Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. This is a telling definition because it states two things: first, by definition, pain is an emotional experience. Second, the experience is unpleasant. Any experience of pain is accompanied by unpleasant emotions. However, as adults, we tend to think only about the sensory aspect of pain, because it demands our attention, but emotions are a major component of the experience of pain.
In childhood, the emotional aspect of pain predominates. Skinning our knee hurts, but some love and attention from our mom or dad -- a hug, a kiss and a quick Band-Aid -- makes the boo-boo all better. Somehow, as adults we lose touch with this connection. Yet, understanding the emotional side of pain is essential to effectively treating chronic pain.
We can see the effects of pain in brain activity. Functional MRI studies show how long-term, chronic pain activates the same areas of the brain as those activated in emotional disturbances. Over time, the experience of pain shifts from what we call the sensory cortex -- the part of the brain that handles sensory input from our body -- to the brain’s limbic system, which processes emotions. Basically, chronic physical pain becomes emotional pain.
What’s compelling for us, at Caron, is that the limbic system is the same brain circuitry that is involved in addiction.
Past trauma and chronic pain
Many people who have experienced chronic pain have a prior traumatic event in their background. It’s not always a physical or psychological trauma such as verbal abuse or neglect. Sometimes the trauma is an emotional event such as grief or loss. When that trauma hasn’t been processed appropriately, it’s a setup for chronic pain.
To treat pain, we must first distinguish the origin of pain. Traditional, western medicine tells us to look for the disease state in the body -- the arthritis, the tumor, the postural malalignment, what have you. But equally important is to look for emotional trauma. That might be childhood abuse, sexual mistreatment, or a substance problem causing emotional turmoil. We also need to look at the emotional trauma caused by physical injury or disease including the emotions around loss of mobility, etc.
Non-physician providers who treat pain -- massage therapists, acupuncturists, reiki therapists, yoga instructors -- know to look for those other sources of pain, so they can be as effective as physicians in treating pain. These professionals are trained to look at the whole person.
Our experience treating chronic pain at Caron shows it responds best to a multidisciplinary approach, not just a focus on the physical. By the time people come to us, they’ve probably undertaken half a dozen other attempts to get pain relief. Sadly, when we ask a patient to tell us about their pain, they often describe experiences where healthcare professionals minimized their complaint or made them feel that their pain was not real. Our team recognizes that all pain is real. We focus on uncovering the causative factors so we can begin to treat them.
Treating the emotional in chronic pain
We pay close attention to chronic pain at Caron because people who have such pain are at a higher risk for substance use disorder and relapse. We also work with patients who suffer from chronic pain and must be safely withdrawn from medications even if they were not misusing them. Patients with chronic pain often take medications to manage their physical pain and the emotional dimension of their pain including anxiety. Key elements to address the emotional side of pain:
Focus on their life stressors. Stress makes pain worse. When people work on the stressors , their chronic pain will also start to improve. In effect, they are modifying brain pathways that touch on the way they experience their pain. It’s an indirect but definite association.
Improve their emotional awareness. Studies show that people who don’t express emotions tend to have a lower tolerance for pain. So, we teach people to become more in touch with their emotions. Techniques like mindfulness or journaling can help people understand the emotions that are surrounding their pain.
Help them overcome their fear of pain. People in pain also tend to have inaccurate beliefs about its impact on their lives. The constant rumination on the pain condition and a feeling of helplessness result in a fear of movement. “I can’t do anything because it might make the situation worse.” There’s a fear that the pain will never get better. Once patients realize that they have non-pharmacological coping strategies to manage or alleviate pain that will work in the long run, they no longer feel trapped by their pain.
Get them moving. Motion is lotion, as the saying goes. Scientific evidence shows that movement reduces stress and improves our outlook and mood. Mind-body therapies such as yoga, acupuncture, massage therapy, physical therapy and hydrotherapy can make a big difference to manage chronic pain.
Teach family communications skills. Family relationships are also an important aspect of treating chronic pain. We teach people to communicate with their family members and their caregivers, expressing their needs and asking for help in an appropriate manner. With chronic pain there’s often a lot of resentment on both sides of a relationship, because relationships are impacted by chronic pain just as they are with addiction.
All pain is real
More and more, medical research is proving this strong connection between chronic pain and emotional pain. People experiencing difficult-to-diagnose chronic pain might once have been told it’s all in their head, that they were just imagining their pain. The truth of the matter is, it is all in the head. Pain is processed in the brain. But the inference that pain without a direct physical cause must be purely imaginary is just plain wrong. The mind and body are intimately connected. All pain is real. Period. The real questions are: What’s the source of the pain and what do we do about it?
The medical community has yet to fully come to terms with this shift in thinking about how to treat chronic pain. They need to understand the multi-dimensional, biopsychosocial nature of pain. Doctors who express empathy and validation of people who come in their office with a pain condition help patients get well. The best doctors don’t brush them off. And their patients don’t rush off with a quick prescription for a pill. That’s just not adequate treatment.
Instead, doctors need to know when to refer patients to addiction specialists, especially for people who are on long-term opioids, which are almost never the right medication for a chronic pain condition. Also, doctors need to know when to refer patients to a pain specialist, whether it’s an interventional pain specialist or a comprehensive pain program. They need to challenge insurance carriers about paying for alternative treatments for pain management. I’ve written about this before. Adequate comprehensive management of a pain condition up front will save money in ongoing costs and use of the healthcare system down the line.
For more on the subject of chronic pain, watch a roundtable of Caron experts discuss What does it mean to be real about chronic pain?