Toward a Culture of Safety, Part 2: Pain Management

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Let’s talk about adverse events and pain management, because it seems like what acupuncturists don’t understand about adverse events reporting overlaps with what they might not understand about pain management. A lot of the acupuncture profession is preoccupied with distinctly individualistic questions like, how skilled is each individual acupuncturist, and how does each acupuncturist distinguish themselves from all the others? What does each individual patient want? Is each individual treatment the right treatment? Adverse events, pain management, and also trauma informed care (next post!), though, are related more to collective understandings and collective processes — things that are bigger than individuals. And building a culture of safety — which is a collective project — can help us be more effective in supporting our patients to manage pain, especially chronic/persistent pain.

Our collective understanding of pain and pain management has evolved over the last couple of decades, and it might bear no resemblance at all to the way many of us learned to think about pain when we were in acupuncture school. This 9 minute video developed by a pain expert and her team in Portland, OR (Nora Stern, who is also an advocate of community acupuncture) sums it up: All pain is a product of the brain, and all pain is real pain; successful pain management often requires changing the patient’s relationship to pain as opposed to getting rid of it.

Many of us acupuncturists were taught to approach pain as if it were an imbalance that we should be able to locate and fix, IF we’re good at what we do. When a patient’s pain worsens after a treatment, we might explain it as a “healing crisis”. If a patient’s pain doesn’t resolve at all, we might blame ourselves for not being skilled or sensitive enough practitioners to discern “the right treatment” and “correct the underlying imbalance”, or we might blame the patient for not being receptive enough in some way. This perspective is oriented toward what individuals are doing right or doing wrong, and can entail expectations of heroic effort from both practitioners and patients.

Research on the neuroscience of pain has a much more global and much less judgmental take on successful pain management. If you’d like to watch an excellent presentation by Rachel Solotaroff, MD, another pain expert in Portland, OR, you can do that here. This is the non-academic summary of that presentation:

From Punking: The Praxis of Community Acupuncture:
“The largest cluster of nerve cells in the body is the brain, and all pain, no matter where we perceive it, is actually happening in the brain. Many people know that we don’t really see with our eyes or hear with our ears; our brain takes information from the sensory organs to produce what we experience as vision and hearing. However, most of us don’t realize that pain is similar: we don’t feel pain with our peripheral nerves, we feel it with our brains — which means the experience of pain arises out of the brain integrating enormous amounts of information about every aspect of our lives, including emotional and social.
One of the most important qualities of the nervous system is its plasticity. All of the nerves in the body, including those in the brain and the spinal cord, are constantly changing in response to what’s happening and what they, themselves, are doing. This has huge implications for pain: it’s a complex, dynamic, organic process as opposed to the equivalent of a light blinking on a dashboard indicating a mechanical problem that can be fixed by replacing a part.
Our brains evolved to survive and what we call neuroplasticity is a function of survival priorities. Our brains are wired to respond as quickly as possible to rewards, and to make our responses more efficient over time. The more we access pathways in the brain, the faster and more efficient those pathways become. Think of an early human who’s foraging for food and trying to avoid saber-tooth tigers. Both reward circuits and fear conditioning operate towards the back of the brain, and they’re much faster than the functions that happen in the front of the brain, like rational judgement and planning. When you need to get away from a saber tooth tiger, you need to move fast and instinctually, not sit back and reflect.
Recent research shows that the neuroscience of persistent or chronic pain has overlaps with both the neuroscience of learning and the neuroscience of addiction, because of the nature of reward circuitry in the brain. Feeling pain is something we learn to do the way we learn to play a musical instrument: the more we do it, the more we practice, the better we get at it. And like addiction, feeling pain involves both anticipation and reward, in the form of relief from pain.
Just like alcoholism involves drinking more and more alcohol to get diminishing returns of pleasure and relaxation, persistent pain can involve diminishing returns in seeking relief by lying down on a couch or taking pain medication. Certain things swamp the reward circuits of the brain, like opioids, smoking, and junk food. The more the reward circuits are swamped, the faster those circuits get, which can look like a person in pain compulsively seeking relief, even when the methods of relief are helping less and less. Meanwhile, as the nervous system learns to feel pain more and more efficiently, it’s as if an amplifier has been turned up and the pain becomes more and more intense. Anticipation of pain increases pain; fear of pain increases pain.
A vicious cycle is engaged, where the back-of-the-brain circuits of anticipation and reward get faster and faster. Feeling pain and seeking relief take over a person’s experience in a similar way that addiction can take over a person’s life. Even if the person rationally knows that what will help with persistent pain is gentle exercise, the part of the brain that can make rational decisions is less and less accessible. The small, ordinary pleasures of day to day life get crowded out, which means that the person gets less practice feeling pleasure and more practice feeling pain. And of course, the social aspect of persistent pain can be as profound as the social aspects of addiction: as anticipation of pain leads a person to withdraw from the activities of daily life, they become isolated. Isolation increases stress and negative emotions, which in turn increase pain.
At this point, research suggests that the only way to heal the brain from the vicious cycle of compulsive relief-seeking and amplified pain is to gently re-establish connections in the brain that provide small, reliable doses of positive feeling. Over time, low-key rewards that don’t swamp and overwhelm the circuitry can begin to have an effect on the pain amplifier, and actually turn it down. Neuroplasticity can be engaged for the purpose of learning how to feel other things than pain.
Recovery from chronic pain is a gentle, supportive, non-judgmental, active process — which is where community acupuncture clinics can really shine. Many of the same principles involved in trauma informed acupuncture come into play, because using community acupuncture to address persistent pain is about people learning to use the clinic as a source of small, reliable doses of positive feeling. Relaxation is a skill. Accessing support is a skill. Being in a social setting even though you’re in pain is a skill. Community acupuncture patients tend to develop a sense of competence around receiving acupuncture, which means developing neural connections of learning and reward that are different from the grooves of the vicious cycle of persistent pain. It’s all about people being empowered to use the clinic on their own terms.”

Let’s reiterate: Recovery from chronic/persistent pain is a gentle, supportive, non-judgmental, active process. According to our biomedical friends who work in safety-net clinics in Portland, acupuncture works because it increases neuroplasticity. (You could probably explain that in terms of qi if you wanted to.) But acupuncture treatment isn’t something the practitioner does to the patient, it’s something the patient and practitioner do together (and we don’t mean the patient has to quit smoking, or otherwise change their habits, in order for the treatment to “work”). Receiving acupuncture is an active process for the patient, even when they’re sitting or lying still. The acupuncturist can support the patient’s process by providing a safe environment in which to practice the skills of relaxing, receiving treatment, and accessing support.

Because of the many complex biopsychosocial factors that affect patients’ experience of pain, it’s entirely possible for patients to experience negative outcomes after an acupuncture treatment that are nobody’s “fault”, and might even be part of the larger process of patients learning how to use acupuncture to manage their pain. Without the support of a culture of safety, though, and in the presence of the expectation that pain is something that acupuncture is supposed to magically erase, it’s easy to fall back on blame as a response. If a patient tells a practitioner that they suddenly have a new kind of pain in a new location after a treatment, and they think the treatment caused it (and why wouldn’t they think that?), it’s easy for the practitioner to get defensive and/or try to turn what feels like an accusation back on the patient. It’s really unfortunate when that happens, though, because successful pain management is often an incremental process that relies on relationship-building. (Please see Punking for more details.) Blaming and accusations can derail both the process and the relationship before anything useful can be accomplished. A culture of safety, though, opens up other possibilities.

A culture of safety allows us to approach unexpected negative outcomes from a place of curiosity, openness and communication, rather than defensiveness. There’s so much we collectively don’t understand about pain, and we’re learning new things every day. There’s so much more to think about in pain management — a much bigger picture — than what individuals are doing right or doing wrong. A culture of safety allows patients and practitioners to approach negative outcomes as allies rather than adversaries.

Up next: Toward a Culture of Safety, Part 3: Trauma-Informed Care

Author: lisafer

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