Hello and welcome to Speaking of Psychology, a podcast produced by the American Psychological
Association. I'm your host Kaitlin Luna. I'm joined by Dr. Beth Darnall, a clinical professor
at Stanford University, whose research focuses on how to best treat and prevent chronic pain,
as well as strategies for opioid use reduction. Welcome, Dr. Darnall.
Hi Kaitlin, thanks so much for having me. Sure, we're happy to have you here.
So first, the national discourse right now often focuses on the negative aspects of opioid
use. Can you talk about when it's a positive thing for, for people to use opioids?
Absolutely. So, I think when most people think about opioids, they think about painkillers
and opioids can be very beneficial for pain in the short run. So, we call that acute pain
after surgery or an injury -- very brief, time-limited use. In fact, a lot of different
types of pain, including acute pain can be well-managed with more conservative pharmaceuticals
and even without pharmaceuticals at all. But opioids can be beneficial for acute pain.
It's when the prescriptions start persisting, when pain becomes chronic and then the evidence
is really limited in supporting their benefit for chronic pain.
And as a pain psychologist, what is your perspective of what's currently going on in this country
with the opioid epidemic? What's happening right now with, you know,
the national discourse on opioids in the opioid epidemic is many different pieces:
Number one, a lot of the focus on opioid overdose deaths is really being driven by some illicit
use or what we would think of as being addiction. This is really important for us to pay attention
to that and to have better strategies to treat substance use disorder and addiction in the
country. Now, I'm not in the field of addiction. I
work with individuals who have chronic pain and most of whom when prescribed opioids are
taking them exactly as prescribed. But what we now know is that opioids aren't
the best frontline treatment for chronic pain certainly, and they come with a whole host
of negative side effects. And so we're coming into much greater awareness that we should
be treating pain more conservatively -- giving individuals with chronic pain a lot of different
treatment options and in particular psychological strategies so that patients can become equipped
to best control their pain, their own experience, their symptoms and to help themselves become
more active and functional. You know, at the end of the day it's not opioids
or no opioids, it's how do we allow people living with chronic pain to live their best
life possible. And this is where psychology is so crucial.
And so, what are some of the most effective psychological treatments?
Yeah, that's a great question. So, you know interestingly psychology is really coming
into the national forefront and focusing on the treatment of pain and in particular, in
this intersection with opioids because the CDC and the National Institute of Medicine
and other agencies have really now called for the integration of psychological strategies
into the treatment of pain. Nationally, in fact, this has been lacking
despite the fact that there's about 25 to 30 years of evidence that really demonstrates
that cognitive behavioral therapy in particular is a primary evidence-based treatment for
pain. So, you know, there are other treatments that
have been shown to be about equally as effective. For instance, mindfulness-based stress reduction.
Also, acceptance and commitment therapy, which is a variation of CBT.
The best evidence exists for CBT. In part, it's the best studied modality but most people
are surprised when they learn that the effect sizes for CBT are sometimes equal to that
of pharmaceuticals but without the side effects, without the health risks.
So, can people find relief without drugs? My philosophy on pain care is that conservative
treatment options should always be put forward first. Always, always, always try lowest risk
treatments first and that necessarily involves psychological strategies.
Psychological strategies, evidenced-based psychological treatment for pain, is shown
to reduce pain-related distress. For many individuals, it reduces pain itself. It helps
patients become more functional, to live better, do more the things that they love. It can
help improve sleep and mood effects. These are often negative consequences of living
with pain and so when we talk about relief from pain, we're talking about certainly a
pain score and we're also talking about much more than just the pain score. We want to
help people live better within the context of having medical conditions and ongoing pain
that can be incredibly distressing for people. And you yourself have had your own experience
with chronic pain and so for people who don't understand what that's like, can you describe
what that experience is and how that helps you with your work?
Yes, so when I was younger I did have chronic pain and you know, when I'm lecturing and
in fact working with patients at the group level, I will frequently, you know, describe
my background and my credentials, but I really believe that my own personal experience decades
ago with chronic pain is my most valuable experience because I have the lived experience
of an individual with chronic pain also trying to navigate the medical system and not understanding,
you know, what the diagnosis might be. The truth is we know that pain is not just
a sensory experience. Even though I thought that it was and most people in our culture
and around the world think of pain as just being a really negative or noxious sensory
experience, but in fact, the international, the International Organization for the Study
of Pain defines pain as both a negative sensory and emotional experience.
So, psychology is actually embedded into the definition of pain, but that's really curious
because we don't tend to treat it that way. We don't tend to focus on the emotional dimensions,
the cognitive dimensions, the psychosocial dimensions as primary components of chronic
pain treatment and that's what was missing for me when I was younger. And so, I had to
figure those pieces out. I also had to figure out how to learn to self-regulate the natural
physiological hyperarousal that comes along with the experience of pain. Our brains and
our bodies really react to pain with a sense of distress or alarm. We become prepared to
escape whatever threat might be afoot. That's how it registers in our central nervous system
and so this is a beautiful part about psychology is that we can both educate people how to
identify -- what those signals are and what they mean but also how to control them.
And so that was really my own journey -- learning how to do that for myself and so I bring forward
my lived experience and also my experience as a doctoral psychologist and researcher
now on these treatments. And you let him right into my next question
about how instinctually humans -- I would say any of the most other beings haven't desire
to escape pain. So, are there instances when pain is a good thing?
Yes, absolutely. Pain helps us survive. So, you know, pain
is really there, you know, to ensure our safety and our survival and so you know the best
example is if you were to place your hand on a hot stove and you feel that pain, that's
a very useful signal because you are going to be highly motivated to escape it. You are
going to pull your hand away so quickly, you don't even have to think about it. It happens
automatically. That's how primal pain is. But you know, while we're all motivated to
escape pain, we're not born with the understanding of how to modulate pain and the distress that
it causes us. So, when we have ongoing pain with no way to escape it, you can't run away
from your migraines -- you can't pull your hand away from whatever medical diagnosis
you have. But those signals are still firing and still causing distress. This is necessarily
a psychological issue and it's normal. It�s human. We all have these same reactions. We�re
hardwired to react and respond this way to pain.
But, the important message for people is that we're able to control it using evidenced-based
psychological strategies and techniques and that's where our freedom lies. That's where
we're able to gain relief and start to realize that we can control so much of our experience
and that allows us to need fewer doctors and fewer pills.
And you've also -- some of your published works -- you've talked about relaxation and
the importance of meditation and in this whole encapsulating way of dealing with pain. Can
you talk about the importance of relaxation, mindfulness, it�s a hot topic these days,
in general? So, how does that relate to pain management?
Absolutely. So, it really links in with one of the concepts we were just touching on,
which is when our nervous system registers pain, no matter where we feel it in our body,
it's processed in our central nervous system. And that is our brain and our spinal cord,
and it necessarily registers as a threat. And so, our brain and our body are going to
be, you know, poised to help us escape that. It's going to lead to a whole host of physiological
and psychological cascade related to distress or simply stress. So, we'll have an elevated
heart rate. Our muscles will tense. Blood vessels can constrict. We can become very
agitated. Our breathing changes and so for some people they may say, well, you know,
my breathing becomes short and shallow and for others they may say, you know, I really
feel like my breathing stops when I'm experiencing pain.
Over time, these become patterns of responses that actually shape not only physiological
patterns, neuromuscular patterns, but they actually contribute to the shaping of, you
know, our brain patterns and brain functioning so that over time we can evidence that the
structure and the functioning of the brain is changed simply by how we are responding
to pain. So, the relaxation response can be incredibly
useful because it counteracts all of these pain and stress responses. It's the first
most important tool that individuals can learn. I describe it as being your antidote to the
way that pain shows up in your body and the way that it can negatively impact your body.
Now, using the relaxation response once isn't going to cure your chronic pain, of course.
But, when these skills are used regularly over time, an individual learns how they can
essentially calm their nervous system on demand, dampen pain processing in the nervous system
and this can lead to beneficial alterations in these neuromuscular patterns that essentially
begin to prime us for relief. And there's very often news coverage about
this topic. So, as a pain psychologist what do you think is missing from the national
conversation in the media about the opioid epidemic?
About the opioid epidemic. I feel that psychology is not integrated enough into the national
conversation. Granted, that is changing. There has been increasing discussions about the
role of psychology in the treatment of pain and also in addressing us preventing opioid
prescriptions and also helping patients deprescribe their opioids. And this is really the focus
of my work. I am working on a nationally funded project
that is helping deprescribe opioids and in over 1,300 individuals with chronic pain across
four states. There is intense focus on how we help people with chronic pain reduce their
health risks. But remember, it's not just opioids or no
opioids. We need to get beyond that binary conversation and always come back to the fundamental
issue -- how do we help treat pain better? And when we focus on that question, psychology
necessarily rises right to the top. It is integrated into the definition of pain. It
will not be solved without full integration of psychology into treatment pathways.
I also feel that at this point policymakers, physicians and prescribers have very -- they
have an acute awareness of the limitations of the biomedical model and they're now asking
for integration. So, this is actually a sea change and the time is right for psychology
to step up and be able to lead in this space. But the caveat there is that we do need some
policy changes to support us in coming forward and helping address the needs of the hundred
million Americans that are living with chronic pain right now.
And do you yet know what those policy changes would be?
I don't know what the policy changes will be, but I do have ideas about what they should
be. So, in 2016, my colleagues and I conducted
the first national needs assessment for pain psychology access and training in the United
States. And what we found was that -- we surveyed 2,000 key stakeholders across, you know, five
or six different groups and that included over a thousand individuals living with chronic
pain. It included doctors, nurses, psychologists, directors of psychology training programs.
It was really a whole host of individuals. And what we learned was that psychologists
and mental health therapists themselves report a lack of education on pain. They're reporting
that they recognize that they'd only have the training and that they want the training.
They need the training. So, we need to better integrate psychology into all levels of education
-- psychology education at the undergraduate level, the graduate level, the postgraduate
level and also community-based training. So, such as at the APA, for instance.
You know, having better pain education integrated and this year's conference, of course, has
a whole host of trainings on pain. So, this is required in order to better integrate
pain and pain education and pain psychology into psychology training programs. We will
need some federal funding streams to support that education, no question about it.
And then just as a follow on that, we really need insurance and payer systems to better
support psychology as primary treatment for pain to dismantle any existing barriers to
psychologists getting reimbursed. Thank you so much for joining us, Dr. Darnall.
Thank You Kaitlin, it's been my pleasure. It's wonderful having you.
Thank you. Speaking of Psychology is part of the APA
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podcasts. You can also go to speakingofpsychology.org to view more episodes and find resources on
the topics we discuss. I'm your host, Kaitlin Luna for the American Psychological Association.