Chapter 6

Why Medications
Don’t Work as Well
for Chronic Pain

It seems that many people have at least one medication that they rely on. “Two of these little pills really took care of my back pain,” or “My sister got fast relief from this, so now I want to take this drug too,” or “I finally found my wonder drug. What allergies? They disappeared!” This kind of adulation for medications makes you want to think that there’s always a drug solution for any problem. The reality is, the story on chronic pain is far more complex. It is a widespread but mistaken notion that medications can be the primary treatment for chronic pain.

Medications Can Play a Helpful Role

I am not saying that pain medications can’t play a role in the treatment of chronic pain. From an integrative medicine orientation, medications can be one part of a broader healing plan. For example, the time-limited use of analgesic pain medication and muscle relaxants may break the pain cycle just long enough for the patient to begin to feel a little relief and take the first steps toward self-care activities. Sometimes the short-term use of a benzodiazepine (tranquilizer) may allow the patient to know what it feels like for a chronically tight muscle to begin to relax. This “experiential reference point” may then help the patient to navigate on his own during the journey to calm his muscles and nervous system. Sometimes the judicious use of an anticonvulsant medication such as gabapentin (Neurontin) or pregabalin (Lyrica) may be helpful in the early stages of treatment, for helping to make the pain symptoms less overwhelming and intrusive. And sometimes antidepressant medication may help a chronic pain sufferer break the pain-depression-anxiety-tensing cycle long enough to “untie their hands” from behind their back and use their other coping strategies more successfully.

A patient of mine who suffered from chronic low back pain and depression described his experience of how medications fit in to the overall treatment with this apt metaphor:

“My chronic low back pain and depression felt to me like trying to start a fire when the wood was wet. For me, the pain medication and antidepressant medication were like dry kindling, helping me to get the fire started. But the mind-body skills and psychotherapy were like the larger logs that kept the fire burning.”

However, the plain fact of the matter is that many medications, especially analgesics (pain medicines), seem to work less and less effectively as time goes on. I’ve seen this in virtually all of my chronic pain patients. Even worse, sometimes certain medications can actually increase the pain. There are several good reasons for this, as we will discuss.

Pain Medications Work Better for Acute Pain

Pain of more recent onset is considered acute (duration from immediate to three months). Precisely because it is of more recent origin than chronic pain, it is more amenable to medication treatments. Briefer, more acute pain is less likely to set off chronic muscle bracing and guarding patterns, as well as negative state-dependent memory. Acute pain is far less likely than chronic pain to lead to either central sensitization syndrome (CSS) or autonomic dysregulation (ANS). As a result, pain medications can work more effectively. Once the pain becomes chronic, the interplay of various neurophysiological factors is far more complex, and thus more challenging to treat with medications.

In Chronic Pain, the Problem Is
More Central Than Peripheral

When we charted the life cycle of an acute pain sensation, the signal began at the point of injury, whether that be a toe, a finger, or a low back, and traveled up a peripheral nerve to the central nervous system, where the signal was processed and experienced as pain. The central nervous system does a good job in these cases of generating an accurate signal of the threat that lets you know something is wrong. It also indicates the source of the pain—a nail in the foot, a broken leg, a stomachache.

However, in chronic pain, the problem is not only in the periphery. The problem is also in the central nervous system itself—it is oversensitized and imbalanced. Chronically sensitized nerves result in central system sensitization (CSS) and autonomic dysregulation—a lack of balance between the sympathetic and parasympathetic functions. We can no longer trust the brain’s conclusion that a stabbing pain is coming from the back. Its report can be both an exaggeration and a misdirection. It is a lost cause to attempt to treat this centralized pain with medicines designed to treat acute pain in the periphery of the body. You’re solving the wrong problem.

This is not to say that there are not still peripheral problems—there are still strained muscles and eroded joints, for example. Rather, an altered central nervous system is complicating things by producing a heightened, distorted report of sensitization and pain.

Medications Cannot Cure Central
Sensitization or Autonomic Dysregulation

Medications can sometimes be used to suppress the effects of central sensitization and ANS dysregulation. Ill effects of a dysregulated autonomic nervous system can be treated with blood pressure medications, tranquilizers, anticonvulsants, and even some pain medications. Depression from similar kinds of dysregulation can be addressed with antidepressants. But none of these medications get to the root of the problem. Some medications may temporarily put out the brush fire, but can’t prevent what is setting off the brush fires. Some medications, such as ketamine, have been shown to temporarily reduce central sensitization. However, there are no medications that cure the underlying problem of CSS or ANS dysregulation.

Medication Tolerance

Chronic pain sufferers often must take pain medications for longer periods of time. The problem is that often pain medications do not work as well in the long term as they do at first. One reason this happens is that the body builds a tolerance to the medication. When the drug doesn’t do its job like it used to, we naturally try a higher dose to see if that works. That works for a while, and so we up the dose again. This becomes especially dangerous when the medication is an opioid, even though medication tolerance is a different problem than addiction. Tolerance may also occur with other types of pain medications, such as non-steroidal anti-inflammatory drugs (NSAIDS), including ibuprofen and naproxen.

Medication Intolerance

Chronic pain sufferers may struggle not only with medication tolerance, but also with medication intolerance. Because their central nervous system is sensitized, some patients find that they are not able to tolerate many medications. Many patients that I have treated report that they are so highly sensitive to most medications that it is always very difficult to find a drug they can tolerate sufficiently to gain benefit. The problem of medication intolerance is far more common in chronic than acute pain because the nervous system is more likely to be sensitized.

Analgesic Rebound

Analgesic rebound is what happens when a pain medication starts increasing pain instead of reducing it. We see this bizarre reaction not only in opioids, but also with other types of analgesic pain medications. When rebound occurs, the medications actually aggravate the nerves that carry pain signals. The nerves are altered and sensitized, becoming in themselves an additional pain amplifier. At the same time, the body reacts to rebound by decreasing its secretion of natural painkilling hormones, such as endorphins. This just intensifies the pain. Another problem with rebound is that patients often mistakenly view the rebound effect as a sign that their pain medication has worn off, and therefore they need to just take more of the same drug—which of course sets up a vicious cycle of more pain and more frustration.

Medications Don’t Treat State-Dependent Memory

A lot of people with chronic pain find that their suffering increases due to negative state-dependent memory. As we discussed earlier, this is the phenomenon where one aspect of a terrible experience will spark a vivid flashback of the entire memory. Like my friend—every time he sees a drill, it makes his finger hurt. Sure, you can reduce some of the intensity of these flashbacks with tranquilizers, antidepressants, and beta-blocking medications, but drugs cannot dismantle the system that brings these bad memories back to us. And medications don’t change the suffering caused by a sensitized nervous system combined with traumatic memory. That is the real source of these bouts that alter the intensity and intrusiveness of pain.

Medications Don’t Reduce the Negative Emotions
About Your Chronic Pain Sensations

Chronic pain is a tough enough problem by itself, but it gets even tougher when people develop secondary reactions to it. A common reaction is bracing and guarding the injured area—which limits mobility and hastens fatigue. Furthermore, the utter frustration of dealing with a pain that won’t go away often leads to anxiety and anger. Finally, people get fed up and become unwilling to accept and work with these sensations. In these ways, the presence of the pain sets off an immediate pattern of intolerance or agitation that invariably increases the pain. Antidepressants or tranquilizers may reduce the intensity of this reaction at first, but over time, these secondary reactions make chronic pain much more disruptive.

Medications Don’t Correct an Altered
Sense of Identity from Chronic Pain

A serious problem that is beyond the reach of medications is that chronic pain patients experience a loss of identity. Their sense of self is altered. I have observed this pattern in many of my patients.

“I used to think of myself as strong, capable, able to respond to problems in resourceful ways,” said Cindy, who has chronic abdominal pain. “I used to be proud of my strengths—now I feel as if my very core sense of who I am as a person is permanently diminished.” She is a good example of how years of pain have reduced people to feeling like they are being victimized by their own bodies.

Opioids—Multiple Troubles
for Chronic Pain Sufferers

I have saved for last what may be the most serious problem in this area—the use of opioid pain medication. Using opioids in the treatment of chronic pain is highly problematic, and it warrants a lengthier discussion. Opioids, also called narcotics, include a range of pharmaceutical preparations often prescribed for pain.

There is no doubt that opioids can sometimes be helpful for acute and severe pain. They are sometimes helpful in the treatment of pain related to a terminal illness, such as later stage cancer pain. However, there is increasing data showing that many cancer patients now suffer with opioid addition.

The United States consumes 83 percent of the world’s opioids. Yet, there is no evidence that they are helpful in chronic pain. Up to 40,000 people die every year due to opioids, and most of these started because of chronic pain.

In most cases, it all begins when a well-meaning prescriber recommends opioids to help patients deal with acute pain. Frequently, the patient is in pain due to an injury, a surgery, or even just a tooth extraction. If you are taking opioids, rest assured that nobody is blaming you or judging you for having gotten on them.

The opioid crisis emerged in the late 1990s, when opioid pain medications were prescribed at greater and greater rates. The pharmaceutical companies that made the opioid medications told providers that their patients would not become addicted. This turned out to be misinformation. It soon became apparent that opioids were highly addictive. The National Institute for Drug Abuse estimates that, by 2017, more than 47,000 Americans had died as a result of opioid overdose. Another 1.7 million Americans suffered from substance use disorders related to prescription opioid pain medications. It is now clear that prescription opioids carry significant risks, and they often lead to serious side effects.

Common types of opioid narcotics

•OxyContin (oxycodone)

•Vicodin (hydrocodone)

•Morphine

•Heroin

•Synthetic opioids

◦Fentanyl (fifty times stronger than heroin; a hundred times stronger than morphine). Note: most cases of fentanyl-related overdose and death are linked to the rise in illegally made fentanyl, sold through illegal drug markets due to its heroin-like effects (source: CDC)

◦Methadone

◦Tramadol

Anyone taking prescription opioids can become addicted and is at risk for accidental overdose, or even death. According to the American Medical Association, about 45 percent of heroin users started with an addiction to prescription opioids.

The risks of opioids are so great profound that a new category of addiction known as Opioid Use Disorder (OUD) has been recognized by the American Psychiatric Association. OUD has been included in the latest version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It describes OUD as a problematic pattern of opioid use leading to distress. The problems related to OUD include:

•Spending a great deal of time recovering from the effects of opioids

•Problems fulfilling obligations at work, home, and school

•Reducing or giving up activities due to opioid use

•Taking larger amounts of the drug

•Taking opioids over a longer period than prescribed

•Experiencing withdrawal

•Taking opioids to reduce withdrawal symptoms

Even when taken as directed, the use of prescription opioids can cause several side effects. Among them is a condition called “opioid-induced hyperalgesia.” Hyperalgesia means an abnormally heightened sensitivity to pain. There is evidence that opioid medications cause sensitization of the central nervous system even after a short period of use. When this occurs, the very drug used to reduce pain will actually increase the pain.

When opioids lead to physical dependence because of the pain, addiction often follows. That’s because opioids also affect parts of the brain that mediate pleasure and reward. The craving for that pleasure may exceed the drug’s ability to relieve pain. That’s when addiction arises, which gives the patient a new problem to face in addition to the chronic pain problem. This sort of addiction tends to come more easily to a person with a preexisting problem with chemical dependency or substance abuse. Whether it is dependency on alcohol, tranquilizers, or another substance—that person is at higher risk for opioid addiction.

Aside from addiction, opiate use has a host of possible side effects that can be very problematic. A person may suffer from nausea and vomiting, dizziness, sedation, drowsiness, confusion, and problems with judgement and decision-making. Opioids can cause balance problems and increase the risk of falls—especially in the elderly. They can disturb sleep quality. Digestion can get slowed, leading to opioid-induced constipation, or OIC. Severe OIC is so common that other medications are needed to counteract it, often leading to further digestive symptoms. And since withdrawal symptoms are so severe, it may create significant motivation to continue using opioids to prevent them.

How Opiates Interfere with Rehabilitation

Chronic pain patients who take opiates have greater challenges than chronic pain sufferers who do not take opiates. For one thing, opiates often intensify the pain by causing central sensitization. Their pain has also likely been made greater by analgesic rebound, where the medication itself increases their pain. This person is likely drowsy and exhausted due to the sedating effects of opiates and because opiates disturb their sleep cycle. They are far more likely to be constipated from the opiates. Plus, constipation leads to digestive pain, cramping, bloating, and distention.

One of the biggest problems with opiates is that they work through dissociation. They disconnect the person from awareness of sensations and emotions occurring in the body. This may be helpful for acute pain. However, over time, dissociation from one’s body and emotions interferes with the healing process. Opioid-enhanced dissociation essentially undercuts the entire rehabilitation process. My approach to tackling chronic pain is founded upon developing awareness of your body and your emotions. Awareness is the A of the ABC method. Opiates alter and distort the patient’s relationship to the sensations and emotions of the body.

Strong negative emotions are a normal part of the process of coping with chronic pain. The sense that your body has betrayed you leads to feelings of anger, frustration, grief, despair, resentment, even shame and disgust. These are difficult feelings to deal with. Nevertheless, you must deal with them to heal, and dealing effectively with your difficult emotions will lead to further improvements. And when you are disconnected from your emotions by the effects of opioid use, this interferes with your healing from chronic pain.

Think of addiction as being driven by any substance or activity that helps you to avoid unpleasant feelings or experiences. Opioids not only dissociate you from painful sensations in your back; they also numb away the experience of these painful emotions. This powerful force of emotional addiction just adds to the big issue of physical addiction. It’s a double threat. This twin addiction becomes reinforced every time the opioids unplug you from the sensations and emotions of your body.

Another hazard of opioid addiction is the “phobic” feelings one has toward bodily sensations. As you may guess, this fearful attitude reinforces the nervous system’s “false alarms” that plague the chronic pain sufferer. Patients on opioids often react with fear, annoyance, and bracing to even nonthreatening sensations. To prevent these sensations from being interpreted as threats by the limbic system—which sets off the fight-flight response—the patient needs to learn different strategies for self-soothing. This will subdue the challenges of painful sensations, and will promote healing.

We will review how to change this pattern in the “Cultivating” section of this book, specifically when I teach you about Limbic Retraining.

When I treat a patient who has been on opioids, I know they are struggling with all the problems discussed above. They have become increasingly estranged from their body, and from all the natural internal mechanisms that we possess for self-soothing. This can be turned around. But first the patient needs to understand how the opioids have affected them and have unwittingly interfered with their rehabilitation. To rehabilitate well, the chronic pain sufferer needs to be able to connect with sensations in their body. They must learn to respond to bodily cues differently before more pain occurs.

Considerations for Patients
Considering Opioid Use

Given all the risks associated with opioids, you should not consider using them without first having a detailed discussion with your health provider. Together you should look at the pros and cons. Will the benefits of prescription opioids outweigh their many possible dangers? If you begin opioid treatment and your pain is not resolving as quickly as expected, you should follow up promptly with your health provider. You should expect that urine testing will be conducted during the course of your therapy.

Before you start your opioid regimen, you should think ahead and plan the endgame. Once it is time to stop opioid treatment, you need instructions on how to taper down safely to minimize withdrawal symptoms. Most importantly, your approach to healing from chronic pain should include a good mix of non-opioid treatment modalities. As I always say to my patients, “If you’re going to take something away, you need to replace it with something else.” It is never a good idea to rely on narcotics without also practicing a range of healthy self-care activities. These will include regular stretching exercises, physical exercise such as walking, calming exercises, and self-hypnosis. You need to create a balance between activity and rest in your daily schedule. Proper nutrition is important, along with establishing the proper amount of social interaction and support.

Medications for Chronic
Pain: Conclusion

With all the concerns discussed above, are there appropriate uses for medications to help in healing from chronic pain? Yes, but only if the drugs are used as a bridge to feel a different experiential state, and if you are learning vital self-care and self-healing skills at the same time. Medications for chronic pain can be helpful for interrupting a cycle of pain. This also disrupts ongoing patterns of negative neuroplasticity, so you can start anew. Just keep in mind that “brief usage” is the key phrase setting a limit on such medications. The actual length of time that you stay on your medication will vary, depending on whether it is an analgesic pain reliever, minor tranquilizer, anticonvulsant, muscle relaxant, or antidepressant medication. Obviously, this will be determined through thoughtful discussion with your prescriber and healing team.

It is very important to work with a prescriber who understands this balance between medication and self-care skills. In this context, the two of you can specify what you expect your medications to achieve—as well as what they cannot achieve.

An appropriate plan for using the drug would look something like this: “I will take just enough pain medication to take the edge off certain episodes of back pain so that I can get up and walk six blocks as part of my self-care.”

An inappropriate drug use plan would be like this: “I will take enough pain medication to no longer have to care that my pain is there. I want to ‘check out’ and not have to do anything else to manage it.”

This second plan is a bad idea, because it is likely to lead to much greater frustration and dissatisfaction with the medication.

In conclusion, even if opioids didn’t carry all the dangers and side effects they do, I would generally caution against their use because of all the ways I’ve listed above that narcotics interfere with rehabilitation and healing.

In the following sections of the book, I will discuss many non-pharmaceutical strategies that work more effectively for chronic pain and with far fewer side effects.