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Trigeminal Neuralgia Treatment|Trigeminal Neuralgia Symptoms|Trigeminal Pain https://instituteforchronicpain.org Sun, 29 Jan 2023 16:00:39 +0000 Joomla! - Open Source Content Management en-gb Dreaded or Embraced? Opioid Tapering in Chronic Pain Management https://instituteforchronicpain.org/blog/item/235-dreaded-or-embraced-opioid-tapering-in-chronic-pain-management https://instituteforchronicpain.org/blog/item/235-dreaded-or-embraced-opioid-tapering-in-chronic-pain-management

Last year, I served on a committee looking into reasons for resistance by the healthcare community to adopt opioid prescribing guidelines. At first blush, this reluctance was perplexing.

At the time, various guidelines had already been published for a number of years, and had periodically gained publicity when updated or when tapering guidelines were added into the mix. So, the reluctance to adopt the prescribing guidelines couldn’t be for lack of knowledge of their existence. Moreover, the reluctance seemed perplexing because the guidelines were largely developed to increase safety of patients who receive opioids. Multiple public and private organizations over the previous five or six years had independently looked at the issues and developed guidelines, all of which largely agreed with each other, and all of which focused on increasing safety for patients taking opioids. So, why resist adopting practices that improve patient safety? 

The committee was thus constituted to look into this reluctance and attempt to understand it. Akin to a steering committee, the committee informed the interviewing strategies of two focus groups, one consisting of providers who had previously been identified as prescribing outside of current guidelines and the other group consisting of patients with a history of long-term opioid management, most of whom had experienced hardships as a result of the publication of the opioid prescribing guidelines.

A number of salient themes came out of the work that shed light on how the adoption of opioid prescribing guidelines becomes inhibited byImage by Aedrian courtesy of Unsplash either providers who prescribe, or patients who receive, opioids. One theme that I found particularly notable was fear. It seemed to manifest in multiple ways among both the provider and patient group. 

Providers tended to fear that they may harm their patients by prescribing less opioids (again, the providers making up this focus group were high prescribers, having been previously identified as tending to prescribe outside of the current prescribing guidelines). Among this group, the prospect of prescribing less opioids seemed to raise the probability that their patients would suffer more. Some also were fearful that patients might be tempted to obtain opioids from other, possibly illegal and unsafe, sources. These fears emanated, it seemed, from a sincere yet unquestionably held belief that suffering is the inevitable result of pain, particularly in the context of opioid management. Any compassionate provider, they seemed to reason, feels obligated to alleviate suffering even if it means going against the recommendations of the published opioid prescribing guidelines.

The patient group also seemed to manifest fear in their reluctance to embrace the prescribing guidelines, despite the fact that the guidelines had been developed largely with the intent to improve their safety as patients taking opioids. Fear, they described, characterized their relationships with healthcare providers and the healthcare system more broadly. Like their provider counterparts, they too tended to see the prospect of managing pain with less access to opioids as something leading inevitably to intolerable pain and suffering. This fear, it seemed, trumped increased safety that’s promised by the prescribing guidelines when recommending lower doses of opioids. The argument that there are a number of such prescribing guidelines, all developed independently by experts in the field, and all coming to largely the same recommendations, remained insufficient reassurance in the face of the potential for increased pain. 

Fear also marked the relationships with their specific healthcare providers. Many recounted occasions when healthcare providers stopped believing them, and, as a result, took steps towards prescribing less opioids. These occurrences were highly threatening. Prescribing less opioids thus came to be seen as providers lacking trust in them. However, lack of trust could also go both ways. They described relationships to the healthcare system in which the potential for mistakes, accidents, or misunderstandings were an ever-present threat to their access to opioid medications. Thus, such perceptions of threat to opioids as a lifeline to normal life seemed to influence their view of opioid prescribing guidelines. These guidelines seemed to be just another threat to access to opioids. From this perspective, it seemed no small wonder as to why they’d remain reluctant to embrace the guidelines despite the assurance of increased safety that the guidelines involve. 

Fear and increased pain are powerful motivators. Compassion to alleviate such fear and pain is also a powerful motivator. They can all lead – and understandably so – to reluctance to embrace opioid prescribing guidelines, particularly when it comes to reducing dosing schedules of patients on high doses. From this perspective, it seems like following the opioid prescribing guidelines runs the risk of harm to patients on high doses by leading them down a path that inevitably leads to increased pain and suffering.

How, then, do we square this perspective of the potential for harm to patients with the intent of the opioid prescribing guidelines to increase Image by Jon Tyson courtesy of Unsplashpatient safety?

It was to this question that the committee was pursuing an answer by providing advice to the interviewers in their discussions with the afore-mentioned focus groups. It led to many lively discussions.

At one point, a colleague on the committee, Erin Krebs, attempted to articulate an altogether different perspective. Contrary to the fear that so often characterizes the use of opioids, she challenged the group to think differently about how to communicate the benefits of prescribing less opioids. In this challenge, she stated, “Everyone [on long-term opioids] deserves the opportunity to pursue a taper.”

Dr. Krebs’ challenge is both profoundly provocative and profoundly insightful. It flies in the face of the above-described common perspectives of prescribing providers and their patients on long-term opioids. The challenge doesn’t just crack open that door, but bursts it wide open: opioid tapering is not to be dreaded, but embraced. It’s dizzying in the amount of cognitive dissonance it creates.

How might you make sense of it? How could it really be that tapering opioids could be embraced as a positive move forward? 

Believe it or not, people with persistent, severe pain who have been managing their pain with opioids can come to embrace the process of a slow and safe taper, when done correctly by combining it with pain rehabilitation therapies.

The most recent webpage on the Institute explains how it’s done. It reviews the process and benefits of tapering opioids as an empowering experience that can, in fact, be embraced as opposed to be feared. 

You can access the article here: Opioid Tapering as an Exposure-based Therapy for Chronic Pain.

Date of publication: 6-23-2022

Date of last modification: 6-23-2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Opioids Wed, 22 Jun 2022 16:46:17 +0000
Is It Time to Talk About Managing Pain Without Opioids? https://instituteforchronicpain.org/blog/item/176-79is-it-time-to-talk-about-managing-pain-without-opioids https://instituteforchronicpain.org/blog/item/176-79is-it-time-to-talk-about-managing-pain-without-opioids Is It Time to Talk About Managing Pain Without Opioids?

Opioids are certainly in the news. The US Surgeon General recently issued a statement on the relationship between their widespread use for chronic pain and the subsequent epidemics of opioid addiction and accidental overdose (US Surgeon General, 2016). The US National Institute for Drug Abuse and Centers for Disease Control have also issued concerns (see here and here, respectively). Mainstream media reports on the problems of opioids appear almost daily.

After a couple of decades of strong proponents and persistent messaging on the benefits of opioids, the tide of public opinion and the opinion of health experts seems to be turning against the widespread use of opioids for chronic pain.

Among people with chronic pain who use opioids, this change in perspective on the use of opioids can be alarming. For about two decades, people with chronic pain have been encouraged to take opioid medications. Many have subsequently come to rely on them. Some may have even come to believe that it is impossible to manage chronic pain well without the use of opioid medications.

We now face a dilemma in the management of chronic pain. We have strong proponents for the use of opioids and strong proponents against the use opioids. Both sides have valid concerns that lead to their respective positions.

Often, the sides in this dilemma seem to get expressed in untenable ways. It’s as if the stakeholders in the field have to choose between two bad options: either you take opioids on a chronic basis and expose yourself to the risks of addiction and accidental overdose, which are actually occurring to people with chronic pain at epidemic proportions; or don’t take opioids, remain safe from addiction and accidental death, but expose yourself to pain, which may be intolerable. Healthcare providers seem to face a corresponding dilemma: either manage patients on chronic opioids while exposing them to addiction and accidental overdose or refrain from opioid management and expose them to what might be intolerable pain. Whether patient or provider, both options seem bad.

Is there a third option?

There is another way, of course. It’s called chronic pain rehabilitation and it effectively shows people how to successfully self-manage chronic pain without the use of opioid medications. Chronic pain rehabilitation clinics have been around for three to four decades. However, it’s hard to get people to go to them. It’s not because they are ineffective. Research over the last four decades shows clearly that they are effective (Gatchel & Okifuji, 2006; Kamper, et al., 2015).

Managing pain without opioids

People who’ve been managing their pain with opioids are often a little leery of recommendations to go to a chronic pain rehabilitation clinic. The recommendations seem to run counter to much of what’s been previously recommended throughout the long course of care for their chronic condition. After years of recommendation and encouragement to take opioids by some providers, it’s hard to understand why other providers might recommend and encourage the exact opposite. Maybe they are recommending learning to self-manage pain without the use of opioids because:

  • They don’t believe my pain is as bad as it is.
  • They think (wrongly) that I’m addicted to opioid medications.
  • They think my pain is all in my head.
  • They just want to make money off their program that they are recommending.
  • They are ignorant of what’s most effective for chronic pain (i.e., they don’t know what they’re talking about).
  • They are not as compassionate as the previous providers who recommended opioid management.

In all these concerns, people become leery of a recommendation to forego opioids because it’s hard to believe that the recommendation is being made in the best interest of the patient. It seems that relief of pain through the use of opioids is what’s best for the patient and anything that runs counter to that recommendation must be in the best interests of someone else.

Moreover, it’s a sensitive topic. Let’s face it, no one feels especially proud of managing their chronic pain with opioids. Rather, people with chronic pain do it because it seems a necessity – they believe that the pain will be intolerable without opioids. The recommendation and encouragement to take opioids by healthcare providers and by society, more generally, is helpful in this regard. Such encouragement supports the decision to use opioids, one in which there’s always been some ambivalence. Again, no one is exactly proud of taking opioids for chronic pain; upon reflection, there is always some degree of doubt or concern about their use that leads to a sense of vulnerability and sensitivity. It’s helpful to have others, especially healthcare providers, recommend and encourage their use.

When, however, other healthcare providers recommend against opioid use and encourage learning to self-manage pain instead, it can sting because it taps right into the inherent sense of vulnerability and sensitivity that occur when taking opioids.

It’s hard to see a healthcare provider as acting in the best interest of patients when they openly question the issue that can be so sensitive. The recommendation to learn to self-manage pain without the use of opioids shines a direct light onto the inherent sense of vulnerability or shame that so many feel when using opioids for the management of chronic pain. 

Photo by Erwan HesryUnsplash 450x300The recommendation inadvertently breaks all the tacit rules that healthcare providers (and pharmaceutical companies) have heretofore been following. The rule up until now has been to reassure patients that it’s okay to take opioids for chronic pain. Over the last two decades, the field has asked patients to trust these assurances that they shouldn’t be ashamed of their need for opioid medications. Now, the field is changing and has begun to question the need for opioids. In so doing, we break the trust of patients who have been on opioids for some time: we expose them to potential pain, but also the shame that heretofore we alleviated with assurances that taking opioids is okay. It’s no wonder that patients are now upset.

In a microcosm, it’s this dynamic that occurs in the offices of chronic pain rehabilitation clinics everyday when, after the initial evaluation and recommendation to participate in the therapies of the clinic occurs, patients leave and refrain from accepting the recommendation to learn to self-manage pain. Such patients are doubtful that it will work and are afraid of the pain that would ensue if it doesn’t. Moreover, though, they tend to leave feeling somewhat ashamed that the provider so openly talked about the fact that they could learn to self-manage pain without the use of opioids. Providers are supposed to provide reassurance that it’s okay to be on opioids, not question their use.

Even when it’s well-informed and done in the best interest of the patient, the recommendation and encouragement to learn to self-manage pain without the use of opioids can be heard as a subtle yet stinging rebuke because of the inherent sensitivity that occurs when taking opioids for chronic pain.

How, then, do we bridge this divide?

The Institute for Chronic Pain has a new content page that may play a small role in such bridge building. When patients come to chronic pain rehabilitation clinics for the first time, they may have never had an experience of a provider talk to them about self-managing pain without the use of opioids. As we’ve seen, it’s a complex and sensitive interaction that occurs under the surface of the words that are spoken. It can be a lot to take in. It can feel like the rules are being broken. As we’ve seen, it can be easy to become angry and accuse the provider of incompetence, ill-will or insensitivity. Oftentimes, people need a little time to reflect on the discussion and talk it over with their loved ones. No one comes lightly to the decision to taper opioids and learn to self-manage pain instead.

The new content page provides assistance with this reflection. The hope is that patients can use the information on the page to further reflect on if and when it may be time to begin learning to self-manage chronic pain. Providers can refer their patients to the page too, ask them to read it, and come back for further discussion.

For countless people over the last four decades, chronic pain rehabilitation has provided hope and a way to take back control of a life with chronic pain. However, it must be approached with sensitivity and compassion. Initially, the idea that one can successfully self-manage chronic pain without the use of opioid medications can be threatening, especially for those who have been managing pain with opioids for some time and for those whose providers have long provided reassurance that it's okay to take opioids. Nonetheless, if your providers have recently begun to express concerns about the long-term use of opioids or if you yourself have concerns about their long-term use, you might find it helpful to read the new ICP page on the common benefits of learning to self-manage pain without the use of opioid medications.

You can find the new page by clicking on the link here.

References

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Kamper, S. J., Apeldorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ, 350. doi: http://dx.doi.org/10.1136/bmj.h444

 

Author: Murray J. McAllister, PsyD

Date of publication: 12-1-2016

Date of last modification: October 5, 2019

About the author: Dr. 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. 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) Self-management Sun, 29 Jan 2017 13:49:15 +0000
How Stigma Prevents Self-Management https://instituteforchronicpain.org/blog/item/143-46how-stigma-prevents-self-management https://instituteforchronicpain.org/blog/item/143-46how-stigma-prevents-self-management

We tend to stigmatize pain because we misunderstand its nature. Specifically, we fail to acknowledge the role that the nervous system plays in producing the experience of pain. If we more fully appreciated this role, we would understand that chronic pain is similar to other health conditions that we don’t stigmatize much, such as high hypertension (i.e., high blood pressure) or type II diabetes.

Stigma of chronic pain defined

Stigma is someone’s negative judgment or criticism of you for having a condition that is not of your choosing. You didn’t choose to have chronic pain, but when getting stigmatized, you are getting blamed for having it or not coping with it well enough. It’s often in the form of a rhetorical question: ‘How could you possibly have so much pain?’ ‘How could you hurt when all I did was hug you?’ ‘Why are you suffering so when others with the same condition don’t suffer as much as you?’ The assumption that leads to these stigmatizing rhetorical questions is that the severity of pain should always correspond to the severity of injury or illness. Small injuries or mild illnesses should cause only mild pain, whereas only large injuries or serious illnesses should cause severe pain. However, more often than not, chronic pain patients don't fit this mold. Herein lies the rub. Patients with chronic pain seem to have severe pain often beyond what this assumption leads us to believe they should have. Simple movements seem to cause severe pain. Hugs can cause pain. Common conditions like chronic back pain lead to severe suffering in some people. This assumption subsequently leads to stigma. It can't be the injury or illness that causes such severe pain or suffering. It must be something personal about you that causes such pain or suffering. In other words, you are to blame.

In reaction to stigma, chronic pain patients can often assert that they didn’t choose to have chronic severe pain and, as such, there’s nothing they can do about it. They go on to assert that it is not something about them, but the condition they have. It is inherent to the pain, not something personal about them. Anyone, they assert, would be the same way if they had such pain.

In its blame of the victim, stigma insinuates that you are choosing your suffering. In defense of such blame, you emphasize your lack of choice in either having pain or its subsequent suffering. ‘It’s not me,’ you might say, ‘it’s the pain.’

Control over unchosen events

As described in previous posts on stigma, this defense is problematic in two ways. First, in asserting your lack of choice in the matter, you can easily fall into the trap of asserting that you have no control over the pain. That is to say, in response to stigma, it’s so easy to go from, say, “Don’t blame me. I didn’t choose this...” to “There’s nothing I can do about it.” As such, we tend to equate lack of choice with lack of control. If we don’t have control, we couldn’t have chosen it and if we couldn’t have chosen it, we can’t be blamed for it. While it might be a successful defense against stigma, the argument wins at the cost of coming to see yourself as powerless to pain. (Indeed, many patients with chronic pain often feel this exact way: like they have no control over their pain.) Powerlessness, however, is not a good thing as it leads right to suffering. Those who suffer have no power to affect the problem from which they suffer. Second, it is not factually accurate. It is possible to have some control over our health, including pain levels and how much one suffers. Now, of course, some patients with chronic pain might have to learn how to improve their health or how to gain better control of their pain and to cope better. However, the fact that some may need to learn how to manage pain well is different than the notion that it is impossible.

We thus arrive at a dilemma that chronic pain patients face: either they acknowledge that they have some degree of control over their pain and suffering, and subsequently become the object of blame or criticism if they are not doing a very good job of it, or they deny that they have any degree of control over their pain and suffering, and subsequently see themselves as powerless.

This dilemma can essentially shut down the possibility of learning how to effectively self-manage pain. To learn how to effectively self-manage pain, people with chronic pain have to learn how to acquire control and responsibility over their health, including their pain. This possibility opens the doors to stigma. To prevent the stigma, it is easy to assert that having some degree of control over pain is impossible -- buying relief from stigma at the cost of denying the possibility of any meaningful ability to effectively self-manage pain. The dilemma, however, is a false dilemma. It is based on a failure to understand the true nature of pain. Like stigma itself, the defense against stigma assumes that there are only two possible causes for severe pain: a severe injury or illness on the one hand or some personal weakness on the part of the patient who has pain. Everyone seems to fail to recognize that there may be a third option. Specifically, they fail to take into account the role of the nervous system in producing the experience of pain.  By taking it into account, you can skirt the dilemma of stigma and learn to effectively self-manage pain.

A subjective experience with neural underpinnings

We tend to think of pain as a physical sensation. However, we are only partly correct. It’s also a subjective experience. We can’t divorce the sensation from the perceiving subject – the person who has the sensation. It’s also not just any old sensation. While involving a bodily sensation, the experience of pain also inherently includes a cognitive appraisal of threat, an emotional sense of alarm or distress, and an automatic behavioral reaction to protect, usually through resting and/or guarding. These are the things that differentiate pain from other sensations, say, tickles. We simply don’t perceive a tickle to be threatening or alarming. We cry when in pain, yell out in distress, grimace, and guard the painful area. We laugh and squirm when tickled.

Pain, in this sense, is a danger signal. It signals to us that something is wrong in the area of the body that has the pain. A tickle doesn’t signal to us that there is anything wrong. Pain does. Inherent to the sensation is this sense that it is threatening and alarming. These are the essentially cognitive and emotional aspects of the experience of pain. (See the generally accepted International Association for the Study of Pain’s definition of pain.)

The nervous system is what produces this experience. The nervous system consists of all the nerves in the body, including nerves in limbs, in our bodily organs, as well as the spinal cord and brain. When an injury occurs, nerves in the affected area detect it. They subsequently send an electro-chemical message from the site of injury to the spinal cord and then up the spinal cord to the brain. Multiple areas of the brain become involved to produce the sensation and its inherent cognitive appraisal of threat, the emotional sense of alarm, and the behavioral reflex of guarding and grimacing (Melzack, 1999; Moseley, 2003).

In this way, the nervous system functions like a fire alarm in an office building. With a fire alarm, a smoke detector senses smoke and sets off the entire alarm system. The loud sound of the alarm signals threat. As a result, everyone becomes alarmed at the threat of fire and leaves the building. Fire fighters come to the rescue and put out the fire. The next day everyone is back at work and things return to normal.

Similarly, the nervous system, acting like an alarm system, can detect some bodily disturbance and sets off the alarm of pain. Pain, like the loud sound of a fire alarm, signals the threat. Inherent to the sense of alarm, the person becomes alarmed and reacts reflexively. Like fire fighters coming to the rescue, the person with pain and/or healthcare providers fix what’s wrong or the body naturally heals and the alarm of pain subsides. Things return to normal.

Alarm systems can become set at different levels of sensitivity

Now, with any alarm system, we want its sensitivity to stimuli to be set just right. Imagine if an office building’s fire alarm system was set too high -- where it doesn’t detect smoke until the fire is raging. It wouldn’t do us any good, would it? We also wouldn’t want the sensitivity of the alarm system to be set too low -- where it goes off, say, every time someone walks by the building smoking a cigarette. Rather, we want our fire alarm systems set at just the right level of sensitivity.

Similarly, we want our nervous system set at just the right level of sensitivity as well. We want to be able to feel pain long before an injury, say, becomes life threatening. Our nervous system wouldn’t be very useful to us in such a case. But, we also don’t want to feel pain in response to stimuli that is typically not painful – such as touch or the light pressure of hugs, normal movements like getting up from a chair or walking, changes in barometric pressure, or emotional stress.

Nonetheless, that is what’s happening in chronic pain. Chronic pain is like what happens with a faulty alarm system – one where the threshold for sounding the alarm is set too low and so it’s getting set off in response to stimuli that is typically not threatening (i.e., painful).

By definition, chronic pain is pain that continues past the normal time of healing. There is no longer a bodily disturbance for the nervous system to detect because the injury has healed. With chronic pain, though, the nervous system remains reactive, detecting normal stimuli as if they are threatening and, as a result, sounding the alarm of pain.

It’s how people can develop pain in the absence of any objective findings of injury. It’s also how people can have pain in response to normal stimuli like touch, mild pressure, simple movements, changes in barometric pressure, or emotional stress.

It’s important for people with chronic pain and the people around them to know that they are not making this pain up. The pain is real. And there is a real explanation for their pain. It’s being produced by the nervous system in much the same way as any other pain. The only difference is that their nervous systems are stuck in a heightened state of reactivity, and so the threshold for sounding the alarm of pain has come to be set too low. It is sounding the alarm bells of pain in response to stimuli that is typically not sufficiently dangerous to elicit the alarms bells of pain – just like an office building’s fire alarm going off when someone walks by outside on the sidewalk smoking a cigarette.

Chronic pain is real pain due to central sensitization – not tissue damage

This heightened state of reactivity of the nervous system is called central sensitization. It’s a real health condition that can be the cause of chronic pain. It maintains pain beyond the normal healing process of an injury or, as commonly occurs, when scans show normal age-related osteoarthritic findings. In such cases, chronic pain is not necessarily due to healed injuries or normal, age-related osteoarthritis in joints or the spine, but rather due to an up-regulated nervous system that is setting off the alarm of pain in response to stimuli that is not typically associated with pain. In other words, central sensitization is what maintains pain on a chronic basis.

Central sensitization is as real as hypertension or type II diabetes. In each of these health conditions, some bodily system or aspect of a bodily system is abnormally elevated – the nervous system having become too reactive in the case of chronic pain, the cardiovascular system becoming regulated too high in the case of hypertension, and heightened levels of blood sugar (an aspect of the neuroendocrine systems) in the case of type II diabetes. All three conditions are common examples of an up-regulation of a bodily system or an aspect of a bodily system that over time has become problematic (i.e., symptomatic).

Why stigmatize pain when we don’t stigmatize hypertension or type II diabetes?

When we understand this role of the nervous system in the production of the experience of pain, we see that chronic pain is real pain that has a real explanation. People make up chronic pain about as often as people make up having hypertension or type II diabetes, which is to say, they don’t make these things up. So, why stigmatize chronic pain?

We typically don’t stigmatize these other conditions because we understand that we don’t choose to have these conditions – at least not in any sense of the word “choose” that we typically use. For instance, no one decides to have hypertension or type II diabetes as if it was a choice between having one of these conditions or not. Choices typically involve having a ready or easy control over a set of options. ‘Would you like coffee or tea?’ – now that is a choice. There is no similar use of the word “choice” that might apply to hypertension or type II diabetes. No one ever faces a decision such as, ‘Would you like to be diabetic or not?’ No, it just doesn’t make sense to use the notion of “choice” with regard to conditions like hypertension or type II diabetes.

Similarly, no one chooses to have chronic pain. Just as we don’t have ready or easy control over our cardiovascular systems or our blood sugars, we don’t have ready or easy control over our nervous systems. It’s not like you can just make a decision and choose to no longer have chronic pain, hypertension or high blood sugar levels. No, it doesn’t work like that.

As such, stigma is misplaced blame. It relies on an overly naïve view of pain as something that one can just make up or will into (or out of) existence. However, as we see, having chronic pain is not the product of a choice or decision.

Chronic pain is not impossible to control

While chronic pain is not the result of a choice, it is possible to control it to some meaningful extent. This control, however, is not readily or easily attained – it’s not like we choose between health and ill health as we choose between coffee and tea. Nonetheless, we can affect change to our health over time and with a concerted effort.

The analogies between chronic pain and hypertension and type II diabetes continues to be helpful here. With a concerted effort over time, we can affect significant and meaningful changes in each of these conditions. It often requires a team effort between medical and health psychology providers and the patient (and possibly even their families). The focus of care is self-management: assisting the patient to make healthy changes over time that will positively affect the condition that the patient has.

In the case of hypertension, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, stress management, achieving a healthy weight, improvements in diet, engaging in an aerobic exercise, cessation of tobacco use, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, hypertensive patients come to down-regulate their cardiovascular system and subsequently lower their blood pressure.

In the case of type II diabetes, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, achieving a healthy weight, improvements in diet, stress management, engaging in an aerobic exercise, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, type II diabetic patients come to down-regulate their blood sugar levels.

Notice that these health behavior changes are difficult to achieve. They take time. They often require coaching and support from medical and health psychology providers, as well as support from family members. However, they are not impossible. That is to say, it is possible to affect significant and meaningful change to conditions like hypertension and type II diabetes. We all recognize that if we were to come to have either of these conditions, we would not be fated to uncontrolled hypertension or type II diabetes. We know that we can affect them. Through a process of learning how and sticking with it over time, we can come to have meaningful control over these conditions.

Chronic pain is the same way. Learning how to manage chronic pain well is possible, but it takes a concerted effort over time. It often also requires a team effort that includes health psychology providers, medical providers, physical therapists, and the patient (and often the patient’s family too). This kind of team is typically found in an interdisciplinary chronic pain rehabilitation program. It also tends to require an accurate understanding of the role of the nervous system in maintaining pain on a chronic course. Why? It’s because the focus of care is to down-regulate the reactivity of the nervous system through a combination of medical, health psychology, and self-management approaches that we know to be effective. By pursuing these changes over time, patients come to reduce pain and increase the ability to cope with the pain that remains.

These therapeutic approaches consist of, but are not limited to, the following:

  • Effective non-narcotic medication management (particularly anti-epileptics and antidepressants)
  • Cognitive-behavioral therapy involving coping skill training
  • Mild aerobic exercise
  • Relaxation therapies
  • Exposure-based therapies to reduce fear-avoidance
  • Stress management & treatment of any co-occurring depression or anxiety disorders
  • Cognitive-behavioral therapy for insomnia
  • Tapering of opioid medications, if applicable

When patients pursue these therapies and strategies, they learn how to engage in them independently and take over doing them on their own. Over time, they come to affect their nervous systems by down-regulating its reactivity and subsequently have less pain. Because they do it themselves, they come to see that they are no longer powerless to pain and subsequently it is one of the most empowering experiences of their life. For the first time in their life with chronic pain, they have successfully learned how to control their pain at tolerable levels and have proven to themselves that they can do it. Such know-how and empowerment comes to further increase their abilities to cope with pain. As such, they develop a positive cycle of increasing self-management that leads to less pain, which in turn leads to improved empowerment and coping, which subsequently leads to improved self-management.

Notice, though, it takes work. In fact, it takes a lot of work. Successful self-management is the product of a long and concerted effort to make healthy changes over time.

As anyone who has ever attempted to make long-term changes to their health, this sense of control is not an object of stigma, but rather an object of admiration.

References

Melzack, R. (1999). From the gate to the neuromatrix. Pain, S6, S121-S126. Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-27-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Self-management Sun, 22 Jun 2014 18:54:58 +0000
Benefits of Managing Chronic Pain without Opioids https://instituteforchronicpain.org/treating-common-pain/benefits-of-self-managing-pain https://instituteforchronicpain.org/treating-common-pain/benefits-of-self-managing-pain Benefits of Managing Chronic Pain without Opioids

On initial reaction, it might seem absurd to talk about the benefits of self-managing chronic pain without opioid medications. "What," one might ask, "would you use to reduce pain? You wouldn't want to live the rest of your life in pain, would you?" The topic seems absurd because pain reduction reflexively seems so important. Indeed, pain reduction from the use of opioids seems so important that it trumps everything else, even problems associated with the use of opioids.

It’s also a common reaction among patients in pain clinics. It seems immediately and obviously true that having pain requires the use of opioid pain medications. It hardly seems worth entertaining whether there's any benefit to going without opioids when having chronic pain.

The obvious veracity of such a reaction is, however, only apparent. For it neglects the fact that there are people who don't manage their pain with opioid medications. Indeed, most people with chronic pain don’t manage their pain with opioids. This fact remains true even of people with moderate to severe chronic pain.1, 2 The majority of these individuals are also satisfied with how they are managing their pain.2

Why do people do that? Why do people with chronic pain choose to live with pain, rather than try to get rid of it through the use of opioid medications?

The following is a list of benefits that people tend to gain when learning to self-manage chronic pain without the use of opioids. Some people prefer these benefits over the reduction of pain that opioid medications can provide. As a result, they choose to live with their chronic pain, using these benefits to help them to cope with pain.

Some caveats are in order before reviewing the list. First, the list below isn't exhaustive of all possible benefits of self-managing chronic pain without the use of opioids. The list contained on this page is simply some of the more common benefits. Second, any list of benefits would surely include reductions in the risk of addiction, accidental overdose, and tolerance. However, this article omits these benefits as they are adequately addressed elsewhere on the Institute's website. Third, the intention of the list is solely educational. It is not intended and should not be understood as a healthcare recommendation or counseling. It simply attempts to describe why some people manage pain without opioid medications. As such, the intention is simply to describe, for educational purposes, why some people elect to live with their pain and not take opioids. Fourth, the decision on any one individual's part, such as the reader, to learn how to self-manage pain should only be done in consultation with your own healthcare provider. It is only your own healthcare provider who is in the position to know what is in your best interest and it is only your own healthcare provider, not the Institute for Chronic Pain, who can give you healthcare recommendations (please see Terms and Conditions of Use of this site). So, do not make any medication changes without first talking to your healthcare provider and obtaining his or her consent and direction. 

So, with that said, let’s move on with the list.

Acceptance

Sometimes, people tend to think that they'd lose hope if they came to accept their chronic pain and stopped trying to get rid of it through the use of opioids. The assumption is that hope lies in a long and steadfast battle to get rid of pain. Given this perspective, the use of opioids becomes the chief weapon in the battle.

This way of defining and finding hope can become hope depleting because success persistently remains just out of reach. The medications never seem to fulfill their promise of being pain killers. Most people continue to have pain even when taking opioids. Of course, the medications can work well, but typically it is only for some period of time. The medications tend to lose their effectiveness after a while. At the direction of their healthcare provider, people who take the medications tend, in such circumstances, to increase their dosage. However, the new dosage again only works well for a period of time. With each increased dose, it is only a matter of time before they no longer work well.

Even with an army of painkillers, the fight to get rid of pain inevitably becomes a long series of losing battles. Hope, when framed in this manner, persistently gets dashed. Indeed, far from being a way of obtaining hope, it becomes in the end the very opposite: depressingly hopeless.

In response, many people stop fighting to rid themselves of pain. They make peace with their pain. They learn to live with it. Going to a chronic pain rehabilitation clinic is a chief way they learn to live with it. This learning involves learning how to self-manage chronic pain without opioids. Rather than being stuck in an endless cycle of trying to get rid of something that can’t be gotten rid of, they accept pain into their life, make room for it, flexibly adapt and adjust, and move on with life.

In fact, as seen above, most people live with their pain, even moderate to severe pain.

Shame reduction

When people rely on the use of addictive medications, it tends to produce stigma and shame. Others tend to look down upon them (i.e., stigma) and those who take the medications tend to feel vulnerable and criticized (i.e., shame). This fact is especially true when people rely on an addictive medication to do things that most others do without the use of the addictive medication. It is the inherent situation in which those with chronic pain who rely on opioids find themselves. Some people rely on opioids to manage pain, while most others with chronic pain, even those with moderate to severe chronic pain, don’t rely on opioids.

Therein lies the rub: the contrast between those who rely on opioids to manage chronic pain and those who don’t puts those who rely on opioids in an inescapably vulnerable position of stigma and shame. (Please note, the simple observation of this fact doesn’t imply that the author supports or condones it.)

In their defense, patients who rely on opioids can become self-righteously angry and assert a number of arguments to support their use opioids:

  • Their pain is inherently worse off than those who don't rely on opioids.
  • Those who question their use don’t understand what it is like to have chronic pain.
  • Healthcare providers who question the use of opioids are incompetent.
  • Those who question their use are mean or uncaring.
  • The pain is intolerable now and it will be worse without opioids.
  • It's impossible to manage pain well without opioids.

Of course, sometimes people without pain are incompetent or uncaring or mean. Some people do in fact engage in stigmatizing those who rely on opioids. Such stigma needs combating at every step by patients, healthcare providers and society generally, (which is why the Institute for Chronic Pain frequently takes up the issue of stigma and how to deal with it: see here, here, here, here, and here).

However, the problem isn't just the stigmatizing comments from others. There is also the corresponding issue of shame. Hard to admit, but it's common for patients who take opioids for chronic pain to be ashamed of their need. The fact that others can self-manage pain without the use of opioids simply highlights this sense of vulnerability of being reliant on an addictive medication. This reliance simply doesn’t allow you to be in control and as such it conflicts with most people’s values for how they believe they should live – as a self-determined, independent person who is in control of themselves. This internal conflict between what is and what should be tends to produce shame.

One of the most liberating experiences patients can have occurs every day in chronic pain rehabilitation programs across the world. It occurs when patients give up the yoke of remaining reliant on a medication that, for all the good it does, also produces a persistent sense of shame for those who take it. By learning how to live well with pain, they stop trying to rid themselves of pain and instead rid themselves of shame. They do so by tapering opioids and by learning to self-manage pain instead.

Empowerment

This experience of tapering opioids and learning to self-manage pain well within a chronic pain rehabilitation clinic is initially scary and threatening, but becomes one of the more empowering experiences of patients’ lives. This experience is why chronic pain rehabilitation clinics consider tapering opioids as not just something one does once the other therapies are successful, but it is considered to be a therapy in and of itself. It’s an exposure-based therapy that fosters patients’ innate coping abilities. Patients come to see, in other words, not just how to self-manage pain, but that they really can do it.

Patients often come to chronic pain rehabilitation programs wanting first to learn how to cope and self-manage pain and only then want to reduce the use of opioids. However, the two actions have to go hand in hand, for otherwise learning to cope with pain remains only theoretical. Coping and self-management are skills. They are a knowing-how.

It would be like wanting to learn to ride a bike, but refusing to get on it until you've learned how to ride. The knowledge gained in such an exercise would only get you so far. We can only say that we know how to ride a bike if we have actually gotten on a bike and have ridden it. This process of learning is initially fraught with fear, but eventually becomes an empowering experience.

Similarly, learning to self-manage pain well is a knowing-how that simply can’t be mastered if pain is avoided through the use of opioids. It requires, in other words, having pain with which to practice the skills of coping and other self-management. Of course, the process is a slow one, but must include a slow taper of opioids. Initially threatening, the process becomes easier with practice and at some point mastery comes and people come to cope and self-manage pain without opioids. This sense of success comes to foster and reinforce their abilities to cope with pain.

This process of gaining mastery allows people to finally take back control of their pain. It not only reduces shame, it produces the empowerment that comes when taking back control of your life.

Self-confidence

The empowerment that comes with tapering opioids and learning to self-manage pain instead can produce a profound sense of self-confidence.  People in chronic pain rehabilitation clinics who taper from opioids and learn to self-manage pain instead overcome the fear of pain that has dominated their lives. They no longer are alarmed by pain and no longer hold the view that pain must be reduced at all costs. Rather, they come to see that it's possible to live well with pain. Pain is no longer central to their lives. In this way, even though pain continues, they overcome their pain and move on with the rest of their lives.

The power of this sense of self-confidence cannot be overestimated.

Self-Esteem

Learning to self-manage pain, including tapering opioids, is a therapy that increases people’s ability to cope with pain because it is a shame reducing, empowering experience that fosters self-confidence. In other words, it is a self-esteem building exercise.

Prior to engaging in this learning process, patients tend to see pain as an alarming experience that they need to avoid by taking opioids and as a consequence they tend to feel bad about themselves for having to rely on opioids. They tend to feel sensitive and defensive about their need for opioids, but nevertheless continue their use because pain is so alarming that it seems it must be gotten rid of. This dilemma wears on their sense of who they believe they should be. In other words, the dilemma wears on their self-esteem.

By learning to self-manage pain without opioids, patients come face to face with their pain and learn that they can still live well even if pain is present. In this way, they overcome the sense of alarm that pain can generate and come to see that it doesn’t have to be avoided at all costs. They come to see that they don’t have to pay the price of shame that comes with needing to rely on opioids to get rid of pain. They overcome the fear of pain and come to see that they can live with it. They come to even see that they can live well. This empowering experience allows them to feel good about themselves again. They take back control of their lives.

Learning to self-manage chronic pain, including tapering opioids, is thus a therapy that when done under the guidance of expert healthcare providers in a chronic pain rehabilitation clinic produces improved psychological well-being: acceptance of what is, empowerment, self-confidence, self-esteem, and the ability to successfully self-manage chronic pain.

References

1. Fredheim, O. M., Mahic, M., Skurtveit, S., Romundstad, P., & Bordchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian prescription database and Nord-Trondelag health study. Pain, 155(7), 1213-1221.

2. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152(6), 1249-1255.

Date of publication: November 20, 2016

Date of last modification: January 29, 2017

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Treating Chronic Pain Sun, 20 Nov 2016 20:24:42 +0000