An evolving understanding of pain is leading us to treatments that are safer — and more effective — than opioids.
Jennifer Kane has been hurting for a long time. Spinal stenosis, degenerative disc disease, and a ripped spine following a complicated childbirth have all contributed to more than 15 years of chronic pain.
Despite multilevel spinal-fusion surgery, six weeks of physical therapy, and x-rays showing she had healed well, she still suffered intense discomfort. Kane’s doctor prescribed opioids to manage her pain, but they made her ill. She also tried the myriad muscle relaxers, antidepressants, and anti-inflammatory drugs her physician suggested.
In the end, she concluded that relief was not going to come in the form of a pill.
“You think doctors have a giant toolbox of things they can give you, but that’s not really true,” says Kane, an author and communications strategist in Minneapolis. “If you keep coming back because your pain isn’t getting better, there’s not much else they can do. They just told me, ‘It sucks, doesn’t it?’”
So Kane set out to research the latest treatments for chronic pain, eventually compiling her findings into a book, Chronic Pain Recovery: A Practical Guide to Putting Your Life Back Together After Everything Has Fallen Apart.
“For me, what worked was a combination of things,” she explains. “Acceptance, my support network, and a bunch of physical and mental lifestyle changes have added up not to a cure but to putting my pain in a manageable place.”
Effective management of chronic pain — an often invisible but life-altering condition suffered by an estimated 100 million Americans — nearly always requires a multifaceted approach, one that takes into account physical, social, and emotional factors.
It’s a difficult puzzle for patients and physicians alike. But with a more thorough understanding of the root causes of chronic pain and a growing number of therapies and techniques to address them, many now believe it can be not only managed but overcome.
The Body in Pain
Pain serves an important purpose: It communicates what is happening in the body. During childbirth, for instance, it indicates progression, a necessary element in the process of labor. Day by day, it alerts us to injury and illness and, like a guardrail, dissuades us from actions that lead to even more painful outcomes.
But what if there’s no discernible cause of pain and its warning signal doesn’t fade, instead wailing like a faulty tornado siren all day and night, drowning out the birds, the voices of friends and family, even one’s own thoughts?
Chronic pain is fundamentally different from what we experience in the immediate aftermath of an injury. Acute pain results from a specific impact or event (such as a cut or a blow) and typically dissipates in less than six weeks. Subacute pain can last up to 12 weeks. Chronic pain lasts for more than three months.
“Studies have looked at the areas of the brain that light up with these different kinds of pain,” explains Joseph Garbely, MD, medical director at Caron Treatment Centers, an addiction-recovery facility in Pennsylvania. “With acute and subacute pain, we see activity in areas known as the pain matrix [including the dorsal anterior cingulate cortex, thalamus, and insula].
“But with chronic pain, different areas light up. There’s a shifting of activation to the mood centers, where anxiety and depression come from.”
That’s the challenge. Even as the brain signature of chronic pain shifts entirely to the emotion centers, patients report the same physical discomfort they felt in the acute stage.
“Unfortunately, in too many cases, acute pain doesn’t cease when it should, but continues long after the original injury has been repaired, becoming chronic pain,” writes Peter Abaci, MD, medical director of the Bay Area Pain and Wellness Center, in his book, Conquer Your Chronic Pain: A Life-Changing Drug-Free Approach for Relief, Recovery, and Restoration.
“While acute pain can be seen as a fleeting symptom, it helps to view chronic pain as a disease in and of itself, like diabetes and hypertension.”
The Mind in Pain
Chronic pain manifests in structural changes to the brain that Abaci refers to as the “pain brain.” These include the actual loss of gray matter (which can lead to cloudy thinking and poor decision-making) and disruption in the hippocampus (which regulates learning and memory). “Chronic pain rewires the whole computer,” he explains.
These changes create neural pathways, and their repeated activation results in a feedback loop of physical pain — and negative thoughts.
“All pain has an emotional component to it,” says Garbely. “When you burn your finger, you feel anxiety and worry. But those emotions are ubiquitous in chronic pain — they become front and center and lead to greater feelings of pain.”
Salim Ghazi, MD, chair of the Department of Pain Medicine at Mayo Clinic’s Florida campus, agrees.
“When pain becomes so chronic that it induces the emotional component of depression and anxiety, then the second beast starts feeding on the first,” he says. “People feel more pain, then they get even more depressed, and the depression makes the pain worse. It becomes a vicious cycle.”
The Opioid Pendulum
Opioids, including morphine and heroin, were popular pain-management remedies in the 19th century. But as their addictive nature became increasingly clear, doctors began restricting their use. From the 1920s to the ’90s, opioids were prescribed only immediately following surgery or to terminally ill cancer patients.
In the mid-’80s, Russell Portenoy, MD, a pain-management specialist, spearheaded a push to expand the use of opioids beyond the treatment of cancer pain. He studied 38 patients suffering from depression and chronic pain and found that they showed marked improvement on both fronts during several months of opioid treatment.
“Because of that study, the pendulum swung from ‘no opioids’ to ‘opioids for all,’” says Ghazi. He also notes that Portenoy never followed up with the patients, despite requests from the study’s funders that he evaluate them at the one- and two-year marks.
“The American Medical Association (AMA) made pain the fifth vital sign. Physicians were required to ask patients about their pain and to give opioids for strong pain,” Ghazi explains. “If we didn’t, we were reported and penalized.” (The AMA has since removed this requirement in response to the opioid crisis.)
By the late ’90s, doctors were prescribing opioids for a wide range of chronic-pain conditions, including arthritis, herniated discs, fibromyalgia, and more. The trend peaked in 2012, with physicians writing 259 million opioid prescriptions — enough to supply every American adult.
Opioids work by mimicking a pain-reducing neurotransmitter the body produces naturally. The drug binds to opioid receptors throughout the body, blocking pain signals sent to the brain through the spinal column.
“We have about 130 neurotransmitters in the body — a river of messenger chemicals that allow the body to do everything it needs to do, from having and expressing emotions to experiencing enjoyment to digesting food to fighting off disease,” explains Loretta Butehorn, PhD, CCH, a Boston-based psychologist and homeopath specializing in substance-abuse and mental-health treatment.
“A lot of pain medications are addictive because they have a structure similar to some of those neurotransmitters,” she says. “And long-term use of opioids diminishes the body’s ability to produce its own pain-suppressing neurotransmitters.”
“When you introduce opioids, you’re affecting how a person works on every level,” notes Abaci, “and there’s a big issue when you try to take them away.”
Addiction and overdoses are not the only devastating results of opioids. Their long-term use can cause increased suffering and sensitivity over time. Opioid-induced hyperalgesia is a cruelly paradoxical condition in which chronic opioid users actually experience a heightened sensitivity to pain.
“Not only do opioid drugs stop working effectively to dull pain,” explains Mel Pohl, MD, in The Pain Antidote, “but over time they actually start feeding and nourishing the pain — which often leads to taking higher and higher doses to get any pain relief at all.”
Long-term opioid users may also suffer from allodynia — a condition in which normal daily stimuli (such as putting on a shirt or receiving a hug) cause excruciating pain. Sustained opioid use causes “pain fibers to do the opposite of what they’re supposed to do,” explains Garbely. “This has been known by pain specialists, but the opioid epidemic is hastening the education of physicians around how pain works.”
Today, as the opioid pendulum once again swings toward restriction, millions who endure chronic pain —and the physicians who treat them — are in desperate need of more effective alternatives to address their very real suffering.
In his book The Wisdom of the Healing Wound, David Knighton, MD, describes the necessary process of cleaning out a wound — whether it’s physical, psychological, or spiritual — before it can begin to heal. Just as we need to remove dirt and gravel from a cut, Knighton suggests, we need to purge the less visible detritus (such as shame, anger, trauma, and despair) that keeps our spirits and psyches from mending.
Multiple studies demonstrate a connection between chronic pain and trauma. As many as half of all pain patients also exhibit symptoms of posttraumatic stress disorder (PTSD), including anxiety, agitation, mood swings, nightmares, and insomnia.
Abaci explains that there are three types of trauma associated with chronic pain: The first is the trauma of the wound itself, such as what a soldier feels when injured in battle. The second is when someone with a history of physical, emotional, or sexual abuse experiences a heightened pain response when a past trauma is reactivated by illness or injury. The third is when chronic pain itself becomes traumatic and results in nightmares, depression, and panic attacks.
“When a person experiences trauma, they aren’t going to get better until you get the trauma quieted down,” says Abaci. “You have to calm down the nervous system.”
At the Bay Area Pain and Wellness Center, Abaci and his team employ a variety of techniques — individual counseling, group therapy, meditation, yoga, physical therapy, nutrition counseling, and art therapy. All of these work together to untangle the web of pain, trauma, and negative thoughts that reinforce the entrenched patterns of the pain brain.
Abaci shares the case of Sgt. Shane Savage as a prime example. An active-duty solider in Afghanistan in 2010, Savage suffered a concussion and 24 broken bones when his armored truck was blown apart by a roadside bomb. He was soon taking high doses of strong painkillers while still suffering from ongoing pain, PTSD, depression, and tremors.
After he attempted suicide by overdose, he was sent to a psychiatric hospital, where he detoxed from the painkillers — but only temporarily.
Upon his release, he promptly resumed his morphine habit, taking up to 300 mg daily. (An average daily dose for managing extreme pain is about 60 mg.)
It wasn’t until he completed a multidisciplinary chronic-pain program at the Veterans Affairs hospital in Tampa, Fla., that he found sustained relief from both his pain and his opioid dependence.
The difference between purely pharmaceutical and more multidisciplinary approaches to treating pain, says Ghazi, is like giving people fish for one meal versus teaching them how to catch their own.
“It’s the difference between giving someone a pill every six hours and a program that teaches them how to cope, how to exercise, when to rest, when to push, and when not to push,” he explains.
Ghazi hopes that integrative approaches to pain, such as the one he uses at Mayo Clinic, will continue to serve as examples for other programs and clinics as the medical system seeks safer, more sustainable and effective solutions.
Changing the Pain Brain
Chronic pain is a complex problem. There is no magic bullet or single pharmaceutical solution. Researchers increasingly understand it as a biopsychosocial phenomenon in which emotions, thought patterns, and beliefs play as much (or more) of a role as physical factors.
This is why the most effective pain-rehabilitation programs now typically employ a wide variety of approaches that address the root causes of chronic pain — physical, psychological, emotional, and spiritual.
“Pain pills, implanted devices, and surgeries have their use,” Abaci notes, “but they do nothing to . . . restore the ‘pain brain’ back to health. The only way to alleviate this kind of pain is to change the brain.”
The notion that the mind plays a role in chronic pain can be a tough pill to swallow for sufferers, many of whom have faced suspicion from family, friends, and doctors who believe they’re inventing or exaggerating their discomfort.
“When it’s invisible, people think you’re making it up,” says Jennifer Kane. “And that delegitimizes the trauma you’re experiencing. No wonder people in pain are depressed!”
This makes it all the more vital to recognize that chronic pain is real pain. At the same time, it is pain whose root causes often lie as much in the brain as in the body — and that is good news, because the brain’s inherent plasticity means that it can change.
Kane has experienced this firsthand. “The multidisciplinary approach is a lot more work than opioids,” she says, “but it’s a better long-term strategy.”
After emerging from the darkest of places, she embarked on her own recovery journey — which involved changing her diet, practicing mindfulness meditation, getting support for her mental health, and making myriad other physical and mental adjustments.
“Pain makes your world so small,” she says. “You stop leaving the house and connecting with people because you can’t rely on your body. You don’t have any hope, any plans. You just have pain.”
And now? “Now I work on my dreams and goals,” Kane says. “I’ve accepted my new ground rules, and I have hope, excitement, and relationships.
“My world still has limits, but my brain doesn’t so much anymore.
This originally appeared as “Pain Relief” in the November 2018 print issue of Experience Life.