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.

advertisement

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.

Carl White
Hardware removed from Carl White’s body after his last surgery. Sarah Stacke for STAT

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.

Carl White
White and a client practice diaphragmatic breathing and passive muscle relaxation as a way to manage pain. Sarah Stacke for STAT

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 (CI), 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.”

Leave a Comment

Please enter your name.
Please enter a comment.

  • Not so much ‘new age’ medicine as ‘faith healing’.

    I have had multiple serious fractures but only my spinal injury involves a ‘psych induced pain’ legacy. How so? It is present when I first awake – thus my dreams must also impact negatively. My Father had a spinal injury and pain issues. Did I learn the psychological vulnerability, or inherit it? Neither methinks. I believe I inherited the physical vulnerability.

    I hold a Psychology Degree and can fully appreciate the role of the mind in the interpretation and experience of pain (ie. as a modulator), but a dangerous Physiotherapist has insisted that my pain is now purely a blend of psychology and nerve memory, a concept I reject on the basis of the above reasoning. My Neuro-Surgeon apparently agrees with me, a he made clear when he pointed out, on a longitudinal series of scans, the ongoing bone bruising that he considered the source of my discomfort.

    So, do we really need a plethora of individuals, with no appropriate qualifications, making absolute Psychological determinations, based on a belief based thesis (they call that theology I believe) – I have seen no meaningful empirical evidence for the more extreme position, merely the lack of a total correlation between injury and sensation (perhaps sensory deficits among non-sufferers?).

    I have a history of anxiety and depression, (consistent with my PTSD diagnosis) that clearly shape my sensations, but to say any more than that, and thus label millions of people as deluded malingerers, appears scientifically invalid, and indeed, dangerous. A new era of back pain discrimination is on the horizon in the rush to simplistic, belief driven, explanations.

    This issue, and my own subsequent invalidation, has had a significant impact on me.

    I await the first related coroners reports.

    Do no harm???

  • Hi,

    Thanks for sharing this information. There are some conferences happening in which medical specialty would be Pain Management and here is one of those conferences the conference details are given below.

    American Osteopathic Society of Rheumatic Disease Organizing Congress of Medical Excellence 2.0: 48th Annual Conference of AOSRD and Integrative Health Alliance from Feb 28 – Mar 01, 2020 at Peppermill Reno, Reno, Nevada, USA.

    For more information please follow the below link:
    https://www.emedevents.com/c/medical-conferences-2020/the-conference-of-medical-excellence-2

  • I had been on narcotics for years through a pain clinic that was strict, they helped, but after losing alot of weight, my dosage caused breathing issues, and retention of CO2. This was eye opening because I could have just stopped breathing. I weaned myself off, slowly Now that I am off, I notice how much worse my degenerative disease in my back, and other painful injuries has become, without meds. But I do not want to resume the meds.

  • I have read the article about Carl White’s and how he dealt with his pain issue several times. I have it saved on my computer. I would like to know if there is a way that the person who wrote the article or Carl White himself can suggest a way for me to find a pain management clinic such as Mayo Clinic who accepts United Health Care Optum insurance. I struggle with continuous pain and would love to be able to get off all medications. Thank-you, Marla Laninfa

  • Understand the opoid issue but what about someone who had a life with opoids and now has been kicked to the curb. I never abused opoids but would like my life at least some of it back. I have done everything and gone to every treatment I was asked to and here I am still no life. Now I truly understand why someone thinks of suicide. Now because I listened to my pain management doctor and always have I’m screwed and that is saying it nicely.

  • I’m in week 2 of the Mayo program. I’ve had RA for 29 years, diagnosed at age 9. I havent taken opioids for decades, and even then I would take one or two doses and get too sick from them and give up on them. I read extensively about the program’s wanting to get people off opioids. I had no problem with this as I’m not on any and believe we have a problem with these types of meds in our society. Once here I was informed I would have to stop my NSAID and taking any tylenol. I was told the reasoning was because tylenol is not a long term solution. I’m not seeing the logic. No medication is a long term solution for a chronic condition. Should I stop taking my diabetes, high blood pressure, and osteoporosis meds because they are not long term solutions to those diseases or the symptoms of them? I’ve been very disappointed with the program overall. Everyone is treated the same regardless of his or her condition(s). You are told repeatedly that the pain is in your head. Pt exercises are increased at a set rate everyday causing flare ups of certain conditions but you are told that your muscles are “waking up” and all of a sudden they will just be able to tolerate an amount of activity they hadn’t before, in my case in 29 years. The classes go over simple concepts that anyone who has been in pain for years has already researched, taken classes on, or tried before. Simplified, the program tells you you can deep breathe to deal with your pain. “Deal,” not lessen or improve. The brochures and information mention evidence of people reporting lower pain levels after completing the program. This conveys that taking the program may lessen your pain. Once here, and $40K in the hole, you are told no, your pain will not be lessened at all, but you can takr deep breaths and function with it. Basically just ignore your pain and go back to normal activities, but without analgesics or “pain behaviors” as they call them. Pain behaviors are any actions that cause you to think of your pain – heating pads, ice packs, rubbing your shoulders, etc. So not only can’t you take the edge off with a tylenol, you can’t use any assistance through organic or adaptive means either.
    Very disappointed and disillusioned with the program but will be seeing it through the next 2 weeks mainly because it took so much work to get here – travel, getting time off work, etc. – and I have a surgical consult the day after it ends.

    • Hi Carrie,
      I was disappointed to hear about your experience. Particularly that it didn’t seem to be individualized to you. I’m curious now that you’ve completed the program, have you changed your opinion or have an different insights?

    • Carrie understand completely for been dealing with pain for over 25yrs and went through what you did at Mayo just did it here and no help in the end. All I can do is say a prayer for you as well as everyone who needs them. I thought I could help people with this issue but not now, too much.

  • Distraction is one way to help deal with pain but not the whole answer. Then what do you do. Answers please. I have lived with a base line pain of 4 for years now what am I to do. This is not a complete answer either. Someone needs to find a way to help people and not just throw them to the streets.

  • Distraction is one way to help deal with pain but not the whole answer. Then what do you do. Answers please.

Your daily dose of news in health and medicine

Privacy Policy