Pain Versus Suffering

You've covered a broad range of techniques in this two-part interview, discussing a great variety of powerful tools that help decrease pain sensation and increase pain tolerance. Over the past few years there has been much said about endorphins and how they relate to pain. How do you think about endorphins?

The endorphins have nothing to do with pain and everything to do with suffering. When we give patients a shot of morphine, which mimics the effects of endorphins, they say, "Well, it still hurts, but it doesn't bother me." We haven't blocked pain. We've enhanced tolerance and reduced suffering. Suffering reflects an ability to handle pain. If someone is not eating or sleeping, not working... that's suffering. The one thing I've learned over the years is that it is possible to have pain and yet not suffer. It depends on one's attitude toward pain and this is where imagery becomes quite vital. If people see their pain as a teacher, as an opportunity for growth and change, they begin to use the pain and its energy to move them through a process of transformation.

If, on the other hand, they imagine pain to be some horrible, catastrophic enemy that's out to get them, they're going to suffer. So imagery is a powerful way to stimulate endorphin release, to elevate tolerance and reduce suffering.

Is that a theory or is this something you've measured?

There is presumptive evidence. Nothing I've measured. But placebos are well-known to increase endorphin activity and placebos utilize imagery. It's the power of positive expectation and faith.

So you can give someone a sugar pill, tell them it's the newest, most potent pain killer in the world and you can measure a rise in endorphins?

Correct. That sort of work has been documented. Now no one has yet monitored the kind of work that Dr. Marty Rossman and I do...Interactive Guided Imagery... and monitored endorphins or B-Enkephalins. But the presumptive evidence is there.

Are there any kinds of pain that are resistant to this vast arsenal of imagery techniques?

One is phantom limb pain, when, for example, the experience of pain remains in an extremity that has been amputated. It's baffling. It's a really complicated issue that is poorly understood. Treatment options are minimal and from an imagery point of view all you can hope to do is to enhance one's tolerance to it. I haven't had much luck. There are other intractable pain states that remain refractory to just about anything that you do...such as thalamic pain.

David, you have shared some truly remarkable and powerful ideas and techniques in this two-part interview. I appreciate your fantastic contribution. Do you have any closing comments?

In my experience imagery is one of the most powerful interventions that we have available to help people in pain. And I hope to see it being used more broadly. I always come back to the lemon experience. As you imagine yourself biting into a lemon, you begin to salivate which is a direct physiologic response. Imagery techniques for pain control also evoke physiologic change in the body with relatively minimal side effects, complications and toxicity. Imagery is a way to produce many of the physiologic effects that medications do but without toxicity. And this is very clearly seen in pain control.

Don't get me wrong. I give thanks every day that we have morphine and other powerful pain-relieving drugs. We're not trying to replace medications because there are certain circumstances where medications are far more appropriate or helpful, such as after surgery. But for management of chronic pain, imagery can often do much more than can medications, and I'm happy to see interest in its use rising.