Less Pain, Fewer Pills

Less Pain, Fewer Pills

Beth Darnall

Beth Darnall

Beth Darnall, PhD, is a pain psychologist and clinical associate professor in the Division of Pain Medicine at Stanford University School of Medicine. Beth, who has 15 years’ experience treating people with chronic pain, also writes the “Ask Dr. Beth” column for National Pain Report.

Beth’s new book, Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control over Chronic Pain, looks at the hidden costs of taking opioids and provides people with alternative treatments for pain management to help reduce their reliance on doctors and medications.

National Pain Report editor Pat Anson recently spoke with Beth about Less Pain, Fewer Pills.

Anson: In your book you wrote about your own personal experience dealing with chronic pain and mention that you also took Vicodin for an extended period. What did you learn from that and how did it shape what you are today?

Darnall: My experience with chronic pain absolutely deepened my understanding of pain psychology, and my work with people with chronic pain. My experience was that the painkillers were not helpful and ended up creating other problems for me, but I recognize that’s not the case for everyone. I help people learn information and tools so they need as little pain medication as possible.

Anson: Can pain management be achieved without opioids?

Darnall: For most people the answer is yes. However, I want to be clear in stating that opioids are helpful for some people. They engage in life more, are able to function better overall, and either have minimal side effects or the trade-off works well in favor of taking the medications.

These cases absolutely exist, but if the data are to be believed, this is true for a minority of people taking opioids long term. There are many other non-opioid pain medicines, such as gabapentin for neuropathic pain, and receiving an evaluation from a board certified pain physician that can help you learn whether other medicines may be better for you.

Many people today are taking opioids for various types of pain that studies show have poor response to opioids. Inappropriate medications can sometimes make pain worse, not better.

Anson: Are opioids overprescribed? Are there conditions they should never be prescribed for?

Darnall: I have an entire section devoted to this topic. Four conditions where opioids are shown to not be effective: Irritable bowel disorder, fibromyalgia, chronic low back pain, and migraine. And yet many people have been prescribed opioids for these exact conditions. Opioids should also not be prescribed for people with a history of substance abuse. And opioids should be avoided in combination with benzodiazepines, because there is greatly increased risk for unintentional overdose and death.

Less Pain Fewer Pills hi res cover imageAnson: One chapter in your book is called “The Painkiller Trap.” What do you mean by that?

Darnall: I entitled the chapter “A Painkiller Trap?” In response to what unfolded in the U.S. over the course of 10 years or so. Opioid prescribing skyrocketed, and without good safety or efficacy data available to support the practice. In the past, opioids were prescribed to treat acute pain or surgical pain, and suddenly they were being prescribed for all types of chronic pain –including the conditions we now know they are not good for. On top of that, opioids were being prescribed by medical providers with minimal training in pain management — sometimes with as few as 2 days of training on the topic.

Opioids can cause numerous side effects, new medical problems, and even more pain. Tolerance develops and people find their pain is worse, so they ask for higher doses. It was a recipe for disaster for many people, and a big part of the problem was the over-emphasis on treating pain with just a pill — it’s a formula that doesn’t work well for chronic pain and can become a trap whereby everyone is chasing the wrong solution.

Anson: You write also about “pain catastrophizing.” What does that mean and what can catastrophizing lead to?

Darnall: Catastrophizing is when our mind stays focused on pain and how awful it is, when we worry that it will worsen, and feeling helpless about it. It is understandable why someone would catastrophize their pain. Unfortunately, it makes pain worse by amplifying pain processing in the brain, something we can see with fMRI scans.

Also, when we stay stuck feeling helpless, we are necessarily not doing the things that would calm the nervous system and dampen pain processing — things that help! Decades of research show that pain catastrophizing — a psychological state — serves to increase pain intensity and is associated with greater disability, greater use of medications, and poor response to pain treatments.

Catastrophizing actually predicts whether someone will develop chronic pain after surgery. I teach people how to stop catastrophizing — how to use their mind-body connection to their advantage to reduce suffering. This is critically important if you have chronic pain and want to maximize your control.

Anson: How important is sleep in pain management?

Darnall: The importance of sleep is underappreciated in chronic pain. One of the best predictors of pain intensity on any given day is the quality of sleep the night before. Make sure you have good sleep hygiene habits or learn more about it. Turn off electronics an hour before bed, take a warm bath, listen to your relaxation audio CD before bed, use custom-made earplugs, and avoid napping during the day so you are tired at bedtime.

These are just some tips to think about. Unfortunately, opioids disrupt sleep architecture and prevent people from reaching deeper stages of sleep, so it’s something to consider if you are weighing whether or not to use opioids in your pain management toolbox.

Anson: What was your main goal in writing the book?

Darnall: I’ve been treating people with chronic pain for 15 years. I found myself talking about the same things, telling the same stories, and getting people on the same plan over and over.

This book was getting down on paper everything I was already talking about and putting it in a format so people could read it and treat themselves. One of main missions is to expand access to pain psychology treatment and this book helps meet that goal. Few people have the luxury of working with a pain psychologist due to costs, insurance coverage, or because there are so few pain psychology specialists.

Another goal was to provide opioid education so people could make informed choices about their pain care. I say this often and mean it dearly: I am not invested in whether people take opioids. I am HIGHLY invested in people making informed choices about their medications and pain care. Know what you are getting into so that you can monitor your risks.

Another goal was to teach people the information and skills that will empower them to have better control over their sensory and emotional experience. And along with this, most people find they need fewer doctors and fewer medications.

Anson: Thank you, Beth.

Do you have a question for Dr. Beth?

Send them to AskDoctorBeth@nationalpainreport.com.

Authored by: Pat Anson, Editor

There are 9 comments for this article
  1. holly at 9:34 pm

    YOU are the reason patients who need opioids and DO benefit from them without side effects feel helpless. YOU should go to medical school if you want to act as a physician–not that going to medical school makes a provider a decent or moral person or fit to treat chronic pain sufferer. I guess you are making a lot of money off a popular topic and helping promote the idea that there is good science behind this load of crap and meanwhile you are killing people. Good going.

  2. Rainey at 11:10 pm

    BL– Whoa! I never said “severe chronic pain by itself caused death.” Please re read my post.

    Maybe the person you work with would benefit from the book “Less Pain Fewer Pills” Dr. Darnall wrote it precisely so that people who don’t have access to pain psychologists could benefit from their wisdom.

  3. BL at 2:58 pm

    Beth Darnall, “evidence-based, low-cost behavioral pain treatment options that will help you develop better control over your experience of pain and will improve your quality of life.” That would be great ! Hope they are no cost because the insurance some people have will not pay for anything for the management of chronic pain. The person I’ve been working with is in bed 23 hrs & 30 mins a day and has been everyday for the past few yrs. So I also hope this help can come to her home.

  4. BL at 6:59 pm

    Access to pain management mat be viewed as a fundamental human right by some. It is a shame that the state of Louisiana doesn’t believe Medicaid patients have this fundamental human right.

    Rainey, if chronic severe pain by itself, caused death, we wouldn’t be having these discussions.

  5. Rainey at 6:29 pm

    The necessary concessions I am taking about include:

    *Cancelling on friends (or work) at the last moment because a severe migraine makes it impossible to drive.

    *Getting government assistance to help pay for medical bills.

    *Applying for state and federal disability.

    *Taking extra time off work, or asking your employer for accommodations.

    *Smoking medical marijuana or taking narcotic medications because that is what works the best.

  6. Rainey at 6:17 pm

    There are a lot of choices people in pain have to make besides when to take a pill. Not everybody with chronic pain is able to work, or afford medical care. Some people have families to support, or risk losing their houses.

    Being in pain and the uncertainty it brings is terrifying. We may die. Especially if we are written off by the medical establishment. If we work, our employers may not be all that sympathetic to our condition and needs. We may not even tell them. Medications like antidepressants and gabapentin are not always effective.

    Then what? How are people in pain supposed to plan their futures and adjust their lives if these necessary concessions are viewed as giving in to their pain?

  7. Kurt W.G. Matthies at 1:34 pm

    Beth, I’ve had a long and productive relationship with a pain psychologist for 20 years. He’s helped in many ways with a range of pain management treatments, including helping suggest appropriate and adequate medications to my physicians when needed.

    I am one of the low back pain (LBP) sufferers who benefits from opioid analgesics and when you imply as an “expert” that LBP should not be treated with opiates, I’m appalled that you’d make such a blanket statement.

    Evidence-based peer reviewed studies are an excellent tool that indicate the efficacy of treatment, however, we’re all individuals and do not all respond within a standard deviation of a data point in the middle of a curve. While opiates may not help a majority of LBP sufferers, and opiates can be detrimental if misused, generalizations about the effectiveness of treatment are often misunderstood by those outside of the medical world.

    I’m concerned that many who live with LBP or have a family member struggling with LBP may avoid treatment because of fears around opiates, abuse, and addiction, and with additional “evidence” that these “bad drugs” aren’t effective against LBP, an effective treatment option may be ignored in favor of a surgical intervention, which can be the cause a lot more suffering.

    You’re correct when you say that sleep is very important in pain management. For many, long-acting opiates are the only medication that can help us stay asleep longer than 3 or 4 hours, without experiencing the next day hangover of certain contemporary sleep medications. In our rush to make medication “safe” we’ve removed some of the more effective sleeping medications in the past 30-40 years. With severe LBP, the medications we’re using today don’t have the strength to maintain unconsciousness during a pain spike caused simply by rolling in sleep. (I spend most nights sleeping in a chair.)

    LBP is a complex medical syndrome involving nerves, bones, discs, ligaments and muscles. In severe back disease, it is rarely a single syndrome but involves a variety of pathology that include degenerative disc disease, spondylosis, scoliosis, sciatica, cord and foramenal stenosis, and other more exotic diseases like tortion dystonia, ankylosing spondylitis, cauda equina syndrome, etc.

    My particular LBP involves 5 of these conditions and I live with other systemic diseases that complicate treatment and contraindicate implantable devices that may help my pain. I use a variety of techniques to manage pain during the day (this is one of them), but without strong opiates that lower my pain by 2-3 points or more, consistently, my life would not be worth living.

    I’m sure that your new book will be a valuable contribution. I am asked all the time “where can I find a pain psychologist, and I usually refer people to your article here “What is a Pain Psychologist”.

    I’ve had the “advantage” of living with pain for 35 years, and have witnessed the growth in the field of pain management. However, today we face a challenge that is making life very difficult for pain patients and the people that treat them. There is currently a great fear of opiate poisoning in America, due to some statistics about a 300-400% increase in “overdoses”.

    In my opinion, these statistics are partially due to ignorance in prescribing long-acting opiates for acute conditions, (I shudder when I hear that a PCP has prescribed methadone for some acute condition), and now we’re beginning to realize that the data used to identify this problem may be inaccurate or even “cooked” for political means. (see National Pain Report — Prescription Drug Overdoses: How Reliable is the Research?).

    As you know, access to pain management Is a fundamental human right, according to the Declaration of Montréal (http://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1821&navItemNumber=582), and statues in 39 of our 50 states passed during the “decade of pain”. Our rights seem to be slipping away.

    Sometimes pain management requires the use of opioid analgesic medications in doses that are politically incorrect in this difficult time for chronic pain patients to receive adequate and appropriate pain treatment.

    Treatment for pain has traditionally been a personal and private relationship between doctor and patient, but in the past two years, the private and personal relationship is being threatened by interference by regulators, politicians, television pundits, and other ignorant parties pursuing their own agendas.

    Now, more than ever before in my 35 years as a participant in the pain community, need to join and fight this war against people in pain. If opiates are ineffective or inappropriate for treatment, then by all means, let’s find other treatment options. But if an opioid analgesic provides a little as a two-point reduction in the pain score of a suffering individual, then that patient needs our support to protect their right to a treatment that improves their quality of life without interference from outside parties with a self-interested agenda.

    The statistic that I never see is that one that bothers me the most — how many chronic pain patients have we lost due to under treatment of pain. How many have decided that it’s just too much and they’re not going to take it anymore?

  8. Beth Darnall at 6:35 pm

    Dear BL,
    This is an important question, and I used it as the basis for my next “Ask Dr. Beth, Pain Psychologist” column here at the National Pain Report. Be sure to look for this column to be posted in the next day or so. While I can’t help you with medical resources, I can help steer you towards evidence-based, low-cost behavioral pain treatment options that will help you develop better control over your experience of pain and will improve your quality of life.
    With warm regards,
    Beth

  9. BL at 2:48 pm

    If your insurance won’t pay for any form of Pain Management for chronic pain, what do you do, besides suffer and lose your life ?