Peter Przekop, DO, PhD, is the author of Conquer Chronic Pain: An Innovative Mind-Body Approach. Most people who have an injury heal. Most people who have physical abnormalities such as osteoarthritis do not experience chronic pain. However, in some instances, people do develop chronic pain. For example, only about 20 percent of people whose spinal discs are degenerating, or breaking down, will have chronic pain. Some of the research I have been involved in over the last 10 years has examined the differences between people who go on to develop chronic pain and those who do not. People who are under a high degree of stress and have been under stress for a long time (possibly because of past adverse or traumatic events) are more likely to develop chronic pain. There are strong links between adverse experiences, the psychological and physical stress that results, and the development of chronic pain. Our research demonstrated that people with the conditions described below are also more likely to have chronic pain: Symptoms of depression—feeling sad, a sense of worthlessness, a sense that your body no longer works, a sense that you can no longer do things you used to do, harsh self-judgment, and trying to change the past Catastrophic thinking processes—expectations that things never go right and will always go wrong, dread of the future, and belief that things can only get worse Poor emotional self-care—difficulty recognizing stress, poor coping, not recognizing emotions, the inability to process feelings and sensations inside of your body, and negative autobiographical narrative You will recognize that most of what we have described results from maladaptive thinking patterns. It is important that you understand them and how they may contribute to your suffering. As you gain insight about these aspects of pain and suffering, you will be ready to learn skills about how to relieve the burden that they impose on your life. Traditional Treatment for Chronic Pain Over the last 20 years, many studies have looked at how chronic pain affects the brain. With most diagnoses that involve pain, specific changes occur in the structure and function of the brain when the pain becomes chronic. This means that chronic pain somehow changes the structure of nerve cells in the brain and negatively affects how those cells interact with one another and process information. This calls into question how we should treat chronic pain, because it appears that the most important organ affected is the brain. Why, then, would it make sense to simply try to stop the pain sensation using medications or to change the structure of the body part where the pain appears to be coming from unless there is evidence of direct impingement on nerves? These treatments often do not address the changes that have occurred in the brains of patients with chronic pain. The mainstay of treatment for chronic pain has been opioid painkillers, such as Vicodin and OxyContin. They work on the part of the brain that turns the pain signal off. In clinical trials that have been ongoing for the past thirty years, opioids have been shown to reduce pain by approximately 20 to 30 percent when the pain is chronic. Unfortunately, this effect only lasts for about the first three months of use. Thereafter, opioids become progressively less effective and can actually begin to increase the experience of pain. Because the receptors that opioids interact with have so many different functions in the brain, patients also experience increased symptoms of depression, the inability to get restorative sleep, increased anxiety, less ability to experience joy, and dramatic changes in many hormones. Probably the worst effect of long-term opioid use is addiction. This occurs because the brain becomes so accustomed to the opioids that it cannot function normally without them and will go into painful withdrawal if the opioids are abruptly stopped. A vicious cycle of negative experience Two of the worst outcomes that chronic pain has on the patient are: Its effect on cognition (our ability to think and understand); and, Its effects on emotions. Chronic pain produces a demonstrated reduction in the ability to think, to pursue a goal, and to regulate emotions. In order for the brain to return to balance and heal, we need to treat the diminished cognitive ability and the inability to regulate emotions. For example, most chronic pain patients unintentionally create more pain by expecting that pain will always be present and that it will continue to worsen. This is referred to as negative expectancy. Negative expectancy creates anxiety, more pain, and more fear of pain. People with chronic pain, then, begin to live with the constant fear of more pain, and such negative thoughts and emotions only create the very increase in pain they fear. Negative expectancy appears in other thinking patterns of chronic pain patients as well. For example, chronic pain patients often ruminate, which means they re-create the same thoughts again and again. Rumination that involves chronic pain generally has a negative narrative. This is especially true when one holds unresolved adverse feelings associated with negative past experiences. Rumination can create anxiety, worry, and the outlook of a negative future—that is, negative expectancy. As chronic pain progresses, patients increasingly lose a sense of optimism, and this loss can also be thought of as negative expectancy. To be optimistic is to expect that a positive outcome will occur, and this has been shown to be the best form of coping. But people with chronic pain get to a point where they think they will always be in pain, as though they have been sentenced to a lifetime of pain. They lose hope for a positive future. This only serves to create more pain, as a lack of optimism is associated with poor coping skills. Studies have shown that many chronic pain patients are under the impression that if they use or move their bodies, the pain will worsen. They falsely assume that any movement or activities, like stretching, yoga, or tai chi and Qigong exercises, will make them feel pain, when in fact, such movements have been shown to help reduce the pain. They also falsely believe that they are unable do much activity, and yet studies show that chronic pain patients are moving much more than they perceive themselves to be. In this way, an important element of chronic pain is the inability to recognize when movement is helpful or harmful. These aspects of chronic pain reveal that chronic pain is a very complex disease and that most current treatments do not address the bulk of these complexities. It is not enough to simply focus on symptoms. We must address the underlying foundation that is holding the chronic-pain patient hostage. Such an approach must address the cognitive, emotional, sensory, and spiritual aspects of chronic pain. Attempts to simply treat the assumed source of the pain most often fail because they do not address what has occurred in the brain as a result of the pain. The treatment of chronic pain must also consider that the brain is constantly changing and any stimulation that it receives can produce an effect. Therefore the successful treatment of chronic pain needs to address and change maladaptive thinking patterns and emotional processing while reducing stress, improving coping skills, and helping the patient learn to move in a pain-free manner. A note from the author I hope you have learned that chronic pain is much more than just long-term physical pain. It is important to understand the new definition of chronic pain that I have proposed as any sensation with a negative context in the mind that is holding you from being able to heal. Therefore, experiencing anxiety, symptoms of depression, rejection, or the loss of a loved one is experiencing pain. This is true because all of these experiences create a negative feeling inside of us. Since this is the case and since all of these painful sensations are processed by the same neural networks in the brain, they can all set the groundwork for the future experience of pain by strengthening these networks. More importantly, they can keep us from healing. It is also important to understand that there is not always a clear relationship between tissue damage and the source of pain when pain becomes chronic. This is supported by evidence that chronic pain is a disease of the brain. When this is understood, it becomes clear that the brain must be treated in order to conquer chronic pain. This is why many traditional treatments have only been partially successful at best. Finally, it is important to keep in mind that chronic pain is extraordinarily complex—it has a dramatic effect on cognition (thinking), perceptions, emotions, outlook, and hope. It can become totally consuming and change one’s life in a very negative manner. The mind and body have the ability to heal. My job and the job of my book, Conquer Chronic Pain, will be to lead you on a path to balance and self-healing. Peter Przekop, DO, PhD, is an academic physician with appointments in neurology, pediatrics, and psychiatry and an osteopath who directs the pain management track at the Betty Ford Center, a part of the Hazelden Betty Ford Foundation, in Rancho Mirage, Calif. Dr. Przekop is the author of Conquer Chronic Pain: An Innovative Mind-Body Approach.