Even with the end of the horrendous year that is 2020, a constant ring has remained which tolls New Year’s resolutions. In pre-COVID years, during the first few months of the years, I am never surprised by the increased crowds in my gym as many put action to their plan for a healthy new year.
As a pain physician, I analyze the pain descriptions of my patients, and one of my primary jobs is to find clinical patterns. There are many times when a patient fits into a diagnosis, but I have found the most predictive pattern for sustained success in patients suffering from chronic pain and it is found in lifestyle change. Physical therapy, medications, injections, and surgery prove helpful but rarely the sole reason that a patient becomes and stays better. These treatments are always targetting to help one exercise more frequently, more effectively, to improve posture, and to improve one’s thoughts and emotions. To live and feel more positive are the keys to success and this is a function of lifestyle, rather than treatment.
New Years Resolutions celebrate the power and struggle of lifestyle change. As every year the enthusiastic crowd pours into the gym making it harder to find a locker in January, it predictably dies down by April or May and I find the ability to secure open space again. Lifestyle change is a constant battle. For the most part, we all know what we should do to live a healthy lifestyle, but keeping the motivation and dedication to keep constantly committed is a separate challenge.
I have always found that making a positive change can come in two separate approaches: slow, gradual changes or through abrupt momentous events.
The careful and methodical little by little approach has merits. It is not scary. A person can identify little problems get used to making these adjustments and then overtime, perpetually make more and more little changes and each adjustment is so minor that on its own, it should have little stress. This approach is the one I prefer when making plans to lower opioid medications. I take on the care of many patients previously treated by other physicians that prescribed high doses of opioids. It is almost universal, that the high doses never allowed dramatic improvements in pain reduction, physical function, or health, but they do carry significant medical risk. My plan is simple in these cases, I take a long term approach. I work every month or two to make a small, barely noticeable decrease in the daily dose of the opioid. The goal is to have the patient not notice this change. Then over the course of five to six months, we take a look back and realize the little changes add up and without much stress, the patient has been able to cut the dose by 30-40%. A real sense of accomplishment is felt. Usually, the pain levels are more or less the same, which on the one hand is not an accomplishment, but on the other hand, the patient is exposed to fewer opioids which improve hormone function, immune function, and clearer thinking. In every single case, there is a greater sense of health and well being and this enables more focus on non-opioid strategies for treating pain. It is this gradual lifestyle change that has been a proven key to success.
Another catalyst to change occurs through epiphany. An epiphany is a sudden, profound, momentous event that shocks you into a perspective shift and inspires immediate change. It is similar to a religious experience where one feels a thunderous power to shift consciousness and value systems. In my experience, these life-changing events can be extremely lasting and effective. Patients are inspired and rejuvenated and there is less resistance to change in these moments. It is hard to simulate a breakthrough in the clinical setting, but in our practice, we have noticed this impact in patients undergoing ketamine infusions for severe chronic pain or depression.
Ketamine is an anesthetic medication that has been used since 1950 to induce or help with anesthesia in humans. It is not simply a horse tranquilizer, which is a popular misconception. Ketamine is safe from the perspective that it does not lower blood pressure or heart rate, and it does not cause respiratory suppression. It has had relatively limited use because one of the side effects is that at higher doses it can cause hallucinations, which many patients find unpleasant. However, some find these visions uplifting. The use of ketamine for pain was exciting because it blocks pain pathways through the NMDA receptor and works differently than opioids or the inflammatory signals of more common pain medications. Ketamine has been shown some promise in complex regional pain syndrome, but it lacks robust studies for universal use. There is growing research to suggest significant benefit in depression, especially when other conventional treatments have failed.
I have noticed excellent results in uplifting my patient’s moods and have a lasting benefit in my patients struggling with chronic pain when depression or anxiety has been a huge roadblock to improvements. A single ketamine treatment acts as an epiphany to many of my patients. They describe a profound life-changing event during the treatment that can have the effect of triggering a new way of looking at the world. This shock to the system stands in contrast to the more calculated and tedious efforts to make a change, but the results are just as exciting and profound.
Anyone seeking lifestyle change needs to find the inner workings of their motivation to find the trigger to make a shift. Whether it is safe and slow or through a single sudden Aha! moment, the evolution of the patient that I am able to witness in my patients is always inspiring.