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Samantha Brodeur
LIB 111 Expository Writing
Professor Ruggiero
1 December 2022
“It Doesn’t Have to Hurt”
Pain is a universal human experience, with chronic pain costing Americans between 560
and 635 billion USD annually in attempts to manage it (Manchikanti). Chronic pain is defined as
pain that persists beyond the usual course of an acute disease or reasonable time for a
comparable injury to heal, intermittent pain for months or years which may continue in the
absence of demonstratable pathologies and healing may never occur, following the updated
biopsychosocial model of pain as tissue damage is not a defining criterion. Pain is multifactorial
explained most accurately by the biopsychosocial model, considering psychological and social
factors in conjunction with biological processes (Engel). The biopsychosocial model manifests as
personal beliefs, priming, and effects of placebo and nocebo affect pain in its intensity and
presence. An accurate understanding of pain is the first step to alleviating the burden of millions.
However, many practitioners may not be aware of the inefficiency of current treatment and the
effectiveness of others such as using the placebo and nocebo to clinical advantage, cognitive
behavior therapies, and multidisciplinary teams, and instead are relying on opioids. This is
problematic because opioids have proved largely ineffective and bear many detrimental side
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effects. A solution may be educating providers on such evidence-based therapies relying on the
biopsychosocial model to understand pain.
The presence of chronic pain is disabling as people are crippled by its impact on their
daily lives. Chronic pain can be a permanent obstacle for people to live with, evident through the
desperate expenditure of billions of dollars to manage it. Between 2003 and 2014, the National
Violent Death Reporting System reported the percentage of people who died by suicide with
evidence of chronic pain increased by 3% (Nazarov). Effective pain management is lacking and
causing preventable deaths.
In understanding the biopsychosocial model of pain, practitioners should be aware of the
effects of the placebo, nocebo, priming, and beliefs. The placebo and nocebo behave as stimulus
expectancies that influence brain markers of pain intensity processing in the brain (Atlas et al.).
The placebo effect is defined as a beneficial effect produced by a placebo drug or treatment that
cannot be attributed to the properties of the placebo itself and therefore must be a result of the
patient's beliefs (Beecher). Responders to the placebo were reported as being more optimistic and
less anxious than non-responders to the placebo (Atlas et al.). Responders showed strong neural
markers of reward responsivity, higher levels of dopamine and opioid binding during pain
stimulation, and larger grey matter density in the prefrontal cortex (Atlas et al.). As the opposite
of the placebo effect, the nocebo effect is defined as the result of a negative outcome because of
a belief that the intervention will cause harm (Wojtukiewicz). As the placebo response is
associated with the emotional response of the patients; the nocebo response is associated with
increased anxiety (Atlas et al.).
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Like the placebo and nocebo effect, the beliefs of patients before and during treatment
largely dictate their outcomes. The patients understood pain as the biomedical model where they
strongly associated structural changes with pain and disability (Bonfim). Because patients
understood the biomedical model to explain their pain, fear avoidance was significant. Fearavoidance increased anxiety in patients and pain continued to dictate their lives possibly by a
nocebo effect. Had the patients learned the biopsychosocial model of pain, would their pain have
been relieved? Clinically, cognitive behavior therapies that involve changes in beliefs and
attitudes toward pain can be effective (Altas et al.). With education on the complexities of pain
and unlearning the biomedical model, patients can experience some relief.
Practitioners also need to be aware of any possible priming they might cause the patient.
Priming occurs when exposure to certain stimuli influences the response to a subsequent
stimulus without an awareness of the connection (Ritter). It matters how providers communicate
with patients and relay information about treatments as pain intensity is manipulated by the type
of words used, even when the conversation is unrelated to the upcoming treatment (Vaegter).
The treatment of pain is inadequate because many practitioners are not properly educated
in the biopsychosocial model. Clinicians often prescribe opioids early in treatment due to
minimal pain management education in medical school and residency programs, and little
guidance for primary care physicians (Manchikanti). Although most prescribed, opioids have not
proved effective. Evident through the vast spending on pain management, the increase of people
reporting disabling pain, and the raising number of suicides due to pain, this quick fix is not
cutting it. An epidemiological study of chronic opioid use in Denmark did not show any
improvement in pain relief, functional capacity, or quality of life in patients with chronic pain
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(Chan). Against placebos, opioids are associated with marginal improvements (Effective Health
Care Program). Even if patients are able to feel some relief on opioids, efficiency can decrease
over time due to opioid-induced hyperplasia- tolerance- and dose escalation may be required to
keep up with the pain, intensifying the side effects (Chan). Opioids have limited, if any, shortterm value for chronic pain, accompanied by significant abuse and side effects of depression,
anxiety, panic disorders, and increased mortality rates (Chan). These side effects can become so
detrimental that any relief patients may have felt on the opiate oftentimes does not out way the
harsh side effects and many patients come off the drug. On the other hand, some patients can feel
increased relief as they become addicted to the drug. Side effects continue accumulating as they
approach abusing the drug and the possibility of an overdose. Presently there is no accurate tool
for predicting opioid misuse, abuse, addiction, or overdose so the prescription remains highly
risky (Effective Health Care Program). As American practitioners have limited education in pain
management they turn to opioids. Opioids however lack the effectiveness and safety required for
millions to relieve pain. The current treatment of pain is inadequate for the millions suffering. To
alleviate the pain, practitioners need to prioritize treatments consistent with the biopsychosocial
model rather than turning to the insufficient quick fix of opioids they are accustomed to.
One alternative to prescribing opioids includes taking advantage of the placebo effect in
the clinical setting. Under the biopsychosocial model, the placebo effect could be used to amplify
the success of treatments. In clinical pain management, the placebo effect would function to
strengthen the effects of therapies rather than being the attributed cause of improved symptoms
as it is in the traditional placebo effect (Bystad et al.). As responders to the placebo effect were
reported more optimistic and less anxious, practitioners can utilize this known correlation to
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optimize treatment efficacy (Atlas et al.). To manifest the placebo effect in clinical practice, a
realistic hope must be built to influence the patient's expectations, and the patient's anxiety must
be alleviated. Practitioners can accomplish alleviating patients’ anxiety by understanding their
concerns and optimistically addressing them. These positively influenced expectations and
comforted worries may activate the placebo effect. The patient may undergo a more successful
treatment as a result of the elevated therapy, utilizing psychology in conjunction with biology.
How clinicians frame information about the risks and benefits of treatments may influence the
patient's perception. Practitioners should utilize optimistic language to optimize the patient’s
outcome (Miller et al.). For clinicians to employ the placebo effect in their practice they should:
describe the basic mechanics of the treatment, give accurate information stating that the
particular treatment is effective, aim for an emotionally warm and empathetic style, and try to
reduce the amount of stress for the patient (Bystad et al.). By catering to the unconscious
psychology of the patient, the clinician may be able to access the patient’s own healing potential
and produce a better outcome for them (Bystad et al.). As word choice is carefully chosen to be
optimistic and the patient's stress is reduced, clinicians can employ the placebo effect with little
risk of harm as the patient's psychology is optimistically manipulated. Clinical implications of
the placebo effect in managing pain could manifest as therapies are amplified by the placebo
effect. Existing therapies for pain management could be made more effective by employing
optimistic expectations to activate the placebo effect. Evident through the billions in expenditure
to manage pain, no current treatment is effective enough for the millions suffering but utilizing
the placebo effect in treatments lacking exceptional efficiency could improve their outcomes and
provide some relief.
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In contrast to employing the placebo, practitioners can do their best to suppress the
nocebo effect in their treatments. The suggestion of adverse effects alone can cause them to
manifest in patients, even in the absence of a biological basis (Colloca et al.). Aware of possible
nocebo effects, clinicians can avoid its manifestation through regulated communication with the
patient. Unlike utilizing the placebo, avoiding the nocebo effect in patients carries many risks
including the informed consent of the patient. Practitioners may be hesitant to avoid the nocebo
effect as they chance patients not understanding the risks of treatments and possible legal
repercussions in battles of informed consent. Practitioners are protected however under the
therapeutic privilege if they act in the best interest of the patient. Therapeutic privilege is the
withholding of relevant health information if nondisclosure is believed to be in the best interest
of the patient (Berg). While law and medical ethics endorse informed consent, practitioners have
the therapeutic privilege to protect them if they feel the patient would benefit (Berg). The threat
of the nocebo effect is justified as it is estimated to affect at least 25% of people in clinical trials,
as placebo groups report adverse effects at the same rate as the treatment group (Wojtukiewicz).
Since the nocebo effect poses a great risk to patients, practitioners are largely justified in
employing the therapeutic privilege to minimize the adverse effects of treatment. Practitioners
must use their best judgment as they balance minimizing the risk from intervention and the risks
from information disclosure (Colloca et al.). Practitioners can use their understanding of the
patient to dictate their course of action for risk disclosure. While practitioners must balance
minimizing all risks, by understanding patient concerns and values practitioners can best treat the
patient to their specific standards. In determining whether information should be withheld to
mitigate the nocebo effect practitioners should listen to the values of the patient and their
understanding of the treatment for the best care. By understanding the patient’s fears and the
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trade-offs they are willing to make the practitioner can make a judgment call on which treatment
course best suits their values (Gawande). Employing a treatment aligned with the patient's values
is important as patients who feel heard in their care plan may be less susceptible to the nocebo
effect (Data- France et al.). In current therapies for pain management, such as acupuncture,
where more pain is a risk, selective disclosure of the possibility of increased pain could lessen
the number of patients experiencing the adverse effect. Utilizing the nocebo effect in the clinical
setting may manifest on a case-to-case basis where understanding both the nocebo effect and the
biopsychosocial model, practitioners can use their best judgment to decide what would be most
beneficial to the patient.
Although not widely studied yet, cognitive behavioral therapy could be combined with
utilizing the placebo and mitigating the nocebo effect to act as a promising treatment in the
management of pain. Cognitive behavioral therapy may be another nonopioid option for
clinicians to use in pain management as it carries little risk but inconsistent results. Cognitive
behavioral therapy may be inconsistent in treating pain because the certification of the therapy is
inconsistent, and it has proven ineffective on people with mental disorders such as depression
(U.S. Department of Health and Human Services). A person without depression and an effective
clinician in cognitive behavioral therapy however may be able to effectively relieve chronic pain.
In some studies, cognitive behavior therapy proved effective in changing the patient's
expectations and mindset toward pain management aligning with the biopsychosocial model.
One trial of cognitive behavior therapy proved to reduce the intensity of back pain by 43%
(Sperry). In a similar study of patients with chronic low back pain, the meditation-cognitive
behavioral therapy intervention was able to reduce both pain severity and sensitivity (Zgierska et
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al.). In another study of participants disabled by chronic low back pain, cognitive behavioral
therapy was able to reduce disability but not pain (O’Keeffe et al.). The U.S. Department of
Health and Human Services reported that the therapy improved coping skills, functional
movement, sleep, and pain in patients. Although the therapy has not been able to produce
consistent pain relief, with growing research on how to utilize the therapy there may be some
promise for pain relief. With virtually no risks of adverse effects, cognitive behavioral therapy is
a safe alternative to currently prescribed opioids. In conjunction with the utilization of the
placebo effect and mitigating the nocebo effect, cognitive behavioral therapy may be an effective
treatment for pain management.
One known effective solution to pain is multidisciplinary teams. Multidisciplinary teams
are medical professionals with complementary skills that work together to manage pain using the
biopsychosocial model, ideally under one roof (U.S. Department of Health and Human Services).
As the team approach proves beneficial to patients, the effectiveness was obvious of a cohesive
team operating together under one roof. Multidisciplinary clinics were successful in managing
pain in America during the 1980s as complicated chronic pain patients were more effectively
treated by a team (U.S. Department of Health and Human Services). Multidisciplinary clinics
housed these teams under academic centers, but the clinics were deprioritized as academic
centers became increasingly concerned with profits (Tompkins). As American policy prioritized
private profits over patient care, multidisciplinary clinics faced opposition. As the
multidisciplinary clinics functioned as a team, they were largely unable to divide their services in
a way for insurances to accept, and insurances rejected bills from the clinics, causing patients to
have to pay out of pocket for multidisciplinary care (Tompkins). Unable to find patients capable
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of paying without the help of insurance, multidisciplinary clinics closed. Multidisciplinary
clinics were successful in managing patients with chronic pain because they had
interprofessional teams that prioritized the biopsychosocial model. While multidisciplinary
clinics may never be as populous as they were before, practitioners can learn from what they
succeeded in and apply it to their own practice. Practitioners can attempt to model this success
by prioritizing working effectively with the patient and using the biopsychosocial model in
evidence-based treatments to manage pain. Effective pain management is based on the
biopsychosocial model of pain as the patient’s psychosocial considerations are prioritized.
The biopsychosocial model provides the most accurate explanation of pain as
psychosocial factors have proved a larger role in pain than biological tissue damage the
biomedical model explains. The biopsychosocial model must be understood as it manifests in the
placebo and nocebo effects, priming, and the beliefs of the patient as they prove significant to the
patient’s experience of pain. Current pain management through the prescription of opioids has
proved ineffective for both acute and chronic pain and instead, practitioners need to prioritize
therapies consistent with the biopsychosocial model of pain as they prove safer and more
effective. The placebo and nocebo effects may be successful for pain management in conjunction
with existing therapies like cognitive behavioral therapy. Although complex, chronic pain has the
potential to be relieved through increased clinician understanding of the biopsychosocial model
and the patient.
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Works Cited
“Opioid Treatments for Chronic Pain.” Opioid Treatments for Chronic Pain | Effective Health
Care (EHC) Program, Apr. 2020, https://effectivehealthcare.ahrq.gov/products/opioidschronic-pain/research#:~:text=risk%20mitigation%20strategies.,Key%20Messages,appear%20to%20be%20dose%20dependent.
Atlas, Lauren Y., and Tor D. Wager. “How Expectations Shape Pain.” Neuroscience Letters, vol.
520, no. 2, Elsevier BV, June 2012, pp. 140–
48. https://doi.org/10.1016/j.neulet.2012.03.039.
Beecher, Henry K. “THE POWERFUL PLACEBO.” Journal of the American Medical
Association, vol. 159, no. 17, American Medical Association (AMA), Dec. 1955, p.
1602. https://doi.org/10.1001/jama.1955.02960340022006.
Berg, Jessica W. Informed Consent: Legal Theory and Clinical Practice. Oxford University
Press, 2007.
Bonfim, Igor da Silva, et al. “‘Your Spine Is so Worn Out’ – the Influence of Clinical Diagnosis
on Beliefs in Patients With Non-specific Chronic Low Back Pain – a Qualitative
Study’.” Brazilian Journal of Physical Therapy, vol. 25, no. 6, Elsevier BV, Nov. 2021,
pp. 811–18. https://doi.org/10.1016/j.bjpt.2021.07.001.
Burich, Molly. “The Changing US Reimbursement Landscape and Biosimilars.” Biosimilars,
2018, pp. 49–73., https://doi.org/10.1007/978-3-319-99680-6_3.
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Bystad, Martin, et al. “How Can Placebo Effects Best Be Applied in Clinical Practice? A
Narrative Review.” Psychology Research and Behavior Management, 2015, p. 41.,
https://doi.org/10.2147/prbm.s75670.
Chan, Bob Kwok Bun, et al. “Opioids in Chronic Non-cancer Pain.” Expert Opinion on
Pharmacotherapy, vol. 12, no. 5, Informa Healthcare, Jan. 2011, pp. 705–
20. https://doi.org/10.1517/14656566.2011.536335.
Colloca, Luana, and Franklin G. Miller. “The Nocebo Effect and Its Relevance for Clinical
Practice.” Psychosomatic Medicine, vol. 73, no. 7, 2011, pp. 598–603.,
https://doi.org/10.1097/psy.0b013e3182294a50.
Colloca, Luana, et al. “The Clinical Implications of Nocebo Effects for Biosimilar Therapy.”
Frontiers in Pharmacology, vol. 10, 2019, https://doi.org/10.3389/fphar.2019.01372.
Data-Franco, João, and Michael Berk. “The Nocebo Effect: A Clinicians Guide.” Australian &
New Zealand Journal of Psychiatry, vol. 47, no. 7, 2012, pp. 617–623.,
https://doi.org/10.1177/0004867412464717.
Engel, George L. “The Need for a New Medical Model: A Challenge for
Biomedicine.” Dimensions of Behavior, 1978, pp. 3–21., https://doi.org/10.1016/b978-0409-95009-0.50006-1.
Gawande, Dr. Atul. Being Mortal. MEHTA PUBLISHING HOUSE, 2018.
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Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders: Quick
Guide for Clinicians. U.S. Dept. of Health and Human Services, Substance Abuse and
Mental Health Services Administration, Center for Substance Abuse Treatment, 2013.
Manchikanti, Laxmaiah, et al. “Lessons for Better Pain Management in the Future: Learning
From the Past.” Pain and Therapy, vol. 9, no. 2, Springer Science and Business Media
LLC, May 2020, pp. 373–91. https://doi.org/10.1007/s40122-020-00170-8.
Miller, Franklin G., and Luana Colloca. “The Placebo Phenomenon and Medical Ethics:
Rethinking the Relationship between Informed Consent and Risk–Benefit Assessment.”
Theoretical Medicine and Bioethics, vol. 32, no. 4, 2011, pp. 229–243.,
https://doi.org/10.1007/s11017-011-9179-8.
Nazarov, Oybek, et al. “Research Utility of the National Violent Death Reporting System: A
Scoping Review.” Injury Epidemiology, vol. 6, no. 1, 2019,
https://doi.org/10.1186/s40621-019-0196-9.
O'Keeffe, Mary, et al. “Cognitive Functional Therapy Compared with a Group-Based Exercise
and Education Intervention for Chronic Low Back Pain: A Multicentre Randomised
Controlled Trial (RCT).” British Journal of Sports Medicine, vol. 54, no. 13, 2019, pp.
782–789., https://doi.org/10.1136/bjsports-2019-100780.
Ritter, Alexander, et al. “How Words Impact on Pain.” Brain and Behavior, vol. 9, no. 9, Wiley,
Aug. 2019, https://doi.org/10.1002/brb3.1377.
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Scherlinger, Marc, et al. “Switching from Originator Infliximab to Biosimilar CT-p13 in RealLife: The Weight of Patient Acceptance.” Joint Bone Spine, vol. 85, no. 5, 2018, pp. 561–
567., https://doi.org/10.1016/j.jbspin.2017.10.003.
Sperry, Len. “Chronic Pain.” Treatment of Chronic Medical Conditions: Cognitive-Behavioral
Therapy Strategies and Integrative Treatment Protocols., pp. 153–171.,
https://doi.org/10.1037/11850-011.
Vaegter, Henrik Bjarke, et al. “Power of Words: Influence of Preexercise Information on
Hypoalgesia After Exercise—Randomized Controlled Trial.” Medicine &Amp; Science
in Sports &Amp; Exercise, vol. 52, no. 11, Ovid Technologies (Wolters Kluwer Health),
May 2020, pp. 2373–79. https://doi.org/10.1249/mss.0000000000002396.
Wojtukiewicz, Marek Z., et al. “It Is Not Just the Drugs That Matter: The Nocebo
Effect.” Cancer and Metastasis Reviews, vol. 38, no. 1–2, Springer Science and Business
Media LLC, June 2019, pp. 315–26. https://doi.org/10.1007/s10555-019-09800-w.
Zgierska, Aleksandra E., et al. “Mindfulness Meditation and Cognitive Behavioral Therapy
Intervention Reduces Pain Severity and Sensitivity in Opioid-Treated Chronic Low Back
Pain: Pilot Findings from a Randomized Controlled Trial.” Pain Medicine, vol. 17, no. 10,
2016, pp. 1865–1881., https://doi.org/10.1093/pm/pnw006.