A pain psychologist explains the culture shift required to help end the opioid epidemic
A record number of Americans—more than 80,000—died from opioid overdoses in 2021. Despite a 60% decrease in opioid prescriptions since 2011, deaths continue to rise, increasingly owing to synthetic drugs such as fentanyl (“U.S. Overdose Deaths in 2021 Increased Half as Much as in 2020—But Are Still Up 15%,” U.S. Centers for Disease Control and Prevention, 2022; Prescription Opioid Trends in the United States, IQVIA, 2020).
“We can’t state with 100% certainty all of the factors that are driving this record high number of overdose deaths, but one thing that has become clearer over time is that the initial opioid crisis was driven in part by a crisis in the management of pain,” said pain psychologist Ravi Prasad, PhD, director of behavioral health in the Division of Pain Medicine at the University of California Davis Medical Center (UC Davis Health).
That’s where psychologists come in. A range of nonpharmacological approaches—including cognitive behavioral therapy, acceptance and commitment therapy, and biofeedback—can reduce physical pain and may even change the way the brain processes pain signals (Driscoll, M. A., et al., Psychological Science in the Public Interest, Vol. 22, No. 2, 2021).
Prasad is delivering some of those interventions to patients at UC Davis Health’s Pain Management Clinic. He is also advancing training efforts for the vast number of psychologists—more than 50% of those surveyed in one study—who say they are unequipped to help people who are in pain (Darnall, B. D., Pain Medicine, Vol. 17, No. 2, 2016).
The Monitor asked Prasad what it will take to end the opioid crisis and how psychologists can help.
Where do we stand now?
Opioid deaths are at a record high, but we lack precise data about who these individuals are. Were these people living with chronic pain who couldn’t get their conditions appropriately managed, and then went on to use illicit substances? Or is this a phenomenon that emerged during the pandemic, when people who were dealing with high levels of emotional distress, loneliness, and other pandemic-related strain couldn’t access mental health care? A combination of both? Other factors? Regardless of the current trends, we appreciate that the initial opioid crisis was partially rooted in how pain was treated, as many individuals relied heavily on a biomedical approach—opioid medications—as the primary mechanism to manage their pain. The problem is that for most forms of chronic pain, there’s no single medication or intervention that’s going to “fix” the condition.
Just as with other substances, chronic use of medications can lead to tolerance, physical dependence, and psychological dependence. With opioids, people have an added risk of developing hyperalgesia, where the medications that they’re taking to treat their pain can cause hypersensitivity to pain itself.
In response to the opioid crisis, there was a strong push to get people off their medications. A large number of patients—including many who had been on stable doses—were rapidly taken off their medications without any sort of additional support, which created a secondary crisis of patients with high levels of pain that weren’t being appropriately managed. Unintended consequences of this process included use of illicitly obtained drugs, increased affective distress, and suicidality.
The U.S. Food and Drug Administration has since released guidance suggesting that clinicians not rapidly wean people off, and that they also take into consideration a patient’s psychosocial needs when making changes to their opioid medications. So now we have many patients who have been taken off their opiate medications and still have pain but lack tools to manage it. There’s a strong need to provide them with nonpharmacologic strategies to help them address their very real pain. That’s where psychology can play a significant role.
What nonpharmacological approaches are you using at UC Davis Health?
We’ve created an 8-week pain management group intervention that provides education and coping skills to help patients as they make changes in their opioid medications and manage their pain. For example, patients learn cognitive strategies to reframe their experience of pain as well as behavioral techniques such as breathing and relaxation exercises.
Primary-care physicians across our network often inherit new patients who are taking high doses of opiate medication but have low levels of functioning. As those physicians make changes to these patients’ regimens—that could be reducing the dose, transitioning to a different medication, or stopping altogether—they refer patients to our group-based intervention, so they’re simultaneously learning new approaches for managing their pain. We also have a pharmacy team that helps patients transition from their current medications to options like buprenorphine, and we work in tandem with that program as well. It’s a joint effort where patients collaborate with multiple specialists to help make the shift as successful as possible.
How effective are these psychological strategies for managing pain and are they embraced by medical providers?
This approach isn’t new—it’s actually been around for many years. Studies show that patients can successfully wean off or make significant changes in their opiate medications with use of these nonpharmacologic tools. They often report improvements in pain-related outcomes, such as better overall functioning and lower affective distress. There’s growing recognition of this within the medical community, but the challenge is that there is a limited number of psychologists familiar with pain who can help this burgeoning population. The dearth of clinicians creates access problems, thereby further limiting a patient’s ability to receive much-needed care.
What can be done to improve education and training around pain management?
I created a pain management fellowship program at my prior institution; however, with approximately one fifth of the U.S. population living with chronic pain, a program that graduates a handful of people each year is not going to be enough. We need all psychologists to have a foundational understanding of pain psychology and recognize when a case might require a higher level of specialization. With this in mind, Drs. Jennifer Kelly, Dan Bruns, and I developed a curriculum that provides training on pain psychology. This initiative was sponsored by APA to help educate the psychology workforce on the essential components of pain psychology. We delivered workshops to live audiences before the pandemic, and APA has now professionally recorded it to allow for broad dissemination.
What else is needed to end the opioid crisis andwhat role could psychologists play?
Moving from a biomedical model of treatment to a biopsychosocial framework that addresses the biological, psychological, and social aspects of pain is a major step in addressing the factors that contributed to the evolution of the opioid crisis, and psychologists will play an essential role in this process. This will require a culture shift. We fundamentally need to change how pain is addressed in this country, and discussions about the role of psychology need to be incorporated into pain care much earlier in the treatment pathway. This by itself is not sufficient but is a great starting point to pave the way for change.
