One of the goals of rigorous science is to disentangle various causes so we can establish exactly where the lines of cause and effect are. In medicine this allows us to then optimize the real causes (what aspect of treatments actually work) and eliminate anything unnecessary.
Eliminating the unnecessary is more than just about efficiency – every intervention in medicine has a potential risk, so this is also about risk reduction.
It often seems to me that the goal of “alternative” medicine is to blur the lines of cause and effect, to exploit non-specific effects in order to promote a useless but profitable ritual (acupuncture comes to mind).
Pain is the area most susceptible to such blurring of lines. Pain is a complex combination of physiological and psychological effects. Physiologically pain is produced by tissue damage or pathology provoking pain signals in sensing nerves (nociceptive pain). This type of pain serves a protective purpose, and does not last beyond the pathology itself. There is also neuropathic pain, in which pain arises abnormally from within the nervous system itself. This type of pain is chronic and not protective.
Pain signals are conducted to the brain where they are perceived. There are two components to this perception, with their own neuroanatomical correlates. The first type localizes the pain – where exactly in the body the pain originates. The second adds emotional context to the pain – it makes it hurt. Pain would not serve its function if it didn’t really bother us or force us to pay attention.
Interestingly, opiates are more effective at suppressing the emotional aspect of pain. Therefore it is common for patients on opiates for severe pain to report that they can still feel the pain, it just doesn’t bother them.
At every step in the process, pain intensity can be modulated. Further, pain is closely tied with attention – the pain hurts more when we attend to it, and less when we attend to something else. Anxiety and depression also increase the subjective experience of pain.
Therefore, a multidisciplinary or total approach to treating pain can address treating the underlying pathology (always the first priority), inhibiting the physiological and neurological production and conduction of pain, reducing the brain’s perception of pain, and modulating all of the psychological aspects of attending to pain and its emotional comorbidities.
When doing pain research it is critical to isolate, as much as possible, all of these various effects. Otherwise no conclusions can be drawn about the effect of any one aspect of the treatment. The kind attention of the practitioner and the hope of a treatment effect alone will likely result in the reporting of reduced pain.
This is all closely related to the concept of “placebo effects.” Operationally, in medical research “placebo effects” are everything other than a physiological response to the active treatment being studied. However, when treating pain these other effects could not only be useful, but already be part of multidisciplinary pain treatment. These non-specific effects, however, do not justify the active treatment, unless the active treatment is shown to independently contribute to the overall pain reduction.
Again taking acupuncture as an example – the point by proponents is often made that even if acupuncture is no more effective than placebo (it isn’t), that’s OK, because placebo effects are useful in treating pain. But acupuncture is not delivering these placebo effects, it is the ritual surrounding acupuncture that is primarily doing so. The sticking of needles into specific points does not appear to add anything to the overall effect.
If we want to maximize the utility of the psychological aspects of pain treatment, then let’s optimize those and dispense with the elements that are adding nothing. There are attempts to do just that. Some methods already in use include biofeedback, stress management, and cognitive-behavioral therapy (CBT).
A recent study looks at combining such methods into a protocol the researchers call “Mindfulness-Oriented Recovery Enhancement (MORE).” The technique is described as:
Mindfulness involves training the mind to increase awareness, gain control over one’s attention and regulate automatic habits.
Reappraisal is the process of reframing the meaning of a stressful or adverse event in such a way as to see it as purposeful or growth promoting.
Savoring is the process of learning to focus attention on positive events to increase one’s sensitivity to naturally rewarding experiences, such as enjoying a beautiful nature scene or experiencing a sense of connection with a loved one.
In other words, meditation and CBT, so it seems like a new spin on these established techniques. That is not necessarily a criticism, however, if the goal is to optimize the effectiveness of non-pharmacological techniques in managing chronic pain.
One of the biggest complications in treating chronic pain is opiate overuse. This occurs because of tolerance, the drugs work less and less well over time so doses have to increase. Also opiates are psychologically addicting, and patient often self-medicate with them to treat the anxiety and depression that goes along with the pain.
The researchers in the above study also looked at opiate overuse as an outcome. They found:
MORE participants reported significantly greater reductions in pain severity (p = .038) and interference (p = .003) than [support group (SG)] participants, which were maintained by 3-month follow-up and mediated by increased nonreactivity and reinterpretation of pain sensations. Compared with SG participants, participants in MORE evidenced significantly less stress arousal (p = .034) and desire for opioids (p = .027), and were significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = .05); however, these effects were not sustained at follow-up.
This is a preliminary, but reasonably designed and powered study. The results are encouraging, but all the caveats apply until it is properly replicated.
The one discouraging result is that reduction in opiate overuse was not sustained. One rule of thumb in pain research is that what patients do is likely more significant than what they say. If they report less pain but use the same amount of pain medication, their report is likely biased.
Conclusion
It’s time to move past the empty rhetoric and deceptive shell-game of “placebo medicine.” Non-specific effects of a positive therapeutic intervention, combined with specific psychological interventions, can reduce the experience of pain and improve quality of life. This should not be used to justify useless rituals and the magical thinking (and risks, however small) that go along with them.
Rather, researchers interested in such effects should study them directly and figure out how to maximize their usefulness and free them from the pre-scientific rituals in which they are often embedded.
