Throughout my career as a physician, I had always believed that pain was based in anatomical structural abnormalities or disease processes that damage the nervous system—a broken ankle, a surgical incision, back pain from a herniated disc, diabetes, or neurological disease. I thought it was all treatable with the right medication, procedural intervention, or operation. Never in my wildest dreams would I have realized that so much of chronic pain, a complex disorder that is entirely different from acute pain, is related to the organ system that’s housed in our skulls—the brain. In fact, treating hundreds of patients at Las Vegas Recovery Center, I’ve observed that the majority of the experience of chronic pain is driven by emotions and thoughts.
Here I will highlight five lessons I have learned over the last six years while working with people with drug dependence and many different types of chronic pain.
1. All pain is real. For so many people with chronic pain, the “validity” of the pain is suspect. Patients with chronic pain are frequently doubted and misunderstood by doctors, family, and friends. Pain is subjective—everyone experiences it differently. There is no easily accessed, objective way to measure another person’s pain level. Each individual’s interpretation and expression of pain is based on a complex interaction of physical, psychological, and emotional factors, all of which originate from the brain.
Chronic pain sometimes has no concrete, identifiable cause, but that doesn’t make the pain any less real. Some conditions, such as fibromyalgia, chronic headaches, and interstitial cystitis, are thought to be exaggerated or unreal. These are interpretations by a group of clinicians who don’t understand chronic pain, and they do a disservice to patients and their families by discounting the validity of the pain.
2. Emotions drive the experience of pain. Many of the people I see in treatment are medicating emotional pain that they perceive as physical pain. They feel anxious, and their back starts to hurt, so they take a painkiller. They’re not making it up. Anxiety causes you to hurt more. Emotional pain is very much a part of chronic pain. In my experience, chronic pain is about 20 percent sensory, and the rest, the other 80 percent, is emotional.
There are five key emotions that make pain worse: fear, guilt, anger, loneliness, and helplessness. For example, a common response is to have an emotional reaction to the sensory experience: “My back hurts, darnit! That means I can’t go to yoga tonight . . . I’ll be in bed for a week . . ., etc.”
The process of thinking and then feeling in response to the thoughts influences the experience of pain.
3. Opioids don’t always make chronic pain better; they may make it worse. Opioids are extremely effective as pain relievers; however, because many people develop a tolerance to the medicines within two to three months, it is often necessary to increase the dosage. Therein lies one of their primary dangers—as the dosage increases and the drug is used over time, physical dependence, and possibly addiction, develops.
Certainly for the acute pain of a broken leg or surgical incision, opioids are appropriate as a short-term treatment over a finite time period. But with opioid use for chronic pain, increasing doses, increasing pain, decreased function, and inability to discontinue the drugs without significant discomfort lead to misery and despair. Opioids have many side effects, and sometimes, using opioids actually causes more pain—a phenomenon known as opioid-induced hyperalgesia.
4. Treat to improve function. It is a certainty that any prescriber can give a patient enough medication to temporarily alleviate pain, but the patient would be left unconscious. This is not the proper goal of the treatment of chronic pain. If we are treating with the goal of taking pain away, but the person is getting worse in terms of his or her ability to be active and productive, that is not good pain treatment. With most chronic pain conditions, the goal of eliminating pain altogether is simply not realistic. When treating chronic pain, improvement of function needs to be taken into consideration.
5. Expectations influence outcome. The answers to many of the problems that plague those with chronic pain lie in the powers of their minds. There are many studies that prove that believing a treatment will work results in a significant percentage of subjects having an effect. What creates this effect? It is the belief that there will be an effect. This belief causes significant changes in the brain and body, which translate into a different experience.
In the case of chronic pain, we can utilize the power of the patient’s mind to cause pain reduction, mood improvement, and improvement in function.
The next series of blogs will address each of these five areas in much more depth, and will include a discussion of alternative measures effective in the treatment of chronic pain.