It’s also a common reaction among patients in pain clinics. It seems immediately and obviously true that having pain requires the use of opioid pain medications. It hardly seems worth entertaining whether there's any benefit to going without opioids when having chronic pain.
The obvious veracity of such a reaction is, however, only apparent. For it neglects the fact that there are people who don't manage their pain with opioid medications. Indeed, most people with chronic pain don’t manage their pain with opioids. This fact remains true even of people with moderate to severe chronic pain.1, 2 The majority of these individuals are also satisfied with how they are managing their pain.2
Why do people do that? Why do people with chronic pain choose to live with pain, rather than try to get rid of it through the use of opioid medications?
The following is a list of benefits that people tend to gain when learning to self-manage chronic pain without the use of opioids. Some people prefer these benefits over the reduction of pain that opioid medications can provide. As a result, they choose to live with their chronic pain, using these benefits to help them to cope with pain.
Some caveats are in order before reviewing the list. First, the list below isn't exhaustive of all possible benefits of self-managing chronic pain without the use of opioids. The list contained on this page is simply some of the more common benefits. Second, any list of benefits would surely include reductions in the risk of addiction, accidental overdose, and tolerance. However, this article omits these benefits as they are adequately addressed elsewhere on the Institute's website. Third, the intention of the list is solely educational. It is not intended and should not be understood as a healthcare recommendation or counseling. It simply attempts to describe why some people manage pain without opioid medications. As such, the intention is simply to describe, for educational purposes, why some people elect to live with their pain and not take opioids. Fourth, the decision on any one individual's part, such as the reader, to learn how to self-manage pain should only be done in consultation with your own healthcare provider. It is only your own healthcare provider who is in the position to know what is in your best interest and it is only your own healthcare provider, not the Institute for Chronic Pain, who can give you healthcare recommendations (please see Terms and Conditions of Use of this site). So, do not make any medication changes without first talking to your healthcare provider and obtaining his or her consent and direction.
So, with that said, let’s move on with the list.
Acceptance
Sometimes, people tend to think that they'd lose hope if they came to accept their chronic pain and stopped trying to get rid of it through the use of opioids. The assumption is that hope lies in a long and steadfast battle to get rid of pain. Given this perspective, the use of opioids becomes the chief weapon in the battle.
This way of defining and finding hope can become hope depleting because success persistently remains just out of reach. The medications never seem to fulfill their promise of being pain killers. Most people continue to have pain even when taking opioids. Of course, the medications can work well, but typically it is only for some period of time. The medications tend to lose their effectiveness after a while. At the direction of their healthcare provider, people who take the medications tend, in such circumstances, to increase their dosage. However, the new dosage again only works well for a period of time. With each increased dose, it is only a matter of time before they no longer work well.
Even with an army of painkillers, the fight to get rid of pain inevitably becomes a long series of losing battles. Hope, when framed in this manner, persistently gets dashed. Indeed, far from being a way of obtaining hope, it becomes in the end the very opposite: depressingly hopeless.
In response, many people stop fighting to rid themselves of pain. They make peace with their pain. They learn to live with it. Going to a chronic pain rehabilitation clinic is a chief way they learn to live with it. This learning involves learning how to self-manage chronic pain without opioids. Rather than being stuck in an endless cycle of trying to get rid of something that can’t be gotten rid of, they accept pain into their life, make room for it, flexibly adapt and adjust, and move on with life.
In fact, as seen above, most people live with their pain, even moderate to severe pain.
Shame reduction
When people rely on the use of addictive medications, it tends to produce stigma and shame. Others tend to look down upon them (i.e., stigma) and those who take the medications tend to feel vulnerable and criticized (i.e., shame). This fact is especially true when people rely on an addictive medication to do things that most others do without the use of the addictive medication. It is the inherent situation in which those with chronic pain who rely on opioids find themselves. Some people rely on opioids to manage pain, while most others with chronic pain, even those with moderate to severe chronic pain, don’t rely on opioids.
Therein lies the rub: the contrast between those who rely on opioids to manage chronic pain and those who don’t puts those who rely on opioids in an inescapably vulnerable position of stigma and shame. (Please note, the simple observation of this fact doesn’t imply that the author supports or condones it.)
In their defense, patients who rely on opioids can become self-righteously angry and assert a number of arguments to support their use opioids:
- Their pain is inherently worse off than those who don't rely on opioids.
- Those who question their use don’t understand what it is like to have chronic pain.
- Healthcare providers who question the use of opioids are incompetent.
- Those who question their use are mean or uncaring.
- The pain is intolerable now and it will be worse without opioids.
- It's impossible to manage pain well without opioids.
Of course, sometimes people without pain are incompetent or uncaring or mean. Some people do in fact engage in stigmatizing those who rely on opioids. Such stigma needs combating at every step by patients, healthcare providers and society generally, (which is why the Institute for Chronic Pain frequently takes up the issue of stigma and how to deal with it: see here, here, here, here, and here).
However, the problem isn't just the stigmatizing comments from others. There is also the corresponding issue of shame. Hard to admit, but it's common for patients who take opioids for chronic pain to be ashamed of their need. The fact that others can self-manage pain without the use of opioids simply highlights this sense of vulnerability of being reliant on an addictive medication. This reliance simply doesn’t allow you to be in control and as such it conflicts with most people’s values for how they believe they should live – as a self-determined, independent person who is in control of themselves. This internal conflict between what is and what should be tends to produce shame.
One of the most liberating experiences patients can have occurs every day in chronic pain rehabilitation programs across the world. It occurs when patients give up the yoke of remaining reliant on a medication that, for all the good it does, also produces a persistent sense of shame for those who take it. By learning how to live well with pain, they stop trying to rid themselves of pain and instead rid themselves of shame. They do so by tapering opioids and by learning to self-manage pain instead.
Empowerment
This experience of tapering opioids and learning to self-manage pain well within a chronic pain rehabilitation clinic is initially scary and threatening, but becomes one of the more empowering experiences of patients’ lives. This experience is why chronic pain rehabilitation clinics consider tapering opioids as not just something one does once the other therapies are successful, but it is considered to be a therapy in and of itself. It’s an exposure-based therapy that fosters patients’ innate coping abilities. Patients come to see, in other words, not just how to self-manage pain, but that they really can do it.
Patients often come to chronic pain rehabilitation programs wanting first to learn how to cope and self-manage pain and only then want to reduce the use of opioids. However, the two actions have to go hand in hand, for otherwise learning to cope with pain remains only theoretical. Coping and self-management are skills. They are a knowing-how.
It would be like wanting to learn to ride a bike, but refusing to get on it until you've learned how to ride. The knowledge gained in such an exercise would only get you so far. We can only say that we know how to ride a bike if we have actually gotten on a bike and have ridden it. This process of learning is initially fraught with fear, but eventually becomes an empowering experience.
Similarly, learning to self-manage pain well is a knowing-how that simply can’t be mastered if pain is avoided through the use of opioids. It requires, in other words, having pain with which to practice the skills of coping and other self-management. Of course, the process is a slow one, but must include a slow taper of opioids. Initially threatening, the process becomes easier with practice and at some point mastery comes and people come to cope and self-manage pain without opioids. This sense of success comes to foster and reinforce their abilities to cope with pain.
This process of gaining mastery allows people to finally take back control of their pain. It not only reduces shame, it produces the empowerment that comes when taking back control of your life.
Self-confidence
The empowerment that comes with tapering opioids and learning to self-manage pain instead can produce a profound sense of self-confidence. People in chronic pain rehabilitation clinics who taper from opioids and learn to self-manage pain instead overcome the fear of pain that has dominated their lives. They no longer are alarmed by pain and no longer hold the view that pain must be reduced at all costs. Rather, they come to see that it's possible to live well with pain. Pain is no longer central to their lives. In this way, even though pain continues, they overcome their pain and move on with the rest of their lives.
The power of this sense of self-confidence cannot be overestimated.
Self-Esteem
Learning to self-manage pain, including tapering opioids, is a therapy that increases people’s ability to cope with pain because it is a shame reducing, empowering experience that fosters self-confidence. In other words, it is a self-esteem building exercise.
Prior to engaging in this learning process, patients tend to see pain as an alarming experience that they need to avoid by taking opioids and as a consequence they tend to feel bad about themselves for having to rely on opioids. They tend to feel sensitive and defensive about their need for opioids, but nevertheless continue their use because pain is so alarming that it seems it must be gotten rid of. This dilemma wears on their sense of who they believe they should be. In other words, the dilemma wears on their self-esteem.
By learning to self-manage pain without opioids, patients come face to face with their pain and learn that they can still live well even if pain is present. In this way, they overcome the sense of alarm that pain can generate and come to see that it doesn’t have to be avoided at all costs. They come to see that they don’t have to pay the price of shame that comes with needing to rely on opioids to get rid of pain. They overcome the fear of pain and come to see that they can live with it. They come to even see that they can live well. This empowering experience allows them to feel good about themselves again. They take back control of their lives.
Learning to self-manage chronic pain, including tapering opioids, is thus a therapy that when done under the guidance of expert healthcare providers in a chronic pain rehabilitation clinic produces improved psychological well-being: acceptance of what is, empowerment, self-confidence, self-esteem, and the ability to successfully self-manage chronic pain.
References
1. Fredheim, O. M., Mahic, M., Skurtveit, S., Romundstad, P., & Bordchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian prescription database and Nord-Trondelag health study. Pain, 155(7), 1213-1221.
2. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152(6), 1249-1255.
Date of publication: November 20, 2016
Date of last modification: January 29, 2017
