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Pain, Part 2

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In my last blog I blog, I began the discussion of chronic pain.   My friend and colleague, Peter Blum, of Woodstock, New York (who actually does everything, including hypnosis, and is a Buddhist, Jewish, Native American priest of sorts who married Barbara and me) had important things to say.  

Peter said, "This is a topic that has been particularly significant in my life, and I would like to weigh in on this discussion. As a hypnotherapist, I have addressed the issue of pain management with numerous clients over the years. As a practicing Buddhist, I have read and studied and meditated for many years on the "Four Noble Truths" - the essence of the Buddha's teaching - which deals with the nature of suffering and attachment. And perhaps most importantly, as a recovering drug addict, I have had direct experience with the cunning, baffling, and seductive nature of what is currently often viewed as the "disease" of addiction.

"In your article, I loved what you said about the "seeking system", and that "seeking has been found in studies to be more rewarding than finding". That would be validated by many addicts, who speak of the "high" of the hunt... the actual physical/emotional thrill of figuring out ways to get more of whatever it was they were addicted to. I was a bit surprised at the revelation, in your article, that in patients receiving prolonged opioid therapy, there is an increase in production of one of the body's endogenous opiates. 

"Years ago an acupuncturist (who was explaining how acupuncture was beneficial to people who were in the process of detoxing from opiate addiction) used the metaphor of the body having little "factories" which produced the endorphines and enkaphalons, the feel-good neurotransmitters, which also regulate pain control. When a person starts "importing" external opiates, such as morphine, heroin, codeine, etc., on a regular basis, these little factories shut down. So a person's natural ability to manage pain, and regulate mood, is impaired and becomes dependent on continuing to receive these "imports". 

"It was heartening to read of others who responded to your posting on this thread speaking of utilizing mindfulness meditation as a tool in helping clients understand the working of mind/body, and find other ways of coping with or alleviating pain as an alternative to synthetic opiates. A recent issue of "The Buddhist Review Tricycle" (Fall 2012) contained an insightful article by Andrew Olendzki, entitled "Pinch Yourself - A Physical Sensation Becomes An Experience To Be Explored". To quote briefly, in the opening paragraph, Olendzki, a Ph.D., and senior scholar at the Barre Center for Buddhist Studies, says "Pinch yourself. Go ahead and give yourself a good hard pinch on the arm or the back of the hand. Now, according to Buddhist psychology, you should be able to distinguish at least three different components to the experience: the touch, the pain of the touch, and the aversion to the pain of the touch. Our mind if very good at merging these all together, but there are actually three different processes - synthesized by three different brain systems - that are then synchronized with one another and interpreted as a unified experience."

"Our culture continually bombards us with media advertisements encouraging us to immediately turn to the pharmacy to deal with the slightest pain. So before we even sit with the touch, and the pain of the touch, we are proceeding instantly to aversion to the pain of the touch. What if, instead, we were to center ourselves and allow ourselves to sit with the pain. My experience, in hearing the stories of many who use opiates, is that the "cover story" of needing them to deal with physical pain, is frequently masking the deeper, underlying story - of inability or unwillingness to deal with metaphysical pain. Some of the therapeutic guidance we can give, is to encourage a person to actually feel their pain - emotional, psychic, etc. To be willing to take a look at the pain of their lives, and look at the situational reinforcements of isolation and obsessive/compulsive behavior that, unless addressed and ameliorated, will bring a person cycling back over and over again to the same lonely and desperate places.

"It was particularly heartening to read your last paragraph: "For all these reasons, I believe we need to work together to create communities of pain sufferers, to change their brains through social interaction (the social brain hypnothesis) and to help each other to live better lives with or without pain." This reinforces the hochoka project - of having community healing circles. Many have found the rooms of Narcotics Anonymous to also fulfill that function.

"But whatever it is, it is a pervasive and rapidly growing problem. Many are probably aware that prescription pain-killers are the drug of choice these days recreationally among many high school and college age folks and are overtaking heroin and cocaine as a cause of death by overdose; hospitalization for complications, and treatment in detox and rehab facilities. Not to be overlooked in this discussion is the mega-bucks of the pharmaceutical industry, and their continued investment in pushing more pills. Thank goodness we have some independent thinkers amongst our prescribing physicians who are willing to explore other, healthier and more wholistic ways of helping clients deal with pain."

In our pain group, we are attempting to create community with people who have been trained to avoid community. Our American culture trains people who are in pain to isolate which only serves to increase their pain.   So often, I hear people in pain say, "I hate other people."   We have to make them come to the group at first in order to get their narcotics.   They must come twice per month.   Some eventually come more often.   Some eventually begin to find that they enjoy coming to group and come more often.   Slowly the stories we tell in group begin to diffuse into the people.    Some begin to feel that they could have an influence by what they do on how much pain they feel.

No correlation exists between the perceived severity of chronic pain and tissue pathology.1 Chronic pain is diffuse and often spreads well beyond the original area of injury.   The measures that are successful in treating acute pain rarely work for chronic pain.   This is because chronic pain is manufactured in our brains as a modifying response to acute pain.   Chronic pain is very much a phenomenon of our brains and must be addressed as such.   It's something we invent after an acute pain.   This is why we need each other to manage our chronic pain.                                                                                                                  

Eighty million Americans suffer with chronic pain and nearly one-third obtains little or no relief from conventional approaches to pain.2 Therefore, new approaches are needed besides the conventional model of writing prescriptions.   We need to combine medicine with physical therapy, family therapy, cognitive/behavioral therapy, biofeedback, support groups, and more. In addition to caring for the chronic pain patient, the entire family is affected and needs to be involved in the recovery process. Care needs to involve all the stakeholders in the chronic pain patient's life.

Treatment with opioids alone is not enough for chronic pain.3     For some people, opioids may reduce chronic pain to a more tolerable level. However, they should not be prescribed with the expectation that they will completely alleviate chronic pain, treat depression or a sleep disorder, or completely relieve suffering.   For other people, opioids are ineffective.   The deeper issue is, as Peter Blum puts it, how can we allow ourselves to feel what we don't want to feel?   Our culture is formed from stories that teach us to avoid pain.   We are full of magic potion stories in which a substance takes that pain away.   Unfortunately, the stories don't seem to fully work.   They are incomplete.   The pain doesn't leave.   The magic potions are not fully effective.   What are we to do in those cases?

Specific regional gray matter decreases correlate with duration of chronic pain, its intensity, and the interaction between duration and intensity4-6, suggesting that being in chronic pain changes the structure of the brain.   Distinct chronic pain conditions have differential impacts on brain anatomy. These brain changes are reversible with pain relief .7-9 Apparently, some of the brain changes are a direct consequence of the presence of the pain, and most likely the underlying mechanism is based on synaptic plasticity that tracks the impact of the pain on the brain. Structural brain changes can be observed at early time points from initial injury as well as after long periods from injury, best illustrated in 2 animal studies.10,11

People with chronic pain rarely just feel pain.   They have a myriad of other symptoms, including fatigue, poor sleep, depression, anxiety, migraine, and so many more.1.   Persistent stress alters neuroendocrine rhythms.   Chronic pain quickly becomes a comprehensive mind-body-community-spirit phenomenon.   It must be addressed from all those levels.  

"We found that of the people who have tears in their discs [between the vertebrae in the spine], some manage well with it and some manage poorly with it," said Dr. Eugene Carragee, associate professor of functional restoration at the Stanford University Medical Center in California.   Carragee and his team compared the results of magnetic resonance images and vertebral disc tear tests among 96 patients who had known risk factors for disc degeneration. Such tears have traditionally been thought to directly cause lower back pain, with ruptures in the discs that cushion contact between the vertebra bones resulting in painful pressure being placed on sensitive nerves.

The researchers were surprised to find that those patients with disc problems were only slightly more likely to have back pain then those without any disc degeneration. They also noted that 25% of those who did have disc problems had no lower back pain at all. Carragee and his colleagues concluded that torn discs are not always painful, and not all lower back pain is a result of a torn disc.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)

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