Recently pain killer addiction has been in the news with record numbers of people becoming reliant on pain killing drugs, causing harm and much concern.

Opioid medication is the painkiller most frequently prescribed and problematic, namely, codeine, morphine, fentanyl, oxycodone, naloxone. Benzodiazepines have also been prescribed for pain, such as diazepam, lorazepam, temazepam, and anti-epileptics like gabapentinoids and the anaesthetic ketamine.

These are all highly addictive drugs and have serious side effects and withdrawal symptoms. Despite this, opioid prescribing has more than doubled in the UK from 1998 to 2018. Keen to avoid the opioid addiction on the scale of the US, the UK Government body NICE, who guide medical practice, released new guidelines this month that GPs should ‘encourage and support’ patients to stop taking all of these addictive painkillers for chronic pain. However, the guidance also asks GPs not to treat chronic pain with other commonly used medications such as paracetamol or the non-steroidal anti inflammatory drug (NSAIDs) ibuprofen and naproxen.

An explanation of the risks of continued use of any of these drugs and the lack of evidence for prescribing these medicines is recommended. As was advice about managing withdrawal and a risk/benefit view of individual cases as to whether medication should be reduced, stopped, or continued safely.

This news will be disappointing and even distressing for those in chronic pain (estimated to be between 1-6% of the population) who will find it harder to access medications that they feel have helped them. These drugs have helped people feel better because of the impact on the mind’s reward centre chemistry, but the medication approach doesn’t help pain sufferers learn about managing it more actively and less intrusively.

Better pain services need to be in place that educate about pain and how our bodies deal with it, but also reassurance that there are other helpful ways to manage pain, that can improve overall mood too. NICE is recommending that GPs ask pain sufferers to consider the alternatives that research is showing to be helpful, such as antidepressants (that are much less addictive), an exercise programme, acupuncture, or psychological therapies such as Cognitive Behaviour Therapy (CBT) or Acceptance and Commitment Therapy (ACT).

At 87%, much of our advice comes from these two evidence-based psychotherapeutic treatment options. So how would they help?

Using CBT or ACT to manage pain

There is a complex relationship between pain transmission and emotions. Science is revealing that by reducing emotional distress, at a very real organic, neurotransmitter level, pain transmission is reduced and in turn reduces the intensity of the pain you experience.

Managing negative emotions

Negative emotions such as anger, anxiety and depression often run alongside pain. These also interfere with sleeping and can also lead to more reliance on the painkillers, and even alcohol, but these drugs maintain negative emotions and increase pain in the long run. To manage the negative emotions, both CBT and ACT actively work on altering unhelpful behaviours and unhelpful negative thinking. Chronic pain pathways run along nerve fibres from the brain to the body and back again, and we can understand that pain is experienced when the mind registers it, but the mind can also amplify it through the thoughts we think.

Managing thoughts

The muscles of the body become tense when we are feeling stressed in response to a situation, our thoughts and feelings, so the pain sensations also feel worse and this then feeds back into our thoughts. Often these are impossible thoughts to answer, such as “when will it end” ”it can only get worse” and “why me” and these further increase tension and pain, and so it continues in a vicious cycle.

Breaking the cycle requires changes in the way that we think, which first requires awareness. We often aren’t aware of these individual thoughts until they take their toll on us. One aim of CBT is to alter thoughts into something less emotional and more rational. Whereas ACT advocates accepting thoughts in order to let go of them using mindfulness techniques, or a method called ‘thought defusion’, that reduces the emotional impact of the thought.

Managing behaviour

Both therapies advocate altering maladaptive behaviours into constructive and helpful actions using goal setting strategies. ACT specifically encourages people to choose activities that align with their values and what really matters to them, so that carrying them out has meaning and purpose. This can especially help when working with pain.

Activity should be increased slowly to improve fitness, flexibility and strength in order to regain control over your body that may have become deconditioned through life being limited. It is again getting the balance right and we need muscles to move us around and take the stress off the body parts that are in pain.

two people in open conversation during ACT session

Relaxation

We can also break the cycle by relaxing the body. Relaxation needs the willingness of the mind to slow down and think differently and then the sensations can be altered; the more relaxed our body and mind, the less pain we feel.

Try this Relaxation Routine

Make your body as comfortable and supported as possible – uncross arms and legs and make sure hands and feet are warm.
Scan your body in your mind working from your toes upwards to your head. Discover which muscles are more tense and if they could be more relaxed, and deliberately relax them saying prompt words like calm, relax, peace, in your mind.
Slow down your breathing to a gentle and rhythmic flow, as if you were falling asleep. Make sure it is your belly that is rising and falling, rather than your chest.
Use your imagination to create a place where you would naturally relax, like a holiday place, or imagine something similar. Add your senses to create a vivid scene, the scent of the sea, the feel of nature around; whatever your place is.
If you don’t like to use your imagination, occupy your mind with peaceful or boring thoughts and steer away from complicated and stressful thoughts. Mindfully focusing on your breathing and body will naturally get in the way of thoughts as your attention can’t be on two things at once. The thoughts will grab your attention again, but you can gently turn your attention back to your body and breath or pleasant imaginings.

Use relaxation or mindfulness audios and/or classes to develop your ability to relax and you will find this is a skill that becomes easier and more natural over time.