The best way to treat it without opioids

Sean Stephens, by his own admission, was an old man in a young man's game.

In 2006, at age 38, he enlisted in the Army National Guard, "a little older, a little used," he says, but he did not let him get in his way. functions in Afghanistan. He could still follow the 19-year-old man's double timekeeping in the desert with 110-pound sacks, still staying for 12 hours in a row at the back of a Humvee wielding .50 caliber. . Of course, the pain at the end of the day had not done away with Advil and a good night's sleep as before, but he could stand it.

At the time of his fourth tour, his works caught up with him. He was 42 years old, and the hours of quad bike training by Afghan police on the eastern border were causing casualties. What began as a strange snap in the neck and a twinge in the back turned into a burning and debilitating sensation, and soon his head no longer felt connected to his spine. His hands began to fail, too, after 18 months of seizing the machine gun. In 2011, after being medically evacuated from Afghanistan, he could not even button up.

The pain – the oldest of our afflictions, a state that no man escapes – is hell. This is one of our oldest inherited traits, an evolutionary system designed to protect us: burn once and you probably will not get your hands on fire. The pain, in a sick way, is good for us. The pain makes sense.

But sometimes, against all evolutionary inclinations, the system runs in circles. When Stephens returned from Afghanistan, his pain did not diminish. Fearing further injury, he limited his movements. His doctors had prescribed tramadol, an opioid that relieved the pain of a surgical wound, but it was at best a fleeting escape from the constant companion that his pain had become. He took three to five pills a day, but the headache at the base of his skull made the world blurry, but his hands would not work. He would have "lost his shit," he recalls, as anger, stress and anguish consumed him.

It is a chronic pain: the tissue healed, the wounds healed, but the silent scream radiates. About 50 million Americans suffer, most of them between 45 and 64 years old. The experience is familiar: the dull knee that you knocked out when skiing in your thirties, the back that you can explode just by getting up from bed, no matter what you did 20 years ago to hurt you in the shoulders now. For nearly 20 million people like Stephens, however, the suffering is really debilitating. This pain costs jobs and relationships and lives.

For a patient with a broken leg or an open wound, modern medicine has made extraordinary progress over the years, with whiskey and leather belt giving way to anesthetics and OxyContin. But in America, the treatment of chronic pain is a despicable disaster. The cure often consists of injections, surgeries with a questionable success rate or what Stephens has had after his four rounds in Afghanistan: potentially addictive pills that alleviate pain but ignore the underlying problems.

Here is the thing, though. We know how to treat chronic pain. We know it since the 70's. But it is not likely that you will receive the best treatment. With effort, you can approach it yourself, but to do this you need to know a little more about the inner workings of chronic pain.

Why it hurts

If you hurt your toe, the nerve endings of your foot trigger electrical impulses in your brain: something bad happened here. Your brain works with specialized nerve cells in your spinal cord to determine an answer. Was it a burn? Better to get that leg out of the home. Have we just broken ankle? Let's turn on the pain and let it hurt for a few weeks so that we stay out of it. Once the injury has healed, the brain closes the dial and stops sending those amplified pain messages to your body. The wound, fortunately, dissipates. But with chronic pain, the neural circuits remain amplified – your brain has rewired itself – keeping the pain set to 11, even if the damage has been repaired. "Chronic pain," says John Loeser, M.D., former director of a legendary pain treatment center at the University of Washington, "means that nature has failed."

John Bonica, MD, the father of pain medicine, did not know this when he began treating wounded soldiers returning from the Pacific to a military hospital south of Seattle 75 years ago. There, patients apparently cured or with missing limbs confused their doctor with complaints of incessant pain. Dr. Bonica, who was then going to write the first modern text on pain, realized that something complex – something not quite physical – was at work. He found that anxiety, depression and PTSD were bedfellows of chronic pain, suggesting that pain was affected as much by emotions as by tissue damage. Much later, research has shown that areas of your brain badociated with anxiety and depression are also related to your response to fear and pain.

But then, based on his observations, Dr. Bonica decided that chronic pain was such a complex and complex animal that it required all kinds of caregivers. Two decades after the Second World War, he opened the country's first "multidisciplinary pain clinic", famous at the University of Washington. "It was not something that only one person could solve," says Dr. Loeser, who headed the clinic after Dr. Bonica's retirement. "The ultimate goal was that it was going to be a team approach." The goal of completely eliminating the pain was out and a team was formed to teach patients how to manage their symptoms and improve their condition. quality of life from all angles. A physiotherapist showed you how to move again, a psychologist taught you not to be afraid of your pain, an occupational therapist helped you understand how to manage your stress at work, a dietitian helped you lose weight and eliminate the stress of your joints. , a case nurse made sure everything went smoothly, and a medical advisor oversaw the entire team and your progress. The combined approach was revolutionary in the treatment of chronic pain and she accomplished something that no other treatment did: it worked.

By the late 1990s, there were more than 1,000 interdisciplinary chronic pain management programs across the country. These were expensive places; Treatment by a full expert group could reach $ 30,000. Yet, many studies have shown that this approach had not only succeeded, but that it was profitable. Having healthy people who are able to work costs society much less in the long run.

In 1995, Purdue Pharma introduced OxyContin. It was an immediate hit. Some early studies have tentatively suggested – and falsely – that OxyContin could be an effective and non-addictive treatment for chronic pain. Insurance companies have recognized a quick and less expensive solution when they have seen one. "They said give them drugs, opioids," says Michael Schatman, Ph.D., pain expert and director of research and network development at Boston Pain Care.

In 2015, there were 20 million opioid-dependent patients in the United States and 56 interdisciplinary pain-treatment clinics remaining.

Treat pain without pill

Sean Stephens was nervous. The Veterans Health Administration had followed the same opioid prescription regime as the rest of the American medical system, and a growing number of veterans with disorders related to the use of drugs. 68,000 of them – were in the ranks in 2015. Veterinarians were twice as likely to die from an accidental overdose caused by other Americans, and a decision from above: opioids were more popular. When Stephens went on show at the San Francisco VA Medical Center in 2010, her doctor, Karen Seal, M.D., told her that they would start working to reduce her tramadol dose. His pharmaceutical crutch, the opioid he relied on to survive, was about to be removed from him. "I was scared."

In the two decades since Oxy, almost all interdisciplinary pain clinics have been closed and HAV has become an unexpected leader in maintaining this approach. Other clinics are for the most part in large institutions, such as the Mayo and Cleveland clinics, because, says Schatman, these facilities can afford to lose money with poorly reimbursed pain care. But the VA does not have to earn money. It's the responsibility to treat your patients for life and, over time, pain management costs less than pills and endless interventions.

Dr. Seal was at the helm of the VA's Integrated Pain Team and was now in charge of adapting pain management regimens that did not require an unlimited renewal of medication. Her message to Stephens was unequivocal: "Pharma tells you that you can take a pill to cure everything." But not here, she says. Here, there would be goals to help manage pain besides relying solely on opioids. Here they would work with him to find his life.

Some of the treatments prescribed by Dr. Seal at Stephens seemed pretty obvious (physical therapy, non-addictive medications, simple goals like doing exercise for 20 minutes at a time), but others were of the kind to make men mad (yoga, deep breathing, meditation, cognitive-behavioral behavior). therapy). Stephens vaguely knew that there were other ways to treat the pain. He tried the pot, but he did not like it. He knew that yoga was one thing, but he did not consider himself a type of yoga. "I was not interested in finding another solution to the pain," he says. "But these people have talked about everything we can do to go beyond this stage. It was this real aha moment. I never understood that stress relief could be pain relief. "

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One of the most difficult components of the interdisciplinary care that men are subjected to is probably the consultation of a therapist. Treating physical pain with cognitive-behavioral therapy may seem like a recent BS, but the brain is a strange thing. Show Catholics an image of the Virgin Mary in laboratory-controlled pain studies and report less pain. Give people a placebo to make them believe that they are about to get relief from the pain and that the brain will actually release natural opioids to block the pain. New studies of brain imaging constantly go against our most basic ideas about pain. Tor Wager, Ph.D., neuroscientist at the University of Colorado at Boulder, recently discovered that if the brain anticipated more pain, it avoided more painful sensations, regardless of physical damage. "When you expect more pain, you really feel more pain," he says. And when you live in constant pain, you are afraid to feel it more. You get a feedback loop that actually worsens the pain. Learning to think differently can help break this cycle.

Combined with physical therapy, light exercise, and emotional support, this holistic approach has had dramatic results throughout the VA. So far, the agency has reduced the number of opioid-dependent veterinarians by approximately 40%, and a study by Dr. Seal showed that patients in interdisciplinary clinics were 50% more likely to significantly reduce their doses. "I almost became an evangelist about it," she says. "When you have no more opioids, you will find your life."

For Stephens, the approach helped him take control. "The pain is still there," he says. "My wife has yet to button my shirt for me." But now he is responsible for his pain – not the other way around. Today, he breathes deeply throughout the day. He has a therapy dog ​​that keeps him calm. And he gives himself breaks for ten minutes to defuse each time he feels the pain go up and his fear worsens. "It will allow me to overcome the pain," he says.

For the tens of millions of non-veterans who suffer, there is a similar way of finding relief, but it takes some effort. Stephens adds that it also takes courage. The courage to be the "old man" during your first yoga clbad, wanting to try something that is not related to your pain, such as deep breathing. Because in the end, feeling uncomfortable at the Y or being embarrbaded to go to a therapist is much less painful than a constant suffering life.

How to take care of your pain

"The best way to combat chronic pain is to treat it as a team sport," said Sean Mackey, MD, Ph.D., head of the Department of Pain Medicine at the University. Stanford. You need different actors to handle different positions. If you do not have access to an interdisciplinary pain clinic, here's what to do:

Talk to a social worker or therapist

"Pain in pain is mainly in the brain," says Dr. Mackey, and a pain psychologist can help you understand this in a relatively short time. It's not mumbo jumbo either. "Your beliefs, emotions, and thoughts about your pain play a key role in your pain experience," he says, and he has brain scans to prove it. Chronic pain rearms the brain and therapy can help reverse this reorganization. Dr. Mackey may not eliminate the pain, "but it can improve it and keep you in control."

Consider PT

"What do you think of the first thing the team doctors do for the 49ers when a guy runs the knee and needs an operation? The answer is physical rehabilitation, "says Dr. Mackey. Although it may hurt, "you have to strengthen these muscles and support the painful areas". Studies have shown that bleeding reduces pain in the long term and that insurers often cover it.

Do not treat it silently

Managing your pain is a long-term effort and many insurers offer support groups. In large cities or nearby, there are often free meetings where you can discover how others treat pain.

Take steps to relax

Reducing stress reduces your pain, says Dr. Mackey. Free apps such as Headspace can guide you through mindfulness lessons, a YMCA can offer meditation clbades and acupuncture provides relief to many people. Your pain may never go away completely, says Dr. Mackey, but that's not the question. By putting all of this together, you can take control and prevent the pain from dominating your life. You win; the pain does not do it.