Guest Blogger, Dr. Beth Darnall, a renowned Clinical Psychologist specializing in biopsychosocial aspects of pain management, shares her insight on various corollaries facing patients that live (or should I say, survive) with persistent pain. Her input is especially timely as efforts are made to bridge the gap among professionals specializing in behavior health and those practicing pain management.
Dr. Darnall has this to say…
Limited Opioid Access
In politics and in the public eye, the issue of chronic pain has been overshadowed by the opioid prescribing ‘epidemic’  and solutions focused on limiting access to opioids. Patient blogs and posts, from patients, including just one example from this site, lament the limited access to opioids and are left feeling punished for the addictive and medication-abuse behaviors of recreational user. People are left wondering how to live with unmanaged pain. I have worked exclusively as a pain psychologist for more than 10 years, so was entrenched in the field when patients had relatively easy access to opioids. Opioids were no panacea. For some they helped, for the vast majority they maybe “took the edge off”, and for most there were negative side effects. Sometimes the side effects made things worse for people. Often the side effects required other medications to deal with the ‘new symptoms’ (i.e., iatrogenic consequences of opioids). Eventually, most people would realize that opioids only helped a bit and that other efforts were required to manage pain, and often that included other non-opioid medications. In short, the question of how to manage pain with limited opioids—or no opioids– is not new, but new opioid restrictions have brought it directly to the forefront of the conversation. And it’s a conversation that is relevant to an increasing number of people.
A consequence of the current political / medical climate is that patients denied opioids may perceive a degree of injustice in their pain care. Despite data showing that long-term use of opioids is often unhelpful [2-18]—people may say that they personally derived benefit from opioid therapy, and therefore feel they are being unjustifiably lumped in with patients who responded poorly. The experience of perceived injustice is an important part of the equation. Across studies perceived injustice is associated with greater pain and worse outcomes [19-24]. Perceived injustice about opioids can be a triple whammy that works against patients: (1) it keeps the conversation focused on medications rather than on other treatment options; (2) can increase feelings of hopelessness and helplessness, both of which are known to worsen pain; and (3) is associated with worse pain and outcomes. Feelings of injustice may leave patients less likely to fully engage in behavioral treatment options, and the only way these methods work is with full engagement. It can be a self-fulfilling prophecy that undermines these non-pharmacologic treatment options, thus leading to greater perception of injustice.
Getting Beyond Opioids
We must extend the conversation beyond opioids or no opioids. We cannot take opioids away from people without giving them something else to replace them. I have helped many people taper off opioids by developing an individualized plan that involved pain education, pain psychology techniques, a very slow taper schedule and specific and tailored behavioral goals to keep their pain levels as low as possible through the taper and beyond . Here’s the catch though: In order for this type of a plan to work, two things must happen: (1) a person must want to taper or optimize non-opioid pain care. Not everyone does, especially when they feel things are being ‘taken away’ from them and they are being forced into a different treatment pathway. (2) A person must be dedicated to working the plan on a daily basis. Implementing a plan once or for a short duration of time is unlikely to lead to measurable differences. Success requires desire, focus, and dedication. If a physician prescribes a medication, such as an antidepressant, she is likely to tell you that in 4-6 weeks the effects of the medication will be evident. It’s helpful to view a psychobehavioral pain plan in a similar light—results accumulate over time, and the fruits of a person’s daily labor will evidence themselves in the weeks that unfold.
For people with chronic pain, an underappreciated problem may be an experience of front-end loss of control within the context of opioids and pain care–coupled with a belief that treatment is being unjustifiably withheld. Given that opioid restrictions are unlikely to go away any time soon, looking beyond them is essential. Some people with chronic pain may understandably have anger, indignation, and perceptions of injustice at the state of affairs with pain care and lack of access to opioids. While such feelings are valid and understandable, they may be serving to worsen one’s pain and outcomes. Given this, specific intervention for the emotional consequences of opioid restrictions and legislation may be beneficial and requisite to enable a person to fully engage in behavioral care, and to optimize response to other pain treatments. In short, the getting better without opioids may depend on moving past the injustice.
Patients with chronic pain now face yet another challenge: moving past the injustice of life without opioids in order to ensure their own best outcomes. While this challenge ascribes additional burden to patients and clearly is not fair, self-empowerment lies in transcending perceptions of injustice.
As always, comments are welcomed with enthusiasm!
Beth Darnall, PhD is Clinical Associate Professor in the Division of Pain Medicine at Stanford University. Dr. Darnall is author of Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain(c) 2014 Bull Publishing. She is a columnist for Psychology Today and the National Pain Report, is a section editor for Pain Medicine, and is former president of the Pain Society of Oregon. More information may be found here: www.bethdarnall.com.
1. Manchikanti, L., et al., Opioid epidemic in the United States. Pain Physician, 2012. 15(3 Suppl): p. ES9-ES38.
2. Campbell, C.I., et al., Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Public Health, 2010. 100(12): p. 2541-7.
3. Crisostomo, R.A., et al., Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history. Am J Phys Med Rehabil, 2008. 87(7): p. 527-36.
4. Crofford, L.J., Adverse effects of chronic opioid therapy for chronic musculoskeletal pain. Nat Rev Rheumatol, 2010. 6(4): p. 191-7.
5. Daniell, H.W., Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. J Pain, 2008. 9(1): p. 28-36.
6. Daniell, H.W., Hypogonadism in men consuming sustained-action oral opioids. J Pain, 2002. 3(5): p. 377-84.
7. Dersh, J., et al., Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders. Spine (Phila Pa 1976), 2008. 33(20): p. 2219-27.
8. Dimsdale, J.E., et al., The effect of opioids on sleep architecture. J Clin Sleep Med, 2007. 3(1): p. 33-6.
9. Furlan, A.D., et al., Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. Cmaj, 2006. 174(11): p. 1589-94.
10. Grady, D., S.A. Berkowitz, and M.H. Katz, Opioids for chronic pain. Archives of Internal Medicine, 2011. 171(16): p. 1426-7.
11. Guilleminault, C., et al., Obstructive sleep apnea and chronic opioid use. Lung, 2010. 188(6): p. 459-68.
12. Kobus, A.M., et al., Correlates of higher-dose opioid medication use for low back pain in primary care. J Pain, 2012. 13(11): p. 1131-8.
13. Korff, M.V., et al., De facto long-term opioid therapy for noncancer pain. Clin J Pain, 2008. 24(6): p. 521-7.
14. Saper, J.R. and A.E. Lake, 3rd, Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines. Headache, 2008. 48(6): p. 838-49.
15. Sullivan, M.D., et al., Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study. Pain, 2008. 138(2): p. 440-9.
16. Tuteja, A.K., et al., Opioid-induced bowel disorders and narcotic bowel syndrome in patients with chronic non-cancer pain. Neurogastroenterol Motil, 2010. 22(4): p. 424-30, e96.
17. Vorobeychik, Y., et al., Improved opioid analgesic effect following opioid dose reduction.[Erratum appears in Pain Med. 2008 Nov;9(8):1228]. Pain Medicine, 2008. 9(6): p. 724-7.
18. Vuong, C., et al., The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev, 2010. 31(1): p. 98-132.
19. Ferrari, R., A prospective study of perceived injustice in whiplash victims and its relationship to recovery. Clin Rheumatol, 2014.
20. Ferrari, R. and A.S. Russell, Perceived injustice in fibromyalgia and rheumatoid arthritis. Clin Rheumatol, 2014.
21. Rodero, B., et al., Perceived injustice in fibromyalgia: psychometric characteristics of the Injustice Experience Questionnaire and relationship with pain catastrophising and pain acceptance. J Psychosom Res, 2012. 73(2): p. 86-91.
22. Scott, W., et al., Anger differentially mediates the relationship between perceived injustice and chronic pain outcomes. Pain, 2013. 154(9): p. 1691-8.
23. Sullivan, M.J., W. Scott, and Z. Trost, Perceived injustice: a risk factor for problematic pain outcomes. Clin J Pain, 2012. 28(6): p. 484-8.
24. Sullivan, M.J., et al., Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 2009. 145(3): p. 325-31.
25. Darnall, B.D., Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain. 2014, Boulder, CO: Bull Publishing.