Chronic pain. It’s one of those terms that you hear about, but you don’t’ know too much about—or you know all about it and you’re definitely in need of relief. Dr. Trevor Campbell, author of The Language of Pain, is going to explain to us what chronic pain is and how to reduce your suffering without being focused on drugs or expensive pain management programs. Here is our conversation with Dr. Trevor Campbell.
Dr. Trevor Campbell: As a kid in school, I did pretty well. But my focus was on languages and literature, you know? Two European languages—Latin, and then I did German later because it came easy to me and I really enjoyed it. That was my first focus at school.
In the end, I chose medicine.
It was only years later that I realized that the basis of both were in the same thing, which was intense interest in people.
While some people say they became a doctor because they had a love of science or they had the humanitarian sort of drive. I have to say, I was just very interested in people. I think it’s the endless variety of thinking patterns and behavior patterns one witnesses on a daily basis.
Thirty-eight years later in medicine, I still find that fascinating. It was a good choice.
I go to medical school, I qualify around about ’81, and at that time, the feeling was okay, you know, after two years in the hospital, doing various jobs, you go out and do what’s called nuts and bolts. General practice we called it inside Africa and the UK and other countries, but it’s called family practice here.
I applied for a job at a very high-profile practice, with really experienced doctors.
To my dismay, I get the job, they take me in. I’m delivering babies, I’m doing senior care homes, I’m doing all that sort of stuff, right?
I get to see some of the other doctor’s overflow, very successful, patients don’t mind seeing me and I’m building up a practice slowly, and then something very strange happens. I see that these patients seek me out for certain things. This is with their doctor’s blessing, even though the doctor’s not on holiday and so forth.
It’s kind of awkward, but I sorted it out with the doctors, they’re very happy. That’s nearly always a psychological problem or existential crisis, and I’m thinking, “Why would you come to t the youngest guy relatively speaking, way less than everyone else?” Obviously, hasn’t had a great deal of life experience.
Now, I have to tell you that at that stage, the fee for cancelling was lower. I mean, you counsel anyway in medicine, it’s naive to think you won’t. You will, in each clinical encounter. But it doesn’t pay every much, and a lot of doctors don’t seek it out. They feel that primarily, physicians are not psychologists, and if somebody wants to do that for the patient, that’s fine.
One day, I asked one specific patient, “Now, your doctor’s here, you like the guy and huge respect. Why would you come to me with this issue?”
He looked me straight back—and this is South Africa where people shoot from the hip, more extroverted—“Because you have the face that says tell me about it.”
What? What’s wrong with my face?
You know, only later do I realize that it probably was based on active listening because I am interested in people, right? Anyway, eventually I accept it and I think well, you know, if people are seeing this, maybe I shouldn’t run away from it. I do it and I learn a ton about life, about medicine. I kind of use literature to describe scenarios related to the predicament they’re in, and then they have these choices and they get insights from them.
It does two things: it removes the problem from right in front of their face, then it basically just makes it easier to get perspective. It’s not such a tender thing to talk about.
So that’s what I end up doing, and I call it “painted in the corner syndrome.”
Mid-40s, I’ve got all these blessings that should be counted, but why am I so unhappy?
It was successful. I kind of was drawn into this, or dragged in if you like. This followed me, even when I came to Canada. My medical officer assistant at that time, she saw my initials, she said, “TCC, what does the C for?” That’s my middle name, Clyde.
I said to her, “It’s called Dr. Trevor Cathartic Campbell,” which was amusing to me. She didn’t know what I was talking about. Obviously, I tried to explain the joke. I guess you had to be there.
Just the short time in another country, and that same thing happens. Maybe I have to accept that I have got the face that says tell me about it. They never mentioned that in medical school, interestingly.
Eventually in Canada, I became very interested in chronic pain, which is a mystery with all sorts of theories. It’s a very vague but rewarding area of medicine. Of course, I see the type of communication required for this sort of thing. Although the learning curve is steep and the work’s really hard, I do feel like I’ve come “home.”
It’s almost like what I was made to do.
The counseling finds me, the pain finds me, and since too much, I’m obviously not the greatest planner or something. You know, that’s what happened. It reminds me of Joseph Campbell, whom I started reading at university.
You know, follow your bliss, things look after themselves. I think that is very powerful. He also says, I think it’s he that said those who stood on a cliff, those who jumped all grew wings, but the ones who were waiting for the wings to grow had to stay on the cliff.
Anyway, that’s how I make sense of it.
On Chronic Pain
Rae Williams: Could you talk a little bit more about what chronic pain actually is?
Dr. Trevor Campbell: Most people have no idea what’s going on. That is part of the problem because how can you present someone with the treatment plan or of quite a bit of due diligence and get their buy in if they really don’t understand A, what is going on, and B, why they should do this to counter whatever it is that’s going on.
That’s the one problem.
The other problem, and the reason that persists is because the training at undergraduate level and even currently physician level, where studies have shown that doctors are actually uncomfortable dealing with chronic pain and say so because of their training. The other thing is that the medical model and Canada is obviously different from the States, but in Canada basically now, if you’re at a walk-in clinic, you get 10 minutes with the physician in your own practice. You may get 15 minutes, and occasionally they’ll double that up as a double consult.
But the current medical model almost, in my view, precludes the satisfactory treatment of chronic pain. There’s a lot of information to convey, there’s a lot of skills to be taught and objections to be handled from the side of the patient, and then of course, repeat, repeat, repeat because these are entrenched behaviors.
You cannot do it once or twice. You’re going to do it several times.
It doesn’t get managed. Now, I happen to lecture physicians and residents, these are people who going to do general practice. But in a two year residency, I don’t think based on the knowledge we have that it’s being adequately dealt with by the universities. I remember my own university, we were more likely to get a question on something that interested the professors than something we would see very often.
Maybe it’s a bit of that, I don’t know. The doctors aren’t really trained. Their training has not increased much from what I can see, regarding chronic pain. It doesn’t nearly match what we already know. I think that’s something that really needs correction.
The other thing is that for any pain treatment to be successful, it has to be approached in the biopsychosocial model. Now, this is a word that intimidates patients when they first hear it. All it is—normally, if you have acute pneumonia, you can approach that biomedically. You can make the diagnosis, you can do the X-rays, take the cultures, get the appropriate antibiotic, give them right support of treatment, and they do well. That’s a biomedical approach.
With chronic pain, you’ve got biopsychosocial. It’s very much a disease that is worsened, prolonged, sometimes even instigated by psychological and social factors. We have a biopsychosocial treatment. Because it’s covering three disciplines, obviously.
It’s not one thing that’s going to save the day. It has to be multimodal.
You’ve really got to address the problem at all three levels in some way—or preferably, ways.
In fact, based on what I’ve seen, my knowledge is mostly learned in the trenches. I’m not academic as such. I am not a researcher as such. I am seeing how people behave, and it’s consistent. I’m making sense of that. Most of my work has been done in pain management programs, which are multidisciplinary and involve psychologists, occupational therapists, physiotherapists, pharmacologists or pharmacists and so on.
I would even say that some patients I’ve seen, I would call the illness socio, psycho, biomedical in that order. It’s hard to do all this work at a medical encounter in a normally structured medical practice.
Now, in Africa, there’s a saying that it takes a village to raise a kid. One gets the feeling that it actually takes a team to treat a person in chronic pain.
On the positive side, this can be handled if the patient can be prepared by knowing the meaning, being coached through acceptance and all of this. That was the reason for all these other factors, the reason for writing the book.
I had wanted something where the patient could read it or the caregiver as well and then absorb the information and be ready to be treated at general practitioner or family practitioner level.
The other thing is that because you’re juggling issues in so many fronts, to impart this vast amount of knowledge and information you have to use metaphors as well as analogies because these tend to fast track learning and increase what’s called these days, stickability. It remains in their head, right?
Because otherwise, it’s overwhelming.
We have to remember that with chronic pain, the outstanding feature is low energy. Often, these people have other pathologies like they are deconditioned, they have the pressure often, anxiety, sleep dysregulation. You are dealing with a person that really doesn’t have a lot of maneuverability from the point of view of learning new things.
I’m very pleased that most of the information could be conveyed in an understandable form. As I say, while the treatment of family practitioners remains at the current level and while our models of delivery don’t change that much, it’s not going to be well handled. It is a shame, because in North America, about 20, 25% of the population have chronic pain.
We also deal with opioid addiction, and I can tell you that part of the problem has been it’s much easier to give a prescription than to go through this tag of war. It wasn’t missing information on the product, but there was also this ease of a prescription and the expectation, there was a time that you could be sued if you were undertreating pain in certain countries.
Things are so connected.
A Different Approach
Rae Williams: What is it that you do or recommend or can tell people to take action on that’s different to treat chronic pain rather than just prescribing opioids?
Dr. Trevor Campbell: A lot of the latest research, if you look at pain scales that go from zero to 10, with 10 is the worst pain imaginable and zero is no pain at all or normality, women often say that men don’t know what the worst pain of all is. We have that conundrum, but the real issue is that these scales we rely on are subjective.
I have had a truck driver who is really having a bad day saying, “You want my pain level? It’s about 400 out of 10, you happy now?”
The pain itself depends on your mental state, whether you slept particularly badly or not last night—a whole list of reasons. We know that there are modulators, which are like volume knobs.
Think of modulators as volume knobs that can ramp up the pain and de-ramp it, or soften the pain.
For example, you have severe pain and then you get a call from some family member who is really demanding and entitled. They bend your ear for 10 minutes and you can feel that pain almost go up. It’s because of the state that you find yourself in. Lack of sleep can do it, financial difficulty—and remember a lot of people with chronic pain are not working or they’re working half time and they really have these stresses.
Now, the opioids, it’s been shown recently that if you look at scores, the best results with opioids is they reduce pain by one unit. For example, the idea is if the group on average had an average of eight pain scale, it will go to seven, which is not that much. That’s the type of change we would expect to see for something like acetaminophen.
Now that opioids are being clamped down on, certainly in Canada and North America, I don’t know about the whole world, we see a renewed interest in cannabis which is another issue completely. With all this interest in cannabis, at best, it only reduces pain about .5.
Now, there is some evidence that some people, having said all of that, do benefit from a trial of opioids, which means they go have some opioids. The dosage is checked on, and it’s a trial.
If their functionality is not going up, the quality of life, whatever their pain is doing, they should still be tapered off.
Opioids work incredibly well for acute pain. You break a leg, you will want opioids. It’s as simple as that. But for chronic pain, it’s because the pain has been changed and areas of the brain are affected, which at the beginning of the onset of the pain, were not involved.
Neuroplasticity is how pain is caused. The brain has the ability to change. We learn a new language, our brain changes. We over time forget a language, our brain changes. With chronic pain, certain changes are made and they kind of extend to an area of the brain called the prefrontal cortex, where it’s tied with memory and emotion.
Then, this alarm signal becomes extended and can be triggered by all sorts of emotional issues, memories. We know that chronic pain is very often in women linked to abuse issues, physical abuse. Opioids were a quick fix, but it was also based on misinformation.
It was presented as something that’s just low risk and so forth. Obviously, we’ve had opioid from overdose. People talk about the opioid crisis, currently an illegal fentanyl crisis, where there’s contaminated drugs. But the prescription crisis is this long-standing issue which started around sometime in the early ‘90s where people were just given opioids for chronic pain.
That’s where we’re at. My view is that for long term chronic pain, we call it non cancer chronic pain, opioids are not indicated for the most part.
On The Language of Pain
Rae Williams: What unique idea or story from your book that listeners can take action on or just use to help themselves figure out their way through chronic pain?
Dr. Trevor Campbell: What I say in my book is that the treatment of pain is often underwhelming when you hear it. You think, “so what?” That is like kitchen table advice, and it does save the day.
I thought very carefully about this for a long time since completing the first draft, and this is going to sound very strange because we have a history of campaigns.
We’re going to fight cancer and we are going to fight addictions and we’ll fight poverty. We fight illiteracy, we’re fighting everything right? So, we fight chronic disease, addictions.
I don’t like the term fight.
For chronic pain, I certainly don’t like it because when you fight it means something very specific to anyone. I would imagine in any culture, you are getting ready for battle. Now that’s your sympathetic autonomic nervous system.
Flight or fight, most people have heard about it. It is great if you are being chased by the saber tooth tiger, you can perhaps get away, or if something or somebody that you don’t know is coming rushing with you with a sharp object. But this is unfortunately, or maybe fortunately, an environment that almost precludes, rules out recovery.
I am trying to get them out of sympathetic mode because sympathetic mode is essential for your survival, but very short periods of it.
We know that westerners and western cultures, materialistic cultures, you are encouraged to basically compete. It is a battleground. The workplace is a battleground. Socially, it’s competitive. Financially it is often a struggle, even if you earn quite well. This just riles people. Any time spent on a toxic zone that is prolonged is likely to make whatever condition you have worse.
People might say, “Well okay that is not the most riveting thing I’ve ever heard,” and I would agree with them. And it’s important.
I don’t know, I just think it is such a simple add here and it goes beyond chronic pain, but specifically applies to it as well. And when we flight or fight, we must also remember that our outcomes are almost assured to be worse because our thinking is, we are on automatic pilot. Thinking gets distorted, behaviors get distorted.
For me, for example, if my neighbor really irritates me and I’m going to ask him to stop doing something, and I go knock on his door in flight or fight mode…I mean who knows what can happen?
Whereas if I go and I say, “Can we speak? This is a bit of a problem…or somewhat of a problem…or I really find this hard to live with.” It could end amicably. The other one could end with a lawsuit or violence.
I use this example because this is the way the book is also structured. It is looking at the issues that can be mopped up or dealt with by the actual patient themselves because this is their environment.
An encounter with the doctor is maybe 15, 20 minutes. What happens to the rest of the time?
One cannot simply go back and behave like one behaved before. So, I give reasons, I use illustrations, analogies to do that. I realize it is not a mind blow, it is not an epiphany, but it is important. It is sad that it is being so overlooked.
We still see all of these campaigns to fight, and immediately you reach maybe for your wallet if you’re sympathetic for that particular cause, but you’re already riled, just as donor.
The Consequences of Pain
Rae Williams: What have you seen happen when we are not addressing chronic pain in the correct way?
Dr. Trevor Campbell: I have seen people unfortunately come in late, because I saw them mostly in the pain program, which are very expensive. If they don’t have good insurance or like a worker’s compensation, a lot of people can’t fund it. It is experts and you’re there for six to eight weeks. So, you can imagine they are not inexpensive, but what can happen is that people try things and they put all their faith in it.
Whether it is acupuncture, which could be part of the solution, or biofeedback or Reiki or whatever you can think of—though it has to be multimodal. It has to be several things going on, but not everything can go on of course because it is a very broad field.
But they end up trying something putting all their faith in it and then being disappointed and eventually many of them or certainly too many of them in my view end up sofa surfing.
Eventually the spouse is dishing their food and they have a terrible life and they give up on themselves. It is kind of just, “you know what? I don’t care anymore.” And that could be avoided because when it hits them it is not only from inactivity, but they stop socializing. Now I say to people, can you imagine if you didn’t have chronic pain and you had the same lifestyle? You’re still on the sofa, you are telling your wife to tell your friends on the phone that you’re asleep because you don’t want to accept the invitation. You are not having any physical activity.
This is not a life for anybody, but it is somehow blamed only on the pain.
In the book it’s repeatedly urges people not to focus on the pain entirely. They should look towards increased functionality and increased quality of life. Make that attempt to socialize like more, make that attempt to do more. It can be as simple as your legs hurt, you can still unload the dishwasher.
Build on this and then things change.
Increased functionality, an increased quality of life are themselves positive neuromodulators for wellbeing. So, they dampen down the pain. That comes as a consequence, but if you focus on the pain, as I say as often, we drive where we are looking.
When you learn to drive, they say keep your eye on the road. And when you want to go somewhere look in that direction, not rubber necking while you are on the road. That same principle applies. I mean it might be a pedestrian, everyday metaphor, but it is true.
Success with Pain Management
Rae Williams: Do you have an example of a success story that you can share of someone that changed their life?
Dr. Trevor Campbell: I had this one lady come and see me, and she was not in the pain program, so I want to show that it can be done in a practice setting. She is 52 years old around about and she was a paralegal. She just said there is nothing at all that can be done for her pain, and all of that.
So, I said to her, “Well how do you know?”
She said she tried everything. So I said, “Well maybe the approach was wrong.” Then she said, “Well, it is fibromyalgia so that is different than any sort of pain.” Over time, I was listening actively, assuring her buy-in to what I was saying so that I could have the chance to go through everything, explaining what was going on.
She said, “Well I’ve had trigger point injections, they haven’t worked for me.” And so on and so on.
Got her to accept it, slowed her down, told her that not everything that happens in someone over 50’s body necessarily is related to their pain you know?
If blurring of vision is attested to be the pain’s fault, what then happens to people at times and get it checked out kind. The pain undoing the brain, preparing it for chronic pain, is a neuroplastic process. You can redo it.
It is a slow process, but it is not going to take you as long as it takes to develop chronic pain if you stick to it and you are diligent.
I think this was the big point for her, I said, “When it comes to chronic pain, it is not so much the variety or the subtype of chronic pain you have, but how you think and behave when the pain strikes.”
It doesn’t matter, it’s no different really if you have a crushed leg, fibromyalgia, inflamed joints—it is how you respond to it. So, in that context, she came to learn that chronic pain is like an alarm system.
When we get acute pain, that’s immediate pain. You touch the hot surface, to protect your body this is an automatic reaction involving two groups of muscles that pull it away and that inhibit the other one that keeps it there. Without knowing it, you take your hand away. It burns, and you recover. Now that is like a good home alarm. There was an intruder the house so to speak, you were warned, and you dealt with the situation.
Chronic pain is a maladaptive or sensitized alarm system.
So, now you are getting the pain alarm, the analogy being in a house, a raccoon past your door or the wind blows very strong and the alarm goes off, even though no one breached the envelop of your house. Nobody intruded.
So it is a faulty alarm system that is caused by beliefs and behaviors. When I say behaviors, this is very important. It’s not just things that the patient did unwittingly that were harmful.
It is more a case of stopping those everyday behaviors that are so important that we all do without thinking.
It is a learning process, and she went on to do very well. She went from half days to full days. She is spending way more time with her grandchildren, and there were no drugs involved, even non-opioids I am talking about.
I focus on non-pharmacological non-drug treatment. I am not saying you can’t use other substances like Gabapentin or Pregabalin drugs, because it is a multimodal approach. I am just saying there is so much that we can do by reversing what happened through behaviors and thinking.
The beauty of it is this applies not only to chronic pain, but to all chronic disease.
A Challenge from Dr. Trevor Campbell
Rae Williams: I would love for you to give our readers a challenge that they can walk away from this episode with—what is one thing they can do?
Dr. Trevor Campbell: I mentioned that my background was in literature, so whenever I see the word narrative, I don’t groan. I am all over it, right?
As I became more and more aware of the approaches for counseling, talk therapy if you like, that was immediately of interest to me. It’s used really by therapists to bring up deficiencies to patient’s previous treatments or issues they’ve had here to be dealt with. But what I soon learned in chronic pain is that it plays a really vital role.
When you have chronic pain, we construct a narrative. A narrative is just a complicated word for story. It’s the story we tell other people, physicians, interested family, interested friends and acquaintances about how we are doing and our history. So there’s usually a few versions.
A very short version, not an elevator pitch, but a short version out of a moderate/long one. People repeat this over and over because other people want to be polite and they are generally interested and so forth.
So what we forget is that every time we tell people, we are repeating it ourselves. I remember I was reading a book once and they said, if you ever remember just three Greek words, it’s the following—I have never forgotten them because the concept was so important. It translates into “character is destiny.”
There is a lot being written about how we end up depends a lot on how we approach life, things, other people. It was called, “ethos anthropos daimon,” were the three words.
What happens with narrative, I have learned—this is my observational insight—is that instead of character becoming destiny, history as related by the person suffering becomes destiny. What are we telling our bodies when we give a narrative that really mostly pertains to the milestones? The negative milestones?
We will mention that the MRI looked worse or the pain levels went up. Maybe not the MRI, but the pain levels went up or that drug didn’t work.
The analogy I use for that is can you imagine playing rugby or football and you are facing a challenging team. The coach comes into the changing room and he gives you the heartfelt plea, “I am with you guys, you’ve trained hard. You are doing well; you will do well and we are rooting for you.”
But each paragraph ends with, “even though you don’t stand one hope in hell of winning.”
I mean we torpedo ourselves by giving a narrative. I am not asking to misrepresent their narrative or edit it to the point where it doesn’t sound like their story. I am just saying be aware and be very careful. If one is in a zone too long, whether it’s sympathetic mode, a very bleak narrative, and most of the narratives I hear they are extremely bleak. Some are justifiably so, but that puts you in fight or flight just narrating it. It becomes a part of your negative internal dialogue.
The body is a complex neurochemical, physical entity with very advanced communication systems. I am not a celebrated physiologist or anything, but it would be naïve for me to believe that constant negative storytelling about oneself does not filter down to even a cellular level. It is shooting oneself in the foot.
Just be very careful. People are going to ask you. Have a narrative, but keep space for good things that happen even if they might at the beginning.
Ultimately, we become our narratives.
If you are only filtering the bleak, it’s like filtering in cognitive behavioral therapy, which is obviously a very widely used intervention as well.
I know these examples are not shattering and people often expect more. But these are the real confounders. You see this clinically because when people are able to start or when they get that aha moment, they get the insight. Remember we are talking non-pharmacological interventions and this is all going on in the background.
It’s no wonder that the medication doesn’t work that well. Any medication in chronic pain.
It sounds like it’s easy to understand, and of course when I am with a patient, I can see by tension in the mouth or the squinting or something that I have to explain more. If you haven’t heard this before, if anyone hasn’t heard this before, then it is kind of a challenge to get one’s head around it.
It is certainly not complicated or rocket science, but it is underwhelming.
It’s like life, there’s no end, there is no beginning necessarily, to the story. I am not saying to chronic pain, I am just saying where you start there is only the infinite amount of knowledge, which permeates it. I think it can be reduced into solid principles that one can literally take to the bank because they are time proven and they actually are intuitive once they’re properly explained.
People do get it. I have very few objections.
I have people in tears saying to me, “I totally get what you are saying and believe it and I have often thought that myself. I thought it is irrelevant, but the trick is still to do it.”
And I say, “Well that’s like anything, the trick to stop smoking, the trick to get up earlier to get to work on time? It takes practice, and it is daily.”