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The United States is in the grip of an unprecedented public health crisis – and unfortunately one in which well-meaning doctors have played a part. Due to chronic pain health issues the sales of opioid drug painkillers on prescription has quadrupled between 1999 and 2014. In 2012 alone, doctors issued 259 million opioid prescriptions – enough to give a bottle of pills to every adult in the entire United States. And in 2015 more than half of all overdose deaths in the USA involved opioids – either pain medications (such as OxyContin and Vicodin) – or illicit substances, such as opium and heroin. To put that statistic in perspective, opioids claimed roughly as many lives that year as car crashes.

Addiction is undoubtedly part of the problem, but experts now agree that the real driver behind the opioid epidemic is chronic pain. According to a landmark study published in 2011 by the Institute of Medicine, an estimated 100 million American adults live with persistent or chronic pain. Many rely on opioids just to keep moving.

There is no question that these drugs provide an excellent defence against acute, short-term pain, which alerts us to an injury or disease and subsides during recovery. But chronic pain is fundamentally different. It lingers long after an injury has healed and can produce a variety of symptoms, from headaches to body aches to crippling fatigue. It may stem from an underlying condition, such as osteoarthritis or multiple sclerosis. But it can often have no obvious source.

For some, chronic pain begins with nerve damage from diabetes, chemotherapy, a virus, a car accident or some other occurrence. In these cases, injured nerve fibres mistakenly continue to send pain signals to the brain, causing what is known as neuropathic pain.

No matter how chronic pain starts, it often increases and spreads, leaving many people reaching or more pills. Unfortunately, higher doses of opioid drugs do not guarantee relief—and can actually make matters worse. For starters, patients build tolerance to these medications, so that over time, it takes more opioids to blunt the same levels of pain. Higher doses increase the risk of dangerous side effects, including addiction, coma and death. And recent research shows that even relatively low doses of opioids can also cause hyperalgesia, or an increased sensitivity to pain: sometimes these drugs intensify the very pain they are meant to suppress.

For these reasons, a significant number of chronic pain sufferers eventually find themselves caught in a delicate – and deadly – balancing act: they need to take more opioid medications to keep their disabling pain in check while somehow dodging the drugs’ serious and life-threatening side effects. Some succeed for decades. But those who lose their footing are flooding casualty departments and hospital beds, battling withdrawal, accidental overdose and a host of other opioid-related complications.

Last year medical authorities began to respond on several fronts. In March 2016 the Centres for Disease Control and Prevention issued stricter guidelines for prescribing opioids. Contrary to what has been common practice, it advised against treating chronic pain with these drugs unless the benefits clearly outweigh the risks. The Surgeon General (Vivek Murthy) amplified that message five months later, when he wrote directly to all the nation’s health care providers— the first time any surgeon general has done so— urging 2.3 million professionals to commit to “turn the tide on the opioid crisis.”

The message is being heard. At a handful of state-of-the-art pain centres around the United States, clinicians are exploring a range of nondrug alternatives, from psychological interventions to complementary therapies. Researchers are also working on next-generation opioid drugs, along with new nonopioid pain-killers These initiatives represent the one upside to the opioid crisis: it is forcing medical professionals to revisit how they care for people in pain.

 

A Different Kind of Pain

Many experts now view chronic pain as a disease in its own right. Over time it engages and changes patterns of activity in brain areas associated not only with physical sensations but with sleep, thought and emotion. No wonder that studies show that chronic pain is associated with higher rates of mortality, sleep disorders, depression and anxiety.

Many chronic pain patients take a cocktail of drugs that would be deadly for a non-chronic pain sufferer. According to a Washington Post/Kaiser Family Foundation survey conducted in Autumn 2016, among people taking prescription painkillers for at least two months, about a third said they did not receive information about the dangers of opioids from their doctor. Only a third said their doctor had outlined a plan to wean them off the drugs. And another third reported that their doctor had never discussed any complementary treatments beyond medications. To treat people more effectively will require an important shift in how we think about pain – something alternative/natural medicine practitioners are well-acquainted with. Scientists are catching up in their understanding that pain is not just a sensation but a brain state and that mind-body (or body-mind) interventions may be helpful.

A team at Stanford University brings together pain psychologists, pain management physicians, psychiatrists, neurologists, anesthesiologists, physical and occupational therapists, and nurse practitioners, who collaborate to help patients safely reduce their use of opioids and replace them with non-drug alternatives. The team members meet every week to fine-tune evolving treatment plans that might incorporate cognitive-behavioural therapy (CBT), physical therapy, mindfulness training, yoga, biofeedback and acupuncture. Above all, it is a customised approach to suit the individual patient.

 

Turning Within

Taking such a broad approach is neither simple nor cheap – and better insurance coverage (in the USA!) of nondrug therapies will be needed to make it widely practical. Experts say the complexity of chronic pain warrants it. Perhaps the complementary therapy that has garnered the most attention in recent years is mindfulness-based stress reduction (MBSR), a clinical and more mainstream adaptation of Buddhist meditation practices. Jon Kabat-Zinn, now a professor of medicine emeritus at the University of Massachusetts Medical School, developed MBSR in the 1970s. Since then, MBSR classes are available in more than 30 countries. A growing body of evidence suggests that MBSR—which encourages nonjudgmental awareness of the present moment and fosters greater mind-body awareness—can mitigate a variety of ailments, from cancer and depression to drug addiction and chronic pain.

In 2016 Daniel Cherkin and his colleagues tested three treatments for chronic low back pain in 342 young and middle-aged adults: MBSR, cognitive-behavioural therapy – designed to change pain-related thoughts and behaviours – and standard pain care. They found that compared with participants who received standard pain care, more patients receiving MBSR or CBT showed a significant drop in “pain bothersomeness” after 26 weeks. In addition, the MBSR and CBT groups improved more in their functional abilities.

Other chronic pain sufferers are making gains with biofeedback. Using sensors to monitor bodily signals such as muscle tension and heart rate, they build awareness of physiological processes and learn to modulate their own pain. A 2017 meta-analysis evaluated biofeedback for chronic back pain in 1,062 patients and found that it not only lowered pain intensity but also improved patients’ coping abilities and reduced the incidence of pain-related depression. Others have tested a more sophisticated technique called neuro- feedback, which provides patients with images of their own brain activity using electroencephalography or functional MRI. This kind of training can teach patients to control brain regions associated with pain processing.

Additional evidence suggests that acupuncture might help ease chronic pain in some cases. The practice remains controversial, in part because it is difficult to study. But a 2014 analysis of 29 clinical trials of acupuncture for chronic pain in nearly 18,000 patients showed that compared with treatment with no needles or misplaced needles, the traditional form – with needles placed according to centuries-old Chinese practice – produced greater pain relief. At the same time, a significant number of people in the control groups also saw benefits, suggesting a strong placebo effect.

That finding reinforces the idea that when it comes to pain, simply being under the care of a receptive health care professional can be palliative. Researchers are investigating how all these complementary treatments work. Thankfully they don’t seem to be waiting for basic science to tell them the optimal way to treat pain. There is broad agreement that mindfulness, yoga, biofeedback and acupuncture may succeed by changing patients’ relationship to their pain rather than actually lowering the intensity of the physical sensation. If patients are suffering then it would seem logical (and human) to find what really works from the various diverging modalities available.

The NCCIH (National Center for Complementary and Integrative Health) recently conducted an extensive review of published clinical trials for a variety of complementary therapies with the aim of finding out which treatments might work best for which patients. It found that acupuncture and yoga benefited people with chronic back pain the most. Acupuncture and tai chi proved most helpful for those with chronic pain resulting from osteoarthritis. Massage therapy provided short-term benefits for neck pain, and relaxation techniques were most effective in those with severe headaches and migraines.

 

Feeling Your Pain

There is another reason why individualised care makes sense for chronic pain: different people can experience the same kind of pain in very different ways. In particular, researchers are discovering that how much chronic pain affects any one person depends heavily on so-called biopsychosocial factors – how someone reacts to pain emotionally, what other sources of stress exist, how much social support surrounds the person. Targeting these influences can not only reduce patients’ experience of pain but dramatically improve their quality of life. Indeed, chronic pain–related disabilities often leave people isolated and cut off from friends, which can, in turn, make the pain more intense.

To identify biopsychosocial factors up front, patients at the Stanford clinic fill out an extensive online questionnaire, capturing everything from work histories and adverse childhood experiences to sleep habits and anger levels. The practitioners there believe that collecting this type of data holds the key to matching patients with effective treatments. The questionnaire is part of a free, open-source repository that has been created, together with researchers at the NIH (National Institute of Health). The system, called the Collaborative Health Outcomes Information Registry (CHOIR), is now in use at medical centres around the USA and soon will be in several other countries. It contains data from more than 15,000 patients. Health care providers can use the system to track patients’ progress over time and to compare their trajectories with similar cases.

This data set has revealed that one factor in particular – a mindset called catastrophising – predicts the impact of chronic pain on a person’s life far better than any other measure. At its core, catastrophising is a tendency to exaggerate or magnify the threat of pain, to fear the worst and remain focused on the experience of pain. For people trapped in this way of thinking, their pain feels overwhelming. They hold little hope that they will ever be well again. That leads to a very strong desire to escape the pain, and they reach for the pain medication. Because catastrophising is such a powerful force on the experience of pain, it seems like a stroke of genius to target it.

For many this sense of powerlessness is common – and doctors who dismiss chronic pain because they cannot explain it only compound that feeling. When surgeries or other treatments fail to help, patients learn to expect failure. They become very demoralised. When patients go to the Stanford clinic the practitioners’ first job is to ‘remoralise’ them! The initial step is giving patients back a sense of control, no matter how small. They often need to know that their pain is real, that it is not their ‘fault’ and that there are some ways that it can be addressed. The patients are invited to learn about how pain and biopsychosocial factors interact. They may receive a relaxation CD so that the auditory experience recorded on the CD works to calm the nervous system. And they are encouraged to think of listening to the CD as taking a dose of mind-body medicine!

 

REFERENCES

■ Acupuncture for Chronic Pain. Andrew J. Vickers and Klaus Linde in JAMA, Vol. 311, No. 9, pages 955–956; March 5, 2014.

■ The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain:

A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Roger Chou in Annals of Internal Medicine, Vol. 4, No. 162, pages 276– 286; February 17, 2015.

■ National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. Interagency Pain Research Coordinating Committee. u.S. Department of Health and Human Services, 2016. https://iprcc.nih.gov/National_Pain_Strategy/ NPS_Main.htm

■ Doctors are Breaking Away. Stephani Sutherland in Scientific American Mind, Vol. 28, No. 3, May/June 2017, pages 28-35.

■ Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults with Chronic Low Back Pain: A Randomized Clinical Trial. Daniel C. Cherkin et al. in JAMA, Vol. 315, No. 12, pages 1203–1299; March 22, 2016.

■ Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Richard L. Nahin et al. in Mayo Clinic Proceedings, Vol. 91, No. 9, pages 1292–1306; September 2016.

■ Efficacy of Biofeedback in Chronic Back Pain: A Meta-analysis. Robert Sielski et al. in International Journal of Behavioral Medicine, Vol. 24, No. 1, pages 25–41; February 2017.