Richard Bronson’s back pain is so sharp that the 58-year-old borrows his mother’s walker for long strolls, floats for hours in the local YMCA pool and takes a modest dose of opioid painkillers at morning and night to cope.
“They take the edge off a little bit,” he said, “kind of like your second beer. … You get that little buzz.”
Bronson could easily find a doctor to up the dosage and numb the pain that has hijacked his life. But he fears the addictive opioids as much as the pain they blunt.
So instead, he receives an array of care at a unique HealthPartners clinic in Coon Rapids that stands at the forefront of a movement to reduce the nation’s dependency on prescription opioids — an epidemic that is killing more than 15,000 Americans each year.
The year-old clinic takes a sum-of-its-parts approach — chipping away at patients’ pain with everything from medication and standard neurology to physical therapy to psychology to massage to self-hypnosis — with the belief that pain and opioid dependence can be reduced simultaneously.
“The secret … is treating people like they’re people and not treating them like they’re a bad joint or … a pinched nerve,” said Dr. Alfred Clavel, the neurologist who launched the clinic.
Studying its first cohort of 23 patients, the clinic found a high washout rate — often patients who were just looking for opioid prescriptions or who balked at all the copays for office visits required by this intensive approach. But 14 patients stuck with strategy, and nine reported reductions in their pain and opioid consumption, Clavel said.
In a country that consumes 80 percent of the world’s prescription opioids, Minnesota’s prescribing rate is relatively low. Yet addictions to legal opioids and illicit heroin are on the rise, along with fatal overdoses; opioid-related deaths in Minnesota rose from 54 in 2000 to 317 in 2014.
Just this month, the U.S. Centers for Disease Control and Prevention published new opioid prescribing guidelines — recommending the lowest effective doses for acute pain or immediate recovery from an injury or surgery, but nonopioids for chronic pain. A state opioid prescribing task force has reached similar conclusions in initial meetings.
Trouble is, pain clinics that provide a broad range of treatments — known as interdisciplinary clinics — are sparse. The United States had more than 1,000 of them in 1995, but a decline that coincided with the explosion of opioid prescriptions has left just 150, according to a report University of Minnesota researchers produced for the U.S. Agency for Healthcare Research and Quality.
Opioids are dismal at treating chronic pain, because they just mask the underlying problems, but alternatives have been unpopular because they don’t offer the quick fix that some patients expect in the era of modern consumerism, said Dr. Chris Johnson, an ER doctor on Minnesota’s prescribing task force.
Johnson also serves on the Institute for Clinical Systems Improvement in Bloomington, which is drafting guidance for doctors and insurers that he said will likely promote a holistic approach.
“Since pain is first and foremost an emotional experience,” he said, “techniques that help put a patient in a better frame of mind help to reduce the experience of suffering.”
Couldn’t wash his hands
One day last week, Bronson grimaced on a table at the HealthPartners clinic, where physical therapist Scott Darling stretched his legs and taught him how to breathe and release tension in his back at the same time.
“Keep breathing, don’t go too far, don’t push,” Darling said.
“I feel the stretch!” Bronson replied through grunts.
Bronson’s back problems came from decades working as a machinist, crafting parts for oil and gas drilling. When he found himself unable to bend over without pain to wash his hands at a sink, he reluctantly retired in 2014.
At one point, he took twice as many painkillers as he does today and found it easier to get out of the house for dinners with his children and other events. But masking the pain didn’t yield the improvement that Bronson wanted. So he started taking a lower dose — living with more pain and losing some mobility at first — so he could identify the contributors to his pain and work to reduce them.
“You become dependent on them,” Darling told him, “and you don’t depend on yourself for pain management.”
Strengthening leg muscles to take pressure off Bronson’s back has helped, along with breathing and relaxation techniques that reduce the back muscles’ instinctive response to tighten up.
Clinic psychologist Georgia Panopoulos takes a similar approach. Unless patients can identify their pain, she said, she can’t teach them coping strategies. She has implored doctors to cut opioids back when patients come to her office numb.
“Unless I get a certain amount of distress from the patient,” she said, “I’m not going to be able to do my job.”
Throw it off a cliff
Carol Johnson has embraced this approach to get relief from fibromyalgia, an incurable condition marked by pain and fatigue. Using one technique at home, she sat still and imagined the shooting pain in her arm to be a little person in a chair. As the psychologist instructed, Johnson imagined putting the person in a box and throwing it off a cliff.
“And it was gone!” Johnson said. “I almost made it through a migraine doing that as well.”
Johnson’s pain had reached a point that she had opioid medication in her body continuously, and her husband was pricing flights to Denver to get medical marijuana. Today, the opioids sit unused.
“When I’m not on them I am more upbeat,” she said. “I used to feel fuzzy; it was like I couldn’t quite get things together … and I was beginning to wonder if I had dementia.”
Clavel and other doctors worry that the current backlash against opioids could cause guilt and stress for patients who rely on them. Clavel said opioids have a legitimate place in medicine, especially for patients suffering short-term pain caused by injuries or procedures.
But overuse has consequences; an estimated 80 percent of heroin users started out taking prescription opioids for medical or recreational use. A recent study found rising death rates for white, middle-aged Americans and pinned it partly to widespread opioid usage.
Bronson is determined to wean himself off the drugs and tries meditation when his pain flares — concentrating on a sandy beach or the garage where he and his sons are restoring a 1960 Mercury Comet.
But as Darling tells him, “motion is lotion.” So despite his limited mobility, he exercises to keep down the weight that could put more pressure on his back. He sneaks exercise into everyday life. Doing the dishes, he puts one hand on the kitchen counter and leans forward on one leg to grab a dish. Floating in the pool brings comfort, but Bronson also joins “the ladies” in the water who dance to 1950s classics.
“I know I have to deal with pain,” he said.