HOPE for Pain: From Treatment to Healing
The woman (we will call her Joan) was 45 years old, and she did everything she could for her health. She ate right, worked out, took vacations, worked hard, and had a great family. But 15 years ago she was in a motor vehicle accident and sustained whiplash on her right side. Although there was no severe physical damage, she began to develop neck stiffness and pain down her shoulder that was intractable. It was then that her 15-year journey of pain began.
Over that 15-year period, Joan was diagnosed with multiple other conditions including depression, anxiety, post-traumatic stress disorder (PTSD), neuropathic pain and neurosis. She continued trying to maintain as healthy a life as possible through exercise, physical therapy, eating nutritious meals and cultivating relationships with friends and family, but like many other patients with chronic pain, it was a challenge for her.
At one point, Joan was taking more than five medications including the opioid Oxycontin. With its strong properties and its tendency to cause addiction, she experienced some trouble quitting the drug. With the help of an inpatient pain specialist, she was able to get off Oxycontin and began taking other medications including Neurontin and Lamictal, which improved both her neuropathic pain and crying episodes.
Still, her pain averaged from 5-7 on a 10-point scale every day and resulted in spasms and stiffness in her neck and right shoulder. So she reached outside the doctor’s office and entered a parallel journey with complementary and alternative medicine. She saw chiropractors, acupuncturists, herbalists, homeopaths and mind-body practitioners. Similar to the effect of the physical therapy, injections and electrical stimulators she got from the regular pain clinics, all of the treatments helped temporarily. Could healing happen, she wondered, after 15 years of suffering?
Joan came to me with skepticism to learn how to enhance her own healing capacity using the Healing Oriented Practice and Environment (HOPE) approach. HOPE is a framework for bringing optimal healing practices and environmental practices, especially those that can induce the inherent healing capacity through self-care practices in the life of those with chronic illnesses.
A HOPE assessment involves exploring the inner environment to the outer environment including:
- The spiritual environment – finding the meaning or purpose for one’s life
- The social environment – nurturing social support, friendship and intimacy
- The behavioral environment – medical treatment, lifestyle and alternative practices
- The physical environment- the space and place where one lives, works and receives care
A HOPE assessment explores with patients what they are already doing to enhance their wellbeing and uses good science to build upon that and integrate it with medical treatment.
Two things emerged in the assessment of this patient with 15 years of chronic pain:
First, Joan noticed that the acupuncture treatments seemed to provide significant relief – over 95%. However, she said that it didn’t last for more than a few days. During the interview, she mentioned that she wasn’t able to get over the threshold of responding to acupuncture in a longer term way.
Second, she felt that she had been getting better less rapidly after a second motor vehicle accident that occurred about five years after the first. During the second crash, she had struck her head on the dashboard, but had not lost consciousness and the doctors said she had recovered after a few weeks. But it was then that the crying episodes began – she was reminded of the fear she had experienced in her previous accident. She was then diagnosed with PTSD and placed on drugs for depression and to help her sleep. More medication, continued pain.
The Root of her Chronic Pain
When asked about mind-body practices, Joan explained that she had been taught mindfulness and had practiced it for a little while, but with her busy schedule and responsibilities, she found it very difficult to continue.
Her care team and I got together and looked at the situation. Clearly, the acupuncture was stimulating her brain’s pain killers – so-called endogenous opioids. But, as the levels of those natural pain killers went down after each acupuncture session, her brain and spinal cord were no longer holding the pain relief. One suggestion by the team was that the density of opioid receptors in her brain was not sufficient for the repeated acupuncture to “take.” We wondered if the head injury had caused that problem. A PET brain scan demonstrated a reduction in glucose metabolism in the left frontal lobe, just in the area where some of the inhibitory pathways on pain might have been damaged. Research shows that engaging in mind-body practices, such as mindfulness or meditation, 20 minutes a day for at least eight weeks can cause those areas of the frontal lobe to grow and repair. What if we were to regrow the brain and then tried the acupuncture?
A discussion with Joan about our recommendations showed that she was excited to try. She felt much better and had less anxiety when she engaged in mind-body practices, but it was a matter of being able to integrate it into her daily life.
A behavioral and health coach came in next and worked with her and her family to design a process for 20 minutes of meditation (enhanced with biofeedback) every day. The first attempts were a challenge because as long as she was in her house, she felt overwhelmed by responsibility and family requirements. The behaviorist, therefore, helped her organize a special place in her house, which turned out to be a corner of a bedroom, where she constructed her own little meditation corner. The team worked with the family to ensure this place was isolated and not invaded by the rest of the household. It was her own little healing environment.
A set of reminders supported by both the family and by a phone app resulted in her finding time to engage in more than 30 minutes of mind-body practices every day for more than two months. At that point, a repeat PET brain scan revealed improved neurological growth in the frontal lobe.
Healing from Chronic Pain
Research indicates that it takes 8-12 weeks for opioid receptor density to change after acupuncture, but the hope was that at least now Joan had the right neurological foundation to maintain the acupuncture’s effects. A series of 20 acupuncture sessions using a combination of body and ear points in which ear studs were left in place overnight were initiated. She began a journal to record her response and any other changes she noticed. During a two-month period of twice weekly acupuncture, the swift return of pain after acupuncture she had experienced before began to lessen. Within three months, her pain levels were down to 2 or 3. More importantly, her quality of life, functional capacity, PTSD and ability to tap into her own self-healing capacity had increased. From then on, when she noticed the pain rising, she realized (from her journaling) that often it was because she had not engaged in sufficient self-care, either from inadequate sleep or excess stress to allow her body to stay well and maintain lower levels of pain. She now knew how to “catch it early,” tap into her recovery rituals and prevent the downslide that she had struggled with for the previous 15 years.
Joan had gone from a patient dependent on medical treatments to an individual who had fully integrated healing into her own life.
The chronic pain issue required reframing, provided by the HOPE assessment and a team including a neurologist, an acupuncturist, a behaviorist and a pharmacologist. This was the team most appropriate for the patient; however, it is not the formula for every patient with chronic illness or chronic pain who walks through my door. The HOPE approach provides a process to walk those unique paths toward healing.
The healthcare system of the future will use team-based integrated approaches like this, drawing from both science and the patients experience to help the patient and their unique circumstances and tap into their own healing power. HOPE helps us move from healthcare to self-care and from treatment to healing.
Dr. Wayne Jonas is a leader in integrative medical research and clinical care. Follow Dr. Jonas on Twitter.