I was going to post a rather benign essay on my outrage that Medicare won’t pay for hearing aids today, but I was distracted this morning by headlines regarding the opioid epidemic and how it has become a national priority.
I am going to reframe this “problem” in this essay and suggest a radical solution. You will need to read through the whole thing in order to find out what I am proposing, but I promise you it will be worth the time and effort.
First though, what are opioids anyway? They are synthetic materials chemically derived from the opium plant used as a strategy for managing pain. Human beings have been using opium as a strategy to manage pain as far back as 3,000 years before Christ was born. Anthropologists theorize that early humans watched animals eating these weird looking plants and then getting buzzed. With nothing better to do, these humans imitated the animals and found when they ingested the plant they didn’t care about the fact that they had to experience pain and suffering and lack and challenge on a daily basis and figure out how to survive against incredible odds. For a little while, all that pain disappeared! Opiates are the modern version of the plant and have been the mainstay of pharmaceuticals and medicine for a very long time.
Just what is this opioid epidemic? There are a couple of ways to explain this and I want to be very clear here and not come across as sarcastic or humorous. A lot of people are experiencing pain of all sorts in our world, and not just in the United States. Some is physical pain ranging from sore muscles (myalgia) to indeterminate joint and muscle pain (myofascial). Some is emotional pain that shows up as physical problems (depression, anxiety). Much is a combination of physical, psychological, and spiritual pain that, because we are unable to discharge it in supportive healing ways, results in feelings of isolation, loneliness, rejection and depression.
And this pain takes on different qualities and lasts for different lengths of time. I may wake up in the morning feeling great, and by dinner time, I am a miserable wreck. What’s worse, my brain remembers that and coaches me to avoid that feeling in the future, so I look for ways to numb out, to escape, and to medicate. Or, I might be feeling tired and achy, and so I reach for something to take away that feeling. Except that it doesn’t go away and sticks around for days, weeks, and months. It may get the point where I just figure that’s what it feels like to be me. The variability of pain is part of its challenge.
Here’s the kicker. Opiates work really, really well in convincing me that the pain doesn’t matter. When I take my codeine, hydrocodone, OxyContin, or fentanyl, my brain’s opiate receptors (yes, those came as pre-loaded apps) cheer and shout for joy, because they now have allies coming to help manage the extreme distress my body was experiencing. And immediate management of distress is the PRIMARY TASK of the brain when it is under siege from pain.
So what is the problem here? This seems like a pretty good strategy! And it is. Please understand that. Pain management using opiates is a legitimate and well understood method for helping the body return to an optimal state of functioning.
The problem here is that our brain quickly becomes used to the strategy of having outside sources of opiates available and just goes off to do other things. When you stop taking the opiates, the brain doesn’t get the message right away and the body feels really crappy until things can get back to an even keel. But this is a mixed message – it goes something like this – PAIN! [Stop the pain], add pain blockers – [can’t feel the pain! Yippee!] PAIN! [Stop the pain], add more pain blockers] PAIN! [Stop the pain], add pain blockers – [can’t feel the pain! Yippee!] PAIN AGAIN! [Stop the pain], add more pain blockers— PAIN MIGHT COME BACK! [Stop the pain], add more pain blockers, just in case – [can’t feel the pain! Yippee!] PAIN!
Pain cycle
Do you see how this cycle works? Do you understand that the pain never goes away?
So what is addiction? For most of us, addiction is a shame-based image of someone living on the streets, unbathed, poorly clothed, and begging for food and money. And, as many of you may be aware, this is not an accurate image. An accurate image can be found by going to your bathroom mirror and looking at the reflection.
I don’t know anyone who isn’t addicted to something. But our culture weighs types of addiction differently. For example, drug addiction and alcohol addiction are considered so bad that they have their very own government agencies – Substance Abuse Mental Health Services Administration (SAMSHSA) and the National Institute of Drug Addiction (NIDA). Addiction to other things such as sugar, smart phones, shopping, exercise or FaceBook hasn’t achieved that kind of status. I find this fascinating.
Addiction is also a booming business. Based on results, however, there do not seem to be any evidence-based “cures” for addiction. 12-Step programs are perhaps best known because they provide structure and community for those who want to try abstinence as a strategy. Inpatient detoxification and pharmaceutical substitutes (e.g., methadone) are another strategy used, although they, too, have poor outcomes in terms of “curing” people.
Psychological approaches include behavioral management, motivational interviewing, EMDR, tapping, mindfulness, analysis and family therapy, but, as with each of the strategies above, the “cure” rate is pretty low.
Addiction is political as well as physical.
Currently the focus on the opioid epidemic is a medicalization of a political problem arising from socio-economic inequities and lack of access to proper medical care.
So what are we really dealing with here? Pain on so many different levels. Frustration in our inability to make that pain go away. Pain caused by people who take advantage of the pain of others. Pain from living in times where we have lost our direction and sense of belonging, which from a neurophysiologic perspective, is a constant cause of pain.
In seeking ways to make the pain go away, our distant ancestors relied on plant-based interventions, altered states of consciousness induced through ingesting substances, movement and dance, and trance states. We have become more sophisticated about these strategies and have created systems for procuring, manufacturing, distributing, and treating using these substances. And sadly, we have added a layer of pain to this, through our criminalization of use.
The last group we should want meddling in pain management is the government. (And this comes out of the mouth of a progressive!) Let me be clear about this. We need regulations and oversight to insure that the manufacture of opiates is done at the highest levels of safety and purity. This is to protect those who need these substances to manage their pain. Government is actually well designed to achieve this end.
When it comes to prescribing opiates, we need to insure that there are evidence-based guidelines that draw on unbiased scientific studies (i.e., not funded by pharma) that are shared widely among the medical community. Again, government already has such structure in place, but should not be policing the prescribers.
We need to let prescribers prescribe. Those of us in the healing profession are being demonized and dummied-down. We need to take charge of our profession again and ransom our skill set from the insurance companies who dictate how much time we spend with our patients, and how we go about helping our patients return to health.
Too many of my older patients experience unrelenting pain from a variety of conditions. Sadly, they tend to rely on what their friends, neighbors, and the internet tells them instead of following recommendations from their healthcare provider. “I am afraid I will become addicted!” is a cry I hear all the time. But what does that mean? What if being addicted for three or four months will get you back to feeling good, and then, under a prescriber’s direction, you can be titrated off the medication that gave you that healing reprieve?
The fear of being addicted is actually a barrier to getting better! How crazy is that?
But, you ask, what do we do about the kids who are overdosing on street heroin and the importers of drugs who are taking over our country? Here, government is poorly organized and probably the least efficient way to manage the issue, at least based on results.
It is my belief that there will always be a percentage of the population that has the disease of addiction. For these individuals, as I mentioned above, treatment is limited. For others who are seeking to avoid pain, to numb out, and to escape whatever psychological hell they are in, we need to offer more than just “counseling” or jail. Our communities must take ownership of the imbalances and inequities found within and begin to systematically address this pain. As a consequence of that, I believe we will find fewer people seeking a high in order to escape.
I certainly see a role for psychological and spiritual interventions. Families need to learn to be together, work together, and help each other get through the pain. We must become self-reliant again, trusting that we can work together and in doing so, decrease the load we each carry.
Tolerance of what is painful needs to be addressed and strategies including music, dance, theatre, shared tasks and problem-solving taught and implemented as well as prescribing substances. This strategy actually builds tolerance in a positive sense. Instead of reaching for something to take away the pain at any moment, learning to ‘lean into the pain gently’, just for a moment will result in a dissipation of the experience of pain and increased capacity to manage the pain.
We must stop the criminalization of use and address the greed and opportunistic activities of those who manufacture and distribute substances. And this must include the local dealer as well as the large pharmaceutical companies.
Finally, we must give up the notion that we can live this life without experiencing pain and instead, start to renegotiate our relationship with it. This renegotiation includes using opiates to gain time and defend against the overwhelm that modern living often thrusts on us. It includes admitting that we cannot do this all by ourselves and need others to help until we can gain traction again.
So this is the radical cure I promised at the beginning. There is no “cure” for pain. The goal is not to be pain free, but to be able to correct the conditions that cause the pain to arise, and in correcting those conditions, develop tolerance and acceptance of what we are currently experiencing.
