Tuesday, February 16, 2016

Chronic Pain Patient Crisis and NPR-Here and Now: Where Chronic Pain Patients Fit Into The Opioid Crisis

I was recommended an excellent interview and wanted to share a link and some discussion. The interview and its points are a much needed highlight of the negative effects that new pain management restrictions and guidelines have had on chronic pain patients, and I highly recommend it as a worthwhile perspective for any listener.

Interview Link: NPR-Here and Now: Where Chronic Pain Patients Fit Into The Opioid Crisis

Note: for resources included in this discussion/review, please see the list at the bottom. Critique, comments, and response are (as always) welcome.

The use of opioids in pain management is under attack, as governing bodies in the US desperately seek to reduce misuse of pain prescriptions and prescription drug overdoses. The CDC, DEA, and FDA have been working towards increasingly restrictive opioid guidelines in recent years, aiming to reduce the number of prescriptions written. As these governing bodies seek to reduce the significant epidemic of prescription pain overdoses and deaths, numbers continue to escalate and chronic pain patients are suffering expansive negative changes in their health care.

How do guidelines affect the broad world of medicine? Insurers, pharmacies, clinics, doctors, healthcare providers, etc., operate in a social-legal environment where the needs of a patient are balanced against laws and guidelines for practice. This continuum exists for practical and beneficial cause--without general guidelines of practice, a patient could not trust their doctors to consistently abide by safe and commonly accepted health practices. Medicine is constantly evolving and changing, relying on expansive empirical, peer-reviewed, and clinically tested treatments; healthcare providers strive to maintain up-to-date care and accreditation by acting within these advocated practices, and we as patients can trust in consistent safe care.

Guidelines for treatments vary according to (1) the practice of providers and (2) diagnoses of patients. Complications arise when different classes of patients are identified as same/similar and regulated the same. For an obvious (and unrealistic) example, consider if pregnant and nonpregnant women were regarded the same by regulation boards. Doctors would be expected to treat pregnant women as not pregnant, even when considering teratogen associated prescriptions, or they will be faced with discrimination fines/review boards. As a result, the rate of birth defects skyrocket as unsuspecting patients use treatments they would otherwise avoid. Or, if the opposite were true, with women treated as pregnant regardless of reproductive status, critical medical treatments with zero contradictions could be withheld without cause. Hormones, antidepressants, pain relievers, mood stabilizers, anti-inflammatories, and many more medications would be unavailable to women on the basis of assigned pregnancy capacity. Neither outcome would be desirable. Thankfully, current guidelines generally recognize such obvious discrepancies; unfortunately, serious consequences arise when they do not. And it seems patients in pain seem to be veering into their own impractical groupings.

Prescription drug overdose is the driving force in regulation changes seen in recent years. The epidemic is not to be trivialized--according to the National Institute of Drug abuse, total deaths due to prescription drug overdose increased 2.8-fold between 2001 and 2014. In response to the overdose epidemic, the FDA and CDC has sought to increase restrictions on prescription guidelines of opioid pain medications. But despite increasingly restrictive guidelines, deaths continue to increase--and chronic pain patients say they are feeling the burden of the changes.

While number of deaths is deservedly a focus of the regulatory response, it seems to be the only focus, and guidelines fail to distinguish circumstances leading to overdose. In fact, they often seem to glance over cause, in favor of simply reducing access. Recognition of specifics for overdose death may seem sterile or harsh, but regulations for any product/action must consider differences leading to misuse/abuse in order to be successful in application and reducing negative outcomes.

For a well known example, age is a factor in the availability of vehicle licensure. In the USA, you must be at least 16 years old to apply for one. You must pass inspection regardless, but certain ages are restricted from even trying to apply. A car can be equally deadly in the hand of an licensed adult, but age of user has predictive value in reducing risk of misuse and negative consequences. If driving license restrictions were instead dependent marital status, the value of that regulation would be far lower. Sure, it would still exclude teens, reduce number of wrecks, and help prevent toddlers from driving, but it would also prevent many unmarried, productive, working adults from efficiently functioning in and contributing to society. As an unintended effect, it may motivate otherwise law-abiding, unmarried citizens to drive illegally, without license, practice or knowledge, in rebellion to the restriction.

In regard to regulations on pain management treatment, rather than acknowledge factors shown to help predict possible misuse, current guidelines functionally consider all pain patients equally susceptible. It requires abiding providers to treat all patients as addicts in hiding. Factors leading to overdose are not explored, doctor autonomy and experience with a patient is reduced in treatment decisions, and the general action is to unilaterally reduce opioid treatment across all chronic pain populations. This approach not only fails to recognize potential patient population differences, but it also glances over the individual percentages of overdoses that we see now. This approach does not address the significant problem of overdoeses that are not based in addiction, such as (1) intentional patient overdoses in pain-related suicide or (2) patients desperate to stop insufficiently managed pain (and thus use too much of their medication in efforts to control their pain).

Research supports that chronic pain patients (especially ones with excessive, unmanaged pain) are at significantly higher risk for suicide. These patients are also more likely to misuse medications when their pain is not sufficiently addressed in their current treatment (e.g. taking increasingly numerous pills because their prescribed dose does not make the pain bearable). Maybe restricting clinical access would reduce their use in the pain population (at least by safe and supervised means), but the outcome would likely be increased suicides by others means. Desperate users will switch to an OTC or illegal overdose risk as they struggle to manage their debilitating pain.

Another, likely more relevant, fact that is ignored by DEA and CDC regulations, is that studies support that the majority of OxyContin addicts seeking addiction treatment have never actually received a prescription (see Carise, et al.). Abuse of prescription opioids tends to happen concurrently with other illegal substance abuse, rather than within the sphere of patient treatment (Wesiner et al., 2009). This supposed link between pain patients and prescription addiction is not even under proper evaluation by relevant governing bodies. By ignoring individual sources of the problem, the value of regulation is fundamentally limited. It's another case of political quick fixes to improve the surface of a problem, ignoring long term potential effects outside the primary goal.

The lack of discussion on such pain-related overdoses is reflective of the problematic predisposition of these regulatory bodies: to see opioid treated users as one cohesive group, rather than a diverse population that includes different types of chronic pain patients seeking sufficient treatment (both responsible and irresponsible). The unilateral nature of current and proposed guidelines disregards differences between various conditions and patients and thus flips the healthcare balance to a focus on legal concerns, reducing a doctor's ability to draw on experience and study to treat different patients with different needs and risks.

These governing bodies state they aim (and I believe they desire) to not negatively affect chronic pain patients, but they seem unwilling to acknowledge the consequences their guidelines carry. And problems go beyond the lack of alternative treatments (which their guidelines imply exist in abundance). The designs do not adequately distinguish between addicts and chronic pain patients or recognize differences between patients and conditions that may require opioid treatment. For example, the major distinction applied in pain treatment is cancer and non-cancer patients, (not anatomical location, duration, symptoms, etc.), and guidelines systematically group all non-cancer patients as needing less pain intervention and as being equal in general pain severity. Their categorical approaches are far too general to be advocating such a serious restriction of treatment--people are going to be negatively affected, including those who have reliably demonstrated responsible use.

Opioids are not a panacea for pain patients. They fail to be the magic solution for intractable, incurable pain. Some conditions do respond well to alternatives. But, for many conditions, there are currently no existing alternatives that manage pain with even near comparable efficiency. In a meta-analysis conducted by Furlan et al. in 2006, over 41 chronic pain treatment studies were reviewed and showed that evaluated opioids significantly outperformed all studied placebos and non-opioid alternatives. Restricting availability will leave patients with less efficient pain treatment. No matter what the ultimate goals of restrictions are, it's dishonest to ignore or gloss over that unavoidable outcome.

Lobbied guidelines and laws regarding opioid prescription cite concern for development of addiction in chronic pain patients. This is a valid and real concern, as some patients do misuse their medications or violate doctors orders. Patients or advocates that gloss over that concern are opening themselves and others to the vulnerabilities and complications of addiction. The problem is, in their methods of describing addiction risks, they lack transparency of sources and do not disclose that there is currently no long-term research on the potential of long-term addiction in the chronic pain population. Yet they constantly make statements about long-term effects, as if that research has been conducted. Many clinical studies conflict on the severity/existence of the risk for addiction in long term, and the meta-analysis mentioned previously found no reported increase. No proper research has supported their cited risks of long term use. They likely exist, but they're not understood nor researched in a manner that could help patients prevent and manage such complications.

Every study I have read on the matter disparages the lack of adequate research in regard to the relationship between chronic pain treatment and opioid addiction. This does not mean a connection does not exist, opioid addiction is a real and serious risk to be aware of, but the extent and nature of the relationship between long term patient use and addiction is not sufficiently supported, explored, or funded. Rather than evaluate what leads to addiction in a treatment setting and how to manage the risk, regulations choose to limit availability to limit number of users, thus limiting total overdoses. Limiting prescriptions may change the number of patients filling prescriptions, but it does not change the percentage of patients or users suffering from addiction and it ignores the lack of research/interest into the causes leading to addiction. And, as evidenced by current statistics, overdoses have only increased despite increased restrictions. It's like a bandaid on a cancer patient: ignoring real intervention in favor of visible 'fixes'.

Rather than just limiting patient access, factors and risks should be the guiding principle in regulations, and regulation should aim to further identify risks for future patients. Psychological and physiological susceptibility to addiction is as significant with opioids as it is with other potentially addictive substances. For example, drinking alcohol is a common behavior in the United States, with about 87% of adults partaking, according to the National Institute of Alcohol Abuse and Alcoholism. But despite the significant addictive qualities of alcohol, less than 8% of drinkers are considered disordered/addicted in their consumption. The difference between a casual drinker and an alcoholic is not a tragic strike of chance; choices, experiences, social environments, physical traits, genetic makeup, and many more personal aspects all combine to determine an individual's susceptibility to the addictive qualities of alcohol.

Studies on chronic pain patients reveal a similar story, in that individuals vary on likelihood to abuse a substance (See Turk, Swanson, & Gatchel, 2007: Predicting opioid misuse by chronic pain patients). In fact, similar to general population (i.e., those who don't use pain killers), individuals with previous substance abuse are the greatest predictive factor for opioid abuse. Other factors, such as type of condition or length of treatment, are not recognized as valid or reliable predictors for whether someone will abuse their prescriptions. Regulations should focus on identifying and enforcing applicable differences between patients which responsible use and those that abuse their prescriptions. Lowering numbers available serves to disproportionately cripple patients that have demonstrated no problem behaviors and depend on such medications for daily living function. Education, awareness, study of risks, and restrictions based in real life application are used for recreational drugs such as alcohol--medical treatments for life altering conditions should be approached with at least the same level respect and practicality.

This is getting incredibly long, so I will try to summarize my view as this: 

Guidelines and regulations have restricted opioid prescribing for over a decade, but delinquent/unconcerned practitioners and addicts continue to increase distribution and access to powerful and addictive narcotics. Response does not utilize or consider investigating patient qualities leading to abuse and overdose. Restrictions have not stopped the escalation of behaviors that lead to increased deaths and tragic loss. Failure of restrictions does not support an increase of further restrictions. It calls for a serious reassessment in approach and a more involved response to the problem. And it requires a more detailed investigation/application into the risks for development of harmful addictions.

These new 'guidelines' have already had real effect in the pain management community, and calling them mere suggestions ignores the legitimate concerns doctors have for maintaining accreditation. These guidelines affect treatment. My pain management clinic, which has actually expanded and is considered a well-respected multidisciplinary practice, is now required to treat all patients like addicts. Every patient is required to submit to monthly urinary analysis and all patients are required to sign an agreement to not consume any alcohol or marijuana, despite both being legal in the state. Patients that previously received prescriptions for medical marijuana were forced to switch treatments or clinics. Costs and  frequency of required care increased, all in hopes of appeasing new guidelines. My pharmacy was forced to reject my regular, low-dose pain prescriptions because corporate policy had switched to adapt to the proposed CDC guidelines. My wonderful pharmacist managed to advocate a temporary extension (as she knows I adhere to a contract and communicate any/all changes to my clinic) but was unable to continue filling them. The cause of change? I am not a cancer patient.

I am a patient that works with my provider to maintain the lowest treatment possible. I don't like being on these medications, I use transdermal low-dose approaches because I dislike the side-effects of pills. My doctor actively strives to help me find and maintain the minimum pharmacological intervention required to allow me to function in day to day living. I'd rather not take any drugs, but I do because I have no other choice. Even with non-opioid treatments, my body cannot tolerate the combined pain of my disorders and nerve damage. Before proper pain management, I only wanted to die. Now I get to live.

Please, when considering the impact of these guidelines and laws, consider the impact it has on the people striving to overcome their destructive conditions with the tools available. Consider donating to research that seeks to study the connections between opioid addiction and prevention. Consider supporting investigations into alternative treatments or increasing availability of such treatments to those in need. Consider working to improve education and awareness of opioid addiction and resources to treat it. Whatever you do, please do it with thought and deliberate action, and consider the outcomes for those affected.

Resources for this post are included below, with links to relevant topics and studies where available without paywall. Proper footnote numbers/links will be added when I figure out how to HTML.
For those struggling with opioid addiction, please do not wait to get help, call 1-800-755-9603 for the nearest treatment center and/or help from trained addiction counselors. If you are considering suicide or are at risk for self harm, please call the National Suicide Prevention Lifeline at 1-800-273-8255.
To read more on perspectives of chronic pain patients regarding regulations and guidelines for pain management, check out the Pain News Network and their response and survey of affected pain patients.
The CDC and FDA are underfunded governing bodies that lack a sufficient number of employees, citizen accessibility, and political support. My disappointment with their actions in this matter does not change the significance of their function or importance in disease prevention and proper drug approval processes. Increased resources and management could result is more attentive regulation.






Cheatle, M. D. (2011). Depression, chronic pain, and suicide by overdose: on the edge. Pain medicine12(s2), S43-S48.

Tang, N. K., & Crane, C. (2006). Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological medicine,36(05), 575-586.

Reddy, B. S. (2006). The epidemic of unrelieved chronic pain: the ethical, societal, and regulatory barriers facing opioid prescribing physicians. The Journal of legal medicine27(4), 427-442.

Furlan, A. D., Sandoval, J. A., Mailis-Gagnon, A., & Tunks, E. (2006). Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. Canadian Medical Association Journal174(11), 1589-1594.

Tang, N. K., & Crane, C. (2006). Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological medicine,36(05), 575-586.

Carise, D., Dugosh, K. L., McLellan, A. T., Camilleri, A., Woody, G. E., & Lynch, K. G. (2007). Prescription OxyContin abuse among patients entering addiction treatment. American Journal of Psychiatry.

Weisner, C. M., Campbell, C. I., Ray, G. T., Saunders, K., Merrill, J. O., Banta-Green, C., ... & Von Korff, M. (2009). Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain145(3), 287-293.

Dworkin, R. H., O’connor, A. B., Backonja, M., Farrar, J. T., Finnerup, N. B., Jensen, T. S., ... & Portenoy, R. K. (2007). Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain132(3), 237-251.


Turk, D. C., Swanson, K. S., & Gatchel, R. J. (2007). Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. The Clinical journal of pain24(6), 497-508.

Michna, E., Ross, E. L., Hynes, W. L., Nedeljkovic, S. S., Soumekh, S., Janfaza, D., ... & Jamison, R. N. (2004). Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. Journal of pain and symptom management28(3), 250-258.

Sunday, January 24, 2016

Update and Forefront

Avoidance tactics are 'great!'. They reduce exposure, prevent encounters with a stressor, allow you to pretend that the problem does not exist, let you sing 'la la la' while ignoring responsibilities... all as the issue at hand snowballs into a bigger and bigger problem. Of course, anyone could only assume avoidance is a foolproof method for reducing stress and increasing productivity.

It sounds ridiculous, but we all do it all the time. We act like we believe that is the truth. Perhaps in response to different things and different problems, each person susceptible to unique stressors, yet the same weakness pervades human nature. We have a fight or flight response to stress, and our mind likes to tell us that both are equally valid options. As if we truly believe that avoidance works.

As I was struggling with another one of my 'I'll avoid this till it goes away' moments, I thought of my struggle with this site and the proper upkeep it deserves. I spend time researching and learning, and I am eager to share what I learn, but I haven't been putting the work into it that it requires. The longer I put it off, the more defeated and stressed I feel.

A problem can never just go away. It either grows in size in the real world, or anxiety grows from not facing it. Or both. Or we pass the buck onto someone else to cope with (though never entirely). We can never run away from them, even if you can manage it temporarily. Our decisions make up our lives and we are the owners of them. There is no sidestepping.

I face my medical issues--I go to appointments I don't like, take medicine I don't want, research problems I wish I did not have, because I chose to live with this. Even when giving up is or never has been on your radar, it does not change that you have made great efforts and decisions in choosing to fight. Remember that when you are faced with the anxiety of stressful tests, treatments, bills, relationships, illness, etc.--you are a strong person who already has faced many difficult burdens of life. As hard as some challenges can be, it is important to remember the ones you have successfully faced. To boost yourself up as you ready for the next stressful thing.

I will face my issue here: I have been avoiding the site. It's pretty obvious. I made a statement that I was ready to resume after grieving my father's passing, but the truth is I am still grieving. I probably will be for a long time. I cannot let that be a barrier from doing something I love or possibly helping anyone else out there. So let's do this. I'll give myself another chance, and I hope you will too.

Thank you.

Monday, September 22, 2014

The Power of Belief: Part III: Strong Self-Efficacy Reduces Pain Severity

Pain Sensation and Pain Perception
Research has shown that there are multiple steps involved in the experience of pain and that pain is not a simple ‘Event-Reaction’ experience. While it may initially seem like a single physical event, psychological factors are involved, and a person’s beliefs and perceptions can heavily influence how pain is experienced.

Step-by-Step Process

When a painful event happens, e.g., stubbing a toe, there are several pathways and junctions that the body must use to ‘inform’ a person of the painful event. When I stub my toe, my nerves in that joint are activated. How intensely the nerves are activated depends both on (a) the severity of injury (how hard did I hit that toe?) and (b) the sensitivity of my nerves (how easily they are activated). Those activated nerves then send a signal to my spine, which then sends a signal for my brain. Again, the path between the toe and spine gives another opportunity for intensity to be affected by the body (the spinal gateway). When the brain finally receives the signal, it must be processed before we are fully aware of what has happened. While this is a very simplified version of events, it gives an idea of how and why an injury sends a signal to the brain.

All signaling feels instantaneous in experience, but it is actually just very fast. In fact, certain areas have set ups called ‘reflex arcs’ so that a possibly injured body part will move from danger before the brain gets the message and can react (e.g., bumping your shin kicks out your leg). This allows the body to avoid the step-by-step process of pain perception and protect itself. In full pain perception, the multiple points of pain signal transmission create opportunities for the body and mind to differ in the sensation of pain and the experience of pain. Each transmission point is an opportunity for the signal to be modified.

Pain sense and pain perceived BOTH factor into this number!

The Mind can Modify a Pain Experience

To give an example, take the pain of being pricked with a needle in your finger when you are paying attention versus when you are distracted. The pain of the same prick is vastly different for when you are focused (e.g., at the doctor’s office giving a blood sample) from when you are thinking of other things (sewing and prick your finger by accident). Even though it is technically the same injury, the attention your mind gives it creates a big difference in the processing the injury receives. A point of signal transmission (your mind) changes how that pain was ‘felt’. So while the sensation is the same (needle prick in finger) the processing is different, and thus the experience of severity of pain differs between the two.

While state of mind (current thoughts/moods) can affect pain processing, characteristics (enduring qualities) of a person can modify pain perception as well. Anxiety and depression can make individuals experience more intense pain than individuals without mood disorders. Genders differ in pain experience as well, though research varies in conclusions regarding these differences. Interpretation tendencies regarding pain (e.g., hypochondria) also affect how pain will be experienced.

Pain Experience Severity is affected by Pain Self-Efficacy

Pain self-efficacy is a characteristic that can affect how the mind experiences pain. Confidence in acting despite the pain and feeling capable of managing the pain while acting are both aspects that affect many mental mechanisms of processing pain. Attention, fear, expectations, etc. (regarding pain and activity), are all influenced by pain self-efficacy. Thus, it makes intuitive sense that a strong sense of pain self-efficacy would impact the minds processing of pain. Research supports this assumption.

Scientific investigation has shown that the experience of pain severity/intensity is affected by pain self-efficacy. In 2006, Meredith et al. executed a study with a sample of 152 chronic pain patients to examine the effects that pain-self efficacy and anxiety had on pain intensity (as well as disability). The group found that pain self-efficacy was a strong predictor of pain intensity, more so than anxiety, as well as being a good predictor of disability (Meredith, 2006). The study supported that pain self-efficacy should be considered when treating/managing pain and that it had an impact on the physical experiences of a patient.

In a practical examination, another study focused on treating pain by improving patient pain self-efficacy beliefs. The researchers taught individuals cognitive methods of pain control and focused on strengthening perceived self-efficacy beliefs (Bandura A. O., 1987). The groups in this study were divided in both their exposure to cognitive methods to improve pain self-efficacy, as well as whether they were given an opioid placebo or no treatment at all. Those who were taught cognitive coping to strengthen their pain self-efficacy far outperformed the others in both their perceived self-efficacy and in the amount of pain they were able to tolerate. Participants given placebos had a high initial perception of pain self-efficacy, but this seemed to waver in the face of actual pain, meaning that the absence of tools directly affected their ability to cope. Thus, building up pain self-efficacy in a realistic and helpful manner has a direct impact on how pain is experienced.

Numerous studies have investigated the impact of pain self-efficacy in regards to patient outcomes. In comparing outcomes for chronic lower-back pain patients undergoing rehabilitation, those with a higher sense of pain self-efficacy reported lower pain than their counterparts at a 6-month follow up assessment (Altmaier, 1993). Another study showed that in long-term outcomes, pain self-efficacy was a strong mediator of pain intensity changes for chronic lower back pain over 12-months (and stronger than avoidance of painful activities) (Costal, 2011). Other studies have also shown better patient outcomes for those with whiplash injuries.

Perhaps most significant for this argument is the large meta-analytic review of multiple studies done by Jackson et al. this year. A meta-analysis takes the results of many different but related studies to statistically analyze the results to measure their consensus or differing meaning. In the review, researchers examined 86 studies for the relationship between self-efficacy and patient functioning (particularly pain severity). The results showed that self-efficacy was significantly associated with lower pain severity in chronic pain patients (Jackson, 2014). This means that, in general, 86 studies found that a higher sense of self-efficacy predicted a reduced pain severity.

What do these papers indicate? What does this relationship between pain self-efficacy and pain severity mean for you? It means that a person’s belief in their ability to do things despite the pain they are in helps to determine how much pain that person is in. This is even if you separate out the painfulness of their condition/reported pain—pain self-efficacy and pain intensity correlate with and interact with one another. Most importantly, it means finding a way to improve your sense of self-efficacy could reduce the severity of pain you experience. 

Sunday, September 21, 2014

The Power of Belief: Part II: Self-Efficacy Protects Against Depression and Disability

Pain Self-Efficacy Affects Patient Outcomes

Now that we understand what self-efficacy and pain self-efficacy is, we can start building up an understanding of how it affects patient outcomes for people with chronic pain. If pain self-efficacy is an important aspect in chronic pain outcomes, what are those outcomes, and why are they affected? 

In this section, we look at two common outcomes found in chronic pain patients: depression and disability. Chronic pain increases a person's susceptibility to both of these conditions, for a variety of reasons. A common factor found to impact both of these outcomes (both in severity and likelihood) is pain self-efficacy. 

Depression is unfortunately common in people with chronic pain, with about 70% of chronic pain patients qualifying for a depression diagnosis (Poole, 2009). As stated in a previous article of mine, research shows that about 75% of depression patients experience chronic/reoccurring pain (Lepine, 2004), and 60% of chronic pain patients report significant depressive symptoms (Bair, 2003). This is a major overlapping issue for pain and, consequently, it gets a lot of attention in research and medicine. There are many factors that likely contribute to the overlap and researchers want to identify those interlinking causes. One identified factor is that of pain self-efficacy.

General self-efficacy already has an impact on any individual’s predisposition to depression (Mukhtar, 2010), but pain self-efficacy is a particularly strong predictor of depression for people with chronic pain. A sense of helplessness in situations (termed 'learned helplessness') is a major part of the thought patterns that lead to depression. Feeling unable to manage pain is a meaningful loss of control. For example, individuals who reported similar levels of pain but differed in their pain self-efficacy, also differed later in their lives in whether they became disabled or depressed. It was not the only factor that led to the difference between groups, but it was a strong mediator between chronic pain and later depression and disability (Arnstein, 1999). Meaning the self-efficacy these people felt in regards to their pain affected their likeliness to develop major depressive disorder.

In another study that examined pain self-efficacy and depression, the same correlation was found between a weak sense of pain self-efficacy and higher proclivity towards depression. This study controlled for pain intensity (meaning the factor was accounted for, its impact quantified, and the effect removed) and still found the same correlation. The study also investigated how the use of pain coping strategies (such as task persistence, coping self-statements, pacing) was associated with pain self-efficacy. Patients who used pain coping strategies were more likely to have a strong sense of pain self-efficacy and a lower incidence of major depression (Turner, 2005). Based on the results of their study, the researchers suggest that not only is pain self-efficacy protective against depression, but that cognitive behavioral and self-management treatments to teach coping strategies could help improve pain self-efficacy.

These observations make sense when we think back to a common cause of depression: a feeling of helplessness. When individuals are able to master this feeling and overcome it, replacing it with a confident belief in their ability to manage their pain, they are less likely to fall victim to this avenue to depression. By developing a strong sense of pain self-efficacy, a person can feel in control over an otherwise distressing challenge.


As mentioned above, a chronic pain patient with a lower sense of pain self-efficacy is more likely to become disabled by their pain. This may appear to be obvious, common knowledge; on the surface, it sounds like a higher pain would result in both lower pain self-efficacy and higher likeliness for disability. But when controlling for pain severity, the finding remains. In a 2001 study by Asghari and Nicholas, higher pain self-efficacy beliefs were found to lower avoidance behaviors for challenging tasks and reduce disability associated with pain, regardless of the severity of pain the subjects were in (Ashari, 2001). This suggests that confronting challenging tasks and believing in the capacity to complete them despite the pain is beneficial in trying to minimize disability associated with a painful condition. And remember, pain self-efficacy is not dependent on the ability to succeed. Rather, it is persistence in the face of failure or success and a centered focus on the task at hand.
short term disabilityAnother study that examined the relationship between pain self-efficacy and disability also included the quality ‘fear avoidance’. Fear avoidance is what it sounds like—the avoidance of activities due to fear. A model called the ‘Fear-Avoidance Model’ was developed to help explain how a type of chronic pain developed despite the absence of a disease/permanent injury. It argues that fear avoidance prevents the use of the body and creates a cycle that leads to debilitating pain and disability. However, in this study, it was shown that self-efficacy had a greater impact on disability than fear avoidance (Denison, 2004). Meaning, based on their findings, they argued that a lack of belief for pain self-efficacy has a larger impact on disability severity than the avoidance of activities associated with pain. What’s particularly interesting about this finding, is that the beliefs that might impact performance of activities seemed to have a greater impact than the actual execution or avoidance of activities.

Disability from pain cannot always be avoided and these studies do not ignore the significant role that pain intensity plays. Neither these researchers nor I are arguing that a weak sense of pain self-efficacy is the sole cause of disability from debilitating pain. What I am trying to say is that it can help protect against eventual disability and offers some amount of buffer against disability, regardless of the severity of pain a person is in. It will benefit both your confidence in and ability to manage the challenges that pain presents. After all, the first step of ability is the belief in a capability to execute it. 

Pain Severity:

Pain self-efficacy has also been found to have an interacting relationship with pain intensity/severity. Numerous studies found that while severity of pain could affect the strength of an individual’s sense of pain self-efficacy, the effect was not limited to one direction. Individuals with a strong sense of pain self-efficacy are better able to manage their pain and report less pain severity. The difference has been observed not only in similarly diagnosed individuals, but also in patients that were taught coping mechanisms to improve their pain self-efficacy. Thus, developing pain self-efficacy can lower the severity of pain experienced. 

***The research explaining and supporting the connection between Pain Self-Efficacy and Pain Severity comprise the next post, Power of Belief: Part III (as there is a lot to cover!)***

Saturday, September 20, 2014

The Power of Belief: Part I: What Self 'Belief' is

The Purpose of this Series:

"The Power of Belief", is my effort to inform/improve the belief readers have in their ability to cope with their pain, and to foster understanding for how that belief impacts their lives. When a chronic pain patient improves their belief in their capability, their outcomes as a patient are better than in patients who do not. They tend to be less disabled by their pain and tend to have less severe pain.

To put it simply, mastering your beliefs in your abilities will help you manage your pain. Physically and mentally.

All sorts of psychological states and characteristics have an impact on our physical bodies. Many, many books exist to describe them. Even more research to support the connection. For now, for this series, I'm hoping to teach you about one of these connections: belief in your abilities. What it is, why it's important, how to create a positive change, and to provide some coping mechanisms to help strengthen your belief.

It may appear a bit wordy, a bit lengthy, but it cannot be avoided. The connection between belief and pain involves a lot of information, and this is my attempt to simplify and communicate all that. This series is written for a general audience with research to support claims. However, if you feel frustrated with how it is written, I have good news. The following week, a simpler version of similar information will be posted, written for an audience that does not enjoy scientific reading. Just remember, a shorter/simpler version means that many statements will be unsupported and further explanations withheld. Less information, but easier information to digest. Each article will have its own pros and cons, so choose which ever you feel most comfortable with, or read both and be a super expert in the effects beliefs have on pain!

The Power of Belief: Part I: What Self 'Belief' is

In psychology and personality theory, the concept of self-efficacy is a critical characteristic of an individual’s development, self, and personality. It contributes to not only their perception of self, but also to how an individual interacts with the world and others. Their actions, reactions, and thoughts are all influenced by this important quality.


Describing self-efficacy can be a little tricky. While the definition may sound simple, trying to understand it and map it onto reality can make it a bit more complicated. Regardless, a definition is a good place to start. Self-efficacy is the belief in one’s ability to coordinate actions in order to complete tasks and meet goals (Bandura, 1977). Essentially, it is the belief that you can handle a situation. A measure of, “Can I do this?”

To help clarify the idea, it helps to look at people who possess strong self-efficacy and how they differ from those who do not. For example, for people with a strong sense of self-efficacy, challenges are problems/tasks to be mastered, whereas those with a weak sense of self-efficacy avoid challenges and regard them with fear. In strong sensed individuals, setbacks and failures in/from challenges are quickly recovered from, versus weak sensed individuals experience loss of confidence and are likely to further in the face of failure. A strong sense of self-efficacy makes a person more likely to fully commit to their tasks and activities, whereas a weak sense will lead to fear and withdrawal. A person with a weak sense of self-efficacy will be too focused on their own personal failings to fully immerse themselves in their activities (Bandura, 1982)

Remember, the examples above are at the severe ends of the spectrum of a strong versus weak sense of self-efficacy. Usually people will fall somewhere in the middle. For above, these are just patterns of behavior you would expect to see in people with particularly strong or particularly weak senses of self-efficacy. The contrasts are to help illustrate the idea, but, in real life, you might not see such clear differences (or maybe even a mix of some behaviors). Hopefully you can begin to understand what self-efficacy is though and how the belief in capabilities impacts a person's thoughts and actions.  

Such a pivotal personality trait is bound to spread into many different aspects of a person’s life. You can take the basic idea of self-efficacy in regards to life in general and looking at it from the angle of how people deal with challenges in general. If you were to put a person in any given random situation, how confident in themselves would they feel? What is their belief in their ability to handle life? You can also approach the concept from the perspective of individual, unique applications. For example, a student’s self-efficacy in academics would have significant meaning for their experience in school. You can also take this concept and apply it to dealing with chronic pain (and many researchers have).

Pain Self-Efficacy:

Pain self-efficacy is a measure of a person’s confidence to do tasks despite the pain they are in (Miles, 2011). This characteristic is obviously is going to be influenced by many different factors. How much pain the person is in, the support they have, the tools they have to manage the pain, their self-efficacy in general, their self-efficacy prior to the development of their chronic pain, etc... But that is why the concept is named as is—it is a measure of a person’s confidence in their ability to perform tasks despite the pain. Nothing more or less. This is important to keep in mind when learning about its impact.

In 1989, researcher M.K. Nicholas developed the Pain Self Efficacy Questionnaire (PSEQ) (Nicholas, 1989). A questionnaire is a tool that has been researched, tested, and validated to be a reasonable measure of a psychological characteristic. While we cannot directly observe thoughts/feelings of people, we can create measures to get an idea of them and somewhat reliably testing for them. For example, IQ tests are considered a well-tested measure of intelligence, but no IQ test can say exactly what someone’s intelligence is—but it gives a useful idea. And this Pain Self Efficacy Questionnaire is just that—a useful idea of what someone’s pain self-efficacy is.

Other, more recent pain self-efficacy measures exist, with varying reliability and accuracy. What is important to know is that in research focused on pain self-efficacy, some useful tool is used to gain a reliable idea of participants pain self-efficacy. Using such tools help to improve the quality of the study and results and give us, the readers, more to trust when making conclusions. 

The Point: 

Why are pain researchers so interested in self-efficacy and pain self-efficacy? Past and current research has supported that self-efficacy, particularly pain self-efficacy, is a useful predictor and contributing factor towards outcomes for people with chronic pain. Self-efficacy affects the outcomes for a patient, and knowing as much is useful in: (a) predicting how the patient will be affected by their self-efficacy and (b) providing a treatment point for improving a patient's pain management. Knowing the relationship between the two helps researchers and patients to better understand how to improve the livelihood for that patient.

Researchers used measures of pain intensity, pain self-efficacy, and other qualities related to chronic illness/pain, and found that pain self-efficacy had an impact on other problems that patients would face. Tomorrow, in Part II, we will go over some of that research and the meaning it has.

***To be continued in Power of Belief: Part II (to be posted 9/21/14)***