Monday, February 15, 2016

Whose Pain Is It?

Having recently arrived in Oregon, studied diligently for (and yes, passed) my ethics exam, and at long last, received my license, I had a few months in which to explore the clinical issues prevalent in my new environment. Chronic pain kept popping up in conversation, sometimes right after "oh, you do hypnosis," and sometimes before.

What I gleaned from my participation in clinical groups and meetings was that the chronic pain treatment pendulum has swung once more. In short, and without citation: Long ago, MDs prescribed heavy doses of medication for pain patients, chronic or acute. The pendulum then swung to a fear of creating addicts. This was not entirely unfounded, as overprescribing of serious pain medication was rampant, and addiction was up. (When my children left a dentist with Vicodin for the removal of wisdom teeth, I knew something was not right). So docs lived in fear of government repercussions for overprescribing, and, as with most pendulums, now it had swung too far, and even deathly ill patients were constrained from receiving comfort, by over-regulation. Back it went, and back came too many addicted patients along with, guess what? too much chronic pain.

So here we sit in a mess. Many factors contribute to the higher incidence of chronic pain in non-terminal patients. One is, indeed, overprescription. Lifestyle is another, in many forms, from bad work conditions, to bad diet, to smoking, to bad habits. Let's look for a minute at the first. How might too much medication contribute to too much pain? From my perspective, clinical psychology, the expectation that has been created that if enough medication is applied, pain WILL stop, is dangerous. Not all pain is responsive to even opiate medication! This has almost been discovered by the world of pain specialists, but not quite. Apparently out here in the wild west, there is a movement afoot to limit pain med. dosage via legal means. To me, setting artificial dosage limits does not speak to the issue of cause at all, while it puts bureaucrats and non-physicians in charge of treatment.

Clearly, I am not a physician. I do not have a license to prescribe, and I do not do so. What I am is a good observer and an experienced clinician, and well-read. In the world of psychology, it became clear to me long ago that many of my clients with chronic pain were on too many medications (11 was not unusual--a number that sticks in my head as it came up too often). I cannot speak to cause nor motivation--I can speak only from the buzz inside my own head.....if this medication did not appear to help the patient, why was it not removed once an even higher dose had no effect? why instead was another added? why are more medications added to cover the side-effects from the first two rather than stopping either of those? I understand that my own ignorance can be at issue, but I also know from the experience of working with psychologically savvy MDs that, many times, the combination of psychological treatment and tapering of medications, is quite effective. I also know that only rarely does this indicate that the pain was not real! Some pain simply is not medication-responsive.

How can doing less from a medical perspective help a pain that is indeed, painful? One theory, the one to which I ascribe, is that pain that arrives in combination with, or somehow linked to, trauma, has a different cause. Rather than being directly caused by bodily damage, it is caused by what we can call trauma circuitry in the brain. Now, nearly all pain (barring reflexive spine-triggered pain) is generated in the brain in response to something signaled from the body indicating danger, but this trauma-involved pain involves the flight-flight-freeze mechanism, which, it turns out, is related to your endogeneous opioid system. Guess what? Yep, this blocks any potential effectiveness of opioid medications. This would be great if we, as a society, were not so positive that all pain is medication-responsive, because, like the Navajo and many other cultures, we would look for what is out of balance rather than what to do to make it go away.

If pain is a signal, then we must be willing to read the signal rather than making a blanket assumption. All pain is NOT a cry for medication, but all pain IS an indicator of something amiss. Where a psychologist comes in, is in helping you to ferret out the complex path by which you got stuck in that chronic pain loop and then teaching you how to break the pattern. Many think all psychologists do for pain is teach "coping", but there are real things a psychologist can contribute to your treatment, whether to teach pain-reduction techniques for the chronically ill, to help a patient with an acute problem be less uncomfortable during necessary medical treatment, or to actually seek a permanent solution for the enigmatic chronic pain that has defeated medical treatment.

Having mentioned clinical hypnosis, allow me to return there. Hypnosis has been shown to actually reduce pain, not just pain perception, in acute situations, such as burns, where treatment can be very painful. Hypnosis is also effective in reducing pain in chronic situation such as cancer. Different hypnotic approaches are used in the trauma-induced pain conditions such as Complex Regional Pain Syndrome and some types of headaches, but hypnosis has indeed been shown to be effective, when used in an integrated trauma treatment program. Remember, hypnosis is not a free-standing treatment, but a treatment method, which ought to be taught by a professional.


Low, CB, Flemming, DC.,& Francis, J.(2012) presentation, The Traumatized Body: Using the Symptoms to Develop the Solution. International Society for the Study of Trauma and Dissociation , Montreal.

Scaer, R. (2014). The Body Bears the Burden. Routledge

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