Sean Stephens, by his own admission, was an old man in a young man’s game.
In 2006, at 38, he enlisted in the Army National Guard, “a little bit older, a little bit used,” he says, but he didn’t let it get in the way of his duties in Afghanistan. He could still keep up with the 19-year-olds double-timing through the desert with 110-pound packs, still stand for 12 hours straight in the back of a Humvee manning the .50-cal. Sure, the pain at the end of the day didn’t wash away with some Advil and a good night’s sleep like it used to, but he could handle it.
By the time his fourth tour rolled around, though, his labors were catching up with him. He was 42, and the hours he was spending on quad bikes training Afghan police on the eastern frontier were taking their toll. What started as a weird clicking in his neck and a twinge in his back devolved into a searing, debilitating sensation, and soon his head no longer felt connected to his spine. His hands began to fail him, too, the result of 18 months of vice-gripping that machine gun. By 2011, when he was medically evacuated from Afghanistan, he couldn’t even button his own shirts.
Pain—the earliest of our afflictions, a state from which no man escapes—is a hell of a thing. It’s one of our oldest inherited traits, an evolutionary system designed to protect us: Burn yourself once and you likely won’t put your hand in the fire again. Pain, in a sick way, is good for us. Pain, annoyingly, makes sense.
But sometimes, against all evolutionary inclinations, the system goes haywire. When Stephens got home from Afghanistan, his pain didn’t subside. Afraid of injuring himself further, he limited his movements. His doctors prescribed tramadol, an opioid that brings sweet relief from the agony of, say, a surgical wound, but it was at best a fleeting escape from the constant companion that his pain had become. He took three to five pills a day, but still the headache at the base of his skull blurred out the rest of the world, still his hands wouldn’t work. He’d “lose his shit,” he recalls, as the anger and stress and anguish consumed him.
We know how to treat chronic pain. We’ve known since the seventies.
This is chronic pain—the tissue has healed, the wounds have scarred over, but the silent scream radiates. About 50 million Americans suffer from it, the biggest chunk of them between the ages of 45 and 64. The experience is familiar: the bum knee you blew out skiing in your 30s, the back you can blow up just by getting out of bed wrong, whatever it is you did 20 years ago to make your shoulders hurt all the time now. For nearly 20 million people like Stephens, however, the suffering is truly debilitating. This pain costs jobs and relationships and lives.
For a patient with a broken leg or an open wound, modern medicine has made extraordinary strides over the years, as whiskey and a leather belt have given way to anesthetics and OxyContin. But in America, chronic-pain treatment is in an ignoble shambles. The remedy is often injections, surgery with a questionable success rate, or what Stephens got after his four tours in Afghanistan: potentially addictive pills that dull the pain but ignore the underlying problems.
Here’s the thing, though. We know how to treat chronic pain. We’ve known how since the ’70s. But chances are you’re not about to get the best treatment. With effort, you can approximate it yourself, but to do so, you have to know a little bit about the inner workings of chronic pain.
Why It Hurts
If you injure your toe, the nerve endings in your foot fire off electrical impulses to your brain: Something bad happened down here. Your brain works with specialized nerve cells in your spinal cord to figure out a response. Was that a burn? Better get that leg out of the fire pit. Did we just break our ankle? Let’s turn the pain dial up and make it ache for a couple weeks so we’ll stay off it. Once the injury heals, the brain turns the dial down and stops sending these amplified pain messages to your body. The hurt, blissfully, dissipates. But with chronic pain, the neural circuits stay amplified—your brain has actually rewired itself—keeping the pain dialed up to 11, even if the damage has been repaired. “Chronic pain,” says John Loeser, M.D., former director of a legendary pain-treatment center at the University of Washington, “means nature has failed.”
John Bonica, M.D., the father of pain medicine, knew none of this when he started treating injured soldiers returning from the Pacific at a military hospital south of Seattle 75 years ago. There, apparently healed patients or those with missing limbs would confound their doctors with complaints of unceasing pain. Dr. Bonica, who would go on to write the first modern text on pain, realized that something complex—something not entirely physical—was at work. He saw that anxiety, depression, and PTSD were common bedfellows of chronic pain, suggesting that pain was affected by emotions as much as by tissue damage. Much later on, research would find that regions of your brain associated with anxiety and depression are also linked to your fear and pain response.
But back then, going by his observations, Dr. Bonica decided that chronic pain was such a complicated, multifaceted animal that it required all sorts of caregivers. Two decades after World War II, he opened the country’s first “multidisciplinary pain clinic”—that famous one at the University of Washington. “It was not something a single person could solve,” says Dr. Loeser, who ran the clinic after Dr. Bonica retired. “The bottom line was this was going to be a team approach.” The goal of fully eradicating pain was out, and instead a squad was formed to teach patients how to manage their symptoms and improve their quality of life from all angles. A physical therapist showed you how to move again, a psychologist taught you not to be afraid of your pain, an occupational therapist helped you figure out how to manage your angst at work, a dietitian helped you lose weight and take some stress off your joints, a nurse case manager kept everything running smoothly, and a doc supervised the whole team and your overall progress. The combined approach was revolutionary in chronic-pain care, and it accomplished something no other treatment did: It worked.
By the late 1990s, there were more than 1,000 interdisciplinary chronic-pain-management programs across the country. They were expensive places; treatment by a full complement of experts could run up to $30,000. Yet numerous studies showed that this approach not only succeeded but also paid for itself. Having healthy humans who are able to work, it turns out, costs society much less in the long run.
In 1995, Purdue Pharma introduced OxyContin. It was an immediate hit. A few early studies suggested tantalizingly—and falsely—that OxyContin could be an effective, nonaddictive treatment for chronic pain. Insurance companies recognized a quick, less expensive fix when they saw one. “They said just give ’em the medication, the opioids,” says pain expert Michael Schatman, Ph.D., director of research and network development at Boston Pain Care.
By 2015, there were 20 million opioid-reliant patients in the U.S. And 56 remaining interdisciplinary pain clinics.
Treat Pain Without Pills
Sean Stephens was nervous. The Veterans Health Administration had gone on the same opioid-prescribing binge as the rest of the American medical system, and a swell of veterans with opioid-use disorders—68,000 of them—filled the ranks by 2015. Vets were twice as likely to die from an accidental overdose as other Americans, and a ruling came down from on high: Opioids were out of favor. When Stephens showed up for an appointment at the San Francisco VA Medical Center in 2010, his doctor, Karen Seal, M.D., told him that they were going to start working to decrease his dose of tramadol. His pharmaceutical crutch, the opioid he’d been relying on to get through the days, was about to be pulled out from under him. “I was scared.”
In the two decades since Oxy, almost all of the interdisciplinary pain clinics have closed, and the VHA has become a surprise leader in keeping this approach alive. Other clinics are mostly at big institutions—such as the Mayo Clinic and the Cleveland Clinic—because, Schatman says, these places can afford to lose money on poorly reimbursed pain care. But the VA doesn’t have to make money. It’s responsible for treating its patients for life, and over time managing pain is cheaper than endless pills and procedures.
Dr. Seal happened to be the head of the VA’s integrated-pain team, and she was now in charge of tailoring pain-treatment regimens that didn’t involve unlimited refills of meds. Her message to Stephens was no-nonsense: “Pharma tells you that you can take a pill to fix everything.” But not here, she said. Here there would be goals to help manage pain without relying solely on opioids. Here they would work with him to get his life back.
Some of the treatments Dr. Seal prescribed to Stephens sounded obvious enough (physical therapy, nonaddictive drugs, simple goals like exercising for 20 minutes straight), but others were the kind that could make men squeamish (yoga, deep breathing, meditation, cognitive behavioral therapy). Stephens vaguely knew that there were other ways to treat pain. He’d tried pot, but he didn’t like it. He knew yoga was a thing, but he didn’t think of himself as a yoga guy. “I wasn’t interested in finding another solution to pain,” he says. “But these people talked to me about all the things we can do to get past this point. It was this real aha moment. I never put it together that stress relief could be pain relief.”
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One of the hardest components of interdisciplinary care for men to sign on to is probably seeing a therapist. Treating physical pain with cognitive behavioral therapy may sound like new-age BS, but the brain is a strange thing. Show devout Catholics a picture of the Virgin Mary during lab-controlled pain studies and they’ll report less pain. Give people a placebo to make them believe they’re about to receive pain relief and the brain will actually release natural opioids to block the pain. New brain-imaging studies are consistently upending our most basic ideas about pain. Tor Wager, Ph.D., a neuroscientist at the University of Colorado Boulder, recently found that if the brain anticipates receiving more pain from an injury, it will dole out more pain sensations—regardless of physical damage. “When you expect more pain, you really do feel more pain,” he says. And when you live in constant pain, you’re afraid of feeling more of it. You get in a feedback loop that truly makes the pain worse. Learning to think about it differently- can help break this cycle.
Paired with physical therapy, gentle exercise, and emotional support, this holistic approach has had dramatic results across the VA. So far, the agency has reduced the number of vets addicted to opioids by about 40 percent, and a study by Dr. Seal showed that patients in interdisciplinary clinics were 50 percent more likely to cut their dosages significantly. “I’ve become almost evangelistic about this,” she says. “When you’re off opioids, you get your life back.”
For Stephens, the approach helped him take control. “The pain is still there,” he says. “My wife still has to button my shirt for me.” But now he’s in charge of his pain—not the other way around. Today he does deep breathing throughout the day. He has a therapy dog that keeps him calm. And he gives himself ten-minute breaks to de-escalate anytime he feels the pain rising and his fear cresting. “That will get me past whatever pain there is,” he says.
For the tens of millions of non-vets who are suffering, there’s a similar way to find relief, but it takes some effort. Another thing it takes, Stephens says, is guts. The guts to be the “old guy” at your first yoga class, to be willing to try something that sounds unrelated to your pain, like deep breathing. Because, in the end, feeling self-conscious at the Y or being embarrassed about going to a therapist is a lot less painful than a life in constant pain.
How to Take Charge of Your Pain
“The best way to address chronic pain is to treat it like a team sport,” says Sean Mackey, M.D., Ph.D., chief of pain medicine at Stanford University. You need different players to manage different positions. If you don’t have access to an interdisciplinary pain clinic, here’s what to do:
Talk to a social worker or therapist
“The strain in pain lies mostly in the brain,” Dr. Mackey likes to say, and a psychologist who specializes in pain can help you understand this in a relatively short time period. It’s not mumbo jumbo, either. “Your beliefs, emotions, and thoughts about your pain play a huge role in your experience of pain,” he says, and he’s got the brain scans to prove it. Chronic pain rewires your brain, and therapy can help undo that rewiring. It may not eliminate pain, Dr. Mackey says, “but it can improve it and give you back control.”
“What do you think the first thing the team doctors for the 49ers do when a guy blows out his knee and needs surgery? The answer is physical rehab,” Dr. Mackey says. Although it may hurt, “you need to get those muscles strengthened and support that area that’s painful.” Studies show that PT reduces pain in the long run, and insurers often cover it.
Don’t deal with it in silence
Managing your pain is a long-term effort, and many insurers offer support groups. In or near big cities, there are often free meet-ups where you can find out how others handle pain.
Take steps to relax
Reducing stress reduces your pain, Dr. Mackey says. Free apps like Headspace can guide you through mindfulness lessons, a YMCA may offer meditation classes, and acupuncture provides relief to plenty of people. Your pain may never fully disappear, Dr. Mackey says, but that’s not the point. By putting all this together, you can take control and stop pain from dominating your life. You win; pain doesn’t.
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