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