S3 E9: Dr. Mel Pohl on Chronic Pain and Healing Without Opioids

Dr. Mel Pohl is a fellow with the American Society of Addiction Medicine (ASAM) and the former Chief Medical Officer at the Las Vegas Recovery Center. He is now a Senior Medical Consultant for the Pain Recovery Program at The Pointe Malibu. A lifetime of experience has taught him about the true nature of pain, and he is challenging the way the medical industry views and diagnoses pain as he works to finding relief for people with chronic pain without the use of opioids.

Podcast Transcript

David Condos
Welcome to Beyond Theory, a podcast powered by Meadows Behavioral Healthcare. That brings you in depth conversations from the frontlines of mental health and addiction recovery. I’m David Condos. According to CDC data, about one in five US adults have experienced chronic pain. And yet, it can still be hard for them to find appropriate care. But Dr. Mel Pohl is working to change that. So how does he hope to help people find relief without opioids, while changing the way the healthcare field views pain? Let’s get out of the abstract and see how this applies in the real world. It’s time to go beyond theory.

Dr. Mel Pohl
Hi, I’m Dr. Mel Pohl. I’m the Chief Medical Officer of the Las Vegas Recovery Center.

David Condos
Alright well Dr. Pohl, thank you so much for being with us here at the US Journal Conference in Scottsdale. Good to be here. Thanks. Yeah. So let’s start with your story. your background and you know, everyone who works in this field has their own personal reasons for promoting motivating.

Dr. Mel Pohl
It’s a very sad story. I hope your listeners can hold on. No, seriously. I’m a family doctor. And I moved out to Las Vegas in 1979 to be a family doctor. And person who hired me was the director of a treatment center, a drug and alcohol treatment center. And he said, “Well, you’re gonna have to cover for me every other weekend.” So you know, I didn’t really know a lot about addiction. It didn’t really call me. But it was interesting in the field was just developing in 1979. So I got interested in what that meant. And four years later, I got sober. So my addiction kind of flourished.

David Condos
So you were using at that time?

Dr. Mel Pohl
Yeah, I gave really good lectures on cocaine on cocaine. With my eyes getting real buggy. Oh, yeah. And four years later, I just, you know, couldn’t go on with the hypocrisy of telling people what to do, and then go on and getting high. So I got sober in the rooms of Alcoholics Anonymous, never went to a treatment program, and been sober since. So since October 13, 1984. And relevant to the topic that we’re gonna talk about today, I developed a chronic pain condition, mainly back and neuropathy of the feet related to nerve compression. And I got interested in what I could do for myself. But more importantly, when the opioid crisis or epidemic really started going, which was in the 90s. I would treat a lot of opiate addicts and typically they would say, about half of them would say at the end of their detox, they’d say, what are you going to do about my pain? And I would say, “I don’t know”…

David Condos
…because there’s a reason they started using.

Dr. Mel Pohl
At the time they were getting them from the doctor or maybe from friends. But you know, they weren’t, frankly addicted shooting heroin, they were taking pain pills to treat a pain condition. And I just got tired of saying, I don’t know. So I got really interested in what could we do in a treatment environment, and got together our management team, and we created the chronic pain recovery program at Las Vegas Recovery Center. It’s been around about 12 or 13 years. And, you know, over the years, I’ve just seen more and more evidence that we blundered when we treated chronic pain with opioids thinking that that was a good idea. And we’re now stuck with a bunch of people on opioids, overdosing and dying from opioids. You know, the crisis has hit the news. everybody’s aware of it. There are a lot of interventions that have been done nationally to help, but the solutions neglect. The other particularly strong factor, which is that so many people on opioids are really trying to get relief from pain.

David Condos
And they’re still dying, even if there’s awareness about it.

Dr. Mel Pohl
Yeah, I mean, yeah, awareness. We became aware of it in kind of a back backward way. You know, we saw deaths, and a bunch of people started yelling and screaming, and a lot of those deaths were in groups of young people who were advantaged, you know, it wasn’t inner city youth. It was white, wealthy, suburban kids who were dying. And that got the attention of the public in a way that other drug abuse did not. And, and but we sort of overreacted in a sense and said, well, it’s opioids are the problem and we have to reduce the opioid prescribing, but we never really got much insight into the fact that people were really trying to get out of pain, and cutting out opioids makes people more miserable. And there’s a whole lot of things that happened as a result of that. And we’re seeing that now, in the last three to five years since, you know, the the CDC guidelines came out to say, basically, don’t use opioids a lot and don’t use them in certain ways. I mean, there’s a sort of a structure around it. But there are a bunch of people on opioids who have no recourse now, no, no resources. And that’s part of the kinds of folks that we treat -people who can’t get opioids or who want to offer opioids, but just don’t know how to cope with the pain.

David Condos
Yeah, yeah. And so looking at kind of a bigger picture view, chronic pain is what you’re speaking on here at the conference, if you just started alluding to it, how would you describe the landscape of chronic pain? Like how we look at it, how we’ve been treating it? You said, we’ve had some blunders, but how would you describe it?

Dr. Mel Pohl
So what I’ll talk about tomorrow is a couple of major misunderstandings. One is that acute pain and chronic pain are in any way related. Acute pain is broken bone infection, surgical incision, it heals, it’s purposeful pain, it’s good that you have the pain, so you protect the tissue. Chronic pain is an entirely different animal, and most of the medical field has missed that boat, they just don’t get it. Chronic pain doesn’t reside in the tissue, it resides in the brain. So the tissue that’s damage or sometimes it’s not even related to tissue damage conditions, like fibromyalgia, where there’s pain all over the body is really a brain phenomenon. And we’ve got a lot of evidence…

David Condos
It’s just mixed signals in the nervous system?

Dr. Mel Pohl
It’s picture, a cascade inside the nervous system where pain is experienced, and it gets activated. So it’s, it’s on hyper, hyper drive volumes up. So that light touch causes pain, in the case of fibromyalgia, but you know, even with people like me who have a bulging disc and nerve compression, the chronic signal hits my brain. And that’s really where it registered. And that’s really where there’s some that something can be done about pain, if we pay attention to what’s happening in the brain. Now, opioids are like taking a blanket over the entire brain and causing typically sedation and, you know, a numbing of the pain experience, not in the long run a very good solution.

David Condos
But for the patient, that seems like relief at the time.

Dr. Mel Pohl
Seems like a good idea. It’s to the doctor too, because the patient leaves happy, you know, but what seems like a good idea ends up backfiring. And that’s really what’s happened with opioids. In the long run, opioids end up causing more pain than the person had before. And when we see patients at Las Vegas Recovery Center, we take people off their opioids, we discontinue them. And invariably, they say, “I can’t believe it, I have less pain, since I’ve stopped taking, you know, 100 milligrams oxycodone and 300 milligrams oxy cotton a day”, you know, my pain is not as bad, it’s not gone. Because if you have a bulging disc, or if you have this chronic pain syndrome that we see, it is going to it’s going to be present, but it’s substantially less troublesome when the opioids go away. There’s a couple of reasons for that. One is that opioids cause inflammation of the brain. And this happens not in every single person on opioids, but with long term use, it happens in what it looks like, it’s the majority of people on opioids. So, you know, you take an opioid, it works. You keep paying an opioid and eventually that pain level goes up. The other thing that happens with opioids, and other drugs that are that are abused, or people get dependent on is that there’s a tolerance that develops in the system. So after a while, the dose of medicine I’m taking doesn’t work anymore. The only thing to do at that time, you know, the logical thing is, “Oh, this is a bad idea. I should stop.” It’s not what people do people increase the dose, doctors are complicit in increasing the dose, because what else are they going to do? Where they add a stronger second drug, you know, long acting drug and a short acting drug is pretty typical. And of course, the pharmaceutical industry is behind promoting this methodology. And the whole thing is a house of cards that has come crumbling down.

David Condos
Yeah. And so you referenced the opioid epidemic that’s been national news for a few years now. What has that changed the way that we view pain? How has that changed this conversation?

Dr. Mel Pohl
The conversation is really primarily about opioids and addiction, the conversation has not in my estimation, sufficiently addressed the problem of chronic pain. And the real bottom line for chronic pain is that I have a couple of principles of chronic pain that I used to teach people about it and the first principle is that all pain is real because the there’s a highly common misunderstanding among doctors and among patients and among families and among employers, that somebody is exaggerating or making up their pain. And the principle that we start with. So people come to us with all sorts of confusion about is it real, and anger because they’ve been misjudged and frustration because they can’t convey what’s going on with a life that’s spiraling down. So the initial premise that I started out with when I sit with a patient is I know that your pain is real. However, the pain is not in the tissue, where you feel that the pain is really in your brain. Now, that’s where some people really have problems, because they get annoyed, or they get frustrated.

David Condos
Well because they don’t know what to do with that?

Dr. Mel Pohl
Well, partly, my best example is a patient who got real red in the face when I said, The pain is related to your emotions and thoughts. In your head. She said, “He’s telling me my pain is all in my head.”And I said, “Well, you have chronic headaches.”

David Condos
So like, Where else would you it doesn’t mean it’s not real?

Dr. Mel Pohl
No, yeah, go back to number one, you know, but when we have this, this dichotomy in our culture, and in our medical system, where it’s either real, or it’s emotional, what’s less real about emotions, and you know, I, I’ve studied psychology and neurophysiology and there’s a clear neurophysiological pathway that causes the pain experience. And it is up in the middle part of the brain. And it turns out that anxiety and fear and anger and frustration and depression, drive that pain center, so that the pain levels go up. I mean, if you if you’re not defensive, it’s pretty logical, you know, when I’m pissed, my back hurts. You know, it’s, it seems pretty logical to me. However, if you say to me that my pain is in my brain, I say, “No, no, no, my pain is right. I can pinpoint it, you know, the muscles are tight.” So there’s there is that, that frustration with understanding? And I think one of the pivotal things that happens in treatment is that people get this. They don’t like it, but they say, “Yeah, okay, I get it now. What can I do about it?”

David Condos
Yeah. So then carrying that to the next step, what do you do? What’s the next thing you recommend?

Dr. Mel Pohl
I describe it’s like the volume knob is turned up in the middle part of the brain. So we want to do anything we can to teach people how to turn the volume knob down. So if the volume knob is up, anxiety makes it worse. So we teach people how to deal with anxiety, we teach them mindfulness practices, we teach them distress reduction practices, what, you know, cognitive, behavioral therapeutic changes to what can I do when I am gearing up to anxiety? And how can I differentiate? You know, the crisis from a toenail, you know, because there’s a phenomenon with people with chronic pain, which is called catastrophization, it’s like, you know, taking an experience and just making it worse, in essence, so we teach people how to turn the lens around. So instead of expanding and contracts, the experience of pain and there’s a lot of emotional techniques that are studied to be able to do that. One of the key things that we teach people how to do is to get moving. Motion is lotion, we say, but people are typically, you know, enact inactive, it hurts to do this. So I don’t do this. And that’s the worst thing.

David Condos
It perpetuates.

Dr. Mel Pohl
Yeah, in fact, you know, the phenomenon of, there’s a thing called frozen shoulder so if my shoulder hurts, and I don’t move it for a while, after a while, I can’t move it because it is literally frozen tissues solidify and scar and hold the joint in place. So the solution for that, maybe have to go to surgery and get it all cut up. But basically, it’s instead of stopping because it hurts, you know, moving through the pain and I happen to have a shoulder problem too. I got a lot of extra you’re demonstrating enough time I’m gonna talk about it. But yeah. So you know, even though range of motion exercises are extremely painful, I do them all the time. And I do strengthening exercises for my shoulders, to support the tissue in there. And though it hurts to do it, it’s hurt, but it’s not harm. And people tend to feel like if I move it’s going to I’m going to harm myself. So they need education they need we have physical trainer and a physical therapist and a chiropractor that work with people on their movement beliefs, but also on increasing their function.

David Condos
Yeah, that’s interesting, that distinction between hurt and harm because we’re our were trained by our body and rightfully so that something hurts is like, Oh, I got to stop.

Dr. Mel Pohl
That’s right. And that sort of perversion of the pain system because typically if it hurts, if you have a broken leg and the pain signal is hurt, Don’t walk on it, you know, but if it’s a chronic joint inflammation, that is not the case, you know, and that that hurt is not a signal to stop the hurt is a signal that something is traveling to your brain. And you have to get moving in order to increase the endorphin levels and dopamine levels, and increase the circulation to this immobilize joint to take away toxins. And to increase range of motion, I’m huge blue, can’t move their shoulder can’t put their jacket on, they don’t want to go anywhere. It’s an example that I use for patients. So it’s really critical that people buy into the fact that they have to move, you have to get out of bed. And the thinking, which goes along with the immobility is, I can’t get out of bed. Well, you know, I bet if I like that bed on fire, you know, I think you’ll be up. One of the things you probably can guess is that I don’t take this too seriously. Because that is one of the key things that I see is it becomes life and death, when it’s really not life and death. It’s just quality of life. And, and, you know, sort of waiting for death. That’s, that’s what the what, that’s what life becomes about. One of the other things that we do is put people on other people that have similar problems, there’s an incredible effect of being in a group of people who have similar experiences, you know, comparing and contrasting, but the ability to identify, because this is a very isolating condition, having chronic pain makes me feel different makes me feel less than, you know, frustrates me antagonizes me, with other people and other people with me, and to be able to sit in a group and be supported for who I am and what I experience, and then move towards a goal is invaluable. And then there’s data that actually supports that most of what I’ve talked about, there is evidence that goes behind all of that.

David Condos
Yeah, yeah. And so what you’re describing, like doing these, you know, motions over and over that kind of hurt. Yeah, you know, doing mindfulness to rein in the emotional side of it. This is all very kind of long term processes. And for someone who’s used to getting a prescription, popping a pill, that can be hard to understand that this is actually what’s going to help. So how do you overcome kind of that that cultural rut that we’ve gotten in where we expect the instant fair?

Dr. Mel Pohl
You know, I don’t have an answer to that sociologically to our culture, because I think that what you just described is one of the reasons we’re in this mess is people go to a doctor for treatment, what is treatment is, you know, typically a prescription. And it’s, and it’s something that will work, and it’s something that works quickly. You know, how many people take 10 days with antibiotics? Most don’t, you know, when I start feeling better, after three or four days, I put them away, and I forget to take them because I feel better. And the truth is that working three or four days, probably it’s you know, the last six days, or just to sort of finish off the little buggers that are causing the problem. But, you know, in the case of using something to make me feel better, yeah, they have to be in for the long haul. And one of the real keys in having a Emilio where there are other people doing it is that we have people who’ve been there three, four or five weeks, who can say to the newbie, Oh, I thought he was full of crap, too. You know, I never thought this was going to work. But here I am out on the track walking, and I have a walker that I’m not using anymore in my room. Can’t argue with that, you know, you can think I’m full of crap. But you can’t, you know, you can’t confound what you what your I see. So the power of that group is really, really essential. And, you know, there’s a lot of cheerleading that goes on. I mean, there’s a lot of encouragement and motivational interviewing is a skill set that that our counseling staff has, and that our medical staff has to basically work with people’s ambivalence, and help them choose something that is on the good side, or the healthy, positive side. And then really, the biggest challenge is sustaining the changes, like anything, you know, people who exercise don’t tend to keep exercising, unless they’re hooked into some positive outcome.

David Condos
Because you think, “Oh, it fixed it. And so I don’t have to do it anymore”?

Dr. Mel Pohl
And I’m not sure what you think, you know, I mean, there’s a lot of things thoughts, but what happens is if you don’t have a sustaining connection with some positive generator, which in our case is the treatment process, but when you go home, you know, if there’s got to be something that keeps you hooked in and, unfortunately, human beings forget how bad it was, you know, yeah, they I mean, that’s why alcoholics and addicts relapse, you know, I mean, it wasn’t that bad, but it is that bad. So most behavior changes sustained through connection and continued connection. So we try and hook people up with a connections. For some people, that’s a 12-step program, recovery program, certainly, if they have drug addiction, that’s a great fit, some of our people come in, and they don’t identify as having drug addiction, they identify as being dependent on the drugs, not being able to be okay without them, but they don’t have the same kinds of drugs seeking behaviors and dysfunctional life related to pursuit of the drug, because they’re pursuing relief. And it turns out brain-wise, the pursuit of relief and reward, which is drug addiction, are inextricably linked. And with our patients with chronic pain, they are pursuing that relief that is hard to pin down. When they get it, you know, then they brighten up I mean, you know, the traditionally, we see people coming in and this, this depressed, a disabled, downtrodden way. And, you know, we take the opioids away, we take other sedatives away, alcohol, of course, is eliminated. And, you know, they wake up and they have… it’s interesting phenomenon, because they have a life that they didn’t see before. And they see the sky that they hadn’t seen in years. They also have to wake up to the emotions and the thoughts because they have been suppressed.

David Condos
Because they’ve been numbed for so long. It’s like that blanket, you describe our covers everything,

Dr. Mel Pohl
and it’s very challenging, that makes the process very challenging. Indeed.

David Condos
Yeah. And so you said that at Las Vegas Recovery Center, you have this dedicated chronic pain program that you’ve built, you developed. Why is that important? Why should that be more integrated, incorporated into this addiction, mental health treatment?

Dr. Mel Pohl
Well, I think what happens is, if you don’t understand the initial principle that the pain is real, and you don’t allow for that fact, everything comes apart when you’re trying to treat someone with co-occurring pain and addiction. You know, what I hear people who go to other treatment centers that don’t specialize in pain, and they sit there told in group, you know, it’s not pain, it’s addiction, you’re in denial, you know, get with it, as opposed to really understanding that no, it’s both, you know – it’s drugs and it’s pain. It’s not either or, no, and it has to be both that are treated concurrently. And you know, it’s not terribly different than integrating trauma treatment in in addiction treatment. I know you’ve talked about that on a guest before, it’s essential to pay close attention to all the factors that are going on in a patient and if pain is one of them, you need a staff that has expertise in dealing with it.

David Condos
Right, so for someone who wants to dive in even deeper on this, what would be one, one book, one resource that you’d point them to?

Dr. Mel Pohl
After they buy my book?

David Condos
Yeah, yeah. So we have your book A Day Without Pain. Yes. Which, which, of course sums up a lot of the things we’ve been taught

Dr. Mel Pohl
And I have another book, The Pain Antidote. You know, there’s a great CD by a guy named Jon Kabat-Zinn. He’s a Buddhist philosopher and psychologist, but he wrote a book called Full Catastrophe Living and the CD is Treating Chronic Pain. And on it are a number of meditations that are specific for pain. I think that’s probably a terrific resource. Another book is Back in Control by David Hanscom. He’s an orthopedic surgeon who learned about chronic pain and believes similarly to what I believe. But he learned it from the surgical side, he was a surgeon, and hardly any of his patients got better after he did back surgery. And he finally said, “I’m on the wrong side of this process.” And he’s given up surgery now he’s just talking about how to heal.

David Condos
Yeah. And quickly, What’s the story behind this book A Day Without Pain?

Dr. Mel Pohl
That was my first book. And it was just kind of an inspiration from the work that I was doing. I wanted to tell people stories I wanted to get the word out is to try and impact the general public who couldn’t access treatment, Las Vegas Recovery. Not everybody gets there. Not everybody is able or willing. But at least to give them a little sprinkle and taste. And we often will send the book out to somebody who’s considering coming into treatment. And, you know, I get comments like it really has offered a new avenue for how to proceed in life.

David Condos
All right, with Dr. Pohl, thank you so much for your time, just to leave listeners with one last thing. What’s a favorite piece of advice, something that’s meant a lot to us something that you find yourself passing on that’s meaningful to others?

Dr. Mel Pohl
I would say probably the best advice is to believe that you can do this, that there’s more right with you than wrong with you and your attitude is going to make or break the opportunity to really improve and have a better life.

David Condos
Alright well Dr. Pohl, thank you so much.

Dr. Mel Pohl is a Distinguished Fellow of the American Society of Addiction Medicine, a clinical assistant professor at the University of Nevada School of Medicine, and the Chief Medical Officer at Las Vegas Recovery Center. Learn more about his work at DrMelPohl.com. Beyond theory is produced and hosted by me David Condos. You can discover more from this podcast including videos of each conversation and BeyondTheoryPodcast.com. Finally, thank you for listening. And I hope you’ll join us again next time for another episode of Beyond Theory.

 

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