There was plenty to blame: the car wreck that broke his back. The job pouring concrete that shattered his spine a second time. The way he tore up his insides with cigarettes, booze, cocaine, and opioids.
It all amounted to this: Carl White was in pain. All the time. And nothing helped — not the multiple surgeries, nor the self-medication, not the wife and daughter who supported him and relied on him.
Then White enrolled in a pain management clinic that taught him some of his physical torment was in his head — and he could train his brain to control it. It’s a philosophy that dates back decades, to the 1970s or even earlier. It fell out of vogue when new generations of potent pain pills came on the market; they were cheaper, worked faster, felt more modern.
But the opioid epidemic has soured many patients and doctors on the quick fix. And interest is again surging in a treatment method called biopsychosocial pain management, which trains patients to manage chronic pain with tools ranging from physical therapy to biofeedback to meditation. It helped Carl White, a 43-year-old social worker from Leroy, Minn.
The catch? It can take weeks and cost tens of thousands of dollars — and thus remains out of reach for most patients with chronic pain.
“We’ve been banging our heads on the wall, and banging our fists on the door, trying to get insurers to pay for this,” said Dr. Bob Twillman, executive director for the Academy of Integrative Pain Management. “For the most part, they will not.”
When pain is not just physical
Chronic pain affects nearly 50 million Americans, according to the American Pain Foundation. The largest drivers include migraines, arthritis, and nerve damage — but in many cases, emotional trauma also contributes to the sense of misery.
“We have a lot of people in this country who are unhappy, isolated, and hurting,” said Jeannie Sperry, a psychologist who co-chairs the division of addictions, transplant, and pain at Mayo Clinic. “Depression hurts. Anxiety hurts. It’s rare for people to have chronic pain without one of these co-morbidities.”
Indeed, chronic pain has a substantial psychological element: Being in pain often leads to self-imposed isolation. That loss of a social network then leads to anxiety, depression, and a tendency to catastrophize the pain — so that it’s all a patient can think about.
So even if the initial cause of the pain is treated medically — with opioids, surgery, steroid injections, or physical therapy — it’s unlikely to go away entirely. That may be why just 58 percent of patients who routinely take prescription painkillers say the drugs are effective in managing their chronic pain, according to the American Academy of Pain Medicine.
“In the past, pain was viewed just as a physical issue,” said Robert Gatchel, a pain management researcher and professor at University of Texas, Arlington. “The thought was, if you cut something out, the pain will go away — but lo and behold, it doesn’t in many cases, and sometimes [the pain] gets worse.”
“In the past, pain was viewed just as a physical issue. The thought was, if you cut something out, the pain will go away — but lo and behold, it doesn’t in many cases …”
Robert Gatchel, University of Texas at Arlington
Acute pain is generated in the peripheral nervous system, which conducts danger signals to the brain. From there, the brain determines whether it’ll experience the pain signals or ignore them, Sperry said. “In the case of chronic pain, that system has gone awry,” Sperry said. “Without training your brain to turn down the alarm system, the alarm keeps going off all the time.”
So although the pain may have originated in the foot, patients end up with headaches, chronic nausea, chronic fatigue, and back pain — developing a host of other symptoms as the brain short-circuits.
“Focusing solely on a pain generator in the body,” like a herniated disc or nerve damage, “utterly and completely misses the chronic, complex, changing nature of chronic pain” as it’s processed and experienced in the brain over time, said Dr. Tracy Jackson, an associate professor of anesthesiology and a pain specialist at Vanderbilt University.
Bracing for ‘New Age-y nonsense’
The second time White broke his back, he decided to shift gears: He left the cement pouring business and got first his high school diploma, and then a college degree. He began working at Mayo Clinic as a neurosurgery coordinator — but still relied on alcohol and painkillers to get through the day.
It’s tough to estimate how many people with chronic pain develop a dependence on medications, but in 2014, about 2.5 million adults had opioid addictions — and many of those addictions started with a prescription for potent pain pills.
White soon found that unless he distracted himself with intense physical labor, he focused obsessively on the pain, and his thoughts spiraled into darkness. “If it’s a 1-to-10 pain scale, a chronic pain patient will say, ‘Mine’s at a 12 or 13,’” White said. “A 1-to-10 scale isn’t even sufficient. When I was at my worst, all I know is that my pain was on my mind 24/7.”
“A 1-to-10 scale isn’t even sufficient. When I was at my worst, all I know is that my pain was on my mind 24/7.”
Carl White, social worker
By then, White had run out of medical options. No one would operate on him, and the pills were making him feel worse, not better. Finally, in 2009, Mayo referred him to its pain management clinic.
White went in with a great deal of skepticism. He recalls sitting in the back of the meeting room, arms crossed, waiting for the pain rehabilitation specialists to tell him some “New Age-y nonsense.”
Instead, in that short, intensive program, White learned tools that worked for him — some of them very simple instructions, like how to lift heavy objects with his legs instead of his back. The program also helped him process some traumas from his childhood, White said, such as when he was orphaned at age 10 when he found his abusive, alcoholic father dead.
The psychological component also helped White learn to be kinder to himself — easing a great deal of self-imposed pressure to overexert himself.
These days, White’s baseline pain stays at a 4 — meaning, it’s always there, but it’s manageable. On the bad days, he considers small things, like getting out of bed in the morning, to be victories. “Instead of lying in bed, I gotta get my butt out of bed — otherwise it becomes a tomb, and the ‘stinkin’ thinkin’’ comes back,” White said.
He’s now working at the Minnesota Adult and Teen Challenge, a faith-based addiction therapy program in Rochester. And he’s working on launching a pain management program for his clients.
Plumbing psychology to deal with pain
There used to be hundreds of integrated pain management centers all across the country. But in the ’90s, the insurance market shifted; more patients joined managed care plans that limited them to a narrow network of doctors. Then in 1996, the powerful opioid OxyContin hit the market. It quickly became the tool of choice for controlling pain.
Soon, there were just four major integrated pain management centers left: Mayo Clinic, Johns Hopkins University, Cleveland Clinic, and Stanford University.
The Mayo Clinic’s outpatient pain program runs for three weeks, and keeps patients busy from 8 a.m. and 5 p.m.
They do physical and occupational therapy — learning, for instance, how to go shopping or do yard work in ways that won’t aggregate their pain. And the program includes four to five hours of lessons each day on how to understand pain. Patients learn to relax, breathe slowly, and meditate to mitigate some of the anxiety-related pain flare-ups. Entire sessions are dedicated to understanding the psychological underpinnings of their own pain.
“By the time people get here, they have a lot of functional disability,” said Sperry, who helps run the program. “They’re fearful, because they’re getting such strong signals in the brain — so we offer a very structured increase in activity, where we’re retraining the brain to soothe the central nervous system to not process these signals as danger.”
The program is not cheap. It costs $37,000 to $42,000 for three weeks. Gatchel, who is affiliated with several pain management programs in Texas, said that price is an “exception to the norm,” and less intense versions of the treatment can run between $4,000 and $10,000.
“We have a lot of people in this country who are unhappy, isolated, and hurting. Depression hurts. Anxiety hurts.”
Jeannie Sperry, Mayo Clinic
Studies suggest the programs can be quite effective. The Brooks Rehabilitation pain program in Jacksonville, Fla., reports that six months after intensive treatment, 9 out of 10 patients reported improvements in quality of life and 3 out of 4 felt decreased levels of pain. The center reported that just 6 percent of patients who were weaned off of opioids during the program resumed taking them afterwards.
Another study, published in the journal Pain, followed 339 patients who completed a three-week program at the Mayo Clinic Pain Rehabilitation Center. Some 70 percent responded to questionnaires six months after their treatment, and reported significant improvements in pain severity, depression, social functioning, and other metrics. The gains held both for patients who had been taking opioids before entering the center and for those who had not.
A renewed interest in alternative treatments
Such results, and anecdotal reports from patients like White, have spurred renewed interest in biopsychosocial pain management.
Insurance coverage is still a battle: Many plans will pay for medical treatments such as surgeries, pills, and steroid injections that can run $2,000 apiece. They’re not as keen to cover therapy, massage, and meditation. “It’s much more efficient for insurers to pay for a pill in a 15-minute office visit,” Twillman said, “instead of a pill, plus a psychologist, plus a chiropractor, plus acupuncture, plus yoga and massage.”
Slowly though, that’s changing, in large part because of the opioid crisis.
The Food and Drug Administration just changed its provider education guidelines to urge doctors to learn about alternative strategies for managing pain.
Some insurers are open to new approaches, too. Oregon’s Medicaid system, for instance, recently began covering more physical therapy and chiropractor visits for people with back pain, so as to help them avoid painkillers and surgery. Cigna, too, has increased its coverage for back pain physical therapy.
Veterans Affairs, meanwhile, is taking steps to reach out early to chronic pain patients, often through their primary care physicians, to coax them into increasing physical activity, sitting through cognitive behavior therapy, and meditating.
Sperry has appealed to Congress to accelerate the shift with more funding — not just for chronic pain and addiction treatment, but also for medical education. She conducts a workshop at Mayo Clinic to teach medical students how to say no to patients who ask for opioid refills — and how to help them instead train their brains to manage their chronic pain.
“We need a cultural shift,” Sperry said. “There’s an implication that there’s a pill for everything — and that’s not accurate. It’s very dangerous.”
I have been in constant turmoil with regard to being reliant on pain meds since a major car trauma 2&1/2 years ago left me with multiple pelvic fractures and a permanent bolt across the back of my spine holding the pelvis rigidly in place.
I have been desperate to find an alternative to what I agree is often a quick fix that causes more problems both physically and psychologically after seeing how becoming reliant on them affected a family member.Up untill the accident I would not use drugs to alleviate medical symptoms but it seems that since it happened it is all I am offered. Be it opioid based specifically for my symptoms or prescribed drugs given for other conditions such as epilepsy which I do not have but are proven to have a side effect of numbing nerve damage pain, I feel the route is very much a drug induced hope for a quick fix which often still remains out of reach!
Having read this article however has given me hope that the more holistic approach I have been constantly battling to find to pain management is out there.Even after visiting some of the top uk hospitals in a desperate attempt to alleviate my symptoms it has become apparent to me now that alternative methods of pain management have just become overshadowed by the drug companies need to sell more medication and have a recipient who will remain a lifetime subscriber to prescription drugs.
Much of the issue for me as a patient has been knowing what to ask for and not losing that hope and belief that there must be another more holistic possibility to manage pain out there as opposed to the surprisingly easy to obtain and quickly written out prescription based reliance that so many of us in constant pain are forced to follow.
Wish me luck and the strength I’ll need to continue seeking the help and guidance which till now has eluded me.I will not give up on a different approach to medication and will seek out a way to unlock that alternative tool which I already possess.The medical profession who have till now seemed blindsided to the notion of anyone who is opposed to the powerful and possibly permanent prescription therapy so easyto offer, and I was about to try to convince myself that there perhaps was no other way to get myself back to some sence of the painfree normality I had pre-accident.Your article has lifted my spirits and given me hope that opioids are not the only way forward for me after all.THANKYOU.
While there are many reasons not to return to the excessive prescribing of pain medication, there is no value in leaving millions of good people to suffer needkessly! I can appreciate how wealthy people with a great deal of time are able to afford “pain rehab”, the vast majority of chronic pain sufferers cannot! To suggest otherwise is ignorant, foolish, and frankly ridiculous! I pray the powers that be will face these facts and stop the hysteria that has led to so many people being left in constant pain and without hope.
Thank you so much for your valuable statement. Unable to give such input myself, because I wear the label…ADDICTED. Here I am; addicted 10 mg Percocet three times a day! What a pile of feces (large amount, well formed and black as tar). No withdrawal when this med was discontinued eleven months ago. Several months no med. Fight or flight? There is no fight left, and too much pain to fly, sit, stand, lay down. Cannabis set my body on fire and took my mind away, and I have had intolerable reactions with medications prescribed since then. Appts are scheduled 3 months apart. Have never met the pain MD, only the NP who seemed to listen the 1st & 2nd visit, but I conclude, did not hear because despite my bilateral hearing aids and need to lip read talks to the computer screen and walks outs the door talking to ? me. I sat in the exam room for quite some time last visit before going out to the desk to say, “I think I am done, I don’ know.” That evening, reviewing my summary I saw that my pharmacy had been changed, so call office next day. “Changed > Pharmacy that had Rx and delivered.” I called Pharm. No delivery to my town. Again call MD office & told NP would call me that PM; no call. Called following Monday: excuses given. I am being medically neglected; patient abandonment, and I know there are others that just give up. Please note: DNA testing showed that I am an intermediate metabolizer. Only one pain MD considered this and that is his reason for ordering the tests and no my insurance (Medicare/Aetna) would not pay for it.
Please spare me .Who has the money? Let’s face it,we are are all chasing our pain while doctors rake in kickbacks by Big Pharma who deceives everyone including our políticians on the effectiveness of their pathetic drugs.In the mean time the FDA is clueless.After having nerve pain for 24 years I have found there are only two methods that work and.they are free , Distraction, and exercise. Everyone is raking in the money except us.
Information on coping with pain
These treatments should no longer be considered as “alternative” treatments – they are “main” treatments. See the article titled “Research Uncovers Potential Treatment for Chronic Pain” Link:
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