Self-described “pain nerd” Donald McGeary, Ph.D., stood at the finish line at a track where a chronic pain patient had almost walked a complete lap during physical therapy.
Suddenly, the patient stopped and said, “I just can’t go any farther.”
Dr. McGeary, a clinical health psychologist, had heard him clearly, but recalls telling the man, “‘I couldn’t hear you. Can you come over here and tell me that?’ And he walked over to me and said, ‘I can’t go any farther.’ And I said, ‘You just proved yourself wrong by walking over here to tell me that.’”
In his specialty of managing pain without drugs, a fundamental goal is helping patients realize that they can do more than they thought.
That’s the focus of his new National Institutes of Health-funded study involving post-9/11 military veterans suffering chronic pain and psychological distress. He applied for the grant in response to an urgent NIH call for new programs for managing pain without prescription opioid medications.
Those with chronic pain after military trauma often have other chronic symptoms, including post-traumatic stress disorder, traumatic brain injury and depression. Such “polymorbidity” makes all the conditions more difficult to treat, and opioids complicate those multiple conditions and worsen a patient’s ability to function.
Yet U.S. prescription opioid sales have increased by 300 percent since 1999, leading to growing dependency on narcotics. In 2014, nearly 2 million Americans either abused or were dependent on opioids, according to the Centers for Disease Control and Prevention.
Some prescription opioid users start using street heroin, an opioid often cheaper and easier to obtain, according to reports by the National Institute on Drug Abuse. The NIH, together with the Department of Veterans Affairs and other agencies, wants to reduce this high opioid use.
While research shows that primary care doctors dislike prescribing opioids for chronic pain, they don’t know of alternatives, said Dr. McGeary, an assistant professor of psychiatry. He believes patients use opioids because they see no other way to manage pain, although the drugs don’t promote rehabilitation and actually worsen a person’s ability to function.
His study compares Functional Orthopedic Rehabilitation Treatment, or FORT, to VA “treatment as usual.” In FORT, a psychologist, VA physician, physical therapist and occupational therapist communicate closely on patient treatment and progress in gaining physical function, such as walking, bending and lifting.
The treatment is broken into four parts: psychology, cognition, behavior and mindfulness.
The psychological part integrates relaxation, guided exercise, and positive and comforting thoughts with elements of physical therapy, occupational therapy, pain medicine, pain-related coping and stress management. Biofeedback measures heart rate, muscle tension, perspiration and respiration—all stress indicators.
The cognitive part targets patients’ thoughts to eliminate “pain catastrophizing,” mistaken ideas such as a back pain sufferer’s belief that excessive activity could cause paralysis, which is usually not true.
Dr. McGeary tells patients that the pain is like a constantly ringing telephone with no one on the line.
“The signal is useless now,” he said. “It doesn’t make sense to pay attention to it or to try to read anything into it.”
The behavioral part focuses on getting patients active—walking around that track, picking up that child, going to work.
“You need to teach people to push themselves over time, so they can get rehabilitative benefit,” Dr. McGeary said. “You know you’re successful when they’re lifting more and they’re telling you they’re lifting more. I want you to be stronger and know that you’re stronger.”
The mindfulness part trains patients to allow pain and catastrophic thoughts to be, without feeling compelled to try constantly to control them. This helps them separate emotion from alarming thoughts.
“When you can get people to step away from their emotional response, they don’t have anything to control anymore,” Dr. McGeary said. “They can make decisions otherwise. They can just go be active. I can feel bad and be active at the same time.”
The program builds on a previous pain study Dr. McGeary conducted with active-duty military. Half stopped using opioids, although that program did not discuss drugs.
He’s also testing medication-free pain management with a study launched last year for the Consortium to Alleviate PTSD, involving Iraq and Afghanistan war veterans with post-traumatic headache and post-traumatic stress. The consortium, in the Health Science Center’s behavioral medicine division, is funded by the VA and Defense Department.
Effective, drug-free pain management could save lives. A recent San Antonio Veterans Integrated Service Network study found that the opioid hydrocodone is the most prescribed medication in the service network and that 40 percent of veterans using an opioid had used it for more than three months. Chronic opioid use among polymorbid veterans has been linked to poor rehabilitation outcomes, abuse of other substances and death.
“With so many people transitioning out of the military to the VA, the VA is going to experience a glut of chronic pain patients, and they need to solve this fast,” Dr. McGeary said. “The solution is not to give everyone hydrocodone, and they know that. They are trying to come up with something better.”
