ALL ABOUT CHRONIC PAIN - LATEST ARTICLES

If you’re living with a chronic pain condition like I am you may have noticed that sometimes you are so fearful about doing even the most basic tasks of daily living, that you become immobilized. It can also manifest as overwhelming anxiety, so much so, that a phenomenon gets triggered which amplifies your perception of pain. I call this Anticipatory Pain.

Because you believe you are going to hurt by doing a certain activity, you can activate the physical pain system. Just by thinking about doing something that you believe will cause you to hurt, you will start to feel pain. This can happen before you even do whatever it is you already believe will cause physical pain. All you have to do is to start thinking about doing that thing.

Once the physical pain system is activated, the anticipatory pain reaction can make your perception of chronic pain symptoms worse. 

Whenever you feel the pain, you interpret it in a way that makes it feel worse, and you think about it in a way that actually does make it worse. You tell yourself that “this pain is awful and terrible,” and “I can’t handle it.” You convince yourself that “it’s hopeless, I’ll always hurt, and there’s nothing I can do about it.”

This way of thinking contributes to the development of emotional reactions that further intensify or amplify the pain response. The increased perception of pain causes you to keep changing your behavior in ways that create even more unnecessary limitations and mounting emotional discomfort. These reactions can make you believe you are trapped in a progressive cycle of disability.

Coping and Moving Beyond Anticipatory Pain

One of the most requested articles I wrote was titled “Coping with Anticipatory Pain. I believe it’s vital for us to support people to not just cope with anticipatory pain, but to move beyond it.

I learned a long time ago that what we expect is usually what we get which can sometimes be both helpful and harmful. When it comes to feeling pain and developing an effective chronic pain management plan, it’s crucial to understand the role of anticipatory pain. It has both biological and psychological components.

On the biological side, the cascade of effects from a pain sensation occurs on many levels and involves a variety of different areas within the nervous system. As a result, a wide variety of nervous system chemicals are produced and dumped into the blood while other brain chemicals are rapidly absorbed or depleted. Pain doesn’t just hurt — it changes the most basic neurophysiologic processes in the human body.

On the psychological side, anticipation of an expected pain level can influence the degree to which you experience your pain. In some cases, when your anticipatory level of pain expectation is lowered, your brain responds by influencing special neurons. This renders your brain less responsive to an incoming pain signal and your sensation of pain decreases. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) will influence or modify the effects on your body.

Fortunately, you can learn how to change your anticipatory pain response. You can lower the amount—or perception—of pain that you anticipate by changing what you believe will happen when you start to hurt. You can also change your thinking, or your self-talk, and learn how to better manage your emotions. You can learn new ways of responding to old situations that used to cause or intensify your pain. As you come to believe that you really can do things that will make your pain sensations bearable and manageable, your brain responds by influencing special neurons that reduce the intensity of your pain. Your brain becomes less responsive to an incoming pain signal.

 
There are things you can do that will make you habitually less responsive to incoming pain signals. Herein lays the rationale for including biofeedback, positive self-talk, meditation, and relaxation response training as part of your pain management treatment plan. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) influence or modify the effects of pain on your body. 

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Chronic pain is often misunderstood and under-treated. In addition to the biopsychosocial impact a chronic pain condition frequently has on a person, a spiritual crisis often accompanies the situation as well. Long-term chronic pain is a body-mind-spiritual problem that requires a multifaceted solution. I believe that complementary spiritual practices are necessary components of any effective chronic pain management plan. 

Chronic pain is often misunderstood and under-treated. In addition to the biopsychosocial impact a chronic pain condition frequently has on a person, a spiritual crisis often accompanies the situation as well. Long-term chronic pain is a body-mind-spiritual problem that requires a multifaceted solution. I believe that complementary spiritual practices are necessary components of any effective chronic pain management plan. 

Many people have found spiritual interventions like the traditions of prayer and meditation to contribute to the reduction of the sense of suffering. Unfortunately, in our fast-paced world and the secular treatment modality, adding a spiritual component to chronic pain management does not get enough attention. 

The concept of spiritual pain requires healthcare providers to go beyond the bounds of traditional clinical treatments and be prepared to devote the time required to give supportive and understanding care.  It is crucial to explore spirituality and its impact on a person’s pain in a multidimensional assessment.

Spirituality is vital aspect of being human which is difficult to fully understand or measure using scientific methods; yet convincing evidence in medical literature supports its beneficial role in the practice of medicine. It will take many more years of study to understand exactly which aspects of spirituality hold the most benefit for health and well-being. 

Many of the world's great wisdom traditions suggest that some of the most important aspects of spirituality lie in the sense of connection, inner strength, comfort, love and peace that individuals derive from their relationship with self, others, nature and the transcendent.

I believe that spiritual healing is an important component of a multifaceted chronic pain treatment plan. One goal of spiritual healing is to help patients improve their well-being and quality of life, rather than to cure specific diseases or in this case eliminate pain. Spirituality as part of a treatment plan may include encouraging patients to use visualization, prayer and positive thinking.

The Difference Between Religion and Spirituality

Over the years I have found it important to have a discussion with my patients regarding spirituality and effective pain management, as a common understanding of terminology is essential as is an understanding of what their beliefs are. 

One concept that rang true was the simple saying: “Religion prepares people for the next life while spirituality helps them live this life to their fullest potential.” Many of my colleagues also recommend clarifying the difference between the terms “spirituality” and “religion.” They advocate developing a broad-based definition of spirituality that encompasses religious and nonreligious perspectives.

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Over the past two decades I have seen that we as a nation have fallen victim to being sold the power of the pure bio-medical model for chronic pain treatment. Even though many research projects have all concluded that ethically, and for better outcomes, effective chronic pain management requires an integrated team approach. Unfortunately, many chronic pain patients have been denied integrated services with the payors saying that there is not enough research to validate paying for these services. 

However, this is not true. In fact, the truth is that there is no level one double blind research that demonstrates opioids are effective for chronic pain management. There are, however, many evidence-based and research-based studies that demonstrate that integrated services such as Cognitive Behavioral Therapy, Acupuncture, Equine Therapy and many others can demonstrate improved outcomes for chronic pain patients. Despite this insurance companies have authorized thousands upon thousands of opioid prescriptions that eventually led to the dire problem we are experiencing today including thousands of overdose deaths all around the United States. 

Part of the big picture is that opioids have proven very effective for acute pain management, such as broken bones, cuts, surgical procedures etc.  Many big companies spent a lot of money and produced credible outcome research that demonstrated opioids we're effective for treating acute pain. 

Some of the same big pharmaceutical companies spent millions of dollars if not more to tout using powerful opioids for chronic pain management. In one instance they purchased the right in the Journal of the American Medical Association to have the line OxyContin is not addictive, inserted. This along with the efforts of several high-powered medical doctors toured the country stating that it was a right for patience to have their chronic pain treated with opioids. At one point they spearheaded the movement to declare pain as the Fifth Vital Sign. 

During the 1990s we started to see the growth of pain clinics cropping up all over the country. Pain clinics became a very lucrative business for many physicians especially anesthesiologists.  In simple terms the bio-medical model became a combination of pills, injections, interventional pain procedures and surgeries.  This model did seem to work very well for many pain patients. Unfortunately, for over 20 percent of the population showed little or no improvement with this model. Unfortunately, in many instances the patient was blamed for it not working. 

There are many reasons why this 20 percent group of patients started over-utilizing most of the chronic pain healthcare dollars (some research shows as high as 80 percent) and they still showed little or no improvement.  Why is that? The answer is complex, but I will attempt to share why I believe this occurs.

The major reason I see for the biomedical model failing with the 20 percent subset of chronic pain patients is their health care providers fail to identify and/or treat the coexisting disorders. Some of the common coexisting disorders that lead to poor outcomes or even treatment failure are medication misuse abuse or even addiction; depression; anxiety disorders; unresolved trauma history such as PTSD; Eating Disorders and other mood disorders. 

Other factors that lead to poor outcomes our patients having poor family or social support. In many cases, family members have been burned out or the patient becomes so despairing they pull away and will not accept help. In other instances, friends or family members tend to enable or over do for their loved one. 

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If you’re living with a chronic pain condition like I am you know how hard it is to explain what is going on for you to even close family and friends. It is also challenging to share with your healthcare providers what is really going on and often come away feeling like “they just don’t get it.” Even worse, some people come away stigmatized and accused of being histrionic or even worse “you’re just drug seeking.” 

Other people, including healthcare providers, make judgements on what they are seeing and hearing from someone living, or suffering, with chronic pain. They see “exaggerated” pain behaviors. When people try to share what’s really going on they are perceived as complaining or maybe “malingering.” Friends and family members mistakenly believe their loved ones are just “making excuses” for not keeping commitments or completing projects. 

When people live with chronic pain for a long time there are various mental health problems and emotional factors that complicate positive treatment outcomes for these people including those coexisting psychological (mental health) disorders including substance use disorders. These patients often become so overwhelmed that their levels of functioning and quality of life are significantly deteriorated. 

When coexisting conditions occur, the family problems also increase synergistically. Effective treatment can be challenging and confusing for therapists and other healthcare providers who may be inexperienced with chronic pain disorders or addiction, but especially problematic for the patients and their families. That is another reason why a concurrent integrated treatment approach is crucial. In the next section we will look below the surface of the Chronic Pain Iceberg.

Understanding The Iceberg Principle – What Is Really Going On Under The Surface

So, if you are trying to be supportive of someone suffering with chronic pain it is crucial to know what’s really going on that most people don’t even realize.  Below are some of the common problems going on below the surface.

Mental Health Conditions Under the Surface – What People Don’t See

• PTSD or other Unresolved Trauma
• Depression
• Anxiety Disorders
• Sleep Disorders
• Cognitive Distortions From Living with Constant Pain
• Medication management problems up to and including addiction
• Eating Disorders – Using food to cope

Pain Symptoms Under the Surface – What People Don’t See

• Aching, throbbing pulsing
• Irritating, nagging disturbing
• Spitting, piercing pounding
• Dreadful, severe awful
• Burning, stinging lacerating
• Irritated, sore, sensitive
• Excruciating, agonizing distressing
• Worrisome, saddening depressing
• Torturing, grueling punishing
• Exhausting, fatiguing debilitating 

Understanding Spoonies

Several years ago one of my patients said she was a “Spoonie.” I told her I had never heard that term before and could she explain it to me. She told me that unless someone walked in her shoes, they could not understand her and gave me a website to check out. Then when I did some research, I found this on the Patient Rising website she gave me regarding the “Spoon” theory:

“Because we look healthy on the outside, one of the greatest challenges we have is explaining to others how a person who looks so good can actually feel sick or be in pain,” writes The Daily Migraine’s Lisa Jacobson. “They do not understand the freedoms many of us have lost.”

One term that helps explain the inexplicable: Spoonie.

“A spoonie can refer to any individual who suffers from a chronic illness or chronic pain,” explains chronic migraine patient Sophie Cowley. “These illnesses are often invisible; to most people, spoonies may appear healthy and able-bodied, especially when they are young. The daily feeling of being invisible can be one of the most challenging parts of being a spoonie.”

The term “Spoonie” was coined by Christine Miserandino, an award-winning blogger and patient advocate, when she was trying to explain to a friend what it’s like to live with lupus. “I thought she already knew the medical definition of Lupus,” Miserandino recalls at her website, But You Don’t Look Sick. “Then she looked at me with a face every sick person knows well, the face of pure curiosity about something no one healthy can truly understand. She asked what it felt like, not physically, but what it felt like to be me, to be sick.” “How do I answer a question I never was able to answer for myself?”

So, she laid out a handful of spoons on the table and explained that the spoons symbolize all of a patient’s daily energy reserves. Every activity, no matter how thoughtless and automatic, depletes from the energy supply. Getting out of bed, showering, getting dressed, eating, and any number of mundane tasks threaten to deplete energy at any given time.

When you run out of spoons, you can choose to borrow against the spoons of a future date, but there are consequences. When you deplete your spoons, you are bedridden. Unable to manage the simple activities of life.

This is clearly what many people with chronic pain, chronic illness or disabilities deal with day in and day out. And yet it is still very challenging for someone who has never had these challenges to understand and help someone who is suffering with chronic pain. There is so much going on under the surface.

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First Published in The California Therapist -  January/February 2022 

Prolog  

This past two years plus of COVID-19 has changed the face of healthcare in many ways; some positive and some extremely negative.  There have been many casualties of COVID-19 above and beyond those living and dying with the exposure to this disease.  Some of those casualties are people with chronic pain and coexisting disorders including addiction, PTSD, Depression, Anxiety and many other mental health problems. The other noted victims are people dying from Opiate/Opioid overdoses, in many cases due to not receiving adequate treatment interventions by their healthcare providers. Because of COVID-19 we have lost focus on the so-called Opioid Epidemic.  This article outlines some of the overwhelming problems that led to what I am calling the Opioid and Chronic Pain Syndemic.  Then I outline the need for implementing a synergistic solution that needs to include everyone. I am also including two case study examples to demonstrate the need and effectiveness of an Addiction-Free Pain Management® synergistic treatment solution.  

Understanding the Problem is Crucial to Finding the Solution 

I believe there is much more than an opioid crisis or epidemic.  It is not an epidemic, rather it is a Syndemic.  What I mean by that is it’s a perfect storm of over prescribing opioids, mismanaged chronic pain by depending only on the traditional bio-medical model and untreated mental health disorders. What we need to focus on is identifying the synergistic nature of the problem and the need to implement a synergistic treatment solution that helps heal the whole person – Biological, Psychological, Family/Social and Spiritual.  A true Body-Mind-Spirit Approach.  There is also a strong political and financial component to our current problem that Harry Nelson outlines so well in his book The United States of Opioids: A Prescription For Liberating A Nation In Pain. 

Also, in his book Dreamland: The True Tale of America's Opiate Epidemic, Sam Quinones also covers some of the financial and political precursors to our current problem. In addition, many people believe what underlies this crisis is a severe deficit in coping skills for those who are suffering with chronic pain and coexisting mental health disorders including substance use disorders.  Combine these poor coping skills with misinformation from leading medical prescribers using opioids for chronic pain, and we see addiction from prescription opioids has increased over 1,000 percent between 2012 and 2016.  

The Center For Disease Control (CDC) posted an update on December 16, 2016 with some other staggering statistics: 

• Over 1,000 people a day are being treated for prescription opioid overdose incidents with the three most common being Methadone, Oxycodone/OxyContin, and Hydrocodone.

• It stated that as many as 91 people a day are dying from prescription opioid overdose events. 

• The report also stated that between 1999 and 2015 there were over 183,000 deaths directly related to prescription opiates.   •

• Finally, in 2014 over 2 Million Americans experienced prescription medication misuse, abuse, pseudoaddiction or addiction.  Many say this is an opioid epidemic. 

The other coexisting epidemic noted is chronic pain. Chronic pain management is a serious health crisis facing the world today. In fact, in the well-publicized June 2011 White Paper The Institute of Medicine (IOM) stated that as many as 116 million people were experiencing chronic pain; the cost of managing it in the United States alone is over $635 Billion per year in direct medical costs and lost productivity. As I write this today the problem continues to worsen.

When a person who is undergoing chronic pain management, they are also experiencing other co-existing disorders, such as medication abuse or even addiction to prescription pain medication and psychological disorders, the problem reaches even more epidemic proportions. Every week in the media there are reports about the problematic use and/or abuse of prescription drugs being used in the treatment of chronic pain. The numbers of people impacted are staggering.

So what is the source of the so-called Opioid Epidemic and is there a link to chronic pain? A study posted in the New England Journal of Medicine in March of 2016, reported some interesting numbers in answer to this question. More than 30 percent of Americans have some form of acute or chronic pain and among older adults; the prevalence of chronic pain is more than 40 percent. In 2014 alone, U.S. retail pharmacies dispensed more than 245 million prescriptions for opioid pain relievers. Opioids are widely diverted and improperly used. In addition, many physicians admit that they are not confident about how to prescribe opioids safely.

This report went on to state that more than a third (37 percent) of the 44,000 drug-overdose deaths that were reported in 2013 were attributable to pharmaceutical opioids while Heroin accounted for an additional 19 percent. There was also a parallel increase in the rate of opioid addiction, affecting approximately 2.5 million adults in 2014.

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Using the Power Knowledge to Rescue The Hijacked Brain

In order to achieve the best quality of life and level of functioning, people living with chronic pain must learn as much as they can about the subject of pain and what constitutes effective pain management. We know that pain is a signal that tells us there is damage or something wrong with our system. However, with some chronic pain conditions the system (including the brain) gets altered. The pain system gets turned on and cannot be turned off. I call this the “hijacked” brain or what is often referred to as Neuroplasticity (also called brain plasticity, cortical plasticity or cortical re-mapping). 

A surprising consequence of neuroplasticity is that the brain activity associated with a given function can move to a different location as a consequence of normal experience or brain damage/recovery.  In the case of chronic pain this can mean that pain signals keep occurring despite lack of a trigger or tissue damage. 

Opioid Use Can Also Hijack The Brain

According to research published in Annals of the New York Academy of Sciences titled Spinal Cord Neuroplasticity following Repeated Opioid Exposure and Its Relation to Pathological Pain; states that convincing evidence has accumulated that indicates there are neuroplastic changes within the spinal cord in response to repeated exposure to opioids.  Such neuroplastic changes occur at both cellular and intracellular levels. Unfortunately, most pain conditions in this country are treated with opiates – research indicates that as high as 90 percent of people undergoing pain management are prescribed opiates. With so many people living with chronic pain and using opiates, these neuroplastic changes need to be better understood.

I like to use simple language and metaphors or visual images when educating my patients. Many of the people I have worked with would not understand the term Neuroplasticity so I use the metaphor of the hijacked brain. I tell them the reality or neuroplasticity science are much more complex but in essence what is happening is that the brain forms pathways (called neuro-networks) that eventually become super highways—in other words the new neuro-network becomes more complex and elaborate. 

Building Better Highways

What I believe needs to happen in chronic pain management is developing new pathways or highways to replace self-defeating pain behaviors or suffering that can lead to a reduction or elimination of pain. My Mentor and colleague Terence T. Gorski uses the example of living in a rural area with an outhouse over a hundred yards from the back door. Between the back door and the outhouse is a field of heavy vegetation that is very hard to walk through. On the first trip it takes a long time and is very difficult but some of the vegetation is getting tramped down just a little so the trip back is not quite as hard. After several trips it gets much easier.

I expand this metaphor by saying treatment is like gaining access to landscaping equipment that will assist you in putting in a paved path to your goal—effective pain management. It is crucial to develop new ways of thinking, more effective methods of managing painful emotions and new ways of behaving that will improve pain management and quality of life.  To do this, new neuro-pathways need to be generated and used over and over until the highway is built. Unfortunately, there are many obstacles that can get in the way and detour people back to the old highways and people need a strategic integrated plan to stay on the new highway. 

Utilizing Addiction-Free Pain Management® 

To assist keeping people on the new highway, I started developing The Addiction Free Pain Management® (APM) Manualized Treatment System in 1996. The APM™ System is a comprehensive method of addressing the four quadrants of suffering: biological (psychical), psychological, social, and spiritual. This system was first utilized by me in my own quest to find chronic pain relief without reliance on opioid medication and to stop suffering with my pain. 

The APM™ Treatment System is based in part on the Gorski-CENAPS® Developmental model of recovery. It also includes the best practice standards reported by the National Institute on Drug Abuse (NIDA), the American Society of Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA) along with the leading evidence-based chronic pain management best practice standards. 

To  request  the remainder of this article, please connect with me at drgrinstead@yahoo.com.