Stethascope on a journal

Emotion and the Experience of (Chronic) Pain

Why is chronic pain so prevalent and such a problem?

In Australia, the United States and beyond, we are facing a rising tide of over the counter opioids being prescribed as a standard solution to the management of chronic pain.  However, health care professionals working in the fields of pain and addition see this as an dangerous oxymoron and know that chronic pain can and does result in opioid overuse, dependence and addiction.

Jenni Johnson, Network Manager – Chronic Pain for the NSW Agency for Clinical Innovation, believes that the NSW Pain Management Plan offers an opportunity for improvement in this regard as the $26 million budgeted into chronic pain services in the next 4 years will be targeted around improvement for the 1/5 people presenting to GPs with chronic pain as well as those diagnosed and living with chronic pain currently.

Jenni questions the efficacy of medication only management as the solution to the management of chronic pain as there is very little medical evidence to support this approach. She believes curbing the use of opioids in the community is essential and considers medication as part of the solution, not the whole solution. Jenni surmised, ‘early identification and management is key and that improvement must be the goal.’

Mel Pohl, a Board Certified Family Practitioner and Medical Director of the Las Vegas Recovery Center (LVRC) concurs. Mel commented that, ‘in the quest for pain relief and in our attempts to avoid pain – we often create more. People with chronic pain syndrome treat emotional and physical pain with medications, typically opioids. They tend to search for a cure and continue to pursue this end with a variety of doctors and procedures.’ Therein lies the problem. The pathological pursuit of relief does not co-exist easily with the time required to manage pain in the longer term and the approach that is required to do so.

If emotions drive the experience of pain, we must therefore deal with the emotions if we are to face and manage the pain effectively and for the long term. By implication then, there is no one pill which will work to cure an illness or to manage pain, and yet this is what is being sought and this is what is being prescribed. What is required is not a quick fix, but a comprehensive holistic solution of which medication simply has a part to play. Since 1989, over 100,000 have died from opioid related overdoses and yet, as Mel asserted, ‘there is little or no data to suggest that opioids are the solution to chronic pain.’

This presents an imposing task to GPs and physicians on the frontline as they are faced with patients who want a solution and who are demanding something to ease their pain. The easiest and quickest results will come from a prescription to opioids. However, if opioids are prescribed for the relief of chronic pain we know that in 50% of cases those patients will still be on opioids 5 years from now. In addition, recent statistics have revealed that 63% have admitted that they use the opioids for purposes other than pain. Changing the conversation around chronic pain at the point of diagnosis is far harder and takes longer than prescribing drugs, yet it is what Mel would suggest is the only real option we have available to us if we wish to arrest this rising tide.

How do you, as a doctor, respond to patients who say, “It’s never going to get better?” and “I can’t do it?” This is a commonly expressed sentiment by people who are suffering with chronic pain. Mel suggested that the first step is to let them know that any statement containing “never” or “can’t” is simply a lie. The lies we tell ourselves are fear-based. The truth is that with a variety of techniques the pain will change – at times be better. For some, simply stopping opioid medications makes it a little better. Everyone can do something about their pain – many don’t want to or are afraid they won’t be successful – and there’s no denying that it’s harder than taking medications and not moving – but the returns on investment of time and energy are bountiful.

Dr. Ben Teoh, Consultant Psychiatrist at South Pacific Private, weighed in on the commentary specific to addiction, adding, ‘pain comes in emotional and physical forms. For many who use opioids, they achieve relief in the short run. The brain regions where pain is experienced and where opioids work are tied to the region where reward is experienced – hence, by taking opioid medications for pain relief, some inadvertently trigger the pleasure centre as well – when the drug wears off, they are drawn to repeat the experience again and again at higher and higher doses, often finding they cannot stop.’

Cognitive behavioural therapy (CBT) has been shown to be more effective than any pain medication and at South Pacific Private a combination of therapy, motivational interviewing, psycho-education and medication management is applied to help provide patients with longer-term improvement.

In addition to CBT, the importance of movement and activity has been demonstrated as a response for management chronic pain. Why is it important to move the body even if doing so hurts more? If we have pain, and we don’t move, and hold the painful part of us in just the right position…. just right at just the right angle…it may not hurt. If we continue to hold our body in a particular position, eventually, if and when we try to move, we are either stuck in that position (like a frozen shoulder) – or when we do move, it hurts worse than before. One of the cardinal rules of treatment of chronic pain is “move it or lose it” –in other words, we must move or the pain will get worse. Moving and exercising temporarily hurts more, but eventually loosens the tissues and decreases the level of pain.

In summary, we need to use foresight and to look into the future. We need to move away from the perception that the management of chronic pain is about ‘feeling good now’ and instead focus upon functional improvement and the management of that pain as a preferred goal of pain therapy. Treating to improve function must be the goal, and we can only achieve this if we can accept that medication only management is not a sustainable or reliable course of management.

For more information regarding addiction and the treatment of chronic pain (specifically with relation to prescription opioids) please click here.