Community health: A new approach to pain
By Andrew DeGiorgio
Suppose you are one of the approximately 100 million Americans with chronic pain. You go to see your doctor and, in the course of the visit, he or she starts asking you questions about your mood, your sleep, and about whether you smoke. The doctor introduces you to a behavioral health professional to work on ways to cope with the anxiety that has been weighing on you in the last year.
That same behavioralist wants to see you back for pain classes to talk about biology and how we think about pain. In the meantime, you and your doctor set some functional goals: what do you value and how can you bring your life into harmony with those values.
You wonder: What does any of this have to do with my pain? Of course working on mood and sleep and goals and perspective seems valuable, but isn’t this all just beating around the bush? The real problem is my back, or my hip or my knees.
In fact, a large body of research has shown that the way we thinkcan have a major effect on the way we experience pain. No matter where in the body you hurt, pain is ultimately generated and controlled by the brain. Things that affect the brain can affect pain. Take, for instance, depression. People who are depressed report more intense pain experiences. In clinic trials, treating depression actually improves pain scores.
As another example, consider the following “mental blocks.” Decades of research have found that “fear-avoidance” and “catastrophic thinking” have a consistent effect on whether pain turns into chronic disability. Fear-avoidance is self-explanatory: it involves extreme fear of pain, and going to extreme lengths to avoid it.
In the short term fear-avoidance can be protective, but in the long-term it prevents a person from living. Catastrophic thinking is the cognitive aspect of fear-avoidance. It involves rumination on how much pain hurts, magnification of potential disaster, and thoughts of helplessness. Catastrophic thinking actually dampens brain areas responsible for blocking pain. Both these mental blocks help transform short-term injury into disastrous long-term disruption of a person’s life.
What can we do? A lot. The practice of interdisciplinary pain control has evolved to address both the triggers of pain (signals from the body) and the way the brain interprets those signals. It involves a commitment of time and hard work by both the patient and his or her health-care team. This team may include physical therapists, behavioral health specialists, primary care doctors, and if necessary, physicians who specialize in pain medicine, all of whom communicate closely with each other.
The goal of modern pain treatment is for the patient to start living again. A key message is that no person can ever expect to be 100 percent pain-free. Waiting until you are pain free to start living life would be waiting forever. By finding creative ways to function despite pain, a person can break through the mental blocks of fear-avoidance and catastrophic thinking that turn pain into paralysis. Studies of this approach, called “Acceptance and Commitment Therapy,” show significant, durable benefits.
The team’s role is to help the patient on his or her journey. Medication is one way a doctor can help. Pain medication today encompasses broader categories than it did in the past, including classic anti-inflammatories, medications like gabapentin that affect the nerves, and medications traditionally used for mood. Medications must be tailored to the particular person and the particular pain experience.
A final note on opioids like oxycodone and Norco. Opioids are a treatment of last resort in chronic pain, because of their potential for addiction, but also because there is increasing doubt that they provide any long-term benefit at all.
A sobering study of injury claims in the state of Washington found that, even after adjusting for injury and pain severity at baseline, getting opioid treatment for more than one week made people less likely to be back at work one year later. Opioids may be part of what turns short-term injury into chronic life-defining pain and disability. That is not what pain treatment should be about, and a modern interdisciplinary approach offers hope for deeper, more meaningful healing.
Andrew DeGiorgio, MD, is a resident physician at Community Health of Central Washington in Ellensburg.