Quick fixes typically don’t work

Understandably, people with persistent pain want to get rid of it. They want it to go away like any of the countless other health conditions that they have had in their lives. In the past, they’ve become ill or injured, experienced symptoms such as pain, but with time the symptoms tended to subside. Oftentimes, in these situations, people sought healthcare and underwent various therapies, and subsequently their symptoms went away. As a result, they were able to get on with their lives. These past experiences subsequently inform how they think they should approach their persistent pain. Namely, they approach their persistent pain with the idea that they need to find the right specialist, with the right medicine or therapy or procedure, as a result it should all go away. Just as every other health condition was cured in the past, it seems to make all the sense in the world to seek a cure for the current condition of persistent pain.

A similar approach is commonly taken in weight management. People find themselves overweight or obese and, having come to a decision to do something about it, they begin the search for a cure for what ails them. Of course, there is no shortage of potential approaches in the current healthcare market: over-the-counter and prescription medications, and countless diets to follow and the ubiquitous best-selling books about each of those diets.

Now, the thing is, many of these approaches can work -- if, that is, the goal is to lose weight. By following these methods, people can tend to lose 5, 10, 15 or 20 kilograms (or pounds) relatively quickly, in a matter of weeks to months. It all seems good when it happens: mission accomplished. With the loss of weight, they also experience relief, satisfaction and a renewed spirit of getting on with their lives.

But then the weight comes back. It turns out that weight loss is relatively easy. What’s hard is keeping the weight off. It’s like the classic joke about smoking cessation: “Quitting smoking is easy. I’ve done it many times.” Rapid weight loss is common, and for a fortunate few, it can work and work for good. However, most of the time, people tend to gain the weight back and they find themselves where they started.

Having regained weight, they also have the added emotional distress that comes along with it. They are upset, experiencing failure, frustration and anger. The future no longer seems so bright.

Like rapid weight loss, rapid pain reduction can sometimes work, but it doesn’t usually last. There are a number of approaches within the healthcare market place that commonly provide dramatic, if temporary, relief from pain. Opioid medications seem to produce significant pain reduction initially, but clinical trials show that over time they have little effect on reported pain levels (Busse, et al., 2018; Krebs, et al., 2018; Veiga, et al., 2019). Likely due to tolerance, opioids lose their effectiveness over time. Clinical trials of interventional pain procedures, such as epidural steroid injections, show temporary, but not lasting pain reduction (Peul, et al., 2007). Spine surgery for disc herniation has been shown to produce early results when compared to other therapies, such as physical therapy, but by one-year out there’s no difference in terms of the symptoms between those who have had surgery and those who haven’t had surgery. Clinical trials of longer duration continue to show no clinically significant added value to having had surgery (Lurie, et al., 2014; Weinstein, et al., 2006; Weinstein, et al., 2008).

Patients, too, commonly report histories of their pain care that involve repetitive trials of therapies, procedures and medications, which initially showed promise, but failed to make any permanent dramatic reduction in their pain. Hope and their initial cause for optimism fade with each occasion of failed pain reduction, often leaving patients reporting a history of an emotional roller coaster ride: it tends to end with bottoming out in frustration, anger or even depression.

The lesson here is that, like with weight management, there is no quick fix when it comes to pain management, at least not in most situations.

Successful pain management aims for incremental change in pain levels

Weight loss and maintaining a healthy weight is possible, but it involves a commitment to lifestyle interventions that become, well, your lifestyle: whole food choices, portion control, exercise, stress management, mindfulness training, and so on. Maintaining a healthy weight is not, in other words, the product of a solitary intervention, with a beginning, middle and an end, like being on a diet, or taking a medication for a certain time, or even a bariatric surgery. Rather, it is about engaging in multiple interventions over time, most of which involve healthy lifestyle changes and making them your new normal.

In this regard, successful weight management is usually the product of slow change over time. On any given day, weight may fluctuate. Sometimes it is up a bit and sometimes it is down a bit. With time, lifestyle interventions bring down the average level of weight.

This gentle loss of weight serves as a useful and scientifically accurate model for successful pain management. Like with weight loss, pain can fluctuate up or down on any given day, but the goal for successful pain management is for the average level of pain to gently come down over time.

Moreover, this gradual reduction in pain is most effectively achieved by multiple lifestyle interventions pursued on an indefinite basis. Pain rehabilitation is the field of pain management that teaches and shows patients how to successfully engage in pain-related lifestyle management that can produce the most successful results. Pain rehabilitation helps patients to put all of the following into daily use: cognitive-behavioral therapies, mild aerobic exercise, contemplative practices such as mindfulness or tai chi or yoga, whole food anti-inflammatory food choices, the use of anti-inflammatory or antidepressant medications, and so on. When combined and pursued over time, these pain rehabilitation approaches down-regulate the nervous system and thereby reduce pain. They are not a quick fix, but they do tend to be effective at reducing pain. It’s just that they work gradually.

Successful pain management is not all about pain reduction

With weight management, it is not all about weight loss. It is about achieving and maintaining a healthy weight that emphasizes well-being over a singular focus on weight loss. It is a subtle, yet important distinction.

Sometimes, with weight management, the focus on weight loss can become too important – in one of those proverbial occasions of losing sight of the forest by overly focusing on the trees. A singular focus on weight loss can lead to an over-reliance on weight loss products and remedies, such as diet sodas, low-fat food products, diet fads, medications and surgery. Each one of these approaches have been shown to be ineffective when used solely by themselves, in the absence of making other healthy changes in life. They tend to promote binge-and-bust cycles of weight loss followed by weight gain.

A singular focus on weight loss can be a product of a persistent cognitive distortion, which might be called, ‘I’ll be better when…’ Cognitive distortions are an identifiable way of approaching life, involving ways of thinking, feeling and behaviors. We have explored many of them in this blog (for instance, catastrophizing, and all-or-nothing thinking). The ‘I’ll be better when…” type of cognitive distortion occurs in many areas of life, of course, and not just in weight management, and it’s typically a set-up for persistent frustration. When the good life, however defined, is conditional on a future state of obtaining some thing, it almost always fails. The good life tends to remain allusive, even if the condition is met. For after all, weight loss, in and of itself, does not produce well-being, just as no other single thing does (such as a six-figure salary, a three-car garage, quitting smoking, resolving a stressor). Any one thing is just insufficient to bring about the good life, and so well-being remains unobtained, which is to say, a persistent state of frustration remains.

A change in the focus from losing weight to maintaining a healthy weight, or even maintaining well-being, de-emphasizes the importance of losing weight, per se, and paradoxically may increase the likelihood of maintaining a healthy weight. The latter involves, of course, weight loss, but much more. It involves the slow processes of making a new normal – incremental changes that are done with the intention of doing them in one fashion or another for the rest of one’s life:

• re-introducing the cooking of whole foods on a more consistent basis
• reducing the consumption of soda to the status of an occasional treat rather than a daily staple
• starting to walk for exercise on a regular basis, no matter how short or slow you go when first starting to make this change
• using small sandwich plates for all meals, including dinner, to reduce portion size
• making a point of eating together with those whom you live and turning off all screens while doing so
• beginning a stress management schedule of behaviors, such as meditation, diaphragmatic breathing or gentle yoga.

Any of these behaviors, and more, are done with the intention to make a permanent change, making a new normal. All of these behaviors have other positive aspects, which subsequently add value to life. They promote overall health and well-being, and in so doing, de-emphasize weight loss as the central focus of what will produce the good life. At the same time, though, they also promote the likelihood of successfully maintaining weight loss by re-focusing attention and efforts onto promoting well-being.

Similarly, it can be helpful to de-emphasize the focus and goal of pain reduction. Indeed, in some circumstances, it is imperative to see that pain reduction is not the only way to get better when living with persistent pain.

The pursuit of pain reduction can be taken too far. Of course, this statement is not a judgment and it is not meant to stigmatize anyone, but rather it is a compassionate reminder that there are times in life in which there can be too much of a good thing. It is not uncommon in pain clinics to see folks who are on too high of doses of opioids – not in the sense that they are misusing them, but that they have been on them for so long that they need very high doses to get any pain relief. They come to clinic reporting that they are managing well, but despite their own subjective assessment of themselves they appear sedated and report engaging in little of life’s activities. It is hard to tell what part of their impairment is from pain or from opioids. It is also not uncommon to see patients who report histories of having had numerous failed spine surgeries, which may now be in part the cause of their pain and impairment. People can also report that they have stopped many, if not all, meaningful life activities in the pursuit of reducing pain. They buy pain relief, in other words, at the cost of guilt and social isolation over foregoing family activities and social activities.

In any of these situations, the pursuit of pain relief has gone too far. It has become too important. They are paying a price for pain reduction that one might reasonably wonder is too high – higher than the experience of pain itself.

It can be easy to fall into this predicament when engaging in the cognitive distortion of ‘It’ll be better when…’ From this perspective, it can seem that life can only start once pain is reduced. Thus, pain reduction becomes the primary or most important value in life. It must be achieved before anything else can be achieved.

Like with weight management, it can be helpful to de-emphasize the importance of pain reduction. It is not to do away with the pursuit entirely, but rather to recognize that there are other valid ways to successfully manage pain.

Referrences

Busse, J. W., Wang, L., Kamaleldin, M. et al. (2018). Opioids for Chronic Noncancer Pain: A systematic review and meta-analysis. JAMA, 320(23), 2448-2460. doi: 10.1001/jama.2018.18472 Video: https://www.youtube.com/watch?v=qWADk7lr6wA

Krebs, E. E., Gravely, A., Nugent, S., et al. (2018). Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or osteoarthritis knee pain: The SPACE randomized clinical trial. JAMA, 319(9), 872-882. doi: 10.1001/jama.2018.0899

Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Zhao, W., Morgan, T. S., Abdu, W. A., Herkowitz, H. & Weinstein, J. N. (2014). Surgical versus nonoperative treatment for lumbar disk herniation: Eight-year results for the spine patient outcomes research trial. Spine, 39(1), 3-16. doi: 10.1097/BRS.0000000000000088

Peul, W. C., et al. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245-2256.

Veiga, D. R., Montenero- Soares, M., Mendonca, L., Castro-Lopes, J. M., & Azevedo, L. F. (2019). Effectiveness of Opioids for Chronic Noncancer Pain: A two-year multicenter prospective cohort study with propensity score matching. The Journal of Pain, 20(6), 706-715.

Weinstein, J. N., Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Blood, E., Abdu, W. A., Herkowitz, H., Hilibrand, A. S., Albert, T., & Fischgrung, J. (2008). Surgical versus non-operative treatment for lumbar disk herniation: Four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine, 33(25), 2789-2800. doi: 10.1097/BRS.0b013e318ed8f4

Weinstein, J. N., Tosteson, T. D., Lurie, J. D., Tosteson, A. N., Hanscom, B., Sinner, J. S., Abdu, W. A., Hilibrand, A. S., Boden, S. D., & Deyo, R. A. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA, 296(20), 2441-2450. doi: 10.1001/jama.296.20.2441

Date of publication: January 19, 2021

Date of last modification: January 19, 2021

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.