(Contributing Author, David Hall, is a member of the RemotelyMe Team serving as Chief Technical Officer)
Acute pain is a temporary biological stressor, while chronic pain is a biopsychosocial enigma. We deﬁne chronic pain as pain lasting over three months. But this simple deﬁnition cannot describe the experience many endure when their primary care physician, or even pain specialist, does not, or cannot, bring relief to a destroyed life. Why do we use the term biopsychosocial when describing chronic pain? We do so because chronic pain wreaks havoc in every aspect of life, and in signiﬁcant ways, harming families, marriages, jobs, and even the economy. Chronic pain is a $635 billion dollar problem in the United States. Approximately twenty percent of the world’s population experiences some type of chronic pain. It is the number on reason people access the healthcare system. Chronic pain is a pandemic. Trust is new hope in pain management Unintended Consequences The CDC recently released its opioid prescribing guidelines, a recommendation for physician prescribing practices, and an update to the original 2016 document, which wrongheadedly attempted—and failed—to solve the so-called opioid crisis by preventing physicians from prescribing pain medication to patients as they deemed necessary. Six years later, with millions harmed, the CDC emphasizes physicians should never use their guidelines as an inﬂexible and rigid standard of care, leading to patient abandonment. However, if you read the ﬁne print, that is precisely what the CDC advocates for.
The original guidelines came about from a lethal combination of bureaucratic arrogance and “do-goodery,” with the organization foolishly trying to stop substance abuse by making prescribing more diﬀicult and, thus, the drugs more challenging to gain on the black market. According to the Journal of Pain Research, “Data suggest that the overdose crisis is largely an unintended consequence of drug prohibition.” This situation has nothing to do with the open borders and the illegal fentanyl now streaming across the border. This issue started long before Biden took oﬀice. The result: untold thousands suﬀering needlessly, increased suicide, and now some seeking relief from drugs on the street that would otherwise never consider (which in part is what the CDC was trying to prevent in the ﬁrst case).
As a Certiﬁed Health and Wellness Coach specializing in chronic pain management, I see the heart-wrenching eﬀects on abandoned patients and their loved ones when denied these essential medications just for the crime of being stricken with chronic pain. And, yes, contrary to whatever those on Capitol Hill or institutions like the CDC or DEA have suggested, these medications are irreplaceable, and a critical element to making modern medicine and daily life possible. This explains why PNE (Pain Neuroscience Education) plays a huge role in my practice. These unmet needs created an even greater need for a new ground-breaking tool in neuroscience and a way to assess it. More on that below. The Untold Story But ﬁrst, let’s start with the brain. One thing you’ll rarely hear come from the lips of any medical practitioner is that chronic pain ravages the brain in at least four ways! As a chronic pain patient, suﬀering with a rare and most painful condition with which there is no cure, none of my physicians, with one exception, ever told me chronic pain aﬀects my brain. Why? Maybe because they do not teach this in medical school? Likely.
In the U.S. and Canada, medical schools invest only 0.3% of the total hours of curriculum to the study of pain management. This is but one ﬁfth what veterinary students are required in their programs. Yet, almost most physicians will write prescriptions for pain with minimal understanding of how those medications work at a cellular or neurological level. But let’s get back to how pain aﬀects the brain.
One of the greatest miracles of nature and creation is the three-pound brain and the complex network of 80,000 yards of nerves throughout all the tissues in our bodies. The collaboration of the electro-chemical reactions enables us to love, speak, sculpt, paint, play Brahms requiems, experience the softness of a baby’s skin, and plot the story of the next great thriller. It is the same brain that experiences fear, anguish, doubt, and, yes, pain. Rarely do we ever think of this marvelous supercomputer and network until problems arise.
Those of us struggling with chronic pain may have heard, “It’s all in your head.” This may be right on target if your pain is chronic and has an established history. Most chronic pain conditions cause literal changes in the brain, reinforcing or fortifying the pain cycle. Neuroscientists call this the “centralization of pain,” meaning pain itself changes how the central nervous system works. Patients actually become more sensitive and experience more pain with less provocation, and there’s more.
Chronic pain changes your brain’s structure. Neuroimaging studies have shown that chronic pain can alter the size of certain brain regions and change the connectivity between these regions. The way various parts of the brain “talk” to each other becomes atypical. For example, chronic pain is notorious for aﬀecting a brain region called the dorsolateral prefrontal lobe. It aﬀects the areas of the brain involved in reasoning, analysis, motor planning, and memory. A chronic pain brain will have diﬀiculty performing these functions normally. This explains why many pain patients experience fear, anxiety, or depression. Unfortunately, these added symptoms just worsen the underlying pain condition.
Chronic pain alters your brain’s chemistry. Chronic pain stimulates the brain to generate abnormal levels of chemicals called neurotransmitters. In the right amount, these chemicals create the perfect balance of activity and inhibition, so the brain reaches a “Goldilocks” level of function–not too much or too little, just the right amount. However, abnormal amounts of key neurotransmitters prevent certain brain regions from “turning oﬀ” when they should. This results in a brain becoming overly sensitive to pain and stimulates a feed-forward cycle that reinforces the chronic pain state.
Chronic pain changes your brain’s activity. Scientists have learned brain activity patterns among patients with temporary pain diﬀer signiﬁcantly from those with chronic pain. Although the sensations of pain feel the same in acute and chronic pain stages, the way the brain processes pain is diﬀerent. Researchers found as pain morphs from acute to chronic, the representation of pain in the brain shifts from classical pain areas to brain regions associated with emotion. This might explain why treatments that work well for acute pain patients don’t provide relief for chronic pain patients with the same injury. Further, performance in clinical chronic pain studies supports a relationship between chronic pain and neurocognitive abnormalities, particularly on tests of memory, attention, and processing speed, with mixed data regarding executive functioning.
Chronic pain aﬀects memory. If you are not getting restful, restorative sleep, going through several sleep cycles, your memory could suﬀer. Memory consolidation takes place during non-REM stages 3 and 4. So, if you are not going through the normal three to ﬁve REM cycles per night, you might experience memory challenges, especially if you struggle with chronic pain. Most with chronic pain suﬀerers are sleep deprived. It goes with the turf. But there is hope. Read on. Tools, Toolkits, and Trust A primary tool health and wellness coaches use with our clients is “motivational interviewing.” It is a skill used to evaluate client’s readiness to adapt and eventually make changes. Change is hard for most. Most resist it with a lot of kicking and screaming along the way, ﬁguratively, some literally. Either way, change is hard. But when you’re struggling 24/7 with chronic pain and the stigma that often goes with it, change can be even harder.
Consider the patient seeking help from multiple practitioners that’s led to disappointment after disappointment, stigmatized as “drug-seeking,” when all he or she’s sought is relief from pain, depression that haunted them, or even just a good night’s sleep. Those who’ve promise to help them have let him/her down, not always by their choice, but sometimes by government bureaucracy and legislation, or insurance company arbitrary mandates. Someone breaks trust along the way. Regardless of the reason, it exacerbated the original pain whether bio, psycho, or social, they’re all an interwoven in the biopsychosocial complex when it comes to chronic pain.
Motivational interviewing is a powerful tool that honors and respects an individual’s autonomy. It enables the coach to walk beside the client while helping them mine those jewels that makes the client the valuable person they are. Jointly, the coach and client develop goals the client ultimately chooses for them self. This is a slow process that takes place after we built a relationship, based on the critical element of trust. Without trust, nothing will happen in the coaching relationship (or any other worthwhile relationship within anyone’s life).
There are dozens of assessments available to better help coaches, psychologists, and psychiatrists better understand their client’s strengths, personalities, make-up, style, etc. But what is lacking is an assessment helping clinicians better understand the client’s make-up regarding trust, and how to best communicate with the client in a trust context, until now.
RemotelyMe, a company in southern California, has a patented assessment for not only assessing trust but also provides “playbooks” for how to best communicate with individuals using language that best resonates with those taking the assessment, based on neuroscience. The assessment is not text-based, it is visual and takes about nine minutes. It is better than 93% reliable, compared to 55% to 75% for other text-based assessments. Trust is the key. No other assessments on the market even consider trust, and yet, this is the most critical element in any working relationship, whether coaching in the health/medical community or otherwise. Trust in any relationship is what makes us human.
Understand, that when a potential client arrives at my doorstep, often healthcare providers, psychiatrists, family members, friends, and others whom they should be able to trust may have violated their ability to trust. All well-meaning, but all of whom don’t understand how chronic pain may have aﬀected their ability to function in their changed world. The chronic pain person’s body and mind no longer process or work as they once did, and now the aﬀlicted (or aﬀected) must “relearn their world” and adapt, and derive new meaning for their life (whatever that might mean). They must develop new constructs undergirded with care and understanding, navigating throughout and among continuums never previously considered. None of this will take place without a foundation constructed without of the critical element of trust.
Now we have a new tool enabling us the ability to evaluate trust easily and aﬀordably, in a non- threatening platform. This is truly ground-breaking and provides clinicians with the ability to view clients/patients in new light with relevant information based on neuroscience. While RemotelyMe uses their platform primarily in business applications, I can imagine uses for their assessment in education, social arenas, marketing, therapeutic, and more. This oﬀers new hope in many potential areas, and is potentially disruptive to the assessment industry.
David Hall is the author of “Striving to Thriving-A practical resource for reclaiming your life from chronic pain,” a Certified Health and Wellness Coach specializing in chronic pain management, advocate who testified before members of Congress, support group leader for the U.S. Pain Foundation, and chronic pain survivor. David serves as Chief Technical Officer for RemotelyMe.