“Thank you. I’m so grateful to all of you. You’ve given me my life back…
but why did it take so long for me to be referred to this program?”
This series of statements, along with the concluding question, is a daily affair in chronic pain rehabilitation clinics and programs across the world. Moreover, this gratitude and unsettled curiosity are commonly expressed with a new-found sense of empowerment, an empowerment that comes only from tapering opioids and coming to acquire the abilities to successfully self-manage persistent, severe pain.
These sentiments are typically expressed by those who previously hadn’t believed that self-managing pain without opioids was possible.
Chronic use of opioids is often associated with an unwavering belief that severe pain is simply intolerable without opioids. Patients on long-term opioids may initially resist coming to a clinic that provides care involving opioid tapers. Once havng started to receive such care, they may become angry with their team of providers when encouraged to taper. They often lack confidence that they can do it. Their healthcare providers, however, support them by showing them how to do it. Just as importantly, their healthcare providers believe in them and express it to them. With time, persistence of effort, and a willingness to learn, patients in these programs and clinics find themselves in a position that they hadn’t previously thought was possible. Having gone through a series of therapies, including a slow and safe opioid taper, they are doing well. Indeed, many find themselves feeling better than when they had been on opioids, despite their earlier perceptions of opioids as literally a lifeline. They can hardly believe it, but here they are, doing well and without opioids. In this place of wonder, gratitude and empowerment, for having taken back control of their lives, it inevitably dawns on them to ask, “Why didn’t anyone refer me to this clinic before?” or “Why did it take so long? I was on opioids for years and no one ever told me that there were programs like this!”
Such experiences of empowerment are the result of a number of pain rehabilitation therapies, but an essential one in the overall mix of therapies is a slow and safe opioid taper. Opioid tapering, in other words, is an exposure-based therapy for pain, making what was once intolerable into something tolerable – in fact making it quite livable.
What is an exposure-based therapy?
An exposure-based therapy is a treatment in which patients acquire skills that allow them to gain incremental control over their nervous system through a process of gradually exposing themselves to stimuli that we naturally and reflexively tend to avoid. In so doing, patients repetitively practice responding to the stimuli differently, so as over time the stimuli is no longer avoided. In this process, patients come to change their experience of these stimuli from something that is perceived as intolerable to something that is tolerable. With more time and effort, they subsequently gain mastery over the stimuli that had previously been perceived as unbearable and which had elicited a reflexive reaction of avoidance.
Let’s take an example. When you think about it, there is nothing natural about riding a bicycle. You sit on a small seat attached to a frame on wheels that can roll from slow to fast, at times much faster than you can walk or run. While on a bike, you can also hurt yourself, sometimes just a little, but sometimes the injuries can be quite severe. When young and learning to ride a bike, despite any desire to be like your older siblings or friends, we have a natural and at times quite reflexive reaction to stop trying. This reflexive reaction is subsequently reinforced with failure to successfully ride and what occasionally accompanies such failures -- injury. In other words, learning to ride a bike is hard. It isn’t natural and it can sometimes hurt when we fall while learning. Sometimes, it can hurt a lot. We have a tendency to avoid such experiences. It is not natural to continue to go back to an activity that we haven’t inherently evolved to do and which involves risk of harm and pain.
Nonetheless, with coaching and encouragement from a more experienced rider, we can and do override these reflexive responses to avoid the activity and instead go back to it, and practice the skills necessary to ride a bike. With time, persistence and effort, we learn to ride a bike.
Now, notice what happens to our experience of bike riding through the beginning, middle, and end of this process of learning. At first, the prospect of bike riding is mixed. You want to be like the others in the neighborhood who seem to be having fun on their bikes, while at the same time it is also scary. You’re not so sure about it. One part of you (such as the frontal lobe of your brain) wants to achieve that skill which others in the neighborhood have and you want to set out to learn how to do it. Another part of you (such as the limbic system of your brain) is reflexively not so sure about it and wants to put it off for another day. This internal conflict is called ambivalence. You want to, but you don’t want to, at the same time.
If the latter part of your ambivalence gets the upper hand, and you keep avoiding it, then bike riding remains a fraught experience. The internal alarm bells go off whenever you entertain getting on the bike and recalling those times when you actually or nearly fell and hurt yourself. With the alarms sounding, you avoid the bike altogether and your perceptions of the prospect of learning to ride a bike is that it is just too threatening. It is best avoided altogether.
If, however, the former side of your ambivalence gets the upper hand and you keep intentionally returning to practice riding the bike, this thing that you naturally and reflexively tend to avoid comes to be perceived as increasingly tolerable as you slowly practice and acquire the abilities to ride the bike. In short, your experience of bike riding goes from a naturally alarming and threatening experience that you reflexively tend to avoid to an experience of empowerment and mastery.
The same stimulus – bike riding – can come to involve two very different perceptions. When it comes to stimuli to which we as humans have inherent, self-protective reactions, we can set out in a systematic way to practice over-riding these reflexive reactions and acquire a set of skills that changes the overall experience. We do so by repetitively exposing ourselves to an inherently threatening experience to which we reflexively avoid and instead intentionally practice a different set of responses. In the process, our perception of these stimuli changes from something that is intolerable to something that is tolerable and eventually something that is quite livable. The stimuli don’t change, but our nervous system’s inherent self-protective reactions do and thus our perceptions of the stimuli do as well.
This systematic process, along with the supportive coaching on how to do it, is called in psychology an exposure-based therapy.
Changing our nervous systems
We don’t tend to think of learning to ride a bike as an exercise in changing our nervous systems. Usually, we think of it as an exercise of practicing balance and coordination, as well as an exercise of effort and persistence. We typically have coaching and encouragement from a more experienced bike rider, one who has mastered the skills necessary to ride.
It is, of course, all those things, but it is also something else. Something important happens in our brain when we gain the skills necessary to ride a bike. In fact, we might even consider that what happens in our brain is the development of a skill unto itself. It’s the skill of gaining mastery over our inherent, reflexive, self-protective reactions to stimuli that are associated with harm.
To fully understand this statement, we need a quick lesson in neuropsychology and neuroanatomy.
In the presence of something dangerous or harmful, we have a part of our brains that sounds the alarm and reacts in ways that protects us. This part of our brain is called the limbic system.
The limbic system lies on the inside of our brain at the top of the brain stem, which itself comes up from the spinal cord. It is sometimes called the mammalian brain, because all mammals have a limbic system that protects us from harm.
When threatened, the limbic system in the brain sounds an alarm. This alarm is made of many reflexive reactions. Cognitively, we become focused on the threat and immediately engage in problem-solving, which usually involves getting away from the threat. Emotionally, we are alarmed – agitated in terms of fear and anger. Hormonally, the limbic system releases danger chemicals that amp us up with energy and tells the immune system to release inflammation that will protect us from bodily harm. Behaviorally, we react in self-protective ways, which, again, usually involves avoiding the threat; but, if we must, it can also involve fighting back against it. Socially, we tend to seek support and help from others.
All of these reactions are not the result of intentional decision making. We don’t, for example, react to threat by going, “OK, wait a minute, let me think about this and weigh my options here… so that I make the best decision possible.” Rather, it is much more automatic. When threatened, we fly into action without making an intentional decision. Like a knee jerk when tapped in a particular spot, they are all reflexive reactions.
This set of reactions is called fight-or-flight, or sometimes, fight-flight-tend-and-befriend.
It helps us to survive threats and go on to live another day. Our mammalian nervous system evolved a limbic system – this part of our brain – because it helps us to effectively respond to threats and survive. It came in handy when there were saber-toothed tigers roaming the neighborhood.
We don’t need, however, something on the order of a saber-toothed tiger for our limbic systems to kick into gear. In fact, it can happen all throughout our present day lives. It can happen with the little things, the big things, and everything in between. We can think of countless examples. We can get amped up when our boss makes a comment that we aren't sure how to take. We can get even more amped up when we hear bad news about a loved one, when we drive on icy roads or when we look down from a tall height. If you have ever flown in a plane, consider what it was like the first time. Maybe just ever so slightly, or maybe to some greater degree, you felt the pull of your limbic system kicking in – heart rate going up, palms getting sweaty, fear rising, feeling pulled to get off the plane and avoid it.
Again, these reactions are not intentionally chosen experiences. Rather, they just start to happen. Our mammalian brain – our limbic system – takes over and starts to sound the alarm in reaction to threat.
Despite these reflexive, unchosen reactions of the limbic system, we can come to unlearn them if it matters enough to us to put in the time and effort to practice over-riding them.
In addition to a limbic system, our brains also have a frontal lobe. The frontal lobe lies behind our forehead and is the seat of higher level thinking and learning. It allows us to engage in self-observation and consideration of options. In other words, we can think about how we should act, consider our choices, and actually make intentional choices. So, if it mattered to us enough (say, for example, you took a job that involved travel and you had to get over your fear of flying) we can use the frontal lobe part of the brain to practice observing the reflexive reactions of the limbic system, catching ourselves when doing them, and practice intentionally engaging in different chosen responses, rather than just automatically reacting. We might also receive coaching in this process, pointers, and encouragement. With time, effort, and practice, we can come to routinely choose responses that are differnt from what the limbic system automatically offers up. As a result, our perception of the original threatening stimuli changes to something more benign. Through an exposure-based therapy, what was once intolerable becomes tolerable and then changes further to something quite livable.
Review of the neuromatrix
Along with other parts of the nervous system, the frontal lobe and limbic system are involved in the production of pain in the body. By changing them in an exposure-based therapy, we can come to interrupt the production of pain and thereby change pain levels from intolerably severe to tolerably moderate and then all the way to mildly quite livable.
To understand how, we need to dive deeper into neuroanatomy and how pain is produced in the body.
Suppose you break your ankle while accidentally stepping into a hole. A broken ankle is usually quite painful. Its pain is the product of a complicated back-and-forth process of communication in the nervous system.
First, sensory nerves in and around the ankle sense the bone fracture and send electrical-chemical signals up the nerves of the leg to the spinal cord, and through the spinal cord to the brain. Once those signals reach the brain, many parts of the brain become activated. Roughly speaking, we can say that these parts fall into three broad areas: the somatosensory cortex, the limbic system, and the frontal lobe.
The somatosensory cortex produces the quality of the sensation and where it will be felt in the body. In the case of your broken ankle, you’d likely feel a throbbing, aching sensation of pain in your left ankle. Despite it being felt in your ankle, the experience of these sensations is produced in the somatosensory cortex of your brain, in communication with nerves in your body.
Pain is also an inherently alarming or distressing sensation. Unlike tickles, tingling, and itches, which are also sensations, pain makes us feel distressed. We do not giggle and get goosey with pain, such as we do with tickles. Rather, we become alarmed, guarded and self-protective of the painful part. We also reflexively seek the help of others. All of this is to say that when the somatosensory cortex produces a sensation of pain, the limbic system also kicks into gear. We go into fight-flight-tend-or-befriend.
After all, pain is our inherent danger signal. It is alerting us to a problem in our body – in this case, an ankle bone fracture. Thus, it would make sense that our built-in alarm system that protects us from danger would also be activated.
As we saw above, a number of things happen when our limbic system kicks into gear. Hormones are released. One of these hormones is cortisol, and cortisol tells our immune system to produce an inflammatory response. Inflammation floods the ankle, making it swollen. It is there to repair damage (and/or fight infection if, for example, it was a puncture wound rather than an ankle fracture). Inflammation also, however, irritates nerves, making them quite sensitive to normal stimuli, like touch or simple movement. It is why it hurts so much, when you seek help in the emergency room, and the healthcare provider examines the broken ankle and lightly palpates it, asking, “does this hurt?” The light touch does indeed hurt. It’s because the inflamed, and subsequently irritated, nerves have become sensitive and the whole nervous system in its two-way communication is producing pain.
The frontal lobe, our center of higher level thinking, such as self-observation, learning and intentionality, is also involved in the production of pain. Over the course of a lifetime of experiences, we come to learn what’s serious and what’s not, what we should seek help for and what we can do on our own. Consider how a young toddler looks to his mother when looking up from a scraped knee and beginning to have an alarming sensation in the knee; consider now how you react in a similar situation given that you are an adult. The reactions and indeed the pain levels tend to be quite different. In other words, through the normal course of development, we come to know when to follow our limbic system’s alarm bells and when to override them; over the course of this timeframe, we actually have already become quite good at over-riding our limbic systems in these situations. In the case of the broken ankle, however, we’ll typically perceive it as serious enough to get help, and engage in other self-protective behaviors.
If we put someone with a broken ankle into an MRI tube and scanned their brain, various parts of the brain would light up, all of which fall into these three broad areas of your brain – the somatosensory cortex, the limbic system, and the frontal lobe. Their involvement in the production of pain has been dubbed the neuromatrix of pain. The overall product of this neuromatrix is a tactile perception of pain.
The neuromatrix works with the spinal cord and the nerves in the body in a two-way communication process – upwards from the site of injury and downwards to the site of injury. In this way, in our example, to have pain in the ankle, we need both the ankle bone fracture and the nervous system in this two-way communication process, as described above.
To reduce pain in these kinds of cases, we do two things. One, we wait for the ankle bone fracture to be healed by the inflammation and as a result the brain will call off the alarms and stop calling for inflammation, and subsequently the nervous system will come back to normal. Two, in the meantime, we do therapies to calm the nervous system.
What does this have to do with pain and opioids?
Most – almost all – therapies for pain target the nervous system, particularly the brain, in order to reduce pain. Anti-inflammatory medications, like ibuprofen or steroids (such as what is given in an epidural steroid injection), reduce inflammation, which itself irritates nerves as described above, lowering the threshold of what will cause pain, like light touch or simple movements. When inflammation is reduced, through the use of such medications, the nerves temporarily come back to a normal threshold and normal things like touch or movement no longer hurt as much. In this indirect manner, the medications calm the nervous system. Antidepressants, like duloxetine, antiepileptics, like gabapentin and pregabalin, and muscle relaxants, like baclofen or tizanidine, calm the nervous system more directly. They work on the brain to create downstream effects on pain. Opioids too work on the brain. MRI studies show that opioids work throughout the neuromatrix that is responsible for producing pain, but particularly in the somatosensory cortex and the limbic system. Interestingly, the limbic system seems most sensitive to opioids1, 2 – calming the emotionally alarming aspects of pain (“Opioid pain medication takes the edge off…” or “I still have pain, it just doesn’t bother me as much anymore…”).
In fact, they are systematic ways of learning to incrementally gain greater control over your nervous system to reduce its reactivity and thus change levels of pain. The target for all these behavioral interventions are the limbic system and frontal lobe.3 They reduce pain by accessing the frontal lobe to learn how to reduce limbic system activation that typically accompanies the sensation of pain. Pain levels subsequently reduce from severe to mild.
Let’s explain the way to do it.
Acquiring the abilities to successfully self-manage pain
Suppose it became important to you to become a good public speaker. Maybe you took a job that required it, but you’ve never done public speaking before and in fact you would have avoided it altogether had the possibility arisen earlier in life. The mere thought of speaking in front of large audiences makes you nervous and queasy. If, by some force of magic, you found yourself in front of hundreds of people with a speech script in your hands, the experience would be unbearable. It would be pure fight-or-flight. However, it now has become important to you to learn how to do it and so you sign up for a public speaking course. In the course, you start to practice giving speeches in front of the mirror, but in time you start to have one or two people listening. With practice and effort over time, you speak in front of larger and larger audiences. You get supportive coaching and assurances along the way to keep you motivated and learning. In this gradual manner, you eventually get up in front of hundreds of people. You do it a number of times and it becomes less and less scary. It goes from an unbearable experience to one that is bearable. With such repetitive practice, you might imagine that you could get really good at public speaking, and even one day come to enjoy it.
In this systematic training, you are essentially targeting your limbic system and training it how to refrain from going into fight-or-flight in the presence of the threatening stimuli of being in front of hundreds of people, engaging them in a speech. You do it through learning, intentional self-observation and practice – all of which are largely housed in the frontal lobe.
By gaining mastery over your limbic system's automatic responses, the same stimuli -- speeches in front of hundreds of people -- is no longer perceived as an unbearable experience, but rather becomes perceived as bearable, perhaps, even quite routine.
Now, of course, you could forego the training course, and target your limbic system with certain types of medications. However, they tend to have cognitive side effects, and you might not be as sharp as you want to be when giving a speech. In these cognitively dulling side effects, you might also not care as much, but giving speeches is for your job and so you want to stay motivated to care and be attentive to the details. Or, maybe it is against your values to take medications, many of which are addictive, for the sole purpose of calming your nervous system, and you’d end up feeling bad about yourself if you had to rely on them. For whatever reason, you make an intentional decision to learn how to incrementally gain control of your nervous system without having to rely on medications and so you sign up for the course.
Similarly, as we have seen, pain is an inherently alarming sensation that we reflexively avoid. It is produced in the neuromatrix of the nervous system involving, among other parts, the limbic system. The limbic system is activated, going into fight-or-flight, when the somatosensory cortex produces a sensation that the frontal lobe has learned to recognize over the course of a lifetime as pain.
Now, we can avoid this experience by taking medications that reduce the activation of the limbic system, among other parts of the nervous system. It is perfectly acceptable to take such medications. If, however, you are tired of the side effects; if, however, you don’t feel good about yourself for having to rely on them; if, however, you are tired of having to defend yourself from others’ judgments of you for taking them; if, however, there’s too much conflict in your family because you believe the medications are absolutely and obviously necessary to manage pain but others don’t seem to believe you; or if, for whatever reason, you decide that you want to be able to self-manage pain without their use, then… you also have the option to pursue a systematic training course on how to do what the medications do for you. You can learn, with supportive coaching and practice, to incrementally gain control over your limbic system when it becomes reflexively activated in the presence of a sensation we call pain.
You do this in either cognitive-behavioral therapy (CBT), pain neuroscience education, or participation in a chronic pain rehabilitation program, in combination with a slow and safe taper of opioids. You have a team of supportive and encouraging providers consisting of at least a prescribing provider, a pain psychologist engaging you in CBT and a physical therapist focusing on mild aerobic exercises and pain neuroscience education. You learn about your nervous system and how it produces pain in the body. You learn about the differences in acute pain, in which it is good and adaptable when the limbic system activates into fight-or-flight, and chronic pain, in which it is safe to calm the nervous system down and reduce the fight-or-flight response. You also learn and practice ways to calm the nervous system down through meditation, mindfulness, yoga or tai chi. From your providers, you also receive supportive coaching on changing your reflexive reactions to pain. In these coaching relationships, you practice staying grounded and active in the presence of pain, rather than alarmed and avoidant of both pain and activities associated with pain. You subsequently come to cope better with pain. With all these changes, you come to have less pain. It goes from what was once a severe and intolerable experience to a mild and tolerable experience. Indeed, it becomes quite livable.
In other words, what you are targeting is your limbic system and training it to refrain from going into fight-or-flight in the presence of a sensation that the somatosensory cortex is producing. The conduit for this training is your frontal lobe, which is capable of higher ordered thinking, self-observation, and the making of intentional decisions. Each time, for instance, you practice observing your reactions to pain, making an intentional decision to focus on staying grounded in the knowledge that daily activities are safe to do, and redirecting your attention onto those other activities, you are using parts of your frontal lobe to reassure your limbic system that it doesn’t have to sound the alarm in the presence of a sensation. You can have persistent, or chronic, pain and it is safe for you to stay active. You practice stepping out of the automatic, or reflexive, reactions of your limbic system, and mindfully choosing your responses from the higher ordered thinking of your frontal lobe.
With time, effort and practice, you get better and better at it. It becomes more and more familiar. Your nervous system changes as a result. The variables of the neuromatrix, which produces pain, change. Your somatosensory cortex may continue for the time to produce a sensation, but the limbic system is less activated, making the sensation more tolerable, and the frontal lobe is learning that the chronic sensation is safe to ignore with certain activities of daily life. In this manner, the experience of pain goes from what was once an intolerable experience to a tolerable one and then progresses to become a quite livable one.
Exposure-based therapy of a slow, safe taper
To practice these approaches and subsequently become highly trained in them, you have to have pain. You have to practice with the actual lived experience of pain. This prospect involves intentional decisions to become more active and, if taking opioids, pursue a slow, safe taper.
Now, again, the use of opioids is a legitimate way to respond to pain. If, however, for whatever reason, you want to acquire the abilities to successfully self-manage pain, then you’ll need to consider the opportunity of a slow, safe taper with the support of your prescribing provider and the rest of your treatment team. (Please note any decision to change medications should be taken only as a result of careful consideration and consent between both you and your prescribing provider, along with the support of the rest of your treatment team.)
There are systematic ways, like training courses, to learn how to do it. They are informative, supportive and encouraging. Some of them, such as pain rehabilitation programs, are done in a group format whereby you progress within a small cohort of people just like you – folks with severe, and often disabling, chronic pain. Moreover, pending any rare, life-threatening dangers, such as a severe allergic reaction or respiratory depression, the taper is slow and safe, at a rate that you and your prescribing provider mutually agree upon in respectful on-going discussions.
People who make the decision to pursue these therapies and learn to successfully self-manage severe chronic pain without the use of opioid medications often describe it as one of the most empowering experiences of their lives. They faced down their pain and learned to gain mastery over it.
Where you find these therapies are in chronic pain rehabilitation clinics and programs. It is important to note, here, that such programs and clinics constitute a specialty within pain management. Many providers who have spent their careers expertly prescribing long-term opioids, whether at the primary care office or long-term opioid management clinics, often do not have the expertise to provide these therapies. Commonly, when they do pursue a taper, it is often too fast and without the supportive therapies that substitute for the opioids, or when their patients show signs of addiction. Surgeons too often have a high level of expertise for surgery, but not for providing pain rehabilitation involving slow and safe tapers. So, typically, where you find providers with this kind of expertise in pain management is in pain rehabilitation clinics and programs. They show patients how to successfully self-manage pain without opioids. Their patients are not addicted to opioids, but they do tend to have severe, chronic, and often disabling, pain.
Few people with persistent pain come to the prospect of tapering opioids with gusto and enthusiasm. Rather, they come with at least hesitancy if not outright fear and trepidation. After all, for many, long-term opioids for severe chronic pain have been their lifeline to a semblance of normalcy. Alternatively, the prospect of a life without opioids seems like a life of intolerable pain and suffering.
As such, a common request at this point in the conversation with patients tends to be something like: “Can’t you show me how to self-manage pain first, and then I’ll start the taper?” It’s an understandable question.
It is in fact true that pain rehabilitation therapies often have patients start to learn and practice a number of skill sets prior to beginning a taper. Much can be learned about how to understand pain, change the perspective on how to perceive pain, and skills that begin to calm, or downregulate, the reactive nervous system. These changes require practice and thus time. So, again, unless something life threatening is going on, there usually is no rush towards a taper.
These skills are important and essential to learning how to self-manage pain. They are also, however, insufficient. It would be like learning how to play a sport without ever actually playing your first game. At some point, you have to get on the pitch or field or court and face your competitor.
Thus, learning to successfully self-manage pain also requires practice in real life situations involving pain. Even this next step may or may not involve reducing opioids. It may just involve a commitment to increasing your activity levels or doing activities that you have long since avoided. Ideally, these situations involve goals that you set for yourself. With the gentle encouragement from the treatment team, it typically makes for the best outcomes when you make your own decision about how to challenge the status quo and thus move forward.
Despite involving no reduction in opioids, these commitments to change and practice, along with the encouraging coaching from the treatment team, are the initial steps of an exposure-based therapy when it comes to pain management. Patients make intentional decisions to engage in an activity associated with pain and then set about practicing skill sets to change their perspective on pain and reduce nervous system reactivity all at the same time. Notice, while no opioid reduction occurs, these steps also don’t involve taking extra opioid pain medications or taking medications early in order to pre-medicate the activities. They involve only taking one's normal dosing schedule.
In this way, patients are coming face-to-face with pain while practicing skills sets that change their nervous systems’ production of pain.
If the goal is to reduce opioids, it is at this point that the next step would be to take an initial dose reduction. The amount and timing is a mutual decision between the patient and the prescribing provider, with the support of the rest of the treatment team. Again, taking ownership of the decision to make a therapeutic change is an important factor in its overall outcome.
So, you make the decision that it is time to get on the bike and practice riding.
Despite the understandable fears associated with making such a decision, it is also important to try and take on the perspective that it is an opportunity to let go of burdens that you’ve carried since beginning to use long-term opioids for pain. These burdens are sometimes not altogether noticeable until you’ve started the process of letting go of the medications. It might just be that it has been so long that they have become overly familiar to you and so you have gotten used to it. It may also be because there is oftentimes an underlying shame that accompanies taking opioids that is hard to admit and so it is easy to keep it out of everyday awareness. However you might manifest them, the burdens are there nonetheless and taking steps to acquire the abilities to self-manage severe chronic pain without the use of opioids is truly an opportunity.
It is an opportunity to let go of the worries about what other people think, including your prescribing provider. It is an opportunity to once again be confident that your healthcare providers believe you. It is an opportunity to not have to submit yourself to urine screens. It is an opportunity to let go of the worry and sense of shame you feel whenever you have to see a new healthcare provider, such as in the emergency room. You will no longer be guilty until proven innocent in such situations. It is an opportunity to no longer worry about what if you lose your medications while away on a trip or vacation. It is an opportunity to no longer be so tied to your prescribing provider and the healthcare system. All of this is to say, it is an opportunity, if indeed the word can be said, to let go of the dependency that has shaped your life since beginning to take long-term opioids for pain.
Now, we aren’t talking about dependency in the sense of addiction. What’s described above, though, are forms of dependency. They are dependency in the sense of having become reliant on opioids despite having to give up important things about yourself. To achieve a degree of pain relief, you have given up a sense of freedom to go wherever you want or a sense of being care-free about what others think of you or a sense of confidence when meeting with healthcare providers. In other words, your self-esteem and sense of confidence about being in the world has taken a hit. Instead, you have bought pain relief at the cost of fear of what others think of you, anger and a sense of injustice when being judged, and, yes, an underlying sense of shame about being dependent on a medication and the prescribing providers who prescribe it.
Just think about this: when people participate in therapies within a chronic pain rehabilitation clinic or program, and successfully acquire the abilities to self-manage severe pain without opioids, they are commonly so grateful they begin to weep. It is a liberating experience. It is an empowering experience. And, as said above in the introduction to his article, they are just as often also upset that it took so long for anyone in the healthcare system to refer them to the clinic or program that helped them to achieve these results.
This kind of thing happens everyday in pain rehabilitation clinics and programs across the world. People acquire the abilities to successfully self-manage severe, often disabling, pain without the use of opioids.
They do so by learning and committing to many pain rehabilitation therapies, while also committing to a slow and safe taper of opioid medication use.
Opioid tapering as an exposure-based therapy
A slow and safe taper is one in which patients and their prescribing provider agree on a schedule of incremental dose reductions. The rate of these reductions is the result of a mutual decision, informed by on-going feedback between the patient, the prescribing provider and the rest of the treatment team. The focus is on safety and success, not speed.
With each successive reduction in the use of opioids, patients practice the therapies that downregulate their reactive nervous system. In other words, they are doing themselves what the medication does for them. As described above, opioid medications work on the brain, particularly the limbic system part of the brain. The limbic system is home to the sense of alarm that accompanies the sensation we know as pain. Pain rehabilitation therapies also target the limbic system and calm it down. It takes commitment and repetitive practice. These therapies don’t work as fast as taking a pill. Over time, however, the nervous system downregulates, or becomes less and less reactive. As a result, the nervous system is no longer in such a hair-trigger-like state, producing pain with simple movements like sitting or standing or bending over. This progress leads to normal activities becoming less and less painful. As a further result, another dose reduction can occur and the process continues.
In this process, you start to regain your confidence. You see the progress and know that you are bringing it about. You take ownership of it and know that you can keep it up. You take assurance that it is okay to go safe and slow. Most pain rehabilitation providers agree that it is better to go slow and successful than fast and unsuccessful when it comes to opioid tapering. As such, you come to see that it really can be done. Subsequently, motivation continues to mount and fear of letting go of the medications lessens. You are taking back control.
This process of both downregulating the nervous system and tapering opioids changes the perspective on how pain is perceived. In the chronically avoided state that comes with long-term opioid management, pain is, almost inevitably, an intolerable experience. It is dreaded. It is seen as insurmountably difficult. Excruciating, it might be said. However, pain rehabilitation therapies, coupled with a slow and safe taper, begin to challenge this state of affairs. You commit to doing the pain rehabilitation therapies that you know are doing what the medication does for you, and so you know that you are now substituting them for the medication use. With each successive dose reduction, you come face-to-face with pain, but also come to see that you can do it, as long as you are doing your therapies. Confidence builds and motivation to continue mounts. With supportive coaching from your treatment team, and with persistence and practice over time, your abilities and skills to self-manage pain take over and you no longer see the medications as a necessary lifeline. They start to become a hindrance to normalcy. This process continues however long you want it to continue. Many people in pain rehabilitation clinics and programs continue all the way to the end and become successful at self-managing severe pain without opioids.
They no longer dread a life without opioids. They are grateful for it.
People achieve these remarkable results in pain rehabilitation clinics and programs. With supportive coaching from their treatment team, they engage in pain rehabilitation therapies, but they also pursue an exposure-based therapy, which is usually known as a slow and safe taper of opioid medications.
1. Murray, K., Yezhe, L., Makary, M. M., Wang, P. G., & Geha, P. (2021). Brain structure and function of chronic low back pain patients on opioid analgesic treatment: A preliminary study. Molecular Pain, 17, 1-10. doi: 10.1177/1744806921990938
2. Lee, M., Wanigasekera, V., & Tracey, I. (2014). Imaging opioid analgesia in the human brain and its potential relevance for understanding opioid use in chronic pain. Neuropharmacology, 84, 123-130. doi: 10.1016/j.neuropharm.2013.06.035
3. Gagnon, C. M., Scholton, P., Atchison, J., Jabakhanji, R., Wakaizumi, K., & Baliki, M. (2020). Structural MRI analysis of chronic pain patients following interdisciplinary treatment shows changes in brain volume and opiate-dependent reorganization of the amygdala and hippocampus. Pain Medicine, 21(11), 2765-2766. doi: 10.1093/pm/pnaa129
Date of publication: June 8, 2022
Date of last modification: June 15, 2022
Cognitive behavioral therapy is a traditional form of therapy that is used for a great many types of health conditions. Historically beginning in the 1970’s, it was first used as treatments for chronic pain and depression,1, 2 but later applied to all forms of anxiety disorders and other mental health disorders, as well as other health disorders, such as diabetes3 and heart disease.4
This article explains the application of cognitive behavioral therapy to the management of pain. In it, we’ll discuss what cognitive behavioral therapy is and how it is used in pain management.
What is Cognitive Behavioral Therapy?
Cognitive behavioral therapy (CBT) is a type of psychotherapy. Psychotherapy itself is a therapeutic process in which the aim is for patients to learn to engage in healthy changes within a supportive, coaching relationship with a healthcare provider. In psychotherapy, patients learn to make health-related changes to how they are living their life, and over time these changes positively affect their health. This process of learning involves supportive counseling, education and feedback from the healthcare provider, and an openness to learning and practicing health-related changes on the part of the patient. Notice that in psychotherapy the aim of getting healthier occurs mostly by patients themselves engaging in healthy changes in living, rather than by the healthcare provider doing something to the patient, such as providing a medication or procedure. It’s patients themselves, in other words, who bring about improved health, rather than the provider delivering improved health to patients. There are many types of psychotherapy, and, as mentioned above, CBT is one type.
CBT is a model of psychotherapy that involves patients making two broad categories of health-related changes: changes that fall under either cognitive changes or behavioral changes. The term cognitive refers to the learning of increased knowledge and skills and the term behavioral refers to the health-related lifestyle changes.
While it is an incomplete list, some examples of the cognitive learning involved in CBT are the following knowledge and skill sets:
- Improved knowledge of the health condition that you have and are attempting to change
- Improved understanding of what you can do to become healthier
- Increased motivation to make healthy changes and the empowerment to bring them about
- Increased abilities to perceive multiple perspectives on the things you want to change
- Increased abilities to make intentional decisions with regard to the things you want to change, as opposed to merely automatically reacting to them as you go about life
- Increased abilities to tolerate distress, stress or pain
- Increased abilities to be happier even if you can’t entirely get rid of the problem(s) that you are trying to change
While again an incomplete list, some examples of the behavioral changes involved in CBT are the following healthy lifestyle changes:
- Improved nutritional choices and/or achieving a healthy weight
- Smoking cessation
- Reducing caffeine or other substance use
- Improving your sleep
- Intentionally engaging in activities that are fun or make you happy or align with your values
By learning and doing these things, and doing them over time, you have a positive impact on your health and well-being.
Let’s take a quick example. Suppose you have uncontrolled type 2 diabetes. Your blood sugars tend to run too high. So, in addition to working with your internal medicine provider, you also see someone for CBT. In the supportive coaching relationship that you develop with your CBT provider, you learn about type 2 diabetes, and its relationship to weight and food choices. You also learn how blood sugars respond to stress and exercise. You also set out to become more aware of how you eat — that you sometimes eat when you are bored or stressed. You come to realize that you tend to eat food as a way to have fun. As a result of these new perspectives, you come to practice making more intentional decisions about when, what and how you eat. All of this learning falls into the category of cognitive learning. These cognitive skill sets come to lend themselves to behavioral changes you subsequently make. For instance, with supportive instruction and feedback from your CBT provider, you come to check your blood sugars and take your medications on a more regular basis. You come to eat on a more regular basis and you switch out your dinner plates for smaller sandwich plates, as a means to reduce portion sizes. You start to cook from scratch more often, rather than eat processed meals you had been heating up in the microwave. You intentionally engage in other pleasurable activities, rather than eating, in order to have fun. You also intentionally respond to boredom or stress with other behaviors besides eating comfort foods. You also start to walk for twenty minutes three times per week. Throughout this process, you are checking in with your therapist, getting supportive feedback and pointers. As a result of all these cognitive and behavioral changes, your blood sugars start to fall into the normal range. You also slowly lose weight. You have a little more energy. You also find this whole process rewarding, empowering, and motivating so you keep all these changes going. These changes, in other words, come to be your new normal and your type 2 diabetes goes from uncontrolled to controlled.
Notice what happens. With openness to learning and feedback, and with a willingness to practice behavioral changes over time, you come to have a positive affect on the physiological basis of the health condition for which you sought care — in this case, diabetes.
CBT is thus an established method for fostering therapeutic changes over time to improve health and well-being.
How does CBT treat pain?
CBT for pain follows the same cognitive and behavioral model as described above — learning about pain and what you can do about it, and engaging in healthy lifestyle changes that can reduce pain and its impact on you. Let’s follow this model while explaining how it works.
To fully understand how CBT is used to treat pain, it is necessary to understand how pain occurs in the body. We often think of pain as the result of an injury or illness, but it is more complicated than a simple understanding of injury/illness = pain. To have pain, we may have an injury or illness, but we also require a nervous system. So, in cases where we have an injury or illness, we also have nerves which sense the injury or illness and these nerves send signals to the brain, which puts it all together to produce pain. No matter what the injury or illness we may have, pain is always produced in the brain in response to the sensory input from the nerves in the area of the body that involves the injury or illness. In this way, pain is like the alarm of a fire alarm system: smoke detectors in the area of the fire send signals through wires to a computer that sounds an alarm when it recognizes certain signals as threatening. Pain is a tactile alarm produced by our nervous system (which includes nerves in the body, our spinal cord and brain) that alerts us to something being wrong. We might thus understand that pain is more complicated than merely injury/illness = pain, and recognize the more accurate depiction of injury/illness + a nervous system = pain.
CBT is a method for targeting and changing one of the variables in this equation. It is not a method to heal injuries or illness, but rather is a method for training the nervous system to produce less pain. To understand how this aim can be achieved, it is necessary to further know how the nervous system produces pain. Specifically, we need to understand how different parts of the brain work together with the nerves in the body to produce the experience of pain.
We rightly consider pain a sensation. It is not an emotion, like being sad, mad or glad, but rather a sensation, like numbness, tickles and itches. Roughly speaking, sensations are produced in an area of the brain called the somatosensory cortex. The experience of pain, however, also involves another area of the brain, called the limbic system. Sometimes called the pain-pleasure area of the brain, the limbic system is home to the fight-or-flight response. It’s what makes the sensation of pain unpleasant or distressing. Unlike tickles that might make us giggle or itches that aggravate us, the sensation of pain is inherently alarming. It makes us gasp and become guarded, tense and vigilant. We go into, in other words, fight-or-flight when in pain, which is why we can be irritable (fight) or fearful (flight) when experiencing pain. What we are describing is what it is like when our somatosensory cortex teams up with our limbic system to produce an alarming sensation that we call pain.
It makes sense that the sensation of pain puts us into fight-or-flight. Fight-or-flight is our danger response and pain alarms and alerts us to danger with regard to our bodily integrity. We need to be alerted to injury or illness.
In this process, another area of our brain becomes involved as well. It is our frontal lobe and it does a number of things one of which is higher level learning. We only need to burn our hand on the stove one time and we learn to be careful around stoves on future occasions. As we grow and develop, we come to learn about pain. We learn, for instance, what is no big deal and can ‘rub it off’ or ‘walk it off’ versus what is a big deal for which we should rest, stay home or seek healthcare. This learning involves the degree of threat that we experience when having an alarming sensation called pain. In other words, when we experience pain as no big deal and so keep living life, we aren't very threatened by it, whereas when we do experience as a big deal and so stop, rest and seek healthcare, we do experience it as more threatening. This degree of threat is thus correlated with the degree to which we can tolerate pain. When we experience an alarming sensation of pain and have been told it might be cancer, but later receive a more reassuring diagnosis that it is not cancer and will be temporary, we come to more readily tolerate the pain. Similarly, acute pain, which we know is temporary, is often more tolerable than chronic pain. The tolerability of pain is thus related to the degree of threat that we experience when in pain. It’s what leads us to either keep living our lives when in pain versus responding with vigilance, avoidance of activities, staying home, resting, and seeking help.
Roughly speaking, these lived experiences of pain are produced in the different parts of the brain:
Sensation + Alarm + Perceived Threat + Behavioral Avoidance = Pain
Somatosensory Cortex + Limbic System + Frontal Lobe = Pain
This understanding of how the brain and the rest of the nervous system produces pain is referred to as the neuromatrix model of pain. It literally has about four decades of basic pain science demonstrating its accuracy.
From this more accurate and sophisticated understanding of the neuromatrix of pain, we can come to see how we might intervene to change the levels of pain that we experience. We might, for instance, set out to retrain this usually automatic response by intentionally practicing having the sensation while reducing its related degree of alarm, threat and behavioral avoidance. In doing so, we could alter the overall experience of pain. In CBT for pain management, there is actually a whole host of cognitive interventions that are taught and practiced by the patient to bring about this aim of retraining the nervous system and how it produces pain.
Before we describe how to achieve this aim, we need to cover one more topic related to how pain is produced in the nervous system. It’s called central sensitization.
When the limbic system goes into fight-or-flight when having the sensation of pain, multiple things happen. One of these things is that the limbic system tells certain glands in the body to produce hormones, which in turn tell the immune system to produce an inflammatory response. In turn, inflammation irritates nerves, lowering the threshold for what will lead the nervous system to produce pain. In this process, stimuli that normally do not lead the nervous system to produce pain come to in fact produce pain. When you have the flu and are achy all over, a massage, which normally would feel good, feels awful. When you bring your broken, swollen ankle to a healthcare provider and the provider lightly touches it while examining it, the light touch hurts. These are examples of inflammation irritating nerves to the point that the nervous system is producing pain in response to stimuli that typically are not associated with pain.
This process starts in the brain. The somatosensory cortex produces a sensation and the limbic system goes into fight-or-flight, while the frontal lobe understands it as a threat. In this process, inflammation is produced in the body that irritates the nerves, lowering the threshold for what will lead to pain. The brain, in other words, is centrally sensitizing the peripheral nerves in the body.
Central sensitization is normal in acute injuries and illnesses. It can, however, remain past the point of healing and become the cause of chronic pain. It can also occur secondarily to other causes of chronic pain, such as rheumatoid arthritis. We sometimes refer to central sensitization as the result of a persistently up-regulated nervous system. From the brain to the nerves in the body and back again, the nervous system is stuck in a chronically reactive state, producing an alarming and threatening sensation, that over time, once having become chronic, becomes physically and emotionally exhausting.
Let’s now review how CBT can be used to alter how the nervous system produces pain. As expected, there are both cognitive and behavioral ways of changing the nervous system and how it produces pain.
In CBT and CBT-informed therapies, such as chronic pain rehabilitation programs, patients initially learn about pain and how it is produced in the nervous system. This learning occurs much like we just described above. Once having this understanding of pain and how it is produced, the aim of the therapy changes to developing a cognitive-based skill set, which could be described in the following manner: In the knowledge that it is safe to remain active with reasonable life activities, we are going to practice remaining grounded in the presence of a sensation that you otherwise normally experience as alarming and threatening. There are countless ways to practice and develop this skill set. Any list would be incomplete, but some of these ways are the following:
- Learning to use diaphragmatic breathing to relax in the presence of pain and/or slow down your typical automatic responses to pain
- Increase awareness of your typical automatic reactions to pain — what you think, feel and do when having pain
- Learning that there are multiple perspectives for how you might react to pain
- Learning to make intentional decisions as to how you respond to pain, as opposed to your typical automatic (i.e., unchosen) reactions to pain
- Understanding that centrally sensitized chronic pain is pain that is being produced in the absence of an injury, so as a result you know that it is safe to remain active with reasonable life activities when having pain (i.e., ‘hurt doesn’t equal harm’)
- Intentionally engage in meaningful or pleasurable activities when having pain in order to distract yourself from it
- Practice accepting that the sensation can be there without it being a constant source of distress; you don’t have to constantly try to get rid of it and fail in your persistent attempts; instead, consider it like a box fan that remains on in the room — it captures your attention when the fan is first turned on, but you can come to ignore it by focusing on other things
In these and many other ways, you change the neuromatrix that makes up the experience of pain by repetitively practicing skills to remain grounded in the presence of a sensation. Recall our equation that makes up pain: sensation + alarm + perceived threat + behavioral avoidance = pain. Oftentimes, we try to reduce or avoid the sensation in an attempt to change pain, but we could go after the other variables in the equation and try to change them in order to reduce pain. We could stop avoiding the sensation and get distracted with other things, while reducing its perceived threat and sense of alarm by practicing remaining grounded. By repetitively practicing these skill sets, we would get better at it and with time what was once an intolerable sensation would become increasingly tolerable. In other words, we would start to rate pain as less severe.
By developing these skills, you retrain how your nervous system produces pain. As with any set of skills, the more you practice this set of cognitive-based skills the better you get at them. Initially, you need coaching and feedback from your CBT provider and it requires a lot of attention and energy to do them. With practice, though, they get easier and require less time, attention and energy. Over time, they become like second-nature. As a result, your nervous system is in a less reactive, inflammatory state.
In CBT for pain, you’ll also be encouraged to engage in certain healthy lifestyle changes that down-regulate the nervous system in more overt ways. Some of them are essential for successful management of pain, while others may or may not be necessary, depending on the individual.
One essential health behavior change is to start a routine of engaging in a contemplative practice. Examples of a contemplative practice are mindful meditation, tai chi or yoga. These therapies are traditional ways to target the nervous system and train it to be less reactive.
We don’t typically think of our nervous system as being under voluntary control. Despite the common admonition to “Relax!” from a friend or loved one when we are upset, we usually cannot relax our nervous system on command. However, humans have developed ways to practice gaining incremental control of the nervous system in order to relax it. They are the three mentioned above.
More often than not, a CBT therapist will start with teaching you how to diaphragmatically breathe. This is a form of deep breathing and it is a way to tap into your nervous system and relax it. However, when you do it for a minute or two, you find that it is actually really hard to do. You’ll notice that your thoughts and attention are repetitively distractible. You set out to simply breathe quietly and relax, and you find yourself lost in thoughts about things completely unrelated. Before you know it, you subsequently stop breathing from your diaphragm.
From here, the CBT therapist might introduce mindfulness as a form of meditation. While engaged in diaphragmatic breathing, you practice being aware of your thoughts and distractions, and without self-criticism you continuously redirect your attention back to your breathing. You might be encouraged to do a few minutes of mindful meditation each day and then gradually extend the length of time that you do it.
In developing this practice, you are doing two things. One, you are developing a skill to relax your nervous system. Once done, your nervous system tends to return to its typical reactive state. However, when doing it repetitively each day (or most days) over time, your nervous system returns to a less reactive state. As a result, your average level of reactivity starts to come down. We call it down-regulating your nervous system. Second, in practicing the skills of self-awareness and redirecting your attention, you are practicing one of the cognitive skills mentioned above — intentionally choosing your responses to the stimuli of life, rather than simply automatically reacting to them.
While less commonly taught in CBT, tai chi and yoga bring about similar results. If you already do tai chi or yoga when coming to CBT, your therapist is apt to have you continue them with the same goal in mind.
Another essential lifestyle intervention for pain is engaging in a mild aerobic exercise. Examples of a mild aerobic exercise are walking, stationary bike, or pool exercises. These forms of exercise are not super rigorous and they are not jarring on joints. They do, however, modestly get your heart rate up for a period of time. What happens after your heart rate is elevated for 20 or 30 minutes is that your brain produces feel-good chemicals that relax the nerve system. You may have noticed that feeling of calmness that follows aerobic exercise, if in the past you ever were an exerciser.
Like with meditation, this feeling of calm doesn’t last forever and so it goes away and your nervous system returns to its higher reactive state. However, if over time you repetitively engage in a form of mild aerobic exercise, 3 or 4 times per week, your nervous system begins to return to a less reactive state. In other words, it is another way to down-regulate your nervous system.
Both a contemplative practice and a mild aerobic exercise have been shown to reduce pain levels. It’s not dramatically effective and it does not happen over night, but you can bring your average pain levels to a more manageable level.
A third essential behavior change is committing to some form of gradually increasing exposure to pain or activities that you have historically tended to avoid because of pain. Now, I know, this prospect sounds terrible! But before you stop reading, hear me out. Maybe you have a goal of using less opioid pain medications or you have a goal of returning to work or regularly doing some other family or social activities. You discuss it with your CBT provider and other healthcare providers involved in your care. Maybe you also discuss it with your loved ones. It is important that the decision comes from you and that it is thoughtful. It’s also important to have a plan and commit to it.
Suppose that your goal is to use less opioid pain medications. In your discussions with your healthcare providers, you develop a slow and gradual taper plan. Suppose your goal is to return to work. So, in discussion with your providers, you participate in a CBT-informed chronic pain rehabilitation program that shows you how to return to work. Or suppose you commit to volunteering a few hours per week as a gradual step towards returning to work.
These plans involve risk — the risk of having more pain. You have historically avoided pain by taking opioids or not working. But you also want more out of life. You see the value of not being dependent on an addictive medication or you see the value of working. You don’t want to be so controlled by pain that you end up compromising these values. So, you make the decision to try and take back that control.
As a result, while practicing your cognitive and behavioral skill sets, you commit to gradually exposing yourself to what you have historically tended to avoid -- pain and activities associated with pain -- with the goal of taking back control.
The importance of this exposure-based aspect of CBT for pain is that you have real life things on which to practice your developing pain management skills. Oftentimes, patients want to learn how to successfully self-manage pain and then taper from opioids or return to work. Now, of course, you can achieve modest progress in developing these skills prior to ever reducing opioid medications or returning to some meaningful life activity, such as work. However, as long as you continue to buy pain relief through avoidance of it by taking opioids or not working or engaging in other meaningful life activities, you’ll never know if and how you could learn to self-manage pain while also achieving these important life goals.
It would be like learning all about bike riding, but never actually getting on the bike.
The goal of successful pain management the world over could be summed up as managing pain well while being able to engage in meaningful life activities and to do so as independently of the healthcare system as possible. In other words, to acquire the abilities to self-manage pain well, you must at some point face the decision to expose yourself to the risks inherent to reducing your dependency on opioids and the healthcare system that prescribes them, and increasing your activities. For these reasons, exposure is an essential aspect of CBT.
These risks are normally threatening. No one embraces them with enthusiasm and joy. However, you do it because it is your decision and you were involved in the planning of it. You do it because the plan is to proceed slowly and gradually, in incremental steps. You do it because you get supportive coaching along the way from your CBT provider. But, most of all, you do it because you want to take back control of your life. Pain has for too long controlled you and dictated what you do or don’t do. You want more out of life and you want to feel good about yourself and the life you live.
The exposure elements of CBT are the confidence building part of CBT. Much of CBT for pain is about learning knowledge and skills that retrain the nervous system to reduce pain and its impact on you. It’s a know-how. It’s about the development of abilities. With the development of any abilities, though, there is also a coming to know that you can do it. If developing skills is the know-how, developing confidence is the knowing that you can do it. You don’t know that you can ride a bike until you take the risk and get on the bike and learn how to ride. Similarly, knowing how to successfully manage pain is one thing, but learning that you really can successfully manage pain s another thing.
You will never know that you can successfully manage pain until you start doing it on less and less opioid medications or until you do it while returning to the activities that you used to do. The exposure aspect of CBT for pain is the means to regain your confidence that you really can live life in the ways you want to do.
In most any CBT for pain, patients will be encouraged to learn and practice cognitive skill as described above, engage in some type of contemplative practice and mild aerobic exercise on a regular basis, and incorporate some form of exposure to achieve their goals of successful pain management.
Depending on the individual needs of the patient, there may be other skills and goals to pursue. These could include CBT for insomnia; reducing caffeine, nicotine or other stimulants which activate the nervous system; eating an anti-inflammatory diet; CBT for a co-occurring anxiety or depression; or weight loss. CBT can be used for the management of these conditions too. They’d involve the development of different skill sets, but the emphasis would be on ways that the patient can bring about improvement in their health. If these apply to you, you might be encouraged to pursue them.
CBT for pain is a traditional form of pain management. It involves an established method of coaching people with pain what they can do to effectively and successfully self-manage pain. This coaching occurs within a supportive and instructive relationship with a healthcare provider. The instruction falls into two categories of skill sets, cognitive and behavioral skills. These skill sets aim to retrain how the nervous system produces pain. In so doing, you learn not only how to manage pain successfully, but you regain the confidence that you really can do it.
For more information, please see: Why See a Psychologist for Pain? and Is It Possible to Manage Pain Well without Opioids?
1. Turk, D. C., Meichenbaum, D, & Genest, M. (1983). Pain and behavioral medicine: A cognitive behavioral perspective. New York: Guilford Press.
2. Beck, A. T., Rush, A.J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
3. Uchendu, C. & Blake, H. (2006). Effectiveness of cognitive-behavioral therapy for glyceamic control and psychological outcomes in adults with diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials. Diabetic Medicine, 34(3), 328-339.
4. Gullicksson, M., Burrell, G., Vessby, B., et al. (2011). Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary prevention in Uppsala Primary Health Care Project. Archives of Internal Medicine, 171(2), 134-140. doi: 10.1001/achinternmed.2010.510
Date of publication: 3-26-2021
Date of last modification: 6-15-2022
People are sometimes surprised that there are psychologists who are not mental health providers. It’s also true for people with persistent pain who might wonder why their physician referred them to a psychologist for the management of pain. ‘I’m not depressed’, they might think. The implication is that you’d only see a psychologist if you have a mental health condition, such as depression, anxiety or insomnia. It can therefore be puzzling when referring providers continue to insist on the recommendation of seeing a psychologist for pain, even when yo don’t have mental health problems.
A little known, yet similarly surprising fact about pain management is that some of the historical founders of modern pain management were psychologists. Ron Melzack, a psychologist, along with Patrick Wall, a physician, developed the first modern theory of how pain is produced in the body, highlighting the central role of the nervous system. Five decades of subsequent research coming from their theory now informs our current day understanding of pain and how to treat it. Bill Fordyce, a psychologist, along with John Bonica, a physician, are largely credited with creating the first team-based, interdisciplinary pain clinic, which continues to this day to be the gold standard for pain management.
Psychologists have thus been integral to pain management since its inception as a field within healthcare, and yet their role in pain management remains puzzling to most people with persistent pain, and even to most in society itself.
What is a Pain Psychologist?
Pain psychologists are psychologists who assess and treat pain of all kinds, including post-surgical pain, cancer pain, and chronic pain. Pain psychologists are doctoral-level healthcare providers who have had training and experience typically in health psychology and then went on to specialize in pain management. To best understand how pain psychologists help to reduce pain, let’s first discuss what a health psychologist is, and then apply this understanding to pain psychology.
Health psychology is a type of psychology that centers on the assessment and treatment of health conditions, such as pain, diabetes, heart disease, obesity, among others. One common factor that underlies all these conditions is that their effective management requires more than simply relying on medical treatments alone. To best manage them, these conditions also require patients to make healthy lifestyle changes. So, for example, people with type 2 diabetes may rely on certain medications to manage their condition, but to best manage their diabetes they also need to know something about nutrition and make healthy food choices, achieve a healthy weight, get regular exercise, and manage their stress well. All of these latter changes are what we tend to call lifestyle change or health behavior change. When done over time, health behavior changes can positively affect the biological basis of these conditions and reduce the impact that these conditions have on the patient.
Here is where the role of the health psychologists, including the subtype of pain psychologists, come into play on the healthcare team. Predominantly, physicians have expertise in medications and procedures that can positively affect conditions such as pain, diabetes, heart disease or obesity, but tend to have less expertise in coaching and motivating patients to engage in health behavior changes that also must be pursued if these conditions are to be successfully managed. In contrast, health psychologists are doctoral level healthcare providers whose expertise lies solely in helping patients to take ownership of their health, educating them on how to best manage their health condition, motivate them to start and maintain health behavior changes, and supportively coach them along the way.
Now, pain psychologists are health psychologists who have a further specialization in the management of pain. They assess pain and its many contributing causes. They also assess how the patient is responding to pain, or, in other words, the degree to which the patient is responding to the pain effectively or not. From this assessment, pain psychologist determine a treatment plan to engage the patient in making health behavior changes, which, when done over time, positively affect the physiological basis of pain and thereby reduces pain. They also show patients how to respond more effectively to pain and in so doing patients also reduce the negative impact that pain has on their life.
The therapies that pain psychologists pursue are empirically-supported. Empirically-supported therapies are therapies that scientific research shows are effective. Pain psychology therapies have been shown to reduce pain, increase quality of life, and reduce the use of opioid medications.
How do pain psychology therapies work?
Pain psychologists have a sophisticated, scientifically-informed understanding of the nature of pain. To understand how pain psychology therapies are effective, it is necessary to understand how pain is produced in the body.
Many people naturally assume that pain requires an injury or an illness to occur. This assumption is apt to come from the many times we injured ourselves or became ill and had pain. We step on a nail, for instance, and the puncture wound usually hurts. We thus come to associate pain with injury or illness. So, whenever we have pain we look for some type of bodily injury or illness that causes the pain. To treat the pain, we subsequently try to treat the injury or illness associated with the pain.
From this way of understanding pain, it’s hard to see why you’d ever want to see a pain psychologist. What role, if any, could a psychologist ever play in treating a bodily injury or illness?
This understanding isn’t necessarily wrong, but it is incomplete. We know from five decades of scientific and clinical research (beginning with Melzack, the psychologist, and Wall, the physician, mentioned above!) that the occurrence of pain also requires a nervous system.
The nervous system consists of nerves in the body, sometimes called peripheral nerves, and the spinal cord and brain. The peripheral nerves are connected to the spinal cord and brain. Many of the peripheral nerves in the body are sensory nerves, which means that they sense things. You can feel a smooth table top because you have sensory nerves in your finger tips, which are connected to nerves in your arm, spinal cord and brain. When you touch the table top, the sensory nerves send an electro-chemical signal up the nerves to your spinal cord and brain. Your brain processes this electro-chemical signal and produces a sensation of smoothness in your finger tips.
The same would be true if you injure yourself by, say, hitting your thumb with a hammer. Your sensory nerves in your thumb send electro-chemical signals to your brain via your spinal cord. Your brain processes this information as threatening and produces a sensory alarm that you feel as pain in your thumb that you hit with the hammer.
We might therefore use an analogy of a building’s fire alarm system when understanding how pain works in the body. Just as there are smoke detectors located throughout a building, we have sensory nerves throughout the body. In the case of a fire alarm system in a building, smoke detectors persistently send signals to a computer on the state of the rooms in which they are located and when the computer recognizes the signal that corresponds to smoke, it sounds an auditory alarm. Similarly, sensory nerves are persistently sending signals to the brain on the state of the body — its position, what is being touched, the temperature, etc. When the brain recognizes a signal as threatening, such as when the body is injured or ill, the brain produces a sensory alarm, which we call pain. We don’t hear pain, like we hear a fire alarm, but pain functions in the same way. In other words, we don’t have an auditory alarm, but rather a tactile alarm. Despite this difference, the alarms function similarly in that they tell us that there is something wrong in the building/body. Just as an auditory alarm is produced by a fire alarm system in response to fire, our sensory alarm, or pain, is produced by the nervous system in response to something going wrong in the body.
Now, there are two things when an alarm goes off. In the case of the fire alarm, there is the fire and there is the auditory alarm produced by the fire alarm system. Similarly, with pain, or at least as we commonly think of pain, there is an injury or illness, and there is the sensory alarm, called pain, that is produced by the nervous system.
Now here’s the important part. Fire alarm systems are set at a certain level of sensitivity. We want it to sound the alarm when there is a fire, but not when we light a candle. We could imagine a fire alarm system that is set at a sensitivity that only goes off when there is a raging fire, but not a small fire. It wouldn’t be very useful. We want it set at just the right level. It shouldn’t go off in response to a candle, but it should go off with any fire bigger than a candle. The reverse settings would be equally problematic. Imagine a fire alarm system that sounds the alarm in response to a candle, or someone smoking a cigarette. Imagine further if the fire alarm system in your building was so sensitive that it went off if someone was smoking just outside the front door or on the front sidewalk. Imagine your building’s fire alarm was set at such a sensitive level that it went off with barometric changes that occur when a weather-related cold front comes through.
In such cases, we’d want to ensure that there is no fire, of course, but we’d also want someone to reset the fire alarm system to a normal level of sensitivity, so it would only go off when there is fire.
Here is where the role of the pain psychologist comes into play. Psychologists in general are experts in helping people change their nervous systems. Usually, as we mentioned in the beginning of this essay, we think of psychologists helping people change their nervous systems to reduce things like anxiety, depression, insomnia, trauma, and addictions. But pain psychologists, with their expert understanding of how pain is produced by the nervous system, can help people with pain change how their nervous systems are producing pain — regardless of the initial cause of the pain.
While it might be a bit overly simplistic, we might say of the two variables involved in the production of pain — injury/illness and a nervous system — that physicians tend to target the former to reduce pain while pain psychologists target the latter to reduce pain.
There are pain psychology therapies that reduce pain by reducing the reactivity of the nervous system that produces pain, whether it is the pain that follows surgery, the pain of childbirth, the pain of cancer, or chronic pain. By reducing the sensitivity of the nervous system, you reduce pain.
What does a pain psychologist do?
All pain psychology therapies target the nervous system and reduce its sensitivity to producing pain. Some therapies target how the brain processes the signals that are sent to it by the peripheral nerves in the body. These therapies help patients take a different perspective and change how they experience pain. Some other therapies target the peripheral nerves in the body and reduce their reactivity. These therapies help patients to learn how to calm the body’s peripheral nerves to change the set point of their nervous system. By doing so, their nervous systems do not react so easily and as a result their nervous system doesn’t produce pain so readily.
The former type of therapies are more cognitive in nature, meaning that they focus on changing how the brain processes the information that is sent to it by the peripheral sensory nerves. They involve helping patients learn about their pain, understand it better, and take the sense of fear or alarm out of pain. Patients come to learn that pain is unpleasant, but that it can be increasingly tolerated. Indeed, these therapies can show people how to increasingly stay grounded in the presence of the sensation of pain, and thereby learn to distract themselves from pain in the knowledge that the sensation itself is not harmful. By repetitively practicing this skill set, patients change how their brain processes the information that is sent to it by the peripheral sensory nerves.
The latter type of therapies are more behavioral in nature, which involve reseting the sensitivity of the overall nervous system, including the peripheral nerves. Reseting the nervous system is sometimes referred to as down-regulating the nervous system. As human beings, we don’t typically have voluntary control over our nervous systems. We typically can’t, for instance, simply calm down and relax despite the common admonishment from a loved one to do so when we are upset. However, pain psychologists can coach you on ways to target your nervous system and repetitively calm it down. When done over time, it tends to reset the set point for when it produces pain. So, for example, pain psychologists can coach patient in diaphragmatic breathing practices and forms of meditation that when practiced repetitively over time down-regulates the nervous system and thereby reduces average levels of pain. Pain psychologists might also recommend engaging in a mild aerobic exercise, such as walking or walking in a warm water pool or riding a stationary bike. When done on a repetitive basis, mild aerobic exercise can also down-regulate the nervous system and thereby reduce pain. There are a number of such health behavior changes that pain psychologists can coach their patients to do in a supportive manner.
In general, the overall goal of pain psychology therapies is to reduce pain and reduce the negative impact that pain has on patients. These therapies focus on what the patient can do to achieve these goals, rather than on what the healthcare system can do to achieve these goals. In this way, pain psychology therapies involve a focus on self-management. Self-management is a catchall phrase that captures the healthy lifestyle changes that patients pursue to positively affect their health.
Some of the most important things that we can do to achieve health involves things that we do, not what our healthcare providers do. In the case of pain management, some of the most effective things that can be done to manage pain are things that the patient does by targeting the nervous system. This emphasis on self-management further helps patients with chronic pain become as independent of the healthcare system as possible, such acquiring the abilities to self-manage pain successfully without the use of opioid medications.
Assessments and therapies that pain psychologists perform
Pain psychologists perform a variety of assessments and therapies. The following is a brief list of the most common types of assessments and therapies.
- Pre-surgical psychological evaluations for spine surgery, spinal cord stimulator implants, and intrathecal drug delivery devices (aka ‘pain pumps’)
- Evaluations for participation in a chronic pain rehabilitation program (sometimes referred to as functional restoration programs)
- Psychological evaluations related to the use of opioid medications
Research over many decades has shown these therapies to be empirically-supported, or scientifically proven to be effective. Indeed, when it comes to chronic pain management, these therapies are some of the few empirically-supported therapies that the field of pain management has.
Healthcare providers commonly refer patients with pain to pain psychologists because they know that what pain psychologists do is effective and important in the overall management of pain. However, it’s equally as common for people with pain to be confused by the referral, as they often do not know what it is that pain psychologists do and why it is helpful. To resolve this lack of understanding, it’s necessary to know how pain is produced in the body. Pain requires more than an injury or illness to be produced. For pain to occur, it also requires a nervous system. Both an injury/illness and the nervous system contribute to the production of pain. While some healthcare providers target their interventions at treating the initial injury or illness to reduce pain, pain psychologists target their interventions at the nervous system to reduce pain. The assessments and therapies that pain psychologists perform aim to show patients how to change the ways their nervous systems contribute to the production of pain. These therapies are empirically-supported in that they have been shown to be effective. They can reduce pain, reduce the negative impact that pain has, and can help people with pain become independent of the healthcare system in the management of their pain (e.g., help people to successfully self-manage pain without opioids). Thus, seeing a pain psychologist can be an important and helpful recommendation in the overall management of pain.
For more information, please see Cognitive-Behavioral Therapy for Pain & Tapering Opioids as an Exposure-based Therapy for Chronic Pain.
Date of initital publication: 2-14-2021
Date of last modification: 6-23-2022
You’d think that we’d all agree on what back pain is. Pain in the low back is almost as common as days of the week. Most everyone has had or will have back pain in the course of their lives and it is one of the most frequent reasons for seeking healthcare.1 Despite this common, everyday experience, we continue to be vexed by competing understandings of the nature of back pain.2
To be sure, our understanding of the cause of common back pain has changed over the last fifty some odd years. However, it’s questionable whether these changes mark true advances in knowledge.
A Brief History: Backache or Back Pain?
At one time, we tended to refer to back pain as backache. The term implied similarity to neck ache and headache. Today, when aches of the head and neck occur without any overt injury or illness, we tend to associate them with over-exertion, working too much, tension, and unresolved conflict, among others. We allow, in other words, for the occasions when problems or people are literally “such a headache” or “a pain in the neck.” Still other times, especially when people are prone to neck ache or headache, we tend to perceive such aches and pains as a barometer for when we need to take better care of ourselves because life has become too busy or problematic in some manner.
In the past, backache was considered similarly. The gradual appearance of low back pain, without injury or illness, was readily taken as a sign that life and/or relationships were getting out of sync: backache could be due to working too much, leading to the subsequent need for more rest and relaxation in life; or it was due to the persistent inactivity of a desk job and the habit of watching night-time TV, resulting in an unmet need for more exercise; or it could be due to the persistent unresolved conflict with, say, a boss at work and the mounting pressure that it entailed over time.
Suffering from backache (or neck ache or headache), people tended to prescribe a return to healthier ways of living – resolutions to get more rest and relaxation, work less, seek the solace of the country or outdoors, or bathe in warm springs or spa.
Today, we might understand this conceptualization of back pain with the concept of stress. We use the term stress to refer to the hectic and chaotic nature of modern life. We work too much. We are our chronically over-stimulated from information, messaging, and screens. We persistently juggle between work, children and their activities, and the management of elderly parents. Despite the apparent promise of connection through social media, urban and rural loneliness are all too common. When such imbalances persist for too long, we experience them in any number of emotional and bodily ways, some of which are headache, neck ache and backache.
We all recognize the grain of truth in this way of understanding the occurrence of low back pain, especially when it comes on gradually and without warning. We used to call this type of pain backache.
Injury/Spinal degeneration model of back pain
A competing conceptualization of backache, however, has coexisted alongside this understanding of backache as a malady of the stress of modernity. It is backache as the result of a condition of the spine brought about by injury or degeneration. Allan and Waddell3 have a rich history of the first published medical papers beginning in the late 19th century hypothesizing backache as emanating from problems associated with the spine and subsequent reports of acute back pain due to railway injuries. By the first half of the 20th century, the intervertebral disc had sunsequently come to be understood as a source of backache. With the advent of CT scans in the 1970’s and MRI scans in the 1980’s, this conceptualization eclipsed all other ways of understanding backache, as so much of the spine had become visible. Having become observable, abnormalities of the spine were readily identified as the source of pain in the back. As a result, it is now commonplace to consider pain in the back as due to injury to the disc or degenerative changes to the spine. Indeed, this view of backache has so taken hold that we no longer readily use the term backache in preference for back pain.
There is, of course, a grain of truth in this way of understanding back pain too. Like any other part of the body, we can injure our low back. We are involved in motorcycle accidents, sports injuries, slips on the ice, and falls from ladders, and countless other ways we can injure ourselves. Sometimes, these accidents cause significant enough injuries that they can be seen on scans.
Indeed, beginning in the 1980’s, but really taking off in the 1990’s and early 2000’s, the use of CT and MRI scans became widespread for all instances of back pain. It seemed to open up a whole new world in our understanding of back pain. Specifically, we made the leap from initially holding that back pain is due to spinal abnormalities from injuries on some occasions to holding that back pain is due to spinal abnormalities on all (or most all) occasions.
The primacy of what we might call the injury model for understanding back pain is evident even in those instances in which there is no overt injury associated with the onset of back pain. In response to the gradual appearance of back pain, we tend to look to what we might think of as micro-injuries: “I must have slept wrong,” “I must have tweaked my back,” or “I twisted the wrong way.” Conceptualizing it as an injury, we subsequently seek medical evaluation and oftentimes want a scan to see what’s going on with the spine. Indeed, both the general population and healthcare professionals now seem to simply assume the association of common back pain with spinal abnormalities. Subsequently, it’s now commonplace to want to look first to the vertebrae, discs and ligaments when seeking an explanation of common back pain.
The term for what’s wrong in many of these instances has tended to be spinal- or disc degeneration. It’s a way to refer to the medical equivalent of what we might think of as micro-injuries. Degenerative changes to the spine are the result of slow, wear and tear.
Moreover, such degenerative changes can and have been, of course, the object of medical and surgical intervention. Physical therapists, physiatrists, interventional pain physicians, orthopedic and spine surgeons – all are experts in the evaluation and delivery of interventions aimed at degenerative conditions of the spine.
Having reached its apex in the early 2000’s, this way of conceptualizing back pain as the result of overt or subtle injury, defined by abnormality of the spinal structures, keeps back pain squarely within the realm of healthcare, rather than lifestyle. People have come to look, not to what they can do to alleviate backache, but to healthcare providers with an expertise in the evaluation and treatment of abnormalities of the vertebrae, disc and ligaments. In this way, people with back pain must become patients, it seems, because they have little control over the abnormalities of their vertebrae, discs, and ligaments once they have them. The implication is that people with back pain went from having a problem that they resolved themselves to patients with a medical condition, akin to an injury, that healthcare providers treat.
During this period of shifting emphasis towards spinal abnormalities as the explanation of back pain, the period of the 1990’s to the 2010’s saw the use of scans, interventional procedures, and surgeries grow at exponential rates.4
2010’s: Cracks in the Injury/Spinal Degeneration Model
Looking back, we might question the logic of what happened. Just because some instances of common back pain are due to injury doesn’t mean that all instances of common back pain are the result of injury. In logic, this type of error is called affirming the consequent and it’s considered a fallacy. It is, however, exactly what happened in our understanding of pain in the back.
We were captivated by a model for understanding a particular set of a phenomenon, through which we came to see all instances of the given phenomenon.5 We sometimes think that science and knowledge comes from empirical observation, which then lead us to developing models for understanding those observations. Of course, it can happen this way, but the reverse can also be true. Sometimes, our models determine what empirical observations we make. Science and knowledge can be a reciprocal process in this regard. It’s the latter that occurred from the 1990’s to at least the early 2010’s, but even to some extent to this day. Our injury model of back pain has determined how we perceive the empirical data of back pain.
Our captivation to this model was aided, of course, by the development of high-powered abilities to perceive spinal structures – the CT and MRI machines in the 1970’s and 1980’s, respectively. With them, we could find abnormalities of the spine even when the onset of back pain occurred without any overt precipitating injury – we could still find micro-injuries, if you will, in the form of degenerative changes of the spine. Thus, the injury model of back pain could still explain back pain even when there was no demonstrable outward injury. In other words, we could see the apparent spinal correlates to those instances when we explain to ourselves that we “must have” have injured our backs with a tweak or a wrong twist, even though we hadn't previously observed such a tweak or twist when the pain had come on subtly and progressively.
Despite the power of explanatory models determining what we see, empirical data can still break through in the form of counter-factuals to the model and lead to a change in the conceptual model itself. It takes, however, time, sometimes on the order of years, and it can be aided by changes in society.6
One early instance of counter-factual data, aided by events in society, was that despite the exponential growth of scans and treatments for spinal degeneration, disability claims for back pain grew at a corresponding exponential rate.7
How could this be? If common back pain is due to injury and we have the capabilities to both accurately assess these injuries with the use of scans and treat them with, say, the use of physical therapy and spinal interventions and surgeries, people with back pain should be get better and go back to work at high rates. It’s not what happened, though. With the practice of scanning and treating spinal abnormalities, people have been becoming more disabled. It is hard to escape the possibility that, in at least some instances of common back pain, we have been assessing and treating the wrong things – things that in fact were not the cause of these instances of back pain.
Another set of empirical data that arose in the 1990’s to challenge the injury model of back pain was the discovery that spinal abnormalities are common even among people without back pain. The use of scans, when turned on people without back pain, find the very same things that are found in people with back pain, and which are used to explain back pain.8, 9 As it turns out, disc herniations and degenerative changes are common in people, with or without back pain. Jarvik, et al.,10 and Borenstein, et al.,11 subsequently followed their subjects without back pain over a period of three and seven years, respectively, to see if the presence of such degenerative changes predict later onset of back pain. The progression of degenerative changes over time had no statistical correlation with who later developed back pain.
To place the importance of these findings in perspective, we might use an analogy of the brown-haired bank robber. Suppose that a bank was being robbed one morning and the police had received a tip that the bank robber had brown hair. They surrounded the bank and out came a young man with brown hair. They promptly arrested him and placed him in the back of a squad car, confident that they had found the robber. Upon entering the bank to tell the customers and staff that they were now safe, the police came to realize that many people in the bank had brown hair. Had they found the culprit? They’d have to admit that their confidence could no longer be so certain.
Similarly, having become able to find spinal abnormalities with the occurrence of back pain, we had become confident that back was due to these spinal abnormalities. However, once we came to recognize that we find such abnormalities commonly in people without back pain, we can't and shouldn't so certain that we have found the culprit of back pain.
At the time of the publication of these findings in the 1990’s and early 2000’s, these findings were indeed puzzling, and made a splash among healthcare providers. Nonetheless, they weren’t sufficient to alter the model through which we had come to understand and perceive back pain. We continued, as we still do today, to understand back pain as the result of injury or degeneration of the spine.
I recall occasions in the 2000’s when patients reported to me, “I never knew how much pain I was in until my surgeon read me my MRI results.” Still, to this day, I have patients who report to me that their interventional pain physician or surgeon, when reading their MRI results, exclaim in wonder as to how they can even walk with a spine like they have. Rather than privileging the facts, in this case that the patient doesn’t report much pain or can readily walk, and thus interpret the scans as not representative of their pain and abilities, they privileged the findings of the scans and then told the patients that they are actually worse than they are. Such is the power of the injury model to captivate and determine our understanding of the phenomenon in front of us.
If, however, we are able to step out of the injury model for understanding back pain, we might not wonder such things. We would understand better why people don’t have a lot of pain or difficulty walking, even when finding the presence of spinal abnormalities on scans. CT and MRI scans commonly reveal such findings in people with or without back pain.
Moreover, we might come to understand that these findings have little or no relationship to pain levels or functional abilities. We might, in other words, realize that we are pointing to the wrong things when attempting to explain many instances of common back pain.
This conclusion bears out in large-scale studies that fail to find either statistical or clinically meaningful relationships between back pain and spinal degenerative changes.12, 13 It’s hard to make a case that we have found the cause of back pain when the purported cause doesn’t even correlate, or correlates poorly, with back pain. The most charitable thing we can say is that the lion’s share of what accounts for back pain isn’t captured by scans. Back pain is likely due to many different things that when put together adds up to pain in a person’s back and that what’s found on a scan is just one small factor that accounts for any given person’s back pain.
Modern lifestyle or injury and degeneration?
While we can, of course, injure our back, as we can any other location of our body, should we then infer that all back pain is due to injury? When we so commonly find spinal abnormalities upon scanning the backs of people who report an injury, it is tempting to think that spinal abnormalities are the objective correlate to the reported injury. Similarly, it is tempting to think that such spinal abnormalities are the cause of back pain when it occurs gradually, without a precipitating injury, as we can find spinal abnormalities in these cases too. Thus, it can come to seem that all back pain is the result of spinal abnormalities, whether as the result of injury or more subtle degeneration of the spine.
This explanation of back pain can seem so compelling until, at least, we come to find similar levels of spinal abnormalities in people without back pain. We now have about three decades of repetitive studies coming to the same finding. Most of these studies find no statistically significant relationship between back pain and spinal abnormalities. Even in the minority of studies that do show statistical significance, the relationship is poor and of questionable clinical significance. At best, spinal abnormalities play only a minor role in the cause of back pain.
This fact might shed some light on why spine surgery, despite its widespread use, has failed to produce any conclusive empirical studies showing its effectiveness. The largest and longest study to date, the SPORT trial for lumbar disc herniation, has shown no considerable difference between those who have surgery for disc herniation and those who do not.14, 15, 16
This study was originally designed as a longitudinal, clinical trial, meaning that subjects, who all had disc herniations in their low back, were randomly assigned to either receive surgery or conservative care without surgery (the clinical trial aspect of the study) and then followed to obtain data on their status over the course of 1, 2, 4, and 8 years (the longitudinal aspect). When the data was compared for the two groups, strictly defined by those who remained in their randomized groupings over the course of the study (which is how a clinical trials are run, for instance, for testing the effectiveness of a medication), outcomes were no different between those who received surgery and those who did not receive surgery, at any of the follow-up periods from 1 to 8 years.
If this clinical trial tested the effectiveness of a medication, or of a psychological treatment, no one would question the conclusion that the treatment failed to work. It was no more effective than usual care, which is to say that adding surgery to the overall treatment provided no value. Surgery for disc herniation is no more effective than not having surgery.
However, a funny thing happens when we are captured by an explanatory model of a particular phenomenon and are then met with counterfactual data. Counterfactual data are hard to believe. It’s no truer when it comes to the specific situation of a widespread treatment for spinal abnormalities like surgery. We all collectively might want to ask: how can this be that surgery for disc herniation doesn’t work? Surely, it can’t be true.
As it turns out, the study had some problems, which ironically leads to a reframing of the data towards an alignment with the explanatory model that back pain is due to spinal abnormalities. Specifically, the study suffered from a lot of crossover of randomized subjects. Crossover occurs when subjects of a clinical trial fail to stay in their randomized groupings and so don’t end up getting the treatment to which they were randomized to get. So, in the instance of the SPORT trial, some subjects randomized to get surgery subsequently decided against getting surgery after all; and some of the subjects randomized to conservative care without surgery eventually decided to get surgery anyway. The investigators did the best they could given this circumstance and compiled the data in accordance to the re-assorted groupings and compared those who received surgery against those who did not receive surgery.
Because the subjects in these newly sorted groupings were not fully randomized anymore, this lack of randomization introduces additional variables that might influence the effectiveness of the procedure, outside of the actual procedure itself. There might be something unique to the individuals who decide for or against a certain treatment that in turn influences the effectiveness of the treatment, something that might have been more evenly distributed and therefore washed out, if they had stuck to the initial randomization of who got which treatment. We know, for instance, that motivation and belief in the effectiveness or lack of effectiveness of a treatment can influence the effectiveness of a treatment. It's feasible that such motivation and belief may have played a role in the degree of crossover from one randomized treatment to another, and, as such, they may have also played a role in the degree of effectiveness that those treatments exhibited in the study.
Nonetheless, the data derived from the re-sorting of the groupings might shed some light on the effectiveness of the procedure, even if it is not as rigorous of a study as a clinical trial. The name for this type of study that the investigator’s secondarily pursued, given the circumstances, is called an observational study. The results of an observational study are not considered as conclusive as the results of a clinical trial.
What they found was that, at the 4-year and 8-year follow-up periods, both the group that received surgery and the group that did not receive the surgery improved, but that there was a statistically significant difference in favor of the surgery. In other words, those who had received the surgery improved a little bit more than those who id not receive surgery. This small improvement amounted to about a 13% greater reduction in pain for those who received surgery, which is roughly the equivalent of a one-point greater reduction on the commonly used 0 to 10 scale. There was no difference in the rate of returning to work between those who received surgery and those who didn’t.
The most charitable interpretation of these longitudinal findings of both the randomized clinical trial aspects of the study and the observational aspects of the study are that surgery for a herniated disc might show a small reduction in pain four years and eight years down the road, when compared to not getting surgery. Again, both the surgery group and the non-surgery group showed improvements, but the surgery group improved just a little more than those who did not receive surgery.
Nonetheless, this small improvement is of questionable clinical significance – is the difference, say, of having a pain level of a 7 rather than an 8, four to eight years down the road, enough of a difference to really make a difference in the actual experiences of one’s life?
Thus, the SPORT Trial, which is the best study to date of surgery for disc herniation is far from conclusive. It points to the conclusion that surgery for disc herniation might produce a small improvement in pain level over time.
This small effect for pain reduction but not work status improvement falls in line with what we have been discussing – spinal abnormalities might play a causal role in back pain, but if they do, it is a small role, and so targeting them surgically produces only small improvement. Again, all of this is to suggest that the lion’s share of what causes common back pain lies outside of what scans can identify and what therapies targeting such abnormalities can effectively treat.
Despite decades of data pointing to a cause of common back pain as more complex than simply the presence of spinal abnormalities, a large portion of society continue to have a default understanding that back pain is due to an injury for which spinal degenerative changes are its correlate.17, 18 This default understanding involves, of course, a subsequent default implication that first-line treatments of back pain should target these degenerative changes.
We continue this default understanding because we are captured by an explanatory model that back pain is due to injury, and spinal degenerative changes are the correlate to injury. We continue to do so at the peril of persistent pain, disability and cost.
What, then, of our alternative understanding of back pain – that of back pain as backache, similar to a headache?
With each time we develop a headache, we don’t automatically think that we must have injured our head, and subsequently seek medical evaluation and a scan to determine the specific nature of the injury that we figure we must have had. We also don’t automatically think that we must seek out therapies that target the presumed injury. Rather, we tend to naturally think of it as due to tension and stress, or working too much, or not getting enough sleep, or just the hectic pace of our modern lifestyle. We subsequently think that we need to take better care of ourselves and engage in some healthy changes to the life we live.
Maybe, it’s time to return to a similar understanding of back pain. We could start by going back to referring to back pain as backache.
For more information, see also:
1. St. Sauver, J. L, Warner, D. O., Yawn, B. P., Jacobson, D. J., McGree, M. E., Pankratz, J. J., Melton, L. J., Roger, V. L., Ebbert, J. O., & Rocca, W. A. (2013). Why do patients visit their doctors? Assessing the most prevalent conditions in a defined US population. Mayo Clinic Proceedings, 88(1), 56-67. doi: 10.1016/j.mayocp.2012.08.020
2. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L… Lancet Low Back Pain Series Working Group. (2018). What low back pain is and why we need to pay attention. Lancet, 391(10137), 2356-2367. doi: 10.1016/S0140-6736(18)30480-X
3. Allan, D. B., & Waddell, G. (1989). An historical perspective on low back pain and disability. Acta Orthopaedica Scandinavica, 60(suppl. 234), 1-23. doi: 10.3109/7453678909153916
4. Brooks, M. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., & Sullivan S. D. (2008). Expenditures and health status among adults with back and neck problems. Journal of the American Medical Association, 299, 656-664.
5. Wittgenstein, L. (1953). Philosophical Investigations. New York: Macmillan.
6. Kuhn, T. S. (1996). The Structure of Scientific Revolutions (3rd Edition). Chicago: University of Chicago Press.
7. Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102
8. Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. Journal of Bone and Joint Surgery: American Volume, 72(3), 403-408.
9. Jensen, M. C., Brant-Zawadzki, M. C., Obuchowski, N., Modic, M. T., Malkasian, D., & Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331, 69-72. doi:10.1056/NEJm199407143310201
10. Jarvik, J. G., Hollingworth, W., Heagerty, P. J., Haynor, D. R., Boyko, E. J., & Deyo, R. A. (2005) Three-year incidence of low back pain in an initially asymptomatic cohort. Spine, 30, 1541-1548.
11. Borenstein, D. G., O’Mara, J. W., Boden, S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel, S. W. (2001). The value of magnetic-resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: A seven-year follow-up study. Journal of Bone and Joint Surgery: American Volume, 83(9), 1306-1311. doi: 10/2106/00004623-200109000-00002
12. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnehan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Alvins, A. L., James. K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2016). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.
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Date of initital publication: 12-6-2021
Date of last modification: 1-3-2021
Twenty some odd years ago, the American Academy of Pain Medicine and the American Pain Society, two large pain-related professional organizations, teamed up to agree upon what it means to have both chronic pain and be addicted to opioid pain medications at the same time.1 They did it because addiction to opioid medications when patients are prescribed them for legitimate health reasons seems different than addiction to other substances like alcohol, cannabis, cocaine, or even illegally obtained opioid medications when not used for pain. The difference involves the phenomena of tolerance, physical dependence, and withdrawal, which in part serve as criteria for the diagnosis of addiction when it comes to all other substances.
The most vexing of all questions in the debate over long-term opioid management for pain is subtle, difficult to articulate, and rarely considered. It lies at the heart of whether and how we maintain patients with severe pain on long-term opioids or whether we help them learn to self-manage it instead.
This most vexing of questions involves how we understand the nature of pain severity and its relationship to its degree of tolerability in the long-term opioid management patient. For depending on how we understand the intolerability of severe pain, it leads to contradictory treatment considerations among well-meaning, competent patients and providers, and even within the larger society.
What is biofeedback?
Biofeedback is a treatment used for a variety of chronic pain and other medical conditions that consists of sensors placed on the patient’s body while physiological data is viewed on a computer screen or other monitor in real time. It is considered a self-regulatory therapy because it is a tool for increasing awareness of and changing individual physiological responses to reduce symptoms or improve performance. The Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Certification International Alliance (BCIA), and International Society for Neurofeedback and Research (ISNR) provide this standard definition:
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.