AN INTERVIEW WITH
DR. BETH DARNALL

Dr. Beth Darnall is a clinical associate professor in the Division of Pain Medicine at Stanford University, a principal investigator conducting pain psychology research funded by the National Institute of Health, and a licensed clinical psychologist. Dr. Darnall’s work focuses on understanding mechanisms of pain catastrophizing in individuals with chronic pain, and she has developed an innovative single-session pain catastrophizing class with the NIH National Center for Complementary and Integrative Health. Dr. Darnall is also the author of Less Pain, Fewer Pills (2012), as well as The Opioid Free Pain Relief Kit (2016). Both works focus on non-pharmacological chronic pain management and treatment options. Dr. Darnall is currently the co-chair of the Pain Psychology Task Force at the American Academy of Pain Medicine, and in 2015 received a Presidential Commendation from AAPM. I recently spoke with Dr. Darnall to discuss the experiences that have informed her approach to pain management and her commitment to broadening understanding of and access to low-cost pain care.

INTERVIEW BY CHLOE WALKER
Chloe Walker is a writer and editor living in Brooklyn, NY. Her work explores the aspects of human thought and feeling that we all share, amidst the increasingly wide spectrum of experiences, identities, and ideologies we might embody. Chloe believes that art, writing, and unlikely animal friendships play an immeasurable role in fostering empathy and kindness, and little could be more valuable in this modern world of complex ills.
Photos By Ian Mackey
Featuring Beth Darnall
An Interview with Dr. Beth Darnall

Hi Dr. Darnall, thanks for chatting with me today. I’d like to start by asking about your path to this career. What first had you interested in pain management?

Well, I had my own chronic pain experience early in life and up until young adulthood. So, you know, it’s funny. I’d like to tell you that my own experience was a clear trajectory getting into pain management, but it really wasn’t. But I have chronic pain myself, I was a patient, and I moved through the medical system with many difficulties as a patient. There were no clear answers and I underwent treatment that wasn’t helpful.

Later in life, I was getting my doctoral degree in psychology and working with veterans in my clinical internship. And veterans have a lot of chronic pain – they have a lot of depression, substance use issues, post-traumatic stress disorder, chronic pain – that’s sort of the constellation that you’re working with. And I found that I really enjoyed working with this population and connected very well with them.

That really informed me going forward to get a postdoctoral fellowship at Johns Hopkins University where I was working with individuals suffering chronic pain, with a focus on people with catastrophic burns, new amputations, chronic pain related to amputations and catastrophic burns, and also spinal cord injuries. So these were individuals experience massive life changes along with chronic pain and a lot of other comorbidities. And, you know, most people would think this was a particularly difficult space to work in, but I just found I really connected well with individuals who were experiencing pain, loss, and suffering.

I REALLY CONNECTED WELL WITH INDIVIDUALS WHO WERE EXPERIENCING
PAIN, LOSS, AND SUFFERING.

And what I discovered was that people responded well to me. That really made it clear that it was a mutually beneficial relationship – it was helpful for me to serve and people were receptive to my service. So I knew I wanted to go into pain and that’s really the story. I’ve been working exclusively with chronic pain for about 15 years now.

That’s such a fascinating genesis story and touches on one aspect of treatment EndPain as an organization spends a lot of time considering, which is the personal relationship between doctors and patients and how valuable that aspect can be in treatment and recovery. So it’s really interesting that you bring up the positive dynamic you experienced early on between yourself and your patients. Do you think the positive response you received from your patients and being able to develop this connection with your patients contributed to your pursuit of this area?

Oh, absolutely. No question about it. I believe that one of the things that was most beneficial to me in pursuing this and how people respond to me is my history. I come at this from the perspective of having a doctoral degree, having a lot of training in a postdoc, I’m a researcher, I have NIH grants. You know, there’s all of this stuff that gives me credibility, but I continue to feel that one of my most valuable assets is my prior experience as a patient. “Mismanaged” is kind of a strong word… but my pain was treated purely from a biological, physiological basis and that was to my detriment. That did not serve me well and I also had bad interactions with the medical system.

So what’s unique for me is that I come at it from both sides: as a clinician, but also really carrying the patient perspective and understanding what that’s like and the frustrations of not getting answers and feeling like things aren’t moving forward.

I CAN CONNECT WITH PATIENTS ON A DEEP LEVEL BECAUSE I’VE BEEN THERE.

I can connect with patients on a deep level because I’ve been there. So when I’m working with an individual, you know, I may work at an institution, but I am really serving that individual. That is my singular goal. And I think that that probably comes through. I’m on their side, I’m working for them, I am hired as a consultant to serve them. That’s really the perspective that I bring to my clinical care.

This seems like something there is a greater and greater demand for within the patient community. One field of study close to EndPain’s goals is narrative medicine, which is really trying to create a coursework around exactly what we’re talking about. It’s an attempt to train practitioners to engage in an empathetic relationship with their patients, but of course you come by it through your own life experience.

I’m not surprised that that’s a new effort — you know, it’s just really needed. I hear this kind of feedback from patients all the time. They’ll just say to me that they feel safe, they feel that they can open up to me in a way they haven’t before. I think they feel heard, I think they feel supported, and it just helps as a practitioner to have had that experience. It’s not that other providers don’t have the capacity, but if you haven’t suffered similarly, or perhaps now had the training, it might be something of a barrier in treatment.

Absolutely. One aspect of this dissatisfying doctor-patient relationship that you hear about from your patients seems to beget a comorbidity that you focus on in your research – pain catastrophizing. For our readers who may not be familiar with the term, pain catastrophizing reflects excessively negative thoughts and feelings about one’s pain, a feeling of helplessness, and the sense that nothing will ever relieve their pain. Pain catastrophizing often increases an individual’s experience of pain, and it’s a condition that will likely sound familiar to many with chronic pain, who can easily lack optimism about future treatments, after having undergone any number of unsuccessful treatments. Do you feel that there has been an increase in pain catastrophizing among patients?

Well, pain catastrophizing has been around the whole time. We’ve been really characterizing it well for the past quarter-century or so, but it’s more in the forefront of consciousness and even simply in conversation about pain. Specifically, because the evidence has accumulated that really shows how powerful this psychological construct is in determining our outcomes. So I think that there’s an increased appreciation for it and an increased measurement of it. I don’t think it’s necessarily getting worse, although perhaps now with the over-focus on opioids in recent years and the stress around that now as opioids are being taken away, and people having barriers to medical care. Possibly people have more to catastrophize these days given financial issues or other environmental factors, but at its core that would just be a product of sort of increased stressors.

There is a lot of [lack of optimism] when I see patients and they’ve just been worn down by the medical system and they’ve tried everything and it hasn’t worked. And one of the roles that I play, and it’s an important role, is just talking with people with chronic pain and instilling some optimism and hope, because no matter what has happened in their treatments, there is so much that we can do ourselves to increase our control over our experience.

THERE IS SO MUCH THAT WE CAN DO OURSELVES TO INCREASE OUR CONTROL over our experience.

It’s not going to cure our chronic pain. It’s not going to take away our medical diagnoses, but we can reduce our own suffering. We can start to get a handle on that experience that we have. We’re better able to self-regulate our thinking, our emotions, the level of stress, the impact of stress. And that translates into being able to modulate actual pain intensity in the long run once we’re using these types of skills and really living this program.

And I think that’s a really exciting, hopeful message for people to hear. Because when we’re just sitting and waiting, pinning all of our hope on the next drug, on the next thing, it’s an externalization and you can feel at the mercy of external things. That’s a passive place to be and it can be anxiety-provoking. And if you had the experience of getting your hopes up eight different times and trying eight different medications and none of them having helped, it’s really demoralizing. It’s easy for people to get into a place of just feeling like this is it, “I’m left with this.”

And so they’re in a negative psychological state based on their experience. And it’s understandable that anyone would feel that way. Those are true experiences. That’s reality. You’ve tried eight medications. They didn’t change a thing. Here we are. But in spite of that, now let’s talk about what you can do to start getting control over your experience, to start moving forward with a better quality of life even with this chronic pain condition. For so many individuals with chronic pain, that’s groundbreaking. It’s a complete shift in perspective and it’s exciting; there’s hope. They just start to shift out of this over-focus on the medical system and, you know, they’re still going to their medical appointments, and still probably going to try the ninth medication, but that’s not the point. They’re not at the mercy of the system, feeling like they’re being experimented on. Rather, the day-to-day focus shifts to learning and applying these skills, this information to help, to actually start to rewire their own nervous system so that the condition that they have is less impactful.

You’ve described “maximizing the mind-body connection” as a cornerstone of your approach to pain management, and as a broad term this could mean so many things. Many of our readers have active spiritual or meditative practices, which help them deal with all manner of pain. When you talk about pain management tools that harness the mind-body connection, what are you referring to?

I’m coming at it from the philosophy that the brain and the spinal cord – the nervous system as a whole – modulate experience of sensory perception, of pain, of distress. And so it’s all about determining how we can calm the nervous system. And if we can do that, we have a completely different experience in our body. We change the way we feel psychologically, we change the way we feel physically. And so that really is the mind-body experience.

How do we harness that control? How do we get it working for us instead of against us? Because pain is such a powerful trigger that brings up all kinds of negative responses and primes us to have more pain. Well, there are things that we can do, techniques we can use to start, and over time it actually leads to rewiring.

THERE ARE THINGS THAT WE CAN DO, TECHNIQUES WE CAN USE TO START, AND OVER TIME IT ACTUALLY LEADS TO REWIRING.

We see physical, structural changes in the nervous system that result from using these skills over time. And I’m talking simple skills that anyone can develop—cognitive behavioral techniques, diaphragmatic breathing, affecting the relaxation response. It’s powerful mind-body medicine when used regularly over time.

These simple techniques can help us gain more and more control over that process so that we are better able to modulate stress, pain, hyperarousal, tension — all of the things that feed into the pain and the experience of pain and the experience of suffering. So a lot of what I do is provide education about how this all fits together and how to gain control over one’s nervous system, one’s responses to pain, one’s responses to life and why that matters, especially if you have pain. Ultimately, one of my key messages is that you’re participating with your pain. Whether you know it or not, you are.

It sounds like you’re harnessing the power of empowering individuals. What in your life or medical experience has led you to this approach and moved away from opioid-based treatment of pain?

Well, it was my clinic and it was my personal experience. So when I went to Oregon Health and Science University and I was working with individuals with chronic pain, patients were coming to me saying, “Why was I prescribed this? I wish they never started me on this medication.” They were having a lot of problems. In dealing with their other doctors, these patients felt that they were not given adequate information on the risks, not being monitored, and not given alternatives. Over and over again I was working with individuals who were having problems with opioids, and helping them to get off the medication because they wanted to. They were asking for alternatives. They would tell me, “Nobody offered me anything else.”

It got to the point where I realized I can’t just work with people one-on-one – I have to write books on this because there are just too many people who want this information. When you look online, some of the most vocal voices in chronic pain are saying, “Don’t take away our opioids. Don’t take away our opioids.” And, look, I’m not here to do that at all. I am not invested at all in whether somebody takes opioids or not. I am incredibly invested in patients being able to make informed choices about whether they start them or not.

And this historically has not been the case. Patients were told that opioids were completely safe, non-addictive, low-risk – and that did not pan out. Patients were given false information and it was tragic. I was in the trenches working with those people to help them, trying to clean up the mess. So I wrote Less Pain, Fewer Pills to give people a huge heads-up. I wanted to say, “Listen, if you’re thinking about this, here’s what you need to know. And if you’re on [opioids] already, here’s what you need to know. And if you want an alternative, here’s what you need to know. And even if you want to stay on them, that’s okay. Stay on them, but here’s what you need to know to minimize your reliance on them because they can’t be the total story, they just can’t.” I want to help patients make informed choices about opioids whether they take them or not, how to minimize their risks, and how to really optimize what we know to be evidence-based medicine, which is comprehensive pain care.

FOR ME, IT’S REALLY MORE ABOUT GETTING PEOPLE THE INFORMATION THEY NEED TO MAKE THE BEST CHOICES.

For me, it’s really more about getting people the information they need to make the best choices. That’s really where I come from. I don’t judge people who decide to be on them. Some people do well on them. I’m actually against draconian rules that are binary, that just say, no, you should never. They can be one part of a pain care plan for some people, but we have to extend the focus and really be practicing evidence-based medicine. I think what we really need are more pathways available for patients to consider and also the encouragement to choose their own path. Patients are not systematically offered that.

The idea of opening up pathways is so near and dear to EndPain’s mission – to increase awareness of the many options individuals have as they experience a painful situation.

Right, and you opened up by asking me, well, how did you go down this pathway? Almost everything that I have done has been informed by my patients’ needs. Just the onslaught of patients coming to me and saying, “Nobody told me about this.” And I started to think, “Okay, this has got to change. People have to have resources to know up front what they’re getting into when they make pain care choices.” So that’s why I wrote my first book.

I really feel it’s incumbent upon us in the medical field and in treatment to give people options to exercise control and have choice. And, you know, that’s really been missing. I feel like it’s just beginning to change. It sounds like your site will help make some of these topics, these pathways and options clearer for people too.

We certainly hope to be a forum to explore different pathways, though of course we can’t replace medical treatment. One thing you have discussed very explicitly which is also parallel to our goals is to broaden low-cost access to pain care. What role do you feel the medical community can play in democratizing this access and what drives you to develop these low-cost treatments?

You know, that’s a really interesting question. Some people say that we have an opioid epidemic; I mean, that’s definitely a term that’s tossed out there and people who use that term will often say there’s a human right to be pain-free. And I don’t personally believe that there is a human right to be pain-free. I do believe that there is a human right to have access to pain education and all of this information. That should be made freely available. I feel passionately strong about that.

Everything that we’re talking about, the options that are available, the ways to approach them, where to learn more, how to get treatments, the classes I teach, these books, these resources, all of that should be freely available online or elsewhere. My fantasy is that in the future everyone has access to all of this freely, and then when someone comes to a pain specialist, at that point the doctor’s role should be more like, “Okay, so you read this book, you watched this video, you learned all of this. What are the specific barriers that you are having now in implementing this information?” So it’s really, more precisely, individualized pain care at that level.

THE WHOLE SYSTEM NEEDS TO BECOME OPTIMIZED AND MORE EFFICIENT.

The whole system needs to become optimized and more efficient. And the way that we do that is we start making these education and treatment resources freely available or as free as possible. You know, there’s operating costs, or we have to print the books, so you have to cover that. But really thin margins to get all of the information out there so that cost should really never be a barrier, almost never. And if it is, then for those individuals we need to find options to make it free, through scholarships or other options.

That’s really the philosophy that I work from – if everyone has access to this, they’re empowered to optimize themselves. I, of course, recognize, we’re human and we have our own barriers and we have our own circumstances that are unique. And that’s when the specialist comes in and really helps with the individual specifics. But we’re not starting from the ground up with every single person because they already have that for free.

It seems like this approach would give doctors more time to consider the individual aspects of a patient and patients would feel more collaborative in the diagnoses process.

Exactly, exactly! It would be much more efficient care. If the majority of Americans would have access to basic pain care, well, then the physicians and specialists would be better utilized as specialists. And from the patient perspective, I just keep coming back to that over and over again. When I hear a patient say, “Nobody ever told me,” well, that’s just got to change! We really need more education so patients can make informed choices.

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