Speaking of Psychology - Using Psychology for Pain Relief and Opioid Reduction (SOP67)

Episode Date: November 7, 2018

The national conversation on opioids focuses mostly on abuse and overdose deaths but there are millions of Americans using opioids to manage chronic pain. Can integrating psychological approaches into pain care offer some patients low-risk pain treatment options? Beth Darnall, PhD, from Stanford University, explains how psychology and mindfulness can treat pain and help people with chronic pain live better lives. APA is currently seeking proposals for APA 2020, click here to learn more https://convention.apa.org/proposals Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello and welcome to Speaking of Psychology, a podcast produced by the American Psychological Association. I'm your host, Caitlin Luna. I'm joined by Dr. Beth Darnel, a clinical professor at Stanford University, whose research focuses on how to best treat and prevent chronic pain, as well as strategies for opioid use reduction. Welcome Dr. Darnel. Hi, Caitlin. Thanks so much for having me. Of course. We're happy to have you here.

So first, the national discourse right now often focuses on the negative aspects of opioid use. Can you talk about whether it's a positive thing for people to use? Absolutely. So I think when most people think about opioids, they think about painkillers. And opioids can be very beneficial for pain in the short run. So we call that acute pain after surgery or an injury, very brief time-limited use. In fact, a lot of different types of pain, including a lot of pain. acute pain can be well managed with more conservative pharmaceuticals and even without pharmaceuticals

at all. But opioids can be beneficial for acute pain. It's when the prescriptions start persisting, when pain becomes chronic. And then the evidence is really limited in supporting their benefit for chronic pain. And as a pain psychologist, what is your perspective of what's currently going on in this country with the opioid epidemic? What's happening right now with, you know, the national discourse on opioids and the opioid epidemic is many different pieces. Number one, a lot of the focus on opioid overdose deaths is really being driven by some illicit use or what we would think of as being addiction. This is really important for us to pay attention to that and to have better strategies to treat substance use disorder and addiction in the country. Now, I'm not in the field of addiction.

I work with individuals who have chronic pain, and most of whom, when prescribed opioids are taking them exactly as prescribed. But what we now know is that opioids aren't the best frontline treatment for chronic pain, certainly, and they come with a whole host of negative side effects. And so we're coming into much greater awareness that we should be treating pain more conservatively, giving individuals with chronic pain a lot of different treatment options, and in particular psychological strategies, so that patients can become equipped to best control their pain,

their own experience, their symptoms, and to help themselves become more active and functional. You know, at the end of the day, it's not opioids or no opioids, it's how do we allow people living with chronic pain to live their best life possible. And this is where psychology is so crucial. And so what are some of the most effective psychological treatments? Yeah, that's a great question.

So, you know, interestingly, psychology is really coming into the national forefront in focusing on the treatment of pain, and in particular in this intersection with opioids because the CDC and the National, the Institute of Medicine and other agencies have really now called for the integration of psychological strategies into the treatment of pain nationally. in fact, this has been lacking despite the fact that there's about 25 to 30 years of evidence that really demonstrates that cognitive behavioral therapy in particular is primary evidence-based treatment for pain. So, you know, there are other treatments that have been shown to be about equally as effective, for instance, mindfulness-based stress reduction, also acceptance and commitment

therapy, which is a variation of CBT. The best evidence exists for CBT. In part, it's the best studied modality. But most people are surprised when they learn that the effect sizes for CBT are sometimes equal to that of pharmaceuticals, but without the side effects, without the health risks. So can people find relief without drugs? My philosophy on pain care is that conservative treatment options should always be put forward first. Always, always, always try lowest risk treatments first, and that necessarily involves psychological strategies.

Psychological strategies, evidenced-based psychological treatment for pain, is shown to reduce pain-related distress. For many individuals, it reduces pain itself. It helps patients become more functional to live better, do more of the things that they love. It can help improve sleep and mood effects. These are often negative consequences of living with pain. And so when we talk about relief from pain, we're talking about certainly a pain score, and we're also talking about much more than just the pain score.

We want to help people live better within the context of having medical conditions and ongoing pain that can be incredibly distressing for people. And you yourself have had your own experience with chronic pain. And so for people who don't understand what that's like, can you describe what that experience is and how that helps you with your work? Yes. So when I was younger, I did have chronic pain. And when I'm lecturing and in fact working with patients at the group level, I will

frequently describe my background and my credentials. But I really believe that my own personal experience decades ago with chronic pain is my most valuable experience because I have the lived experience of an individual with chronic pain, also trying to navigate the medical system and not understanding what the diagnosis might be. The truth is we know that pain is not just a sensory experience, even though I thought that it was, most people in our culture and around the world think of pain as just being a really negative or noxious sensory experience.

But in fact, the international organization for the study of pain defines pain as both a negative sensory and emotional experience. So psychology is actually embedded into the definition of pain, but that's really curious because we don't tend to treat it that way. We don't tend to focus on the emotional dimensions, the cognitive dimensions, the psychosocial dimensions, as primary components of chronic pain treatment. And that's what was missing for me when I was younger.

And so I had to figure those pieces out. I also had to figure out how to learn to self-regulate the natural physiological hyper-arousal that comes along with the experience of pain. brains in our bodies really react to pain with a sense of distress or alarm, we become prepared to escape whatever threat might be afoot. That's how it registers in our central nervous system. And so this is a beautiful part about psychology, is that we can both educate people how to identify what those signals are and what they mean, but

also how to control them. And so that was really my own journey, learning how to do that for myself. And so I bring forward my lived experience and also my experience as a doctoral psychologist and researcher now on these treatments. And you lighted right into my next question about how instinctually humans, I would say, any of most other beings,

have a desire to escape pain. So are there instances when pain is a good thing. Do you know about that? Yes, absolutely. Pain helps us survive. So, you know, pain is really there, you know, to ensure our safety and our survival.

And so, you know, the best example is if you were to place your hand on a hot stove and you feel that pain, that's a very useful signal because you are going to be highly motivated to escape it. You are going to pull your hand away so quickly. You don't even have to think about it. It happens automatically. That's how primal.

pain is. But, you know, while we're all motivated to escape pain, we're not born with the understanding of how to modulate pain and the distress that it causes us. So when we have ongoing pain with no way to escape it, you can't run away from your migraines, you can't pull your hand away from whatever medical diagnosis you have, but those signals are still firing and still causing distress. This is necessarily a psychological. issue. And it's normal. It's human. We all have these same reactions. We're hardwired to react and respond this way to pain. But the important message for people is that we're able to control it using evidence-based psychological strategies and techniques. And that's where our freedom lies.

That's where we're able to gain relief and start to realize that we can control so much of our experience and that allows us to need fewer doctors and fewer pills. And you've also, some of the, your published works, you talk about relaxation and the importance of meditation and in this whole encapsulating way of dealing with pain. Can you talk a little about the importance of relaxation, mindfulness, it's a big hot topic these days in general. So how does that relate to pain management? Absolutely.

So it really links in with one of the concepts we were just touching on, which is when our nervous system registers pain, no matter where we feel it in our body, it's processed in our central nervous system. And that is our brain and our spinal cord. And it necessarily registers as a threat. And so our brain and our body are going to be, you know, poised to help us escape that. It's going to lead to a whole host of physiological and psychological cascade related to distress or simply stress. So we'll have an elevated heart rate, our muscles will tense, blood vessels can constrict, we can become very agitated, our breathing changes. And so for some people they may say, well, you know, my breathing becomes short and shallow. And for others, they may say,

you know, I really feel like my breathing stops when I'm experiencing pain. Over time, these become patterns of responses that actually shape not only physiological patterns, neuromuscular patterns, but they actually contribute to the shaping of our brain patterns and brain functioning, so that over time we can evidence that the structure and the functioning of the brain is changed simply by how we are responding to pain. So the relaxation response can be incredibly useful because it counteracts all of these pain and stress responses. It's the first most important tool that individuals can learn. I describe it as being your antidote to the way that pain shows up in your body and the way

that it can negatively impact your body. Now using the relaxation response once isn't going to cure your chronic pain, of course. But when these skills are used regularly over time, an individual learning. how they can essentially calm their nervous system on demand, dampen pain processing in the nervous system, and this can lead to beneficial alterations in these neuromuscular patterns that essentially begin to prime us for relief.

And there's very often news coverage about this topic. So as a pain psychologist, what do you think is missing from the national conversation? in the media about the opioid epidemic? About the opioid epidemic. I feel that psychology is not integrated enough into the national conversation. Granted, that is changing.

There has been increasing discussions about the role of psychology in the treatment of pain and also in addressing us preventing opioid prescriptions and also helping patients deprescribe their opioids. opioids and this is really the focus of my work I am working on a nationally funded project that is helping deprescribe opioids and in over 1,300 individuals with chronic pain across four states there is intense focus on how do we help people with chronic pain reduce their health health risks but remember it's not

just opioids or no opioids we need to get beyond that binary conversation and always come back to the fundamental issue, how do we help treat pain better? And when we focus on that question, psychology necessarily rises right to the top. It is integrated into the definition of pain. It will not be solved without full integration of psychology into treatment pathways. I also feel that at this point, policymakers, physicians and prescribers have very, they have an acute awareness of the limitations of the biomedical model and they're now asking for integration. So this is actually a sea change and the time is right for psychology to step up and be able to lead in this space. But the caveat there is that

we do need some policy changes to support us in coming forward and helping address the needs of the 100 million Americans that are living with chronic pain right now. And do you yet know what those policy changes would be? I don't know what the policy changes will be, but I do have ideas about what they should be. So in 2016, my colleagues and I conducted the first national needs assessment for pain psychology, access, and training in the United States. And what we found was that, and we surveyed 2,000 key stakeholders across five or six different groups and that included over a thousand individuals

living with chronic pain. It included doctors, nurses, psychologists, directors of psychology training programs. It was really a whole host of individuals. And what we learned was that psychologists and mental health therapists themselves report a lack of education on pain. They're reporting that they recognize that they don't have the training and that they want the training, they need the training. So we need to better integrate psychology into all levels of education, psychology education at the undergraduate level, the graduate level, the postgraduate

level, and also community-based training. So such as at the APA, for instance, you know, having better pain education integrated. And this year's conference, of course, has a whole host of trainings on pain. So this is required in order to better integrate pain and pain education and pain psychology into psychology training programs, we will need some federal funding streams to support that education. No question about it. And then just as a follow on on that, we really need insurance and payer systems to better support psychology as primary treatment for pain, to dismantle any existing barriers to psychologists getting reimbursed. Thank you so much for joining us, Dr. Donnell.

Thank you, Caitlin. It's been my pleasure. It's wonderful having you. Thank you. Speaking of Psychology is part of the APA podcast network, which includes other great podcasts like APA Journal's Dialogue about the latest and most exciting psychological research and progress notes about the practice of psychology. You can find our podcasts on iTunes, Stitcher, or wherever you get your podcasts. You can also go to speakingofpsychology.org to view more episodes and find resources on the topics we discuss.

I'm your host, Caitlin Luna, for the American Psychological Association.