Absolutes in Chronic Pain Treatment Can Backfire

Absolutes in Chronic Pain Treatment Can Backfire

By Ed Coghlan.

Beth Darnall PhD is a pain psychologist, noted researcher and Clinical Professor at the Stanford University as well as successful author on chronic pain. She and her research team have just landed a major grant to study chronic pain. We interviewed her on the grant, the opioid controversy and the National Pain Strategy.

NATIONAL PAIN REPORT: “Beth, you wrote a great piece for Huffington Post last year that argued more needs to be done to address chronic pain than just limiting opioids. Yet it seems a year later, little has changed. The attack on opioid use has intensified but alternatives are seldom heard. Thoughts?”

BETH DARNALL: “Humans tend think in binary terms and we are certainly seeing that play out with opioids. It’s not a black or white issue. We need to allow for the grey, and that means treating each patient with respect for their individual factors. I have always worked to help patients need fewer medications to manage pain and symptoms. That does not mean that medications and opioids have no place in pain care because they do. Getting away from the binary thinking allows us to appreciate that physical, self-management and psychological approaches are important for each and every one us – regardless of whether opioids are taken or not. Many people who use these modalities find that their medication use is reduced, but not for everyone. In the current political climate absolutes in either direction will backfire against best patient care.”

Beth Darnall, PhD.

“You raise the point about opioid alternatives receiving scant attention. Recent articles in Scientific American, Time Magazine, The Washington Post and the NY Times are helping to get the word out about non-drug pain management strategies. But at the end of the day patients need better access to skilled providers and treatments such as physical therapy, cognitive behavioral therapy for pain, Mindfulness Based Stress Reduction, and chronic pain self-management. Insurance barriers often prevent patients from accessing this care. And, often patients cannot find skilled therapists where they live. We need policy changes to better support insurance coverage for non-drug pain treatments, and we need better federal investment in chronic pain treatment education for physicians, psychologists, and physical therapists. Ultimately, we need to improve access to the lowest-risk evidence-based pain treatments.

NATIONAL PAIN REPORT: “I recently spoke with Bob Twillman, executive director of the Academy of Integrative Pain Management who was arguing that implementation of the National Pain Strategy is slow to non-existent. Do you agree?”

BETH DARNALL: “Yes. Dr. Twillman is spot on. A federal task force is being developed, so that is promising. But solutions have been slow while the opioid reduction policies have been quickly implemented. It’s easy for me to play armchair quarterback, but I wish policies that targeted improved non-drug pain treatment had been implemented before opioid reduction policies were enacted. Many patients have been traumatized and suicide has been a horrifying outcome for some. I understand the rationale of federal and state policies, but the implementation has not been supportive of patients with chronic pain with tragic consequences.”

NATIONAL PAIN REPORT: “I follow you with great interest on Twitter and noted an added emphasis on patients taking control of their lives, more exercise and lifestyle adjustments etc. Share some tips for patients who are looking for a better way. “

BETH DARNALL: “I wrote 2 books on this very topic! It is difficult to provide tips without sounding trite to those who have chronic. But interested readers can check out these two free articles I recently co-authored in Time Magazine, and The Washington Post with Dr. Emma Seppala. A short sound bite is that our thoughts, emotions, stress, and choices all impact our pain and can make it better or worse. If you don’t have the right information and formula to help keep your pain as low as possible, you will need more medical care to manage symptoms for you. That’s a trap. Opioids or no opioids, I encourage everyone to learn everything they can to train their brain and body toward relief. It’s not a one-off solution. Pain management is a lifestyle.  Just like someone manages diabetes with a focus on healthy daily behaviors, chronic pain self-management is dedication to active, empowered living. Karen Duffy, a.k.a. Duff Lambros (actress, author and former MTV VJ) is such an inspiration to me and countless others. She has lived with severe debilitating chronic pain for many years. She states publicly that she uses opioids, and states that her foundation for pain relief is her daily dedication to actively self-managing her pain and symptoms. Opioids are just one part of her overall pain care plan. By the way, she has a fantastic book coming out later this year and I highly recommend it!”

NATIONAL PAIN REPORT: “You were just awarded a sizeable federal grant. Congratulations. What will it allow you to work on for the benefit of chronic pain treatment?”

BETH DARNALL: “The Patient-Centered Outcomes Research Institute awarded me and my research team $8.8 million to conduct a multi-state study to help patients with chronic pain reduce pain, opioids and associated risks. We aim test the ability of behavioral treatments to facilitate pain and opioid reduction. Nobody wants to take opioids, patients just want less pain. It is important to note that we are not forcing anyone to reduce their opioids in this study. We are only studying patients who want to enroll in a patient-centered opioid reduction program – it is voluntary. I am constantly amazed at how many patients tell me they want to reduce their opioids but do not know how or fear they cannot do so. This project is for them. Patient partners helped us design our study, and we are measuring the outcomes patients told us are most meaningful to them. I’ve been talking about what needs to happen for years; with this award I am honored to lead the work at a national level. We aim to provide patients who wish to reduce pain and opioids, their families, and their physicians with the evidence they need to successfully meet these health goals.”

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Authored by: Ed Coghlan

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May I add a comment three months after initial publication of this article?

I would gently suggest that the medical evidence for so-called “non-invasive, non-pharmacological” alternatives to opioid therapy is so weak that we really don’t know if any of these techniques work better than placebo or sham therapies. In December 2017, the US Agency for Healthcare Research Quality (AHRQ) circulated a draft “Comparative Effectiveness Review” for multiple alternative therapies in five categories of chronic pain (chronic low back pain, chronic neck pain, osteoarthritis, Fibromyalgia, and chronic tension headache).

“Poor” quality was very widespread in this literature. Over 4500 trials reports were located in medical literature and boiled down under rigorous criteria for research quality, to a mere 205 publications. The only reports summarized by the systematic review were those for which outcomes were followed for at least a month after the trials concluded. Even in these selected publications, the strength of medical evidence was evaluated as “weak” in more than 100 instances.

Results for Fibromyalgia seem to be fairly representative of overall findings. I quote directly from the report below (SOE = Strength of Evidence):

=============begin extract

“Fibromyalgia: Function improved slightly in the short term with cognitive behavioral therapy (CBT) and tai chi and qigong mind-body practices (SOE: Low) and with acupuncture (SOE: Moderate). Improvements in pain were seen in the short term with exercise (SOE: Moderate) and mind body practices (SOE: Low). Small functional improvement continued into the intermediate term for acupuncture and cognitive behavioral therapy CBT (SOE: Low) and was seen for myofascial release massage and multidisciplinary rehabilitation (SOE: Low). Long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: Low for all) and no clear impact on pain for exercise (SOE: Moderate) or multidisciplinary rehabilitation was seen (SOE: Low)”

============end extract

From a deep reading of the draft report, I suggest that the largest weakness in trials data published so far on alternative therapies is failure to describe and evaluate effects of “usual therapy” to which alternative therapies are typically added. It is frequently unclear from these reports whether the alternative therapy was trialed as an add-on or as a replacement for drug therapy. The AHRQ reviewers surmised that few trials attempted an outright replacement and this surmise is generally confirmed by the small observed improvements in outcomes.

At present, the jury is still out on the question of how effective various non-pharmaceutical therapies can be as replacements for opioids. The evidence so far published offers little support for the idea that such therapies can replace opioids in a safe and reliable way. Outcomes suggest to me at least, that such therapies presently may have value only “at the margins” of drug treatment, but not as replacements.

Jim Moulton

This is so frustrating, nothing is said bout the heroin users and illegal drug user, it is all about the pt who has chronic pain, and lives a tormented life of pain and trying to get by, as my doc said I need to get you off this [edit], after 6 years of giving it to me, without a problem. I am on disability and can hardly walk because of my deformed body, due to bad scoliosis. I can just pray.

Susan Smith

Any news on how to participate in the grant? I live in Charlotte NC. My Ortho MD Ordered and IT in my home as I can’t get out to a clinic for that.But the chronic pain always continues 24/7 despite using all modalities.SIMPLE FACT,I NEED MY PAIN MEDS TO LOWER MY PAIN LEVEL SO I CAN EVEN FUNCTION! I don’t get high,take them only as prescribed just to reduce my pain level, so maybe I can do ADL’s without getting frustrated and hopeless. CDC,don’t make chronic pain sufferers pay for your lack of intellectual and scientific knowledge.Stop assigning every chronic pain sufferers an addict simply because WE NEED OPIATES as part of an overall regime to manage our debilitating. Pain that just won’t go away. Until you walk in my body,you have no clue. GET PROPERLY EDUCATED PLEASE and hopefully. Understand us,not label chronic pain sufferers as addicts out of control. Life is not black or while and gray areas exists when you live with 24/7 chronic pain.I DIDN’T ASK FOR THIS PAIN,


my heart goes out to you Neldine Ludwigson, because I two am one of the many victim of Haborview in WA. But I have a question for anyone who has heard of this or has tried it? Wild Lettuce? I am told it is not addictive but works like opioids.

Scott michaels

THEY SHOULD NOT HAVE TAKEN THE MEDICINE FROM THE GOOD PATIENTS THAT WORKED FOR THEM. YOU WANT TO TRY the Torture on new patients fine. They dont know any better. But to go from bedridden to happy functional life back to bedridden is just messed up mean cruel and outright torture. I k ow how great the medicine works i always took it as directed. Now im wondering how to get it illegally or just be a statistic.

Neldine Ludwigson

I am sitting, as best I can, once again after less than two hours off restless sleep. I live every day at at least a seven on the silly pain scale, by the time I have done the best I can to fake my way through a day of doing WAY more than I should, my husband suffered a severe degloving in the moulder at work, which led to losing his lower right leg. I received no help at any time during his rehabilitation. Harboview released him on Xmas eve, 4:30pm, no medications, not even the medicated dressings for his wounds. He had 1 crutch and a few abdominal pads. My primary care doctor had just scored a job for a privately owned boat builder. She had been my rock over 18 years of slowly getting worse and worse. Over the holidays I had to share my pain meds with my husband, while hurting myself more and more doing EVERYTHING and heavy lifting constantly, that continues now, nearly 3 years later. With either his walker or the cheesy prosthetic Labor and Industries covered, he still can’t lift anything heavy. So, in spite of compression fractures throughout my spine, and now severe stenosis that makes my legs feel like they’re on fire. The pain is making even urinating a struggle, and when my IBS flares up, well, shitting yourself because even with the rollator I can’t always get there quickly enough is really mortifying. The moron of a primary care physician we see now took away my prednisone and, while claiming he gets backaches too, cut my narcotic pain med in half. The day he did this, as I was stuffing the walkers into the backseat, went by, JOGGING! Oh right! Backaches my aching a**. He now is pushing me to have back surgery, but how can I let it heal properly while taking care of everything Damned thing. He and my husband claim that my husband will help, yeah, how pray tell when he can’t hardly get a grocery bag into the house? With my previous doctor, who really worked with me, I tried all the PT I could tolerate, every NSaid available, which not only made the IBS worse, but jacked my blood pressure to scary levels. I tried TENS, numbing creams, more PT and after all that we decided to try the narcotics. Took awhile to find the best one, but I finally had some relief, until Xmas 2014. Yeah, life’s a big pile of crap struggling to fake a life, and all the while waiting for the next chop of the axe. I don’t want to “live” like this anymore. One gimp doing her best to take care of another. Now my knees and hips are not only arthritic, but bursitis has settled in too. What the heck am I supposed to do? Hopefully the pain will just stop my heart. I’m sure that’s what the powers that be hope happens to all of us. BTW, a… Read more »

A Vascular Anomaly

You know what would reduce pain? DOCTORING. No one is seemingly interested in learning about the disease or illness, the root of the pain. My spouse is practically begging to have surgical removal of an entrapped nerve. She has muscle adhesions that are enormous. First of all, doctors either write the prescription or they don’t. I am being so forceful about diagnosis for my own treatment so I can actually get better, if I had the chance. Unless I demand it, they won’t run a particular test unless I bring it to their attention. That said, some of us want the cure, or at least a vague interest in treating the disease and not just the syndrome. Secondly, many of these suggestions are great but if you are poor-unable to get disability and yet nearly bedbound-affording massage, acupuncture, etc. But other people seem to be really into this article and all I’m hearing is ‘mind over matter’ and training yourself to transcend pain. This also assigns pain to us, our problem, and doesn’t assign this to a society that incessantly talks about painkillers and never about PAIN. We go to doctors for help and often use what limited mobility we have to even make those appointments, and they treat (if you’re lucky) pain, as if pain were a disease in and of itself without an etiology. What is underneath my pain is a ticking time bomb. I have no use for this insult of an article and the philosophy that undergirds it. A therapist who gets to live their life and work and have sex and leave the house trying to tell me how to better experience life in my failure of a body?


The elephant in the room…long term opiate studies on chronic patients.

Anyone beg to answer WHY?

Misty Morse

You know I love how IBIN say’s non opioid’s are not feasible yet. WTH does that mean. It should never BECOME a feasible option. We need our opiates and I am sorry but multi modality tools are often not helpful and can make patient’s pain worse.
Here we go again , let’s make this all about losing weight and excercising and diet.
When WE NEED our opiates.
Are you aware that many patient’s have done these therapies to death and they put us in more pain?
When is someone going to FIGHT for our rights for our dr’s to be the ONLY one’s who are involved in what we need?
Not the government , nor the CDC , not the psychological people?
I am not depressed nor do I need couseling. I have been a chronic pain patient since 95 and have done great without psychological care.
We NEED our meds.

Martin John

As a chronic pain patient the notion that one single fix is not the remedy for improved pain management. That tipping point when medication only increases our angst, is the idea that a 10% reduction of our continuing pain is the best available.

In 91 Professor Galasco gave me the best advice, try to develop learn to live at best with what you have. That honesty took courage, it gave me responsibility rather than relience on others.

That muti-faceted simultaneous array of tools which I developed have been my best option, from CBT to increased exercise, pacing to distraction.

Dr Forrest, has provided invaluable methods, that collective strategy, viewing the same chronic pain from an alternative way-point.

An avid reader of all academic research has enable a better understanding of the complexities.

Be kind to yourself.

For two decades this has been my extended lifestyle, those ripples impacting far beyond this challenging arena.

Kathy C

Here we go again! Psychologists studying Chronic Pain. We no longer have much actual Science involved, while the Opinions of Psychologists have been elevated as equivalent to Evidence Based Medical Science. While these “Alternative Treatments” may help some people, they are dependent on Socio Economic, Location and other Factors. While these Psychologists are doing another Study, many have already been done, and the Conclusions have already been broadcasted as fact by our Media. These clever “Studies” have been referred to even by Doctors, and Policy Makers, on this issue. The unfounded Conclusions, like “Mindfulness May Help Chronic Pain.” or Chiropractors Can relief Chronic Pain” have already been reported as factual in popular Media. A local TV News Station reported that Anesthesiology Tape, can “Cure” Opiod Addiction. The general Public already believes what they read in the “News.” After all a minuscule Study somewhere claimed that Rats, could have their pain amplified by opiates. This narrative made it’s way into nearly every discussion of pain,and drug abuse, and is now part of General Knowledge by our misinformed and gullible Public, Politicians and Journalists. Many Psychologists are just as susceptible to this nonsense as the general public. They fail to make the distinction between Scientific Facts, and Opinions. They are unable to distinguish credible ideas from the ridiculous. If one were to follow the popular “Psychology Sites and Publications, they would not see much Critical Thinking. If we track down the “Research” and the Researchers we can find careers built on promoting certain “Alternative Treatments.” They study in such a way that it appears credible, until a few questions are asked. If we look a little deeper, many of not all of these Studies are flawed, and Unscientific. No one in the Industry has been amplified by the Media questioning any of the Methodology. There are even Studies done to Prove, the Subjects who failed were “Not thinking Positive enough.” We are Post Science. Instead of these “Researchers Striving for more Scientific Accuracy, they found that less is better. This is about what the gullible believe, not facts, accuracy or accountability. No “Study” has bene done about the people subjected to “Mindfulness” Instead of Pain Care, oir a clear Diagnosis of a Painful Condition. Not one “Study” has been done about the effects of foisting Mindfulness, instead of treating or even acknowledging any underlying Pain Condition. We have no way of knowing how many people Committed Suicide when denied treatment for pain, and given “Mindfulness instead. No Studies were done on the number of people who attempted Mindfulness rather than getting a condition diagnosed and treated with Opiates. The failure to even quantify these numbers has been very convenient, and unscientific. These Psychologists have already failed, because they refused to look at the alternative. This is all by design, a signal of the sickness and rot at the core of our Society. Even the most flawed studies can be used to advertise Alternative Treatments. After all each one contains a Disclaimer, if… Read more »


Good logical observations Beth. Reduction/removal of medication from patients without any other resource to combat, manage established pain is simply not feasible yet, it is done. Even a temporary reversible of 90 mme for patients, DETERMiNED by the provider to prevent the harmful, costly, and deathly situations that are occurring now with the unilateral maximum of dosage as prescribed by the CDC “policy” is ridiculous. Perhaps a comprehensive plan to treat pain for future patients, and their will be…..future patients can be realized but, again, a single treatment, single one therapy, one type or dosage of medication for one and all is not realistic. The social experiment of 90 mme daily, maximum, that the CDC has ENFORCED and unleashed upon patients with well documented beneficial use of opioid medication is not the answer. Opioid medication may not be the only effective pain management treatment possibility for one and all but, for the very many of us, it is. Good luck, positive results for all with life time pain with the grant.


Pain management is underpowered and ill conceived. Researchers and doctors have failed to explore cures for pain as Dr Dworkin clearly stated at the Federal Pain Research Strategy meeting.
It is clear that there has been terribly neglect in pain research and practice. Dr Darnall and Sean Mackey lack the vision and motivational intensity to make pain care much better. They are stuck on old models of care that reflect paradigm paralysis. Even Dean Minor of Stanford has called for curing pain. Its tragic that most of pain care has such low expectations and hopes.


Well said brett. Especially dog feces part!

I did so many steroid epidurals I developed cataracts.

I was not told of risk.

Countless hours spent in pt, chiro, and other things including 2 cervical spine surgeries that did nothing to stop pain.


When I was receiving adequate pain treatment, I was able to exercise, lose weight and go out occasionally. I accepted that with CRPS my pain would never go 100% away. I accepted living with a level 5 pain with pain meds. Now, I receive no pain management, can barely get out of bed and am scared of my future. I am permanently disabled at 49. I have a law degree but can’t work. I should be able to get the meds I need. Don’t doctors realize I would do anything, even amputate my affected arm, to get better? I’ve tried it all. Ironically, a doctor cut my median nerve during carpal tunnel surgery and caused the CRPS. I also lost the use of my hand. I lost everything so for the love of God, let me decide to live my life and give me the meds I need until someone cures my disease.

Brett Husebye

I continue to write because I still live and breathe on this planet on this side of the grass. Many of us have already tried the alternatives and we have been in Physical therapy, had Tens treatments, shots to our spines of steroids, swam in pools, fell on our heads doing yoga, had needles poking out everywhere. We depend on the drugs and committing everyone in pain clinics that have grown their opiod tolerance after years and years of careful upticks to our plans to some forced drug therapy is wrong. There is no doubt that moving our opiods down after years of raising them can be done. Yet it should not mean that they should not move back up. Some of us with MULTIPLE issues cannot take the pain and still maintain a lifestyle that does not include disability if we can get it. The problems with Suicide is these people still count everyone of us that dies as an overdose. I quit taking Oxycontin cold turkey so I could take Methadone thinking my doctor would leave me alone and quit complaining about the CDC and his license. We would rub dog feces on ourselves if it lessened the pain but the things being offered as “alternatives” have had no effect on many of us. I laughed at supposed experts that say we need to remove the emotion from pain. Let me bonk them with a ballbat in the spine a few times and see if they have emotion with their pain. A University of Michigan expert said there are NO good alternatives to Opiates. None. We need a ton of R&D and progress with treatment. I love the idea that some people do not need drugs. The govenor of Florida said all we need to do is get up and move. Some of us work our asses off and all we do is move and none of it helps. The pain never goes away, and it never stops. If someone wants to do something useful figure out how to turn the Brain pain amplifier down. In the meantime 25.3 million of us can vote a whole lot of people out of office. I am all for getting special interests out of government completely. For all I know this has been forced upon us to save the insurance industry money for the losses in Obama Care. It makes sense after what they did to those kids in Florida in CMS. Kicking them off with a loaded questionaire made up by some boob to save millions. I know the CDC does not have elected officials but we do not have to take lightly those in office who let this carelessness happen, causing suicides for the sake of money or having their “expert” opinion shoved down everyone’s throats without careful consideration of their medical history. This has been the most despicable thing that the government has ever done. And the CDC has admitted that they are feeling pressure outside of their… Read more »


Excellent points about changing lifestyle. In the U.K. If you are one of the few fortuneate enough to get to a pain clinic many hospitals offer 3 week residential or longer outpatient programmes on all the lifestyle changes that reduce pain. Usually hydro, Physio, OT, psychology and Mindfulness & meditation. CBT does not work if you are in any way intelligent ( I hold 4 qualifications in psychological medicine) and Mindfulness carries substantial risks >15% of severe psychiatric reactions. For me mindfulness just made my brain literally hurt - severely. Odd as the brain has no pain giving nerves. You are still over criticising and singling out opiates in your article this is not appropriate: only opiates taken in first two years of pain will
Prevent life long disability. Do you not understand how pain states form in the dorsal horn of the spinal cord? Only opiates act directly on these cells ( and ketamine). I have had no side effects from
Years on opiates and yet serious circadian rhythm disorder and itching caused by Topiramate, an effective pain killer licensed as an epilepsy medication. Please get off the anti opiate horse and get pain
Management courses set up for all pain patients. All the science can be found at painscience.com

Sue Smith

I am excited about the Grant! I have chronic pain 24/7 and on opiods to help reduce my pain but the pain always exists although the med reduces the severity of the pain. I have been swimming which helps mobility for me. I ice my left side as needed. How can I get involved in the study? I don’t like taking pain meds but without them my pain is intolerable. I was in an accident that was not my fault,but will have to suffer the rest of my life due to someone else’s fault.Thank you for your invaluable time.God Bless

Barbara Stead

Good Morning, I am interested in the Study of Chronic Pain Management that Beth Darnell is Managing……I am a Registered Nurse,who retired early from my Nursing Practice, due to Multiple Chronic Pain Challenges. Thank you,Barbara Stead