After fighting her own battle with chronic pain at a young age, Dr. Beth Darnall is on a mission to provide people in pain with the answers and access she wishes she had all those years ago. These answers, she believes, don’t lie in pills, but in the human brain. Darnall is currently leading a $9M research award to find effective strategies for tapering off opioids and to validate the psychological interventions she believes can help many of those who suffer. Join us as she offers advice for pain sufferers, providers, and payers on how to move forward from the opioid epidemic, and reduce pain safely.
You can find information on Beth's work on her website. Download her team's pilot study from JAMA Internal Medicine here.
Women are disproportionately affected by chronic pain, and there’s a lingering stigma from when conditions like migraine and fibromyalgia were dismissed as “women’s issues” or purely psychological. As a result, a lot of women to shy away from any sort of approach to pain treatment that includes psychology, even though these options can be very helpful. What advice do you have for women who feel this way?
It’s unfortunate that women have been stigmatized because of pain. The medical system has certainly contributed to that over the past few decades (but really, probably since the dawn of time).
My message to women is that this treatment pathway is vitally important for you in particular. It is your pathway to freedom and to regaining control. Women DO suffer disproportionately from pain. In broad averages, about 60-70% of people who have chronic pain are women. For some conditions, that’s much higher - up to 90% of the sufferers are women. When women do experience pain, it also tends to be of greater intensity and longer duration. We just see a greater impact on women. Women are also more likely to suffer from mental health comorbidities in addition to their pain, such as depression or anxiety.
Women’s nervous systems are quite malleable. Really, the human nervous system is quite malleable - it’s plastic, it can be shaped, we can change it across our lifespan. But women in particular have a very plastic nervous system. For better or worse, they are more easily “programmed.”
So women are more likely to be exposed to an event and to develop PTSD from it - they are greatly impacted by it. But that works in both directions. So in the same way that the female nervous system can make you more vulnerable to developing chronic pain, you are also better equipped to respond to these treatments that reshape your nervous systems. That is exciting news!
It’s really important for women in particular to engage in these psychological treatment pathways because they stand to gain more. And if they don’t pursue those pathways, they also stand to lose more. The stakes are simply higher for women.
You are currently leading a $9M research award at Stanford to test pain management strategies and address the opioid crisis. Can you tell me more about the work you are doing in this area?
A couple of years ago I was working with a physician to conduct a study to learn about how to help people taking opioids reduce their need and use of those drugs. There’s a common perception that people who are taking opioids really want to KEEP their opioids, and not to reduce them. But for most people, that’s not true at all. They don’t want to take opioids - they just don’t want to have pain, and so they take the opioids to get rid of the pain.
But what’s interesting is that if you look at the research on people who have successfully reduced their use of opioids, they don’t have more pain. And that’s interesting because the #1 fear of people who are taking opioids is that if they stop using them or reduce their use, they’re going to have more pain. But the data actually flies in the face of those fears. The data tells us that when people reduce their use of opioids, pain does not increase.
The catch is that all of these studies were done in costly inpatient settings, where patients had access to physical therapy, psychology, occupational therapy, and all of these exciting treatments in an intensive setting. And let’s face it - the vast majority of patients in the US will never be able to access one of these sophisticated inpatient settings. So the question is: how do we help the millions of Americans who are taking long-term opioids to reduce their use cheaply and without additional resources. This was the study that we conducted.
I partnered with a physician in Colorado. We invited patients in his clinic who were taking opioids, and we presented them with the data. We said “Look, the studies show that people who reduce their use slowly over time do not have increases in pain. We want to partner with you in a patient-centered way to help you reduce your opioids. Are you interested in doing this?”Much to our surprise, people were highly receptive to this - so that really challenged this perception that people are not interested in reducing. People are interested in reducing their opioids, they just haven’t been invited. They haven’t been given an alternative.
Those who engaged in our program (which was basically just a very slow taper over 4 months) were able to successfully reduce their opioids by at least 50%. For some people, it was closer to 75%, and some people tapered off completely in four months without having increased pain. This was really interesting to us because it suggests that if a patient-centered formula is used, then you can partner with patients over the course of several months and have them reduce their health risks without having increased pain or costs.
We published this study in JAMA Internal Medicine in February, and these data served as the foundation for a new award that I’m leading - a $9M research award to study opioid tapering in four states (CA, AZ, UT, CO) over the course of one year.
What’s interesting about our pilot study is although patient reduced their opioids without any pain increase, nothing else really budged. Their depression, anxiety, and sleep did not improve. That’s no surprise, because we weren’t really targeting that. But in this follow-up study that we are doing, we are going to be reducing opioids with everyone who enters the trial. In addition, we will give 1/3 of those patients cognitive behavioral therapy for pain. We will give another 1/3 of those patients a chronic pain self management program. The remaining 1/3 will only receive the tapering, without behavioral support. What we hypothesize and expect to find is that these methods help reduce opioids without increasing pain AND if we give them some of this psychological support, they will have an even better response. We will help them live better with pain, function more, and do more of the things that are meaningful to them.
What can providers do to bring these sorts of treatments into their practices now? Do they have the time and resources they need to really help their patients this way on an individual level?
For providers, my recommendation is to download the JAMA Internal Medicine article. We describe these very simple methods for helping patients taper these opioids over the course of months. The biggest problem with opioid tapering today is that it’s simply too aggressive, so patients experience discomfort and withdrawal symptoms. They’re likely to stop the taper and falsely believe that they can’t reduce their opioids because they can’t do the taper, when in fact, it’s just too aggressive of a formula.
We don’t say that everybody will get to zero. I think it’s a nice goal, but if zero isn’t achieved, it isn’t a failure. I think the goal is to simply be successful in starting to reduce opioids and to get to the lowest level for each individual patient. This is something that any physician can help their patients with.
Regarding the other treatments that are available, that’s sort of variable. Not everybody has access to CBT. But that’s the beauty of online solutions like Curable. You offer these types of therapies in an accessible way that is not dependent on clinicians in the community. So I think a patient-centered simple taper combined with psychological support (to the extent at which it’s available to each patient) is the way to go.
In a perfect world, people would have access to individual or group psychological support, web-based or digital tools that can provide education and support on-demand, and a supportive physician who can work with the individual to reduce the opioids. A physical therapist, too. Movement-based therapies are so vitally important to reducing pain and opioids as well.
[This was an excerpt. Listen to the full podcast above]