The Pain Antidote

Part 1

UNDERSTANDING

Your pain is the breaking of the shell that encloses your understanding.

—KHALIL GIBRAN

ONE

ALL PAIN IS REAL

Everything You Wish You Never Needed to Know About Chronic Pain

Few experiences in life are more universal than pain, which flows like lava beneath the crust of daily life.

—PAUL BRAND AND PHILIP YANCEY

Loretta was complaining about her chronic pain. As I shifted in my chair, careful to keep my expression neutral, trying my best to hide my impatience and frustration, I found myself thinking that the words whining and exaggerating certainly applied.

“I have excruciating pain in my back.” Loretta touched her lower back and grimaced, shifting her weight. “And in my neck.” For perhaps the third time, she closed her eyes and bit her lip, as if to underscore the severity of her pain.

I found myself not liking her very much. I wanted her to go away. A voice inside me whispered, “So, what do you expect me to do about it?” After all, I was an addiction medicine specialist. My work was to help people get off drugs, but Loretta, like so many patients with chronic pain, wanted relief from the pain at any cost and that meant she wanted more drugs than I was comfortable giving her. She admitted she was addicted to drugs and reluctantly agreed to enter treatment to deal with her addiction because of the pressure from her concerned family members, but she also reiterated in a rising tone of voice that her pain was intolerable without drugs.

“You have to give me something to take this awful pain away! I’m begging you!” she said. I found myself tightening my jaw and noticed a throbbing ache in my low back.

“And my hands,” Loretta said, gently rubbing her left thumb and index finger against the knuckles of her right hand, which were red and swollen. “My hands are killing me.”

“Killing you?” I asked, careful to keep my tone even. Clearly she was in pain, but I knew it wouldn’t kill her—what I needed to help her understand was the very real possibility that the drugs might. She was taking massive doses of painkillers: 10 mg of Vicodin, up to ten per day; 30 mg Percocet, six per day; and, depending on which doctor she saw that week, 80 mg of OxyContin or 60 mg of long-acting morphine three times per day. Her primary care doctor originally prescribed Vicodin and when that drug stopped working to relieve her pain even at higher doses, he referred her to a pain specialist who prescribed Percocet, then added OxyContin and, finally, long-acting morphine. She continued to visit her family doctor who dutifully prescribed 180 (10 mg) Vicodin per month, unaware of the magnitude of her opioid habit or the fact that she continued to get medications from her pain doctor and occasionally visited a local urgent care center or emergency room . . . where she was prescribed even more meds.

But at some point, even the morphine stopped working. In fact, she told me that she was in more pain than ever.

I pointed to the pain level chart prominently displayed in my office. “On a scale of 0 to 10, with 0 representing no pain and 10 being the worst pain imaginable,” I asked Loretta, “how would you rate your pain?”

“Nine,” she said, with no hesitation.

I consulted her file, flipping through the pages. “When you first went to your doctor for pain and started using Vicodin, what was your pain level?”

“Oh, maybe a 4 or 5,” she sighed. “But it’s gotten so much worse. I’m in agony. I can’t live without my drugs. I’m miserable with them, but where would I be without them? I’d rather die than live with this pain.”

I took a deep breath and mentally reviewed the facts of her case. As Loretta’s tolerance increased, the drugs stopped working. Even steadily increasing doses of potent painkilling drugs didn’t appear to touch her pain. In fact, her pain was worse than ever. From everything she was saying, it became clear that the drugs were adding to her misery on many levels, rather than subtracting from it. I had seen this before in many other patients. At these dosage levels, overdose was a real possibility and in the meantime, the drugs were gradually robbing her of all meaning in her life. She could no longer work as a grocery store cashier, her marriage was in serious trouble, her three adult children were so frustrated after years of listening to her complaints that they rarely called or visited, and her friends had “abandoned” her. She couldn’t drive and was dependent on her husband for just about everything. She often spent the entire day in bed—even getting up to go to the bathroom was such a painful ordeal that her husband purchased a bedside commode. At forty-eight years old, she was, essentially, an invalid.

In the month before she voluntarily came to treatment, she had seriously contemplated suicide. “Sometimes I empty the bottle of pills into my hand and think about taking them all just to put an end to all our misery,” she confessed. “But I’m too big a chicken.”

Loretta’s emotional state deeply concerned me, and I found myself wondering about the connection between the depth of her pain and the intensity of her emotions. As her pain increased, she admitted that she had become increasingly angry and depressed. Was it possible that her emotions were intensifying her pain, functioning as internal megaphones that amplified the “sound” of her physical pain?

MY EPIPHANY

And that’s when the lightbulb came on. Loretta wasn’t simply a complainer or a whiner. She wasn’t exaggerating. She was in real pain. Real pain that wasn’t being helped by the drugs she was taking; in fact, the drugs were making her pain worse. And she was suffering—mentally, emotionally, spiritually—as well. Her 9 on the pain scale was an accurate description of her overall experience of pain.

At that moment, almost a decade ago, something inside me shifted. Loretta’s pain was real. Her suffering was real and was a substantial part of her overall experience of pain. It was not my job to judge or label her; in fact it was my job not to judge her. It was my responsibility to help her as best I could, and I wasn’t going to be much help if I did what so many other doctors had done, and just passed her down the line—treating her addiction, assuring her that I had done all I could do, and referring her right back to her primary care doctor, a specialist, or a pain clinic. Loretta would go full circle and end up right where she was before she came to treatment, except even more frustrated and depressed.

I knew from experience that most doctors treat chronic pain with opioid drugs, increasing the dosages in a well-intentioned effort to reduce the pain. Or they refer their chronic pain patients to pain specialists who may prescribe even stronger drugs, adding anxiety meds and sedatives to the painkiller mix. The patient might be scheduled for a series of cortisone injections into the spine (epidurals) or other procedures, such as radiofrequency ablation, whereby the nerves are actually burned with electric current to prevent them from transmitting pain signals. When those procedures don’t work, the pain specialist or clinic might refer the patient to a surgeon who, in all likelihood, would suggest surgery because the medications and other techniques weren’t successful in relieving the pain. If a surgery was performed and judged a “failure” because it didn’t offer long-lasting pain reduction, the surgeon might suggest more surgery or, just as likely, tell the patient that even though the pain persisted, the surgery was technically a success and therefore there was nothing more that could be done.

In essence, the message to the patient would be: “I did my job, so if you’re still in pain, you’re just going to have to live with it,” almost implying, “It’s your fault!” (That’s exactly what happened to Loretta after her fourth surgery.) A referral to a neurologist or rheumatologist might come next. Or a psychiatrist, who might prescribe antidepressants and more anti-anxiety medications. And on and on it goes.

At the time, back in 2006, I had almost twenty-five years of experience in addiction medicine. I was an expert at detoxing patients and guiding them through the recovery process from the disease of addiction. But when it came to chronic pain, I felt horribly inadequate. Loretta was not an isolated case—a huge percentage of the patients I was treating for opioid addiction, perhaps as many as 50 percent, were also experiencing chronic pain. In fact, many had started using opioid drugs because they were in pain, not because they wanted to “get high.” What was I going to do with these patients? How was I going to help them?

I knew at that moment that if I wanted to successfully care for people who were dependent upon or addicted to opioids and who are also living with chronic pain, I had to strip myself of those automatic judgments, learn everything I could, and find creative and innovative ways to approach the problem of chronic pain. I was already well equipped with a team of caring, highly skilled professionals adept at helping addicted patients by guiding them into long-term recovery. Adding chronic pain to the treatment plan would require that we rethink our approach and adjust our clinical services.

PASSED DOWN THE LINE

If you are a person in chronic pain, you will almost certainly know what I am talking about. You have been passed down the line and as the months and years wear on, assuming your doctors stick with you, they are likely to get more and more frustrated with their inability to relieve your pain. You might catch them rolling their eyes or checking their watch as you visit them. Trust me—they are unintentionally, even unconsciously, expressing their frustration and fear at their inability to help you. But of course that doesn’t make you feel any better. As Diana, age seventy, says:

I’ve lived with fibromyalgia for sixteen years. I know that all doctors are busy and I have yet to find a doctor who is interested in researching and finding out what is wrong with me. No doctor wants to even hear me say the word pain. That is a forbidden word now. My primary care doctor confessed he is afraid of me and my status as a chronic long-term pain patient. He is sending me to unsuspecting specialists. Having no safe, caring doctor in sixteen years has taken its toll on me, for sure.

Diana’s complaints about her “doctor disasters” and the “You again?” attitude she feels every time she enters a doctor’s office highlight a deeper problem. Doctors are, indeed, busy and often pressured to get patients in and out of the office as quickly as possible. It is rare for doctors to spend the time to research and find out the complexity of what is truly wrong with their patients—by research, I don’t necessarily mean spending hours on the Internet (or, as we once did, in the library) but, rather, spending time with you, the patient, to uncover the multiple dimensions of your physical and emotional pain and really listen to you.

Acute pain is generally well managed and doctors are usually comfortable treating it, because the pain indicates tissue injury that can be treated effectively in most cases and, best of all, generally resolves within days to a few weeks. A child burns her hand on a hot stove . . . a woodworker slices off the tip of a finger with a skill saw . . . you twist your knee skiing . . . your appendicitis requires surgery. These are all repairable conditions, and doctors know what to do to treat the wound, reduce pain, and help you heal and move on with your life. Doctors also know that they have a willing and remarkable ally—your innate ability to heal. When an injury occurs, your body springs into action, initiating marvelously complex mechanisms to facilitate healing.

But chronic pain—lifelong pain that may ebb and flow depending on a variety of conditions but never wholly disappears—can be overwhelming to doctors. I am certain of one thing, which I have learned in recent years from teaching thousands of physicians about chronic pain and the inherent dangers of using opioid drugs for relief of chronic pain: Doctors get frustrated with their chronic pain patients because they are discouraged and disturbed by their inability to help you. We doctors get angry with you because we are annoyed with ourselves due to our own powerlessness. After many attempts, we may adopt what Diana calls a “get her outta here” attitude because you, the chronic pain patient, remind us that we do not have all the answers. With patients stacked up in the waiting room, that sense of powerlessness (and exasperation with our inability to do what we are supposed to do—heal the patient) leads to one of two solutions: write a prescription or admit we can’t help and refer you to a specialist. These actions relieve us of responsibility and require only a few minutes, whereas taking time to really listen to a patient—witnessing the pain, probing the physical, mental, emotional, and spiritual depths of the problem—may take hours.

EMOTIONS DRIVE PAIN

A few months after Loretta was in treatment at the Las Vegas Recovery Center (LVRC), I attended a conference sponsored by the California Society of Addiction Medicine. One of the full-day workshops was “Pain and Addiction: Addressing the Tough Cases.” That’s where I met Barry Rosen, MD, and Jodie Trafton, PhD, two brilliant, sensitive, and extraordinarily talented individuals who have had a profound and lasting impact on my work.

From the first time I met Barry, I knew I wanted to be like him. Gentle, self-effacing, and sweet natured, Barry radiated concern, empathy, and, yes, love for his patients. He stood well over six feet tall (at least in my memory), with big bushy eyebrows, a receding hairline, and dark brown eyes that conveyed warmth and intelligence.

I loved watching him interact with patients. He would sit down next to them, often patting their hands or gently touching their shoulder as if to say, “I’m here, I’m listening; nothing is more important to me right now than you and this moment.” Fear, anger, and hostility seemed to evaporate as they realized that he was not the “MD-eity” they had come to expect but, rather, a fellow human being who wanted nothing more than to help them and ease their concerns. Rarely had I seen a doctor interact with a patient in a way that conveyed such depth of caring and human connection.

Witnessing these interactions, I understood immediately why patients trusted him—why they loved him. He was so completely different from most of the physicians I had encountered in my life (including me at the time), who seemed always to be pressured by time and thus impatient, curt, and even rude as they delivered their diagnoses and medical advice in a stern and professional tone of voice, often finishing their patients’ sentences for them, scribbling barely readable prescriptions, and ending the brief interview by looking at their watch with a weighty expression to indicate “time is up.”

From watching Barry with his patients and working hard to model his unique, empathic style, I learned essential lessons that I use every day in my own work with people in chronic pain. From Jodie Trafton, who has had an equally profound influence on my life and my work, I learned what goes on inside our brain to drive us to think, behave, and emotionally respond in ways that cause us long-term harm. The basic principle here is that our brain is circuited to take shortcuts, even if the quicker route ends up not being in our best interest in the long run. For example, if you take an opioid medication, you get an immediate hit in your brain that is more instantaneous and powerful than the endorphin “high” generated by exercising. And exercise can be drudgery, with gains accumulating only with consistent effort and over time.

Furthermore, if you’re in a lot of pain, exercise may actually make you feel worse temporarily. Exercise is thus the “longer” route and, when gauged in terms of instant relief, not necessarily the most “scenic” pathway. It makes sense that a brain that has become accustomed to the immediate reward and relief of opioids would choose that pathway. In contrast to the “no pain, no gain” rule of exercise, opioids offer the alternate route of “less pain, less gain.”

Barely five feet tall (when she was seven or eight months pregnant, I remember fearing she would topple over), Jodie is brilliant, most evident in her descriptions of work in the research lab, where she has studied brain circuits and neurotransmitters involved in addiction and the behavioral consequences of neuroplastic changes, and on the lecture circuit, where she summarizes this elegant research for physicians like me. Although much of the information she discusses in her talks is hard to follow, I’ve been able to latch on to key pieces and a deepening understanding of the neurological underpinnings of habit formation and willpower. Jodie also describes how addictive drugs pharmacologically hijack the brain’s reward system, causing dopamine neurons to fire vigorously, triggering huge rewards that in turn lead to craving for more drugs to experience more rewards.

In one of the first of a half-dozen lectures I heard Jodie give, she described an experiment that appeared in the Journal of Neuroscience in 2004 in which research subjects received an electric shock. If they pressed a button quickly enough, they were told, they could modify the intensity of the shock so that it was less painful. Subjects reported that pressing the button worked to reduce pain, and scientists confirmed through MRIs that there was less brain activity, indicating lower pain levels—and yet the button was not connected to anything. In other words, the subjects’ expectation that they would have less pain if they quickly pushed the button, led to reduced signals in the pain-receiving areas of the midbrain and a decrease in their pain levels. As I listened to Jodie lecture, I got really excited, because it validated what I witness in my work with patients—if you “push the button” of believing good things will happen in treatment, knowing that you have some control over your situation, your pain lessens. The better the sense of control you have over your situation and the more you commit to the work needed to continue to reduce your pain, the greater the benefit of the treatment.

THE GIFT OF PAIN

Not long after I met Barry and Jodie, I picked up a copy of The Gift of Pain by Dr. Paul Brand and Philip Yancey.

A compassionate healer and consummate storyteller, Dr. Brand spent much of his life working in India with patients who had Hansen’s disease, a bacterial infection more commonly known as leprosy. The prevailing medical theory held that leprosy itself caused grotesque disfigurements in untreated patients, whose noses sometimes shriveled away or who lost fingers and toes and would often go blind. From the work he did with patients in India, Dr. Brand arrived at a different theory: People with leprosy had disfigurements because the disease-causing bacteria destroyed the nerves that signaled pain. And without pain to guide them, they unwittingly put themselves in harm’s way.

While researching his theory at a leprosarium in New Guinea, Dr. Brand observed a woman roasting yams over red-hot coals. One of the yams fell into the fire and as she tried to stab it with a stick, she drove it deeper into the blazing hot coals. She motioned to an old man sitting nearby, who shuffled over to the fire, reached into the coals with his bare hand, and rescued the yam. With no expression of pain whatsoever, he returned to his seat. Shocked and horrified, Dr. Brand immediately went to the old man’s aid and examined his hand—it was covered with oozing blisters and scars. Although he eventually lost his hand, the old man displayed “an utter nonchalance toward self-destruction,” in Brand’s words, because he did not, could not, feel pain.

Pain, as unpleasant and even dreadful as it can be, serves a life-giving purpose by protecting us from hurting ourselves. In fact, it is precisely the unpleasantness of pain that warns us away from the cause of the pain, thus protecting our body from damage.

Yet prolonged pain can also become a destructive force. People with chronic pain can experience such interminable agony that they may begin to question the meaning and value of life itself. Some, tragically, feel like a mere shell of their former self and don’t want to go on living. Thus in this modern age of believing that virtually all ills can be defeated with the right procedure or drug, we view chronic pain as the enemy to be defeated, a mysterious, unrelenting force that strips us of our strength and dignity, and a harsh reminder of our own limitations and powerlessness.

How, then, can there be “virtue” in chronic pain? With another story in the first chapter of The Gift of Pain, Dr. Brand recounts “the darkest night” of his life. After a week-long bout with influenza and an exhausting trip, Dr. Brand was suddenly, terrifyingly aware that part of his foot was numb.

I had no feeling in half my foot. I sank back into a chair, my mind whirling. Perhaps it was an illusion. I closed my eyes and pressed against my heel with the tip of a ballpoint pen. Nothing. No sensation of touch whatsoever in the area around the heel.

A dread fear worse than any nausea seized my stomach. Had it finally happened? Every leprosy worker recognizes insensitivity to pain as one of the disease’s first symptoms. Had I just made the wretched leap from leprosy doctor to leprosy patient?

Dr. Brand knew all too well what to expect after working with hundreds of leprosy patients. “Ordinary pleasures in life would slip away,” he wrote. “Petting a dog, running a hand across fine silk, holding a child—soon all sensations would feel alike: dead.” He feared his career as a surgeon would end. What would happen to his work, his patients? Worst of all, he would need to shut himself off from his children, for children are most at risk of infection. Frightened and alone, he would join “the society of the accursed.”

After a sleepless night, he woke up, jabbed his heel with a sewing needle, and immediately felt the sharpness of the point. With the pain came overwhelming waves of relief and joy. His heel, he realized, had been temporarily numb, most likely from sitting too long in one position. He could feel pain, there was no leprosy, he was free—and for the first time he understood at a deep, visceral level why leprosy victims look with envy upon those of us who feel pain. In this story, Dr. Brand also illuminates the emotions associated with chronic pain, especially fear and anxiety about the unknown, and he demonstrates negative projecting and catastrophization, which we will discuss later in the book.

Later in his career, Dr. Brand had the opportunity to work with rheumatoid arthritis patients, who begged him to relieve their pain with drugs. Some patients took such massive doses of steroids in an ill-fated attempt to relieve their pain that their bones gradually decalcified, growing soft, fragile, and vulnerable to injury.* One bedridden patient had taken so many steroids that “when she finally ventured from bed her foot bones crumbled like chalk.” Reflecting on the nature, purpose, and meaning of chronic pain, Dr. Brand describes what he calls “the conundrum of pain.”

“Why,” Dr. Brand asked himself, “would our own minds inflict on us a state that we automatically choose against?”

PAIN’S PARADOX

Pain functions to protect us. When we are hurt or injured, the life-saving message we require to save us from further injury is: “Pay attention to me! Now! Something is wrong!” Pain is a warning sign, a red flag alerting us to danger, and its signals and symptoms serve to protect us from harm. Which makes perfect sense when we are talking about acute pain—but why does pain persist when it has accomplished its essential function, when its meaning and purpose have been fulfilled? This is what I see as pain’s paradox: while pain is an exquisitely intricate and impossibly complicated system designed to protect us from harm, this system also can go haywire, lasting long after it has outlived its main purpose—that of warning us that something is wrong. People with chronic pain do not get the same relief that comes with the healing of a broken arm, a ruptured tendon, or a surgical incision. The pain lingers even though it serves no purpose. This is what physicians call maladaptive pain—it sets up house (a distinctly unwelcome guest) in the pain center in our midbrain. And it never goes away.

Never? You might be tempted right now to toss this book in the nearest wastebasket. But please—don’t give up now or you’ll miss the best part. I am here to tell you there is a way out. You don’t have to have a miserable life because of pain. You can learn how to manage your pain so that it no longer rules your life and your relationships.