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Comment by varispeed | Hacker News Reader

This is dangerous thinking. For example when it comes to chronic pain, there is that belief being pushed that opioids are actually a placebo and they don't help. Then people are being sentenced to a talking therapies instead. These therapies try to implant the thought that all the pain people experience is in their heads and it is not real. If only they could just stop thinking about pain, then they wouldn't need to take any pills. This is one of the reasons why people turn to dealers, if doctors start to believe this and are made afraid of prescribing anything. Also organisations who get involved in such "therapies" promote them, because that is, let's be honest, rather easy money from the public health organisations. It fits the western perception of suffering, that it is noble and virtuous. I wish this topic was explored more by investigative journalists.

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This is a baffling mischaracterisation of the arguments.

People don't say that opioids are a placebo. They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time. This means that people are still in pain, but are now also taking dangerous and debilitating amounts of opioid meds. Their function is worse because of the opioids.

Providing talking therapy to these people isn't saying that the pain is not real. You saying this causes harm and you need to stop saying it, because you clearly do not understand what's happening.

When people have long term pain they lose function. They stop doing activities they used to enjoy. Their quality of life plummets. This makes their pain worse. (We know this, there's plenty of research.) Talking therapy aims to get people their life back by helping them regain function. They start to learn to live with pain. They get back to doing activities they enjoy. This doesn't eliminate pain, but it does lessen the pain and it improves quality of life.

You seem to think that "pain free but on opioids" is possible. For most[1] people in long term pain that's not possible, because opioids don't work like that.

[1] most, not all.

I've always heard the problem with opioids are when you get too many or too few.

> They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time.

And this is the root of those claims. Some people even started to believe that patients fake chronic pain just to get those sweet sweet opioids. I've been taking them for over five years and I have not noticed that they lose effectiveness, nor I had to increase the dose. You do still feel pain, but the difference is between being able to function in the society and thinking about killing yourself. I've been through many of those therapies and I have seen disbelief on people faces. You can't get your life back just by thinking there is no pain or that the pain will not take it away. What they do is they get people to learn some basic thought patterns that any CBT therapy do and then sprinkle it here and there with theories about pain. This is not bad in itself, but when you marry it with the thought that opioids are unnecessary, you sentence people for unimaginable suffering, while patting yourself on the back, that you are "helping".

6:30 in this radio programme: https://www.bbc.co.uk/sounds/play/b04wv052

From 9:00 they interview someone who was on huge amounts of opioids and who managed to get off them.

I dealt with a case of chronic patellar tendonitis for years between ages 23 and 26. Debilitating to the point where I could not go anywhere that would require me to stand in line. The book Healing Back Pain by John Sarno, which is basically the talking therapy you mentioned, was hugely transformative for me. I was able to stop fixating on the pain and focus on strength training knowing that flare up were no big deal. I'm recovered now and regularly skateboarding and standing in line again.

Edit: I should mention I spent upwards of an hour each day for those years doing physical therapy rehab. I turned down recommendations of surgery during that time as well.

I think there is evidence that people's attitudes toward pain can affect both the amount of pain that they feel and how much they suffer from it, and more generally that there are mental skills related to pain management and experience that are genuinely useful. (Also, there are cases where classic psychotherapy or psychoanalysis methods led to an alleviation or complete disappearance of somatic pain symptoms, even without focusing at all on the symptoms or pain themselves... although it doesn't seem ethically appropriate to somehow assume that that would be the best treatment for everyone.)

I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area.

I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.

> "all the pain people experience is in their heads"

The funny thing about this one is that it is literally true, and not easily actionable.

I remember reading during my neuroscience MSc that there are two distinct areas in the brain activated during pain, one which is to do with the feeling of pain, and the other which is to do with the mental anguish caused by that pain. It makes sense to me that there are non-medical ways of diminishing the anguish aspect of pain (although of course whether something "makes sense" doesn't automatically mean it's true). It also matches the different psychological responses to pain of soldiers in battle, where the pain is not as intrusive, vs a sportsperson who's injured during a game and who's in an otherwise safe space where they can ruminate about what the injury means for their career.

The easiest "psychological technique" in this case is to simply understand the pain is likely not caused by any obvious identifiable physical cause. Just have people go through all the information. Pain usually signals something's wrong. Once you truly understand there's no basis for that pain, you will process it in a different way.

Many reports of chronic pain completely going away just by reading. Psychotherapy sounds like a much less efficient way with potential to create new problems.

There’s an enormous mental aspect to pain. As an extreme example, soldiers being shot may be happy getting a ticket home, even if their injury is severe.

https://theconversation.com/emotions-affect-how-pain-feels-a...:

“In 1943 and 1944, Beecher, who was described by friends as a street fighter in the field of medicine, travelled to the Venafro and Cassino fronts in Italy, where he questioned 215 seriously wounded men who were waiting on the beachfront to be evacuated by boat to hospital. He concluded that the anecdotal evidence was correct: there was no necessary correlation between the seriousness of any wound and men’s expressions of suffering. In fact, three-quarters of wounded soldiers claimed that they weren’t experiencing significant pain and didn’t ask for pain relief, even when offered it.

[…]

In contrast, suffering a similar kind of injury in civilian contexts (a car crash, for example) was excruciatingly painful because it heralded “the beginning of disaster”. Beecher confirmed anecdotal evidence that being wounded was viewed as good luck: wounds enabled men to escape “this hell with nothing more perhaps than the loss of half a foot”, as one World War I soldier put it. Emotions and expectations affected physiological sensations.“

Also, I think we should educate people that, if an expert says “we can’t find anything physical, so I think it’s in your head” doesn’t mean you put it there, or that you should be able to take it out without any help and, hence you’re to be blamed for it.

(I also think we should educate doctors to tell patients that “we can’t find” doesn’t mean “there isn’t”)

You don't need to go to war and study soldiers to observe this very human phenomenon. You just have to be around young children for a short while.

Kids will run and tumble and bonk their heads and get up laughing. Then they'll catch their finger and look at it: if it looks fine, they carry on but of they see a drop of blood, suddenly they're in mortal pain and the end times are nigh as they scream in agony.

I don't think people grow out of that. The stakes just change as they get older.

Good example, but I think the military example better shows how enormous the mental aspect is.

For kids, one could argue that they still have to learn what pain is, just as they have to learn what it is to be physically tired (go on a walk with them until they say they’re too tired to make another step. At that moment, point out there’s an ice cream vendor or a playground a kilometer away, and be amazed).

Kids sometimes also (consciously or unconsciously) play the tired/injured card just to get attention (that probably applies to some grown ups, too)

I don't think there are any doctors, except perhaps a handful of cranks, who believe that opioids are "a placebo". Perhaps you mean something else? There are definitely doctors who underprescribe pain medications to certain groups of people - as I understand it, women are notably underprescribed pain medications for example - but that doesn't mean that those people think opioids are a "placebo".

This really isn't true. (Source: I'm a psychiatrist who treats some forms of chronic pain, while also treating people with opioid use disorder who started with prescription pills).

Good psychotherapy for chronic pain explicitly acknowledges that pain is real and not just in the patient's head. Chronic pain is thought (at a grossly oversimplified level) to be due to nerve sensitization rather than acute trauma, but experience, co-morbid health problems, and life stressors all interact to influence this.

Psychotherapy for chronic pain helps people identify maladaptive behaviors that could be worsening chronic pain, and then help to set goals and learn skills to improve their overall function. On average, it's only modestly effective, but it's better than many alternatives.

Some people might say that opioids are a placebo. A more nuanced statement would be that most trials can't distinguish between opioids and placebo for chronic pain. That doesn't necessarily mean they don't work for an individual, it just means that it's an intervention based upon low-quality evidence. On the other hand, opioids come with significant (and occasionally catastrophic) risks, and so the decision to pursue a high-risk/low-benefit treatment is discouraged. There are always exceptions, but I've been really pleased with the results I've seen as we've moved further away from opioids for chronic non-cancer pain.

What does it mean for pain to be "real" vs experienced in one's head? I don't think this is an easy question, which is why our medical system struggles to deal with chronic pain.

And what if suffering does actually promote noble and virtuous thoughts? You left the most influential thought in the western tradition unexamined.

From experience suffering, in any form, certainly enhances the idea of the golden rule, that is ‘Treat others as you would like others to treat you’.

There are actually many many people who have overcome chronic pain through mindbody methods when nothing else worked. Look up Dr. John Sarno.

Also, all pain even acute is literally 'in your head'

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