Transcription:

Scott Webb (Host): You would think that people who've been prescribed opioids for chronic pain would have severely painful physical pathology, but this is probably more the exception than the rule. In the United States, we have been prescribing opioids as a psychotropic medication for the last 25 years. And now we have hundreds of thousands if not millions of Americans who have been prescribed opioid pain medications for pain, who are looking for a way off the medication, but our healthcare system struggles to help them to do this safely. And today, Dr. Bennet Davis, Director of the Pain Recovery Program at Sierra Tucson, will explore how we got to this point and what we can do about it.

This is Let's Talk Mind, Body, Spirit by Sierra Tucson. Sierra Tucson ranked number one best addiction treatment centers, 2020 in Arizona by Newsweek. I'm Scott Webb, Dr. Davis, it's so great to have you on again today. Today we're talking about chronic pain and opioids and opioid addiction crisis in this country and Sierra Tucson's perspective on all of this. As we get rolling here, can you explain why people have chronic pain and briefly define what chronic pain is exactly?

Bennet Davis, MD (Guest): I think defining chronic pain, the best way to start is talk about acute pain, something everyone has experienced. And this will just take me a moment to lay this out. We've all broken something, had a burn, had a cut, something like that, that hurts. That's what we would call acute pain. Number one thing to understand is chronic pain is very different from that process, biologically different. With acute pain what's happening is you've got some sort of tissue damage or injury that is stimulating these little nerve endings that can sense things that damage us can sense too much heat, too much cold, too much pressure, inflammation, things like that.

Those sensors fire a little signal through the nervous system to the brain and voila, we're warned that something is wrong and we need to take action. That's acute pain. Chronic pain is very different. Sometimes that process I just described is involved, but not always. And let me give you an example explain phantom limb pain using the paradigm for acute pain that I just gave you. So, a person has lost their right leg and they feel their right foot hurts. How can you explain that using that acute pain biology scenario that I just gave you? There is no foot, there are no sensors being stimulated by too much cold, too much pressure, too much heat.

That's not happening. So, where's it coming from? That's usually the first thing I'll ask when I'm sitting down with people and spending some time explaining what chronic pain is. Well, it's coming from the nervous system. It's coming from in the nervous system somewhere. And a lot of people will point to their head and say, it's coming from the head. Not necessarily. The whole nervous system, the hyphen between the mind and body is the nervous system. And that's where that's coming from. So often chronic pain is coming from within the nervous system.

Host: It's really interesting. You've given me, you know, as I'm sure for listeners as well, you've given me a lot to think about here cause I'm thinking, okay. So it's not really the limb per se, it's the nervous system. And that's just a great way to understand, you know, we've all suffered as you say, acute pain. And now understanding really where chronic pain originates from probably informs where we're going in this conversation about how we got where we are with opioids and so on. Before we get there, how does anxiety and depression play into chronic pain?

Dr. Davis: Anxiety and depression don't make anything better. Right. And everyone agrees with that. I mean, I can't think of one person who said, yeah, I'm better when I'm anxious and depressed. So, they will make pain either acute or chronic, worse. However, as far as we can tell, the evidence is that neither depression, nor anxiety can cause pain. There are other things that can cause pain, but they aren't in there. So, when we're treating people with chronic pain, I've heard people sort of lapse into yeah, it's cause of my depression or something. That's not true. We actually don't have evidence that depression and anxiety can change the way the nervous system works and cause that kind of pain from the nervous system that I was talking to you about.

However, and I'll just hang this out there. Opioids are really good at alleviating depression and anxiety, particularly anxiety, and even at low doses, we're experimenting with low doses of some opioids to see if we can use them to treat depression and anxiety. And I don't mean to say in the same sense as somebody who gets drunk and can't feel anything, I'm not talking about numbing out. It's another common narrative out there. I'm talking about using opioids at low enough doses so people can almost not even feel the effect except they reduce anxiety. So that's something to keep in mind.

Host: Yeah. And you and I were speaking before we got rolling here, just about you mentioned there too about the narratives that are out there, and I know there's a big narrative out there and I don't know how much you want to get into, but at least briefly, what type of patient is being prescribed opioids for pain?

Bennet Davis, MD (Guest): So the patient's getting opioids for pain could be in the obviously the acute pain group. You know, you go to hospital, after surgery, people are getting morphine shots, things like that. I think what we're really talking about is the chronic pain population. So, in the last 20, 30 years we decided, I used the word decided, there was a lot of marketing that kind of led us. We were led to prescribe a lot of opioid for people with chronic pain without really understanding what it is. I think most healthcare providers in the last 30 years, prescribing opioid to a patient with chronic pain had in mind that acute pain biology I was talking about, they thought that's what they were treating, something wrong with the tissue.

It turns out that a large percentage, maybe the majority of people with chronic pain have pain coming from that hyphen between the mind and the body from in the nervous system. And I give you an example of phantom limb pain, but that actually the thing that seems to be causing pain from the nervous system in our chronic pain patients, the most, would be exposure to trauma, traumatic events and also grief.

So trauma and grief are experiences. This is really hard to get your head around, but they're experiences that look like they can change the nervous system. So it kind of does that in phantom limb pain. It reports essentially a lie to the brain. It says your tissues are on fire. Like somebody with fibromyalgia would say, my skin is on fire.

Well, no, it's not. Nothing wrong with the skin. The nervous system is reporting pain signals to the brain in this case, because of the changes in the nervous system, consequent to trauma and, or grief. That's the majority of our chronic pain patients. They'll present with pain and we've been prescribing opioids essentially to treat trauma and grief.

Host: Interesting. Yeah.

Dr. Davis: That's a good leader right there.

Host: Yeah. There's a lot of layers here to peel back and I'm just trying to process all of this. One of the questions that comes to mind is then based on what you're describing and who the typical patient is, and really what doctors have been treating, whether they realized that or not. Now, what are the implications of this for your type of evaluation and treatment there at Sierra Tucson?

Dr. Davis: Yeah, that's a great question. Let me take a step back on that. What are the implications of what I'm saying to deprescribing opioids? So, we've got a lot of Americans on opioids. In the last few years, we've seen a couple of things that warn us that you can't just take people off because that increases the risk of psychological decompensation of really bad things.

Even suicide attempts. There was an article recently published from UC Davis and they should get credit for doing that, that work showing how bad it can be psychologically simply to take people off opioids. The FDA issued a similar warning and if you think about it, why are people struggling psychologically when we take them off of opioids. Getting back to what I said just a while ago, because it turns out we're treating trauma and grief with the opioids. And if you simply take the medicine, that's sort of keeping that at bay away, people often decompensate. So, at Sierra Tucson, what we're doing is we're looking at the whole person to find out well, is there a physical thing in the tissue that's causing pressure, inflammation, that sort of thing that we need to further work up and treat?

Is there a change in the nervous system from nerve injury or from trauma or from grief that we need to address. And finally, how much is the opioid simply being used to treat depression and anxiety? That sounds weird, but underscore treat depression, anxiety, not an addiction disorder, those exist of course, but that's a different scenario. And we're going to evaluate to see if substance use disorder has cropped up because that does come our way as well of course.

Host: And do you see better results when you use that combined approach that behavioral and medical approach?

Dr. Davis: Absolutely. We're not treating people who are suffering the consequences of trauma and grief, medically and vice versa. The majority of people have a combination of all the types of chronic pain I'm talking about. They may have a injury to the back, something like that, and also the trauma and the grief. So we're treating the whole thing at once. That's why you have to have that sort of medical behavioral model and the results are much, much better. In fact, that's why I came to Sierra Tucson. I'm a medical doctor. My background is in orthopedics, anesthesiology, pain medicine, that sort of thing. But I'm here because we need the tools that a place like Sierra Tucson has to treat chronic pain.

Host: Yeah, that's really interesting. And glad to hear your personal story just a little bit there, and I can see really the benefits as I'm sure listeners can. The benefits of the behavioral medical approach, that combined approach. I know you have to be careful due to privacy issues and concerns, but can you share an example of a success story?

Dr. Davis: Yeah, I have a thank you card from a gentleman who was here oh, four six months ago. Retired military. Special Forces career. And he had many injuries, from sports when he's growing up, military related injuries and had that type of pain I described at the very beginning for sure, broken parts and so on.

But it turns out he had had a really rough upbringing. And he had been exposed to traumatic events in the military. All we did for this guy who was really struggling with pain, he felt pain in a number of parts of his body, back, head, neck, and kind of an all over pain as well. All we did was really push the trauma grief narrative, the losses that he'd had in his service in the military, the trauma from growing up primarily, the developmental trauma we would call it. That's all we did. We did some physical therapy and kept him active. I've got the card sitting behind my desk that says, two months or three months after I left, I have no more nerve pain. So, what he was dealing with for years and years and years, and the medical system, wasn't really helping him with, he was getting a lot of surgeries and things like that. Trauma therapy was the trick. So, that's a story I put out there. I keep that card to show patients to say, look, have faith. Oftentimes treating the trauma will do the trick.

Host: Yeah, and that's such a lovely story and you can just really understand. At least I'm beginning to understand, and you're such a good guest because in just a short matter of time here, 10, 11 minutes, we've covered so much ground and I have a much better understanding of sort of what was being done or maybe what's still is being done, but what's being done at Sierra Tucson that mind, body, spirit approach, the combination of behavioral and medical and the benefits to patients, and then that, you know, lovely card, that's amazing. As we wrap up here, Doctor, and I really do believe I could talk to you all afternoon, but there's no way they're going to let us do that.

So, as we wrap up, what would be your takeaways when it comes to chronic pain, how it's been treated, the narrative and what you folks are doing there at Sierra Tucson.

Dr. Davis: Chronic pain is different from acute pain. Chronic pain can be caused by experiences in our lives, typically trauma and grief. And also that leads to the idea that chronic pain can be treated effectively by treating trauma and grief. I'm going to slide this in there, there are six randomized controlled studies of specific trauma treatment, like EMDR, that show it's really effective for treating chronic pain. So, what I'm saying, isn't my opinion. It's now evidence-based care and also a lot of our patients are using opioids to treat anxiety and depression. Those are the main points. Obviously, a place like Sierra Tucson, where we can get our handle on both the medical and the physical and start the trauma and the grief treatment, is a place where people with chronic pain are gonna want to consider.

Host: Yeah, that is really well said. And I have appreciated this conversation as I'm sure listeners have. So Doctor, thanks. Great speaking with you again and you stay well.

Dr. Davis: Thank you so much.

Host: Visit Sierratucson.com or call 800-842-4487. Sierra Tucson, we work with most insurance. And if you found this podcast to be helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest.

This is Let's Talk Mind, Body, Spirit by Sierra Tucson. I'm Scott Webb. Stay well.