PAC 230 Module 4 Pain and Its Management Example

Pain Without Pills: Gate Control, Opioid Evidence and a Pain Plan for a Young Man in Recovery

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 230: Families and Health Psychology

Instructor Name

Month Day, Year

Pain Without Pills: Gate Control, Opioid Evidence and a Pain Plan for a Young Man in Recovery

Mike Dawson is twenty-six. Four years ago he fell from a roof and injured two discs in his lower back. He was prescribed opioid pills, and over the following year his use grew beyond the prescription. He later bought pills, then heroin, before entering residential treatment. Nine months into recovery, he takes buprenorphine, attends a recovery group and works for a landscaping company, and he lives with his mother, Carla. His back still hurts, most after long shifts and on cold mornings. At a visit to Maumee Valley Family Health, the fictional clinic that serves his family, he said he was afraid of the pain and more afraid of anything that might lead him back to pills. This paper explains pain and builds a management plan that protects his recovery. Mike, his family and the clinic are composites invented for teaching; the research is real.

How Pain Works

Melzack and Wall (1965) proposed the gate control theory of pain, which transformed the field. Before their theory, pain was widely understood as a direct signal from injured tissue to the brain, so that the amount of pain should match the amount of injury. Melzack and Wall argued that pain messages pass through a kind of gate in the spinal cord, which can let more or less of the signal travel on to the brain. Signals from small nerve fibers carrying pain information tend to open the gate, while signals from larger fibers carrying touch and pressure tend to close it, which helps explain why rubbing an injury can ease pain. Crucially, signals descending from the brain also influence the gate. Attention, emotion, expectations and past experience can open or close it.

The theory explains features of Mike's pain. His pain is worse when he is stressed or tired and better when he is absorbed in work he enjoys. It also suggests that treatments addressing attention, mood and behavior, not only the injury, can reduce pain.

Opioids and Chronic Pain

Opioids relieve acute pain effectively, but their role in chronic pain is limited and risky. Vowles et al. (2015) systematically reviewed studies of patients prescribed opioids for chronic pain. Rates varied widely across studies, partly because of different definitions, but their best estimates were that misuse, meaning use contrary to instructions, occurred in roughly 21 to 29 percent of patients, and addiction in roughly 8 to 12 percent. Mike's history, from prescription to misuse to addiction, followed a path the review describes.

Krebs et al. (2018) tested whether opioids offer enough benefit to justify those risks. In a randomized trial among veterans with chronic back pain or hip or knee osteoarthritis pain, patients received either opioids or nonopioid medications, such as acetaminophen and anti-inflammatory drugs, for twelve months, with doses adjusted to their response. Pain-related function did not differ between the groups. Pain intensity was slightly lower in the nonopioid group, and patients taking opioids had more medication-related side effects. The trial found no advantage for opioids in this population.

Options for Mike

The Pain Plan

Mike's plan, developed with his primary care physician and coordinated with his buprenorphine prescriber, has four parts. First, a course of physical therapy, followed by a home exercise routine he can do before work. Second, a referral to the clinic's behavioral health team for cognitive behavioral therapy for pain, which will teach him to notice how stress and worry amplify his pain and to use relaxation, pacing and attention shifting. Third, a nonopioid medication schedule recommended by his physician for flare-ups. Fourth, his prescriber will review whether the timing or dose of his buprenorphine could be adjusted to help with pain, a decision for the prescriber alone.

Mike also asked for a plan for severe pain or an emergency. He and his physician agreed that if he needs care for acute pain, such as after another injury, he will tell every clinician about his recovery and his buprenorphine, and his recovery sponsor and mother will be told.

Pain, Stress and Relapse

Pain is one of the most common reasons people in recovery from opioid use return to use, and the link runs through more than physical discomfort. Pain disrupts sleep, makes work harder and lowers mood, and each of these is a relapse risk on its own. Mike describes the worst mornings as the ones when he lies awake at four o'clock with his back aching, thinking about how easy it used to be to make the pain stop. Gate control theory suggests that this combination of fatigue, worry and attention fixed on the pain opens the gate further. The plan's psychological component therefore serves two purposes at once: it reduces his pain and it gives him skills for exactly the moments when cravings are most likely.

The Family's Role

Families can reinforce pain behavior, for example by taking over every task when someone complains of pain, or they can support active coping. Carla has tended to do the former, out of love and worry. The plan asks her to encourage Mike's exercises and to ask how his pacing is going rather than whether he is hurting. His grandfather, Walt, who has his own cardiac rehabilitation exercises, has offered to do their routines together on Sunday mornings.

Conclusion

Mike's pain is real, and so is his risk. Melzack and Wall explain why stress, attention and mood change how much pain he feels, Vowles and colleagues document the risks of opioids in chronic pain and Krebs and colleagues show that opioids offer no advantage over nonopioid medications for function. A plan built on physical therapy, psychological treatment, nonopioid medication and family support treats Mike's pain while protecting the recovery he has worked for.

References

Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., Kroenke, K., Bair, M. J., & Noorbaloochi, S. (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA, 319(9), 872-882. https://doi.org/10.1001/jama.2018.0899

Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150(3699), 971-979. https://doi.org/10.1126/science.150.3699.971

Vowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., Ney, J. P., & van der Goes, D. N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain, 156(4), 569-576. https://doi.org/10.1097/01.j.pain.0000460357.01998.f1