Pain isn’t just a physical sensation — it affects your mental and emotional health. Pain psychologists Dr. Wes Gilliam and Dr. Matt Schumann explain that chronic pain management requires addressing both physical and mental factors to enhance daily quality of life.
- Purchase Ending the Crisis by Dr. Holly Geyer
- Learn more about pain management and safe opioid use on our Opioid Resource Center
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- If you or a loved one are dealing with a substance use disorder, visit Substance Abuse and Mental Health Service Administration.
Read the transcript:
Dr. Benjamin Lai: Hello. Welcome to Ending the Opioid Crisis. I’m Dr. Benjamin Lai.
Dr. Holly Geyer: And I’m Dr. Holly Geyer.
Dr. Benjamin Lai: This is a podcast series aimed at getting a deeper understanding of the opioid crisis that has ravaged our country. We’re thrilled to have two psychologists with us today. Dr. Gilliam is a board certified clinical psychologist who specializes in behavioral health management. He has been a clinical director of the Rochester Pain Rehabilitation Center for the past eight years and is the co-chair of the Division of Addiction, Transplant and Pain within the Department of Psychiatry and Psychology at Mayo Clinic.
Dr. Matt Schumann is a pain psychologist and researcher with the Mayo Clinic Pain Rehabilitation Center. He is also an assistant professor of psychology with the Mayo Clinic College of Medicine and Science.
As pain psychologists, I would love to get your input on when you first meet a patient with chronic pain. How do you approach that interview? What do you first assess and what kind of questions do you ask first? Wes, maybe I’ll start with you first.
Dr. Wes Gilliam: Trying to take this from a biopsychosocial perspective, so I’m going to ask some questions about what their diagnoses are, ask them a little bit about the severity of the pain that they’ve been experiencing and also some of the functional limitations that they’ve had, but primarily what I’m interested in is how they make sense of what they’re feeling and what their experiences are like.
So much of how people function with pain is how they make sense of it. The pain experience is a multidimensional one, and so there are emotional and cognitive components to the pain experience. Those are the two dimensions that really account for a lot of the subjectivity in pain: Better understanding how people are making sense of what they’re feeling, what is the dialog in their head when they’re hurting.
Then also the emotional byproducts of the pain are really important from my perspective to get to know them as a human being with pain as opposed to just what their pain feels like.
Dr. Benjamin Lai: Matt, how do you connect with the patient? I mean, some of these are pretty personal questions. Is there an approach that you might take to really connect with that patient, to get that patient to open up? To talk about how it affects them functionally, emotionally and so forth?
Dr. Matt Schumann: My attempt is to meet the patient where they’re at and get a sense of their story and let them tell their story. I’ll often validate that they probably told this story dozens, or hundreds of times in the past to several different providers, and when they’re meeting with me, often they’ve tried a lot of different things and those things haven’t worked in terms of managing their symptoms.
I validate that path and their experience and try to also de-emphasize how the messages that they’ve heard about their pain, and why they might be meeting with pain psychology and de-stigmatize why they might be meeting with pain psychology to begin with. I emphasize that managing and effectively managing pain includes addressing not only psychological factors, but the medical factors at play, and emphasize that affective care is the combination of addressing all of those factors.
Dr. Benjamin Lai: Are there any specific questions or tools that you might use to assess somebody’s function? What does it mean? Functionality.
Dr. Matt Schumann: The questions that I might ask are: “what are the things that you’re doing in your life currently? How is pain impacting those things that you enjoy, and what would you like to be seeing differently if your pain was better managed?” I often focus on things that an individual values, things that are often taken from them when pain has impacted their lives for a prolonged period of time.
I’ll also ask about their expectations for their own pain treatment. Are they hoping for complete elimination of pain before they get back to the things that they enjoy? Or are they looking to just get back to their life in some form or fashion?
Dr. Wes Gilliam: Sometimes just a simple question of “walk me through what a typical day looks like. From when you’re getting up in the morning to when you’re going to bed at night. What does that look like?” For a lot of the patients that Matt and I work with, which you’re going to hear, is a lot of sitting, a lot of secondary activities, inconsistencies in their day and in their schedule.
That can really give you a general sense of what somebody’s function looks like on a day to day basis and can give you some real good insights into the extent to which people are coping adaptively with their pain.
Dr. Benjamin Lai: Wes, do you have a different approach between patients with kind of acute or subacute pain, versus somebody who’s had pain for years and years and years?
Dr. Wes Gilliam: Well, absolutely. Many of the patients with acute pain likely aren’t coming into my office unless it is maybe an acute injury on top of a chronic one. But the reactions that people are going to have to acute pain are going to be best treated with more biomatically focused treatments, typically for acute pain.
But when we’re talking about somebody with chronic pain, then the differences are pretty dramatic. I’m going to be focusing, in many ways, trying to deemphasize biomedical approaches and focus more on some of the rehabilitative and the psychosocial approaches to treatment that are going to give that person the best chance long term, to regain some functioning and quality of life.
Dr. Benjamin Lai: You mentioned at the very beginning the biopsychosocial approach. Tell us a little bit more about that.
Dr. Wes Gilliam: Really when you conceptualize chronic pain, at least this is how I try to do it with my patients, is that there’s multiple components to the chronic pain experience. There is the clear sensory experience that people have, and this is the element of pain that we are really, really good in healthcare at assessing; where is the pain located? How intense is it on that 0 to 10 scale?
What does it feel like? We do that quite well in healthcare.
What we don’t assess particularly well are the real clear emotional and cognitive components to the pain experience. There is a very clear emotional component to what people are feeling. How could it not be emotional when you’ve got chronic pain and it’s been impacting your ability to do the things that are important to you in your life and meet the responsibilities that you have?
To feel depressed, to feel anxious, to feel angry is part of the pain experience. I want to get a sense of the extent to which emotions are relevant to this person. I haven’t met too many people for whom they’re not. There’s also a cognitive and an evaluative component to the pain experience. What I mean by that is how are people making sense of what they’re feeling? What is that dialog that’s running through their head on a day to day basis?
It’s not unusual for me to ask a patient: “what is it like to be hurting the way you’re hurting?” It’s not unusual for me to hear patients say things like, “Doc, it’s killing me.” I’ll often follow up with: “Do you believe it could kill you in the moment, like a heart attack or a stroke?”
99.9% of the time patients are saying, “no.” It’s more of an expression of distress than anything. But imagine what happens if that type of a thought process is playing on loop day in and day out for potentially years. They start to believe what they’re saying to themselves.
I would argue that the thought process itself becomes part of pain. So that’s what I mean by the biopsychosocial evaluation. I also want to get a sense of how that person’s social environment might be potentially influencing how they’re responding to pain, because that’s also very critical and there are also cultural variables that might influence things as well.
It’s a really comprehensive approach to try to understand the entire human being that’s experiencing the pain as opposed to just focusing on the sensory experience.
Dr. Benjamin Lai: That is actually very fascinating in thinking about really changing ones, or at least reevaluating how one perceives pain and all the emotions that that’s associated with it. Correct me if I’m wrong, but that is one of the main approaches or philosophies of Mayo Clinic’s Pain Rehab Center, the program you both work in, the pain rehabilitation clinic. Maybe Matt, we can start with you. Tell us a little bit about the clinic. What are some of the elements in this clinic and generally how long are some of these programs?
Dr. Matt Schumann: The pain Rehabilitation Center three week program is what we’re primarily known for. We’re an interdisciplinary team and it is a group-based practice, meaning that we bring in individuals into the program and work with them for three weeks daily, Monday through Friday, 8 a.m. to 4 p.m., and within that day they’re structured; meeting with our interdisciplinary team that includes pain psychologists such as Dr. Gilman and myself, but also physical therapists, occupational therapists.
They’re monitored by our medical staff. They have a nurse case manager. They meet with the pharmacy and work to, not only improve their functioning in the given day and across those three weeks, but we focus on decreasing external factors that influence their pain management. This includes maybe moving away from polypharmacy or other types of medications like opioids or analgesics that have been prescribed in the past and promoting more internal factors to manage pain, which includes daily activity, stretching, strengthening, pain psychology, addressing thoughts and emotions in response to pain, and decreasing pain related distress and avoidance, along with learning different ways to move about their life. We also look at things like moderation and modification to promote increased functioning in their days.
Dr. Benjamin Lai: Do people start the program on opioids, or are they off opioids before they can join the program?
Dr. Wes Gilliam: Roughly 40% of our patients are coming in currently on chronic opioid therapy, and so we are tapering those folks off the opioids over the course of the three weeks that they’re with us. We are replacing the opioid with self-management skills. The other 60% may not be on opioids, but may also be on things like central nervous system depressants.
So a lot of benzodiazepine, a lot of hypnotic, a lot of muscle relaxants our patients are prescribed an hour on. So we’re working towards trying to streamline those medications to alleviate some of the polypharmacy that’s frankly contributing to their problems.
Dr. Benjamin Lai: How has it worked? What are some of the general patient comments after they complete the program?
Dr. Wes Gilliam: 85% of patients are completing the full three weeks, which I think is a pretty good retention rate, quite frankly, considering the complexities of the patients. The effect sizes are pretty robust, cut across all of the outcomes that we look at. We’re measuring outcomes both with self-report measures with our provider. Observed measures in physical therapy. Our occupational team. The occupational therapy team also has measures that we’re looking at. All of these measures are focused on functional status just through different lenses.
The outcomes are fairly robust and even when you look at the level of individual patients, 80% are making very clinically relevant improvements in outcome. It really is the gold standard for patients that have, what we would call, high impact chronic pain.
Dr. Benjamin Lai: That’s fantastic. Those numbers actually blew my mind. Wes, for our listeners who may live in more rural areas, who may not have access to such a program, what would you suggest that they do? Or maybe our provider colleagues who practice in a more rural setting?
Dr. Wes Gilliam: There are some creative ways that you can approximate a pain rehab program. If we can find somebody in their area that does mental health, that has some experience with pain, and also find folks that have local physical therapy, we can actually combine those two things, have them running concurrent, having a psychologist or an advanced practice provider that specializes in psychology, psychiatry, working with a physical therapist to approximate a rehabilitative model of care.
Is it the same thing as a three week intensive dose? Likely not. But I think it’s a very reasonable dose for patients that need both the physical therapy and the psychological piece of things.
Dr. Benjamin Lai: Matt, what sort of advice would you give patients upon completion of the program? Is there anything that you would give them or a handout so that they can sustain their success?
Dr. Matt Schumann: Part of our programming here is also aftercare. We have virtual and in-person aftercare that we encourage individuals to utilize as they need, as they reintegrate back into their lives and utilize the skills that they’ve learned over the course of 100 hours of treatment. We often encourage individuals to have a difficult day plan. Because pain is complex and is embedded in different types of responses in the nervous system, those responses within the nervous system can still occur in a future date.
We encourage individuals to prepare for those times by utilizing the strategies and skills in the moment if their symptoms start to flare and increase again. We also encourage them to maintain a daily schedule that balances leisure, productive activities and physical activities and exercise. What I hear for individuals who often return back from aftercare, or individuals looking to maintain the progress that they’ve been working on is, when they’re able to stick to that routine as practically and as feasibly as they can, balancing those things back into their lives, they tend to do better.
When we look at our outcomes, usually we measure it about six months after treatment. Looking at how they’re thinking about their pain and their confidence to manage pain, typically sustains after treatment, but is also much better than when they were prior to starting pain rehabilitation. Part of that embedded progress and process is creating a plan for the individual to manage their pain within our program and then taking that back home.
That plan often requires adjustments, and requires overcoming obstacles in the future. But if we can give them the best chance to address those obstacles in the course of our treatment here, they tend to do pretty darn well.
Dr. Wes Gilliam: We have a pretty robust family programming component of our practice, so we’re really encouraging all of our patients to be bringing spouses, children, parents, etc., even just peers into the program and be part of our formalized family program. We offer about two full days of family programming over the course of every patient’s three week experience.
The idea behind that is, to not only educate family members that might not know exactly what the best ways are to help their loved ones, but to also help prepare them for what they’ll need to likely do to continue to facilitate improved functioning of our participants once they finish our three weeks. To the extent that we can, we want to provide the social environment that these patients are going to be going back to with the tools needed to facilitate ongoing functional improvements in our patients.
Dr. Holly Geyer: In March of 2023, the FDA approved the first over-the-counter Naloxone nasal spray to fight the opioid epidemic in the United States. As we continue to navigate the crisis of opioid use, Mayo Clinic is here for you. My book, “Ending the Crisis,” is a handbook for anyone whose life has been touched by opioid use. Read personal stories of those struggling with addiction, hear advice for safe opioid use, and get step by step instructions on how to administer the life saving drug naloxone.
Visit the link in the notes of this episode or visit mcpress.mayoclinic.org/opioids to get your copy today.
Dr. Benjamin Lai: Would you be able to briefly elaborate on a few of those tools or strategies you might give to patients or their families?
Dr. Wes Gilliam: Well, one of the biggest things is helping better understand how family members are responding to their loved ones when their loved ones are struggling, and determining if there are ways that we can make modifications. On one side of the continuum, you’re going to have family members that tend to be highly solicitous when their loved ones are struggling.
When they see someone struggling, they want to jump in and immediately take over responsibilities for them in an attempt to help. They’re doing it because they love their family members, but as that dynamic plays out over the course of time, what can start to happen is that the patients themselves begin to view themselves as not capable of doing things because of the environment. Every reaction the environment is having suggests that they shouldn’t do those things.
A lot of it is working with family members to manage their own anxieties around taking a step back and giving these patients the opportunity to struggle a little bit while also learning how to best self manage. You do that and you actually promote confidence in people, whereas if you just jump in immediately, you’re actually detracting from their confidence to self manage.
The flipside of that coin is you’re going to have some loved ones that have become extremely frustrated. Not because they don’t care about the patient with pain, but because the movement forward in terms of functioning has not happened, despite all the effort that’s been put into trying to improve things. Helping family members realize that being critical or punitive is also not going to be helpful and then we have to take more neutral approaches to working with loved ones.
Dr. Matt Schumann: The skills and strategies that we focus on emphasize replacing what is an unpleasant experience in pain and replacing the typical danger responses to pain with more safety responses or balanced responses. Those can include, as Dr. Gillan mentioned, patients learning ways to attribute their pain to something that’s less dangerous and viewing a different conceptualization of pain as an always negative experience that, where one cannot manage or one does not feel confident to manage, to viewing it as something as “things that I can do to manage the pain in the moment.”
There are internal analgesic effects that I can create by engaging with the relaxation response that could also include addressing stress and amplifiers of pain. It could be looking at and expressing emotion effectively, looking at one’s self-criticism in response to the impact of their pain and their life where they’re at right now. Then also implementing things like mindfulness of taking a step back from a lens of safety and viewing their symptoms in a less threatening way and incorporating positive experiences.
Engaging in pleasant experiences can often help with addressing difficulties with co-morbid moods, but also emotional responses to pain and engaging in avoidant activities in a safe manner, in a gradual manner that includes moderation and modification.
Dr. Benjamin Lai: That is a lot of material actually to cover in a three week period. The fact your patients can go through all of that and sustain success. It sounds like it requires cognitive reframing and a lot of these additional tools that they use. Kudos to you all. I work in primary care. Increasingly, I hear some of my patients and my specialty colleagues use the term central sensitization.
For our listeners, who may not be familiar with this term, can you maybe just explain to us what that term means? Maybe I’ll start with you, Matt..
Dr. Matt Schumann: We think about sensitization as changes within the nervous system and changes that occur in response to repeated unpleasant experiences. Nerve amplification or nerve sensitization can be influenced by a lot of things. That can be things like persistent presence of input. Let’s say an area of the body is repeatedly sending a signal. The brain accommodates that by expecting the signal and then what the individual makes of that signal altogether. How is it impacting the individual in the moment, but how has the history been impacted?
We see that over time, the repeated attention, ongoing difficulties with pain, magnification and concern about pain leads to hypersensitivity at an erronal[sic] level from that level of analysis, but also influences at larger levels of analysis through the individual’s awareness and attention. Anything that you want to add, Dr. Gillam?
Dr. Wes Gilliam: Over the course of time, the brain becomes used to creating pain. There’s a hypersensitivity component that can start to kick in, even in the absence, frankly, of any peripheral pain generator. The brain itself becomes a generator of the symptoms, even if there isn’t any clear tissue damage to account for what people are feeling.
It’s incredibly confounding to patients when they’re feeling something in a really pronounced way, but objectively we can’t tell them why they’re feeling what they’re feeling. Frankly, it’s confounding for providers too to be able to articulate to somebody your pain is very real, but it’s being generated by pain circuitry as opposed to peripheral damage.
Dr. Benjamin Lai: Are there certain individuals who might be more prone to developing central sensitization? People with, for example, certain other conditions or maybe trauma history?
Dr. Wes Gilliam: Trauma is the one that stands out the most to me. Trauma, history, early life experiences with adverse events that maybe don’t meet the criteria for a PTSD trauma based on DSM five, but it’s an accumulation of adverse events that happen early in life that also dysregulates the nervous system and puts people at increased risk for the development of chronic pain.
When you look at the literature for trauma, just in a general population, roughly 5% of folks are going to have a diagnosis of PTSD, and when you filter that data down, and you look only at people that have chronic pain, what you’ll see is that number goes up four or five fold. It’s anywhere from 20 to 37%.
There are very, very common comorbidities, and there is very fair evidence to show that early life trauma can lead to increased probability of development of chronic pain later on in life. The same holds true for depression as well. Somebody that has early life struggles with depression is about four and a half times more likely to develop musculoskeletal pain later in life than somebody that has no history of depression at all.
Dr. Benjamin Lai: A comprehensive pain management, or to maintain somebody’s functional status we really need to think about treating perhaps, or addressing these important issues too. Is that correct?
Dr. Wes Gilliam: No question. A lot of it comes down to how do we articulate that to the patient? Because for a lot of patients, particularly those that have central sensitization, they don’t have any clear peripheral generator for their pain, to hear that we want to treat your depression might be akin to saying your pain’s all in your head.
We’re really trying to thread a needle here by validating the legitimacy of the pain that they’re feeling, but also being able to identify all of the other variables that play a role in how somebody experiences pain. You can make a really strong argument that if you optimize somebody’s depression treatment, that that in and of itself is a pain treatment.
But you’ve got to be really careful in how you articulate that. In an interdisciplinary program like ours, what we can do is take evidence based treatment approaches that share theoretical underpinnings, frankly, with evidence based treatments for post-traumatic stress disorder, for example, substance use disorder, depression… We can deliver those interventions targeting pain, but then also get kind of a generalized effect, meaning that we also see reductions in PTSD symptomatology.
We also see reductions in depression symptomatology over the course of the three weeks the patients are with us. I would argue that the pain intervention overlaps significantly with depression and anxiety interventions. Then just to take it another level, the interventions we’re delivering are targeting very specific areas of the brain that make up pain circuitry in the brain, and of course, those areas of the brain overlap with depression and anxiety circuitry.
Dr. Benjamin Lai: This is all kind of coming together. It’s all unified, really. Matt and Wes, I want to open the floor up to you both. If there is one piece of advice or pearl you could give to our patients, to our providers and to our audience, family members of chronic pain patients, for example, what might that be? Maybe I’ll start with you, Wes.
Dr. Wes Gilliam: We have the tools to help people with their pain. A willingness, openness to exploring the complexity of pain and taking a more interdisciplinary multimodal approach is going to give you the best chance to have an improved quality of life. The biggest challenge too is we can improve quality of life, even if the pain severity doesn’t disappear. There’s hope for that.
Dr. Matt Schumann: I would emphasize focusing on values, the things that are important to the individual, whether that’s the patient and experiencing “What are the things that are most important to me that I want to get back to in my life that I’m not doing because of my pain?” Or for the provider: “What does this individual want to get back to and how can I help get that individual back to be on the right path to that?”
I’d be so bold as to state that a biopsychosocial approach is essential in treating pain. If we think about the definition as an unpleasant sensory and emotional experience. That if one aspect doesn’t work in isolation, that often means that coordinating those aspects together, which often isn’t easy, especially in rural or areas of less access and thinking more flexibly of how can we deliver the care to the individual where they’re at and providing that type of approach, a non-pharmacological that can support other types of pharmacological approaches as well to optimize one’s pain care, there’s possibility in pain relief in non-pharmacological strategies as well.
Dr. Benjamin Lai: This is just tremendous. This is so helpful for me. I’ve learned so much just talking to the two of you today, and I’m sure for our audience as well. Dr. Geyer, do you have anything else to ask or add?
Dr. Holly Geyer: I think they’ve given us great information. There was one question that I was a bit curious about. We recognize that many of the people that come to you have used opioids on a chronic basis to manage their pain. We recognize in the literature that many of those people will go on to develop addiction. Now, whether or not that’s recognized is a bit of a challenge in the medical industry, and I was curious from your perspective, when you see an individual who has come to you with chronic opioid use, how do you begin to evaluate them for the possibility of perhaps an overlapping addiction problem, and how do you assess that?
Dr. Matt Schumann: Yeah, I start by just assessing the level of addiction and assessing how their use has impacted them and why they’re using the medications that they’re taking or the opioids or substances that they might be taking. If I understand the impact, how they’re using it, why they’re using it, then we can start to think about interventions to replace the function of that medication or substance.
There are good treatments for co-occurring substance use concerns and pain. One type of treatment that I’m familiar with is called mindfulness oriented recovery enhancement and it tends to be a mindfulness approach that emphasizes addressing addiction craving, or substance use craving, but also the impact of pain in the process of all of that.
Dr. Wes Gilliam: It’s a great question, Holly, and I’ll tell you honestly, we miss this, as so many do, because it can be difficult to tear those things apart, particularly with the limitations of the time that you have with patients. What I will say is when patients come into our practice, this is the luxury of having the staffing model that we have and the time with patients that we have, what starts to happen is the addiction starts to emerge itself while they’re in our program,
As we start to taper people off of their opioids, in particular, we start to see the addiction kick in. What we really work hard on doing is identifying that as quickly as we can, talking with the patient about it as they’re working through their taper and then utilizing our addiction colleagues that are right upstairs from our unit to get formal assessments and diagnose this to help make decisions about future state.
It’s not unusual if we have an opioid use disorder that we’ve identified during treatment to get people induced onto Suboxone while they’re with us and then carry them forward on Suboxone to try to stabilize the addiction while they’re with us so that we can rehab them for their pain. Because poorly managed pain is going to be a risk factor for relapse while then trying to identify resources for them moving forward to supplement the Suboxone with psychosocial intervention.
There’s going to be some cases where the addiction is so pronounced, this doesn’t happen very often for us, but it does happen from time to time, where we get them moved up into addiction treatment immediately because it’s clear that that is the primary issue that needs to be addressed.
Dr. Holly Geyer: My other question had to do with the overall quality of life of the individual who’s experiencing pain. I had a colleague once tell me that one of the ways he explains it to his patients is that he may not be able to cure their pain. In fact, it’s probably unrealistic. But if their pain is so big in their world that’s so small, perhaps expanding the size of their world will make the size of the pain look smaller.
I was just curious if you guys had thoughts on how you frame the concept of pain in the overall experience of going through life to your patients.
Dr. Matt Schumann: I’ll frame pain as – – if we’re thinking about chronic pain – – as a system that shouldn’t happen. The pain often in terms of chronic pain is prolonged and the body has gotten too good at protecting itself. In that case, the emphasis of these types of skills and strategies are “How can we calm the central nervous system? How can we calm the nervous system’s response, given that the body is trying to be overly protective of threats?”
With that, that conversation, the focus then is how can we, if we can calm the body, get back to some of these things that you enjoy and often as a byproduct of focusing on the things that you enjoy, engaging in activities that are important to you, pain tends to decrease from a biological perspective, and a psychological perspective is that attention starts to shift.
The body can only attend to so many things at once, and when the body is focused on pain and the impact of pain that’s been occurring for a prolonged period of time, it becomes harder to shift. By engaging in things that are valid to the individual, the opportunity to shift widens the lens, if you will, and can open and view things as moving back into one’s life a little bit easier.
Some people report that their pain goes away, which is the ideal state. Other individuals report that pain is there, but I’m engaging in things that are important to me and that meaning-making decreases as the suffering that one experiences in the context of their pain.
Dr. Benjamin Lai: We thank you so much, Dr. Gillam, Dr. Schumann, for your time, your expertise and your continued care of our chronic pain patients. That is all from us on today’s episode of Ending the Opioid Crisis. You can check at our website at mcpress.mayoclinic.org/opioids for more episodes of our podcast series and other resources for safe opioid use.
If you or someone you know are struggling with an opioid or another substance use disorder, we recommend speaking with your healthcare provider or going to the Substance Abuse and Mental Health Services Administration website.
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