Emma Seppälä recently gave birth to her second child without the aid of painkillers.
Instead, the Madison mom was armed with what may sound like either wishful thinking or an ability straight from a comic book: the power of her mind.
Seppälä is a psychologist and co-director of the Yale College well-being program at the Yale Center for Emotional Intelligence. She is also science director of Stanford University’s Center for Compassion and Altruism Research and Education. She has researched and written about the interplay between perception and pain, and the ways in which how we think about our pain can have a real and often profound effect on what we actually feel.
Previously, Seppälä studied Iraq and Afghanistan veterans and found they were able to normalize their anxiety after one week of practicing a type of yoga involving intensive breathing exercises. During labor she used a self-hypnosis program taught on the website hypnobabies.com to reduce her pain.
“If we’re able to address the psychological components, if we’re able to calm our own mind down, then we are able to handle pain much more gracefully and allow our body to do the healing that it’s trying to do,” she says. As for her labor, “the birth went very quickly, very smoothly and I was not in a state of stress.”
These types of techniques and strategies are part of a multifaceted approach to pain management that is gaining traction in medicine as the risks from prescription opioids become better documented. According to the Centers for Disease Control and Prevention, as many as one in four people who receive prescription opioids long term in non-hospital settings “struggles with addiction,” and in recent years more than 2 million Americans abused or were dependent on prescription opioids. Opioid prescriptions have helped fuel the larger, illicit opioid epidemic, and researchers have found no evidence indicating they are effective at providing long-term pain relief. As a result, medical providers are increasingly looking for different treatment options.
“The definition of pain is that it’s a negative sensory and emotional experience, so psychology is actually part of what we know to be pain, but we don’t treat it that way,” says Beth Darnall, a psychologist and colleague of Seppälä’s at the Stanford University School of Medicine and author of The Opioid-Free Pain Relief Kit. Darnall adds, “We treat pain as purely a sensory experience and that puts people at a disadvantage because we’re not targeting that whole half of the definition that actually determines how much we suffer from pain, and often how much pain we experience and how long it lasts. So it’s a really important therapeutic target that we’re missing.”
The connection between pain and mind appears to be even more significant for the approximately 100 million Americans who suffer from chronic pain. About 50 percent of those with post-traumatic stress disorder also report chronic pain.
In addition, a history of childhood drama is believed to be underdiagnosed and likely very common in those with chronic pain, says Dr. Daren Anderson, the director of the Weitzman Institute and vice president and chief quality officer of the Community Health Center, both based in Middletown. “What we’re coming to know now is that the vast majority of people with chronic pain do not suffer from an underlying structural musculoskeletal problem. They suffer from a complicated web of factors that often and almost always include psychosocial and behavioral factors, as well.”
The Weitzman Institute is the research arm of the Community Health Center, and Anderson and his colleagues are researching ways in which primary care providers can be retrained to better understand the diverse underpinnings of chronic pain.
“When a person comes in and says, ‘my back hurts,’ typically your first reaction is get an X-ray, try medications, but your first reaction should also be to screen them for underlying depression, to ask them about their childhood, to explore any other factors that may have contributed to it,” Anderson says. “Once you’ve identified those, you realize that a significant portion of what you need to bring to the table to treat that person are behavioral strategies, not just medical.”
These strategies include working with other medical staff and offering a wide range of coordinated care, from consultations with chiropractors, psychiatrists or psychologists to mindfulness and yoga therapy.
“The important thing is to give primary care providers options to steer away from opioids in favor of these evidence-supported interventions,” Anderson says. “Every patient is different. The patient who is going to respond to yoga may not be the same as the patient who needs mindfulness, because anxiety is driving their pain. There’s really no shortcuts. You need to get to know your patient, get to know what’s driving their symptoms and come up with a custom approach for each one.”
At Community Health Center there are pain-therapy groups as well as individual sessions. Daniel Bryant, a counselor and Quality Improvement Committee chairman at the center, likens the effectiveness of this approach to when a kid falls and scrapes his knee. The child will keep playing and only starts crying after his mom sees the scrape and brings attention to it. “This isn’t because the kid is seeking attention, it’s because now they’ve brought their attention, their cognitive focus, to the source of the pain and now they feel it,” Bryant says. “Before, when they were thinking about jumping and running in trees and having fun, they did not feel the pain in the same way because they weren’t focused on it. Our patients have the ability to do the same thing if we teach them the skills.”
For example, Bryant says, if a patient is thinking, “Everything hurts so bad, I can’t do anything. This is terrible,” it will be hard for them to function, but they can increase their quality of life by reframing their internal monologue to something along the lines of, “Even though I’m in some discomfort and pain today, I can still do the things I need to do, even if I do them more slowly.”
Bryant stresses that because the cause of someone’s pain is not purely physical, the pain itself isn’t any less. “What people hear us saying is that your pain is all in your head. That is not at all what we’re saying. … You may not be able to see the pain visually, but they are experiencing it in very real ways.”
Bryant adds that this treatment is actually similar in its approach to a drug prescription. “If you give someone a narcotic to treat their pain, it doesn’t work on their broken ankle, it works on their brain. This is the same idea, your pain is an experience in your brain even though it is activated in your body. So we have to help [people] to understand there are ways to change your brain other than just medication.”
This process has been observed in the laboratory, Darnall says. Thinking about pain “actually increases pain processing in the brain and the spinal cord. The regions of the brain that are associated with pain, we see that they light up in functional magnetic resonance imaging studies. It literally increases blood flow to those regions of the brain that process pain and it correlates with reports of increased pain.” She adds, “What we’re seeing is that our brain, our mind, our psychology is so powerful that we have the ability to dial up our pain or dial it down simply by how we focus our minds and our attentions. … A very powerful pain-relieving technique is to simply become aware of this.”
Outside the clinical setting there are many resources available for those looking to minimize their pain, including mindfulness, meditation and hypnosis apps, books and recordings. Both Darnall and Seppälä have websites where they share pain management resources. Some are surprisingly simple yet effective. One study showed that holding the hand of your romantic partner could limit pain, and even just thinking about something positive or listening to music seems to have a similar effect.
“We want to focus on something that brings us comfort, pleasure and joy,” Darnall says. For a new parent that might be thinking about their baby, “for someone else it may be listening to very positive, soothing music. When we engage in something positive and self-soothing, the research shows that that actually steers our brain not only away from pain but toward actual relief and comfort.”
In January, the Virginia-based Academic Consortium for Integrative Medicine and Health published a paper that analyzed existing data and studies to identify evidence-based, nonpharmacological strategies for the treatment of pain.
Dr. Heather Tick, the report’s lead author, is a clinical associate professor of family medicine and of anesthesiology and pain medicine at the University of Washington School of Medicine. She says, “We’ve found that for post-surgical pain, acute pain and chronic pain, you can use things like mindfulness, acupuncture and massage to help to reduce pain and reduce medication uses, including opioids.”
She adds, “The use of things like music therapy, meditation and biofeedback also offer effective care,” and “the other benefit of these therapies is they are low risk and well accepted by patients.” Beyond any specific therapies, getting enough sleep and exercising more can help with pain management.
“We know that when we exercise, when we move, we make endorphins which are our own natural opioids and we also increase the levels of our own anti-inflammatories, and those things do affect us body-wide,” Tick says.
The American College of Physicians updated its guidelines for treating lower-back pain last year to encourage conservative treatments first, citing heat therapy, massage, acupuncture and spinal manipulation (the type performed by chiropractors) as possible safe therapies that did not require drugs.
Dr. Cheryl Vincent of the Simsbury Chiropractic & Wellness Center says patients respond to a variety of chiropractic treatments and research shows “conservative care first is really more appropriate when it comes to pain conditions.” At her office, she adds, treatment is “hands on instead of prescriptive.” Vincent also offers the SHAPE ReClaimed program, a four-tiered approach to pain management that focuses on decreased inflammation, enhanced immune function, detox and cleanse, and weight loss.
When it comes to pain management, Vincent says, “the best thing is to have a lot of tools in your tool belt.”
Matt Maneggia, owner of Connecticut Family Acupuncture in West Hartford and Bolton, says he’s seen a growing openness to alternative treatment from patients and other health care providers. “Definitely in the past five years we’ve seen not only a huge uptick in our patients coming in for pain but we’re getting a ton more doctor referrals, referrals straight from MDs, and I’m convinced that goes hand in hand with the opioid epidemic,” he says. “As doctors are more reticent to prescribe opioids, they’re looking for alternatives, so they’re sending a lot of people our way. More and more research is coming out showing that acupuncture works spectacularly in terms of pain relief.”
The report that Tick co-authored found that acupuncture after total knee replacement reduced pain and was associated with delayed opioid use, and that it helped with back pain.
Maneggia says that a majority of patients he sees improve with acupuncture treatments. Their pain is not necessarily eliminated but they have “significant enough improvement that their quality of life is improving.”
Dr. Michelle Nisenbaum, a pain specialist at the Western Connecticut Medical Group Physical Medicine and Rehabilitation office in Newtown, which is affiliated with Danbury Hospital, has noticed a recent shift in patients’ attitudes toward opioids.
“Less than a year ago people would come in wanting their opioid pain medications,” she says. “Now more and more, especially since President Trump declared the opioid crisis and it was all over the news, people have come in not expecting that anymore.”
Today, Nisenbaum works with patients on a variety of pain-relieving treatments ranging from physical therapy and shoe orthotics to non-opioid medications and steroid and steroid-free injections.
“Targeting the problem, and focusing on the problem causing the pain as opposed to giving a medication to just take pain away, that definitely works better,” she says.
While prescribers and patients alike are coming to realize the problems with opioid prescriptions, several of those interviewed for this story said another cultural shift is necessary.
“The goal of pain management has long been that patients should have a zero pain score,” says Bryant, the counselor at Middletown’s Community Health Center. “This is utterly and completely ridiculous and this is exactly how we ended up with the opioid crisis. … A therapy approach says pain is a part of life, pain is a part of living, it’s what we do with it that matters.”
This article appeared in the April 2018 issue of Connecticut Magazine.
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