Is chronic pain something more people should accept?

Amid the opioid crisis, the concept of “pain acceptance” is gaining credibility.

Is chronic pain something more people should accept?

Amid the opioid crisis, the concept of “pain acceptance” is gaining credibility.

When she was 42 years old, Gwenn Herman was in a car accident that left her with excruciating pain in her head, neck, and shoulders. She underwent a succession of treatments from surgery to acupuncture and was prescribed a range of medications, including opioids and antidepressants. There were complications from the surgeries; side effects from the medications gave her headaches and stomach pains and made her break out in hives all over her body.

The accident changed every aspect of her life. She was in so much pain she had to temporarily stop seeing clients in her private practice as a social worker in Potomac, Maryland. She couldn’t do activities with her kids like she used to and felt constant guilt as a result. She couldn’t drive. She couldn’t pick up a gallon of milk or slice a carrot. She felt lonely and isolated, and like nobody could understand what she was going through. “You lose yourself almost, because it feels like you’re not the same person that you were before,” Herman said. “I had suicidal thoughts. It wasn’t that I wanted to, or was going to, kill myself, but it was the only way I could see the pain ending.”

Then, Herman says, she “learned to change the messages” in her mind. It happened gradually as she moved through the stages of grief over the loss of her former identity and the intense physical pain that had become part of her daily life. She went from denial to anger to depression until finally she arrived at acceptance, a process that took about four years. Attending support groups also helped her come to terms with the fact that her pain wasn’t going away. “For me, acceptance was realizing that there had been a trauma that had fundamentally changed my body and I had to change with it,” she said. “With the body that you have now, you need to create a new life for yourself. You have to let go of the past and live as you are now.”

Listen to a behind the scenes interview with Clare Fonan about the making of this feature, and additional thoughts on pain acceptance therapy.

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Research dating back more than a decade suggests  that people with chronic pain may be able to improve their quality of life if they stop trying to avoid or get rid of their pain and instead learn to live as well as they can as the pain persists, a concept referred to in clinical settings as pain acceptance. Some psychologists and psychiatrists believe that pain acceptance might even help counteract opioid abuse in the United States, a problem so severe that it has contributed to a decline in American life expectancy. The idea that pain acceptance might serve as an effective alternative to opioids is an emerging area of research and not something that has been definitively established. As the idea attracts attention in the world of pain management and in the media, it has also generated controversy.

An estimated five to eight million Americans take opioids to manage long-term chronic pain, and the number of people in the U.S. who have died from overdosing on opioids — a class of drugs that includes prescription painkillers like oxycodone and illicit substances like heroin — has risen dramatically in recent years. In 2016, prescription opioids were involved in roughly 40 percent of opioid overdose deaths, according to the U.S. Department of Health and Human Services. There are plenty of people who don’t become addicted to prescription opioids, but taking them involves serious risks, from adverse side effects to the potential for dependence. A backlash against the drugs, from state laws limiting access to federal guidelines warning of their risks, has sent doctors searching for alternative treatments. In the midst of the crisis, some pain and addiction researchers are interested in determining whether pain acceptance could help people cut back on opioids.

Several studies have raised the possibility that people who are less accepting of pain may be more likely to become dependent on painkillers. A 2015 article in the journal Drug and Alcohol Dependence found that people who were better able to live with pain without attempting to reduce or avoid it had less severe problems with opioids. The study reported that pain intensity itself was not significantly associated with the severity of problematic opioid use. That led the authors to conclude that the extent to which a person accepts and adapts to pain, or doesn’t, may be “more important as a risk factor for the misuse of prescription opioids or heroin than is the actual severity of pain.”

In September 2017, an article in the Clinical Journal of Pain found that people who were more accepting of chronic pain used less pain medication, including opioids, regardless of the severity of their pain. “We think that’s a good indicator that increasing pain acceptance in people with chronic pain might reduce their reliance on pain medication,” said Dr. Anna Kratz, an assistant professor of physical medicine and rehabilitation at the University of Michigan who helped carry out the study. “They might turn less to medications on a day-to-day basis if they have more pain acceptance.”

It may not be surprising that people with chronic pain don’t necessarily like the idea of accepting it. When researchers at the University of New Brunswick asked women with chronic pain from arthritis and fibromyalgia what they thought about pain acceptance, many had a negative reaction. Most of the women associated acceptance with “giving up or giving in to their pain,” the researchers wrote in the journal Pain Research and Management in 2008. But many of the women had learned to live with their pain in a way that roughly aligned with the concept of pain acceptance: They were determined to live as well as they could despite their conditions. Rather than describing that as acceptance, the women preferred to use words like “embracing,” “coming to terms with” or “dealing” with their pain.

There’s no one way that people learn to accept and live with chronic pain. What works for one person might not work for another. But some individuals participate in a form of therapy called acceptance and commitment therapy — commonly referred to as ACT. Developed in the 1980s and 1990s, acceptance and commitment therapy emerged out of the tradition of cognitive behavioral therapy. In contrast to traditional cognitive therapy, acceptance and commitment therapy asks people to accept thoughts, feelings, memories, and bodily sensations that are beyond their control, rather than attempt to change or get rid of them. The therapy then encourages people with chronic pain to take part in activities that add value and meaning to their lives, even as pain persists.

“The message of traditional pain management is that you’ve got to manage the pain first and then get back to your life. But entire lives can be lost in the pursuit of pain relief that may never come,” said Dr. Kevin Vowles, a clinical psychologist and associate professor at the University of New Mexico. “The message of acceptance and commitment therapy is that it’s possible to begin to rebuild one’s life even with pain.”

The Society of Clinical Psychology, a division of the American Psychological Association, considers the research in support of acceptance and commitment therapy for chronic pain to be strong. The therapy is typically covered by insurance in the U.S. as long as a particular plan covers psychotherapy, and is used to treat chronic pain in men, women, adolescents and children. Women are more likely than men to experience chronic pain, according to the Centers for Disease Control and Prevention, and may become dependent on prescription painkillers faster, though men are more likely to die of an overdose.

Mary Ann Harvey, a 56-year-old woman who lives in Pittsburgh, Pennsylvania, started acceptance and commitment therapy in 2014 shortly after she was diagnosed with Ehlers-Danlos syndrome, a connective tissue disorder. “I was falling apart physically and mentally and knew I needed help,” she said. So she found a therapist who specialized in chronic pain and anxiety.

It may not be surprising that people with chronic pain don’t necessarily like the idea of accepting it.

Harvey has pain all over her body as a result of her condition. The worst of it is a constant ache in her spine. She also experiences stabbing pains in her neck and numbness and tingling in one of her hands. Wet and cold weather can cause the arthritis in her spine, hands, knees, and hip to flare up, which she says makes the pain “practically intolerable.”

She credits acceptance and commitment therapy with helping her develop coping strategies to take her mind off the pain so that she can focus attention and energy elsewhere. Sometimes that means trying to find joy in day-to-day moments despite the pain. Sometimes it means deciding to go out and see a movie instead of staying inside all day fixating on the pain. “I may as well do things I want to do even though it will hurt, rather than just do nothing and still be in pain," she said. Harvey also credits acceptance and commitment therapy with helping her stop taking tramadol, a prescription opioid painkiller that made her nauseous and left her feeling like she couldn’t think straight.

But acceptance and commitment therapy is only one way Harvey manages her pain — and sometimes the pain gets so bad that she feels like all the progress she’s made in therapy nearly gets undone. “There are times when it’s very hard to accept it,” she said. “It can be very difficult to come back from that.” To deal with the pain and recover from setbacks, Harvey turns to her support system: Her husband and online support groups for people with Ehlers-Danlos syndrome. She gives herself time to rest. She tries to maintain a healthy diet and exercise as regularly as possible. And she still takes pain medication. She has several prescriptions for non-opioid pain relievers, including one that’s similar to ibuprofen. She also takes antidepressants. “There are definitely times when therapy alone would not cut it. No way,” she said.

Pain acceptance is not without its detractors. Vox recently devoted an episode of its podcast “The Impact” to pain acceptance. The episode called it “a possible future for pain treatment.” In response, the website The Mighty, which describes itself as “a digital health community” with more than a million users, published several posts critical of the idea. “The podcast prompted a backlash from people with chronic pain, who argued that saying a level of chronic pain is ‘acceptable’ essentially abandons chronic pain patients,” an editor for the website wrote in one post. “Rather than tell them they need to accept their pain, they need more pain-relief options, doctors who are willing to fight for them, and less stigma against using opioids responsibly.”

That backlash may be fueled by fears that some people with chronic pain have expressed that the health care system is leaving them  behind in the rush to condemn opioids. Some doctors and patients warn that the movement to decrease opioid use for chronic pain has gone too far, amounting to a dangerous overreaction that risks cutting people off from medication they need.

“What worries me so much is that insurers and regulators have convinced themselves that if a patient is forced off of opioids and told ‘go do A, B or C’ they are somehow safer,” said Dr. Stefan Kertesz, a professor at the University of Alabama at Birmingham School of Medicine. “Patients who are stable and functional on opioids are being forced to go off them and told, ‘hey, this is in your head and yoga or ACT or whatever else is better.’”

Misconceptions over what pain acceptance means and the kind of negative reactions that people sometimes have when they hear about it may also prompt pushback. After all, learning to live with pain inevitably clashes with the the hope of finding a cure.

“Pain acceptance is still controversial in the broader medical community. Patients and doctors tend not to want to hear that they need to accept pain. They think it sounds pessimistic and defeatist,” said Dr. Mark Sullivan, a psychiatrist at the University of Washington who has written critically about opioids. “The way the health-care system is set up is: Come see us, we’ll fix it, there’s an answer for everything. There are lots and lots of promises and some of them are unrealistic, but people don’t want to hear that. They want a machine or a needle or a pill to take the pain away.”

Even people who believe that accepting pain has benefited them don’t necessarily think it should be used as a way to cut down on prescription opioid painkillers.

Even people who believe that accepting pain has benefited them don’t necessarily think it should be used as a way to cut down on prescription opioid painkillers.

“I see acceptance as a way of dealing with the psychological and emotional aspect of chronic pain, not as a replacement for anything else,” said Herman. It’s been more two decades since the car accident that left her with chronic pain and she now runs support groups as part of a program called Pain Connection, which is affiliated with the non-profit U.S. Pain Foundation​. “There are people who have taken opioids for years so that they’re able to function,” she said. “Nobody should have the medicine that they need to live or function taken away.”

Pain acceptance doesn’t have to be an alternative to anything else. It can serve as a coping mechanism alongside other forms of pain management. But as long as the opioid crisis continues, researchers, doctors, and policymakers will continue to look for solutions. And that might include approaches to pain management that don’t rely on avoiding or getting rid of it.

Clare Foran is a writer in Washington, D.C. Illustration by Ariel Davis for The Outline.