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Working with Chronic Pain

Chronic pain is bad enough, but at least there are ways not to add to your misery.

Everyone adores my friend Liz. She's a gregarious blond surfer girl with a killer smile and a hearty laugh. She's also in daily pain and fatigue arising from a rare and debilitating medical condition. Before her illness, Liz and I would run together for up to two hours and chat about everything, occasionally touching on my Buddhist practice. She would grin dismissively and shake her head saying, "That's just too wild." The truly wild thing is now when she tells me how she copes with her chronic pain, it's pure dharma. Liz says her greatest techniques are just accepting what is and being in the moment.

Like Liz, many people experience chronic pain. According to current estimates, ten percent of North Americans experience daily pain; the percentage is far greater for those over 65. Medicine has made great inroads into the control of acutely painful conditions using medications and anesthetic techniques. It has also had some success with the types of pain associated with terminal cancer, using morphine and related drugs. But the long-term pain that attends non-fatal conditions—such as injuries or lower back maladies—often responds poorly to standard medical treatments.

It can be difficult for people living with such chronic pain to escape a long, slow slide into progressive disability unless they have adequate coping skills. Pain by nature can be awful, dispiriting, exhausting. The fight to maintain a positive frame of mind is demanding and often punctuated with brutal episodes of despair. But there are methods to help prevent a high degree of reactivity to chronic pain from adding yet another layer of misery. Chronic pain management does not, however, usually focus on fixing the cause of the pain. By the time a person gets to chronic pain management, standard surgical and medical treatments have been judged ineffective. Chronic pain management is about reducing suffering.

This kind of emphasis in chronic pain management points to the astounding interface between evolving modern medical practice and the dharma. Respected researchers such as Dr. Jon Kabat-Zinn have demonstrated that mindfulness techniques improve quality of life for those in chronic pain. Major institutes such as the National Institutes of Health recommend relaxation techniques for pain, including breath-focused meditation.

In the pain clinic where I sometimes work we introduce patients to relaxation techniques immediately. They can choose from various methods, but the simplest and most accepted one is to follow the breath. The instructions are often almost exactly those used in Buddhist meditation techniques such as shamatha (mindfulness). People regularly report that these techniques change their relationship to pain. The pain is there but their reactivity to it decreases.

A friend gave Liz a copy of a book by Thich Nhat Hanh. He advises when doing the dishes to just do the dishes. Liz - s response to this reference to mindfulness was one of respectful amazement: "This is what I do! When I do the dishes, I just enjoy doing the dishes." Although this had always been her natural tendency, Liz seized upon this technique even more vigorously to manage her pain. It's not so much a distraction technique for her; it's just that her focus is broader than her pain when she lives in the moment of her experience. It's akin to forms of vipashyana (awareness) meditation where we are aware of sensations, including pain, but not exclusively focused on any one sensation for any length of time.

A core concept in chronic pain treatment is pacing—essentially the middle way of approaching physical activity. Liz is the pacing queen. She does one activity most days, but mindfully adjusts her activity to her current energy and pain levels. If she is having a bad day, she stays at home and has her friends visit her. Pacing is simple in concept but difficult to execute artfully, as the emphasis is on staying active but not overdoing it. Many people give in to the seductive trap of doing too little and avoiding short-term pain. In the long run, unfortunately, this can worsen many types of chronic pain by decreasing flexibility, weakening muscles and reducing our ability to get enough oxygen to our muscles. The opposite tactic of continuously pushing the envelope and denying true limitations can lead to constant exhaustion and continuous flare-up pain. Pacing is about finding the fine balance.

Cognitive behavioral therapy (CBT) is a form of psychological treatment that helps overcome irrational, self-defeating thoughts that lead to depression and anxiety. In Buddhist terms, this technique is essentially the replacement of unskillful thoughts with skillful thoughts. What we believe and think about pain affects our experience of the pain and our progress in dealing with it.

A woman who worked on a hospital ward with paralyzed spinal patients suffered acute low-back pain while lifting a patient. Her doctor prescribed routine exercises to help her get better. As with many patients, she suffered flare-up pain during physiotherapy. She was adamant in her belief that this pain meant that the back exercises could paralyze her, so she refused to continue despite the repeated reassurances of her many health providers. Sadly, she became deconditioned, put on weight, became progressively more inactive and remains painfully disabled years later. She also subsequently developed depression, which happens to half of the people who are in chronic pain.

CBT is helpful to seventy percent of the depressed patients who try it, so perhaps it could have successfully challenged this unfortunate woman's irrational fear of paralysis. CBT provides effective antidotes to various unhelpful thoughts such as obsession with blame, misinterpretation of symptoms and inability to see the remaining positives in life. Liz—now restricted to walking—doesn’t bother to mourn her lost athleticism; instead she revels in the positive aspects of her present experience: "I love walking. You wouldn't believe all the people I meet!"

Paradoxically these techniques—relaxation, pacing and mindfulness—work best when not combined with a high or immediate expectation of pain reduction, as that may inadvertently enhance pain aversion. Health-care providers working with chronic pain patients are usually careful to point out that these techniques are about increasing daily functioning and adapting to living with the pain, not eliminating the pain. People new to chronic pain don’t often appreciate the inherent contradiction in frantically striving to reduce suffering. Experienced guidance is crucial in learning to develop a relaxed approach to living with pain.

Liz now lives with a degree of equanimity, grace and balance far greater than most of us, and tenaciously maintains a warm engagement with the world despite her pain. I certainly miss our runs, but Liz brings something more precious to my life now: inspiration. At one point Liz was so sick she was hospitalized. When she went home, she was bed-bound and had to be spoon-fed by her mom. She suffered some transient despair but then rebounded, saying, "Hey, I'm gonna write a book on my laptop." Even at the nadir of her illness, Liz avoided the potential decline from active surfer girl to suffer girl. In terms of her spirit, she's morphed into super girl.

CHRIS STEWART-PATTERSON, M.D., is assistant professor of medicine at the University of British Columbia and an emergency department physician at an inner city hospital in Vancouver.

Working with Chronic Pain, Chris Stewart-Patterson, M.D., Shambhala Sun, May 2003.

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