Chronic pain is an epidemic, currently affecting over 100 million American adults – more than diabetes, heart disease, and cancer combined. This doesn’t include children, 1 in 3 of whom live with a chronic pain condition ranging from migraine to chronic stomachaches. Chronic pain disrupts life, impeding the ability to work, exercise, have sex, engage in hobbies, even go outside. It’s the number one cause of long-term disability in the U.S. As if this wasn’t bad enough, we now find ourselves in the midst of an opioid epidemic – what the U.S. Department of Health calls “the most daunting and complex public health challenge of our time.”
We find ourselves in this pickle because pain has historically, and incorrectly, been framed as a purely biomedical problem, due exclusively to biological issues like tissue damage and system dysfunction. It has, therefore, primarily been treated with biomedical solutions, like pills and procedures. However, chronic pain is neither being cured nor solved. Addiction rates are skyrocketing, and the prevalence of chronic pain is actually on the rise. This is particularly true during COVID-19, when rates of chronic pain and opioid overdoses reached all-time highs.
To better understand pain, let’s first define it: The International Association for the Study of Pain (IASP) defines pain as an “unpleasant sensory and emotional experience.” Said another way: Pain is both physical and emotional, 100 percent of the time. It’s never just one or the other. This is confirmed by neuroscience research indicating that pain is processed by multiple parts of the central nervous system, including the limbic system – your brain’s emotion center. “Physical” pain is also, and always, impacted by your emotions.
So why do we have pain? Pain serves as the body’s warning system, keeping us safe and alive by warning us of possible danger or harm. Pain teaches us to avoid dangerous situations in the future, and motivates us to take action in the present. Step on a nail? Pain galvanizes you to pull it out! Break your leg on a run? Pain motivates you to stop, get help, and heal. And after you burn your hand on that hot stove, chances are high you’ll learn never to do it again.
You may reasonably believe that pain is located exclusively in your body, in the part that hurts. But pain is not constructed by your back, and it’s not constructed by your foot. It’s actually manufactured by the brain. Evidence of this is a condition called phantom limb pain, in which a patient loses a limb but continues to feel terrible pain in that missing body part. If pain were located exclusively in the body, no limb should mean no pain!
It’s also reasonable to believe that pain is due exclusively to body-based, biological issues, as promoted by the biomedical model (e.g., “the issue is in the tissues”). However, what we now know – and have actually known for decades – is that pain is not biomedical, but rather biopsychosocial. This means there are three overlapping, equally-important domains to target if we want to effectively treat pain: biological, psychological and sociological factors. The biological domain includes genetics, tissue damage, hormones, inflammation, anatomical, and system dysfunction, even sleep, and nutrition. This domain typically receives the most attention. But two-thirds of the model remain, and psychosocial factors, critical to address for effective treatment, are frequently ignored.
The psychological domain of pain includes thoughts and beliefs (e.g., “I’m broken, I’ll never get better”); emotions (e.g., anxiety, anger, depression); and coping behaviors (e.g., withdrawing, avoiding movement and activity). Social factors include socioeconomic status, access to care, race and ethnicity, social support, environment, and other sociological factors. Neuroscience research reveals that negative emotions; negative, anxious thoughts; and unhealthy coping behaviors actually amplify pain, exacerbate symptoms, and keep you stuck in a cycle of fear, inactivity, and pain. Said another way: stress, anxiety, depression, catastrophic thinking, negative predictions, focusing on pain, social withdrawal, lack of exercise, and activity avoidance all make pain worse.
On the flip side, however, this revelation offers some optimism: Research confirms that we can exert some control over pain by taking charge of emotions, thoughts, beliefs, attentional processes, and coping behaviors using treatments like cognitive behavioral therapy (CBT), biofeedback, and mindfulness-based stress reduction (MBSR). Pain education, or understanding pain, can also reduce pain and disability. Biobehavioral strategies like these have been shown to change both brain and body, neuroscience and biology, calming the pain system and increasing functioning. Indeed, psychosocial approaches to pain management are so critical that the CDC, FDA, National Academy of Medicine, Pain Task Force, and The Joint Commission recommend these treatments be prescribed before opioids, and be included as standard chronic pain treatment. As a pain psychologist, I see the effectiveness of these therapies every day in my practice, as patients get out of bed and resume their important lives.
If you treat chronic pain, or are someone living with it, remember this: Changing the brain can change pain. Addressing emotional health directly impacts physical health, because brain and body are always connected. Pain psychologists can serve as pain coaches – it doesn’t mean you’re crazy, and it’s not “all in your head” (it’s in your brain!). Try biobehavioral interventions like CBT, biofeedback, and mindfulness, and demand that your insurance company reimburse these treatments. If you’re a health care provider, spread the word about biopsychosocial pain management. Teach patients how pain works, connect brain with body, and offer hope. Knowledge is power. Let’s empower our patients – and each other – to find integrative solutions that work.
Rachel Zoffness is a pain psychologist.
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