There's an epidemic ravaging American lives that’s related to but distinct from the opioid crisis, and EMS providers encounter it often in their patients and sometimes firsthand: Chronic pain impacts around 100 million Americans and costs an estimated $635 billion per year in medical expenses and lost productivity.1
For too many Americans this condition has been treated with nothing but increasing amounts of opioids. Now, with addiction and overdoses and associated problems rampant, clinicians are looking far more skeptically at what we’re prescribing and to whom, and with far more interest at other ways to address chronic pain.
“What we’ve done is tremendously overmedicalize chronic pain,” says Ben Bobrow, MD, FACEP, distinguished professor of emergency medicine at the University of Arizona College of Medicine and medical director for the Arizona Department of Health Services’ Bureau of EMS & Trauma System. “We just assume everyone needs opioids, and that’s been part of the issue. That’s a terrible disservice we in the medical industry have inadvertently done to people. I’m not saying we should never use opioids, but we need to be way more judicious about whom we give them to and how much.”
There are better options. While chronic pain may not be completely eliminable, diet, physical activity, and certain long-term therapies have shown promise in helping people manage it.
Such alternative strategies are at the heart of The Pain Project, a new effort Bobrow is spearheading to make expert advice and alternative treatments available to sufferers of chronic pain, including first responders. Most notably it offers “telepain therapy”—virtual connection to remote experts who can securely counsel victims through treatment strategies centered around mindfulness-based approaches designed to restore a sense of control and get people back to pursuing meaningful, enjoyable activities.
“When people are hopeful and engaged and trying,” says Bobrow, “that can cause a critical change in mind-set that actually helps us feel better. But it’s not about being a passive recipient of care—it’s more about engaging and becoming the director of your own care.”
Taking that ownership is vital to nonopioid approaches.
Chronic Pain and Its Impact
EMS providers likely understand the difference between chronic and acute pain. Acute pain results from an injury and is generally of limited duration. Chronic pain is non-cancer pain that lasts more than 3–6 months or longer than would be expected for an injury to heal. It’s usually not documentable by tests or physical findings but is quite real and can be debilitating.
Chronic pain may begin with an injury and persist after healing, or it may develop without a clear cause. Symptoms such as fatigue, sleeplessness, reduced appetite, and mood changes may accompany and exacerbate it. Genetics and environment may contribute. Sufferers can become frustrated, angry, and depressed. It is, at its heart, a chronic illness, not unlike diabetes, asthma, or hypertension, and requires similar long-term management.
What it doesn’t necessarily require is an endlessly increasing spiral of addictive painkillers.
“What we’ve done for so long is tried to give people opioids for chronic pain, and this has really been a flat-out disaster,” Bobrow told Phoenix radio station KJZZ in January; “Opioids for chronic pain was more…a marketing marvel than it was a medical marvel,” added Cynthia Townsend, director of the Chronic Pain Rehabilitation Center at the Mayo Clinic’s Arizona campus. “And opioids [are] the only medication where, when someone reports worsening symptoms and declining functioning, the response has been to increase the dose.”2
When tissue is injured it releases arachidonic acid. As this is metabolized it produces eicosanoids such as prostaglandins and leukotrienes, signaling molecules that are part of the body’s inflammatory and immune responses. They also stimulate pain.
Pain medications work by inhibiting this process at various points. NSAIDs impede the enzymes that trigger the arachidonic cascade. Opioids attach to nerve cell receptors in the brain, spinal cord, and elsewhere and block pain messages from the body to the brain.
With chronic pain those signals can remain active after or without an injury. This is associated with substantial changes to the brain’s structure and neurochemical composition. These changes may cause the brain to “oversense” routine, nonthreatening nerve signals as threats.3 Besides pain this can lead to muscle tension, mobility limitations, and low energy/motivation—but the key point is that chronic pain can literally alter the brain.
“We know now from functional MRI studies that when people have chronic, long-lasting pain, the actual function and structure of the brain changes,” says Bobrow. “Certain parts of the brain become more active, other parts become less active. And parts of the brain that are involved with emotions, the limbic system, actually become a lot more overactive. And the other things we see are neurochemical changes: different levels of neurotransmitters like serotonin and norepinephrine and dopamine, and these are the same neurotransmitters that are associated with, for example, depression. So a lot of the same changes in the brain that are seen when people have depression and anxiety are seen when people have chronic pain.”
What’s more, even emotional trauma can rewire the brain, which is particularly relevant to emergency providers and victims of accident and disaster. The Substance Abuse and Mental Health Services Administration (SAMHSA) acknowledges natural disasters can have damaging mental health effects, and with the popularity of social media, notes The Pain Project’s chief psychology officer, Michael Munion, MA, LPC, information can spread worldwide in near-real time, which can make tragic events seem more frequent than they really are.4 Recognizing this (not to mention their high rates of suicide, addiction, and injury), The Pain Project will be developing sections and content specifically for first responders.
Traumas are a matter of individual perception—more about a person’s reaction than the event that prompted it. Seeing a serious accident or crime can be as traumatizing to some as a mass shooting or military combat experience may be to others. Stress reactions can range from mild to full post-traumatic stress disorder. The good news is that some of the approaches used for chronic pain are also beneficial against traumatic stress.
CBT and MBSR
Our best current nonopioid approaches seem to combine physical, mental, and social therapies. Recent trials suggest such integrative, complimentary practices can reduce chronic pain and its disability.3 Two with promise are cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR).
CBT is a form of psychotherapy intended to repair maladaptive emotions, thoughts, and behaviors by changing patients’ distorted perceptions and destructive actions.5 It’s based on the idea that individuals themselves, not outside circumstances or events, create their own experiences, including pain, and by “changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same.”6
MBSR combines aspects like mindfulness meditation, body awareness, and yoga to help people become more mindful. Its concept is that the experience of pain varies among individuals because the body’s relationship with pain is cultivated and maintained in the mind and thus manifests differently in people with varying experiences and influences.7
Such approaches, Bobrow notes, are safer, cheaper, and less invasive than opioids and thus more congruent with medicine’s primary edict to “first do no harm.”
“There are a lot of different ways cognitive therapies help,” says Bobrow. “One is by instilling a sense of control. None of us likes to feel out of control. And when we don’t feel well, and nothing’s helping and nobody can figure out what’s wrong, it’s very frustrating. When you start to regain a sense of control and see you can actually manage your condition—such as pain, depression, anxiety, high blood pressure, addiction, etc.—you become engaged and active and start to heal.”
Nutritional changes can also help interrupt pain pathways. Among these, Carol Johnston, associate director of the nutrition program at Arizona State University, told KJZZ, are avoiding meat (which is high in arachidonic acid) and consuming fish oil (which has fatty acids that counteract it). A vegetarian diet can eliminate most sources of arachidonic acid, and antioxidant-rich foods—especially those high in vitamin C—can reduce pain associated with free radicals damaging cells. Lack of vitamin C has been linked to surgical pain, infectious diseases, and cancer.2
Essential to the success of any of these, though, is a change in patient mind-set. We can become conditioned to be passive recipients of care—but managing chronic pain requires a proactive taking-charge and increased stewardship of one’s own health affairs. Chronic pain therapies that show the greatest long-term benefit are those that actively engage the sufferer in their treatment.8
“People have to own whatever it is they’re dealing with,” says Bobrow. “They can’t just say, ‘This person isn’t helping me!’ or ‘This treatment isn’t working!’ With cognitive therapy, you become the master of your destiny and understand it’s up to you.”
The Pain Project
Live for roughly a year now, The Pain Project gathers the latest science, success stories, and strategies for managing chronic pain beyond opioids into a single portal. It added the teleconsults late in 2017.
“People like the telehealth because they can do it from the privacy of their homes,” says Bobrow. “It’s confidential, it’s HIPAA-compliant, and they can talk with therapists who have walked the walk and actually dealt with these issues themselves. They’re experts not just because they’ve become psychologists but because they’ve actually lived it.”
The Pain Project has partnered with EMS and resilience experts like Matthew Carlson, a decorated firefighter and licensed professional counselor, addiction counselor, and EMDR-trained PhD candidate. Carlson’s extensive firsthand experiences and understanding of EMS and emotional trauma allow him to effectively help sufferers like EMS professionals.
Concurrently, the state of Arizona is now approaching chronic pain as a chronic disease and recently launched a state public health program to help people better understand and self-manage chronic pain without opioids.
Unlike most of our previous major public health problems, Bobrow noted in a recent article, we ourselves—the medical community—helped create and exacerbate our current opioid and chronic pain crises.3 That now gives us even more than the usual burden of treating them.
1. Committee on Advancing Pain Research, Care, and Education; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, https://www.uspainfoundation.org/wp-content/uploads/2016/01/IOM-Full-Report.pdf.
2. Gerbis N. Experts Offer Non-Opioid Options For Managing Chronic Pain. KJZZ 91.5, http://science.kjzz.org/content/584455/experts-offer-non-opioid-options-managing-chronic-pain.
3. Bobrow B. Healing our epidemics of opioid overuse and chronic pain concurrently. iPain Living, 2018 Edition 1, https://s3.amazonaws.com/online.anyflip.com/mjqb/lwgn/mobile/index.html#p=10.
4. Munion M. Tele-therapy treats adverse reactions to national traumas. AZBigMedia, https://azbigmedia.com/tele-therapy-treats-adverse-reactions-national-traumas/.
5. Psychology Today. What Is cognitive behavioral therapy? https://www.psychologytoday.com/us/basics/cognitive-behavioral-therapy.
6. Bowers ES. Managing chronic pain: A cognitive-behavioral therapy approach. WebMD, https://www.webmd.com/pain-management/features/cognitive-behavioral#1.
7. UC San Diego Health. Chronic Pain? MBSR Can Train the Brain, https://health.ucsd.edu/news/2011/Pages/06-15-mindfulness-based-stress-reduction.aspx.
8. The Pain Project. What is Chronic Pain? https://www.thepainproject.com/what-is-chronic-pain-the-pain-project/.