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Non-drug techniques to ease chronic pain


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In the UK, at least, researchers are looking for non-drug methods to treat chronic pain.


Phone Therapy, Exercise Helpful in Chronic Widespread Pain


Megan Brooks www.medscape.com


November 22, 2011 — Both brief cognitive behavioral therapy (CBT) delivered by telephone and exercise can yield "substantial, significant, and clinically meaningful" improvements in global health in adults with chronic widespread pain, according to a new study from the United Kingdom.


The study, by John McBeth, PhD, from the Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, and colleagues, was published online November 14 in the Archives of Internal Medicine.


Non-opioid-based alternatives to chronic pain management are "desperately needed," Seth A. Berkowitz, MD, and Mitchell H. Katz, MD, from the Los Angeles County Department of Health Services, California, point out in an accompanying editorial. The current study makes "an important contribution" to that goal, they write.


"An Important Contribution"


In their article, the researchers note that no drugs are currently approved in the United Kingdom for chronic, widespread pain, the cardinal feature of fibromyalgia. In addition, none of the 3 drugs currently approved in the United States (duloxetine hydrochloride, milnacipram hydrochloride, and pregabalin) adequately controls the multiple symptoms of fibromyalgia.


Current guidelines recommend pharmacological, physical, and psychological therapies, although the value of individual therapies is unclear. Traditional CBT has shown promise for fibromyalgia, and telephone-based CBT (TCBT) is potentially more acceptable, accessible, and cost-effective.


Dr. McBeth's team randomly assigned 442 patients meeting American College of Rheumatology criteria for chronic widespread pain to 6 months of TCBT, graded exercise, both interventions, or usual care (control group).


TCBT was delivered by a trained therapist and involved an initial assessment and 7 weekly sessions, each lasting 30 to 45 minutes, plus 1 session 3 and 6 months after randomization. The exercise intervention involved 6 monthly sessions led by a fitness instructor who took a 1-day training session on exercise for chronic pain. Exercisers were also encouraged to be physically active and work out at least twice a week on their own.


Usual care was delivered by the patients' family physician, and the precise nature of the care was not known.


TCBT, Exercise Bests Usual Care


At the end of the intervention (6 months), and at 9 months after randomization, significantly more patients in the TCBT, exercise, and combined groups reported a positive outcome compared with those patients the usual care group. A positive outcome was defined as feeling "much better" or "very much better" on a standard self-rated global assessment scale.



"Receiving both interventions was associated with a slight improvement in outcome but were not substantially better than single treatments," Dr. McBeth and colleagues note in their report.


"It's interesting that the TCBT continued to show improvements over time, while the benefits of exercise began to decrease with time (as is usual in exercise interventions)," Dr. McBeth told Medscape Medical News.


After adjusting for age, sex, center, and baseline predictors of outcome, the likelihood of a positive outcome was significantly higher with TCBT, exercise, or both, relative to usual care.



Despite meaningful improvements in self-rated global health with TCBT and exercise, there was no apparent effect on chronic pain grade, the investigators report.


Increased Availability at Lower Cost


Although CBT and physical exercise are recommended for patients with chronic widespread pain, evidence to date in support of these modalities is equivocal, Dr. McBeth and colleagues note in their article.


"I think this has risen, in part, due to methodological limitations in some previous studies," such as small sample sizes, Dr. McBeth told Medscape Medical News. "However, the results of 2 recently published meta-analyses were also equivocal."


He says there are several possible reasons why CBT and exercise had a significant effect in their study.


"Our study was conducted among patients presenting to primary, rather than secondary, care, with possibly lower levels of factors such as psychological distress that may influence response to treatment," he explained. Also, "the therapists delivering treatment were very experienced, and adherence to the treatment was very high possibly due to the nature of treatment delivery (ie, patients weren't required to get to a therapists office)."


Delivering CBT by telephone should "increase treatment availability at lower costs," Dr. McBeth predicted.


Although an economic analysis suggested that in the short follow-up period TCBT was not more cost-effective than usual care, "there was a trend towards cost-effectiveness. It will be interesting to follow these patients up for a longer period to determine whether, over the longer term, TCBT is a more cost-effective option," Dr. McBeth said.


Dr. Katz told Medscape Medical News that CBT "done in person or by phone could save money because patients will get fewer unnecessary tests and medications and specialty visits."


Putting Patients in Charge


In their commentary, Dr. Katz and Dr. Berkowitz note that CBT and exercise "represent a management strategy that puts patients firmly in charge. The skills learned in CBT, for example, are available after hours and over long weekends and do not require monthly refills. Moreover, because CBT can be administered by telephone, this intervention is convenient and can be made available to a wide range of patients."


"As practicing physicians who treat many patients with chronic pain, we welcome additional research that seeks to minimize the use of pharmacotherapy, with its unclear efficacy and attendant consequences, in favor of a regimen that focuses, in a truly patient-centered way, on teaching skills for self-management of symptoms and return to meaningful lives," they write.




Arch Intern Med. Published online November 14, 2011. Abstract, Editorial



This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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I like that. I would like to see that in the US. I didn't know CBT could be for pain management.

Taper from Cymbalta, Paxil, Prozac & Antipsychotics finished June 2012.

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I agree. It seems to me that if you could phone someone when you get stuck, you could get CBT advice you could immediately put to use and practice.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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  • 3 weeks later...
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Mysterious pain is a psychiatric drug withdrawal symptom suffered by many. This article reviews some mind-body techniques that medicine is starting to take seriously, with evidence from clinical studies.


Rewiring the Brain to Ease Pain

Brain Scans Fuel Efforts to Teach Patients How to Short-Circuit Hurtful Signals


By MELINDA BECK Wall Street Journal NOVEMBER 15, 2011


How you think about pain can have a major impact on how it feels.


That's the intriguing conclusion neuroscientists are reaching as scanning technologies let them see how the brain processes pain.


That's also the principle behind many mind-body approaches to chronic pain that are proving surprisingly effective in clinical trials.


Some are as old as meditation, hypnosis and tai chi, while others are far more high tech. In studies at Stanford University's Neuroscience and Pain Lab, subjects can watch their own brains react to pain in real-time and learn to control their response—much like building up a muscle. When subjects focused on something distracting instead of the pain, they had more activity in the higher-thinking parts of their brains. When they "re-evaluated" their pain emotionally—"Yes, my back hurts, but I won't let that stop me"—they had more activity in the deep brain structures that process emotion. Either way, they were able to ease their own pain significantly, according to a study in the journal Anesthesiology last month.


While some of these therapies have been used successfully for years, "we are only now starting to understand the brain basis of how they work, and how they work differently from each other," says Sean Mackey, chief of the division of pain management at Stanford.


He and his colleagues were just awarded a $9 million grant to study mind-based therapies for chronic low back pain from the government's National Center for Complementary and Alternative Medicine (NCCAM).


Some 116 million American adults—one-third of the population—struggle with chronic pain, and many are inadequately treated, according to a report by the Institute of Medicine in July.



"There is a growing recognition that drugs are only part of the solution and that people who live with chronic pain have to develop a strategy that calls upon some inner resources," says Josephine Briggs, director of NCCAM, which has funded much of the research into alternative approaches to pain relief.


Already, neuroscientists know that how people perceive pain is highly individual, involving heredity, stress, anxiety, fear, depression, previous experience and general health. Motivation also plays a huge role—and helps explain why a gravely wounded soldier can ignore his own pain to save his buddies while someone who is depressed may feel incapacitated by a minor sprain.


"We are all walking around carrying the baggage, both good and bad, from our past experience and we use that information to make projections about what we expect to happen in the future," says Robert Coghill, a neuroscientist at Wake Forest Baptist Medical Center in Winston-Salem, N.C.


Dr. Coghill gives a personal example: "I'm periodically trying to get into shape—I go to the gym and work out way too much and my muscles are really sore, but I interpret that as a positive. I'm thinking, 'I've really worked hard.' " A person with fibromyalgia might be getting similar pain signals, he says, but experience them very differently, particularly if she fears she will never get better.


Dr. Mackey says patients' emotional states can even predict how they will respond to an illness. For example, people who are anxious are more likely to experience pain after surgery or develop lingering nerve pain after a case of shingles.


That doesn't mean that the pain is imaginary, experts stress. In fact, brain scans show that chronic pain (defined as pain that lasts at least 12 weeks or a long time after the injury has healed) represents a malfunction in the brain's pain processing systems. The pain signals take detours into areas of the brain involved with emotion, attention and perception of danger and can cause gray matter to atrophy. That may explain why some chronic pain sufferers lose some cognitive ability, which is often thought to be a side effect of pain medication.


The dysfunction "feeds on itself," says Dr. Mackey. "You get into a vicious circle of more pain, more anxiety, more fear, more depression. We need to interrupt that cycle."


One technique is attention distraction, simply directing your mind away from the pain. "It's like having a flashlight in the dark—you choose what you want to focus on. We have that same power with our mind," says Ravi Prasad, a pain psychologist at Stanford.


Guided imagery, in which a patient imagines, say, floating on a cloud, also works in part by diverting attention away from pain. So does mindfulness meditation. In a study in the Journal of Neuroscience in April, researchers at Wake Forest taught 15 adults how to meditate for 20 minutes a day for four days and subjected them to painful stimuli (a probe heated to 120 degrees Fahrenheit on the leg).


Brain scans before and after showed that while they were meditating, they had less activity in the primary somatosensory cortex, the part of the brain that registers where pain is coming from, and greater activity in the anterior cingulate cortex, which plays a role in handling unpleasant feelings. Subjects also reported feeling 40% less pain intensity and 57% less unpleasantness while meditating.


"Our subjects really looked at pain differently after meditating. Some said, 'I didn't need to say ouch,' " says Fadel Zeidan, the lead investigator.


Techniques that help patients "emotionally reappraise" their pain rather than ignore it are particularly helpful when patients are afraid they will suffer further injury and become sedentary, experts say.


Cognitive behavioral therapy, which is offered at many pain-management programs, teaches patients to challenge their negative thoughts about their pain and substitute more positive behaviors.


Even getting therapy by telephone for six months helped British patients with fibromyalgia, according to a study published online this week in the Archives of Internal Medicine. Nearly 30% of patients receiving the therapy reported less pain, compared with 8% of those getting conventional treatments. The study noted that in the U.K., no drugs are approved for use in fibromyalgia and access to therapy or exercise programs is limited, if available at all.


Anticipating relief also seems to make it happen, research into the placebo effect has shown. In another NCCAM-funded study, 48 subjects were given either real or simulated acupuncture and then exposed to heat stimuli.


Both groups reported similar levels of pain relief—but brain scans showed that actual acupuncture interrupted pain signals in the spinal cord while the sham version, which didn't penetrate the skin, activated parts of the brain associated with mood and expectation, according to a 2009 study in the journal Neuroimage.

One of Dr. Mackey's favorite pain-relieving techniques is love. He and colleagues recruited 15 Stanford undergraduates and had them bring in photos of their beloved and another friend. Then he scanned their brains while applying pain stimuli from a hot probe. On average, the subject reported feeling 44% less pain while focusing on their loved one than on their friend. Brain images showed they had strong activity in the nucleus accumbens, an area deep in the brain involved with dopamine and reward circuits.


Experts stress that much still isn't known about pain and the brain, including whom these mind-body therapies are most appropriate for. They also say it's important that anyone who is in pain get a thorough medical examination. "You can't just say, 'Go take a yoga class.' That's not a thoughtful approach to pain management," says Dr. Briggs.


Write to Melinda Beck at HealthJournal@wsj.com



This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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This is very interesting and timely for me as I am about to make another reduction. It perhaps emphasises that 'belief' of getting better someday is imperative in recovery. Something I struggle with. There are times I can read a book to 'escape' the pain, but not always. Now for someone who sees the negative word 'atrophy' this worries me, however, perhaps as we discover so many things can regenerate that were once thought of as impossible, the liver, heart blockages, perhaps so too can grey matter regenerate.


Science thinks it know so much about health. Antibiotics saving the world, vaccines eradicating diseases. Yet we know nothing. Evolution continues to mutate and getting rid of those diseases, means that others take their place. We mess too much with things we don't understand, as a species we are arrogant in the extreme. So much illness, stress and sickness would not exist if humanity could only see its errors and live in peace and harmony. If people feel secure and safe, in all ways, the healthcare deficit could be slashed.


Wherever I go I try to help others and teach my children to be the same. Something as simple as letting cars out of junctions. Helping an old lady reach something high in a supermarket. These things make both parties 'feel good', if people could only have that sentiment how much nicer the world would be to live in.

Sept 2010 - Citalopram 1 day

Sept 2010 - Zopliclone for ten weeks (paranoia ended a couple of months after coming off this and sleep settled down again until the last couple of months)

Ocober 2010 - Cymbalta 30mg

November 2010 - Cymbalta 60mg

February 2011 - 60mg to 30 mg (lasted 10 days)reinstated 60mg

March 2011 - Took 2 60mg tablets on one evening in error - paralysis of face, back of head, shoulder, stabbing in right kidney, lost 30% of hearing)

March - June 2011 went down quickly 1mg a day until I got stuck at 25mg, went up to 27mg, because couldn't breath.

26th June - 26mg

3rd July - 25mg

17th July - 24mg

24th July - 23mg

7th Aug - began reducing by a bead every couple of days or so went well at first then hit a wall

24th October - now on 18.5mg. Since the kidney infection at start of September, have been in constant pain and anxiety, no let up. Given Ciprofloxacin.

8th Jan 2012 17.8mg (currently reducing 0.2mg a week)

8th Jan 2012 17.6mg last reduction was 6 days ago.

15th Jan 17.4mg

21st Jan 17.2mg

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Absolutely, InNeed.


There's a lot of evidence that meditation, solving puzzles, enjoying companionship, etc. increases neurogenesis -- grows new brain cells. It's not clear what that means, just as it's not clear what "atrophy" of parts of the brain means, but it does show that purely emotional or cognitive processes can cause physical effects.


Also, when you are moving your thoughts in soothing or positive directions, you're not turning them back on yourself in ways that might hinder healing or be destructive.


So "changing the channel" to any of these techniques that works for you can be a way to help yourself heal.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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  • 1 year later...

Inspired by a member of this board I put together a collection of links that deal with chronic pain from Beyond Meds. I've gotten to the point where my pain is now relatively tolerable and this list includes most of what I've pieced together to get here...along with TIME...you know what they say about TIME :)


Perhaps it will be helpful to some of you.


Chronic pain (psych drug withdrawal induced and chronic pain in general too)

Everything Matters: Beyond Meds 


withdrawn from a cocktail of 6 psychiatric drugs that included every class of psych drug.

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