlie this physical dependency and so we could point to their non-normal nature as evidence that this state of affairs is problematic, but we really don’t have to do so in order to see that physical dependence, tolerance and the potential for withdrawal are not benign. As pain management providers and as loved ones of long-term opioid management patients, we can see it everyday in the people for whom we have been charged to care. Their physical dependence manifests as diminished capacity for reasoned consideration to choose whether to be on opioids or not. Indeed, in the highly physically dependent patient who is subsequently highly averse to the potential for opioid withdrawal, a loss ensues in one’s ability to even perceive that a life with chronic pain is possible in any other way but with opioids.14

Precursor to addiction or an aspect of addiction?

As physical dependence increasingly leads to the loss of the ability to perceive the possibility of managing pain well without opioids, the ability of long-term opioid management patients to make entirely rational decisions about whether to remain on or reduce opioids becomes diminished. This statement is not a moral judgment, but an observation about what it is like to be physically dependent on a substance, such as an opioid medication. The potential for withdrawal is perceived as so averse that fear and angry avoidance reigns over any misgivings that might otherwise lead one to consider their use in a more rational manner. Considered decision-making, whether in the office between provider and patient, or inside the head of the patient as internal conflict or ambivalence, can readily and quickly be shut down.

This diminished capacity for reasoned consideration, or what mental health providers call insight, is an essential aspect of compulsive or aberrant behaviors indicative of addiction. For without suchPhoto by Steve Johnson Courtesy of Unsplash capacity for reasoned consideration, urges to use, when withdrawal starts to occur, will become increasingly unstoppable. Insight, in other words, acts as a break on the urge to use, allowing for some degree of reasoned consideration as to whether to take the medication or not.

For this reason, distress tolerance is commonly taught and practiced in substance use disorder (i.e., chemical dependency) treatment. Increasing distress tolerance is one way to foster greater abilities to observe and consider one’s potential responses to aversive stimuli, such as withdrawal and the subsequent urges to use. It allows for greater intentionality in choosing a response to these stimuli, as opposed to immediately and automatically reacting with using behaviors in response to an urge to use without ever thinking about other potential behavioral options.

As we’ve seen, however, patients with an extended duration of long-term opioid use and increasing tolerance to opioids, become increasingly averse to withdrawal and subsequently their capacity for tolerance to aversive stimuli diminishes. As long as access to opioids remain uninterrupted, they experience no reason to test this diminished capacity to aversive stimuli because they do not go into withdrawal. This is how we might connect the dots between the decades-long practice of long-term opioid management and the opioid epidemics of addiction and accidental overdose.

Specifically, as a field, we have been managing a generation of long-term opioid patients who are so physically dependent and subsequently so averse to opioid withdrawal that the only thing that keeps them from engaging in aberrant behaviors of uncontrolled use is that they do not go into withdrawal because they maintain regular access to opioids by means of their healthcare providers. In other words, if prescriptions of opioids abruptly ceased, even if for inadvertent reasons, such as a job termination with subsequent loss of health insurance, they’d likely exhibit loss of control in reaction to the urges to use that accompanies their withdrawal. They’d likely exhibit such loss of control simply because of their diminished capacity to tolerate the aversive nature of withdrawal. They no longer have full capacity to engage in reasoned consideration of their options in response to the stimuli and so automatically react with using behaviors indicative of addiction. Their addiction thus becomes apparent, having previously been lying hidden (or misunderstood) in what had heretofore been thought of as something categorically different -- physical dependence.

Thus, the central question here is whether physical dependence and addiction are two distinct categories or aspects of each other? I argue that the field of pain management made a mistake in conventionally agreeing to consider physical dependence on prescription opioids as benign and distinct from opioid addiction. Rather, they are aspects of the same thing and they are not benign, but alarming.


The epidemics of opioid addiction and accidental overdose that has become manifest in our society reveal that the pain-related professional organizations’ re-definition of addiction and its categorical distinction between physical dependence and addiction are misguided. It led to false assurance that physical dependence, tolerance and the potential for withdrawal are largely benign and as a result the healthcare system has unwittingly led the opioid management patient down the garden path, a garden that in actuality is full of thorns. In other words, by re-defining addiction solely along behavioral lines, we have failed to recognize the not-so-benign nature of how the long-term use of opioids lays the physiological underpinnings that lead to the manifested behaviors of addiction. Physical dependence is not categorically different from addiction, but rather it is a related aspect of the same phenomenon.


1. American Academy of Pain Medicine and the American Pain Society. (1997). The use of opioids for the treatment of chronic pain: A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clinical Journal of Pain, 13, 6-8.

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

3. American Academy of Pain Medicine, American Pain Society & American Society of Addiction Medicine. (2001). Definitions related to the use of opioids for the treatment of pain: Consensus statement of the American Academy of Pain Medicine, American Pain Society & American Society of Addiction Medicine. Wisconsin Medical Journal, 100(5), 28-29.

4. O’Brien, C. P., Volkow, N., & Li, T-K. (2006). What’s in a word? Addiction versus dependence in the DSM-V. American Journal of Psychiatry, 163(5), 764-765.

5. Stephens, S. Opioids: Key differences between physical dependence and addiction. December 27, 2008; Updated August 9, 2018. Health Central. Retrieved 2-23-2019.

6. Center for Disease Control and Prevention. (December 19, 2018). Understanding the epidemic. Retrieved 2-24-2019.

7. National Institute on Drug Abuse. (January 2019). Opioid overdose crisis. Retrieved 2-24-2019.

8. Cicero, T. J., Ellis, M. S., Surratt, S. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry 71(7), 821-826. doi: 10.1001/jamapsychiatry.2014.366

9. Fibbi, M. Silva, K., Johnson, K. Langer, D., & Lankenau, S. E. (2012). Denial of prescription opioids among young adults with histories of opioid misuse. Pain Medicine, 12(18), 1040-1048. doi: 10.1111/j.1526-4637.2012.01439.x

10. Han, B., Compton, W. M., Bianco, C., Crane, E., Lee, J., & Jones, C. M. (2017). Prescription use, misuse, and use disorders in U. S. adults: 2015 National Survey on Drug Use and Health. Annals of Internal Medicine, 167(5), 293-301. doi: 10.7326/M17-0865.

11. Ahmed, S. H., Koob, G. F. (1998) Transition from moderate to excessive drug intake: Change in hedonic set point. Science, 282, 298-300.

12. Koob, G. F., Ahmed, S. H., Boutrel, B., Chen, S. A., Kenny, P. J., Markou, A., O’Dell, L. E., Paron, L. H., & Sanna, P. P. (2004). Neurobiological mechanisms in the transition from drug use to drug abuse. Neuroscience & Biobehavioral Reviews, 27(8), 739-749.

13. Volkow, N. & Li, T.–K. (2004). Drug addiction: The neurobiology of behavior gone awry. Nature Reviews: Neuroscience, 5, 963-970.

14. Another interesting problem, which we won’t discuss here, is when providers come to believe that these experiences of physically dependent patients are objectively true – in other words, the providers too come to believe that pain without opioids will inevitably lead to intolerable suffering and so come to believe that opioids are necessary for the well-being of their patients. Providers can thus come to align themselves with these experiences of patients, and subsequently become resistant to changes in the field, such as new opioid prescribing guidelines that recommend reducing and/or tapering opioids, in the belief that they are advocating for the rights of their patients.

Date of publication: 10-5-2019

Date of last modification: 10-5-2019

]]> (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Sat, 05 Oct 2019 17:59:01 +0000
Energy, Fatigue and Pain

Readers of the Institute for Chronic Pain website recognize it as a source of trusted and transparent information. The Institute for Chronic Pain aims to bring scientifically accurate information on pain and make it approachable to everyone. In so doing, the findings of scientific research is translated to provide understandable and hopefully helpful information to those with persistent pain and their families.

Photo by Joshua Rawson Harris courtesy of Unsplash1

To this end, last week, we published an article on fatigue and fatigue management, written by Jessica Del Pozo, PhD. Dr. Del Pozo translates the latest scientific research on fatigue and provides a number of concrete, simple-to-follow, strategies to access energy.

While acknowledging the role that insomnia can play in producing fatigue, the article doesn’t focus on insomnia and its management. Rather, Dr. Del Pozo reviews and explains the nature of the biological clock that’s inside all of us and which governs a variety of physiological processes, including our natural energy levels. Akin to a clock, these physiological processes form repeated patterns or rhythms of ebbs and flows across different bodily systems. They take their cue from both internal sources, such as hormonal levels, and external sources, such as natural light exposure. Energy levels, she explains, has a normal ebb and flow in a predictable rhythm.

With this knowledge in mind, Dr. Del Pozo reviews ways to accentuate these normal ebbs and flows. Knowledge, as the old adage goes, is power. She teaches us that you can predict when and how energy levels rise and fall, and what you can do to accommodate.

We hope you find Dr. Del Pozo’s article, Fatigue and Chronic Pain, informative and helpful.

Date of publication: 1-13-2019

Date of last modification: 1-13-2019

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) Self-management Sun, 13 Jan 2019 18:13:21 +0000
Adopting an Attitude that You're Healthy despite having Chronic Pain: Coping with Pain Series

Chronic pain rehabilitation programs are a traditional and effective treatment for chronic pain. Such programs are based on cognitive-behavioral principles that aim to change how you experience pain. By doing so, chronic pain rehabilitation programs help you to a) reduce pain and b) return to meaningful life activities even though some level of pain may persist. In other words, by participating in chronic pain rehabilitation, you change your relationship to chronic pain. You no longer perceive pain as an alarming and disabling condition, but develop the know-how to understand your pain as a benign condition that no longer needs to disrupt or prevent your daily life activities.

Wouldn’t it be good to become so competent at dealing with persistent pain that you no longer are disabled by it?

Pain would continue to occur, of course, but it would now be occurring in the background of your day-to-day life. The reasonable activities of life, like work and family activities, would become what occupies your time and attention, not pain. Again, wouldn’t it be good to learn how to do it?

Everyday, people with moderate to severe chronic pain learn to do it in chronic pain rehabilitation programs across the world.

There are countless strategies for coping better with pain, which can be learned in chronic pain rehabilitation programs. One strategy, which has been taught ever since there have been such programs, is to adopt an attitude that you remain a healthy person even though you have chronic pain. By assuming this attitude, you come to change your understanding of how you should relate to chronic, or persistent, pain.

Do you remain a healthy person when having persistent pain?

Like many questions in life, the answer to the above question depends on whom you ask. There may or may not be a universally correct answer for all people across all conditions and all situations. Pragmatically, however, the answer is important because it can determine how well you cope with persistent pain.

Many people with persistent pain consider themselves injured or ill. It’s common, for instance, for those with chronic low back or neck pain to think of themselves as injured. Another possibility is that individuals with such pain might have been told they have degenerative disc disease and as such they consider themselves to have a disease of the spine. Still others might consider migraine headache (aka, “sick headache”) or fibromyalgia as an illness. In all these scenarios of thinking of pain as the result of injury or illness, the implication is that you are unhealthy.

Indeed, this way of understanding pain goes hand in hand with seeking healthcare for it. It’s what sick or injured people do. You go to the doctor in order to get better. In this light, pain medications are often thought of as “medicine”.

It can also lead those who conceptualize chronic pain in this manner to engage in other behaviors associated with injury or illness, such as stopping life activities, staying home from work, and resting. It’s what injured or sick people do to get healthier, right?

Together, these beliefs and behaviors make up what’s called the sick role. They are the normal ways of understanding yourself as injured or ill and therefore what you do when you think of yourself in this manner.

Is there really any other way of thinking about it?Healthy Person Exercising

For many, this way of relating to chronic pain doesn’t involve a choice. It’s just how they experience pain. The presence of pain is simply and necessarily a sign of injury or illness for which there is nothing you can do but stay home and remain inactive. It’s never questioned and when it is, such questioning is perceived as invalidating or stigmatizing the reality of the pain as it is experienced.

This way of experiencing pain is apparent when people express such beliefs as “I can’t work” or “I can’t go to my kids ball game this afternoon” or “I have to take pain medicines.” For them, the presence of pain requires certain behaviors like staying home and resting or taking pain medicines. Open discussion of other possible ways of reacting to pain is perceived with skepticism at best and as invalidating or stigmatizing at worst. “You just don’t understand,” they might say. There really is nothing else they might do in the presence of pain, for its very experience requires that one must stay home, rest or take pain medicines. It’s just how it is.

What we are trying to articulate is the underlying conceptual framework or categories through which people experience pain.

Or, more specifically, we’re trying to articulate the conceptual lens through which some people experience pain (see also, Jensen, et al, 1999).

Do all people experience persistent pain in this manner?

While the above noted ways of experiencing pain are common, they are not universal to all people with chronic pain. We know, for instance, from empirical research but also from everyday experience, that some people with moderate to severe pain don’t take opioid pain medicines or don’t perceive themselves as disabled and so remain at work (see, for example, this article here).

For them, the presence of pain doesn’t rise to any level of urgency that requires action. It’s experienced as inconvenient or bothersome, but largely normal. “It’s just what happens when you get old” or “My migraines are a barometer that tells me I’m not taking care of myself very well” or “I heard that back pain is just something we have because early humans stood up on two feet” or “Doesn’t everybody have back pain?” Notice the lack of alarm or urgency with which these people experience pain. They have pain, but there’s no need to do anything about it. They accept it as normal. They don’t enjoy it, of course, but neither are they distressed by it. Pain is something we have and it's accepted as a bothersome fact of life that we put up with.

One way in which people experience pain in this manner is that they don’t understand pain as a health problem. In other words, pain lies outside of the conceptual categories of health or disease or injury. For them, knees and hips and backs and stomachs and necks and heads hurt because that’s how we’re made. It just comes with the territory of playing sports or getting older or getting stressed. It’s the given. It’s not abnormal. It’s normal.

This conceptual lens through which they perceive pain has for them no bearing on whether they are healthy or not. They might, for instance, consider themselves healthy even though they have to mind their persistent knee pain because of the sports they play. Indeed, the presence of chronic pain can sometimes serve as the cause of maintaining a healthy lifestyle. “I have a desk job and so when I sit all the time my back tends to hurt a lot and so it makes me insistent that I block my lunch hour so that I can walk everyday.” “I’m prone to migraines, almost everyone in my family gets them, and so I really have to stay on top of my stress and get regular exercise.”

Notice in these scenarios that pain isn’t understood as in itself an injury or illness. Rather, it’s due to playing sports or sitting too much or getting older or having too much stress. These ways of understanding pain don’t lead to illness behaviors such as staying home or resting or taking pain medicines. Indeed, it just might never occur to them that they should respond to their pain by staying home or taking pain medicine.

To learn to cope better, you have to be open to learning how

What we are trying to do in this discussion of contrasting experiences of pain is to articulate the underlying conceptual frameworks with which people understand pain. Pain is a complex subjective experience and we are attempting to make apparent the possible differences in the subjectivity of these experiences. Pain may be a universally human sensation, but it is subjectively experienced differently by different people in part because different people perceive pain through different conceptual frameworks.

For some, the sensation falls into the categories of injury or illness and poor health. From this way of understanding and perceiving pain, pain is an abnormal sensation that requires actions that sick or injured people do: seeking the advice of healthcare providers, getting tests and medical procedures, staying home from work, resting and taking medicines.

For still others, the sensation of pain falls into different conceptual categories, such as a sign of a hard fought sports game or getting really good work outs or getting older or sitting too much or having too much stress. From these ways of experiencing the sensation, there’s no sense of urgency to do something about it. It’s because they are understood as normal experiences.

The observation of these differences involves no intention to stigmatize. There are times, of course, when pain is due to injury or illness. Acute pain, for instance, is commonly the result of an acute injury or illness. So, it is not inherently wrong to conceptualize pain within the frameworks of injury or illness.

Not all pain, however, falls into these categories and it is sometimes in the best interest of those with chronic, or persistent, pain to begin to understand their pain differently.

It’s possible to learn how to experience pain differently. You have to be open to learning and it helps if you can learn from teachers or coaches within a non-judgmental or stigma-free environment. People with moderate to severe chronic pain learn everyday in chronic pain rehabilitation programs across the world.

Adopting an attitude that you remain healthy despite persistent pain

More often than not, if you see healthcare providers for chronic pain, they will encourage you to remain active, use the painful body part, exercise, manage your stress, stay at work, and try not to take opioid pain medications. Sound familiar? Despite these common recommendations, there’s often little instruction as to how to do these things when actually having pain. In fact, it almost seems impossible because the presence of pain seems to demand that you rest, guard or stay off the painful body part, stay home and take pain medicines. So impossible, it seems, that maybe they don’t really get how much pain you have or otherwise they wouldn’t recommend doing things that you know you can’t do.

With the discussion above, however, we can now begin to articulate how you might actually go about engaging in these recommendations, despite how impossible it might seem at first. It starts with adopting an attitude that you are healthy even though you have chronic pain.

Begin by reflecting on this essay. Consider the possibility that understanding your chronic pain as a long-lasting injury or illness leads naturally to behaviors that healthcare providers recommend against doing: staying home from work, resting, guarding the painful body part, taking pain medicines. This combination of beliefs, perceptions and behaviors lead to what we call identifying with the sick role. It puts you in a dependent role to your healthcare providers, on whom you rely to make you better. It also often puts you in a dependent role to family members, on whom you rely to take up the slack of what you can’t do. However, healthcare providers don’t have many effective ways to make you better, short of helping you to engage in the above recommendations. Reliance on family can foster guilt in you or increased stress and conflict with them. So, in all, experiencing pain through the lens of the sick role doesn’t typically amount to much improvement and sometimes it can even make your overall situation in life worse.

Maybe, then, it’s time to re-think how you think about pain.

Once you decide that it is in your interest to be open to learning new ways to respond to pain, then practice thinking of yourself as a healthy person with persistent pain. Recognize that healthy people have pain, even persistent, or chronic, pain. Low back pain, for instance, is by far the most common form of chronic pain and to manage it well you have to engage in behaviors that healthy people do – stay active, remain at work, use your back, get regular exercise, manage your stress, and maintain a healthy weight.

To adopt the attitude that you remain healthy despite having persistent pain, it helps to recognize that persistent pain is common. A third or more of the population has persistent pain. As we age, pain becomes increasingly more common (Fayaz, et al., 2016). It isn’t, therefore, abnormal to have chronic pain.

From this understanding, the occurrence of persistent back, neck, joint or head pain doesn’t have to be cause for alarm. It’s not signaling a state of urgency. Pain can be accepted as a fact of life. Many of us, as we get older, have a harder time keeping weight off. This biological condition isn’t a pathological condition of illness, but rather just something that is accepted. Most forms of chronic pain can be considered in a similar light – not something that is a pathological condition of illness or injury, but just something that tends to happen. It may occur because of sedentary lifestyles or sports activities or age or stress or maybe we don't even question why because it happens to so many of us. From this way of understanding it, pain isn’t abnormal and it's not alarming, but just bothersome.

This way of experiencing pain seems considerably more preferable than experiencing it as an abnormal and alarming event for which valued life activities must be given up. Rather, pain is something for which you stay active. Motion is lotion, as the old saying goes. Experiencing it this way, pain persists, but occurs in the background of daily life in which you stay active, remain at work, get regular exercise, manage your stress, maintain a healthy weight, and otherwise engage in the healthy behaviors of the healthy person you are.

Now that’s what really good pain management looks like.


Fayaz, A, Croft, P., Langford, R M., & Jones, G. T. (2016). Prevalence of chronic pain in the UK: A systematic review and meta-analysis of general population studies. BMJ Open, 6, e010364. doi: 10.1136/bmjopen-2015-010364

Jensen, M. A., Romano, J. M., Turner, J. A., Good, A., Wald, L. H. (1999). Patient beliefs predict patient functioning: Further support for a cognitive-behavioral model of chronic pain. Pain, 81(1-2), 95-104. doi: 10.1016/S0304-3959(99)00005-6

Date of publication: October 7, 2018

Date of last modification: October 7, 2018

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

]]> (Murray J. McAllister, PsyD) Coping Sun, 07 Oct 2018 20:12:55 +0000
Changing Pain: A New ICP Heading for Published Articles

With the posting of our new webpage, Opioid Dependency and the Intolerability of Pain, the Institute for Chronic Pain marks the addition of a new category of publications under our Changing Pain banner.

On the Changing Pain heading, we’ll publish articles that thoughtfully take a stance that is different than the generally accepted views on the particular topic of the article. These articles may offer a Yousef al Nasser courtesy of Unsplashnew perspective or challenge conventional wisdom.

As such, you may not always agree with the articles published under the heading of Changing Pain. Indeed, even those of us who publish at the Institute for Chronic Pain might not all agree on a particular author’s viewpoint.

But that’s really the point of the Changing Pain banner. The articles published here will be well-argued stances on topics that are not fully settled among stakeholders in the field of pain management. These articles, in other words, will take stances that reasonable people might disagree.

Our hope is to create a space in which stakeholders can come together to initiate dialogue. In this dialogue, we recognize that not everyone will agree, but we aspire to thoughtfully consider the points of view of others. Often, in pain management, like politics these days, stakeholders have very strongly held views in which dialogue ensues, not as reasoned discourse, but personal attacks against the character of those who hold the contrary view. Issues related to opioids, disability, the role of coping, stigma, and even the nature of pain itself can often be such points of contention among different stakeholders.

Changing Pain attempts to be a place to publish articles from different points of view in the hope that all of us thoughtfully reflect on views that may or may not adhere to our own. Our hope is that these articles serve to bring us together in our differences, rather than being an arena for attacking each other.

To this end, as stated, we publish the first of these articles, entitled Opioid Dependency and the Intolerability of Pain. This article explores the different, and often contradictory viewpoints, of whether and how severe pain is intolerable and thus requires opioid therapy. In it, we see the reasoning that leads to two contradictory treatment recommendations: how some in the field conceptualize the intolerability of pain in such a way that the long-term use of opioids is the only ethical and humane practice; while still others conceptualize the intolerability of pain in patients using long-term opioids as the result of the therapy itself and so opioid tapering is the only ethical and humane practice.

Anyone remotely familiar with issues of pain management will readily recognize that we live and work in a highly unusual time: stakeholders in the field can hold diametrically opposing views, both espousing to be the most ethical and humane practice – some espousing long-term opioid management for patients with severe persistent pain while others espousing that we taper those very same people from opioid management.

It’s a unique time in the history of our field and society.

So, upon reading Opioid Dependency and the Intolerability of Pain, we hope you reflect and respectfully discuss these views and arguments with all the stakeholder with whom you live and work – even those with whom you might diagree.

Date of publication: April 22, 2018

Date of last modification: April 22, 2018

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) Values Sat, 21 Apr 2018 15:53:11 +0000
Opioid Dependency and the Intolerability of Pain

The most vexing of all questions in the debate over long-term opioid management for pain is subtle, difficult to articulate, and rarely considered. It lies at the heart of whether and how we maintain patients with severe pain on long-term opioids or whether we help them learn to self-manage it instead.

This most vexing of questions involves how we understand the nature of pain severity and its relationship to its degree of tolerability in the long-term opioid management patient. For depending on how we understand the intolerability of severe pain, it leads to contradictory treatment considerations among well-meaning, competent patients and providers, and even within the larger society.

Succinctly put, it occurs in the following all-too-common scenario:

  • A patient on long-term opioids reports that his or her severe pain would be intolerable without the use of opioids and becomes threatened by open discussion of reducing or tapering opioids, even when the discussion proceeds in a professional manner with caring and empathy.

This all-too-common scenario leads to two contradictory treatment considerations among patients, providers and the greater society, depending on how thePhoto by Cherry Laithang courtesy of Unsplash phenomenon of intolerability of pain on long-term opioids is understood.

Some will look upon the intolerability of pain as solely a function of pain severity. In this manner of understanding, pain occurs wholly independently of the use of opioids. It’s a common sense understanding: pain is intolerable because it’s severe, and only because the pain is severe; the use of opioids is what keeps the intolerably severe pain at bay. With this understanding of the patient’s pain relative to the use of opioids, many consider the only right thing to do in terms of ethical and humane practice is to continue opioids and even increase them should the severity of pain break through the alleviating properties of the present opioid regimen.

Still others understand the intolerability of pain in the patient’s case as evidence of harm by the opioid therapy itself and thus consider cessation of opioid use as the only right thing to do. By this way of understanding, the severity of pain plays only a partial role in its intolerability. The intolerability of pain is also due to the additional long-term exposure to opioids1, 2, 3 and the likely effects of this exposure on the central nervous system,4 which changes the perceived tolerability of pain. In other words, both the patient’s belief in the intolerability of pain without opioids and the related fear-based response to the possibility of opioid reduction are functions of opioid dependency. Succinctly put, these cognitive and emotional perceptions of pain are not commensurate with solely the pain itself, free of its potential influence by opioid-induced changes to the central nervous system.

Rather, they are a function of how opioid dependency lowers pain thresholds, leaving patients increasingly vulnerable and thus fearful of pain. In this view, opioid dependency is a secondary contributor to the overall experience of pain as intolerable.

As a result, opioid tapering, when done with caring and empathy, and in an interdisciplinary fashion, is an exposure-based therapy that leads patients to overcome their perceived intolerability of severe pain and the resultant fear-based vulnerability to pain. In their stead, patients with severe pain become an empowered self-manager of their pain. In comparison to maintaining patients in a persistently dependent, fear-based state on long-term opioids, the benefits of opioid tapering make tapering the only right thing to do, in terms of ethical and humane practice, when the intolerability of severe pain is conceptualized in this manner.

Herein lies the current state of practice within the field of chronic pain management: two contradictory treatment considerations both espousing to be the most ethical, humane practice – one maintaining patients with persistent, severe pain on long-term opioids and the other tapering the very same patients.

Epistemology as ethics

The conviction that severe pain is necessarily intolerable has held a firm position over the last two decades within the movement to treat chronic pain with long-term use of opioids (and now the proponents of medical cannabis make this very same assumption as well). Indeed, it’s seems an easy viewpoint to assume: the belief that severe, persistent pain is intolerable without the use of opioids seems epistemologically self-evident. Severe pain, it seems, is synonymous with agony or suffering. Once this synonymity is assumed, it becomes an imperative to get rid of the pain by any means necessary. The only apparent alternative is to allow people with severe pain to suffer in agony, which, of course, is unacceptable. As such, treatment with opioids becomes a moral imperative.

No doubt such reasoning forms the basis for the high level of sensitivity that comes with the use of opioids, either as a patient or as a provider who espouses the use of opioids. From this perspective, it can be hard to even understand how anyone might hold a contrary perspective and advocate for the withholding of opioids. Any such advocacy brings with it an immediate rejoinder, bordering on doubt of the advocate’s sense of humanity: “What, you want people with severe pain to suffer?”

Of course, in this view, the only other possible explanation for advocating a taper or withholding of opioids is disbelief that the pain is as severe as the person says it is. Indeed, commonly, those of us who recommend self-management over opioid management for those with severe, persistent pain are accused of disbelieving patients or, worse yet, stigmatizing them as weak in their inability to tolerate pain. A common rejoinder in these cases center on something akin to “You wouldn’t be able to cope with this pain either!” Notice the operating assumptions here: it’s self-evidently true that severe pain is necessarily intolerable and to suggest otherwise is simply to engage in some type of offensively critical value judgment.

Despite its appearance as morally suspect, is it invalid to assert that it’s possible to have severe pain and tolerate it – and tolerate it so well that one can work and engage in other valued life activities, all without opioids?

Pain severity and pain tolerability: Distinct phenomena?

These arguments against the recommendation to taper or otherwise withhold opioids border on ad hominem attacks. Of course, those who advocate for tapering opioids are, or at least should be presumed to be, well-meaning. Most providers who engage in tapering opioids in the process of helping people learn to self-manage pain instead aren’t in it to make people suffer or stigmatize them.

Nonetheless, are they misguided in their belief that severe pain doesn’t have to be intolerable?

The historical clinical evidence would suggest that they are not. Tapering opioids for those with persistent, severe pain has had a longstanding history within pain management. Certainly overshadowed over the years by the rise of opioid management for persistent pain, interdisciplinary chronic pain rehabilitation programs (CPRP’s) have been tapering people with severe pain from opioids for about four decades.5, 6 CPRP’s are an interdisciplinary, cognitive-behavioral and exercise-based therapy that exposes patients with persistent pain to what they have long avoided through the use of opioids (or other means, such as reduced activity). In the process, the CPRP’s show patients how to self-manage pain and increase activities in a work-like schedule of therapies. As a result, patients taper opioids and learn how to maintain a weekly schedule of activities. In learning, they moreover regain confidence that they can successfully self-manage pain and return to work at the same time. Instead of opioid management, CPRP’s, as stated previously, have been teaching patients to successfully self-manage severe pain and return to valued life activities for the last four decades. Various meta-analyses over these four decades testify to the empirical effectiveness of such programs.7, 8, 9, 10 These studies repetitively show that participation in a CPRP allows for the cessation of opioid use, while mildly reducing pain, and significantly increasing functioning.

While facing declines in numbers over the years that correspond to the rise of opioid management,11 many healthcare systems across the Western world continue to have interdisciplinary chronic pain rehabilitation programs. Some systems, such as the Veterans Affairs and the Mayo Health systems, are even expanding the number of such programs. The state of Minnesota recently moved to increase access to such programs through their Medical Assistance program.12

Patients in such programs, after having managed their pain for years on opioids, come to find that they really can learn to self-manage pain – they become empowered self-managers of their severe pain. Initially, it’s a threatening experience to let go of the opioid medications and expose themselves to pain, for the doubt lingers that they’ll experience nothing but intolerable suffering. With caring, empathy and expertise, the staff of CPRP’s coaches them to increasingly face their pain in a gradual opioid taper and learn to self-manage it instead. In so doing, patients learn how to successfully self-manage severe pain. However, just as importantly, they learn to overcome the fear of giving up their dependency on opioids in an empowering experience of taking back control of their lives. In other words, they learn that successfully self-managing severe pain is possible. Anecdotally, one of the most common comments upon discharge is “Why didn’t anyone ever refer me to this program earlier?”

In both the empirical evidence (as evident by multiple meta-analyses cited above) and the anecdotal evidence of the last four decades, CPRP’s produce successful, independent self-managers of severe and persistent pain.

It must, therefore, be possible to self-manage severe, persistent pain and do so successfully. As such, perhaps it’s not so misguided to conclude that severe pain isn’t by necessity intolerable. Suffering and agony are not the inevitable result of managing pain without opioids.

If learning to self-manage severe pain through a concerted effort of interdisciplinary training is possible, isn’t it preferable to maintaining people with severe pain in a vulnerable and fearfully dependent state on opioids? Indeed, doesn’t it become a moral imperative to alleviate such dependent vulnerability and arm patients with the health literate skill sets that allow for successful self-management of severe pain?

Population based studies of self- and opioid management of pain

Studies on the effectiveness of CPRP’s, such as those cited above, have been published for years and yet the belief that severe pain is necessarily intolerable without opioids remains widespread among patients on opioids and providers within the healthcare system. Obviously, publication of empirical evidence to the contrary is insufficient to dispel the belief that without opioids severe pain inevitably leads to suffering and agony.

Epidemiological studies of pain severity and opioid use, over the decades of the rise of opioid management, are pertinent here. What they show is that only a minority of people with chronic pain utilize long-term opioid management. In a US-based study conducted in 2000-2001, early in the era of widespread use of opioids, Hudson, et al.,13 found that, among people who had moderate to severe chronic pain, roughly 6% were engaging in the use of opioids for their pain. In a later study conducted in 2007, Toblin, et al.,14 found a modestly larger minority of people managing their pain with opioids, even though more than half of all people with pain rated their pain as moderate to severe. In a more recent study performed in 2012, Nahin15 found that about 17% of the US population reported having severe pain on some to most every day. However, estimates of the use of opioids for pain lie in the 3-4% range.16, 17 These data show that throughout the era of opioid management, even at its height, only a minority of people with severe pain manages their pain with opioids.

Data from diverse researchers have clearly shown that this minority of people with severe pain who manage it with opioids have psychosocial vulnerabilities that differentiate them from those in the majority of people with severe pain who do not manage their pain with opioids.18, 19 In a phenomenon dubbed “adverse selection”, an identified risk factor for becoming a long-term users of opioids for pain is having psychosocial vulnerabilities to dependency, with or without aberrant prescription drug use behaviors indicative of loss of control. These psychosocial vulnerabilities are pre-existing or comorbid mental health and substance use disorders,20, 21, 22, 23, 24, 25  lifestyle related medical conditions,20, 23  lower economic status,26 lower educational levels,21 and rural areas lacking access to non-opioid related therapies for pain.26

Acknowledgement of these data doesn’t entail stigmatizing judgments

The striking lesson from these data is clear: managing severe pain with opioids is not the norm. Most people in the general population with severe, persistent pain have the health literacy and psychosocial capacities to cope with pain and do so without opioids. A minority of the people with severe, persistent pain unfortunately do not have such capacities and as a result they become vulnerable to pain once onset occurs and thus susceptible to depending on opioids to manage their pain for them.

Just as we do not, or should not, stigmatize anyone with mental health and substance use disorders, we do not, or should not, stigmatize the identification of psychosocial comorbidities with persistent pain. The appropriate response for healthcare providers and society alike is not critical judgment, but caring and empathy.

From this light, we can better understand the belief that seems inevitably associated with opioid dependency: the conviction that pain is intolerable without opioids. For those who do not have the psychosocial wherewithal to self-manage severe pain, opioids must seem a Godsend. This opioid dependency becomes self-referential. Dependency on opioids fosters conviction to the false belief that it is impossible to manage pain well without opioids, thus furthering the need to depend on opioids to manage pain.

In this manner, opioid dependency is not dissimilar to dependency on other substances. Substances, like alcohol, can become the means to cope with adverse life events for those who, due to unfortunate life circumstances, do not have the psychosocial capacities to cope successfully on their own. Once having developed an alcohol use disorder, the thought of accepting ‘life on life’s terms’ without alcohol is a highly threatening experience, which simply further reinforces the need to rely on alcohol to cope with the disturbances of life.

Unlike with opioids, however, healthcare providers and the rest of society do not become susceptible to the alcoholic’s conviction that life and all its problems are intolerable without alcohol. As such, we do not feel compelled to make alcohol available to those with an alcohol use disorder.

Why might we do so with opioids?

Providers in the healthcare system can fall prey to the false belief that severe pain is intolerable without opioids. Since the majority of people with severe pain are independent self-managers of their pain, they do not present for pain management and so healthcare providers do not tend to see them in clinic or hospital. Rather, healthcare providers tend to see only those people with persistent pain who are psychosocially vulnerable to pain and who, in their opioid dependency, assert that suffering and agony is the inevitable result of severe pain. Thus, it is understandable that healthcare providers might come to mutually believe that severe pain is necessarily intolerable and so therefore assert that severe pain requires the use of opioids.

A new moral imperative?

It’s time to recognize that pain severity and one’s personal assessment of pain as intolerable or not are distinct phenomena. Just as pain severity varies across individuals along a spectrum from mild to severe, individual differences in the ability to tolerate pain occur along a related yet different spectrum, ranging from low to high pain tolerance.

The acknowledgement of these individual differences in pain tolerance is simply an observation, not a stigmatizing judgment. Of course, some people do judge, but the fact that they do only means that their judgment occurs in addition to the observation that people vary in their abilities to tolerate pain, even severe pain. Some people struggle to cope well with severe pain while others tolerate severe pain and remain engaged in valued life activities. The appropriate response to these observations is not stigma, but empathy and compassion.

Recognition of individual differences in the abilities to tolerate pain, even severe pain, underpins the clinical- and research-based observations that many people rate their pain as severe, yet do not manage their pain with opioids. They live and work and engage in other valued life activities even though they have severe pain and do not use opioids.

This recognition directly challenges the long-held belief that managing severe pain well is impossible without opioids. This belief has been a mainstay for those who espouse opioid management and it underlies the unrelenting fear of those who are reliant on opioids that agony and suffering will inevitably result if they do not have opioids to manage their pain. When, however, we recognize that many people with severe pain fair well without opioids, we cast the long-standing conviction that it is impossible into a new light. We come to see that as a universal statement it is false. We also come to see that the unrelenting conviction with which this false belief is held may be a function of opioid dependency.

Four decades of care from CPRP’s show that self-managing severe pain is a skill set that can be learned. Everyday, people across numerous facilities and multiple countries come to learn how to self-manage severe, persistent pain and do it successfully. Whereas they were once reliant on opioids out of a fear that suffering would inevitably result from their severe pain, they are now no longer vulnerable to their pain. They have pain, but in an important way they have moved on and are now engaged in valued life activities. In other words, they are empowered, independent self-managers of their severe pain.

From this light, a question compels us to be asked: how can we not encourage people with severe pain and reliance on opioids to follow suit? We do not help people with severe and persistent pain by maintaining them in a dependent state of vulnerability and fear that comes with long-term use of opioids for pain. When we have established, empirically-supported therapies that allow such patients to overcome their dependent state of vulnerability to pain, don’t we have a moral obligation to offer it to them and encourage them to access it?


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]]> (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Sat, 07 Apr 2018 15:23:13 +0000
Reducing Pain Talk: Coping with Pain Series

A common complaint among people with chronic pain is that their pain has come to occupy too much of everyone’s time, attention or energy. In other words, it can sometimes feel like their pain is the only thing anyone ever talks to them about – that they’ve become almost synonymous with their pain.

We call it pain talk. Pain talk is the persistent verbal focus of everyone’s attention on the pain of someone with persistent pain.

Most, but not every person* with persistent pain has experienced pain talk. They quickly and inevitably add that they appreciate, of course, the attention of their friends and loved ones, but it comes to get old.

Might the same be true of you?

Friends and family can develop over the years a tendency to make you and your chronic pain, its treatments, and your overall well-beingImage by Priscilla du Preez courtesy of Unsplash the topic of conversation. For after all, it tends to be the socially appropriate thing to do. When people are sick or injured or otherwise unwell in some way, we are all supposed to ask about it, express condolences and offer help. Indeed, most people want to express their concern in these ways.

This normal behavior is all well and good. Most of us appreciate some attention when not feeling well or injured or what not. People bring over dinners and help out around the house. Maybe they bring your kids to piano lessons or sports practices for a few weeks following a surgery. Everyone, on both the receiving and giving ends, tend to appreciate these gestures.

It’s also common that after a while these kinds of overt offers of assistance tend to fall away. Life goes on for other people and it’s hard to keep up with such overt helping behaviors. However, the well-being of the sick or injured person tends to remain in the object of everyone’s attention when others do in fact come around. In other words, despite overt helping behaviors falling by the wayside, most people continue to talk to you about your well-being. Again, it’s thing that we are supposed to do.

While initially nice and helpful, when this state of affairs continues on a chronic basis, it can become increasingly problematic. There comes a point for many people where it’s preferable that you are no longer the focus of everyone’s attention. The attention, in the form of you being the object of everyone’s conversation, can become problematic in a few different ways.

It causes inner conflict for you

Suppose that your spouse when she comes home from work tends to ask, expectantly, “How’d you do today?” which implies that she’s hoping you’ll be better. You tell the truth, which you can see in her demeanor is disappointing, and so you feel bad for disappointing her that your pain is still as bad as it ever was. Suppose your four-year-old daughter comments that she wishes you could pick her up, but knows you can’t because it hurts your back. Out of the mouth of a babe, she means no ill will. It’s just an innocent yet accurate comment and yet you end up feeling terrible. Or perhaps, you see your cousin for the first time in a number of months and the first thing she asks about is the surgery that she had heard you had. You know she just had a baby and you want to be there for her, yet she’s trying to be there for you. The brief interaction immediately puts you on edge.

What lies at the heart of these interactions is what, in psychology, we call feeling conflicted. You end up feeling guilty or awkward or ashamed or irritable that you’re yet again the topic of conversation. At the same time, however, it’s not that you can get upset with them. They are expressing a sincere regard for your well-being! It would be socially inappropriate for you to express your displeasure with their attempts to care about you. It’s a no-win situation. You feel conflicted.

This recurrent sense of feeling conflicted is stressful. It wears on you and reduces your abilities to cope with pain. Stress, of course, also makes pain worse.

As a result, pain talk that was initially helpful and nice can become increasingly problematic once it continues on a chronic basis.

People tend to give you unsolicited advice

Suppose your neighbor sees you across the yard and asks, “How’s your back?” and then goes on to ask whether you’ve ever tried chiropractic. He continues for a few minutes on how much it helped so-and-so. Or suppose your friend at church or synagogue or mosque sees you and comes over to tell you about laser surgery that he saw advertised on TV last night. Your cousin insists that you absolutely must try some salve that he absolutely swears by.

You’ve heard it all before, but what do you say? Of course, you’ve considered those therapies or maybe you’ve even tried them. Nonetheless, you nod your head and politely let them finish their thought, but the whole experience makes you irritable.

People trigger bad emotional reactions

Sometimes, people trigger an emotional reaction that you’d rather not have. In fact, as an active coper, you try to stay out of either the victim perspective or the perspective of perceived injustice. Nonetheless, other people’s attitudes can put you into a bad emotional place. Suppose your brother-in-law exclaims, “If they can put a man on the moon, why can’t they fix your back?” Or suppose a friend comments on how unfair it is that nothing legally happened to the person who caused the motor vehicle accident that started your chronic pain. Or perhaps it was your sister who, getting mad that your disability claim was denied, expresses, “It’s so unfair that you can’t get disability – you paid into it for years!”

Such comments, while understandable and perhaps wholly accurate, put you in a bad emotional place. They stoke the resentment that occurs deep inside you. They tap you into the long-held anger and powerlessness and lack of control that you can sometimes feel. You try not to go there too often, because you find yourself too depressed when you do, but it is difficult to hear such comments without going there.

It’s not anyone’s fault

Please notice that in observing these complicated interactions no one is blaming anyone or criticizing those who talk too much about your pain. It’s not anyone’s fault. Pain talk is normal and natural, while at the same time it isn’t helpful.

So, what do you do about it?

One long-standing recommendation in chronic pain rehabilitation is for patients to have a discussion with their friends and loved ones and ask them to stop talking about pain. The discussion might go something like the following:

“I’d like to talk to you about something that is important to me. It’s the fact that we talk about my pain a lot – how I’m doing, whether it’s a good pain day or a bad pain day, and how my therapies are going. I know that you ask about all these things because you care about me. I appreciate your caring – I want you to know that. However, I’m also trying to cope better with pain and to do that I need to focus on my pain less. I need to get involved in other things that also matter and preoccupy my time and energy with these things, not my persistent pain. So, one thing I’ve learned recently is that I should ask everyone in my life to stop talking or asking about my pain. This will free us up to talk about all the other things that matter in life. It will also serve to keep me focused on these things, and less on my pain. If we all agree, I’ll make you a deal in that I will update you on my pain if there is any significant change for the better or for the worse. But as long as my chronic pain remains chronic, let’s try to stay off the subject. OK?”

Reducing pain talk leads to improved coping

Pain has a natural capacity to command our attention. When it’s a bad pain day, it’s hard to focus on anything else. This relationship between pain and attention is reciprocal or self-reinforcing: the more pain we experience the more we focus on it, but the more we focus on it the more pain we experience.

It is possible to counteract this natural tendency for focusing on pain. It involves a learning process over time and it takes repetitive practice, but it is possible. It’s a process of recognizing in the moment that your attention is focused on pain and making an intentional effort to change the focus of attention to something else – something that it is stimulating or interesting or pleasurable or meaningful in some way.

This process of repetitively recognizing and changing your focus of attention is helped along when others stop talking about your pain. Your interactions with them become focused on other things in life that are stimulating, interesting, pleasurable or meaningful.

When other things in life that matter start to compete for our attention, we can come to experience less pain. Pain gets relegated, as it were, to the background of our everyday lives. It’s a little bit like white noise. When a box fan gets turned on, it seems loud and it competes for our attention. But as we get involved in other activities, the stimulation remains, but we stop paying so much attention to it. We start to hear it less. We’ve all had the same experience with pain. When we get involved in other things that compete for our attention, we come to experience the pain less.

When we talk about pain less, life is less stressful. We don’t have to put up with feeling conflicted – knowing that others care about us but wishing they’d stop talking about pain so much. We also have a greater likelihood of staying out of bad emotional places, like experiencing the resentment that’s common when you have a chronic pain condition that you didn’t deserve or ask for.

Reducing pain talk also reminds you and everyone else that you are more than just your pain. You have endeavors and aspirations, activities about which you are passionate, and relationships that are meaningful. Reducing pain talk takes these issues off the back burner and puts them front and center. They can again come to define your identity.

Of course, when you see your healthcare providers, go ahead and talk about your pain. But in the course of your everyday life, it is best to repetitively practice staying off the subject. It's what people do when they cope well with pain.

*Such concerns are not always true of all people with chronic pain. Some people report basically the opposite experience. In their case, no one in their life asks about their pain anymore. They tend to feel alone and can understandably wish for someone to ask about their well-being once in a while. This state of affairs is also problematic. It deserves a discussion of its own and so we’ll save it for another post in the Coping with Pain Series. So, for now, let’s focus this post on how to cope when your pain occupies too much of everyone time, attention and energy.

Date of publication: October 21, 2017

Date of last modification: October 21, 2017

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.


]]> (Murray J. McAllister, PsyD) Coping Sat, 21 Oct 2017 14:07:52 +0000
Reducing Pain Behaviors: Coping with Pain Series

One of the more long-standing recommendations of chronic pain rehabilitation is to reduce pain behaviors. It’s one of the ways that people with persistent pain can learn to cope better with pain. Let’s review how to do it.


Pain can be, of course, a naturally distressing and impairing experience. When in pain, we tend to be alarmed and react with grimacing, guarding, resting, or stopping any activities associated with pain. In these ways, we can see how pain involves distress and impairment.

Indeed, we might go as far as the International Association for the Study of Pain (IASP) in acknowledging that such emotional and behavioralImage by Milada Vigerova courtesy of Unsplash aspects of pain are part and parcel of the very experience of pain itself. Often quoted, the IASP defines pain as an “unpleasant sensory and emotional experience… associated with actual or potential tissue damage” (IASP, 2012). In other words, pain is a sensation, of course, but it isn’t any old sensation. It’s a distressing sensation. Tickles and itches are also sensations, but tickles make us giggle and itches are aggravating, at least until we feel the relief that comes from scratching. Sensations thus have an emotional aspect, which in part is what differentiates them from one another. Pain’s emotional aspect is distress or alarm. Pain is an inherently alarming sensation in which we automatically exhibit grimacing, groaning, bracing, or guarding behaviors that lead to stopping activities and resting. These latter emotional-behavioral expressions of pain are referred to as pain behaviors.

Unchosen nature of pain behaviors

The sensory, emotional and behavioral aspects of pain are typically not chosen. We do not have a certain sensation and, upon reflection, choose to become alarmed and express it by groaning or grimacing and protecting the painful area. No, the distress and associated behaviors occur along with a certain sensation and are part and parcel of the experience of pain. They occur reflexively or automatically, without intentionality or choice.

We might put the point in terms of an equation:

Pain = sensation + emotional alarm + reflexive behavioral avoidance

The essential variables of the equation occur in most any experience of pain. Let’s take an example. Suppose we are hiking through a forest and I accidentally step into a hole in the trail and break my ankle. Without reflection or intentional choice, I begin to have a sensation in my ankle, become alarmed, grimace, call out, and reflexively engage in protective or guarding behaviors. It all happens in an instant and automatically.

All of these variables are what we call “pain”.

Bringing pain behaviors under voluntary control

Pain behaviors are typically reflexive and not the result of intentional decision-making because we lack awareness of when we will feel pain. Pain, in other words, takes us by surprise. Without ever thinking about it, we grimace, garb at the painful part of the body, and exclaim “ouch!” or some other expletive.

In the broken ankle example above, I have no reason to anticipate the pain of the broken ankle. Rather, I simply and unwittingly step in the hole and the injury occurs. With the pain of the broken ankle, I grimace, brace, favor my ankle, and exclaim a painful utterance.

In cases of chronic pain, an important difference typically occurs. It’s the fact that chronic pain is persistent or repetitively present under certain circumstances. This persistent or repetitive nature lends itself to being aware enough to anticipate pain.

Suppose I have chronic low back pain. It’s a persistent dull ache that is always present. Whenever I get up from a chair or sit down on a chair, though, I additionally experience a sharp stabbing pain. It occurs most every time I sit down or get up and it has done so for years. Suppose further that because of the pain I also tend to grimace and hold my back stiffly, and whenever I sit down I tend to brace myself and let out an audible sigh.

The persistent and repetitive nature of chronic pain offers an opportunity that doesn’t occur in cases of acute pain, such as when I unwittingly step into a hole and break my ankle. The opportunity is that the persistent and repetitive nature of chronic pain allows for bringing a degree of awareness to the pain and even to anticipate it. With this degree of awareness, it becomes possible to develop greater intentionality with regard to pain behaviors. That is to say, one might begin to practice bringing pain behaviors under greater voluntary control.

In the example of chronic low back pain with repetitive stabbing pain upon sitting down or getting up from a chair, I could set out to bring my awareness to it and make an effort to control my grimacing, bracing and exclamations whenever I sit down or get up from sitting.

Of course, it would take some practice. There’s no pain behavior switch that can be turned off like a light switch. Rather, it would take repetitive practice to bring awareness to the pain and to anticipate it, such as when sitting down, and make an effort to control its behavioral expression. With practice, one could gain greater and greater voluntary control over pain behaviors and even the sense of alarm that goes along with the sensation.

The process of practicing thus involves bringing awareness to pain and its behavioral expression, anticipating pain, and the practice of choosing a different set of behaviors than the reflexive and automatic behaviors associated with pain. It could also involve reassuring self-talk that you know what your pain is, that you have it no matter what you do or don’t do, and, as such, the pain of chronic pain isn’t always signaling harm. Your chronic pain, you remind yourself, is like a broken fire alarm that keeps sounding the alarm whether there’s smoke or not. So, when you sit down and experience the sharp stabbing pain, the pain you experience isn’t necessarily signaling that the sitting motion is injuring you. The dull ache that you feel at all times of the day whatever you do or don’t do isn’t signaling that you are continuously injuring your back. Rather, the pain you experience is chronic pain and you experience it whether you are injuring yourself or not. The purpose of this reassuring self-talk is to begin turning down the sense of alarm that accompanies the sensation of pain. The goal would be to remain emotionally grounded in the presence of pain. With your increased awareness of pain, you might, for instance, take a deep breath to calm yourself and clear your head before sitting down and experiencing the sharp stabbing sensation. The improved emotional control over pain lends itself to improved control of the behavioral expressions of pain.

Imagine a day when you still experience the same level of pain that you do today, but you are no longer alarmed by it, and you confidently engage in life activities without any degree of vigilance to pain or fearful bracing and guarding. No one would ever know that you have the pain that you do. When, on some occasion, you tell them about the severe pain that you do in fact experience, they’d believe you and say something like, “Wow, you cope so well with it.”

Coping well with pain involves controlling pain behaviors

After all, what is coping well with pain? Coping isn’t getting rid of the pain, but rather putting up with pain. It’s tolerating pain. Now, everyone tolerates pain. It’s not ever a question of whether you or anyone else tolerates pain or not. Rather, coping involves a question of degrees. How well does one cope? Coping, as I like to say, occurs along a spectrum from low levels of coping to high levels of coping.

If we understand that coping or pain tolerance occurs along a spectrum, then we can recognize that no matter where you are on the coping spectrum you can always get better at it. Reducing the emotional distress and behavioral avoidance of pain is a way to get better at coping with pain.

Suppose we worked with a woman who experienced recurrent migraine headache. She had migraines most every day and she preferred to lie in bed with the shades drawn and the lights off when experiencing a migraine. Over the years, she found herself engaging in these behaviors more and more. She came to a chronic pain rehabilitation program because she wanted more out of life. She also needed to keep her job. When she forced herself to remain at work, she tended to rub her temples and the back of her neck on a persistent basis. She tended to have a grimace on her face and also sighed frequently.

When we initially brought up the recommendation to begin practicing controlling her emotional alarm and pain behaviors, she was offended. She thought we were judging her and asked rhetorically ‘what else am I supposed to do?’ We acknowledged, just as we did above, that such alarm and behavioral avoidance of pain is normal and natural. The point is that no one is judging her because engaging in these behaviors is normal.

We pointed out, though, she was coming to the program to learn how to cope better with pain and that if she’d trust us and practice what we were teaching her, she would in fact learn to cope better with pain.

So, she began to practice bringing her awareness to the pain and how she was coping with it. She recognized that, even though it was painful to remain erect and out of bed, it was safe for her to do. She acknowledged, in other words, it wasn’t injuring her or harming her to remain at work even though her head pounded. With such awareness, she further considered that she could make a value cost-benefit decision in which she weighed the value of pain reduction by remaining home in bed in the dark versus remaining at work, secure in her job, and involved in meaningful activities that brought value to her life.

She subsequently began, over time, to choose the latter. She made a concerted effort to remain grounded in the presence of her pain and redirect her attention to work or other valued-life activities. She would catch herself sighing and rubbing her temples and remind herself to stop and get involved in the activities she was pursuing.

We gently and respectfully pointed out such behaviors to her to help her in becoming more aware of them. She trusted us that we weren’t just picking on her, but helping her to cope more effectively with pain.

She came to conclude that if she were home on a Friday night watching a movie and wanted to rub her temples, it would be okay; but she wanted to be able to have the wherewithal to keep herself from engaging in such behaviors if, for examples, she were at a work meeting with colleagues or in a job interview. In the latter situations, it would be better for her to be able to cope with pain without engaging in such behaviors.

With effort, practice and openness to feedback, she came to be able to remain at work, engaged in the activities of work, even though she had a migraine. People stopped worrying about her at work and she stopped worrying that her job was in jeopardy. She felt self-confident in the presence of pain. She felt productive and proud of herself. Her career path was again heading in the right direction.

Even though she continued to have migraines, they were nowhere near as distressing and impairing as they once were. In other words, She had learned to cope really well with her pain.


Reducing pain behaviors is a long-standing recommendation in chronic pain rehabilitation because it is a way to learn to cope better with pain. It takes coaching from providers who you trust and who are gentle and respectful in their feedback. It takes time and effort. It also takes repetitive practice. However, it is also possible. It’s possible to learn to cope better with pain and reducing pain behaviors is a way to do it.


International Association for the Study of Pain (IASP). 2012. IASP taxonomy. Retrieved from:

Date of publication: October 9, 2017

Date of last modification: October 9, 2017

About the author: Dr. Murray J. McAllister is a pain psychologist and the founder and editor 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.


]]> (Murray J. McAllister, PsyD) Coping Mon, 09 Oct 2017 15:19:13 +0000
Minnesota Leads Nation in Developing New Payment Model for Pain Rehab Programs

This past summer, Minnesota Governor Mark Dayton signed into law an omnibus health and human services budget bill and in so doing he marked a significant milestone in the recent history of chronic pain management. The bill contained language, introduced by State Representative Deb Kiel and State Senator Jim Abler, authorizing the trial of a new payment arrangement through Medical Assistance, which makes it possible for state recipients of the public health insurance to receive care within an interdisciplinary chronic pain rehabilitation program.

The increasingly pressing need for effective alternatives to prescription opioid medications for the management of pain fueled the passage of the provision.

In over a three year effort, a number of additional organizations and individuals pooled resources to ensure passage of the bill, including: the Minnesota Department of Human Services’ Health Services Minnesota State Capitol 1Advisory Council, led by Jeff Schiff, MD, and Ellie Garret, JD, which authorized the state to seek to increase use of non-pharmacological, non-invasive pain therapies among Medical Assistance recipients; the Institute for Chronic Pain; Courage Kenny Rehabilitation Institute; State Representatives Matt Dean, Dave Baker, Mike Freiberg, and State Senator Chris Eaton. To our knowledge, with the passage of the bill, Minnesota became the first state in the nation in recent history to pay for an interdisciplinary chronic pain rehabilitation program in a viable manner through Medical Assistance.

The problem until now

Interdisciplinary chronic pain rehabilitation programs are a traditional, empirically-supported treatment for people with chronic pain conditions. The focus of the care is to assist patients in acquiring the abilities to successfully self-manage pain without the use of opioid medications and return to work or other meaningful, regular activity. Multiple physical and psychological therapies performed on a daily basis for three to four weeks constitute typical chronic pain rehabilitation programs. An interdisciplinary staff of pain physicians, pain psychologists, physical therapists, nurses, social workers and others deliver the different therapies. Research over the last four decades has shown that such programs are highly effective (Gatchel & Okifuji, 2006). Indeed, in 2014, the American Academy of Pain Medicine dubbed such programs the “gold standard” of care for those with chronic pain.

Despite the long-standing research base supporting its effectiveness, interdisciplinary chronic pain rehabilitation programs have historically faced obstacles to obtain adequate insurance reimbursement (Gatchel, McGreary, McGreary, & Lippe, 2014). Component therapies within such programs, when billed on a per therapy basis, are commonly reimbursed at below cost or not reimbursed at all. These low rates of reimbursement make it unviable for chronic pain rehabilitation programs to survive if they accept such reimbursement.

Historically, chronic pain rehabilitation programs have gotten around this problem by repetitively proving their superior outcomes through research and using this research to negotiate “bundled” payment arrangements with individual insurers within each state. The bundled payment is typically one fee for all the services delivered over an agreed upon time frame (usually, as indicated, for three to four weeks). Worker’s compensation and most commercial insurers pay for chronic pain rehabilitation programs in this manner.

State Medical Assistance programs over the last few decades have refrained from negotiating such bundled payment arrangements, due to lack of legislative authority to provide such arrangements. As a result, they’ve pursued more customary reimbursement practices. As indicated, though, such customary reimbursement effectively makes accepting the public health insurance unviable for interdisciplinary chronic pain rehabilitation programs. As a result, recipients of Medical Assistance were cut off from being able to receive this effective form of chronic pain management for many years.

During this time, society has also witnessed the onset of alarming epidemics of opioid-related addiction and death (CDC, 2017; SAMHSA, 2016). It is generally accepted that the impetus for these epidemics has been the large-scale adoption of the practice of prescribing opioid medications for acute and chronic, benign pain that began late last century and continues to this day.

These epidemics have led to increasing societal demand for safe, effective non-opioid options for the management of pain.

With the passage of the Minnesota bill, patients who have state-funded Medical Assistance insurance within Minnesota can now obtain chronic pain management that effectively helps them eliminate the need for opioid medications and return to work or other valued life activities, such as returning to school, job re-training or volunteering.

Not just a local problem

The importance of Minnesota’s legislative action to develop and trial a new payment arrangement for an interdisciplinary chronic pain rehabilitation program is highlighted by the fact that it’s a solution to a problem that is long-standing and widespread. This problem is not isolated, in other words, to the time and place of Minnesota in the year 2017. In other states throughout the nation, chronic pain rehabilitation programs face the problem of telling patients who would benefit that their insurance will not cover the cost of the program and as such would have to pay out of pocket if they attend. To be sure, most patients in this predicament choose to forego the therapy and resort to continuing their use of opioid medications for the management of their pain.

State-funded Medical Assistance programs are not the only insurer that has failed to cover interdisciplinary chronic pain rehabilitation programs. Medicare and some large commercial plans in the nation either do not cover such programs or only do so in a cost prohibitive way. As such, chronic pain rehabilitation programs and many would-be patients face the dilemma of being unable to access a therapy that could go a long way to resolving the epidemics of addiction and death associated with the opioid management of pain.

This problematic insurance reimbursement for interdisciplinary chronic pain rehabilitation programs has had significant consequences for the availability of such programs nation-wide. Because different insurers over the years have not covered chronic pain rehabilitation in a viable manner, many programs have struggled to remain open. While estimates vary, the number of interdisciplinary chronic pain rehabilitation programs in operation has dropped precipitously over the last two decades (Gatchel, McGreary, McGreary, & Lippe, 2014; Schatman, 2012).

This problem of reimbursement is both ironic and tragic at the same time. For the last two decades, we as a society have had a safe and effective alternative to the use of opioids for chronic pain and yet many people cannot access them because state-funded Medical Assistance programs, or Medicare, or some commercial insurance do not reimburse for them. All these insurers readily pay for opioid medication management, with all its adverse consequences, but not for chronic pain rehabilitation programs that show patients how to manage pain without the use of opioids. This irony becomes all the more tragic considering how many lives could have been saved from addiction and accidental death had people been allowed to access chronic pain rehabilitation programs as a substitute to opioid management.

Not yet a permanent solution

The bill, as passed, provides authorization of a two-year trial of a bundled payment arrangement for a chronic pain rehabilitation program within the state of Minnesota. Its intent is to provide demonstration of the effectiveness of both this type of treatment and its corresponding type of insurance reimbursement. In turn, this subsequent data will provide lawmakers with further justification to make it a permanent benefit within Medical Assistance. The long-term goal would be to bring Medical Assistance in Minnesota into alignment with the current reimbursement practices of most commercial and worker’s compensation insurers in the state.


Centers for Disease Control and Prevention (CDC). (2017). Understanding the epidemic: Drug overdose deaths in the United States continues to increase in 2015. Last updated August 30, 2017.

Gatchel, R. J., McGreary, D. D., McGreary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130.

Gatchel R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic malignant pain. The Journal of Pain, 7(11), 779-793.

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

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Opioids. Last updated February 23, 2016.

Date of publication: September 24, 2017

Date of last modification: September 24, 2017

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.

]]> (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Sun, 24 Sep 2017 01:45:58 +0000