Dr. Joe Tatta: Welcome back to the healing pain seminar. I’m your host, Dr. Joe Tatta. Today we are talking about pain psychology with Dr. Beth Darnall. She is a clinical associate professor in the division of pain science at Stanford University. She is an NIH funded principal investigator for pain psychology and is examining the mechanisms of pain catastrophizing treatment including a novel single session to solve the pain. She’s the coach here of the pain psychology task force. She’s also the author of less pain for your pills as well as the opioid-free pain relief kit. It’s a great interview on pain psychology. So grab your green tea and enjoy the interview. Dr. Beth Darnell, welcome to the healing pain summit. It’s a real pleasure to have you here. So I’m really excited talking about paying psychology cause I think it’s probably one of the integral places where we can make a huge difference in people with pain. It’s also missing from our national healthcare system. I would study. So I think you know, first when people think about pain, the first thing they think about is their body. So I painted my back, my neck, my knee, and my joints, wherever the pain is. It could be, you know, body-wide pain. But what is the role of psychology in pain?
Dr. Darnall: It’s really a great question and you hit the nail on the head that most people really think about pain is being situated somewhere in, in the physical body. Uh, but the actual definition of pain is that it’s a negative sensory and emotional experience. So it’s not just what you feel in your body, it’s also your responses to what’s happening and what you feel in your body. And it also is influenced by just your general emotional status. So psychology is actually built into the definition of pain. And this isn’t my definition, this is a definition from the international association for the study of pain. And so this is really well appreciated scientifically, but it hasn’t quite seeped down to the clinical level and to the everyday person who has pain.
Dr. Joe Tatta: Yeah. This is really interesting cause I think you know to the average layperson that if you have an MD or if you have a psychology degree or a doctorate in physical therapy, no matter what your degree, I think there’s an assumption that we’re taught about pain in school. And the truth is most professions including physical therapy and psychology have learned very little in school. It’s usually, let me get out of school. We take two education courses and we’re doing a better job at educating the public and ourselves. But we don’t get a whole lot in school. Correct?
Dr. Darnall: No that’s correct. And really the data are striking. So as recently as 2011 physicians in medical schools, so these are medical school, you know, hoping to become physicians across four years of medical school. They would receive between four and 11 hours of education on pain. And this education would be fragmented across different topics like cancer or diabetes. So there really isn’t a cohesive targeted curriculum on pain that really includes the bias psychosocial treatment approach. And that’s the key piece that’s missing. So we, we almost have two conversations here. One is if there’s not enough of a focus on pain across all healthcare professions, but right now I’m just giving the example of medical doctors, but then right on the heels of that, how much of that medical education or pain education includes the role of psychology, this integral rule that’s so critical to how much pain we experience, how much we suffer from pain, and how much treatment we’re going to need. Well, it turns out that we have fallen woefully short, that it’s almost ignored across disciplines and this fundamentally needs to change.
Dr. Joe Tatta: Yeah. And I think that’s where pain psychology and of course, you know, your message, the books you’ve written, your website, the work you do obviously at Stanford is really so important. But talk to us about some of the evidence that has existed in pain psychology for a couple of decades now. But it’s really starting to build some solid momentum as far as, you know, being, um, a way to help people, you know, alleviate their pain.
Dr. Darnall: Yeah. So the, the data have actually been, um, pretty solid for a couple of decades showing that when people received psychological treatment, meaning that you, you learn about the rule of psychology and pain management and learn strategies to better manage your pain. You know, people tend to get better. And this has been known again for decades. Um, but that hasn’t really been well appreciated by the public or the everyday clinicians. What has really brought it more to the forefront recently is some of the mirror imaging data because they’re really sexy and people love pictures of brains. Everyone can get behind that and it’s sort of like, Oh wow, here we are looking at the brain changing in real time. And we finally have, you know, that evidence and it’s a really strong, that’s really clear and it’s been demonstrated and confirmed across multiple independent research groups that how you direct your attention in the context of pain, how much you think about pain, whether you focus on how awful it is, if you’re ruminating about pain.
Dr. Darnall: The science shows that it very clearly amplifies pain processing in the nervous system. So how we direct our literally has the capacity to light up areas of the brain associated with pain. So the way I talk about it with my patients is I say, you know, you have the capacity to grow pain in your brain. That’s kind of what we’re doing and this is really new information for most people who tend to think of pain as being something of a passive process. Like, Oh I just, you know, sort of wake up and have a migraine today and now I’ve got to deal with it, but we’re actually participating with that experience. If we’re directing our attention in the wrong way and if our emotions go down a very negative pathway, which is easy to have happen, then we are unwittingly, unwittingly contributing to our own suffering. So part of the science of pain psychology is understanding how these pieces fit together and then learning the keys skills to be able to start to shift things in our favor so that we’re using the power of our minds to our advantage rather than to our disadvantage.
Dr. Joe Tatta: I love that using the power of your mind because if, if pain is an output from your brain, then the mind is the one place you really should go probably first and foremost as we started on this transition to a pain free life. You know, in, in the research there’s, um, a lot talked to a lot, he’s spoken about pain catastrophizing and I know a number of pain psychologists talk about something that you talk about in your books. I’d love to hear you explain what pain catastrophizing is and how someone can start to integrate that into their care and treatment.
Dr. Darnall: Yeah, yeah. It’s, it’s really, um, an area of, of my passion is pain catastrophizing and I’ve dedicated a, a portion of my career to it. So I’m really happy to talk about this topic. So pain catastrophizing is something that sort of happens naturally and automatically, but it’s the clearest example of the power of our minds working against us. So it’s when we are focused on pain and how negative it is. So we’re sort of magnifying pain, we’re ruminating about it and feeling helpless about pain. So feeling like there’s nothing I can do. I’m at the mercy of my pain. Look how awful it is. And it’s also when we get into that space of focusing on worst case scenario. So expecting the pain to worsen and sort of bracing oneself for the pain to worsen. Well it turns out that those expectations about pain and our emotions about pain actually see that the pain experience.
Dr. Darnall: So I was just talking about that. Neuro imaging data. Well in fact the best neuro imaging data exists for pain catastrophizing. And this is really interesting cause you know, most people think about the impact of chronic and we know about depression and we know about anxiety, you know, sort of these big diagnoses that we give. But pain catastrophizing isn’t actually sort of a a diagnosed disorder. It’s just a thought pattern. It’s a cognitive pattern that any of us can easily slip into. So this is the reason why it’s so important to understand. You know, what, what are our thoughts? What are your thoughts? If you have chronic pain, what is your thought process? Are you catastrophizing? And if so, learning those skills and techniques to shift your brain away from catastrophizing because shifting your brain away from catastrophizing is literally shifting your brain away from pain.
Dr. Darnall: So in my work, um, you know, I D I’ve done a lot of work investigating how can we best treat catastrophizing and there’s solid science behind it and most often it’s treated individually with a pain psychologist, um, across multiple sessions. And I was really curious, could we treat pain catastrophizing more efficiently and therefore broaden access to a targeted treatment that anybody could, could access like over the internet for instance. So I developed a two hour targeted class that focuses on the science of catastrophizing and the skills needed to self treat it. And this was published in 2014 we found some phenomenal results in our pilot study, subsequently received an a large NIH grant to study this brief intervention further. Um, if it proved successful and we’re hoping that it does, we’re starting our clinical trial in the next couple of months. If it proved successful, we will have literally discovered a really important, almost groundbreaking way to treat pain.
Dr. Darnall: Because one of the things about pain catastrophizing is that it determines how well any future medical treatments work. So if you’re going to do surgery, if you’re going to do an injection, or even if you’re going to prescribe medications, treatment response is reduced. If a person is engaging in in pain catastrophizing. So catastrophizing is serving to undermine patient response to everyone’s treatments. And so that sort of elevates it. It’s importance is one of the very most therapeutic targets right out of the gate when when somebody has pain, we need to assess for catastrophizing and rapidly treat it so that they’re optimized to best control pain and have their best response to any of the future treatments their doctors and clinicians will try.
Dr. Joe Tatta: That’s incredible. I mean, I think you know, where you can develop a technique that has a significant way to reduce pain in the matter of two hours. It really should be commended. It’s, you know, huge work you’re doing, especially with, you know, getting grants from the government and trying to get that out in front of the public as you talk. One of the things that I think about it, my brain always goes to prevention because ultimately that’s where we all want to be. We want to prevent this wave of pain that we already have. So around catastrophizing. Is there a certain person or personality that is more likely to develop catastrophizing behaviors?
Dr. Darnall: Yeah, so in truth there’s a, there’s an overlap between anxiety and depression and catastrophizing. So you know, if you know that you have depression or if you know you have anxiety, you will be more likely to also be a catastrophizer. But you don’t need to have anxiety and depression. Catastrophizing can be very focal and specific to the experience of pain. And you’re right, you know, the future is really about how do we prevent catastrophizing. You know, a fascinating statistic about catastrophizing is that it actually PR, it predicts the development of chronic pain in people who are pain-free today. So you could take a, these are population studies, so any of us could be in this study and you measure our tendency to catastrophize in the context of pain. Maybe we go to a dentist or we twist our ankle. All of us experience pain from time to time.
Dr. Darnall: And how do we tend to think and feel in the context of pain, those of us who have higher catastrophizing tendencies, we can measure that now and then go out a whole year. And individuals who are catastrophizers are more likely to have developed chronic pain prospectively following an injury or any type of a acute pain episode. So one of the best ways to prevent chronic pain is actually to, uh, identify catastrophizing before an injury. And one of the biggest injuries that occurs in, in this country and globally is surgery. I mean, surgery is a controlled injury. And so how about we optimize people to have their best response to surgery? Because the studies of course show that one of the biggest predictors of postsurgical pain and opioid use is presurgical catastrophizing. So we’re actually running a randomized controlled pilot studies right now at Stanford, taking my two hour class and testing it. And women who are undergoing surgery for breast cancer. So if we treat catastrophizing before the can, we reduce their postop pain, opioid use and time to recovery.
Dr. Joe Tatta: I think that’s brilliant because in all my years as a physical therapist, I, you know, I’ve worked with a number of postsurgical patients, whether they’re total hip replacements, knee replacements, spine surgery. A lot of times the surgeons want to see that patient go through predictive postoperative course. So let’s say it’s six weeks or eight weeks. And a lot of times there are patients that are outliers and they always say, what’s the difference with this patient? I always tell them that pain is a unique, unique experience to that person. So this person is having a different kind of experience with their postoperative pain. So I think something like that, it’s just, it’s really groundbreaking. If we can get that into hospitals, into rehab units, into outpatient settings, it’s really incredible.
Dr. Darnall: It’s critical. And, and I also want to recognize, you know, today we’re talking about pain, but consider, you know, the woman who’s having surgery for breast cancer, well, she has a whole lot to catastrophize. Pain is just one of, it’s one aspect, you know, that she may catastrophize, but if you think about it, pain as a trigger for us to worry about. What else might be going wrong in our body? So a person who’s having surgery for cancer might be worrying, does that mean something went wrong? Does it mean the cancer is still there? And we can see how pain can be an impetus to literally lead people down a negative psychological pathway in which again, they’re unwittingly undermining their treatments and their recovery. And so nobody wants more pain and nobody wants delayed recovery. So it’s incumbent upon us and you know, as a national health care system, I mean literally to plug the patients into these low cost, low burden, easy to implement treatments that empower patients to have best control over their own experience and their own health.
Dr. Joe Tatta: Yeah, and I think you’ve probably just answered this question, it’s been on my mind since we kind of scheduled this, but why is pain psychology a really positive way that we can undo our opiod epidemic?
Dr. Darnall: Yes. Well, you know, in part the opioid epidemic, um, was started through, you know, primary care. I mean, actually largely the number one reason people go to their physician is pain. And so you’ve got your physician for pain. And let’s rewind to the earlier part of this interview. The physician that you go to will have minimal training in chronic pain, most likely. And number two, they’re unlikely to have knowledge about the role of psychology and pain. And what they do know how to do is prescribe medications. So physicians are more likely to then, you know, write a prescription for opioids. And we’ve seen over the course of the past decade and a half where that has led us as a nation, this over prescribing of opioids, which are risky medications, a lot of side effects and risks come along with opioids. But you know, as a pain psychologist, um, one of the, the, the riskiest effects of opioids is that it may, they may prevent patients from focusing on alternatives such as effective self management strategies such as, you know, pain psychology.
Dr. Darnall: And so if we’re not using these strategies, you know, physical therapy, if we’re not using these rehabilitative strategies, then we’re simply becoming more and more reliant on the pill bottle, which really is a disservice to patients. So, you know, I, I’m all for minimizing opioids as much as possible, but recognizing that for some people they may be appropriate treatment. And my message there is it’s not about yes or no to opioids, it’s about no matter what you do in regards to your pain treatment, what medications you take or don’t take, the focus should be on optimizing your control over your own experience. And by doing so, you will naturally find that you reduce your need and your reliance on them. And that’s the really critical part right now. There’s a big focus in the United States and just taking away opioids, that’s not so helpful. We can’t just take something away without connecting people to the alternatives. And so that’s really my body of work is focused on that. And that was really the impetus for me writing my second book to give people immediately something that they can do in the absence of opioids. Let’s focus on opioid free pain care. What can we do?
Dr. Joe Tatta: Yeah, I think it’s a wonderful point. I mean, you know, I think part of the job you and I have or is being an advocate for people with pain and I know when you take, when you take something away does obviously if we’re going to create a little bit of fear, an anxiety and you know we have to be mindful of that and got to help people either get the treatment they need, we have to help the insurance system expand so they can access some of that care. You know, one of the things that I’ve come across recently is the Cleveland clinic as a pilot study going where when someone calls with chronic back pain, the first person that they access is a pain psychologist and a physical therapist. They’re not seeing the physician first. And I think it’s a really interesting site to see what comes out of that and what the outcomes will be from that. Cause I think it’s going to change care. It’s going to get people kind of… I think the two arms of care they need both the physical and the mental basically.
Dr. Darnall: No, I absolutely agree. And I’d love to see more and more of that in the future where the focus in pain is in always, always optimizing conservative care first, then moving to medications, then you know, considering the appropriateness of some invasive procedures such as surgery and whatnot. You know, I just wanted to circle back to a really important point you made just now Joe, which is, you know, the idea that when opioids are taken away that it could engender some anxiety and stress. And, and really from my perspective, the worst part about this, um, is that it reinforces to patients that they are not in control of their bodies, of their health, of their pain. And that, I mean, let’s go back to catastrophize and remember that one part of catastrophizing is feelings of helplessness. And then as a healthcare system, we start, you know, picking away at their care plans and facilitating more and more of this helplessness and loss of control. So my fantasy would have been that before we impose these guidelines and restrictions that we would have optimized psychological care, behavioral medicine, access to these alternatives. But unfortunately it didn’t go that way. And so now we have to move very, very quickly to connect patients to these, to these alternatives that they’re desperately seeking.
Dr. Joe Tatta: Yeah. And obviously we’re talking about a big problem. We’re talking about more than a hundred million people in the United States. And you know, pain is obviously a global phenomenon that we have problems in almost every single country with chronic pain. Um, you have written two incredible books on pain. Can you tell us about them?
Dr. Darnall: Yeah, so, um, my first book was called less pain, fewer pills, avoid the dangers of prescription opioids and gain control over chronic pain. And I wrote, this was published in 2014. I really wrote it in 2012 and 2013. Um, while the rest of the country is, is just now really focusing on the opioid over prescribing, um, epidemic and the consequences of opioids. I was really in the trenches in the mid two thousands in Oregon working with my patients were having so many problems related to opioids. And I literally just felt like I have to write this book to connect people. To the information they need. So the first half of the half of the book is opioid education. Know your specific risks and the consequences of these medications. I always say I’m less concerned with whether or not people take opioids, but I am highly invested in people making informed choices about their care.
Dr. Darnall: And I really believe that over the years when we’ve done an extreme disservice to people with pain in this country because they were not given full disclosure on the risks and consequences and later found themselves in this big gotcha. When they found that the opioids are of limited value, they feel they’re painted into a corner, they’re taking more and more medications to treat the side effects. So that’s really what this book was about. The second half of the book is all about pain psychology. Okay, well if you want to treat your pain differently, what do you do? So I provide that information. In that book, what I found was, you know, there’s a lot of science and less pain, fewer pills, and some patients would like a simpler, more accessible book. So it’s almost more of a practical manual that they can wear, you know, chalk full of strategies that they can implement.
Dr. Darnall: That’s what my second book is about. And this is called the opioid free pain relief kit. 10 simple steps to ease your pain. And this literally just came out, um, in the last couple of weeks. And again, it’s, it’s written for the everyday patient with chronic pain who is looking for solutions, um, is looking for alternatives to opioid medication. And I wanted it to be easy enough so that, you know, a person with pain eight out of 10 and at their doctor’s office wouldn’t be intimidated by a, a book that seemed very complex. And so it’s large print, there’s lots of exercises. It’s easy to read, there’s engaging graphics and I’m so far we’re receiving some great feedback about it.
Dr. Joe Tatta: It’s an incredible book. I can’t wait to, I read your first book and there’s so many good points in there and I’m sure your second book is even better. Um, what are the things that I want to talk about? I know you and I are talking as professionals, as colleagues, and we’re using certain words and language and those are some things that I really pay attention to more and more as I talk about this topic. And the two things that come up in my mind throughout every interview is the word chronic and the word manage. And I have certain personal biases towards, towards those words because I think at times they can be hurtful and maybe cause more catastrophizing and people. But can you talk to me about the words chronic and manage and why they may not be the best words that we should use?
Dr. Darnall: Oh, that’s an interesting question. Well, so we use the word chronic when we talk about pain extending essentially beyond the point of expected healing. Um, so you know, after surgery, let’s say that’s a couple of months, you know, so you would be expected to have healing occurring to return back to normal functioning. Um, a lot of people don’t, a lot of people have symptoms persist, primarily pain, um, limitations. And that’s the point at which we call something chronic at his, you know, it’s just persisting for instance. Um, I think on the one hand it’s a useful term in the sense that it’s a descriptor for ongoing pain. Um, but it does come with some, some pretty heavy stigma attached to it. I have seen, um, people very, I mean, almost flinch if they’re told they have chronic pain because they themselves haven’t conceptualized it that way. For some people, there’s almost a connotation of permanence to it and that’s, that’s actually an accurate because chronic pain does resolve.
Dr. Darnall: It does, you know, I had chronic pain when I was younger. I don’t have pain now. I am pain-free, um, and I take care to implement strategies to ensure that remain pain-free. But you know, this idea that, Oh, you have chronic pain. It’s, it’s permanent. You’re forever changed. Um, that, that is an accurate for a lot of people. However, um, I will say that that once a person has ongoing pain that has changed their life, it is important to really acknowledge that pain, it’s impact and to then immediately begin focusing on strategies that will optimize functioning and quality of life despite the pain. So a trap that a lot of people get into is, well I can’t walk, I can’t do the things I love, I can’t be with my kids and my partner because of the pain. And they start withdrawing from life, social activities and work their worlds get smaller and smaller.
Dr. Darnall: It’s depressing and eventually, you know, usually that will set in, you know, some degree of depression. So the solution as you know, is a physical therapist of course, is for us to help people become more and more active. You know, integrating inappropriate levels of activity to help people adopt sort of a rehabilitation mentality so that they are expanding their engagement in activities that are meaningful to them and the things that they love in spite of their pain. If we wait for the day that the pain goes away and we’re going to be waiting a long time because as it turns out, the way that the pathway to becoming pain-free is paradoxical. It’s actually to begin rehabbing to begin doing the things you love. And then as a consequence of moving more and more into a fuller life, pain can start to extinguish. We see this over and over again, and this I believe, is fundamentally evidence of neuroplasticity, of the nervous system rewiring itself.
Dr. Darnall: And we are in the driver’s seat. If we understand this, um, how this operates. So idea of chronic connotes permanence, which isn’t necessarily the case. And the idea of manage somehow connotes that, you know, now we have this job that’s forever and I really like, you know, it rather than managing, it’s more like optimizing daily quality of life. Um, rewiring the nervous system, training your brain away from pain. Um, these are the, this is the language that I use in my books and in my lectures and here today. I think that that’s more useful language. That’s not so depressive Genet
Dr. Joe Tatta: you know both what you and I are talking about really in, in, in a large context is behavior change and behavior change can be a challenge. Cause at times as professionals we’re asking patients to take on a lot. So at times we have to say, okay, one behavior change at a time. This happens over over the course of time. How much do we have to educate maybe you know, primary care providers to start the conversation that this is a transformative process and it may take a little bit more time than, you know, taking an opioid for let’s say three weeks.
Dr. Darnall: Yeah, absolutely. So, you know, one of my key messages in the opioid free pain relief kit is that the most important person on your healthcare team isn’t your doctor. It isn’t your nurse, it isn’t even your psychologist or your physical therapist. It’s you. You are the most important person on your healthcare team. And so it’s not so much what you get during any medical visit that makes the difference. It’s what you do in your daily life. That’s where the rubber meets the road. And so fundamentally the onus is on us. Every single one of us, we’re all patients in this world. And the onus is on each and every one of us to ensure that we’re doing everything possible every day to help best, you know, optimize our, our bodies, our minds, our functioning. And so that’s really a critical, critical message and it’s that type of language and approach is not yet well integrated, particularly into the medical system, the primary care setting where doctors are more trained to intervene on, on patients.
Dr. Darnall: But you know, the, the Cleveland clinic and other others, um, have the right approach. It’s to immediately engage patients in this conversation. So one of the things I’ve done at the Stanford pain management center is that as soon as the patient sets foot in the clinic, they are immediately invited to attend my two hour, uh, pain psychology class that focuses on catastrophizing. You don’t even need to see a doctor, you don’t need to see a psychologist, you don’t need a referral. And I do it for free. So as soon as you come our philosophy, let’s optimize you. And let’s really not only optimize your psychology and your behavior, but your understanding of your role in your outcomes and in whether or not your pain gets better or not.
Dr. Joe Tatta: Right. Like the breath door. Now your books and your message is incredible. I really so enjoy having you on the healing pain summit too. This is the second summit I’ve run. I think it’s incredible to have you as a guest. Please tell our viewers and listeners how they can learn more about you, your website, your books, everything you have to offer.
Dr. Darnall: Yeah, thanks so much Joe. So I’m pretty easy to find on the internet. I firstname.lastname@example.org and almost no matter how you spell it, you will find my website. So it’s Beth darnell.com my books are, you can find them on my website and they’re also available on Amazon. I also have columns on psychology today and on the Huffington post, but if you just visit my website, I have links to direct you to all of my videos, Collin’s books and resources.
Dr. Joe Tatta: Excellent. So please check out doctor Beth Darnell and her website. Check out her new book called the opioid free pain relief kit and her a book before that called the book before it was called, um,
Dr. Darnall: less pain, fewer pills, avoid the dangers of prescription opioids and gain control over chronic pain.
Dr. Joe Tatta: Excellent. Thank you for that. And you have an opportunity to help dr Beth Darnell out, spread her message. So make sure you click on the link below so you can share it out onto Facebook, Twitter, or whatever social media presence that you have. I’d like to thank her once again, and we’ll see you on the next episode of the Healing Pain Summit. So thank you so much. It was such a pleasure.