In early 2010, I underwent a pair of surgeries to remove a giant cell bone tumor from my leg and repair the significant damage it left behind. After several days in the hospital, I came home with an opioid medication to ease my pain.
It worked very well. So well that I stopped taking it three days in.
It wasn’t that I didn’t appreciate the relief. I did. But at the time, I was also the stressed-out working mom of four busy teenage kids, including one with severe special needs. In one swallow, that medication took away the heft of those stressors too. I was suddenly the most serene person on the planet. And I knew instantly how hard it would be to let that go.
Fast-forward a decade. My octogenarian dad is now the patient who is immobilized by pain, in his case from severe arthritis in his back. Despite his age and incapacitation, opioids are off the table, courtesy of a nationwide epidemic of substance abuse that has left medical professionals battling for effective ways to ease pain while curtailing that epidemic. Factor in the COVID crisis that has even the sturdiest among us self-medicating, and pain patients and the doctors and therapists who treat them are even further challenged to keep minds and bodies protected and pain-free.
How Did We Get Here?
According to medical toxicology specialist Dr. Jillian Theobald, an assistant professor at the Medical College of Wisconsin and associate medical director at Wisconsin Poison Center, the path toward epidemic began in the early ’90s when Dr. Mitchell Max, a National Institutes of Health pain specialist and prominent member of the now defunct American Pain Society, lamented the medical community’s ongoing struggle to quantify patients’ pain levels and provide effective relief. In nationwide speeches, Max also challenged the idea that long-term opioids for pain unrelated to cancer could result in dependence or serious side effects, augmented by a pair of small, retrospective studies to that effect. Others within the pain community jumped on the bandwagon, based on what Theobald calls “this small little snippet that was published in a journal that essentially said, ‘We looked at all the patients that we gave long-term opioids [to] for non-cancer pain and they did not get any addiction issues.’”
Pharmaceutical companies wasted little time in further convincing an already anxious medical community that these powerful medications in generous doses were a true panacea for suffering. Meantime, the American Pain Society’s designation of pain as a “fifth vital sign” — one not measurable with medical equipment, but no less significant — took hold with the Joint Commission on Accreditation of Healthcare Organizations, the Veterans Health Administration and beyond. Theobald says that while the campaign was well intentioned, it also left health care workers hyper-focused on pain. Patients scored their pain level on a 1-10 scale or pointed to a cartoonish chart and doctors reached for their prescription pads.
“What happened then is that our prescribing escalated,” Theobald says. “If you look back to the ’80s, we now prescribe four times the amount of pain medication. We don’t have four times the pain as we did 20 years ago or [more] than in the rest of the world. The prescriptions just dramatically escalated. What happened then is that there are now these patients on long-term opioids — whopping doses of them — and we started to realize that people were getting addicted.” And no one knew quite what to do next.
Some drugmakers produced abuse-deterrent formulations. Many doctors shied away from opioids altogether. New prescriptions plummeted.
“2015 was the first time that we saw the total number of prescriptions written in the U.S. decrease,” Theobald says. “And now that we in the medical community knew this is a problem, the Center for Disease Control came out with opioid prescribing guidelines for people with chronic pain a few years ago. So you have all these people on crazy doses of opioid pain medications and they can’t get their prescription.”
They started looking elsewhere for powerful relief, ushering in a burgeoning heroin [an opioid made from morphine] epidemic as patients across all socioeconomic strata realized that the drug was cheap and relatively easy to come by.
“I see this as a problem that the medical community created, and we’re not doing very much to fix it,” Theobald says, noting an emerging methamphetamine epidemic as well. “We’re not doing much in terms of education on how [do] you wean these patients off of these whopping doses of opioids that are so dangerous for them to something else? How do you condition them to other pain modalities? … We have this aftermath from what had happened, and I don’t know that we’re doing the same well-intentioned approach this time.”
The Head and The Hurt
Doctors also remain challenged to fully address the emotional and psychological issues that result from — or preclude — the pain event.
“Pain is such an interesting condition, because I think, even more than many medical conditions, it really is defined by a physical and an emotional experience,” says Dr. Chantelle Thomas, executive clinical director at The Manor, a residential addiction treatment center in the hills of Wisconsin’s Kettle Moraine Forest. “So it’s a really unique area of treatment, because oftentimes it gets relegated to being addressed in an entirely medical setting — when we know that a significant component of it has pretty serious emotional implications. Expectancy and beliefs about pain and fear about pain have a direct impact on how someone experiences pain in their life, whether it be acute or chronic.”
Thomas grew up in a family of physicians and understood early the interplay between psychology and medicine. She arrived in Madison from California at roughly the same time the CDC opioid guidelines were put into place, earning a Ph.D. in clinical psychology and a post-doctoral fellowship in health and rehabilitation psychology from the University of Wisconsin. Thomas witnessed firsthand the sort of relief doctors felt at having the protocol to work from, coupled with the distress of patients who were on excessive doses of medication having the proverbial rug pulled out from under them. And how each struggled to find common ground.
Thomas worked with addiction specialist Dr. Randall Brown toward establishing addiction treatment programs inside primary care clinics, so patients diagnosed with a substance use disorder in a primary care visit could be seamlessly connected to an addiction medicine specialist and behavioral health provider.
She stresses that most primary care physicians are deeply compassionate people by nature, highly invested in forming a long-term, trusting bond with their patients. Confronted with a patient in severe pain, Thomas says, “if they say no to an opiate, what are they going to offer them instead when their entire job is to alleviate suffering and to help someone literally with their pain?
“So a very big part of my job working in primary care was really supporting physicians in having difficult conversations, and providing them with a different level of support in ascertaining what might be some of the behavioral and emotional aspects of self management that are contributing to this person’s difficulty in feeling better,” Thomas continues. “What other vulnerabilities they might have in their life and their relationships and their reflexes for self-care, or lack thereof, contribute to them being in a cycle of feeling really stuck and very much suffering. And also fixated that this medicine is going to be the thing that cures it.”
Both Theobald and Thomas reinforce the importance of doctors managing the latter expectation in addition to managing the actual pain, helping patients realize that some discomfort is necessary to recognize that their situation is improving and that healing is taking place since pain medications only stop the patient from feeling discomfort.
“It’s really tricky,” Thomas says. “You can give someone a bottle of pain pills and say, ‘Here, take these.’ But [it is tougher] having a more nuanced conversation about, ‘Here’s a scale of one-to-10, so should I take it when I feel a two? Or do I take it when I feel an eight?’ Really getting specific with people about, ‘Look, if you take it when you feel a two every time, you’re probably going to take more than you need. You’re not going to be as connected to the actual healing process that’s happening in your body, so you won’t get helpful cues from your body about what you should and shouldn’t be doing.’”
Theobald and Thomas agree that true relief is a multimodal effort — which comes with its own set of challenges. Theobald cites the mixed blessing of medicine’s warp-speed progress, creating a wide range of hyper-focused specialists that often force patients to see multiple doctors for total relief, requiring time and additional medical bills that can compound patient stress. “They end up getting bounced around in the system, and a lot of the time it’s a physician reading the clinic note which doesn’t always detail the long conversations you have with patients about a plan of care,” Theobald says.
Adds Thomas, “With just a little bit of discussion, you can find that, with a lot of patients who have a pain condition, whether it be acute or chronic, what they tell you they believe the problem is and how the pain meds are working for them, and what the physician will tell you the problem is and how they believe that the pain meds are working for the patient, the chances of those two stories matching up is very low. Which is really unfortunate.”
Both doctors support the move toward integrated-service settings — “primary care clinics or even chronic pain management clinics having therapists embedded in the clinic so that when you go see your doctor you’re also seeing a therapist or behavioral health provider at the same visit together or in tandem,” Thomas explains. “It’s the gold standard for what we should be doing … and I think there’s something really powerful about integrating services so that the full onus of responsibility is not on the physician to act potentially outside of their scope.”
Theobald says that, in America’s quick-fix culture, pain-mitigating lifestyle changes such as weight loss and exercise, or progressive treatments such as hypnotherapy and physical therapy aren’t always well received when a patient expects immediate relief from a pill. Still, she says, there are a host of effective options that doctors can offer patients, singularly or in combination, to ease that transition, including lidocaine patches, topical ointments, injections of steroids or numbing medications, splinting or bracing of the joints, and oral NSAIDs.
Thomas, a certified biofeedback practitioner, says the therapy is another tool for regulating an unsettled nervous system. She is also a great proponent of physical and occupational therapy, though she recognizes that many patients have trouble accepting the initial added physical discomfort that is often part and parcel before real relief is achieved.
“Therapeutic massage is also very powerful,” says Thomas, “because, in a lot of chronic pain conditions, people are living in this constant state of vigilance or hyper-vigilance because they’re always anticipating when they’re going to feel a jolt of pain, or the chronic pain has just been too much and there are muscles that are constantly in tension — and the person doesn’t even realize it’s happening. Therapeutic massage can be a really great way to build that awareness.”
In short, she says, any form of treatment that helps patients form and grow comfortable with the mind-body connection is helpful in managing pain both now and in the future.
“We know that stress and anxiety and even depression can amplify the experience of pain as felt in the body,” Thomas says. “And so if you don’t tune in to those signals and learn how to modify them, you’re essentially handing a megaphone to your body’s pain system.” MKE