Chronic Pain

How Many Deaths Will It Take? Prince Is Just the Latest

Opiates are not helpful for chronic pain, but psychological flexibility is

Posted Jun 03, 2016

Prince died of an overdose. The news stories will claim it was an overdose of a medication but that’s not the whole story: his death came from our collective overdose on the medicalization of chronic pain. A champion against drug abuse, Prince succumbed to a medical system and a culture that took him by the hand, and in the name of compassion, walked him off a cliff.

The over-medicalization of chronic pain is deeply rooted in our own common sense—so we all need a little consciousness raising. 

It’s not our fault. Every one of us has experienced acute pain and most of us know what it feels like when pain medication took it away. I was only eight when an injection of morphine took away the pain of a stingray wound suffered an hour earlier on a California beach. The relief was so dramatic I literally cried, and my mother, seeing that sudden relief, cried with me. Of course she did. Who would not want that for people we love when they are in pain? 

Photo by Sharyn Morrow, used with permission
Source: Photo by Sharyn Morrow, used with permission

It is just common sense to think that pain itself needs to be eliminated. Surely that is true whether the pain is from a recent bite, sting, or wound—or whether it is the long lasting suffering from aching knees, or a sore back. It is all the same thing, right? Pain is pain, right?

No, it is not. Only the word “pain” is the same. 

Chronic pain refers to pain that persists after adequate time for tissue healing. 

Chronic pain is more like a difficult emotion than an acute signal of tissue damage. Chronic pain is everywhere—about a third of adults of middle age or more have it. It correlates only weakly with the amount of injury.

The biggest determinant of life functioning for those with chronic pain is not the amount of pain, but how pain is handled psychologically.1

And here is the kicker: opiates have only small benefits for chronic pain, that diminish over time and carry enormous side effects, including addiction. Just 3 months ago the Center for Disease Control (CDC) looked at decades of data and said very directly “don’t use opioids routinely for chronic pain.”

So what can you do?

The CDC had an answer for that too: “Use nonpharmacologic therapies (such as exercise and cognitive behavioral therapy) and nonopioid pharmacologic therapies (such as anti-inflammatories) for chronic pain.”

It’s great guidance and had his doctors done that, perhaps Prince would be alive today. 

We are now learning why cognitive behavioral therapy (CBT) for chronic pain works. Two weeks ago the American Pain Society (APS) issued a press release suggesting that psychological flexibility may be the key to improving treatment for chronic pain, citing data showing that CBT works by increasing “psychological flexibility.”

Psychological flexibility is the name for the model of change underlying Acceptance and Commitment Therapy (ACT)—a form of CBT I began developing 34 years ago. Based on the scientific evidence, ACT is listed by the American Psychological Association as strongly supported for persistent or chronic pain. 

Psychological flexibility refers to the ability to open up to inner experience with an attitude of self-compassion and curiosity, even if experiences are difficult, and then to shift ones’ attention toward actions that are meaningful and values based. I came upon those processes originally through my personal struggle with anxiety—a story I told in a recent TEDx talk—but it turns out that this combination is a powerful predictor of outcomes in chronic pain too. That is the case, the APS press release notes, not just with ACT but in other forms of CBT.

A study came out a few weeks ago that helps explain why.2 In this study, chronic pain patients who were also addicted to opiates were exposed to experimentally induced pain delivered via a thumb screw. Some patients were randomized to health education —learning about pain and health—while other patients were randomized to ACT. Brain imaging was done before and after the 8-week treatment program.

What the researchers found was remarkable. After treatment, the brains of ACT patients were more resilient at rest, and less reactive to pain even when it was deliberately induced. It was the kind of result we’ve seen before in long-term meditators, but in this case it was done in just 8 weeks of psychotherapy. The ACT patients learned how to carry their pain is a less entangling way: chronic pain and induced pain.

After enough time has gone by to heal tissue damage, dealing with pain is more like dealing with a very difficult emotion than it is dealing with a cut. You cannot find wise ways to do that by filling an opiate prescription. Chronic pain patients need skills, not just pills.

We know some of the skills that will help. Psychological flexibility is arguably the best currently available marker of long term adjustment to chronic pain. We can teach it and it empowers lives. 

How many more deaths before we confront our over-medicalization of chronic pain? How many more deaths before it becomes a national priority to give chronic pain patients the skills they need? 

The CDC has it right. The time to change course is now.


1. McCracken, Lance M.; Vowles, Kevin E. (2014).  Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress.
American Psychologist, 69(2), 178-187.

 2. Smallwood, R. F., Potter, J. S. & Robin, D. A (2016). Neurophysiological mechanisms in acceptance and commitment therapy in opioid-addicted patients with chronic pain. Psychiatry Research: Neuroimaging, 250, 12-14.