Pain management beyond prescription pills [PODCAST]

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In this episode, we welcome Cindy Perlin, a licensed clinical social worker and chronic pain survivor, to discuss the ongoing issue of prescription painkiller abuse and the dangers of relying on medication to treat pain. Research shows that physicians continue to prescribe large amounts of opioids for patients with minor pain issues, as well as other potentially harmful drugs like NSAIDs and gabapentinoids. Despite the risks, these medications are often preferred over safer, alternative treatments like medical marijuana, kratom, low-dose naltrexone, nutritional interventions, mind/body therapies, massage, acupuncture, and light therapy. Insurance companies also often do not cover these alternative options, leaving patients suffering unnecessarily and turning to dangerous street drugs. Cindy shares her personal experience with chronic pain and the importance of advocating for oneself to find the most effective and safe treatment options. This episode discusses the need for a shift in the way pain is treated and the availability of safe, effective alternatives.

Cindy Perlin is a licensed clinical social worker, chronic pain survivor, and author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. She is founder and CEO, Alternative Pain Treatment Directory.

She shares her story and discusses her KevinMD article, “It’s time for a reckoning in pain medicine.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Cindy Perlin. She’s a licensed clinical social worker, chronic pain survivor, and author of the book The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. She’s also the founder and CEO of the Alternative Pain Treatment Directory. Cindy, welcome to the show.

Cindy Perlin: Thank you. Thank you for having me on.

Kevin Pho: We’ll get into your article in a little bit, but first off, just briefly share your story and journey to where you are today.

Cindy Perlin: I would say that one of the biggest influences on my life was when I was 25. I was in graduate school, and I hurt my back, and that was the start of three and a half years of 24/7 excruciating pain. I wasn’t able to find a doctor who could help me. Toward the end of that time, I went to a very well-respected orthopedic surgeon, and he spent 45 minutes with me and said, “I don’t know what’s wrong with you. I don’t know how to help you. This could be the way you feel for the rest of your life.” That was pretty devastating, and I didn’t quite know what to do.

I tried to go back to work at that point. I’d been nonfunctional for about three and a half years, and a friend of mine suggested that I read a book called Anatomy of an Illness by Norman Cousins. He had healed himself from a progressively crippling joint disease with laughter therapy. He was told he had almost no hope of getting better, and he didn’t like that idea, so he did some research, and he came up with the mind-body connection: that if you were in a good mental state and had a will to live, you were more likely to heal. That book just turned my life around.

He mentioned biofeedback, so I went for biofeedback treatment, and in one day my pain was reduced by 50 percent. That was because I was in so much fear, and fear was driving the pain. I felt so out of control. So I kept working with that and kept getting better.

Then I developed a foot problem that I couldn’t figure out for 14 years, and neither could the doctor. That’s when I discovered there’s no one-size-fits-all for chronic pain. That involved very deep bodywork to rebalance the muscles in my foot, which had gotten out of balance because of some foot surgery that I had for a bone spur. I just got really enthusiastic about researching pain, and then the opioid crisis came along, and I decided to write a book and then do a website to educate people about pain options.

Kevin Pho: Chronic pain, both for clinicians and patients, is one of the most challenging areas of medicine. So talk about your interactions with the health care system in terms of the attempts that they made to try to alleviate your chronic pain.

Cindy Perlin: I was enrolled in one of the first HMOs in my area, and they had a limited range of options that they offered. It was mainly medication, and they put me on all different kinds of medication, none of which made any difference at all. I discovered many years later that one of them was a narcotic. I don’t think they prescribe it anymore; it’s called Talwin. They gave me anti-inflammatory drugs. They gave me Valium as a muscle relaxant. I was just a zombie with that, but I was still in pain.

They put me through X-rays, and they couldn’t find anything. I think that if I was older and had age-related degenerative disc disease, they probably would have pointed at that and said that was my problem. So I’m very glad that they didn’t see that on my X-rays. They would just leave me hanging. I pursued chiropractic care on my own, and that made a tiny bit of difference, but not enough to really alleviate the pain and get me back to functioning. So basically, they were washing their hands of me and saying they couldn’t do anything.

Kevin Pho: After they did that, where did you turn in terms of looking for other options to help with your pain?

Cindy Perlin: Well, as I mentioned earlier, I was referred to a book by a friend of mine. She happened to be a health reporter, so she was kind of up on what was coming out in the health field. At the time I read that book, I was in bed most of the time. I was seeing an osteopath who told me to do nothing but stay in bed until I felt better. Now we know that’s a really bad idea, that people’s pain gets worse.

But while I was in bed, just to make matters even worse, I was watching the Holocaust miniseries and reading books about World War II and the Holocaust, and that’s pretty depressing. I had no idea that the mind and the body were connected and that what I was putting in my mind was affecting my body.

Kevin Pho: You mentioned that you wrote your own book on this issue, The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. Your KevinMD article is titled “It’s time for a reckoning in pain medicine.” So take us into the background. What led you to write this article for KevinMD?

Cindy Perlin: Well, I guess years of frustration, watching them continue to prescribe opioids and defend opioids and not look at other options in spite of the opioid crisis. The two are connected. We’ve now had many lawsuits that have affirmed that the pharmaceutical companies promoted opioids as the solution for chronic pain, and health insurance companies dropped other options.

When I first started to practice as a clinician, because I’m also a clinician working with chronic pain, there were multidisciplinary pain clinics all over the country that were really helping people. They were residential programs where people would get evaluated by multiple providers, and they’d get a treatment plan, and they’d be put through a rigorous treatment plan, and they’d get better. It was the most well-validated, evidence-based treatment for chronic pain at the time. When opioids came along, or started getting promoted as the solution, health insurance companies threw out those programs, and they all closed. There were about a thousand of them at the time; now we’re down to about 50.

We need to turn that around. We need to start looking at pain as the complex problem that it is, and recognize that it’s not a medication deficiency. More and more people are in chronic pain. So I was just frustrated with policymakers not paying attention, and with doctors. Most of them are either afraid of the DEA and getting arrested, which I don’t blame them for, or they’re prescribing for new patients and don’t understand, still don’t believe, how addictive these drugs can be.

Kevin Pho: When you say that clinicians need to treat chronic pain as the complex problem that it is, what exactly do you mean by that?

Cindy Perlin: Well, first of all, it has a cause, and the causes are varied, and they need to look at what’s contributing. Some of the things they don’t look at are chronic overarousal from either chronic stress or unresolved trauma, muscle imbalances, nutritional deficiencies, and poor diet. Things like that contribute to pain, and they don’t look at them.

It’s also recognizing that it’s cyclical. When people are in pain, they get stressed and lack sleep, and the pain drives more pain and more stress, and they have to interrupt the cycle and get at why people are in pain. Treating with medication will numb the pain for a little while, but I don’t know of any medication that cures pain.

Kevin Pho: Tell us about some of these other options that you alluded to previously in terms of our toolbox on how to treat chronic pain.

Cindy Perlin: One set of interventions would be in the mind-body realm, helping people get out of chronic arousal, which, as I said earlier, can come from just being chronically stressed. When you’re in chronic pain, there are a lot of losses. There’s loss of activities you enjoy, work, income, and often relationships. You have to deal with that stress. You have to work through the trauma, and talk therapy will not resolve trauma. It will help you understand it, but it doesn’t get it out of your nervous system. So there are techniques that will get it out of your nervous system.

Then you have to look at whether there are muscle imbalances, whether there are trigger points that are contributing, and treat those with some kind of bodywork, usually massage, chiropractic, or physical therapy. There are nutritional interventions. Vitamin D deficiency can cause widespread pain that can look like things like fibromyalgia. There are inflammatory diets that you need to change.

Then there are interventions like medical marijuana that are much less risky than opioids, and people who switch from opioids to marijuana for treating chronic pain tend to report that they get more effective relief with fewer side effects. One of the most important things about marijuana is that it’s been used for 5,000 to 10,000 years that we know of, and no one’s ever died of an overdose. So it’s encouraging that we’re seeing more and more recognition and more and more accessibility through legalization, so people can access marijuana.

Kevin Pho: When you talk about exploring that mind-body connection when it comes to pain, is this something a primary care clinician like myself can do? Does this need to be referred to some type of therapist or specialist? What are our options for that?

Cindy Perlin: Well, I think the first problem with primary care physicians is that they don’t have the time. The way that our insurance is structured now, primary care physicians can’t spend a lot of time with patients, and that’s something that takes time. Some people are completely unaware of what’s driving their pain, and it takes a while sometimes to discover what’s driving their emotional distress. They don’t understand it.

There’s something called little-t trauma that people don’t really think about as trauma, but it’s where, as you’re growing up, you’re constantly criticized or emotionally neglected, not having your emotional needs met, and that is often a driving force behind pain. So you really need the time to explore with people what’s going on. Pain patients, and all patients, are very sensitive to any implication that it’s in their head. It’s not in their head. It’s physiological, but their brain is often driving the physiology. So it’s something that generally would involve a referral.

Besides time, there’s quite a bit of training needed. Sometimes people without specific psychotherapy training can be very good at helping people through emotional distress, but usually it takes a trained provider.

Kevin Pho: You mentioned medical marijuana. What about CBD oil?

Cindy Perlin: CBD oil can also be very effective. With both of them, it’s really important to figure out the dose that’s right and the route of administration that’s right, because you can use either one: You can smoke it, you can use it topically, or you can take it orally. Then with both, though I’ve seen this more with CBD, there’s like a bell curve: Too little won’t help, and too much won’t help. So you have to find that sweet spot that works for you, and a lot of people give up on it too soon.

I’m one of those people who can’t tolerate the THC in marijuana at all. It makes me dizzy and ramps up my heart rate and my blood pressure, and I can’t use it at all. But many people tolerate it well, and it’s really effective for them. If people can’t tolerate marijuana, or it’s not legal where they are, CBD can also work well. There are preparations out there now that combine CBD with essential oils, and that seems to be a really good combination for topical pain relief.

Kevin Pho: When clinicians send patients to a CBD dispensary, there’s a wide variety of options. What are some of the things that patients should look for when looking for CBD?

Cindy Perlin: Well, I think that’s a hard question to answer. Hopefully, if they’re at a dispensary, the dispensary has vetted the products for purity, standardization, and lack of contamination, so they’re good-quality products. Then it’s looking at the strength of the preparation and basically starting low and going high. If you combine topical with oral, that’s probably your best combination. If your pain is localized, you can use a topical right on the area of pain, and then you can use the oral as a systemic treatment.

The thing about the cannabinoids that are in CBD and marijuana is that our body makes similar compounds and uses them to treat stress and injury. So in that case, some people may be cannabinoid-deficient, and they’re actually replacing or augmenting their natural cannabinoids. That’s why, if they get the right dose and the right kind, it tends to be low in side effects and well tolerated.

Kevin Pho: Now, you mentioned the mind-body connection, nutrition, medical marijuana, and CBD. What other options should we consider when it comes to chronic pain management?

Cindy Perlin: One of my favorites is light therapy. It started out with people talking about low-level laser therapy, which is laser therapy in the red and infrared light spectrum, and it’s very highly concentrated light. Now people are using LEDs, which are less concentrated, and there are home-use devices. What this does is change the permeability of the cells so that they can admit more cellular energy, oxygen, and nutrition, and toxins can leave the cells more readily. What happens is it promotes pain relief, it’s anti-inflammatory, and it also accelerates healing.

So that’s something that I use myself almost daily for various ailments that I have, and I find it very helpful. Once you make the investment, and these days you can get devices for home use that are relatively inexpensive, it’s there to use for years and readily available. So that’s another thing that I really like.

Kevin Pho: I’m actually not too familiar with light therapy. Walk us through the device and the process, and what kind of pain does it particularly treat?

Cindy Perlin: As I mentioned earlier, it’s red and infrared light, and there are different devices. You can get very high-priced clinical devices. Most devices have a small probe that you would put on the spot for a specified amount of time. If it’s a very powerful clinical device, like one of the devices that I have, you would keep it on the area for 30 seconds to one minute. That’s a very expensive device. Another device that I have that’s a lot less expensive, you would keep on the area for half an hour. So the timing of the dose is dependent on the power of the device. You basically put it against your skin and leave it on there for the specified amount of time, and use it at least two to three times a week optimally. If it’s a home-use device, you could use it every day or twice a day. As I said, it accelerates healing and reduces inflammation, so the more you can use it, the better.

In terms of the types of pain that it helps, just about anything: muscle pain, joint pain, neuropathy. It also promotes wound healing. Once your wound is uncovered, since it has to be used with no barrier between the device and the skin, you can use it on a wound. It’s being used for diabetic ulcers. It’s being used for, I don’t know what the technical term is, but mouth ulcers that come from chemotherapy; it’s been used in the mouth for that. It’s been used for brain injury.

I have a device that’s called an Auragen, A-U-R-A-G-E-N, and it’s basically a hood. You put your head in the device lying down, and besides the red light therapy, you can use gamma frequency, and it entrains your brain to gamma frequency, which is a healing frequency for the brain. So that’s being used to treat long COVID, and that device can deal with systemic and localized pain too. It’s one of my favorite things now.

Kevin Pho: Now, in general, how expensive are these devices, and are they covered by insurers?

Cindy Perlin: Well, the answer to the second question is no, and that needs to change. You can find devices for very little, and I’m not sure how good they are. You can go on Amazon, and they’ll say red light therapy, but you really have to look at the specifications, because some of them are like light bulbs, red light bulbs, and you don’t want that, because that’s not going to really do much for you. You want a device that is in the right frequency and wavelength range.

The most inexpensive one that I recommend is called the DNA Vibe Jazz Band, and you can get it discounted for about $200. It plugs into the wall, and it’s got different settings. Another thing I like about this device is that it not only has red light therapy, it also has pulsed electromagnetic therapy, which is another therapy with similar benefits. It sends the body electrical frequencies that are healing frequencies. Then it also has vibration, and vibration helps circulation. So you’re getting all three of those in one device.

I tried that. I had broken my ankle, and my ankle had chronic swelling, and I didn’t use anything else. I just used that for about three weeks, and it really helped. I had pressure sensitivity and swelling, and it went away while I was using that device regularly.

Kevin Pho: We’re talking to Cindy Perlin. She’s a licensed clinical social worker and author of the book The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. Her KevinMD article is titled “It’s time for a reckoning in pain medicine.” Cindy, what are some of your take-home messages that you want to leave with the KevinMD audience?

Cindy Perlin: Well, I’d like pain patients and doctors to know that there’s a lot more out there than pharmaceutical and surgical interventions, and they are generally safer and more effective for chronic pain and acute pain. For people who think they’ve tried everything, they probably haven’t even started, because there’s so much out there, and there is hope for getting better. Don’t lose hope. Keep looking for solutions.

I highly recommend that people go to my website, the Alternative Pain Treatment Directory, at PainTreatmentDirectory.com. At this point, there are hundreds of articles and over 100 recommended products and provider listings, and people can find lots of information there that can help.

Kevin Pho: Cindy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Cindy Perlin: Thank you so much for inviting me.

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