Speaking of Psychology: Using psychology for pain relief and opioid reduction, with Beth Darnall, PhD

The national conversation on opioids focuses mostly on abuse and overdose deaths but there are millions of Americans using opioids to manage chronic pain. Can integrating psychological approaches into pain care offer some patients low-risk pain treatment options? Beth Darnall, PhD, from Stanford University, explains how psychology and mindfulness can treat pain and help people with chronic pain live better lives.

Beth Darnall, PhD, is a clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University. Broadly, her research investigates how to best treat and prevent chronic pain. Darnall brings to her work the perspective of having lived through her own chronic pain experience. She delivers pain psychology and opioid reduction lectures and workshops nationally and internationally and is the author of three books on the topic.

Kaitlin Luna: 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.

Beth Darnall: Hi Kaitlin, thanks so much for having me.

Kaitlin Luna: 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?

Beth Darnall: 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.

Kaitlin Luna: And as a pain psychologist, what is your perspective of what's currently going on in this country with the opioid epidemic?

Beth Darnall: 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.

Kaitlin Luna: And so, what are some of the most effective psychological treatments?

Beth Darnall: 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.

Kaitlin Luna: So, can people find relief without drugs?

Beth Darnall: 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.

Kaitlin Luna: 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?

Beth Darnall: 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.

Kaitlin Luna: 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?

Beth Darnall: 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.

Kaitlin Luna: 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?

Beth Darnall: 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.

Kaitlin Luna: 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?

Beth Darnall: 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.

Kaitlin Luna: And do you yet know what those policy changes would be?

Beth Darnall: 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.

Kaitlin Luna: Thank you so much for joining us, Dr. Darnall.

Beth Darnall: Thank You Kaitlin, it's been my pleasure.

Kaitlin Luna: It's wonderful having you.

Beth Darnall: Thank you.

Kaitlin Luna: Speaking of Psychology is part of the APA podcast network, which includes other great podcasts like APA Journals Dialogue about the latest and most exciting psychological research and Progress Notes about the practice of psychology. You can find our podcasts on iTunes, Stitcher or wherever you get your 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.