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OPINION | Haider Javed Warraich

Managing pain without painkillers

istock photo/globe staff illustration

A day hardly passes without another death from heroin use in New England. One of the main drivers of the heroin epidemic is the rise in prescription drug abuse, triggered by the prevalence of highly addictive opioid-based painkillers.

That’s a particular concern in this region, which according to a recent study in the American Journal of Preventive Medicine has highest sales of, and some of the highest rates of overdoses from, these drugs. That’s why it’s important that doctors and researchers here are leading the way toward alternative ways to treat pain.

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Pain is perhaps the most common of all human symptoms, yet our understanding of it is still evolving. Our sense of pain is highly dependent on context. Given that doctors have no way of “measuring’’ pain, we must rely on a subjective description from the person experiencing it. One way researchers are trying to better understand pain is through studying its close cousin, the itch, which is unique in that the sensation can be reproduced just by thinking about it. However, the most interesting insights about pain medications are coming from the study of medications that are meant to achieve nothing at all — placebos.

When Henry Beecher, a pioneer in anesthesiology and bioethics at Massachusetts General Hospital, went to serve in World War II, he became interested not just in those soldiers who were crying out in pain but also in those who weren’t. Beecher performed some of the pioneering work exploring the placebo effect.

Recent research has demonstrated that the placebo effect is more than just a mental trick. As with actual pain medication, placebos can result in the release of the body’s own opioids in the brain, similar to pain medications. Thus the placebo effect and pain medications share a common pathway in the brain. Furthermore, the placebo effect can be neutralized with the antidote used for heroin overdoses, naloxone. We now know that not only can the placebo effect be demonstrated, it can be regulated much like any other intervention.

Sometimes placebos work even when patients know they aren’t receiving actual pain medication. In a recent clinical trial by Ted Kaptchuk of the Beth Israel Deaconess Medical Center, patients with migraines responded better to placebos that were labeled medication than to those honestly labeled placebos. Yet the group that knew it was taking placebos still did better than a control group that took nothing at all.

It may seem puzzling that a known placebo could have actual pain-relief effects. It would seem counterintuitive that an inert substance would recreate such reproducible effects in patients. Yet what we are now realizing is that the placebo effect is not produced as much by the pill as it is by the physician giving it.

In another clinical trial, Kaptchuk demonstrated that patients with irritable bowel syndrome responded much better when placebo acupuncture was provided in an environment in which the provider spent extra time with the patient and addressed their emotional needs. Remarkably, the results were equivalent to the most effective medical therapy.

To me, those results show that there is more to being a physician than just diagnosing and prescribing. Physicians should aspire to be healers of illnesses, as opposed to just treaters of disease. When I asked Kaptchuk the best way to enhance the placebo effect, he told me to make a “commitment to being present.” Physicians definitely need to be more vigilant about treating pain. Although it is quicker and easier to write a prescription for Oxycodone, whenever possible we need to be a bigger presence in helping our patients cope with pain.

Patients also need to take a more proactive role. Back pain, which accounts for a fifth of all clinic visits in the United States, is a major reason patients are prescribed opioids. Yet a recent program of intense exercise at the New England Baptist Hospital suggests some patients can be treated without surgery, MRIs, or painkillers. One important part of the program is the advice therapists give participants: Stop “worshipping the volcano god of pain” and instead resolve not to let it interfere with doing what they love.

As the medical community searches for ways to treat chronic pain and reduce pain-medication abuse, the placebo response suggests that the key lies within ourselves. Physicians need to support their patients in a way that helps them in their battle with pain so that they can be their best placebo-genic selves. That problem may be best addressed at the bedside, with physicians and patients working more closely together to solve pain problems.

Haider Javed Warraich is a resident in internal medicine at the Beth Israel Deaconess Medical Center.
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