If we don’t use opiates to treat chronic pain, what else can we do?
The opiate debate rages and observing from the sidelines, it looks like a horrible stalemate where no one is winning. We have enough credible evidence that suggests these drugs are a poor choice for helping most people with chronic pain (1). However their effect is significant enough that their use enables many people to function at an acceptable level, with various side effects. For these people, opiates make life liveable, keeps them functional and coping with their symptoms, without unmanageable side effects. The way we talk about and manage pain, and the way that opiates have been prescribed, seem to have created a moral and legal issue out of the condition of people’s lives and health.
The crux of this to me seems to be “if not opiates, what else?” and can we deliver something else with no side effects and equal or better positive outcomes? Despite the American Chiropractic Association’s attempts — it’s not going to be more appointments and getting your “alignment fixed”. We can help people do a lot better than that. Pain is a public health issue that we need to talk about, and redesign how we care for people that have pain.
Pain is Created By Your Brain
When we use opiate medication, we are treating the brain. This mechanism works because pain is an output of the brain, and is a signal to say there is evidence we’re in danger. The growing pain science research base is showing us that we’ve been talking about pain the wrong way for a long time.
Most of us think that pain is caused only by damage and injury. Pain actually exists to tell us about the perceived danger and threat to our body, and to give us a mechanism to stay safe in our environment. This happens in a more complex way than simply related to the state of our tissues, and it’s a decision made by our brain that is influenced by our thoughts, emotions, life situation and the context of the experience.
You can have no pain with a severe injury such as a broken leg, if your survival is at stake, and you need to be able to run away. We have a stronger “medicine chest” in our brain than anything we can prescribe — and your brain can stop you feeling serious damage to your body. On the flip side, you can have severe pain in a “phantom limb” after a limb has been amputated. This is a seemingly bizarre phenomena where the brain retains the memory of the sensations that came from the limb, and continues to generate the pain even after the limb has been removed. Ask anyone with phantom limb pain about their symptoms, and they will tell you about the power of the brain in constructing a pain experience. We will do better in helping resolve long-term pain when solutions comes from our understanding these mechanisms, and how we can get your brain to stop causing pain.
Opiates are “Suffering Medicine”
When we take an opiate drug, we’re making the brain care a little bit less about the danger it is perceiving, and thus we feel less pain. Opiates are “suffering medicine” — they make things “feel better” by their action on the brain. This is incredibly useful when we have an acute injury from trauma, or after an operation. It allows us to do “normal” things like move around, sleep and interact with the supportive people around us. When we normalise things in the acute pain phase, we can use opiates as a secret weapon to get back in to normal life. Things go well when we use strong medicine in a controlled and appropriate way such as this! Opiates are absolutely marvellous for reducing suffering and getting people back on their feet, and back to normality. The drug doesn’t help you to get back on your feet and return to normal, they enable YOU to do so without it hurting too much!
The Problem with Persisting Pain
When pain is persisting beyond the time when tissues have healed, then we have to go looking for the other drivers of pain. This is where things get really tricky. This is where we think back to the person with phantom pain and what we have learnt there about the brain — that your brain creates pain. In persisting pain, when things don’t seem to heal and just go away, and feel better, things get scarier. We want to stay safe, so we continue to look for disease and damage, and continue to ask for help. We spend a lot of money to get better, sometimes as our ability to work and participate in life decreases. Here we enter suffering — or at the brain level, Central Sensitisation. It’s hard to see light at the end of the tunnel, and even harder to fit in to an overstressed and time pressured health care system. Opiates make things a bit easier, both for Patients and Doctors (2), so there’s no surprise we prescribed them and crossed our fingers that it would work. It didn’t. People got addicted and lives continue to be profoundly affected. And pain persists. Buddhists have a doctrine of “all life is suffering” however in the context of medical care, we can’t accept that philosophy that we must endure. Human lives and potential is too important for that.
If not Opiates, then what?
It would be really nice to have a pill to throw at pain, and have it work as a sustainable solution, but that won’t happen. From my years in clinical practice, treating pain involves a person’s whole life, and how they conceptualise their body and sensations. Sounds hard right? It is, and it isn’t. The science tells us that being able to explain pain and create new meanings and stories in the brain has a significant analgesic effect, even in the hard to treat conditions such as fibromyalgia (3).
Innovation in pain medicine might come in digital form like an online course or clinic, or perhaps there is a magic drug waiting to be released that changes central sensitisation of the brain. There’s a lot of promising research about how we can use Virtual Reality to normalise the brain in PTSD, and there’s similarities in pain. Your health professionals should be “Hope Dealers”, teaching you how things can and will change when we work together to keep your brain happy. Since that’s not something that many people with pain experience in the health care system, here’s my “help yourself” list of resources to start learning about pain and your brain.
- “Explain Pain”
This is the bible on pain science that we can all read and understand together. Written by David Butler and Lorimer Moseley, and fabulously illustrated, it helps you both understand and create a new story about how pain works and how to change it.
- Retrain Pain is a free, online course translated in to 16 languages providing a very useful resource for learning about pain and making changes.
- Dr Beth Darnell, Associate Professor at the Division of Pain Medicine at Stanford University, has written two books with accompanying CDs to help you use clinically proven psychological coping strategies to manage your pain. Read more about “Less Pain, Fewer Pills”
- Think you’re alone and your pain is too hard to manage? Check out the story and insights of Joletta Belton who has documented her recovery from disabling pain on her beautifully written blog.
- Dr David Hanscom is a “recovering orthopaedic surgeon” and has his own experiences to draw upon in his excellent book “Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain”. This book is especially useful for people who have surgery, or failed surgery, as part of their pain story.
The path out of the current challenges in pain management looks like a murky one, and one that we might be cutting a path through for many years. It makes us think of our mission here at PainChats, and in the words of Ralph Waldo Emerson, “do not go where the path may lead, go instead where there is no path and leave a trail.” May we all trailblaze in treating pain better, and seeing the whole person in the problems of pain.
- Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jul;176(7):958–68. PubMed #27213267.
- Howard L. Fields The Doctor’s Dilemma: opiate analgesics and chronic pain. Neuron. 2011 February 24; 69(4): 591–594.
- Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, Nijs J. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin. J. Pain. 29:873–882, 2013