Integrative Medicine: Reframing Chronic Pain in the Opioid Era
The overuse of opioids in our country is deeply associated with chronic pain. In 1995, the American Pain Society warned of the insufficient treatment of pain and launched a campaign to make pain the fifth vital sign. One month later, the Food and Drug Administration approved OxyContin. Both the concept and the drug caught on quickly.
When you treat pain as a vital sign, you have to take action. In a healing profession, it's difficult to see somebody in pain and to not respond when you feel you're equipped to do so. In the context of a 15- or 20-minute visit — and the assurance that OxyContin was non-habit forming — that response primarily became medication. And thus we began to see the uncanny spiraling of opioid prescribing and addiction.
Now, we're looking back and saying, "What have we done?" The opioid epidemic has led to a staggering number of overdoses and deaths. To counteract years of opioid overuse, state and federal officials have created new opioid prescribing guidelines and are ramping up prescription drug monitoring programs across the country in an effort to get a handle on the crisis. The need for non-opioid treatments for chronic pain has stimulated new interest, among clinicians and patients alike, in integrative medicine modalities such as acupuncture, meditation, yoga, and reiki, which have decades of research behind them and are effective for many patients with pain.
Having seen the impact these modalities can have, integrative medicine physicians welcome this surge of interest. But it's important to recognize these treatments are not simply substitutes for opioids. We need an approach to chronic pain that is more deeply rooted in the fullness of a person's life, which is where chronic pain is manifested, experienced and perpetuated. Integrative approaches to health allow us to ground our clinical engagement on a richer understanding of patients' unique experiences and their capacity to make and sustain healthy lifestyle changes.
The true value of integrative medicine lies in teasing out how life and symptoms come together and moving people toward solutions. If we wish to realize the true effectiveness of these therapies and disentangle opioids from chronic pain, healthcare providers must cultivate a deeper understanding of the root causes and social factors that propel pain. We must reframe for our patients the experience of pain on a fulcrum of self-efficacy and self-worth. And we must redefine the role of integrative medicine in chronic pain management and our healthcare system.
Social factors and chronic pain
Chronic pain is a multidimensional problem that requires a multidisciplinary approach. As physicians, we can't think of a person's pain — whether it's chronic migraine or back pain — just in terms of their organ system. When we zoom in too much on pathophysiology and mechanisms, we end up thinking we just need a better Tylenol or a tamperproof opioid. Instead of zooming in, we need a wider lens that takes in the whole person.
If we wish to disentangle opioids from chronic pain, healthcare providers must cultivate a deeper understanding of the root causes and social factors that propel pain.
Understanding the social determinants of health is integral to addressing chronic diseases and conditions, and chronic pain is no exception. For patients experiencing pain, we must ask questions that go beyond the back, liver, or kidney. What challenges are they facing? What do their social and spiritual lives look like? Do they have stable housing? What is their immigration status? There's a deep correlation between chronic pain, the social factors affecting wellness, and a person's sense of meaning, purpose, and hope. If someone is experiencing a variety of challenges in their life, that suffering can exacerbate pain.
To bring these concepts into a clinical setting, the Boston Medical Center (BMC) Program for Integrative Medicine and Health Disparities has developed a group visit model that helps patients with chronic pain understand the connections between their life and symptoms and apply that knowledge in a self-empowering way. Known as Stronger Together, the group meets for 2.5 hours per week for seven weeks.
Much of the first session is dedicated to the neuroscience of pain. We help patients understand that pain involves the dynamic interaction between multiple regions of the brain. In fact, those regions create the experience of pain, to a large extent — there's no pain until the brain assigns meaning to a stimulus experienced by the body. How the brain processes the stimulus impacts significantly what the person will experience in response. If I have a memory that's associated with a lack of safety or the loss of control, for example, I'm more likely to actually experience physical pain. On the other hand, if I have a memory that's positive and non-threatening, I'm less likely to experience chronic pain.
We use a variety of tools in the group, including meditation, movement, visualization, discussion, and self-reflection, and have a strong focus on hands-on nutrition education to decrease inflammation and improve healing. We first create a safe space, which is essential for meaningful participation, and then use a variety of mind-body tools to help our patients develop a commitment to shifting internal monologues. The patients come to us with chronic pain, but we use the chronic pain as an entry point into learning how to create greater self-awareness and self-powered healing experiences. Through the use of mindfulness techniques, patients learn to recognize the mental patterns that may be limiting their healing, such as the belief that only medications can improve pain, as well as their inner healing resources, such as their resilience, adaptability, and their ability to modulate the experience of pain. When people are able to shine the light of awareness on their thought processes — through meditation, for instance — they all of a sudden become aware of their own subconsciously self-imposed limits.
Pain isn't an isolated thing. It's a symptom of a much larger experience in life, and what shapes that experience is our conception of ourselves. Do patients see themselves as capable and worthy, or beaten down by structural inequities and historical trauma? The health and lifestyle choices they make will be very different based on their self-concept.
The Stronger Together group builds self-efficacy and reframes the experience of chronic pain in terms of self-worth. The tools we teach are rooted in a fundamental understanding that our patients are capable and worthy of healing.
Some patients who join our group may say to themselves, "My pain is never going to get better, but you told me I need to do this." We want to move their thinking to, "I'm not doing this just because you told me to and you're the authority, but because I am capable of making wise choices and want to live the best life I can live."
That cognitive reframing is extremely powerful. No matter how severe their pain or how compromised their function has been, we teach them their bodies have an innate capacity to recover a more harmonious and a more highly functional state. Patients come to the group with severe pain and are often taking high doses of opioids. Some have stopped working, some are very depressed. But many really connect with meditation as a practice and a way to modulate their pain and in some cases are able to taper off opioids altogether.
Rethinking how we treat pain
Integrative medicine can be transformative, for individual patients as well as for our healthcare system. In addition to the incredible societal pressure created by the opioid epidemic, the shift to value-based care delivery is also driving the interest in integrative medicine. Consider, in dollars and cents, the enormous positive impact to our healthcare system of patients who return to work.
There is a profound need for enhancing our medical training to include nutrition education and integrative modalities in addition to sick care and the study of pathophysiology and mechanisms. Physicians need to expand their own framework in terms of our training.
We also need to rethink the randomized placebo-controlled trial as the gold standard for evidence. Randomized controlled trials are very good at measuring the effectiveness of a drug, but they are less useful when a practitioner-patient interaction is an essential part of the intervention. Mixed-methods and outcomes-based research may do a better job of capturing the effectiveness of integrative medicine modalities. For conditions as complex and deeply subjective as the experience of chronic pain is, we need research methodologies that accommodate that subjectivity, address patients in real world settings, and focus on outcomes rather than mechanism.
Human beings have a profound well of resilience, adaptability, and wisdom that can be harnessed in a supportive setting to kindle sustained self-efficacy and healing. Offer a person with chronic pain the tools that enhance the fullness of their life — a safe and supportive group environment, a wide range of practical self-regulation and stress-reducing tools, and a nutrition plan that is doable, affordable, and rich in anti-inflammatory nutrients — and you will see that person improve.