Your book, The Opioid-Free Pain Relief Kit is about pain relief without opioids. Why are opioids so harmful to pain patients?
Prescription opioids come with various health risks that patients should know about. Among them are hormonal changes: Opioids can reduce testosterone, estrogen and progesterone. Low hormones can lead to other problems, such as irritability, low mood, sexual dysfunction, and fertility issues. And ironically, while people take opioids to reduce pain, over time for some people they can cause greater pain sensitivity, meaning greater pain intensity. Opioids are not recommended for certain chronic pain conditions, including back pain and fibromyalgia, because the data show they simply don’t help most people. In fact, opioids can make some pain conditions, including headache and migraine, worse.
Are there other problems with opioids as well? Such as sleep issues?
Yes, absolutely. Opioids may make you feel sleepy, so you possibly fall asleep faster, but that doesn’t mean you sleep better. In fact, many studies show that opioids erode sleep quality as they prevent you from reaching the deeper stages of restorative (or REM) sleep. You wake up tired the next day, and are likely to feel more pain.
The news is filled with people taking too many opioids — is that one of the most common risks?
Yes: there’s a risk for overdose. Combining opioids with alcohol or certain medications such as benzodiazepines (such as alprazolam, Xanax, Valium and Soma) can be fatal. Alcohol, opioids and benzodiazepines all are central nervous system depressants. In other words, they slow your breathing. Combine two of the three, and you’re at risk for an “overdose” — a fatal suppression of the central nervous system that can cause breathing to stop, and result in death. Better to avoid taking opioids and benzos together at all. If you happen to be prescribed both, talk with your doctor right away about how to stay safe. And never take alcohol with either of these classes of medications.
What is the role of cognitive-behavioral therapy when it comes to pain relief?
Pain is a negative sensory experience that’s very much influenced by our thoughts and feelings. Most people are surprised to learn that negative thoughts amplify pain in the nervous system. But multiple brain imaging studies show that when the mind stays focused on the pain — worrying about it, and being very distressed by it — that only serves to make pain worse. Without knowing it, people are contributing to their pain and suffering.
What we can do with Cognitive Behavioural Therapy (CBT) for Pain is shift the focus away from the pain. It’s evidence-based behavioral medicine: there is great science to show its effectiveness. In pain-CBT, you learn the skills to shift your attention away from the pain. You learn how to change negative thoughts so they no longer amplify the pain, and instead lead to pain relief. You learn how your daily choices can make your pain better or worse, and how to set yourself up for success with pain relief. Pain-CBT is all about becoming empowered to be able to reduce your own pain and suffering. It has 25 years of science to back it up.
Really, pain is best treated with a comprehensive approach. Have a great physician, a great physical therapist, and absolutely learn everything you can about pain-CBT and pain psychology skills.
What’s the first step pain patients should take in order to wean themselves off opioids?
Go S-L-O-W. In this case, the tortoise wins this race. Some doctors will suggest a quick taper of 1–2 weeks, but just because you can doesn’t mean you should. By tapering slowly, you can prevent symptoms of withdrawal, stress and anxiety. That’s especially important if you suffer from anxiety, such as panic attacks, post-traumatic stress disorder, or generalized anxiety. Ask your doctor to make small reductions (decrements) in your opioid dose about every 2 weeks. Even if you feel good, stay on a slow taper schedule, and make it easy for your body.
You talk about a patient’s “harm alarm.” What do you mean by that?
Humans are hard-wired to perceive pain as a signal of danger, a threat. Pain is your harm alarm. It prepares you to escape harm by creating muscle tension and stress responses. But you cannot run away from pain when it’s coming from inside you. So when the alarm rings, your stress response cascade kicks off, and there you sit, unable to escape your pain. Over time, these stress responses and pain responses shape your neural and neuromuscular patterns.
Essentially, they prime your nervous system for more pain. It’s really unfair, but the human body wasn’t designed for chronic pain. So your brain and body will naturally respond to pain in ways that will make it worse over time. That’s the bad news. The good news is that you can change this hardwired pattern by using a clear formula to train your brain away from pain. It’s the formula I give in my book, and it is rooted in basic pain-CBT skills and information about pain neuroscience.
How does deep relaxation contribute to pain relief?
When humans are in pain, they naturally brace their muscles against it in an effort to protect themselves and reduce the pain. You may notice you brace your core muscles, begin breathing shallow, and you may even find yourself stopping breathing. All of these natural responses maintain and worsen pain in the nervous system. But we can treat these automatic “tension” responses with deep relaxation: by relaxing the breath and muscles, body and brain are trained away from pain.
Used regularly, the brain gradually becomes less attuned to pain, and less tension is stored in the muscles. Remember, the tension is there to prepare you to escape the “danger” when your “harm alarm” rings. And by discharging this tension, you effectively quiet your harm alarm. It works really well, but for deep and lasting effects it’s important to use the skills daily. I included a CD with the book that induces deep relaxation, and should be used daily.
How can patients prevent pain flare-ups?
Preventing flare ups is about activity pacing. When people have a good day they often overdo it, thereby creating a pain flare, and theyn they need lots of down time to recover. It’s a depressing cycle that can leave people needing more pain medication and feeling at the mercy of their pain. The trick is to proactively monitor your activity – when you’re starting out, remember that less is more.
Stop when you still feel good, and save some of that good energy for tomorrow. You’ll thank yourself when you wake up the next day feeling good. Pain relief demands a longer range focus: focus not just on doing what you can today, but about feeling good for the whole week and beyond. While you may move at a slower pace on any given day, in the long run you will find you can do more because you no longer need all that recovery from pain flares.
Do you have a website or blog (or both) where readers can learn more about your work and The Opioid Free Pain Relief Kit?
Absolutely. My website is BethDarnall.com. I also have a blog, and my website provides a lot of information about my books and about pain psychology, including videos of my talks and links to research on the subject.