Rex Marco, MD, from Houston Methodist talks about using meditation as an alternative to opioids for pain relief.
Interview conducted by Ivanhoe Broadcast News in March 2019.
You have to wean off of opioids first?
Rex: If they wean off of narcotics before the operation, then they can respond to normal levels of narcotics and their pain is better controlled. But when they are on chronic narcotic medications before the operation, their body can’t make endorphins and they need all the narcotic medications or narcotic-like medications to be given to them. But their narcotic requirements are at such ahigh level that they stop breathing. So I tell them it’s similar to where Michael Jackson was – he had so much pain that he almost had to stop breathing to have control of his pain. And when we operate on patients that don’t get off the narcotics first, that’s what we have to do. They have to be so sedated with high levels of narcotics that they’re almost not breathing, and then their liver, which is overactive due to the chronic narcotic use, eats up the narcotics so quickly that they wake up screaming. So I had tried that early in my career and it just didn’t work for my patients, their families, the nurses and my team. I had no advice for them. I had a breakthrough moment when I saw a patient who had failed 8 previous back operations and was bent over so much that his chest was parallel to the ground. He was on high doses of narcotic medications for over 30 years. I told him that he had a horrible problem and we can do something about it. But I need you to get off the narcotics first. And he said, well that’s not a problem, I’m going to a narcotics cessation program in a couple of weeks. And I was so happy. When he returned to my office a couple months later, he was off all narcotic medications. He was calm and appeared so much more peaceful and healthy. I asked him how he weaned himself off the narcotic medications, and he told me he attended many meetings and learned mindfulness tools like meditation and yoga. The rehabilitation center slowly weaned him off of all the narcotics. Much to my surprise, he said that he felt so good that he didn’teven want the operation any more despite being bent forward and stuck in a horrible position. He came back about six weeks later and he was in a panic. He said something like, “my back is horrible. I can’t take this. I have to go on three cross-country trips and I have to travel over a thousand miles in the next few weeks. You have to fix me.” I said, “well did you check in with the people that are helping you with this process of weaning your narcotics?” He said no. I asked him to check in with them and he did. He went on his trips and returned to our office. When he came back, he was still off narcotics and he was much calmer. He said that he was again using his tools to get his natural dopamine levels up. His pain was better controlled but he realized that he no longer desired to live deformed and bent over, so he wanted a corrective operation done. Immediately after the operation, he was sitting there calmly. He just looked at me and said, “I have a lot of pain.” He wasn’t screaming. He was alert and calm. Most importantly, he didn’t need tremendous doses of narcotic medications that stopped his breathing.
Can you just kind of sum up why is it a big deal to have these other tools, alternatives, to describing opiates for pain relief?
Rex: The other tools that I’m encouraging them to use?
Yes. Why is it a big deal to have that other option?
Rex: Well I think it’s really helpful for people that are on chronic narcotic medications and people that are going to have surgery, in general, because a lot of people are scared of the surgery that’s coming up. And when we have fear, when the body has fear, the amygdala triggers the brain to create a stress response. And that stress response increases the pain. And then when the pain is increased, the stress response is increased. And so people with some anxiety or a lot of anxiety need some ability to help them through this stress response so that they can experience less pain. And so when we give them these tools, they’re able to generate medicines called endorphins and dopamine that will lower their stress response. The endorphins lessen the pain, which in turn decreases the stress response to pain. And when their stress response is lower, then their pain is lessened even more. And so we encourage them to do mindfulness techniques like the meditation app, Stop, Breathe & Think. When they tell that app that they have pain and they listen to what the app says, their brain makes dopamine and their stress response is lower, so their pain is lower. When they combine the use of this mindfulness app with moving mindfulness techniques like yoga, then their brain will make endorphins, which helps lessen the pain and stress response; dopamine, which helps them feel better and lowered the stress response; serotonin, which helps with sadness; and GABA, which helps with anxiety and sleeping problems.
What are most patient’s responses when you mention using an app or mindfulness for pain relief?
Rex: Lately it’s been really good. So when I first started, it was not good. Maybe 20 percent would be willing to listen to it or try it. I think more and more are willing to listen to it and try it. And almost 100 percent of my patients that are on chronic narcotic medications do try it because I’m requiring narcotic cessation prior to scheduling their operation now. So if they’re on chronic narcotic medications, then I require that they have a negative urine test without any narcotics on board. All of these patients have been open to receiving any information that will help them wean off the narcotic medications. My patients who I am treating nonoperatively and using chronic narcotic medications are more willing to try mindfulness activities now that I am able to explain the rationale behind its use and ask them if they are open to receiving more information on the apps that we show them. Initially, many people would say, “so you think this is in my head?” I I do not recall the exact wording that I was using back then, but I soon realized that I needed to try a different approach. My current approach is explaining some of the science about what pain does and how pain causes a stress response. I believe patients are more open to hearing that pain causes a stress response than hearing that pain causes stress. Because when I used to say pain causes stress or if I used the term anxiety then patients misinterpreted those words and frequently stopped listening to mindfulness as an option to manage their pain. Regarding my own personal experience with stress and anxiety, I denied that I had anxiety for most of my life. I didn’t know I had anxiety and I didn’t know I had a stress response. I didn’t realize that I was repressing my anxiety and stress. I now know that most people do feel anxiety and it’s OK to feel anxiety. I used to spend a lot of time explaining the importance of realizing that a patient’s anxiety may be contributing to their pain. I believe that spending less time on helping them understand the role of anxiety in worsening the pain caused a disconnect between me and my patients.
So if there’s someone who’s taking a lot of pain medications and they’re wanting to lower that and they’re thinking maybe this is an option for me, what would the one takeaway for them be?
Rex: If someone is trying to lower their pain medication intake and trying this option, I would recommend going slow. If they are taking 10 pills in a day, I would say take nine pills for a week and then eight pills for a week, and then taper down to no pills in a day. If they’ve been on narcotic medications for a long time, then many patients prefer to taper down with a doctor helping them. I discuss the option of weaning off the narcotic medications while using the Back Doctor app exercises to trigger the brain to release endorphins, which are strong narcotic like medications that help with pain control, which in turn lowers the stress response and further lessens the pain. I then explain that they can use the Stop, Breathe and Think app to trigger their brain to make dopamine, which helps them feel better and lessens the stress response. The patients can check in on the app and tell the app that they have pain. When they listen to the suggested audio, then their brain will make dopamine and they will feel better and their stress response will be less. I then ask them if they are open to receive more information on these apps and most of the patients say yes. Most of my patients have weaned off of their narcotic medications on their own by stimulating their brain to make endorphins and dopamine using these apps. One key message is that I would say is to avoid low-dopamine states, which are HALT states. HALT is Hungry, Angry, Lonely or Tired. Avoiding HALT states helps because when you make sure you’re not hungry, angry, lonely or tired, you avoid the low dopamine state, which helps you feel better. If a patient avoids low dopamine states and then does things to trigger their brain to create endorphins and dopamine, then they can experience less pain without narcotic medications. So in combination, I believe I have had many patients use nature to trigger their brain to make dopamine. I had one patient who sat by a lake and she said she sat there until she didn’t need to take the narcotic medications anymore. Another person would knit. A lot of patients use music. Functional MRI studies have shown that all of these activities trigger dopamine release. It’s just not at the really high, supraphysiologic levels that other medications like narcotic medications, alcohol or nicotine cause.
So have you noticed a trend of people looking for just other outlets, other ways to raise their dopamine even if they might not know what they’re doing?
Rex: I haven’t noticed a trend that people are looking for it. I’ve noticed an openness to trying it and I’m not sure if that’s because it’s much more popular now. And in the media, in the grocery store you see it on the magazines. You see mindfulness all over the place. And I don’t know if that’s why or if because of that combined with the approach being different, and the explanation that there is a scientific reason why this might help you.
And probably the opioid crisis, people are a little more mindful of addiction and doses. Would you say that’s part of it as well?
Rex: And having another option for patients is really helpful. In the past, we almost felt obligated to prescribe opiates before the operations and after the operations. And now more and more studies are coming out that this policy led to more problems and more deaths. And pain is a natural part of life. Emotional pain and physical pain will always subside. Knowing that it will subside is really helpful. The fear of it not subsiding is anxiety. And that anxiety increases the stress response which increases the anxiety, which increases the stress response. And it’s this vicious cycle which can be slowed down by narcotics or by mindfulness techniques.
What are your concerns for doctors who don’t use these methods and why wouldn’t they?
Rex: In all honesty, I would be concerned for some doctors if they still think that narcotics are the only way to go because that might lead to more patients with more narcotic dependence. And if more doctors were open to using these techniques, we might have more patients that are using these techniques rather than becoming narcotic dependent.
Is there a reason why doctors wouldn’t want to use these apps?
Rex: Well from my experience the reason why someone might not want to use the apps is because they might perceive it takes a little longer to explain the apps rather than to write a prescription. It might be less time consuming to write a prescription than to explain the apps. They might not have someone in the office that can explain the rationale for using the apps. Their office staff might not have buy-in regarding the applicability of these apps to patients. I know that from firsthand experience because my staff didn’t believe it could work. And I did, so I kept using it. The downside was that my clinic was running longer and I was running further behind and patients were getting upset because they were waiting longer for me to come in and I was doing my best to give them time too. But when you wait a long time, most people aren’t understanding of that. So practicing it more and more, and finding a way to present it in a more timely fashion has been really helpful. And just being open to letting them try it or not try it and asking them if they’re open to trying it rather than insisting that they try it has also helped. And if they are interested in trying the apps and they want the information, then I give it to them and if they are not open to using the apps or mindfulness then I accept them for where they are at. This shift has been really helpful for me and my staff.
END OF INTERVIEW
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