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Central Sensitization https://www.instituteforchronicpain.org Tue, 31 Jan 2023 10:24:54 +0000 Joomla! - Open Source Content Management en-gb The Reality of Modest Effectiveness https://www.instituteforchronicpain.org/blog/item/239-the-reality-of-the-modest-effectiveness-of-cognitive-behavioral-therapy-for-pain https://www.instituteforchronicpain.org/blog/item/239-the-reality-of-the-modest-effectiveness-of-cognitive-behavioral-therapy-for-pain

The other day I heard someone make the claim that psychological interventions for persistent, or chronic, pain are at best modestly effective. She went on to rhetorically ask why the field should promote such therapies when the empirical support for them is so unimpressive? 

I’ve heard such statements countless times before.

It would be an important point if the field of pain management was filled with effective therapies. Pain management has many offerings in terms of therapies and procedures and, were it the case that these offerings were highly effective, it would make little sense to recommend behavioral therapies that are only modestly effective.

But it is not the case that there are many, highly effective therapies and procedures for the management of persistent pain. With one possible exception, there are actually no highly effective therapies for chronic pain.

Most often, opioids are thought to be powerful analgesics. This impression, however, doesn’t stand up to scientific scrutiny. The most recent meta-analysis on the effectiveness of opioids for chronic pain shows that they are better than placebo, but just a little bit more.1 The greater effectiveness of opioids amounts to less than 1-point greater reduction on the 0-to-10 rating scale. This study also looked at whether opioids were better at reducing pain than anti-inflammatory medications, tricyclic antidepressants, or anticonvulsants. The researchers found that they were all equally effective, which is to say, not very much more effective than a placebo.

Cannabis is a recent and increasingly common recommendation for the management of chronic pain. The most recent meta-analysis found that a “small to very small percentage” of people taking medical cannabis achieve 10% or more pain reduction.2 Again, these results show that cannabis is not very effective on average for the management of persistent pain.

Epidural steroid injections (ESI’s) are commonly recommended and performed for the management of chronic back and sciatic pain. The most recent meta-analysis showed that ESI’s reduced sciatic leg pain more than a placebo injection at 3-months following an injection, but not at 6 months following an injection. The difference in leg pain at 3-months between the real ESI and the placebo injection amounted to less than 1-point on a 0-to-10 pain rating scale. There was no difference between ESI’s and placebo injections for back pain at any of the follow-up periods.3 So, ESI’s are at best minimally effective. 

Over recent years, spinal cord stimulators (SCS) have increasingly been utilized in pain management. However, they reduce pain by about 1-laura kennedy elvys5dsMmA unsplashpoint more than a placebo intervention on the 0-to-10 scale.4 Another recent study showed that SCS's are no more effective than a placebo intervention when it comes to reducing disability.5

Surgery for back pain is also commonly recommended and performed. The ICP recently performed a systematic review of meta-analyses for the various types of surgeries for back pain and showed that they too are at best minimally effective in much the same ways as ESI’s and SCS’s.

State of the art physical therapy combines physical therapy with pain education and the two are now commonly recommended and provided for those with persistent pain. The most recent meta-analysis shows that the combined therapies provide clinically large effect sizes in terms of reducing pain and disability at greater than 12 weeks.6 So, here is a therapy that most everyone would agree is effective.

Cognitive behavioral therapy (CBT) has long been recommended and provided to those with persistent pain. Most commonly provided by pain psychologists, CBT can be provided by any number of healthcare providers. Recent meta-analyses show, as we indicated above, modest effect sizes for those receiving surgery for low back pain7, chronic low back pain8,9 diabetic neuropathy,10 and fibromyalgia.11

Technically, for all these conditions, CBT showed modest effect sizes in its outcomes. However, these modest outcomes are superior to all other forms of treatment cited above with the exception of physical therapy. Physical therapy does show greater effectiveness than CBT, but both therapies have greater effectiveness than all other therapies and procedures. 

The truth about the modest effectiveness of psychological interventions for the management of chronic pain is that it is pretty good when compared to all other therapies for chronic pain. True, cognitive-behavioral therapy for many chronic pain conditions is only modestly effective. However, most commonly performed therapies for chronic pain are not very effective at all. In comparison, CBT looks pretty good.

For more information, please see: Why Healthcare Providers Deliver Ineffective Care.

References

1. Busse, J. W., Wang, L., Kamaleldin, M… & Guyatt, G. H. (2018). Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA, 320(23):2448-2460. doi: 10.1001/jama.2018.18472.

2. Wang, L., Hong, P. J., May, C… & Busse, J. W. (2021). Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: A systematic review and meta-analysis of randomized clinical trialsBMJ, 374. doi:10.1136/bmj.n1034

3. Verheijen, E. J. A., Bonke, C. A., Amorij, E. M. J., & Vleggeert-Lankamp, C. L. A. (2021). Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis. European Spine Journal, 30, 3255–3264. doi.org/10.1007/s00586-021-06854-9

4. Duarte, R. V., Nevitt, S., McNicol, E., Taylor, R. S., Buchser, E., North, R. B., & Eldabe, S. (2020). Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain. Pain,161(1), 24-35. doi: 10.1097/j.pain.0000000000001689

5. Hara S, Andresen H, Solheim O… & Gulati, S. (2022). Effect of spinal cord burst stimulation vs placebo stimulation on disability in patients with chronic radicular pain after lumbar spine surgery: A randomized clinical trial. JAMA,328(15):1506–1514. doi:10.1001/jama.2022.18231

6. Marris, D., Theophanous, K., Cabezon, P., Dunlap, Z., & Donaldson, M. (2021). The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials. Physiotherapy Theory and Practice, 37(4), 461-472, doi: 10.1080/09593985.2019.1633714

7. Parrish, J.M., Jenkins, N.W., Parrish, M.S… & Singh, K. (2021). The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis. European Spine Journal, 30, 1365–1379. doi.org/10.1007/s00586-021-06747-x

8. Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E… & Lamb, S. (2015) The effectiveness of cognitive behavioural treatment for non-specific low back pain: A systematic review and meta-analysis. Plos One, 10(8): e0134192. doi.org/10.1371/journal.pone.0134192

9. Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26(1), 1–9. doi.org/10.1037/0278-6133.26.1.1

10. Bai, Y., Ma, J., Yu, Y., & Wang, Z. (2022). Effect of cognitive-behavioral therapy or mindfulness therapy on pain and quality of life in patients with diabetic neuropathy: A systematic review and meta-analysis. Pain Management Nursing, S1524-9042(22)00124-2. Advance online publication. doi.org/10.1016/j.pmn.2022.05.005

11. Bernardy, K., Klose, P., Welsch, P. & Häuser, W. (2018). Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain, 22, 242-260. doi.org/10.1002/ejp.1121

Date of publication: 12-14-2022

Date of last modification: 12-14-2022

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. The Institute for Chronic Pain (ICP) provides academic quality information that is approachable to all. The goal of the ICP is to change the culture of how pain is managed, making it more effective and compassionate. 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Effectiveness Reviews Mon, 28 Nov 2022 21:48:48 +0000
Should the Definition of Opioid Addiction Change? https://www.instituteforchronicpain.org/2014-12-07-20-47-14/should-definition-of-opioid-addiction-change https://www.instituteforchronicpain.org/2014-12-07-20-47-14/should-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.

Conclusion

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.

References

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

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Sat, 05 Oct 2019 17:59:01 +0000
Changing Pain: A New ICP Heading for Published Articles https://www.instituteforchronicpain.org/blog/item/213-changing-pain-a-new-icp-heading-for-published-articles https://www.instituteforchronicpain.org/blog/item/213-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.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Values Sat, 21 Apr 2018 15:53:11 +0000
When Good Things Become Bad Things https://www.instituteforchronicpain.org/blog/item/203-when-good-things-become-bad-things https://www.instituteforchronicpain.org/blog/item/203-when-good-things-become-bad-things

I am nearing the end of a forty-five minute initial evaluation for our interdisciplinary chronic pain rehabilitation clinic and my patient is an amiable woman in her late forties from the suburbs. She drove a minivan to the clinic and attends the evaluation while her three children are at school for the day. Her primary care provider had referred her to us because of her chronic and disabling low back pain, which over the years had become progressively worse and more widespread.

On a daily basis, she has back and right leg pain, she tells me, but on some days, she has pain all over. She has undergone two lumbar spine surgeries, which she expresses were successful even though her pain continued and in fact worsened over time. She explains the discrepancy by stating that the “degenerative disease in my spine keeps getting worse.” She has undergone various series of epidural steroid injections, which, when she first starting getting them, were helpful in that they produced about a week’s long reduction in pain, but she states now, “They don’t work anymore.” She reports also having had a neuroablation procedure that unfortunately “made things a bit worse.”

My patient tells me that her low back pain began during the second pregnancy of her three children. At first, it came and went, but over time it came to stay. She began to seek healthcare for it eight years ago with her primary care provider. At the time, the provider prescribed a short-acting opioid two times daily and recommended that she walk for about twenty to thirty minutes, four times a week. She indicated that her primary also reassured her that her pain would dissipate as it had in the past. After her third refill request, her provider re-evaluated her and ordered an MRI scan with subsequent referral to a spine surgeon. Her first lumbar surgery, an L5-S1 fusion, reduced the pain initially, but after having returned to full-time work for a few months the pain worsened. With an increased dose of opioids, she attempted to return to work yet again, but eventually she stopped working altogether. Her burgeoning career had ended. Since having given up attempts to return to work, she underwent another fusion. She repeats to me today that this secind surgery was successful, but it’s unclear to me how it’s been successful. She has remained distressed and disabled by pain and it continues to require the use of opioid medication that’s been increasing in dose over time. I decide against asking further about the topic and move on with the evaluation.

Understandably, the loss of her career has been a persistent source of grief and loss for her. To make things worse, with some individuals of her extended family, this loss of work has been a source of stigma too. She professes a number of times she loved her job. She implies, with an endearing sense of humility, that she was good at what she did. Between the lines, it seems clear that her self-esteem seemed grounded in her highly adept multi-tasking abilities to raise three children, be a loving and helpful spouse, and work a 40+ hour professional position in a career for which she had gone to college. By all accounts, she was really good at all of it and she was rising through the ranks of her organization. Until, her pain became too much.

But then, she became caught between either maintaining the career she loved with increasing back pain or reducing her back pain and acquiring a persistent grief and stigma over giving up her beloved career.

Again, I don’t challenge her reported history and the dilemma she experiences. I have no reason to do so, as her experience is so understandably common. In the interview, I repetitively try to empathize with her and show her that I understand and do not judge.

Nonetheless, throughout the interview, in what seems like anticipation of potential criticism from me, she recurrently stresses that she has tried everything in order to remain at work – multiple surgeries, numerous interventional procedures, multiple physical therapies, occupational therapy, and increasing levels of opioids. She persistently expresses to me how much she loved her work. She says a number of times that she would return to work in a heartbeat if she could find something that would reduce her pain.

The only thing that she identifies as at all helpful is her “pain medicine,” by which she means opioids. She acknowledges that the opioids haven’t helped her return to work, but stresses that it’s because her pain is just too great. She volunteers often in the interview that the opioids “take the edge off” and that they “allow me to function enough to get my kids off to school and keep the house running.”

Like the fact that she’s not working, my patient seems vulnerable about her use of opioids. She acknowledges that she’s becoming quite tolerant – she’s now on moderately high doses of both long-acting and short-acting opioids for pain. Nonetheless, she recurrently stresses how bad her pain would be without them. She also asserts a number of times that she’d give them up in a minute if there was something that would get rid of her pain, but as her treatment history demonstrates, she’s tried many procedures and therapies and nothing has worked. So, she’s caught in yet another dilemma: she has to take something that she doesn’t want to take.

My patient offers these repetitive assertions without any prompts or inquiries from me. Throughout the evaluation, I never challenge her reported inability to work or the necessity of her use of opioids. Rather, I maintain a friendly, neutral, and non-judgmental demeanor.

We near the end of the evaluation and it is customary at this time to discuss a proposed treatment recommendation as well as other potential treatment options from which she can compare and contrast the proposed recommendation. Other than my experience of having performed this kind of evaluation countless times before, I have no indication that the ensuing discussion will be anything but collaborative. For indeed, because of her repetitive expressions of distress about both her job loss and the necessity of having to take of opioids, I might have every reason to believe that she’ll welcome my recommendation to transfer her care to our clinic, as we specialize in the things that she finds most distressing: her persistent intolerable pain, her resultant disability from work, and the fact that at this time she needs opioid pain medications to manage her pain. What we can offer her, in other words, is the opportunity to have a team of supportive, non-judgmental experts help her to gradually acquire the abilities to self-manage pain without opioids and return to work in some meaningful capacity – both of which are things that no other pain clinic that she’s previously seen has offered her. So, given her repetitive assertions that she’s tried everything and so must remain on opioids, I can offer her hope that we have a therapy that she hasn’t yet tried, which allows her the opportunity to learn how to manage pain without opioids.

Given my past experiences, however, I approach the recommendation in a gentle manner. I review with her my understanding of the dilemmas she has faced and empathize again with how anyonechuttersnap 193778 compressor would find such problems difficult. I want her to know that I understand – that I get it. I then talk about her treatment history – the different types of surgical, interventional and opioid management that she has had. I want to demonstrate that I’ve been listening and know the many different procedures and therapies she has had. I review that none of them were unreasonable, and in fact that they all have had their time and place. I then change the focus of the conversation to the fact that there has always been another type of pain clinic, called chronic pain rehabilitation, which pursues care differently, just as a surgeon is different from an interventional pain physician, we are yet again different from either, though we treat the same conditions. I review that in our healthcare system often times patients tend to get referred to our type of pain clinic after the other types of treatment have been tried and failed, which seems the case for her.

I review with her that, while we don’t typically cure people of their pain, we have an interdisciplinary team of providers who essentially serve as her coaches and we slowly and gradually teach folks just like her how to self-manage pain so successfully that they no longer require opioid medications to manage their chronic pain. I stress that it takes time and effort, but with the right kind of coaching, it’s possible to learn to self-manage pain without opioids. We also help people find some type of meaningful, structured activity to pursue, such as work, school or volunteering, which helps folks just like her get back on a track in life that they feel good about again. I review that she may or may not be able to return to her previous position, but through a combination of creatively coming up with options we might be able to identify some type of meaningful work that she could strive to obtain.

I also share with her that we have been maintaining outcomes on our program for years and that what we find is that our patients have a more than 90% reduction in opioid use and over 50% of our patients return to work, volunteering, or job retraining/school. I add at the end of my gentle and hopeful message that on average our patients report 20% less pain then when they started, even after they’ve achieved these other gains. In other words, on average, our patients have 20% less pain even though they are no longer taking opioids and have significantly increased their daily activities, by returning to work or school.

From my chair in the consulting room, this message can be heard as a beacon of hope – that she does not have to settle for the life she currently has; with hard work, coaching, and learning, she can get better. She will, of course, continue to have pain, but she will likely have less pain, be off her opioids and engaged in some type of regular, meaningful activity that allows her to feel proud of herself again. It’s a hopeful message that details a way to get better while grounded in the realism that she truly has a chronic – lifelong—pain condition.

As I near the end of this feedback and recommendation, I can tell, however, that from her chair, my message is not a beacon of hope at all. It began when her legs started to fidget. Then, tears began to well up in her eyes. By the time I finished, she had become intensely vulnerable and subsequently very angry.

I could tell that the good things our clinic has to offer had become bad things.

Now, the patient that I describe in this encounter is not an actual person. I made her up. She’s not, though, no one. She could be most any one of my patients. She could be a man in his thirties or a man in his fifties or a woman in her sixties. He might have recurrent migraine. She might have had persistent neck pain.

The point here is not the details of the individual’s presenting problem, or their gender, or whether the individual has children in school or not. The point is how an individual hears and tolerates feedback about themselves and the recommendations they receive. It’s also about one’s capacity for hope – that hope often lies in the eye of the beholder.

Because we are a clinic that specializes in people with persistent pain who are disabled by pain and/or reliant on opioids, we tend to see a lot of patients who fit these descriptions. Sometimes, we see patients who welcome the help we can provide. Nonetheless, we often see patients who become threatened by the help we provide.

It all tends to boil down to two things: one, the degree of shame, or vulnerability, that patients have for finding themselves in the position that they are in, whether it be reliant on opioids or unable to work or both; and two, the degree to which they can openly acknowledge this shame in some constructive manner.

When people have high degrees of shame and significant difficulty acknowledging it, they tend to experience stigma when others broach the sensitive topic even when no stigma was ever intended. As a result, they tend to shun open discussion of their role in their health, and instead engage in discussions of how there's nothing more to do, but what they are doing. This impassable stance thus comes to justify the sense of vulnerability, or shame, they feel for taking opioids or being disabled or both. I didn't choose this; I have to do this.  

From this perspective, my patient might make any number of counter-arguments:

  • My surgeon told me that there’s nothing more that can be done.
  • My doctor told me that I’d probably have to be on these medications for the rest of my life.
  • I have a degenerating disc disease. It’s just going to keep getting worse. You‘re not going to cure that!
  • If pain rehabilitation programs are as successful as you say they are, why wouldn’t my doctor have referred me earlier?
  • Look, I’ve done everything humanly possible to get back to work. If it’s as easy as you say it is, then you aren’t seeing people like me.
  • I have the highest pain tolerance of anyone I know and my pain would be intolerable without pain medicines.
  • I don’t know who you’re seeing in your program, but I’ve got real pain!
  • Every doctor I’ve ever seen has reassured me that it’s okay to be taking pain medicines (i.e., opioids) and to be on disability, why are you questioning it now? You talk to me all calm and gentle like, but you’re actually the meanest doctor I think I’ve ever seen!
  • You think I want to be this way? I can’t believe I’m sitting here listening to this.
  • Are you in pain? I know you’re not, because if you were you wouldn’t be saying the things you’re saying.
  • You don’t have my pain! You have no idea how bad it is. How dare you say that I can learn to cope with it. If you had my pain, you’d know I'm coping better than anyone possibly can under the circumstances!

Such responses and more are common reactions to a recommendation to participate in a chronic pain rehabilitation program where patients learn how to self-manage pain and return to work. The recommendation, of course, is meant as a good thing, a beacon of hope, that with hard work, openness and motivation, they can achieve these goals. Implied in these responses to the recommendation, however, is the rejection of the notion that patients can't do anything about their pain. The above reactions imply that patients have done all that can be done; they’ve learned all that they can learn. They've done everything humanly possible and so are beset with having to be on opioids and/or disability. The reactions are all versions of these implications -- dare not question the conclusion that remaining on opioids and/or disability is the only possible things left, because I didn't choose this -- I have to do this.

It is, however, these very conclusions that come into question with a recommendation to participate in a chronic pain rehabilitation program. The recommendation is indeed an affirmation of the pssibility of change for the better -- that, with effort over time, they can come to cope better with pain -- so good, in fact, that one wil be able to self-manage pain without opioids and return to some meaningful, structured activity, such as work. One might think that this message is a good thing – there is still more to be done and so therefore there is still hope!

Why shun, then, this possibility of hope? Why shun the possibility of having a greater sense of control – even a potential control that one doesn’t yet have?

Shame and pain

It is shame. It's the sense of shame that comes when people recognize that they have a role in their health and in the conditions in which they find themselves. This shame is threatening. In some ways, it's safer to view oneself as powerless. Acknowledgement of power – even the power to get better – cuts both ways.

Is it a good thing or bad thing? It depends on the perspective. Good things can easily become bad things.

In early psychoanalytic thinking, Freud (1943) called it resistance and considered it one of the hallmarks of a mental health, as opposed to a physical health, condition. Cancer patients, for instance, don’t tend to resist the recommendations of their oncologist, but will rather readily do most anything to beat their cancer. Later Kleinians (cf. Ogden, 1990) focused on patients’ sense of vulnerability and the shame that underlies it. They recognized that any one of us, with whatever health condition we have, can move fluidly in and out of perspectives that we take when interacting with others. Sometimes, we interact in strong and mature ways and so accept feedback as constructive, while other times we become vulnerable and so hear the very same feedback as shaming. As a result of the latter, we can become defensively angry or offended. In such  scenarios, we tend to resist the feedback, come to see the person who is providing it as being judgmental or incompetent or mean. In more contemporary times, Miller & Rollnick (2013), for example, call it ambivalence. Ambivalence captures the fluidity of perspectives that we can all take: we all might recognize the experience of wanting to start an exercise routine and not wanting to at the same time or getting feedback from a healthcare provider about the need to lose weight as a realistic observation or as a criticizing judgment to which one responds with resistance. These common perspectives can be taken with most any health condition. It’s one of the reasons that we might advocate to no longer split up health conditions between mental and physical health, but rather recognize that all health conditions are biopsychosocial in nature.

Nonetheless, we don’t have to use complicated conceptualizations to describe what occurred between my patient and myself when giving her feedback and a recommendation. We might just call it the experience of when good things become bad things. 

References

Freud, S. (1943). A general introduction to psycho-analysis. Garden City, New York: Garden City Publishing.

Miller, S. & Rollnick, W. R. (2013). Motivational interviewing: Helping people change, 3rd edition. New York, New York: Guilfard Press.

Ogden, T. H. (1990). Matrix of the mind: Object relations and the psychoanalytic dialogue. Oxford, UK: Jason Aronson.

 

Date of publication: August 28, 2017

Date of last modification: December 7, 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. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Mon, 28 Aug 2017 12:32:05 +0000
Do We Tend to Misunderstand the Nature of Pain? https://www.instituteforchronicpain.org/blog/item/161-64do-we-tend-to-misunderstand-the-nature-of-pain https://www.instituteforchronicpain.org/blog/item/161-64do-we-tend-to-misunderstand-the-nature-of-pain Do We Tend to Misunderstand the Nature of Pain?

We live in an interesting time within the field of pain management. We literally have two competing ways of understanding the nature of pain – what it is and how it works and what to do about it.

One way of understanding pain is more commonly held than the other, but the other is more scientifically accurate. We are thus faced with the prospect that much of society and even many healthcare providers misunderstand the nature of pain.

It’s a provocative prospect, to be sure.

Competing models of pain

Most people, including many healthcare providers, associate pain with tissue damage, a phrase we might use to refer to some form of abnormality of bodily tissue. We might come up with any number of examples -- a cut finger, a burn, or a broken bone, but, of course, there are countless ways we might suffer bodily harm. Generically, we might call such conditions “tissue damage” and we tend to associate it as the cause of pain. Indeed, we tend to think that some form of tissue damage must occur in order for there to be pain. So, if there’s pain, there must be some form of tissue damage that’s causing it.

This way of understanding pain is commonly used in many areas within the field of pain management. Suppose a person develops low back pain and seeks evaluation with a healthcare provider. It’s likely that both the patient and provider will assume that the cause of the back pain is some form of tissue damage in the area of the low back: a muscle strain, a ligament tear, nerve root compression, a disc bulge or herniation, or so forth. Testing, in the form of scans or diagnostic injections, might be pursued in order to identify the tissue damage, which is sometimes further referred to as the “pain generator.” Any number of treatments is subsequently pursued based on the view that some form of tissue damage must be causing the low back pain. Often unspoken, this way of understanding pain thus justifies what healthcare providers go on to do about the pain – various forms of physical therapy, chiropractic care, epidural steroid injections, nerve blocks, and spinal surgeries, all of which are commonly pursued as ways to heal the damaged tissue that must be causing the pain.

In the field of pain management, we refer to this way of understanding the nature of pain as the "Cartesian model." Rene Descartes, a 17th century philosopher and mathematician, was likely not the first person to ever think of pain as occurring in this way, but he was the first to systematically write about it and publish it (Descartes, 1633/2003). This view has had great influence on subsequent generations, so much so, that most people today and many healthcare providers still unquestionably assume it to be true: if there’s pain, there must be some form of tissue damage causing it; so, we have to find the tissue damage and fix it or heal it; once successful in this endeavor, the pain should go away.

The problem with this way of thinking about pain is that, despite how common sense it seems, the empirical evidence doesn’t support it, especially when we use it to understand problems such as back pain.

  • Current established guidelines recommend against routine use of MRI or CT scans for low back pain because doing so doesn’t make people better and in some cases makes them worse; in other words, a search for putative tissue damage in the spine doesn’t help when attempting to find ways to have less pain (Cf. Chou, et al., 2011; Flynn, Smith, & Chou, 2011; Koes, et l., 2010).
  • The potential identifiable forms of tissue damage that might cause back pain in actuality don't correlate with back pain; if potential forms of tissue damage, such as degenerative conditions of the spine, caused back pain, then we’d expect them to highly correlate with back pain, but they don’t (or at best they are only weakly correlated with back pain) (see, for example, Carragee, et al., 2005; Bogduk, 2012; Videman, et al., 2003).
  • Despite varying attempts to prove it over the years, there’s been no demonstrable evidence showing that interventional and spinal surgical procedures are any more than nominally effective (Atlas, et al., 2005; Gibson & Waddell, 2007; Leclaire, et al., 2001; Mirza & Deyo, 2007; Pinto, et al., 2012; van Tulder, et al., 2006; Weinstein, et al., 2006; Weinstein, et al., 2008).
  • Few in the field of pain management would argue that back pain isn’t overteated; that is to say, society has seen exponential growth rates in the use of interventional and spinal surgical procedures, but people aren't getting better – they don't return to work faster; they don't reduce their use of opioids; and rates of disability for back pain are increasing, not reducing (Deyo, et al., 2009; Martin, et al., 2009; cf. Nguyen, et al., 2011).

Maybe we need to completely re-think how we think of back pain. Our attempts to provide interventional and surgical therapies to putative "pain generators," or tissue damage, in the spine assumes that because there is pain in the back there must be tissue damage in the back that causes it. However, the widespread and persistent failure of these approaches should suggest that there must be another cause for back pain, something that doesn’t rely on tissue damage to cause it.

And don’t we know already that this must be the case? How else do we make sense of people with back pain who don't exhibit some form of tissue damage that might reasonably account for their pain? Patients with back pain commonly present without objective findings on MRI or CT scans. Just as commonly, patients with back pain present with findings on their sans, but the findings aren't of a type or in a location that might reasonably cause their pain. It’s a common, everyday occurrence. Put together, these two types of back pain patients are likely to be more numerous that the percentage of back pain patients with objective findings that are concordant with their pain.

What often happens in the large percentage of cases in which scans fail to explain the pain is that the legitimacy of the pain is questioned. The basis for such doubt is the Cartesian understanding that pain must have some form of corresponding tissue damage; since there is none in these kinds of cases, their pain is doubted.

Moreover, if the field more fully understood and appreciated the ramifications of the fact that degenerative changes of the spine fail to substantially correlate with pain, we’d have to acknowledge as a field that degenerative changes of the spine as seen on scans simply cannot be the cause of our patients pain as often as we tell them it is – even in cases in which the scans show findings that are of the right type or in the right location to infer a causal role. (Similarly, just as a suspect in a murder case was in fact at the scene of the crime doesn’t mean that he is the murderer.) As such, in a large percentage, if not the majority, of people with back pain, we simply cannot say that the putative tissue damage as seen on scans is the cause of their pain.

How can this be?

th 2 225x288This Cartesian view might not be radically inaccurate, but it's likely only accurate in certain circumstances. If I suffer an injury, and so cause some form of tissue damage, such as stepping on a nail, I'll feel pain most of the time. So, in some cases, pain is associated with tissue damage. However, we would commit a logical fallacy (viz., affirming the consequent) to subsequently conclude that all pain must therefore be caused by tissue damage.

We actually have in the field of pain management a competing view of the nature of pain, how it works, and what to do about it. It’s referred to as the “neuromatrix of pain” (Melzack, 1989; Melzack, 1990; Melzack, 1999; Melzack & Loeser, 1978). It explains pain as a function of the central and peripheral nervous system. The nervous system, particularly the brain, is what produces pain. Sometimes, the nervous system produces pain in response to tissue damage, but it can produce pain in response to many other forms of stimuli as well.

In this way, the Cartesian model of pain can be subsumed within the more encompassing neuromatrix model of pain. We might see the Cartesian model of pain as akin to Newtonian physics – Newtonian physics isn’t exactly wrong, but it's only right in certain circumstances and as such it can be subsumed within the larger general relativity theory of physics. Similarly, tissue damage might cause pain, but not all pain is caused by tissue damage.

In the neuromatrix of pain model, we have a scientifically supported understanding of pain that can explain how people have, say, low back pain whether or not they have any identifiable tissue damage in the spine. Consider, for the moment, the wide-ranging and important ramifications of a scientifically accurate model of pain that explains all pain and not just pain for which we can identify a corresponding form of tissue damage:

  • Patients would no longer feel the legitimacy of their pain is at stake when, in the majority of cases, no identifiable tissue damage can be found and providers would no longer be at a loss to understand how or why such patients have pain.
  • Patients and providers would no longer need to pursue an exhaustive search for putative tissue damage through the use of scans, diagnostic injections, and other assessments when initial findings upon evaluation yield none.
  • We could subsequently explain to patients in a convincing way why scans aren't routinely necessary or helpful when it comes to non-specific back pain (i.e., now it simply doesn’t make sense to most patients and some providers because the assumption is that there must be tissue damage otherwise there wouldn’t be pain and so why withhold the use of the technology that might be able to find it?)
  • Rates of interventional and surgical procedures could be significantly reduced because we’d no longer be so certain that putative tissue damage must be the "pain generators" of back pain.
  • It provides an understandable explanation as to why interdisciplinary chronic pain rehabilitation is persistently shown to be the most effective form of chronic pain management, despite it doing nothing to resolve potential tissue damage that we tend to associate with the cause of pain.

Thus, the wide-scale adoption of the neuromatrix of pain model by patients, their healthcare providers, and society, more generally, would have far-reaching positive effects. In short, we would stop misunderstanding the nature of pain and what we should do about it.

The ICP Mission: Ideas that are Changing Pain

The Institute for Chronic Pain identifies the need to bring our societal understanding of pain into line with the findings of basic pain science of the last fifty years. In so doing, we aim to bring about the afore-mentioned important and necessary changes to the field of chronic pain management. We also understand that to do so it is not sufficient to focus solely on changing provider practice patterns. That is to say, we also need to change how the public at large understands the nature of pain. The guidelines for use of scans in low back pain is a case in point that attests to this fact: if patients don’t understand the basic rationale as to why scans are typically unhelpful in acute low back pain, then they'll continue to expect that the field provides them. No amount of concerted effort on changing provider practice patterns will achieve a change in patient expectations. Instead, we need to explain why a search for putative tissue damage is unhelpful – it’s because in most circumstances back pain isn’t caused by overt tissue damage to the spine and mistakenly believing that it is leads to ineffective overtreatment.

The Institute for Chronic Pain steps into this need for providing understandable, yet scientifically accurate, explanations for the nature of pain and how to best, or most effectively, treat it. We use the internet and social media to proliferate these ideas. Our goal is the widespread adoption of these scientifically accurate ideas about pain, which in turn will change how we treat pain for the better.

To this end, the Institute for Chronic Pain has launched a new webpage on the neuromatrix of pain. Please take look at it and pass it on through your social networks. The more people proliferate these ideas, the more our field of pain management changes for the better.

References

Atlas, S. J., Keller, R. B., Wu, Y. A., Deyo, R. A., & Singer, D. E. (2005). Long-term outcomes of surgical and non-surgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. Spine, 30(8), 927-935.

Bogduk, N. (2012). Degenerative joint disease of the spine. Radiology Clinics of North America, 50(4), 613-628.

Carragee, E. J., Alamin, T. F., Miller, J. L., & Carragee, J. M. (2005). Discographic, MRI and psychosocial determinants of low back pain disability and remission: A prospective study in subjects with benign persistent back pain. Spine Journal, 5(1), 24-35.

Chou, R., Qaseem, A., Owens, D. A., & Shekelle, P. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Annals of Internal Medicine, 154(3), 181-189.

DesCartes, R. (1633/2003). Treatise of Man. Amherst, NY: Prometheus.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68.

Flynn, T. W., Smith, B., & Chou, R. (2011). Appropriate use of imaging for low back pain: A reminder that unnecessary imaging may do as much harm as good. Journal of Orthopedic & Sports Physical Therapy, 41(11), 838-846.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved July 4, 2015, from The Cochrane Library, Wiley Interscience.

Koes, B. W., van Tulder, M., Lin, C.-W., Macedo, L. G., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific back pain in primary care. European Spine Journal, 19(12), 2075-2094.

Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

Martin, B. I., Turner, J. A., Mirza, S. K., Lee, M. J., Comstock, B. A., & Deyo, R. A. (2009). Trends in health care expenditures, utilization, health status among US adults with spine problems, 1997-2006. Spine, 34(19), 2077-2084.

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

Melzack, R. (1990). Phantom limbs and the concept of a neuromatrixTrends in Neurosciences, 13(3), 88-92.

Melzack, R. (1989). Phantom limbs, the self, and the brain (The D. O. Hebb Memorial Lecture)Canadian Psychologist, 30, 1-16.

Melzack, R. & Loeser, J. D. (1978). Phantom body parts in paraplegics: Evidence for a central ‘pattern generating mechanism’ for pain. Pain, 4, 195-210.

Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.

Nguyen, T. H., Randolph, D. C., Talmage, J., Succop, T., & Travis, R. (2011). Long-term outcomes of lumbar fusion among worker's compensation subjects: A historical survey. Spine 36(4), 320-331.

Pinto, R. Z. Maher, C. G., Ferreira, M. L., Hancock, M., Oliveira, V. C., McLachlan, A. J., Koes, B. W., & Ferreira, P. H. (2012). Epidural steroid injections in the management of sciatica: A systematic review and meta-analysis. Annals of Internal Medicine, 157(12), 865-877.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

Videman, T., Battie, M., Gibbons, L. E., Maravilla, K., Manninen, H., & Kaprio, J. (2003). Associations between back pain history and lumbar MRI findings. Spine, 28(6), 582-588.

Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296(20), 2441-2450.

Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008) Surgical vs nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

Date of last modification: 7-4-2015

Author: Murray J. McAllister, PsyD 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Neuromatrix of Pain Sat, 04 Jul 2015 10:44:36 +0000
Fear-Avoidance of Pain https://www.instituteforchronicpain.org/blog/item/118-21fear-avoidance-of-pain https://www.instituteforchronicpain.org/blog/item/118-21fear-avoidance-of-pain

There’s a divide between chronic pain experts and their patients that rarely gets crossed. The divide centers on the issue of fear-avoidance of pain. 

On one side of the divide, among chronic pain experts, fear-avoidance is one of the most well established facts about chronic pain and chronic pain-related disability. Over more than a decade, researchers and clinicians have extensively studied fear-avoidance and almost every month another study on it gets published in the professional journals. As such, it’s a well established fact among chronic pain experts. On the other side of the divide, it’s rare to find a chronic pain patient who has ever heard of it.

It’s a strange state of affairs that goes on between chronic pain providers and their patients. We know something important about chronic pain and chronic pain-related disability and our patients don’t know it. And yet, it goes unsaid. You’d think that everyone involved would want it shared. But, still, it doesn’t.

While I’ve never seen a study that could shed light on why the divide occurs, I have some thoughts about it. There are actually two reasons, but they go hand in hand.

First, we don’t share what we know about fear-avoidance because we aren’t very good at teaching patients (and maybe even the public) about what chronic pain is. Patients (and the public) commonly consider the sensation of pain as solely and only a physical sensation. As such, it’s thought that psychological aspects have very little to do with the sensation of pain itself. At most, the psychological aspects of pain are thought of as consequences of pain – that the distressed thoughts and moods, like fear, and the behaviors that go along with them are really just reactions to the physical sensation of pain. As chronic pain experts, though, we know that it isn’t true. While it requires and involves a physical sensation, to be sure, the experience of pain also inherently involves unpleasant and distressing thoughts, feelings, and behaviors. Any explanation of fear-avoidance requires this understanding of chronic pain – that it is more than simply and only a physical sensation. However, it is hard to communicate this notion. It’s difficult to teach patients to expand their understanding of chronic pain and incorporate its inherent cognitive, emotional, and behavioral components. Moreover, besides being hard to communicate, it has to be communicated well – with compassion and sensitivity -- in order for most patients to succeed in understanding the true nature of chronic pain. This point leads us to the second reason for the great divide between chronic pain experts and their patients.

Second, to be frank, there can be a little pushback from patients when it comes to explaining that chronic pain is more than simply a physical sensation and that it in fact involves psychological as well as medical aspects. Frank discussion of the inherent psychological aspects of chronic pain can tend to get inhibited because it opens up the possibility of critical judgment and stigma by others. It’s safer to insist that chronic pain and its related difficulties are solely and only physical because in our society it is acceptable if you struggle with a medical condition. It’s not acceptable to acknowledge that you’re psychologically struggling. Consequently, and understandably, patients can resist coming to understand how chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition.

This resistance reinforces any unwillingness of healthcare providers to bring up the notion of fear-avoidance because it assumes a foundational understanding that chronic pain is both a medical and a psychological condition. To convey the latter, though, as indicated, it’s hard work. To succeed in doing so, it requires a high level of skill on the part of healthcare providers – a degree of interpersonal compassion and sensitivity. It also involves a level of interpersonal skill on the part of the patient – the ability to develop a safe, trusting relationship in which the patient can be assured that no critical judgment will occur.

Fear-avoidance is therefore a sensitive issue, which challenges the skills of both chronic pain experts and patients, if we are to ever bring it up. We have to admit that providers have a hard time talking about it and patients tend to have a hard time hearing about it. So, we avoid the topic. It’s a bit ironic: we avoid discussions of fear-avoidance. The great divide in knowledge and understanding subsequently continues.

If you’re game to talk about it, though, I’m game. Let’s give it a try.

There’s significant benefit if we can pull this off. As chronic pain experts, we know that fear-avoidance is one of the most important factors that lead to chronic pain-related disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Leeuw, et al., 2007; Vlaeyen & Linton, 2012). If you can learn about it, and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important. So, let’s talk about it. Ready?

Fear-avoidance defined

Pain is a naturally unpleasant and distressing experience. We don’t laugh or jump up and down for joy when in pain. Rather, we cry and become alarmed. Pain captures our attention and our thoughts become concerned about it. We think about what’s causing it and how to get rid of it. Emotionally, we are alarmed and distressed. These cognitive and emotional aspects to the experience motivate us to get help, stop the pain, and avoid it again in the future.

These ways of experiencing pain and reacting to it are not chosen or the result of intentional decisions. When in pain, we don’t intentionally decide to perceive it as unpleasant or distressing, and subsequently begin to cry and emotionally become alarmed. Moreover, we don’t typically choose how we are going to think about pain and how we might make sense of it. Rather, pain just is inherently emotionally distressing and alarming. As such, even though we can tend to think of it as solely a physical sensation, we cannot wholly divorce the sensation of pain from how we perceive it, cognitively and emotionally. The cognitive and emotional distress is just part and parcel of the experience of the sensation. The whole experience also involves behaviors that are indicative of being in pain – the grimacing, verbal expressions, guarding, and the like. None of these behaviors are typically thought of as chosen behaviors. Subsequently, we might say that all these cognitive, emotional, and behavioral aspects to the experience of pain are automatic or reflexive.

Let’s take an example. Consider what happens when you burn your hand on the stove. Behaviorally, you reflexively pull your hand away and guard it. Tears might come to your eyes and you might exclaim all sorts of utterances. Cognitively, your thoughts are focused on the pain and what to do about it. Emotionally, you are upset and alarmed. Your emotional distress motivates you to act. It also motivates you to be careful next time. Later, you’ll apt to be apprehensive and take steps to avoid getting burned again.

Experts in chronic pain management call this constellation of cognitive, emotional, and behavioral components to the experience of pain, “fear-avoidance.”

Fear-avoidance is all well and good in an acute injury. It’s an adaptive and helpful response. It helps us to get better and avoid future injury.

What’s good for an acute injury, however, is not always good for chronic pain. Persistent fear-avoidance in chronic pain leads to persistent emotional distress and impairments in activities. In other words, chronic fear-avoidance is one of the most important factors that lead people with chronic pain to become disabled.

If, like the alarming nature of acute pain, chronic pain remains alarming indefinitely, then the natural reaction to pain is to always try to stop it or get rid of it. Since, though, the pain is chronic, there’s not much the typical chronic pain patient can do to stop it. Of course, there are medications and various kinds of therapies, but at best these approaches only reduce pain. It can then seem like the only thing that’s left to do is to stop doing activities that make pain worse.

If work makes your pain worse, and you struggle to tolerate it, coming home distraught by the pain night after night, then it can seem reasonable to conclude that maybe you shouldn’t go to work anymore. If the pain of sitting in the bleachers at your child’s sporting event or musical performance was too excruciating the last time you went, then you might find yourself making the tough decision to stay home tonight instead. Over time, you can come to anticipate when pain is going to become too overwhelming and consequently avoid those activities too. You end up declining invitations to the extended family reunion, the weekend trip that includes the long car ride, the outing to the amusement park, or other similar activities. All these examples are examples of fear-avoidance of pain and its associated activities.

Notice that inherent in all these examples is that pain is something that’s concerning and distressing, which then leads to not doing the activities that bring on pain. For after all, if, when doing some activity, the pain wasn’t alarming, then we’d say the pain was tolerable and we’d keep doing the activity. The pain would still be there, of course, but we’d do the activity without any concern or sense of alarm about it. In the examples above, though, the pain involved in the activities is distressing and alarming and so the activities are stopped. In the short hand of pain experts, these examples involve fear-avoidance of pain and the activities associated with pain.

What it all comes down to is that, when it comes to chronic pain-related disability, the cognitive, emotional, and behavioral aspects of the experience of pain are the most important components, not the actual physical sensation. It’s the sense of alarm that is the tipping point and stops people from doing things. Of course, the sensation plays a role, but without the sense of alarm – the cognitive and emotional ways of perceiving the sensation – the sensation itself would be tolerable and there’d be no need to avoid or otherwise stop the activity.

Now, here is where patients can start to get a little uncomfortable.

Common patient reactions to the notion of fear-avoidance

When first hearing about fear-avoidance, a common reaction among patients is something like the following: “It’s not my emotional or behavioral reactions to pain that disable me, it’s the physical pain!” The sentiment involves a concern for being judged and also being a little put off. Both sentiments are understandable.

At the end of the day, though, is it accurate and is it necessary? Would the patient be better off by coming to understand the truth about fear-avoidance and then learning how to overcome it? Let’s take a close look at these issue.

As suggested above, the point of the resistance to fear-avoidance is really two-fold, but they go hand in hand. First, it is an assertion about what pain is – that pain is a physical sensation that is wholly different from any cognitive, emotional, and behavioral factors related to pain. Second, it is an assertion that if psychological aspects of the experience of pain are acknowledged, then they open up chronic pain patients to the potential shame of stigma and the critical judgments of others. The two assertions work hand in hand because insistence on the notion that pain is solely and only a physical sensation puts it into the medical category of conditions and it is typically socially acceptable to be disabled from medical problems. But, if we acknowledge that there are psychological aspects to the pain experience, then we run the risk of putting it into the psychological category of conditions, and it just isn’t acceptable to be disabled by psychological problems.

As we said, it’s a sensitive issue.

Any response to this common patient reaction requires, not only an expert understanding of what chronic pain is, but also a deep level of compassion and sensitivity in order to convey this understanding to patients, making it okay enough for them to acknowledge and learn from.

Let’s try to show how it might just be true that the psychological aspects of the experience of pain are more important than the physical sensation, especially when it comes to chronic pain-related disability.

Consider, for the moment, two patients with chronic low back pain, Mr. Smith and Ms. Jones. Let’s further suppose that they each have the same exact degenerative changes in their lumbar spine, as evidenced by recent scans. Over the last month, each of their pain has been worsening.

Mr. Smith has been told and therefore believes that the degenerative changes in his spine are inevitably progressive. He conceptualizes his condition as that his ‘discs are degenerating.’ He believes (and may have been told) that given the degenerative nature of his condition he will likely end up in a wheelchair someday. During the last month, his pain has been worsening and he takes it as evidence of his inevitably degenerating condition. This perception of his pain is alarming. Out of this resultant fear, he responds with rest and inactivity. From his perspective, it makes all the sense in the world to rest and remain inactive. Given his understanding of his pain as the result of a fragile orthopedic condition that is inevitably getting worse, he reasons that he needs to not engage in activities as a means to prevent, or at least slow down, the degenerative process in his spine. Just as you wouldn’t walk on a broken leg, rest and not doing too much seems like the best approach for his condition. He rates his pain as intolerable.

Ms. Jones has been told that she has degenerative changes in her spine, but she has also been told it is normal for a person of her age. It was explained to her that the term ‘degenerative disc disease’ is actually a misnomer and that we now know it really isn’t degenerative or a disease. We know, for instance, that most of the time degenerative changes of the spine get better, not worse, and even in those situations where they don’t get better, they almost always stay the same. It was explained to her that chronic pain is actually a complex condition and that her pain is only partly attributable to her stable degenerative changes in spine. The overall state of her nervous system, in terms of central sensitization, and external stressors, can also play a role in maintaining her chronic pain.

Ms. Jones has taken these lessons to heart and is confident that she knows what her pain is and that it is chronic and stable. She has so fully accepted it that it no longer alarms her. She knows that reasonable activities are not going to make her stable degenerative changes worse. She’s identified for herself that if she stays home when having a bad pain day she has nothing to do but focus in on how much pain she has. As a result, her response to pain is to get up and go do something. Of course, she’s reasonable about it and she paces herself when needed. Nonetheless, she sees staying active and productive as ways to cope with pain. Because she knows her degenerative condition is stable, she reasons that the increase in pain over the last month isn’t due to a worsening of her spinal condition and subsequently looks to other reasons for the pain increase. She recognizes that the increase in pain corresponds, for instance, to the last few months of poor sleep and, sometimes, outright insomnia. She knows that her poor sleep is itself due to the stress of some recent family issues -- one of her children is going through a difficult divorce and her grandson, from another one of her children, was recently diagnosed with autism. She recognizes that her increased pain is due to the stress of these family issues and the resulting insomnia. So, she sets out to take better care of herself and manage her stress better. She notes that her pain has increased but it still remains tolerable.

Mr. Smith and Ms. Jones have the same degenerative condition and, we assume, the same physical sensation. However, how they make sense of it is very different. How they feel about it is very different. How they behaviorally cope with it is very different. Mr. Smith experiences pain through the lens of it being indicative of a threatening condition that’s inevitably going to bring about severe impairments. Ms. Jones sees her pain as indicative of a benign and stable condition. She also recognizes that she has some control over how much pain she has by managing the state of her nervous system and how much stress she has. Mr. Smith sees his pain as largely out of his control. Mr. Smith’s moods are mostly fear-based. Ms. Jones is mostly confident. Mr. Smith engages in passive coping strategies of rest and inactivity. Ms. Jones engages in active coping strategies of remaining active, productive, and often getting out of the house. Mr. Smith experiences his pain as intolerable. Ms. Jones still rates her pain as tolerable, even though it has increased over the last month.

Mr. Smith, we might say, is fear-avoidant. Ms. Jones is not.

While hypothetical, the case examples show how it is possible that the psychological components to the experience of pain can make all the difference. The physical sensation, we assume, remains constant across both individuals. However, the beliefs about the sensation, the quality of the attention given to it, the mood states that occur during the sensation, and the behavioral responses to it, all have a reciprocal affect on the quality and intensity of the overall experience of pain.

In one instance, these psychological components make the pain intolerable and impairing. In the other instance, the psychological components make the pain tolerable and she refrains from becoming disabled.

A vast array of experimental and clinical research supports our hypothetical cases. Of course, a review of the biopsychosocial nature of chronic pain is beyond the scope of this blog post. I’d refer the reader, though, to any of the numerous reviews of the matter (e.g., Bushnell, Ceko, & Low, 2013; Linton, 2000). You’ll find that beliefs, particularly beliefs of the threatening nature of pain, can influence the self-rated unpleasantness and intensity of pain (Gracely, et al., 2004). It’s well established that people rate their pain as worse when they believe it’s somehow threatening to them, than if they believe it’s benign, even when the painful stimuli is held constant across both groups. You’ll find that it is well established that pain is worse when your attention is focused on it than when your attention is distracted (Bantick, et al., 2002; Eccleston & Crombez, 1999). It’s well established that people with negative mood states will have higher pain ratings than people with more positive mood states, again, even when the painful stimuli is held constant (Tang, et al., 2008; Villemure & Bushnell, 2009; Wiech & Tracey, 2009; Wiech, Ploner, & Tracey, 2008). It’s also well established that people who engage in passive coping strategies, such as rest and inactivity, tend to have higher rates of pain and disability than those who don’t (Jensen, Turner, Romano, & Karoly, 1991; Samwel, Evers, Crul, & Kraaimaat, 2006).

In all, there’s just no getting around the fact that the nature of chronic pain is such that it has both physical and psychological aspects inherent to it. The notion that pain is solely a physical sensation that can be wholly divorced from cognitions, emotions, and behaviors is just not true. In fact, like in the case of fear-avoidance, the psychological components can make all the difference in what makes pain tolerable or not.

As chronic pain experts, we need to find a way to routinely educate patients and the public about the true biopsychosocial nature of chronic pain. We also need to be able to do it well – with compassion and sensitivity. We need to understand why patients might tend to resist what we take as established truth. It’s because of stigma. It’s because in this day and age it is still not socially acceptable to see chronic pain as a psychological condition, even if it is only in part psychological. We need to be able to develop trusting relationships where the truth can be told and discussed, and patients remain accepted and respected.

Patients too need to practice having the ego strength to acknowledge this truth and do so without shame. You don’t have to buy relief from stigma by insisting on something that’s not true – the belief that chronic pain is solely and only a physical sensation that is separable from any psychological factors. The challenge is to practice remaining confident that you are doing nothing that’s worthy of criticism. We might rightfully judge and criticize someone who lies, cheats, or steals. But, we don’t judge or criticize those who struggle to cope with any of life’s psychological problems, chronic pain included.

Indeed, if we all could overcome stigma, then healthcare providers could openly talk about the well established psychological aspects of chronic pain, such as fear-avoidance, and our patients could openly hear it. Together, we could make significant progress in helping people to learn to live well despite having chronic pain. In so doing, we could bridge the divide that has prevented us from acknowledging what we all know is true.

References

Bantick, S. J., Wise, R. G., Ploghaus, A., Clare, S., Smith, S. M., & Tracey, I. (2002). Imaging how attention modulates pain in humans using functional MRI. Brain, 125(2), 310-319.

Bushnell, M. C., Ceko, & Low, L. A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews Neuroscience, 14(7), 502-511.

Crombez, G., Vlaeyen, J. W., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than pain itself: Evidence on the role pain-related fear in chronic back pain disability. Pain, 80(1), 329-339.

Eccleston, C. & Crombez, G. (1999). Pain demands attention: A cognitive-affective model of the interruptive function of pain. Psychological Bulletin, 125(3), 356-366.

Gracely, R. H., Geisser, M. E., Giesecke, T., Grant, M. A., Petzke, F., Williams, D. A., & Clauw, D. J. (2004). Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain, 127(4), 835-843.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of he literature. Pain, 47(3), 249-283.

Leeuw, M. Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. (2007). Fear-avoidance model of chronic musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77-94.

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1125-1156.

Samwel, H. J., Evers, A. W., Crul, B. J., & Kraaimaat, F. W. (2006). The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients. Clinical Journal of Pain, 22(3), 245-251.

Tang, N. K., Salkovskis, P. M., Hodges, A., Wright, K. J., Hanna, M., & Hester, J. (2008). Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients. Pain, 138(2), 392-401.

Vlaeyen, J. W. & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.

Villemure, C. & Bushnell, M. C. (2009). Mood influences supraspinal pain processing separately from attention. Journal of Neuroscience, 29(3), 705-715.

Wiech, K., & Tracey, I. (2009). The influence of negative emotions on pain: Behavioral effects and neural mechanisms. NeuroImage, 47(3), 987-994.

Wiech, K., Ploner, M. & Tracey, I. (2008). Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8), 306-313.

Author: Murray J. McAllister, PsyD

Date of last modification: 9-9-2013

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

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Fear Avoidance Mon, 09 Sep 2013 19:03:45 +0000
Trauma https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/trauma https://www.instituteforchronicpain.org/understanding-chronic-pain/complications/trauma Trauma

What is trauma?

Trauma is the psychological and bodily response to experiencing an overwhelmingly terrible event. Some examples of events that can lead to trauma are the following:

  • Combat
  • Domestic violence
  • Sexual assault
  • Natural disaster
  • Terrorism
  • Physical or sexual abuse in childhood

These events are not run-of-the-mill bad things that happen in life. Rather, events are typically considered traumatic when they threaten the life or bodily integrity of the individual who experiences them.1 Also, traumatic events tend to overwhelm a normal person’s ability to cope with them.

After experiencing events like the above, people tend to develop certain predictable reactions. Examples are the following:

  • Persistent and unwanted thoughts, memories, or dreams of the event
  • Heightened physiological arousal, such as tension, nervousness, irritability, startling easily, poor concentration, or poor sleep
  • Avoidance of places or things or events that are reminiscent of the traumatic event

All these reactions are related to anxiety. The persistent, unwanted thoughts and memories produce fear and anxiety. The arousal reactions are the physical manifestations of this anxiety. It’s the nervous system in action – tense and nervous. Avoidance is a common coping strategy for things that are anxiety provoking. It’s a way of not getting reminded of the event.

Relationship between trauma and anxiety

Whether due to trauma or other causes, anxiety in general is a state of the nervous system. When anxious, people are literally nervous. They are nervous in their feelings, their body, their thinking and in their behavior. With anxiety, the nervous system is stuck in a state of alarm, as if some scary thing were actually happening.

Psychologists have dubbed this state of alarm the fight-or-flight response. It prepares people to respond to danger by making the body ready to fight or flee from danger. The nervous system gets kicked into high gear, as it were, and it responds with feelings of being alarmed, with physical changes of the body that increase the capacity for action, with an increased cognitive focus on the danger, and avoidance behaviors.

In actual dangerous situations, this fight-or-flight response of the nervous system is a helpful thing. It’s the body’s natural overdrive system and it helps people to survive dangerous situations.

Anxiety is the result of the nervous system going into fight-or-flight in the absence of a real or actual danger. It’s anxiety when the nervous system kicks into fight-or-flight at the mere thought that something dangerous might happen. Such thoughts are called worry – thinking something bad is going to happen and consequently becoming nervous.

The anxiety reactions that occur as a result of trauma are similar. Whether it was an assault, violence or a natural disaster, the original traumatic event was actually dangerous. The person who experienced it had a nervous system that went into fight-or-flight. It was likely helpful at the time. After the event has come and gone, though, the thought of the traumatic event or a memory of it can still kick the nervous system into fight-or-flight as if the event is happening now. It leads to anxiety, increased arousal and avoidance behaviors, as described above.

This reaction is considered a form of anxiety because the event is not actually happening. Instead, the reactions are brought on by the thought or memory of the event.

High rates of trauma in people with chronic pain

As a group, people with chronic pain tend to report much higher rates of having experienced trauma in their past, when compared to people without chronic pain. It is a common and consistent finding in the research.

Upwards of 90% of women with fibromyalgia syndrome report trauma in either their childhood or adulthood and 60% of those with arthritis report such a trauma history.2 With or without back surgery, upwards of 76% of patients with chronic low back pain report having had at least one trauma in their past.3 Sixty-six percent of women with chronic headache report a past history of physical or sexual abuse.4 Among men and women, fifty-eight percent of those with migraines report histories of childhood physical or sexual abuse, or neglect.5 Women with chronic pelvic pain also report high rates of sexual abuse in their past, upwards of 56%.6 

As a point of comparison, rates in the general population for physical abuse in childhood are 22% for males and 19% for females; rates in the general population for self-reported childhood sexual abuse are 14% for males and 32% for females.7 Rates of adult sexual assault in the general population are 22% for women and about 4% for men.8 Domestic violence is upwards of 21% in the general population.9 

As is evident, when compared to the general population, people with chronic pain tend to have at least double the rates of trauma in their past.

The relationship between trauma and chronic pain

What accounts for this high rate of trauma in patients with chronic pain?

To be clear, these statistics do not prove that trauma causes chronic pain in any wide scale sense. Of course, traumas, such as injuries sustained in combat or assaults, could lead to chronic pain, but most of the time the onset of chronic pain is independent of the prior history of trauma. Indeed, many people with chronic pain have no history of trauma in their background. So, trauma doesn’t typically cause chronic pain in a direct way.

Nonetheless, the high rate of trauma in people with chronic pain suggests that it might have some relationship to the development of chronic pain.10

The relationship might be the following: a history of trauma might make a person more prone to develop chronic pain once an injury occurs. Let’s explain.

The nervous system & the transition from acute injury to chronic pain

Assume, for the most part, that painful accidents, injuries or illnesses occur on a random basis. Everyone has an accident or gets injured or gets ill on occasion. The vast majority of the time people get better and the pain goes away. Sometimes, though, they don’t. They transition from an acute injury or illness to chronic pain. Most experts agree that the process that accounts for this transition from acute injury or illness to chronic pain is central sensitization.11, 12

Central sensitization is condition associated with chronic pain in which the nervous system becomes stuck in a state of heightened reactivity. In central sensitization, the sensations of pain can become more intense and things that are not normally painful, like touch or massage, can also become painful. Central sensitization maintains pain even after the initial injury or illness heals.

So, here is the relationship between chronic pain and trauma. Trauma and its resultant anxiety is also a condition of the nervous system being in a persistent state of reactivity. As described above, trauma leads to anxiety, physiological arousal, and avoidance behaviors. These reactions to trauma are all indicators of a persistently aroused or reactive nervous system. As such, when patients with a history of trauma get injured or become ill, their nervous system is already in a state of persistent reactivity.

Might it be the case that such persons are more prone to develop central sensitization and transition from an acute injury or illness to chronic pain?

Many experts think so.13, 14, 15, 16 There is research that supports this hypothesis. Young Casey, et al.,17 showed that past traumatic events (along with depression) predicted continued pain and disability three months after onset of back or neck pain. In a prospective study, Jones, et al.,18 found that childhood adversities significantly raised the risk of developing chronic widespread pain by mid-life. Chronic widespread pain is an indicator of central sensitization. McBeth, et al.,19 found that altered levels of a stress hormone prospectively predicted the development of chronic widespread pain. Scarinci, et al., found that patients with histories of trauma tend to have lower pain thresholds.20 Lowered pain thresholds is another characteristic of central sensitization.

The common denominator between chronic pain and trauma is thus the nervous system. Trauma can make the nervous system persistently reactive. Once an acute painful injury or illness occurs, people with an already reactive nervous system are more prone to develop chronic pain.

Of course, a history of trauma is not necessary to develop chronic pain. Many people without a history of trauma can also develop chronic pain.  There are likely multiple routes to the development of central sensitization. Nonetheless, a history of trauma and its resultant anxiety are likely one route.

Treatment for chronic pain

Chronic pain rehabilitation programs are the only form of chronic pain management that makes it a point to also focus on psychological factors that can complicate chronic pain. Such programs routinely focus on helping patients to acquire the abilities to self-manage pain and return to work. However, they also focus on treating anxiety, depression, sleep problems, and also, importantly, anxiety related to trauma.

References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, test revision. Washington DC: American Psychiatric Association.

2. Walker, E. A., Keegan, D., Gardner, G., Sullivan, M., Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II Sexual, physical, and emotional abuse and neglect. Psychosomatic Medicine, 59, 572-577.

3. Schofferman, J., Anderson, D., Hines, R., Smith, G., & Keane, G. (1993). Childhood psychological trauma and chronic refractory low-back pain. The Clinical Journal of Pain, 9, 260-265.

4. Domino, J. V., & Haber, J. D. (1987). Prior physical and sexual abuse in women with chronic headache: Clinical correlates. The Journal of Head and Face Pain, 27, 310-314.

5. Tietjen, G. E., Brandes, J. L., Peterlin, B. L., et al. (2010). Childhood maltreatment and migraine (part I). Prevalence and adult revictimization: A multicenter headache clinic survey. Headache, 50, 20-31.

6. Walling, M. K., Reiter, R. C., O’Hara, M. W., Milburn, A. K., Lilly, G., & Vincent, S. D. (1994). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics & Gynecology, 84, 193-199.

7. Briere, J. & Elliott, D. M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27, 1205-1222.

8. Elliott, D. M., Mok, D. S., & Briere, J. (2004). Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress, 17, 203-211.

9. Schafer, J., Caetano, R., & Clark, C. L. (1998). Rates of intimate partner violence in the United States. American Journal of Public Health, 88, 1702-1704.

10. Nicol, A. L., Sieberg, C. B., Cauw, D. J., Hassett, A. L., Moser, S. E., & Brummett, C. M. (2016). The association between a history of lifetime traumatic events and pain severity, physicacl function, and affective distress in patient with chronic pain. Pain, 17(12), 1334-138.

11. Apkerian, A. V. (2011). The brain in chronic pain: Clinical implications. Pain Management, 1, 577-586.

13. Arendt-Nielsen, L. & Graven-Nielsen, T. (2003). Central sensitization in fibromyalgia and other musculoskeletal disorders. Current Pain & Headache Reports, 7, 355-361.

14. Macfarlane, A. C. (2007). Stress-related musculoskeletal pain. Best Practice & Research Clinical Rheumatology, 21, 549-565.

15. Basser, D. S. (2012). Chronic pain: A neuroscientific understanding. Medical Hypotheses, 78, 79-85.

16. Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1-35.

17. Young Casey, C., Greenberg, M. A., Nicassio, P. M., Harpin, R. E., & Hubbard, D. (2008). Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors. Pain, 134, 69-79.

18. Jones, G. T., Power, C., & Macfarlane, G. J. (2009). Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain, 143, 92-96.

19. McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

20. Scarinci, I. C., McDonald-Haile, J., Bradley, L. A., & Richter, J. E. (1994). Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: A preliminary study. The American Journal of Medicine, 97, 108-118.

Date of publication: April 27, 2012

Date of last modification: August 7, 2017

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Complications Fri, 27 Apr 2012 13:15:07 +0000