How behavioral conditions worsen chronic pain

The opioid overdose epidemic is worsening at alarming rates, and current and near-term proposed strategies are not likely to turn the tide over the next few years. One nearly universally adopted strategy to curb overdoses has been to reduce the dose and quantity of prescribed opioids. In 2016, the Centers for Disease Control released guidelines for prescribing opioids, which were not intended to force reductions in opioid prescribing but rather to prioritize non-opioid pharmacotherapy, carefully consider the risks of prescribing, limit new prescriptions and monitor for the development of opioid use disorders. Despite the CDC’s emphasis on collaborative, multidisciplinary approaches rather than involuntary tapers, many providers and policy makers have interpreted the guidelines as a mandate to restrict opioid prescribing in a blanket fashion. 

Although the overdose crisis is driven by several factors including the widespread availability of opioids, the resulting restrictions have often left patients with chronic pain and chronic use of opioids in withdrawal or forced to seek relief through the practice of “doctor shopping” or the use of illicit opioids. Since people with chronic pain often live in fear, the idea that they may not be able to achieve relief from pain or may have to suffer debilitating opioid withdrawal only serves to worsen their experience, producing anxiety and despair—in some cases leading to suicide. As I told an audience of physicians in Texas a few weeks ago, “we have no right to help one set of patients by harming another.” Fortunately, the primary solution to the opioid overdose crisis does not require a singular focus on turning off the spigot, and with adequate planning and resources, chronic pain patients can receive the care they so desperately need. Over time and with enough resources, we will likely be able to manage much chronic pain without the widespread use of opioids, although some cases will likely always require opioids long term.

We have no right to help one set of patients by harming another

What People with Chronic Pain Really Deserve

If you spend enough time talking to people with chronic pain, you’ll come to one conclusion—it affects every area of a person’s life. Marriage, family, work, school are all affected. Basic activities of daily living—actions that most people take for granted--can become extremely challenging. Fear and anxiety are often the driving emotions. For many with chronic pain, multiple medical procedures that offered hope proved to be ineffective at best, and sometimes produced even more pain and often financial distress. Nobody would choose this life. The management of chronic pain has always been challenging, even before the opioid epidemic but in the face of restricted treatment options and societal vilification, the challenge is even greater. And chronic pain is not one condition—there are many types of pain, many disorders and syndromes that can contribute to daily debilitating pain. (And here and throughout, “chronic pain” is short for “chronic non-cancer pain.”

On the other hand, it’s not clear that opioids help people with chronic pain over the long haul. A Cochrane study of studies on opioids for long term pain concluded that there was essentially no evidence to recommend long term opioid therapy for chronic pain. Clinicians have long noted that chronic exposure to opioids can reduce the pain threshold—that long term use of opioids may actually make pain worse. Most chronic pain treatment guidelines recommend individualized, interdisciplinary, integrated care approaches. In part due to our fragmented approach to healthcare, very few patients actually receive this type of resource-intensive care.

In general, our healthcare system has not done a good job of providing effective integrated care for chronic pain patients. People with chronic pain deserve social compassion and evidence-based care.

Pain and Mental Illness Have A Bidirectional Relationship

About 25 million Americans suffer chronic daily pain which is roughly 11% of the U.S. population.[1] While prevalence estimates vary by study, by type of chronic pain and by type of behavioral health condition, it appears likely that the majority of individuals with chronic pain also suffer from at least one behavioral health condition. One study by Fishbain et al found that fewer than 6% of people with chronic pain have no behavioral health conditions and several other studies have found rates much higher than in the general population.[2] Living with chronic pain is challenging and can exacerbate co-occurring behavioral health conditions. Pain is not always the primary driver--there is some evidence to suggest that anxiety disorders often precede the onset of chronic pain, and behavioral health conditions may also be contributors in the conversion of acute pain to chronic pain.[3] Furthermore, over half the opioids prescribed in the U.S. are dispensed to people suffering from depression or anxiety.[4] Clearly we cannot expect to effectively solve for chronic pain—or the widespread prescribing of opioids without addressing the behavioral conditions that accompany and worsen chronic pain.

Smoking, Suicide and Sexual Violence Are Common

Sexual violence is extremely common among sufferers of chronic pain, especially women. One study showed that a history of childhood sexual violence was present in 39% of chronic pain patients.[5] Another study found that 80% of youth with childhood chronic pain reported at least one adverse childhood experience (ACE).[6] The impact of sexual violence on pain is not limited to childhood--a longitudinal prospective study of adult sexual assault survivors noted that 60% experienced pain 3 months after the assault in areas not physically related to the trauma.[7]

Suicide rates are also elevated in people with chronic pain. A significant portion of the risk of suicide in chronic pain patients is driven by the presence of depression and substance use disorders in this population, but chronic pain is thought to be an independent risk factor for suicide.[8]

Cigarette smoking has a complex relationship with chronic pain. Approximately one in 4 chronic pain patients smokes cigarettes and while the rate of cigarette smoking in the general population has declined in the U.S., among chronic pain patients use remains elevated.[9] There is also some evidence to suggest that tobacco use interferes with the effects of opioid treatment and that pain relief is more difficult to achieve in smokers. Many chronic pain programs emphasize tobacco cessation as an important component of chronic pain treatment.

Fear-Avoidance Model Provides A Useful Framework

All evidence points to the idea that living in fear is bad for your health. The fear-avoidance model provides a useful framework for understanding the relationship between fear and beliefs and behaviors that worsen pain.[10] In this way of looking at chronic pain, what individuals with pain think about, feel, focus on and do can drive both beliefs and behaviors that worsen pain.

People with chronic pain “catastrophize” by interpreting pain-related health information negatively, and also begin to dwell on the potential threats that pain poses. They then avoid activities that they fear might worsen pain and may isolate or avoid activities that would otherwise provide value and enjoyment. Taken together, avoiding physical activity and positive life-enhancing activities results in worsening pain, which drives even more fear. This cycle worsens and, unless interrupted, leads to debilitating chronic pain.

Its important to note that this framework does not suggest that chronic pain is “not real” or is “all in your head.” Rather, it provides a useful construct for understanding how thoughts and beliefs about pain can lead to behaviors that worsen pain. This is useful because it provides a series of intervention-points that can help people in the cycle of chronic pain alter their response to pain and improve their lives.

Non-Intoxicant Based Strategies Can Be Effective

The race is on to find “safe” opioids. It began when the Bayer corporation developed a cure for morphine addiction, a safer alternative called Heroin. Since then, the technology behind opioids has advanced with synthetics opioids, long acting preparations, preparations that are harder to crush or inject, and other abuse-deterrent technologies. There is almost no evidence to suggest that any of these have actually reduced the misuse of opioids or impacted overdose rates or the development of substance use disorders.  

There is some evidence to suggest that effective treatment of behavioral health comorbidities can reduce the severity and impact of chronic pain. This is why most interdisciplinary approaches to chronic pain will also include medication treatments for depression, anxiety and other psychiatric conditions--for example selective serotonin reuptake inhibitors (SSRI’s) or Serotonin and norepinephrine reuptake inhibitors (SNRI’s) as a component of effective pain care.

While research focus on medications that can safely alleviate chronic pain is much needed, it’s important to note that behavioral treatments for chronic pain have fairly strong evidence for effectiveness. Put another way, the evidence of behavioral therapy for chronic pain is far stronger than the evidence for opioids for chronic pain.

Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are two well-studied behavioral treatments for chronic pain. While behavioral therapies have shown positive effects in treating chronic pain, effect sizes for CBT for pain are often small to moderate. However, there are now at least 5 randomized controlled trials that support the efficacy of ACT in treating chronic pain.[11] In particular, these approaches appear to reduce disability and depression and improve acceptance of a life with pain. 

Clearly more research is needed to refine treatment approaches—no single therapy has emerged as effective treatment for chronic pain.

Conclusion

Chronic pain is common, debilitating and difficult to treat. Restriction of access to opioids, including involuntary tapers of opioids for chronic pain patients, will result in worsening disability and further alienation of these patients. Behavioral conditions, trauma and medical comorbidities are common and must be addressed. While no single therapy has emerged as effective for all chronic pain conditions, the evidence for psychological therapies is promising and most experts agree should be an important component of interdisciplinary pain treatment.

Omar Manejwala, M.D. is the Chief Medical Officer of Dario Health.

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[1] Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16(8):769-780.

[2] Fishbain DA, Cutler BR, Rosomoff HL, Rosomoff RS. Comorbidity between psychiatric disorders and chronic pain. Current Review of Pain. 1998;2(1):1-10.

[3] Knaster P, Karlsson H, Estlander A-M, Kalso E. Psychiatric disorders as assessed with SCID in chronic pain patients: the anxiety disorders precede the onset of pain. General Hospital Psychiatry. 2012;34(1):46-52.

[4] Prescription Opioid Use among Adults with Mental Health Disorders in the United States. - PubMed - NCBI. https://www.ncbi.nlm.nih.gov/pubmed/28720623.

[5] Wurtele SK, Kaplan GM, Keairnes M. Childhood sexual abuse among chronic pain patients. Clin J Pain. 1990;6(2):110-113.

[6] Nelson S, Simons L, Logan D. The Incidence of Adverse Childhood Experiences (ACEs) and their Association with Pain-related and Psychosocial Impairment in Youth with Chronic Pain. Clin J Pain. September 2017. doi:10.1097/AJP.0000000000000549

[7] Ulirsch JC, Ballina LE, Soward AC, et al. Pain and somatic symptoms are sequelae of sexual assault: results of a prospective longitudinal study. Eur J Pain. 2014;18(4):559-566.

[8] Hassett AL, Aquino JK, Ilgen MA. The risk of suicide mortality in chronic pain patients. Curr Pain Headache Rep. 2014;18(8):436. doi:10.1007/s11916-014-0436-1

[9] Orhurhu VJ, Pittelkow TP, Hooten WM. Prevalence of smoking in adults with chronic pain. Tob Induc Dis. 2015;13(1):17. doi:10.1186/s12971-015-0042-y

[10] Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000; 85(3):317-332.

[11] McCracken LM, Sato A, Taylor GJ. A Trial of a Brief Group-Based Form of Acceptance and Commitment Therapy (ACT) for Chronic Pain in General Practice: Pilot Outcome and Process Results. J Pain. 2013;14(11):1398-1406