Dealing with a World of Hurt
I had a rare opportunity last week to listen to an entire radio interview in my car (rare because I work at home so time spent commuting is as minimal as I can make it!). Terri Gross of US public radio's program "Fresh Air" was talking with Barry Meier about his just released e-book, "A World of Hurt: Fixing Pain Medicine's Biggest Mistake" (2013) (which can be ordered here).
I was captivated by their discussion for several reasons. First, Gross and Meier waded into the continuing controversy about the use of opioid medications with chronic pain patients. Second, their talk highlighted the challenges presented by efforts to treat persistent and chronic pain patients: Resistance to treatment with many therapies including prescription drugs; the fact that pain patients require much more time than other patients; and the often irritable, demanding, complaint-filled interactions that often ensue.
Meier, a veteran reporter for The New York Times and a finalist for the Pulitzer Prize, is well-regarded for his reports on the intersections between business, medicine, and public health. He has exposed the dangers of various drugs and medical devices and interventions and was the first journalist to shed a national spotlight on the abuse of OxyContin.
A World of Hurt traces the rise of opioids in the treatment of various pain conditions, dating from the mid-1980's. His Ground-breaking reports first released in 1986 by Dr. Russell Portenoy, pain specialist in New York, and his colleagues, suggested that not only could cancer patients use opioids for many months effectively without addiction, but so could patients suffering from more common pain conditions such as back pain and nerve damage. Although Portenoy's research was based on only 38 patients, it made a huge impact, serving as the impetus for a campaign known as the "War on Pain."
The War on Pain
Supported by pain experts as well as pharmaceutical companies, the goal of this effort was the eradication of pain as if it were a conquerable disease, instead of the multi-determined complexity that more recent research has revealed. However, the simplicity of the "War on Pain" movement made it both compassionate and compelling. Why should millions of pain patients "suffer without drugs because of outdated medical views and social stigmas?" (Meier, 2013, p. 49).
OxyContin became the "flagship drug" of the pain movement and it was heralded as a long-acting, time-release medication that was safer than faster-acting painkillers like Percocet. Prescribing doctors were easily reassured at this point, and the opioid painkiller boom was launched.
Meier points out that in 2012, doctors prescribed enough opiates to "keep every man, woman, and child in the U.S drugged round the clock for days." (p. 65). More disturbing, prescription overdose deaths (second only to deaths in car accidents) are now at the root of the country's biggest public health disaster.
Recent findings have linked the long-term use of narcotic painkillers at high doses to many difficulties including addiction, psychological dependence, reduced sex drive, extreme lethargy and sleep apnea, as well as increased falls and fractures in the elderly. Meier and other have also emphasized that long-term use of prescription narcotics may even worsen pain conditions. Studies published by German researchers in 2013 concluded, for example, that when some long-term opioid users were weaned off the drugs, they reported less pain then when they were on medications. Other data has demonstrated that instead of helping workers injured on the job return to work, they have led to thousands of workers becoming disabled and chronically unemployed.
In the 1990's, professionals including Dr. Jane Ballantyne, now pain management specialist at the University of Washington, became convinced that the constant increase in dosages of narcotic medications due to tolerance (patient habituation to dosage leading to plateaus so that more medication is required to provide the same results) was far more damaging than originally believed.
Ballantyne published an article in the New England Journal of Medicine in 2003, suggesting that ever-increasing doses of narcotics to overcome tolerance might actually alter the neurological system itself and create significant hypersensitivity to pain. In time, other physicians began to join her cause, which endeavored to undo some of the damage that the "War on Pain" had generated.
Addiction, Pain and Opiate Medication
Health care and insurance experts became concerned about the costs stemming from the large percentage of injured workers treated with high-dose opioids who did not return to the work force. The pendulum began to swing the other way among insurers who had originally been attracted to the low costs of treating chronic pain patients with medication when compared with pricy, multi-disciplinary alternatives.
It seems like the war on pain has come full circle. Meier concludes that both government and insurers should be encouraged to pay for ways of treating pain that don't involve drugs such as physical therapy and other alternative approaches. Unfortunately, however, just this year, more insurance companies cut their coverage of physical therapy, massage therapy, acupuncture and other non-drug modalities.
A clear barrier to treating both pain and addiction, according to the latest issue of the American Psychological Association's Monitor, is the lag between science and practice. Author David Sheff, who will speak about his new book, Clean: Overcoming Addiction and Ending America's Greatest Tragedy at APA's annual convention in August, found help for his meth-addicted son and learned first-hand about how our current system fails those in most need.
Sheff has chronicled the fact that even though effective treatment methods have been developed, few of them exist in existing treatment programs. The science-practice gap may be due to several factors-a long history of treating substance abuse as a moral failing, a health insurance industry that rarely covers addiction treatment in any depth, and a licensing system that does not consistently require addiction counselors to have adequate training.
Unfortunately, even when the best treatment programs and their use of "evidence-based methods" such as structured motivational interviewing and cognitive-behavioral approaches have been studied rigorously, the findings point to only a slight increase in retention rate in the programs, and the targeted non-drug treatments did not improve the outcomes for patients in the end.
The Third Challenge of Trauma
Perhaps part of the reason why extensive research has not been able to demonstrate efficacy in the area of pain and addiction is because neither research or treatments have pinpointed the root causes of these disorders. The role of childhood trauma in "driving" pain and addiction is gaining increasing scientific traction in linking various types of trauma to the underlying causes of pain and addiction.
Neuroscience has clarified that early life experience via attachment programs the brain and body for the environment it encounters. A relatively calm, nurturing environment will orient a child to thrive, while a stressful, chaotic, and agitating one tends to predispose it to connect with conditions of anxiety and unpredictability. The research is clear that early neglect, as well as early abuse, is an important part of this picture.
The Adverse Childhood Experiences (ACE) study involving 17,000 participants in California's Kaiser Permanente insurance program, found highly significant relationships between severe childhood stress and all types of addictions. Adverse childhood experiences measured in the ACE study included emotional, physical and sexual abuse, neglect, having a mentally ill or addicted parent, losing a parent to death or divorce, living in a house with domestic violence and having an incarcerated parent. Similarly, incidence of various types of trauma has been linked to the tendency to develop chronic pain. Individuals who have experienced significant trauma are more than 20-50% times more likely to suffer from chronic pain than those with a low incidence of trauma.
Further, the work of Stephen Porges and colleagues exploring the polyvagal nervous system sheds important life on even earlier trauma (view here). Porges has suggested that when a fetus or infant is in a state of chronic, global high activation (for example, the mother is in an abusive relationship and is chronically, highly stressed), the child absorbs the stress and unfortunately, the autonomic nervous system becomes chronically disregulated so that any approach to the infant, even if soothing or tender, becomes a threat and triggers further activation. This kind of situation can set the stage for the inability to bond, as well as various difficulties, which can lead to attachment trauma.
Yet the role of trauma is just now being addressed in the treatment of pain and addiction (Levine & Phillips, 2012). Our Freedom From Pain program suggests simple skills that can be learned and practiced to help resolve this underlying traumatic stress that results in chronic hyperactivation (mobilizing of the sympathetic fight/flight responses that can manifest as anxiety, fear, and rage) as well as hypoactivation (turning on the dorsal vagal shutdown that results in numbing, dissociation, withdrawal, and other similar symptoms). We can teach clients to regulate both types of activation, which when long-standing can keep the individual outside of their window of experiential tolerance and therefore vulnerable to the use of drugs, alcohol, food, and other substances in their attempts to regulate their distress.
Depending on where the individual is "trapped" in autonomic disregulation, symptoms of pain and other health problems can ensue, such as anxiety that leads to irritable bowel, chronic muscle tensions and spasms, and panic at
tacks (hyperactivation) and chronic fatigue, fibromyalgia, reflux, migraines, and low heart rate or blood pressure (Levine, 2012).
The good news is that there are ways to emphasize the use of medications at doses that will help to regulate pain and trauma symptoms while the individual learns skills that will maintain autonomic balance - in other words, the judicious use of medication in a program that emphasizes skills rather than pills.
If you'd like to learn more about this skill-based approach, please sign up now for my webinar Working Effectively with the Triple Challenges of Pain, Trauma, and Addiction on Thursday, June 26 from 9 am-10:30 am Pacific (time of the live event though as always we provide immediate replay and download if your schedule is in conflict).

Thanks for your interest in my work and for your time to read this newsletter.
Enjoy the beginning of summer,
Maggie