Our new JAMA study on opioid tapering challenges assumptions, holds promise for patients

Chronic pain affects up to one-third of the world population. We recognize that an individual approach to treating pain is needed and that for some patients, prescription opioids are necessary. However, the overemphasis on treating chronic pain with opioids has been associated with substantial morbidity and mortality. With 6.8% of the U.S. population now taking long-term opioids, there is an urgent need to reduce opioids and patient risks and to treat pain better.

In my team’s new JAMA Internal Medicine study, we report our pilot data showing a potential method for effectively tapering patients on high-dose opioids without increasing their pain. This is the first report of community-based voluntary outpatient opioid tapering -- a method that can be scaled and broadly implemented across the U.S. with limited or no additional resources. Our results challenge common assumptions held by patients and the medical community about opioid tapering (that it will increase or cannot be done on an outpatient basis if doses are high), establishes a low-cost solution suitable for further study, and may dismantle several key barriers to reducing opioids effectively for patients who wish to do so. Limitations to note: (1) we studied patients who engaged voluntarily; (2) the study methods focus on increasing patient willingness to taper by helping them feel and be in control of the taper pace, and by providing them the right information; (3) anyone receiving treatment for substance use disorder was excluded; (4) replication is needed.

Read the full research here.

Dr. Darnall is now leading a team to study these patient-centered voluntary opioid tapering methods further. She recently received an $8.8 million PCORI research award to do so.

This multi-site study includes the implementation of these opioid tapering strategies and a randomized controlled trial (RCT) of two evidence-based behavioral chronic pain treatments (compared to patient-centered voluntary taper only) in almost 900 patients taking long-term opioids in 4 Western states. Patients were involved in the design of the study and will be involved at all stages of research.

The impact of this implementation research is underscored by our team having just received a Plenary Research Highlights Award and a feature presentation slot at the American Academy of Pain Medicine annual conference in Vancouver, Canada in April 2018 (post-doctoral fellow Dr. Maisa Ziadni will present our research findings).

"The Tao of Chronic Pain Relief" My feature in Jan/Feb 2018 issue

I was honored when Stephen Kiesling, the editor of Spirituality & Healthasked me to contribute content on addressing chronic pain with psychological strategies for the magazine. I ended up having a lot to say, and compiled it into a 5-page feature for the Jan/Feb 2018 issue! In the feature I describe the role of psychology in the experience and treatment of pain, and most importantly -- how pain can serve as a useful teacher that guides life choices, encouraging adaptation and correction where needed. Nobody wants chronic pain, but here I illustrate stories -- including my own -- wherein pain presented an opportunity for positive adaptation and growth. Pain is not commonly framed in those terms, and I hope you enjoy the discussion. Stephen encouraged me to include my story in a side-bar "The Making of a Pain Psychologist." Lastly, this article is practical. I included a 3-step actionable plan for empowered pain relief. The issue is on newsstands now, and it's also available for purchase online for immediate reading. Also in this issue are great articles on practices for cultivating future happiness and anti-inflammatory nutritional practices -- two topics that are highly relevant for pain relief!

Happy Reading,

Beth | @BethDarnall

TIME Features Science-Backed Pain & Stress Relief

Dr. Emma Seppälä and I were pleased to publish in Time Health "3 Science-backed Ways to Relieve Pain and Stress"! We focus on natural, empowering relief techniques that can help you feel better.

Stress and pain are inevitable parts of life. As many as 1 in 3 individuals lives with ongoing pain, and everyone is likely to experience it at some point in their life. While you cannot always control what happens to you, you can control how you respond to it. In the face of stress and pain, how you respond will determine the course of both! Humans are hardwired to focus attention pain and to want to escape it. Neuroimaging research and other studies show that focusing attention on pain unwittingly feeds the fire. Worse, not being able to escape pain naturally causes further stress, thereby further stoking the flames.

Rather than feeling trapped, try learning a simple formula to help steer your brain and body away from pain and stress; in doing so you starve the flames of both. Get motivated to help your brain and body respond to pain and stress in a different, more helpful way. Hardwired human biology will work against you until you learn some basic information and skills to take back your control. Gaining confidence in your ability to reduce your own suffering is half the battle. The road to confidence is paved with your daily use of pain and stress management skills. Over time, this new, helpful way of responding becomes your second nature, and suddenly: you got this!

Most people make the understandable mistake of focusing on what they don't want:  pain and stress. But, human physiology doesn't understand negatives. In the language of the brain, focusing more attention on pain only begets more pain because it lights up regions of the brain associated with pain processing (here's a technical article).  Your solution is to focus your attention more and more on what you do want:  peace, calmness, comfort. Doing so actually steers your brain away from pain and fosters calmness in mind and body -- the very things you were wanting.

Our article in Time goes into some detail about evidence-based treatments for relief. If it feels like a teaser, you can learn a lot more about harnessing the power of your brain to relieve pain by reading The Opioid-Free Pain Relief Kit, and Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain.

Wishing you the best of health!

Read my post on Medium!

Changing Mindset for Pain Relief

Cognitive Behavioral Therapy is evidence-based medicine for reducing the detrimental effects of negative mindset in the context of pain.

Transforming negative mindset is shown to reduce pain and improve pain treatment outcomes. The best part is that psychological treatment is non-pharmacological and very low risk.

In fact, treating negative mindset in the context of pain can help pain medications work better – which may lead to fewer pills. Click here to read Beth Darnall’s full story in Clinical Pain Advisor.

FREE Webinar on Alternatives to Opioids for Pain Treatment

Please join me and the President of the American Academy of Pain Medicine, Dr. Steve Stanos, on May 9, 2017, from 11:00 AM - 12:30 PM CST, for a lively discussion on reducing opioid use in the treatment of chronic pain.

Discussion topics include:

  • The psychology of pain and its role in determining a path to treatment
  • Leading non-opioid treatment modalities to address chronic pain and the latest research on pain catastrophizing
  • The need to support better integration of pain education and pain psychology into physician practices and treatment planning

Space is limited! Register to reserve your spot!

The webinar is hosted by OutFront Ideas.

"Scientific American" Feature on Treating Pain without Pills

The opioid crisis is forcing doctors to take different approaches to treating pain. In some cases, patients who have been prescribed opioids for years or decades are being abandoned or forced to quickly taper off opioids -- two poor approaches. Other patients are being steered in new directions that can improve pain and function with lower risks. I was honored to be featured in this Scientific American story (May 2017, Author: Stephani Sutherland, PhD) in which the stories of patients are told. Similar to patients I have treated in the past and detailed in Less Pain, Fewer Pills, one featured patient had an astounding result from stopping her opioids while receiving cognitive behavioral therapy for chronic pain (not general counseling).

There are many sides to the opioid crisis. The patients with a clear medical need should maintain access to the medications that work for them-- including opioids. And, there are so many patients taking opioids for whom opioids are not effective for them but have not been offered a different, better pathway that's right for them.

The notion of supporting access to opioids for some while fighting for access to evidence-based alternatives to opioid treatment can and should coexist. It's the same fight: The right treatment for the right patient. 

I invite you to read the May issue of Scientific American and learn more about what we are doing in the Division of Pain Medicine at Stanford University. Catch a glimpse of my view of how pain psychology is working to help patients with chronic pain reclaim their lives.

Using Psychology to Help People Have Less Pain After Surgery

At the Stanford Systems Neuroscience and Pain Lab, one of our active research studies is focused on how to help prepare people who are heading to surgery. We are equipping them with the information and skills they can use to reduce their own distress and discomfort after surgery. Ideally, this helps people need less pain medication. The program is called "My Surgical Success", and we are testing in women undergoing surgery for breast cancer at Stanford University.

Author Christina Frangou features "My Surgical Success" in her article published in Pain Medicine News this week. Read it here and learn what we and others (including surgeons) are doing to approach pain control from different angles.

Pain Psychology Resources Available to You Right Now

Optimize your mind-body connection with information and resources that empowers you to reduce pain and its impact on your brain and body.

(1) Understanding Pain in less than 5 minutes, and what to do about it! (5:00) View it here.

(2) Learn out Pain Psychology (12:47) View it here.

(3) What Is Pain Catastrophizing? (6:53) View it here.

(4) Free Online Mindfulness-Based Stress Reduction (MBSR)  8 week course. Learn more here.

(5) Free Mindfulness App and Guided Meditations. Download here.

(6)  Free Mobile Relaxation AppBreathe2Relax(from the Department of Defense) Download here.  

The Great Need for Pain Education in Psychology and Mental Health Training

Clinical Psychiatry Advisor features Beth Darnall and the work of the entire Pain Psychology Task Force of the American Academy of Pain Medicine in the August 2016 article "The Importance of Pain Psychology Curricula in Training and Education." (Author: Tori Rodriguez, MA, LPC).

Read about the national needs assessment that was conducted in almost 2,000 individuals across 6 key stakeholder groups in the U.S., and published in Pain Medicine earlier this year. Learn why a major solution to the pain treatment crisis includes better integration of pain education into mental health education at all levels of training.

Read the Psychiatry Advisor article here

Read the original Pain Medicine research article ("Pain Psychology: A Global Needs Assessment and National Call to Action", 2016) here.

"The Opioid-Free Pain Relief Kit" - FREE Copy, Enter to Win!

My inspiration for writing this second book was the patients I treat -- and the millions of other people living with pain who are seeking relief. I was also inspired by the legions of healthcare providers who are desperately looking for accessible, low-cost, non-opioid solutions to offer their patients.

The Opioid-Free Pain Relief Kit is an easy-to-read resource that’s chock full of information that patients can put to use immediately. Written at the 8th grade level, it is for the everyday individual who is missing crucial information about their pain: How they can best help themselves.

More than ever, there is pressure to reduce use of opioids to treat chronic pain and this leaves many patients wondering, “How will my doctors and healthcare team help me?” Perfect for handing out or recommending at point-of-care, this book serves as a foundation to emphasize that treating pain is not a passive process. Patients don’t want more pain, they simply lack the information they need to do it differently and reclaim their control from pain.

Best results are achieved when patients follow a plan and regularly use evidence-based skills that reduce pain processing in their nervous system—thereby reducing need for pain medication. This book gives them the understanding, the skills, and the plan they need to get started today:

  • Pain education about the essential role of psychology in the experience of pain
  • Evidence based pain psychology skills
  • Comes with a binaural enhanced pain management CD / audiofile
  • Simple and engaging exercises to develop self-management practices
  • How patients can reduce their need for pain medication through self-management (improved self-care, activity, sleep, pleasurable activities, exercises that reduce pain processing).
  • How to train the brain away from pain.
  • Self-empowerment by developing a “Complete Pain Relief Kit” based on evidenced-based skills and principles they learn in the book.
  • The slippery slope of opioids; how to minimize opioid use and how to keep yourself safe.
  • Generous use of graphics and illustrations deliver key messages visually and make reading the book fun.
  • Each chapter contains Beth’s Tips; think of it as “Your pain psychologist in a book!”

This book is perfect for all patients with pain—whether on or off opioids. It puts the patient in the driver’s seat—so they need fewer doctors and fewer pills! If purchased in bulk the book less than $6 per unit. Very low cost was our goal and I think we hit the mark!

Enter to win your free copy from Goodreads! Hurry, contest closes soon (August 3, 2016)!

"Less Pain, Fewer Pills" on The Healing Pain Podcast

I was excited when Dr. Joe Tatta invited me to be on "The Healing Pain Podcast" about psychology and its role in pain management, and symptom and medication reduction. We covered a lot of ground in our hour-long video interview, including what's needed to help patients suffer less and gain control over their experience. I talked about my new book, The Opioid-Free Pain Relief Kit ©2016 and learned that Dr. Tatta has a book of his own coming out in early 2017. A DPT who promotes the biopsychosocial model of pain treatment -- and educates the public about it -- he is a tour de force in the field.

Thank you Dr. Joe for a great and lively chat about reducing pain and improving function.

Our JAMA Internal Medicine Study of Opioid Risks After Surgery Published Today

Stanford Medicine News Center covers new research led by Dr. Eric Sun from the Stanford Division of Pain Medicine. The study, published in JAMA Internal Medicine, describes the incidence of and risk factors for chronic opioid use among opioid-naïve patients in the postoperative period. The study highlights which patients may be particularly vulnerable. Read the JAMA story here.

The Stanford Medicine News Story (author: Tracie White) includes a discussion about how to treat pain differently to minimize risks. I was pleased to weigh in about how to treat pain comprehensively with pain psychology skills, and to describe our current presurgical research on this topic. 

Dr. Sun's coauthors included Dr. Laurence Baker, myself, and Dr. Sean Mackey.

An International Furor Over Opioids and Long-term Solutions for Pain

Opioid limits alone are not good pain care policy. In the international furor over opioid overprescribing and overdose deaths, we must extend beyond the current zero-sum conversation that pits overdose deaths vs. patients who need access to pain care. This Huffington Post explores what's needed so everyone wins. 

Stanford Back Pain Education Day 2016! FREE!

Please join us for the 2016 Stanford Back Pain Education Day taking place on September 11, 2016 at Cemex Auditorium on Stanford University campus.

If you have back pain, please join us for an exciting day filled with lectures from Stanford pain experts and information on community resources, research opportunities, and state-of-the-art back pain treatments! 

In addition to great information and resources, all attendees receive complimentary lunch, goody bags, and other giveaways!

Registration is now full. Please join the waitlist.

Topics Covered

  • Pain and the Brain
  • The Psychology of Pain Relief:  Train Your Brain Away from Pain
  • Back Pain Self-Management: Help yourself feel better and live better
  • Pain and Relationships
  • Movement as Medicine for Back Pain

Read about last year's event: http://stan.md/27llFp2

Insurance Restricts Opioids - Now What for Pain?

The National Pain Report publishes a feature interview to address the question - what happens after opioids are limited or stopped? Patients with chronic pain are being unfairly punished for for the actions of addicts. And, importantly: how do we treat pain differently?

Beth Darnall, PhD addresses all of these questions and more. Read the article here.

Tapering Off Prescription Opioids: 7 Tips for Success!

Dr. Darnall's Healthgreatness article on Opioid Tapering HERE.

The specter of tapering off prescription opioids may be fraught with anxiety for the people taking them. Patients often worry about how they will manage the difficulty of the taper process. Patients also often mistakenly believe they will have more pain without opioids because they may have experienced more pain when they missed a dose and had withdrawal symptoms.  With the right formula and plan, tapering can go smoothly and easily-- without more pain.  Beth Darnall, PhD helps set you up for success with these 7 Tips for Prescription Opioid Tapering in this Heathgreatness article!   

Feature Interview with Pain Pathways Magazine - Less Pain, Fewer Pills

I was honored to be interviewed by Pain Pathways Magazine about Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain (Bull Publishing). Though Less Pain, Fewer Pills published almost 2 years ago, today it is more relevant than ever. In a climate of opioid restrictions, people with pain need alternatives. And, even if opioids are part of your medical plan, the book teaches you ways to reduce their own pain so that fewer pills are needed.

In this interview I discuss my own journey with chronic pain, and how it lead me down a road of working with others, so that their suffering might be lessened. Read the full interview here.

San Francisco Chronicle editorial on the pain and opioid crises, and a national call to action

My editorial published today in the San Francisco Chronicle. Topic: the pain and opioid crises, and what we need to do differently as a nation. The IOM Report, the National Pain Strategy, and the Pain Psychology Task Force at the American Academy of Pain Medicine are cited. 

Dr. Kate Lorig on the National Pain Strategy: The Golden Age of Self-Management

The 2016 National Pain Strategy has placed self-management firmly in the spotlight as a critical pathway to better treat pain in the U.S.

 Kate Lorig, DrPH

Kate Lorig, DrPH

Cue Dr. Kate Lorig, the Godmother of Self-Management. Dr. Lorig spearheaded the development of self-management education and treatment at Stanford University 3 decades ago, beginning with the Arthritis Self-Management Program. She and colleagues studied participant outcomes for her program and demonstrated some of the best results for any behavioral or educational intervention -- doubly impressive due to their incredible durability. Randomized controlled trials show that self-management programs confer improvements in self-efficacy and health status -- improvements that are sustained at 4 year follow-up (Lorig KR et al 1993). What's more, similar results are found for the internet-based adaptations of her programs across various pain conditions, including rheumatoid arthritis, osteoarthritis, and fibromyalgia (Lorig KR et al 2008).

What started out as self-management for arthritis has been expanded to HIV, cancer, chronic disease, and diabetes. All of the self-management programs teach participants how to help themselves become more active, manage symptoms, and problem solve effectively. Self-management is all about engaging patients in their own care (click here to learn more about self-management). Her programs are available in every state in the U.S. and in about 30 countries worldwide. They are offered widely in the US in Spanish and English and around the world in 20 different languages. In short, thirty years ago Dr. Lorig began a self-management movement that has literally changed the world.

All of Dr. Lorig's self-management programs have a component of pain education and self-management of pain.

Unsurprisingly, the National Pain Strategy includes language about the need to systematically integrate self-management into pain care.

I took the opportunity to sit down with Dr. Kate Lorig and hear in her own words what this all means.

This is very exciting 30 years ago we started with self-management for arthritis. In fact my first peer reviewed paper focused on how both patients and rheumatologists viewed arthritis pain. We conducted numerous randomized trials on the effectiveness of community based self-management programs for arthritis, pain, and co-morbid chronic conditions.     
People live 99 percent of their time outside of direct medical care. What they do during this time greatly determines their pain, their quality life and also their utilization of the health care system. To live this time most effectively, patients must learn self-management skills, and have the confidence to practice these skills on a day to day basis. Our research has shown us that patient confidence of the key to successful self-management. Fortunately, with carefully crafted programs with emphasis on action planning, modeling and reinterpretation of symptoms, confidence can be enhanced and in turn improve self-management. Over the years we have conducted many randomized trials and found that people attending our programs have less pain,  and less depression, are more active and utilize few health services than usual care controls. We now have more than a million people who have taken our community based or Internet based programs. These programs are usually free or low cost and in a few places are covered by third party insurers. 

With the endorsement of self-management by the National Pain Strategy -- what are the implications?

It means making changes for both patients and providers. For patients it means that they sometimes have to change the way they think about pain. We tend to think that when we are not feeling well, we can go to the doctor and get fixed. Unfortunately, for most people with pain this is not possible. For providers it means that they may have to think beyond the traditional treatments of medicine, surgery and physical therapy. Treatment for pain is not usually passive, it takes active participation of both provider and patient and the patient must learn the skills and gain the confidence to be an effective self-manager. This cannot be done in a few minutes.  Rather these are gained over time in a structured setting. For pain, self-management will continue to be a central part of pain management.

What does it mean for your work, and the work of your group?  

We will continue to spread our programs and hope to also develop an Internet based pain self-management program. We are in the best of all worlds for doing this. At Stanford we are part of the division of Rheumatology (arthritis) and also have an excellent working relationship with the Stanford Pain Management Center.

What’s the most exciting thing on your horizon at the moment?    

With the National Pain Strategy we stand ready to work with our pain partners to expand our programs and to forming new partnerships with health care providers. We will also release a Spanish pain self-management program later this year.

To find a program near you go to http://bit.ly/1R3xwwd. Look for the Pain self-management or the chronic disease self-management program. 

Read the final report of the National Pain Strategy here.