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.

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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.

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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.

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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.”

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  • KDN,
    If you want to prove what your saying is true a meta analysis is not the way to go. Those are only used when the fact are lacking and to give a greater “punch” to the weak studies. Tobacco Control are fond of using such tactics which I’m well aware of so you won’t convince me or anyone here of those “alternative theories” junk you’re trying to peddle. Hardly even a good try. You must work in PH? If you’re willing to convince yourself that it can work for you bravo! For most of us we tried these theories long before the pain was overwhelming and crippling physically. I’m also aware of the front groups & lobbyists who end up pushing these “new regulations” as well but hey! There are many in the public willing to buy into anything….like the new POTUS.

    • Hi C.B. The meta-analyses I cited is published in a reputable journal – so you cannot deny that evidence, just because it does not align well with what you prefer to believe in. Also, don’t underestimate the placebo effect – Placebo effects can be very powerful. Check out the documentary “Brain Magic: The Power of Placebo” in ‘nature of things.’ Also check out the book titled “Brain Wars” by Dr. Mario Beauregard (it has a whole section citing academic references on the placebo effect).
      Also, you need to remember that many drug trials are conducted by pharmaceutical companies and they have a great deal of selective reporting, medical ghostwriting, data mischaracterisation and academic malfeasance. You prefer to believe in those because those findings align with your belief systems – this is phenomenon is called “confirmation bias.”

  • 100%% of us who do try to work and have never accepted a dime from the government use MEDICINE to lessen that physical pain enough to work,,for all humans need to feel useful,,,which is exactly why all of us who use medicine responsibly for years to work are pisst-off by limiting our medicine now a days to non-effective dosages to be able to work,,,,,maryw

  • I’m impressed with all of the commentors who indicated they’ve lived with chronic pain and managed to continue leading as much of a normal life as possible including maintaining employment. It seems like it would be easy to just ride the disability train and let the government support you so I applaud those took accountability for their situation.

  • Wow,,to kdn;since when has smoking a pack of cigs a week [grow our own tobacco btw,]a ,”substance use disorder,”????I guess all who enjoy a beer at dinner,,or a drink at a gathering all have substance use disorders now??!!wth,,,your grasping at straws,,,its amazing what snake oil people will use/say to make a buck off people or insurance companies,,,no-wonder partly why our health care is such a f— mess,,,,other pushing their ,”will” onto other adults,,what geeks,,,maryw

    • Sorry, maryw, I just don’t understand your comments (even though I try hard and even read them a couple of times to see if I can make sense). Consider taking a writing class – that can help your pain issues too. Studies a have shown that focusing too much about your pain and ruminating about it only make things worse.

    • This is thee exact arrogance +ignorance that has willfully killed 11 vets today and at least 12 CPP today,,,,,Sorry your incapable of reading or acknowledge logic and truth,,,Your ideology of mind control for physical pain is SNAKE OIL,, can u understand that,,,it is based upon thee assumptions u have the rite decide who suffers in physical pain and who does not,,,can u understand that,,Can u understand that it literally physically impossible for u or anyone to physical feel the physical pain of another,,can u accept that fact as truth??!!!for it is factually TRUE,,, thus as a humane civilized society,,no-one has a rite to decide who suffers in physical or force another human being to suffer in physical pain by denying them access to effective ,timely MEDICINE,, that is why thee definition of torture,is defined,,Denial of access to timely effective medical care that causes severe physical pain,,Torture is illegal,,are u capable of understanding that??it carries a life sentence if any government employed entity is convicted of torture,,,can u understand that,,,,For your assumption u have the rite to decide who,or ,how much physical pain another human being is to suffer,,is thee ideology/capabilty of a human being who could sit there and watch another human in agony from a physically painful medical condition,,and tell that poor soul to make that physical pain from deseases,medical error,,”misses,” in medical technology of mri ‘s ct,echo’s,etc to stop that physical pain by telling it w/their mind,,,”to stop it physical pain,,,”it absurd,,its SNAKE OIL,,,,but if u can sit there and watch another human being in agony from physical pain,,then maybe ask yourself,or look in mirror,,and ask yourself why doesn’t human suffering bother me,,for it is the symptoms of psychopathic ideations,,U know,,emotion maybe in the brain,,but the brain is the physical part of the body,,and when the physical part of the body is registering physical pain,,,there is a PHYSICAL REASON FOR IT,,, not,,a mental one,,for no mental reasoning can stop physical pain,,,wow,,,amazing the crap people will try to sell to the public for monies,,,,,,but sadly in process,,26,000 more human being died last year from forced endurement of physical pain via denial of access to MEDICINES,, to lessen that physical pain,,and u preach snake oil,,,,,do u know the definition of humane??maryw

  • This is the same nonsense they floated {and still do!} while trying to get people to quit smoking even down to using the same phrases like “stinkin’ thinkin’. ” While this may work for those who believe in these theories I’ve found they are next to useless for me. I’m curious as to why they almost never report about those for whom these “alternative therapies” are an abysmal failure. I don’t think trying to go back to 1950’s type dealing with pain is useful to anyone and certainly teaching new doctors to to “just say no” to refilling opiate prescriptions is totally inane when it is warranted, or needed by the patient.
    All the hysteria around opiate overdoses never mentions that patients using their meds responsibly seldom have serious issues like dying from multiple drug OD’s. What I see is those using heroin or methadone then trying to get high so they add in benzodiazipines and some of the drugs used to lower BP which apparently boost the effects of the methadone. I saw this time and time again in Boston in the 90’s. There will be doctors willing to write a prescription for cash and those are whom should be targeted not pain patients with legitimate needs. One size does not fit all.

    • Before you set aside mind-related therapies as ‘nonsense,’ I would suggest that you to take a look at the following articles that relate to mindfulness training for substance use disorders (such as smoking):

      Li, W., Howard, M. O., Garland, E. L., McGovern, P., & Lazar, M. (2017). Mindfulness treatment for substance misuse: A systematic review and meta-analysis. Journal of Substance Abuse Treatment, 75, 62-96.

      Garland EL (Jan 2014). “Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface”. Front Psychiatry. 4(173). doi:10.3389/fpsyt.2013.00173.

      Brewer, Judson A. et al. “Mindfulness Training for Smoking Cessation: Results from a Randomized Controlled Trial.” Drug and alcohol dependence 119.1-2 (2011): 72–80. PMC.

      Chiesa, A., & Serretti, A. (2014). Are mindfulness-based interventions effective for substance use disorders? A systematic review of the evidence. Substance use & misuse, 49(5), 492-512.

      Black DS (Apr 2014). “Mindfulness-based interventions: an antidote to suffering in the context of substance use, misuse, and addiction”. Subst Use Misuse. 49 (5): 487–91.

      Ruscio, A. C., Muench, C., Brede, E., & Waters, A. J. (2016). Effect of brief mindfulness practice on self-reported affect, craving, and smoking: a pilot randomized controlled trial using ecological momentary assessment. Nicotine & Tobacco Research, 18(1), 64-73.

      Tang, Y. Y., Tang, R., & Posner, M. I. (2013). Brief meditation training induces smoking reduction. Proceedings of the National Academy of Sciences, 110(34), 13971-13975.

    • To KDN;;,,,,all your ,”references,” did I miss the M.D.,,, on any of them w/pain management as their profession,,ie,,12 years,,,,,,??????For some financial reason your combining physical pain management w/substance abuse gee,,,maybe to inflate datas to justify monies??maryw

  • I am very very proud of my brother Carl who had come a long way. He has helped others through his own experiences….he is changing peoples lives everyday. We need more people like Carl to help others in there difficult time of need….thank you to all the Dr.s out there making a difference.
    Sincerely,
    Cynthia White

    • Cynthia White – thank you for your note. I know your brother and am also very proud of what he has accomplished since completing PRC in 2009. I lost track of him when he changed jobs and only recently heard of his work at Teen Challenge. He has always been such an inspiration to his peers and to the staff. Please tell him Dr. T says ‘hello’ and that I continue to give him and his family my best wishes!

  • The 20+years I have been dealing with chronic, degenerative, escalating pain (13 with the help of low dose opioids), I have continually been asked, “are you depressed, have anxiety etc?” I have always said no, I have enough problems to deal with without adding that. I have used a lot of mind over matter, self talk type stuff all along, no training, just desperation. Pacing helps, diversion whether physical or mental. It’s all just part of my “bag of tricks” to try to get thru each day the best I can. Never resorted to street drugs, alcohol or any of that. No doctor ever “handed pills out like candy”. What a lot of non chronic pain folks don’t seem to realize is that we patients are a strong bunch of characters who have done a lot of things to deal with these conditions the best we can over the years. Now, all of a sudden, they say opioids don’t work long term, they make pain worse and the hysteria goes on and on. Instead of rat studies, short term opioid users, alcohol and street drug users being used in these studies, someone should do one with us very long term pain patients. Five, 10 and 20 years. Ask us what works, what we have done on our own to still have a job, have families and get the best out of this life we can. All on the ‘killer opioids”. Scare tactics might work for the new pain patients but not us long time users. Opioids work the best, cause very little if any medical problems (would have shown up by now) and should always remain an option that is decided between a patient and their doctors. Not committees, government officials (looking for votes), celebrity grabbing so called doctors or financial incentive doctors with interest in addiction clinics.

    • Dorlee, The article you posted stated the reality of living with chronic pain. When I read about “your bag of tricks” it actually made me smile( &) sigh because we all have to dig into that bag daily. Most doctors prescribe with due diligence the medications we need to function. Luckily my husband provides the daily care I now need. Thank you.

  • There is an excellent six week Chronic Pain Self-Management Workshop that was designed to be led by trained volunteer peer leaders in the communities where they live. It was developed by the Stanford Patient Education Research Center and is evidence based. A book that accompanies the workshop “Living a Healthy Life with Chronic Pain” is available from Bull Publishing. In September 2017 the administration of the workshops will be transitioning to the Self-Management Resource Center in Palo Alto, CA. We offer this workshop through our rural county’s Public Health Department. I have seen how empowering the workshop is for the volunteer workshop leaders we have trained and the particpants who attend the workshop.

    • Do we all have to live up to community dictated norms & expectations?
      Do we all and each of us have the knowledge and experience to back up every enforced dictated expectation?
      How many individuals would take control of their own feelings/pain and investigate root cause before being subjected to numbness?
      A need to better assess root cause and map out a safe way to subside impact is more amenable & amicable in my experience.
      We are not all equal, we do not all concur in mutual understanding and we experience pain and cause roots differently.
      I find Carl White’s experience very moving and successful by means of his own findings and change in life including reaching out and helping the community.
      Carl, I appreciate your sharing insight into pain management and medical centers knowledge.

    • Bonnie,
      Thanks for the information. I will investigate the program and consider. Sounds great!

  • People reacting negatively to this article probably have many misconceptions (and have not seen the large evidence-base) on how various mind-states can significantly affect both our mental and physical wellbeing.

    Various psychological stresses are known to result in adverse structural changes in the brain (see for example the following article: Popoli M, et al. (2012). The stressed synapse: the impact of stress and glucocorticoids on glutamate transmission. Nature Reviews Neuroscience. 2011;13(1):22-37). There are many other studies as well.
    The above article (Popoli et al) describes how mice that are subjected to various psychological stresses (such as being restrained) show dendritic atrophy and loss of dendritic spines, and how these changes are reversible through psychological means (when these restrained animals are released).

    Apart from psychological stress, other mind-states too change the brain. Studies have shown that as taxi drivers do their jobs (psychological causes), the brain changes. Various acquired psychological habits, choices, etc., also change the brain (lots of research support this). Research has also shown that impulsivity results in reductions in gray matter whereas, mindfulness practices gradually reduce impulsivity and also change the structure and function of the brain in positive ways (such as increases in gray matter and cortical thickness).
    All this refers to well known phenomena known as ‘neuroplasticity.’

    Regarding physical pain, when practicing mindfulness, it is possible to notice how much the mind adds to the physical pain by constantly worrying about the pain, anticipating future problems, etc., creating a whole new ‘second level’ of pain. It is also interesting to note here that studies have shown that mindfulness meditation reduces physical pain and this change is associated with unique neural mechanisms (see: Zeidan et al., 2016, The Journal of Neuroscience, 36(11), 3391-3397). Also see the following TIME magazine article: http://time.com/4108442/mindfulness-meditation-pain-management/?iid=sr-link1

    I completely agree that assuming there is ‘a pill for everything’ is not only wrong but very dangerous. In any case, meta-analyses have shown that most active pharmaceutical drugs and placebos have similar effect sizes [see the article: Howick J, et al. (2013) Are Treatments More Effective than Placebos? A Systematic Review and Meta-Analysis. PLoS ONE 8(5): e62599].

  • Hey let me break your leg and tell u to control it w/your mind,,Hey every have thoracic lamectomy w/undiagnosed pancreatitis /gallbladder packed w/stones,,,,it will hurt to breath,eat sleep,move for life,,but please answer 1 question for me ,”author,”,,,Since it is fact,,your e.b.m. crap ,,but since its fact,,that no-one can physically feel the physical pain of another,,,why do u think u have the rite to decide who is to be in agonizing physical pain and who is not???as a humane society are we not suppose to be HUMANE,, to one another human being,,,not barbaric by denying timely effective medical care to lessen physical pain w/effective medicine???maryw

    • it’s called “chronic pain”, maybe you should learn to read an article title before you post ignorant comments. Everything you mentioned does NOT belong to that category of pain. Thanks for being such a strong member of society

    • To Tommy,,,the definition of chronic pain is over 6 month,,Your responds is based upon thee assumption you have the rite to decide how much physical pain another human being is in or is to endure or endureing,,,when it is literally impossible for u or anyone to physically feel the physical pain of another,,Why do u think u have that rite to decide how much we are in,or how much we forcible should endure??I beg you to answer that question,,Furthermore please name your ,”huge,” evidence,and please not 1 involving rats,,and please any evidence done that has been repeated at least3 times as that is the very bases of scientific research,,u must be able to repeat it,not 1nce but 3 times,,,,maryw

    • MARYW: Regarding your statement “rite to decide” – right now, it is the pharmaceutical companies that decide what medicine is best. This is worst for various psychiatric conditions for which they use a ‘hit/miss’ approach to come up with various medicines and also use neuro-jargon explanations to justify how these pills work (explanations that have never been proved, but seem to impress ordinary innocent people who do not understand these scientific phrases). Also, please read my other comments here.

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