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.
Anson: 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.