Living with Chronic Pain? There is Hope

Chronic pain is one of the most common reasons people seek medical attention in the U.S. Defined as pain that persists for six months or more, chronic pain typically involves the interplay of biological, psychological and social factors. Given that, I always recommend a multi-faceted approach to managing chronic pain.

Most healthcare providers in the U.S. address chronic pain purely through medication, but this singular focus on medication doesn’t provide the relief patients seek. It’s not a sustainable way to manage chronic pain and – where opiates are involved – it can easily develop into a substance use disorder (SUD). At Caron, we see many patients whose struggle with chronic pain and subsequent opioid use resulted in an SUD, and our experience with these patients has led us to help them manage their pain in alternative and more successful ways.

Taking a holistic view of chronic pain

When people come to Caron – and chronic pain is involved – we start by obtaining the best history possible, not just about their substance use but also their underlying medical, mental health, psychosocial and chronic pain conditions. This is crucial to building a clear understanding of the situation, and, once we establish a suspected cause for their pain, we can work on a plan.

Take someone experiencing back pain because of a spinal condition. People usually come to us already having undergone surgery. The surgery should have been corrective, yet the person is still experiencing pain, baffling outpatient providers. That's when people show up to Caron. Once we establish the absence of a physiological or anatomical issue, we explore the multiple reasons a person could still have persistent pain.

The foremost culprit is often the opioids themselves.

Opioids are often at the root of a patient’s pain

The problem with long-term use of full agonist opioids – such as morphine, oxycodone, Percocet, heroin and fentanyl – is that the brain adapts to them. Long-term use of opioids causes the brain to amplify pain signals, a well-known phenomenon called hyperalgesia. The anatomical source of the pain won’t have changed, but the brain’s perception of the pain intensifies.

The first order of business at Caron with patients experiencing chronic pain is to get them off full agonist opioids. Such medication is never appropriate for non-cancerous chronic pain. Not only are they not effective long term, but they create new problems.

One of the approaches we take in getting people off full agonist opioids is to wean them using buprenorphine. Buprenorphine is an opioid as well, but as a partial agonist it has distinctive characteristics. It tends not have the same complications and side effects seen in full agonist opioids, and a special property of it is – once an optimal dose is established – the body typically doesn’t develop a tolerance. In fact, some people safely remain on this medication as a part of their ongoing treatment.

On beyond medication

There are indeed medications that can be useful in treating chronic pain, especially if they are well-targeted and optimized for a person’s condition. Every pain is different. Some medications might be helpful for nerve-related pain, like sciatica, while others are better for pain in a single, localized area, such as a joint injury.

Proper medication is just part of what must be a broader plan to manage chronic pain. At Caron, we involve patients in a wide range of non-pharmacologic pain management modalities, such as:

These are examples of the non-pharmacological approaches we use at Caron to treat the physical side of chronic pain, sometimes in lieu of medication. However, treating only the physical impact of chronic pain is not enough.

Treating the emotional and psychological side of chronic pain

There is a strong mind-body connection involved in people’s experience of chronic pain, and any attempt to treat it must address both to be fully effective.

As a brief overview of how the brain experiences pain, our pain receptors are distributed throughout the body, and signals from those nerves gather through our central nervous system into an area of our midbrain. This happens to be adjacent to the areas responsible for regulating emotions, thoughts and judgment. As a result, emotionally dysregulation can activate our pain receptors.

When people experience anxiety or depression, pain signals from the peripheral nerves become amplified by the brain. The pain itself is the same, but a person’s perception of the pain becomes much greater. As people resolve their emotional dysregulation and feel better emotionally, their perception of pain reduces. This important mind-body connection may be overlooked in the outpatient setting, but it is a crucial part of chronic pain treatment at Caron.

Once a week, pain patients at Caron attend a chronic pain group session, where they each share how they experience pain. The group is there not only as a support system but also to help people shift their perception of their pain. When people first come to Caron, they look at their pain as an adversary they’ve been fighting daily for years. Instead, we work to help them establish a different relationship with their pain: How do I live with this pain? How can I look at this differently?

Social factors also play a significant role in managing chronic pain, especially for patients at Caron, who are simultaneously undergoing treatment for alcohol or substance use disorder. Caron’s family program involves the closest family members – the spouse, parents or children – in the recovery process. Unless treatment addresses social dynamics, a patient is likely to return to a home environment that could not only derail recovery but also reactivate their pain condition.

The end goal in managing chronic pain

In conversations with patients, I often describe Caron’s chronic pain management program as a parallel track to the work they do in recovery. Just as the biological, psychological and social factors have an impact on their recovery journey, so too these factors shape their experience in managing their chronic pain. And just as their time at Caron is only the beginning of their recovery journey, so too is their journey in managing chronic pain. They should continue with the approaches that worked best for them while at Caron, whether that was PT, medical massage, exercise or psychological counseling.

At Caron, we don’t guarantee that patients will leave treatment pain free. However, I would estimate that most patients do report better function and perceive having better quality of life when they discharge. The goal of treatment is for our patients to achieve a different relationship with their pain, experience better functionality and improvement to their overall quality of life as they re-enter the world in recovery.