ON A SCALE FROM 1 TO 10…
Andy Tu, AmeriCorps VISTA – SafeRx
“The biggest misconception about opioids is that opioids will help you experience less pain.”
This is what Andrew Chinnock, Nurse Practitioner, tells me during an interview at the Live Well Clinic on September 28th. Seeing my confusion, he grabs a pen and paper and draws a diagram of a neurosynapse—two bulb-like shapes separated by a thin space; it resembles the joint of two bones side by side.
“These are two neurons,” he says. “And these…” he jots tiny circles along the adjacent edge of the right neuron. “Are the receptors that receive the signal to feel less pain. The left neuron sends signals to the one on the right, telling it to feel less pain, that’s how normal physiology works. That’s the system we borrow when a person takes an opioid to treat their pain.”
“Okay…” I’m familiar with this process, and am curious how he will support his claim.
“When you take an opioid you are artificially overstimulating the nervous system to feel less pain.”
“So then, the person does feel less pain,” I say. “That conflicts what you just said.”
He smiles. “Yes, they do feel less pain, for now, but the effect does where off.”
I recall how, when eating chili peppers, drinking water only provides temporary relief before the flames reemerge, amped with intensity.
He continues. “After six weeks, their tolerance for the opioid increases, meaning they feel less of an effect because the receptor sites have been rendered ineffective due to overstimulation with an opioid. Now the body’s normal endorphin system which regulates pain doesn’t work and this can causes pain to increase.”
The Live Well office murmurs with energy. The receptionist greets me with invested eye contact and a casual smile. Upon entering, Andrew asks me to wait in his office as he finishes some charts, slipping in and out through the opened door, checking in with me each time.
“Do you want some water?” he asks. “Make yourself at home.” He begins clearing his desk but I tell him it’s not necessary. I ask him for the Wi-Fi password; he returns within seconds with it before heading into a conference room for a quick meeting. “I’ll be back in a moment.”
On the desk, a replica of curved spinal bones steadies its own weight, sprouting yellow, noodle-like tubes connected by red, dried-gum-like splotches. A photograph on the wall frames Andrew, holding his then one year old, Lucy, in his arms. The flannel shirt he sports compares to the one he’s wearing today—colorful, friendly, yet professional. I feel a sense of familiarity.
When he returns, I ask him if a patient’s attitude toward pain treatment affects how well it works.
“I can help almost anyone as long as they want to try, and that’s 95 percent of the people with chronic pain. Most people have muscle and skeleton pain that’s treatable here. It’s only the rarer autoimmune diseases that I think—maybe—opioids are right for them.”
Andrew sketches the neurosynapse diagram for every new patient who doesn’t already know about it. He talks to them about what opioids do, and he tells them what he can do. Each patient requires an individual assessment that informs Andrew of how to help them. Sometimes the treatment plan doesn’t work right away, and they have to try something different moving forward.
“At the end of the day, though, if the patient comes in and has a positive experience, learns about their condition, is shown their x-rays, MRI’s, and is educated about why they have pain, they leave better off then they came.”
“We never just write them a prescription, and then they leave. That doesn’t actually fix their chronic problem. People with pain often have holding patterns in their bodies that aggravate their pain. Just getting meds doesn’t heal them. They need to have a healing experience with their body and their pain. Research suggests that people who take opioids for chronic pain don’t experience less pain than people who have chronic pain and don’t take opioids. In fact, I see this frequently in my practice. The people who don’t take opioids consistently have less pain.”
Throughout our interview, staff members pop in and out. One hands him a folder of documents requiring his signature, which Andrew quickly flips through. “Stuff,” he says, tossing it onto his desk. It’s clear that the focus here is on the patient’s journeys; everything else is just paperwork.
Another staff member, on her way out of the office, exclaims, “Bye Andy!”
“That was for you,” Andrew tells me.
Earlier that day, Andrew treated two patients who ranked their pain as level 8 (1 being very little pain and 10 being excruciating). They both walked out of the clinic with ratings of zero.
“How’d you manage that?” I ask Andrew.
“My ninja skills,” he says. “Just kidding. I treated them with myofascial release. See, when the body is injured the musculoskeletal system contracts and creates an incredible amount of force, as high as 2000 PSI, or pound per square inch. This connective tissue restriction is meant to support the body during a time of injury but the constriction can last for years after the injuring event. Myofascial release, a treatment based on manual pressure and stretching, helps normalize the tension in the body, reducing pain. Sometimes all the pain goes away, sometimes the pain moves to a different location but almost all my patient’s report improvement in pain and mobility.”
“What about people who are already using opioids? Are you able to get them off?”
“All the time,” he says confidently.
Andrew will often place patients who are using opioids on a tapering process as other forms of treatment are integrated into their lives, such as a targeted exercise program, myofascial release, counseling, chiropractic care or physical therapy.
“People who come in have better pain scores than people on opioids,” he says. “I remember one patient who was on opioids. She had significant stress at home, which contributed to chronic neck pain. When she was on opioids, she never smiled. I mean, never. She was just in too much pain. When she started coming in, I tapered her off the opioids while working different modalities with her, such as touch therapy and myofascial release. You can see the difference on her face. Now, she smiles.”
“People live out their stories,” Andrew says. “For example, one person’s story might be: Wake up, brew a cup of coffee, drink it while reading the newspaper, have a cigarette, eat breakfast, shower, go to work, eat lunch at work, come home, have a glass of wine, get ready for bed, go to sleep. What we tend to do repeatedly becomes our story.
“When people take opioids, it becomes part of their script. People get focused on—addicted to—taking the pill, the ritual. They tell themselves that they can’t go to the store because they might get stuck in traffic and miss their next pill. Or they can’t go out for a walk because they might aggravate their pain. They begin to have a constant conversation with their pain meds. This is true of any addiction. Instead of just living your life, you become consumed with thinking about your next dose.”
Andrew leads me through the maze-like hallways of the Live Well Clinic to his office upstairs, where he shows me a book, “Crooked”, by Cathryn Jakobson Ramin. He flips to the middle and points out a paragraph sprawled with pink highlighter:
“The volcano god of pain is your master. You’ve sacrificed things you love, activities that give your life joy, to be kept free from pain. You say to the volcano god: ‘I will give up walking long distances if you keep me out of pain. I will give up lifting my children if you keep me out of pain. I will give up travel, because long trips stress my spine. Just keep me from pain.”
“Much of depression and addiction is about our stories,” Andrew says. “Someone gets hurt, and is also emotionally hurting. They take opioids. They feel everything less, physically and emotionally. They smoke cigarettes on their couch, watch television. They watch the clock for their next medication. They don’t leave their homes in fear of missing their pill, aggravating their pain, or facing emotional pain. Their lifestyle becomes chronic. Their story becomes a downward spiral.”
Andrew’s goal is to help people change their stories. To help them do something different than what they’ve been doing—watching a sunset, yardwork, taking a walk outside and breathing clean air. He points to another passage:
“When a patient reported that his surgeon said that moving would make him hurt more, Siegel encouraged him to take the risk of living a rich, full life in pain. The other option was to be disabled and without prospects—while still living in pain. ’Most people thought it would be better to have their lives back,’ said Siegal, ’and so they would begin moving normally—opening windows and taking out the garbage and loading the washer, just like everybody else. And then they started to feel better. Most people aren’t actually afraid of pain… Patients are afraid of disability, of the prospect of not being able to live their lives, to do their jobs.’
“People who can’t get off opioids are also living in fear,” Andrew says. “Fear of withdrawal and being in pain. Withdraw can feel like the worst hangover of your life, and people fear that misery. They also fear the resurfacing of the emotional pain that’s been numbed while on opioids. They start to believe they can’t do life without pain medication.”
Micro and Macro
As an AmeriCorps VISTA working with SafeRx, I believe that we, too, are trying to change the story, working on a micro level to achieve macro results. The projects we implement can alter lives in our community, deter someone from experimenting with drugs, inform a user’s relative about addiction or Substance Use Disorder, educate about statistical trends, reverse an overdose with Naloxone. Something small can amount to something big.
Perhaps, in the same way that Andrew’s patients can decrease their pain by living fully despite ongoing pain, our community can decrease the ravages of the opioid epidemic by forging forward despite everything that threatens our efforts.
Similar to an athletic star who has suffered major injuries, Lake County’s heyday as an idyllic vacation getaway has been disrupted by the opioid epidemic as well as poverty, crime, violence, and trauma. In a sense, Lake County has been dealing with chronic pain and has allowed this story to be written into its reputation.
As Andrew said, things won’t get better until there’s a healing experience, until we’re willing to re-write the scripts of our own efforts and challenge ourselves in the fullest way we know, until we cast off all resistance, complacency, and fear, and push forward so enraptured by our commitments that it hurts.