5 Questions: Beth Darnall on opioids and pain management

A Stanford Medicine psychologist is helping patients reduce pain without opioids and prescription drugs. She offers practical steps for people to harness the power of their mind-body connection to reduce symptoms of pain and increase their quality of life.

Beth Darnall

Beth Darnall, PhD, is a clinical associate professor of anesthesiology, perioperative and pain medicine at the School of Medicine. She has more than 15 years of experience as a pain psychologist treating a variety of individuals with chronic pain. For example, she has worked extensively with patients suffering from spinal cord injuries, catastrophic burns, amputations, chronic low back pain, migraines, fibromyalgia and various types of musculoskeletal pain.

Darnall is co-principal investigator for a National Institutes of Medicine-funded project that is studying treatment for pain catastrophizing, which is a distressing pattern of thoughts and emotions commonly experienced by those with chronic pain. She has also developed a novel pain psychology treatment that can be delivered over the internet to patients before surgery to help reduce distress and optimize post-surgical healing and recovery. The treatment uses meditation and cognitive behavioral therapy to help patients avoid negative thought patterns that can amplify pain. This is currently being tested in women undergoing surgery for breast cancer.

Her clinical practice, research and public-education efforts focus on empowering people with chronic pain to target their daily choices, thoughts and emotions that can worsen pain and harness the power of their mind-body connection to reduce their symptoms and increase their quality of life.

She is co-chair of the Pain Psychology Task Force at the American Academy of Pain Medicine, and is a 2015 recipient of the Presidential Commendation from the American Academy of Pain Medicine.

Stanford Health Care writer Jana Chow recently spoke with Darnall about pain management and her newly released book, The Opioid-Free Pain Relief Kit, which includes tools to equip patients to manage pain. The book includes a relaxation CD that is designed to calm the nervous system. Darnall is also the author of Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain, which was published in 2014.

Q: What are the best tools you’ve found to reduce pain without opioids?

Darnall: While the term “painkiller” is common, it’s a misnomer when applied to opioids for chronic pain. Studies show that when used long-term, on average, opioids only reduce pain by about 25-30 percent. It’s critical that other strategies be used by patients to gain relief.  Brain-training therapies, such as cognitive-behavioral therapy, mindfulness-based stress reduction, and meditation have similar pain-relieving effects, with none of the side effects. By learning techniques that reduce attention to pain — and distress about pain — pain is relieved. It’s not just about teaching patients how to cope with their pain — the techniques actually reduce pain processing in the nervous system, thereby directly reducing its intensity and impact. Think of it as mind-body medicine.

Learning how to calm one’s own nervous system is a critical aspect of pain management. It’s vitally important to learn and use skills to control the cognitive, emotional and physiological factors that amplify pain. Even if opioids are prescribed, they should be just one part of an overall, comprehensive pain care plan that includes pain psychology, self-management, movement therapy or appropriate exercise, and other disciplines.

By learning to calm the nervous system, people can gain confidence in their ability to manage their own pain and related distress. We call this confidence “self-efficacy,” and it’s a powerful predictor for whether people will get better or not. People who believe they have tools to reduce their distress and suffering are more likely to use those skills, and gain good results from them. Part of our job as pain psychologists and health-care providers in general is to help connect patients to the right information so they can employ strategies and techniques to self-manage their symptoms.

Q: What happens when patients taper off of opioids? Does their pain increase or decrease?

Darnall: Many people remain on opioids out of fear that their pain will increase if they stop taking them. However, the data show that when people taper off opioids slowly, their pain tends to remain the same or improve. If opioids are stopped too quickly or if a single dose is missed, withdrawal symptoms are likely to occur, along with worse pain. A good, slow opioid taper will help patients avoid withdrawals altogether.

Q: How can medical schools better equip physicians to treat pain without medication?

Darnall: Most medical schools do not prepare physicians to handle the complexities of chronic pain management. A 2011 study showed that most U.S. medical schools included only four to 11 hours of specific educational content on pain across the entire four-year program — and that small amount of content was fragmented by topic. Pain was addressed within disease education — such as cancer or diabetes — instead of through a dedicated curriculum on comprehensive pain treatment. Physicians and all health-care providers need better training in the biopsychosocial model of pain treatment, and this need was identified by the 2016 National Pain Strategy developed by the U.S. Department of Health and Human Services.

Earlier this year, I, along with my colleagues on the Pain Psychology Task Force at the American Academy of Pain Medicine, published results from a national needs assessment we conducted about pain psychology training and resources. We surveyed 2,000 individuals across six key stakeholder groups in the U.S. Our results showed that, similar to physicians, the majority of mental health professionals and psychologists feel inadequately trained to address pain in the therapeutic context. Consequently, therapists may avoid the topic with their patients, thereby missing a critical opportunity to help their patients better manage their pain by emphasizing evidence-based behavioral skills and techniques.

While better education on the biopsychosocial treatment model of chronic pain is needed in medical schools, we also must give physicians and health-care professionals the resources to actually implement biopsychosocial pain care. This goes back to needing better training for mental health professionals so that primary care providers can easily refer their patients to competent therapists in the community who will directly address pain as a therapeutic target. In the pain psychology national needs assessment, we identified that pain education is needed at all levels of psychology education, including undergraduate, graduate, postgraduate, to continuing education for community professionals.

Q: How does the mind impact pain?

Darnall: The mind has a tremendous influence on the experience of pain. Multiple fMRI studies show that focusing on pain or ruminating on it can cause it to worsen. Rumination is one aspect of pain catastrophizing — when a person focuses on pain, magnifies it and feels helpless. The good news is that pain catastrophizing is treatable, and this is the focus of much of my NIH research. It’s an important therapeutic target because catastrophizing is linked to the development of chronic pain after surgery or an episode of acute pain. I teach my patients that even though they have a diagnosed medical condition, they are participating with their pain through their choices, thoughts and emotions. While we can’t change the medical diagnosis, we can target daily choices, thoughts and emotions to gain control and change the trajectory of pain.

Q: How do people with psychological distress respond differently to opioids?

Darnall: Anxiety and depression are common in individuals with chronic pain, and these conditions serve to worsen pain. Research shows that individuals with anxiety and depression are more likely to be prescribed opioids, and at higher doses. This is problematic because opioids may be unwittingly prescribed to treat the psychiatric symptoms that feed into pain. Opioids don’t just blunt physical pain, they blunt emotional experience, too, and this can be a powerful reward to an individual suffering from emotional distress related to pain or just life in general — and it can prolong opioid use. It’s critical that we address psychological distress with evidence-based treatments that emphasize behavioral medicine — psychological treatment. Emotional pain serves to increase physical pain, and vice versa; it is crucial that we treat both the physical and emotional experience because this yields the best results, and it helps avoid overreliance on medication and addiction.

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2024 ISSUE 1

Psychiatry’s new frontiers