Chronic pain, PTSD, mindfulness and psilocybin

Individuals with PTSD frequently experience chronic pain as well.  According to the Veterans Administration website on chronic pain and PTSD, approximately 15% to 35% of patients with chronic pain also have PTSD. Only 2% of people who do not have chronic pain have PTSD. One study found that 51% of patients with chronic low back pain had PTSD symptoms.

Just for the record, I am not a fan of the Veterans Administration when it comes to providing quality medical care for Veterans.  Although there are some notable exceptions, Veterans are provided with inferior medical care when compared with health care provided in the civilian sector. There is a culture at the VA where a significant percent of the employees have an attitude that the VA exists for them and having to deal with those Veterans is a pain in the ass. Plus they know it is almost impossible to get fired from the VA. I speak from experience having worked at 4 VA hospitals and having been a patient in 3 of them. It is time to shut it down and provide Veterans with the quality of care they deserve while saving taxpayers the expense of propping up a broken, outdated system.

Veterans should be allowed to receive local healthcare with a provider of their choice. What the Veterans Administration should focus on is research, in close collaboration with the Department of Defense, to improve medical treatment for issues that are unique to this population. I am not alone in criticism of the current care our Veterans are receiving. See New Commission on Care Report: VA Too Broken to Fix from the Federal Practitioner (6 April 2106).

Unfortunately many PTSD/chronic pain patients have been treated with opioids which are great for acute pain but very destructive for those with chronic pain.  Recent statistics provide an estimate of 40 deaths per day in the U.S. from the current epidemic of opioid prescription overdoses. In an attempt to address this issue the CDC has recently published new guidelines for prescribing opioids for chronic pain. CDC Director Tom Frieden, MD, MPH, stated in a news teleconference on 15 March 2016 just prior to the new guidelines. "For the vast majority of patients, the known, serious and all too often fatal risks far outweigh the unproven and transient benefits, and there are safer alternatives."

So what are some of the safer alternatives and why do individuals with PTSD tend to experience more chronic pain than those without PTSD?  This essay will attempt to clarify these issues.

On 22 March 2016, the Journal of the American Medical Association (JAMA) published a very timely article regarding research that attempts to find a nonpharmacologic approach to treating low back pain (LBP).  The article is titled "Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial" and is freely available online.

Results of this breakthrough study concluded "among adults with chronic low back pain, treatment with mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT), compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain."

It should be noted that while the researcher in this study were primarily from the University of Washington, Seattle, the mindfulness-based stress reduction (MBSR) program they utilized was developed at the University of Massachusetts Medical Center in the 1970s led by Jon Kabat-Zinn.  Becoming trained as a provider in MBSR involves much more than getting a certificate for having taken a weekend course.  To be effective, you must be a practitioner of MBSR yourself which takes much dedication and training. Therefor finding  therapist trained in MBSR can be rather difficult but still much easier than finding a therapist trained to lead you through a therapeutic psilocybin session.

Just 5 days prior to the release of the JAMA study, the National Institutes of Health (NIH) commented on a newly released study published in the Journal of Neuroscience titled "Mindfulness-meditation-based pain relief is not mediated by endogenous opioids" that was partially funded by the NIH. The authors of the study concluded "results demonstrate that meditation-based pain relief does not require endogenous opioids. Therefore, the treatment of chronic pain may be more effective with meditation due to a lack of cross-tolerance with opiate-based medications." This study is important because opioid and non-opioid mechanisms of pain relief can interact synergistically to increase the effectiveness of pain control.

Although the Journal of Neuroscience study does not indicate what the non-opioid pathway may be, there is a plethora of evidence to suggest that it may involve the default mode network (DMN).  Hyperconnectivity of the default network has been linked to rumination in depression and chronic pain. Mindfulness meditation and therapeutic use of psilocybin both have shown similar functions in reducing activity of the DMN.

A key structure within the default mode network is the posterior cingulate cortex which is activated during self-referential thinking and deactivated during meditation and psilocybin intake. It is possible that decreasing self-referential processing distracts the individual from ruminating over their life condition and allows them to have the experience of being connected to the world outside themselves and to live a more contented, productive life with a significant decrease in pain. Individuals who have taken psilocybin as part of a Clinical Trial for cancer patients have made statements indicating that after taking psilocybin they just do not pay that much attention to their pain anymore.

After all these years, it is very satisfying to have the CDC, NIH, and JAMA all joining me in an attempt to treat conditions like chronic pain and PTSD in a nonpharmacologic manner such as mindfulness.  If medication is needed, lets stick with the natural non-addictive variety such as psilocybin. Besides being non-addicting, psilocybin has shown profound medical benefits and need only be taken a once or twice - a pharmaceutical company's nightmare.