When we consider the 50 billion brain cells and trillions of connections that are involved in the experience of pain, it’s preposterous to think that administering a pill or a series of pills or a patch is really going to change the environment substantially. There are so many ways to impact that environment that are non-pharmacologic, that I think we’re missing the boat if we don’t include them. And these non-pharmacological measures can be offered in a primary care setting. Sometimes physicians say, “I don’t have time. I don’t have the skill set.” A lot of things can be suggested to patients that they can then take home and engage without much heartburn or much expenditure of energy and time, and which return good results. Mindfulness practice is one of the very inexpensive measures that patients can do to really impact their thinking and their feeling processes with respect to pain. For a clinician to mention that--“have you considered mindfulness?”--it becomes prescriptive, and I think it’s our responsibility as clinicians, as physicians, to be prescriptive or at least suggestive. One of the responses that I often hear about mindfulness is that people won’t do it. Well, when I teach about mindfulness, hundreds of physicians are meditating in the room, so everybody will give it a try. Some people won’t carry on with it. Some people won’t get results with it, but it’s really worth a suggestion and a try.
Some of the other measures that can be undertaken and are non-pharmacologic involve thinking processes. We have cognitive behavioral therapy. Evidence based results from over 200 studies, shows people can be trained to think differently to decrease their overgeneralization and their black and white thinking and the phenomenon we know as catastrophization, which is making their pain worse than it really is. People who are trained to change the lens have less pain, have better experience of life. Dialectical behavioral therapy, acceptance, commitment therapy are other measures that can be suggested in a clinician’s office. I don’t expect people to become adept at this but these are all evidence-based measures that actually work as well or better than opioid therapy.