Tag Archives: CBT

Mindfulness, CBT Can Be More Effective for Pain Than Meds

When it comes to easing chronic pain, non-drug treatments such as mindfulness and cognitive behavioral therapy (CBT) can be more effective than medication and without the side effects.

Researchers examined 21 clinical trials that enrolled 2,000 people. They focused on CBT and mindfulness-based stress reduction as therapies for chronic pain in those trials. The latter involves meditation and simple yoga poses.

Patients in the studies had pain resulting from arthritis, fibromyalgia and temporomandibular joint disorder (TMJ), which involves the jaw. Some dealt with lower back pain.

Results, published in the journal Evidence-Based Mental Health, found that changes in physical functioning, pain intensity and depression were better in those who engaged in CBT and mindfulness compared to those who took medication. However, the researchers noted that those effects were “small.”

CBT is a widely used approach to treating chronic pain. It’s not clear whether CBT is more effective than mindfulness as only one of the trials examined compared the two against each other.

Quick Hits: Medical Treatment Adverse Event Death Drop and Antidepressant Tapering With Psychotherapy

Deaths related to the adverse events of medical treatments fell between 1990 and 2016. Researchers examined the causes of death listed on death certificates as well as data from the Global Burden of Diseases, Injuries and Risk Factor tool. Overall, the mortality rate due to adverse events declined by 21.4% from 1.46 per 100,000 people to 1.15 over the time period. However, researchers noted that age was a significant factor in mortality. The mortality rate for those aged 70 and over was nearly 20 times higher than for those between 15 and 49. Location also influenced the rate, with California having the lowest and Mississippi the highest. The most common reason for an adverse event from medical treatment was surgery and post-operative complications. Posted January 18, 2019. Via JAMA Network Open.

Tapering off antidepressants is more successful and a person has a lower risk for relapse if it is done along with psychotherapy. Researchers conducted a meta-analysis of 15 studies and found that after two years, the risk for relapse was between 15% and 25% for cognitive behavioral therapy and tapering compared to 35% to 80% with just regular clinical visits and tapering. The study’s authors note that in western countries, antidepressant prescriptions have doubled over the last decade. In addition, the average length of time on an antidepressant in the US is five years, and the medications are often prescribed by a primary care physician, not a psychiatrist. Posted January 22, 2019. Via Annals of Family Medicine.

Areas of the country where drugmakers spent more money marketing to doctors are linked to higher rates of opioid use, according to a new study. Researchers say that counties that had the most opioid marketing from pharmaceutical companies to healthcare providers subsequently had the highest rates of opioid prescribing and opioid overdose deaths. Between August 2013 and December 2015, drug companies spent about $40 million on opioid marketing to more than 67,000 physicians. The Northeast US had the highest marketing and the Midwest the lowest, the study found. Also, for every three additional payments made to doctors per 100,000 people in a county, opioid deaths increased 18%. Posted January 18, 2019. Via JAMA Network Open.

5 Non-Pharmacological Treatments for Depression

An estimated 17% of Americans will experience depression at some point in their lives. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs), the most commonly used drugs for depression, are usually the first-line treatment, along with talk therapy. However, these drugs are only effective in 50–60% of people, and even when they do work well, there may still be side effects ranging from headache, nausea and sexual dysfunction to loss of motor control and suicidal thinking.

While antidepressants have certainly helped many people manage their symptoms, the poor response rate makes it clear that alternatives are needed. But first things first: Before trying to figure out what kind of treatment to opt for, make sure you’re covering your self-care basics, including regular exercise, adequate sleep, and proper nutrition as all three of these can have an influence on depression.

“For instance, it is well understood that sleep deprivation can adversely impact mood, yet 1 in 3 American adults are sleep deprived,” according to Fraser Smith, ND, assistant dean of the naturopathic medicine program at National University of Health Sciences. Naturopathic medicine is focused on using natural remedies and techniques such as herbs, acupuncture, exercise and nutrition to help the body heal. Also, the brain “needs adequate proteins and other nutrients to make the chemical compounds that we see as prerequisite for emotional balance. So, this is the start.”

If you’re doing well in those areas but still struggle with depression, there is a range of other options that have been found to be helpful.

1. Cognitive Behavioral Therapy (CBT). “From my biased perspective as a psychotherapist, I believe that all depressed patients should try a strong evidence-based psychotherapy like CBT as their first choice of treatment,” says Desmond Oathes, PhD, assistant professor of clinical psychology at the Perelman School of Medicine at the University of Pennsylvania.

Psychotherapy teaches patients new skills that can help them take control of their symptoms and manage stress better, and research suggests that it works as well as antidepressant medication and may benefit patients for a longer period of time after treatment ends.

A main goal of CBT is to help patients change negative behaviors and ways of thinking that are linked to depression. Tevin Blackwell often thought the worst when things didn’t go his way. If a friend didn’t return his call, for example, he would automatically focus on thoughts like, “No one likes me.” With CBT, he has learned to think more rationally and remind himself that there are lots of reasons someone might not return a call, and that it doesn’t mean people don’t like him.

2. Acupuncture. Acupuncture is a traditional Chinese medicine technique in which thin needles are inserted into the skin at specific points on the body with the aim of balancing the flow of energy in the body to reduce symptoms of various conditions, including pain, insomnia, and depression. Some acupuncturists suggest using the technique to complement psychotherapy.

A Cochrane review of studies suggested that this approach may reduce depressive symptoms more than usual treatment or no treatment. However, the review noted that comparing the effects of acupuncture to medication and psychotherapy is unclear because of low-quality evidence. But there appear to be fewer side effects with acupuncture than with antidepressant medications.

Two studies even showed that acupuncture was an effective treatment for pregnant women with major depression disorder – with the same rates of adverse events as those who received massage. In other words, this treatment appears to be quite safe. The most commonly reported side effects are soreness or slight bleeding or bruising in the areas of the body where the needles were inserted.

3. Supplements. Researchers have demonstrated the benefits of some dietary supplements on depressed mood. “There are herbs that boost the levels of chemicals in the brain that are linked with improvement in depression,” Dr. Smith explains. A 2016 review of 35 studies involving St. John’s wort found it to be as effective as antidepressants, but with fewer side effects, in those with mild to moderate depression. However, its effectiveness in those with severe depression is uncertain. Jennifer Keely turned to the herb after trying two different antidepressants and finding that they made her feel “emotionally numb,” and she has noticed a big difference in her mood.

There is one major downside to St. John’s wort: It can interact with many drugs, so the use of this herb in patients who take medications should be carefully planned and monitored by a healthcare professional. “Herbs sometimes get a bad rap for causing interactions, although there is far more documentation about drug-to-drug interactions,” Dr. Fraser points out. “All the same, consumers should take the risk of an herb-drug interaction seriously and tell their healthcare providers what they are using – including over-the-counter drugs and dietary supplements.”

While St. John’s wort has the strongest evidence so far for improving depression, other supplements, such as S-adenosyl-L-methionine (SAMe) and omega-3 fatty acids like those in fish oil pills, have also shown promise for this purpose.

4. Repetitive transcranial magnetic stimulation (rTMS). “For patients with severe depression that don’t respond to therapy or medications, there are a variety of options ranging from less to more invasive,” says Dr. Oathes. On the non-invasive side, rTMS is a technique provided on an outpatient basis that does not require anesthesia. This FDA-approved treatment delivers magnetic pulses to the brain to stimulate nerve cells that influence mood and depression.

Results of numerous studies indicate that rTMS is safe and effective for many patients who do not get better with other types of treatment. When side effects occur, they are usually mild and include headache and scalp discomfort where the stimulation took place. “Risks also include the possibility of inducing a seizure, but this risk is extremely small in people who have been medically screened and cleared for rTMS treatment,” notes Dr. Oathes. “Treatment with rTMS requires sessions five days a week for more than one month and possible booster sessions, which is not an option for everyone.”

5. Electroconvulsive therapy (ECT). ECT is a moderately invasive approach in which patients are given a shock (hence the term “shock therapy” that ECT was known as in the past), resulting in a seizure while under anesthesia. “Although this looks scary and has been given a negative stigma due to memory problems – usually temporary – that it can induce, this treatment is effective for severe cases,” says Dr. Oathes. “Benefits include possible dramatic symptom relief in six to 12 sessions.”

By some estimates, ECT is effective for 64–87% of patients with severe major depression. Since ECT was first invented in the 1930s, it has become much more refined and safer. For example, less electricity is now used during the procedure.

“Depression is common and treatable, but there are many patients for whom standard treatments do not work,” states Dr. Oathes. Fortunately, the approaches described above offer hope for individuals who do not respond to antidepressant medications or for whom side effects are too severe, as well as those who prefer or require a non-pharmacological option.

Need to Know: ADHD Medications

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental health disorders in the United States. As of 2016, 9.4% of kids aged two to 17 years had been diagnosed with ADHD, and an estimated 4.4% of U.S. adults aged 18 to 44 years have also been diagnosed. This translates into millions of people who take ADHD medications. Here’s what you need to know about these drugs to help you make empowered decisions.

Common Names

There are two main types of ADHD medications: stimulants and non-stimulants. Stimulants include methylphenidate (Ritalin LA, Concerta, Daytrana, Quillivant XR, others), dexmethylphenidate (Focalin) and amphetamines like lisdexamfetamine (Vyvanse), dextroamphetamine (Dexedrine, ProCentra, others) and mixed amphetamine salts (Adderall, Mydayis). The most commonly prescribed non-stimulants for ADHD are atomoxetine (Strattera), clonidine (Catapres), guanfacine (Intuniv) and bupropion (Wellbutrin), though bupropion is not FDA approved as an ADHD treatment.

How They Work (Method of Action)

It’s unclear exactly how they work, but stimulants seem to increase levels of the neurotransmitter dopamine, while non-stimulants boost the neurotransmitter norepinephrine, both of which help different areas of the brain communicate more effectively. This in turn improves alertness, impulsiveness, attention and hyperactivity.

Side Effects and What to Do About Them

The most common side effects of taking any of the stimulants are dry mouth, difficulty sleeping, irritability, decreased appetite, weight loss, headaches, tics, feeling jittery and a racing heartbeat.

The non-stimulant Strattera can cause the same effects, as well as constipation, sexual difficulties, dizziness, nausea, fatigue and sweating. Catapres and Intuniv can both cause sleepiness during the day. Some or all of these side effects may go away after you’ve been on the medication for a while, but if they don’t or they’re severe, your doctor can try changing your dose, switching you between long-acting and immediate-release versions of the drug or trying a different kind of medication.

More serious side effects are rare, but with stimulants, they can include heart problems, hallucinations, suicidal thinking or behavior, or becoming aggressive. For the non-stimulant Catapres, watch for rash, hives, difficulty breathing, difficulty swallowing and swelling in your tongue, mouth, face, hands, feet, ankles or legs. Some of Strattera’s serious side effects are dizziness, chest pain, racing heartbeat, difficulty breathing, slowed speech, weakness and itchy skin. With Wellbutrin, serious side effects include hallucinations, seizures, paranoia, fever, fast heartbeat and pain in your muscles or joints. Intuniv’s serious side effects are rash, blurry vision, fainting and a slowed heartbeat. If you notice any of these, call your doctor right away.

User Experiences

Diagnosed at the age of 20, Collin Lindhorst, 39, has tried Adderall, Ritalin, Ritalin XR, generic Ritalin (methylphenidate) and Vyvanse. Currently, he’s taking Vyvanse and Wellbutrin together. He says that Adderall “made me feel like I had 10 cups of coffee in one sitting and gave me headaches,” and that Ritalin put him on edge and made him feel snippy and grumpy. Though all of the medications, except Adderall, helped him feel more motivated, energized and focused, “Vyvanse has been the best,” Lindhorst says. “Most of the other medications felt like they kicked in, worked for a short while and then I came down quickly.” Like others with ADHD, Lindhorst has been on and off ADHD medications over the years “because I feel like I have a handle on things, but after two to six months, I fall back into the same pattern of low motivation, depression and falling behind on tasks. What I know now at 39 is that I can’t function properly or efficiently without my medications. They are a need.”

Andy V., 38, was diagnosed with ADHD eight years ago. At first, he was on Adderall XR for a few months, but he says even just being on that initial low dose made him feel jumpy and excitable. “I recall multiple instances of hopping up from my desk and jogging through my office to catch co-workers between calls for impromptu face-to-face meetings,” he says. “I believe it was also the cause of me not being able to climax during sexual activity with my spouse.” However, he has been on increasing doses of Vyvanse for the past seven and a half years and says he has no side effects. Though he had side effects with Adderall, he says,“both medications worked extremely well. They allowed me to focus on specific tasks without being sidetracked by unimportant or unnecessary thoughts and actions.”

Anita Drink’s* son, 15, was diagnosed with ADHD four years ago in sixth grade, and he’s been on generic Concerta, a long-acting version of methylphenidate, ever since. He’s also tried, but didn’t like, intermediate-acting methylphenidate to get him through shorter times, like half days of school, and Intuniv for his issues with falling and staying asleep. “The first night [on Concerta] was horrible,” Drink says. Not only was he unable to fall asleep for hours, his arms and legs were jerking and he was shaking uncontrollably. “Fortunately, the second night was better, and that never happened again,” says Drink. Her son’s main side effect is a lack of appetite, which has prompted growth monitoring via regular weight checks and X-rays of the growth plate in his wrist. Because of his sleep problems, he’s extremely tired in the morning and before starting Concerta, he often fell asleep at school. Concerta keeps him awake and “really helps him pay attention in school. If he doesn’t take his medication, he finds it difficult to focus and often doesn’t remember what happened in class.”

Drug Interactions

Both stimulants and non-stimulants may interact with other medications, so let your doctor or pharmacist know about all other over-the-counter or prescription drugs you’re taking, as well as herbal remedies, supplements and vitamins.

Effectiveness and Considerations

The majority of people on ADHD medications take stimulants, since they are the most effective, improving symptoms in 70% to 80% of children and 70% of adults. However, non-stimulants are an option for patients who can’t take stimulants, haven’t been responsive to them or don’t want to use them.

Medications affect people differently, so what worked for one person may not work as well for another. With ADHD medications, it’s important to be patient until your doctor can find the best kind for you, and this can take some trial and error. It should give you the most effective relief with the fewest side effects.

Stimulants do have the potential to be habit-forming, but taking them as prescribed for ADHD doesn’t cause dependence or abuse. A 2003 study found that untreated ADHD leads to more substance abuse disorders than treated ADHD. Still, especially if your kids are taking these drugs, make sure they only take them as prescribed and that they understand the dangers of both taking too much and sharing their medicine.

People with heart conditions shouldn’t take stimulants because they can cause sudden death in children and teens, and sudden death, heart attack or stroke in adults.

Alternatives to ADHD Medications

Medication is usually the first-line treatment for older children (12 to 18 years old) and medication along with behavior therapy is also recommended for children aged six to 11, according to American Academy of Pediatrics (AAP) guidelines. Cognitive-behavioral therapy (CBT) can also be a helpful adjunct treatment in learning to cope with relationships and functioning at work or school.

For children under the age of six, the AAP recommends behavior therapy first, with the addition of medication if necessary. Behavior therapy teaches kids new behaviors that help them cope with school, relationships, disorganization and impulsiveness. Parents can also learn effective ways to reinforce these skills. Studies have shown that behavior therapy is just as effective as medication in this age group.

For kids aged six years and older, both medication and behavior therapy are recommended and it’s best if they’re used together.

Some people prefer to use alternative treatments like taking dietary supplements, acupuncture, neurofeedback or yoga. According to the National Center for Complementary and Integrative Health, research has shown either no benefit or mixed outcomes regarding using these approaches to treat ADHD. Be sure to talk to your doctor before trying any alternative treatment, even if you’re just planning on adding it to your current treatment. This is especially important when it comes to supplements, as they may create an interaction with ADHD medications.

*Name has been changed to protect privacy

Quick Hits: Oral Contraceptives May Cut Ovarian Cancer Risk, Lyrica and Chronic Pain & More

The newest generation of oral contraceptive pills may help to reduce the risk of ovarian cancer in young women. Prior research on older contraceptives, which contain higher levels of estrogens and older progestins, showed that they were effective in reducing ovarian cancer risk, though there was uncertainty whether this also held true for newer contraceptives. Researchers looked at data on 1.9 million Danish women who were categorized as either never having used contraceptives, current or recent users (up to one year after stopping use) and former users (more than a year since use). Women who never used contraception had more than twice the risk of developing ovarian cancer compared with women that were using contraception or had used it. Authors noted the study was observational in nature, so they can’t make conclusions about cause and effect. Posted September 26, 2018. Via BMJ.

The pain medication Lyrica (pregabalin) is no more effective than a placebo in lessening chronic pain following a traumatic nerve injury, according to a new study. Although Lyrica is not approved for this purpose, many doctors prescribe it to patients after car accidents, falls, injuries and knee or hip replacements. Researchers followed 539 people who were experiencing nerve pain. Half were given Lyrica and the other half a placebo. In patients that experienced a traumatic nerve injury, both groups reported a lowering of pain symptoms during the study, though it wasn’t any greater in those taking Lyrica. Researchers, however, did find that those participants whose pain resulted from surgery had better pain relief from Lyrica compared with a placebo. Posted September 24, 2018. Via Journal of Neurology.

Cognitive behavioral therapy (CBT), delivered online, can be an effective way to treat insomnia as well as improve other aspects of a person’s health – and without the side effects of medication. Researchers enrolled about 1,700 people with insomnia in their study. Half received digital CBT and half received sleep hygiene education. Digital CBT was found to improve one’s ability to do daily activities only modestly better than via sleep hygiene education. However, CBT led to a larger improvement in sleep-related quality of life compared with the sleep education. One limitation of the study is that only 58% of those in the CBT group completed 4 or more sessions. The study was also sponsored by Big Health Ltd, the developer of the digital CBT program. Posted September 25, 2018. Via JAMA Psychiatry.

How to Kick Insomnia Without Turning to Pills

Although sleep is one of the most basic human needs, many people treat it as optional. We’ve all had the occasional sleepless night. But when tossing and turning in the night or having trouble falling asleep becomes chronic, you’re likely suffering from insomnia.

Lost sleep can have serious consequences. Studies have found that sleeping less than 7 hours per night is linked to a higher risk of high blood pressure, diabetes, stroke, heart disease and death. Not sleeping enough also increases the risk of accidents on the road, in the workplace and elsewhere.

Many insomnia sufferers seek relief with sleeping pills, among the most commonly prescribed medications in the US. However, these rarely help the situation, adding less than 35 minutes of sleep per night – and they often create new issues, according to the American Academy of Sleep Medicine.

Sleeping pills can be addictive and may lead to even worse sleep once you stop taking them — there’s a rebound effect. They can also cause drowsiness during the day and other problems like dizziness, hallucinations, sleepwalking and sleep-eating.

Behavioral Therapy Beats Sleeping Pills

Fortunately, there are lots of other ways to improve sleep without the side effects seen with medications such as Ambien (zolpidem). For example, studies have found a type of counseling called cognitive behavioral therapy (CBT) to be the best treatment approach for insomnia.

CBT is the “gold standard treatment for insomnia, in which patients meet with a sleep behavioral psychologist to complete an individualized plan involving behavioral changes to improve sleep,” explains Rachel Marie E. Salas, MD, MEHP, FAAN, an associate professor of neurology and nursing at Johns Hopkins Medicine. CBT helps people improve sleep-related behaviors and addresses negative ways of thinking that can make matters worse — like “If I don’t fall asleep soon, there’s no way I’ll make it through the day tomorrow.”

In 2016, the American College of Physicians issued a guideline that CBT was better than sleeping pills for treating insomnia. The professional group noted that CBT was more likely to lead to longer-lasting effects compared to sleeping pills, which are only meant to be taken for 4 to 5 weeks at most.

It’s also important to deal with ongoing stress or anxiety, says Eddie Reece, MS, LPC, DCC, a psychotherapist in private practice near Atlanta. “I think most people with insomnia, including me, are fairly anxious people.”

He points out to patients that “it’s not just what you’re doing during the night that matters — if you’re revved up all day until it’s time to go to bed, it’ll be difficult to get to sleep.”

Additionally, people are often unaware of how their surroundings and habits may be affecting their sleep. Amy Rothenberg, ND, a Connecticut-based naturopathic physician, asks patients with insomnia to first adopt regular sleep and wake times that they should follow every night, including weekends, and to make sure that their mattress and pillows are comfortable. If noise is a common problem, a fan or white noise machine can be helpful.

Turn Those Electronics Off!

She also advises patients to turn off all electronics at least 1 or 2 hours before bedtime. “This is extremely challenging for many people, but research now confirms that constant screen time, especially late into the evening, may interfere with the quality and quantity of sleep,” she notes.  “The light from devices will have your brain thinking it’s not time for bed. Then the stress of reading emails or watching shows adds cortisol to the bloodstream, which further interferes with sleep.”

Unplugging in the hours before bed has made all the difference for Rich Mallard, a customer service rep who used to stay glued to his laptop right up until he turned off the lights — and often ended up tossing and turning for half the night. Since he started shutting the screen down a couple of hours before bed, he says, his sleep has improved dramatically.

Dr. Rothenberg also recommends regular exercise of just about any type — walking, running, swimming, dancing, biking — which is associated with better sleep.

Apps or online resources that guide you through breathing exercises or mindfulness meditation may also help calm your mind to prepare you for a good night’s sleep. UCLA’s Mindfulness Awareness Research Center has free guided meditations you can download.

Reece teaches patients various techniques like these, and has them pick the ones they like best and practice them when they have sleep trouble. “Then, when they’re not sleeping, instead of that being a bad thing, it’s great because now they have time to practice,” he says.

He also encourages patients to focus more on rest than sleep, which can help ease the anxiety that arises from not being able to sleep. “You have much more control over resting than you do going to sleep — and it just so happens that if you rest well at night, you might just fall asleep!”

Natural Remedies to Promote Sleep

As for natural remedies, the herb valerian has long been used as a mild sedative that can help with sleep problems. “We generally recommend standardized extracts, which are available at health food stores, with 1 to 2 caps taken before bedtime,” says Dr. Rothenberg. “Valerian is gently relaxing — it won’t knock someone out like a pharmaceutical sleeping aid, and it should not cause morning grogginess.”

Another natural substance that may be helpful is melatonin, a “hormone that helps to keep biorhythms including the wake/sleep cycle in good working order.” The recommended dosage varies for each person, as some need more while others need less.

In addition, Dr. Salas offers the following tips to improve your chances of sleeping well:

  • Make your room darker. Light interferes with a person’s circadian rhythm. He recommends using lamps and dimmers in the evening, and to remove glowing bedside clocks.
  • Limit caffeine after noon.
  • Wash bed sheets every 1 to 2 weeks.
  • Create a bedtime routine. For example, take a warm shower or bath, don your PJs, and do some relaxing reading.
  • Keep your room somewhere between 65 to 69 degrees, which is an ideal range for most people. (Being too hot or too cold can interfere with sleep.)
  • Spicy or fatty meals may cause you to wake up with indigestion. Eat 3 hours before bed. Same goes for alcohol. If you’re hungry before bed, a light snack such as yogurt or cereal is okay.
  • Lastly, talk with your healthcare provider. Insomnia is interesting because while it can be a sleep disorder itself, it can also be a symptom of something else that often can be treated. If improving your sleep practices, behaviors, environment and patterns does not improve your sleep, it is time to seek medical advice.

Got Chronic Pain? Cognitive Therapies May Provide Relief

Elderly people living with chronic pain may find some relief if they treat it with psychological interventions, such as cognitive behavioral therapy (CBT), according to a study published in JAMA Internal Medicine.

Researchers looked at 22 studies that evaluated 2,608 participants undergoing psychological interventions. The results indicated that psychological interventions proved effective for many adults battling chronic pain. CBT methods reduced their pain, minimized their catastrophic thinking and improved their self-efficacy, equipping them with the confidence to successfully manage their pain.

Even though many of the studies didn’t evaluate the long-term effects associated with the psychological therapies, this study still demonstrates the benefits that come with the treatment, the authors say.

Can the Pain Without the Meds: 8 Non-Pharma Therapies

“When your whole body is a giant toothache, nothing fixes it,” observes Charley Pavlosky, 62, recalling the systemic pain that plagued him 11 years ago. A lifelong athlete, he was familiar with the aches and pains of being active – he’d even had surgery to repair a disc – but this was new to him.

His chronic pain was so severe that he was only getting 2 hours of sleep a night, and during the day he experienced anxiety and panic attacks. The Santa Barbara, Calif., resident found a comprehensive nonpharmaceutical pain management program developed by spine surgeon David Hanscom, MD, author of Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain.

With the exception of a temporary prescription for Ativan (lorazepam) to help him sleep, Pavlosky began to create a pain-reducing lifestyle. Pavlosky was mostly pain free within 6 months of working on sleep hygiene along with cognitive behavioral therapy (CBT) and twice-daily expressive writing techniques. Then he gradually weaned himself off the Ativan. He also eats a whole foods diet, stays physically active, drinks plenty of water, and allows himself a massage as needed.

Pavlosky is one of the estimated 100 million adults who live with chronic pain, a condition that costs the United States between $560 and $630 billion annually in healthcare expenses and lost productivity, according to the American Academy of Pain Medicine.

People living with pain may be offered surgery or medications from numerous classes of drugs, including corticosteroids, muscle relaxants, anticonvulsants, antidepressants, opioid pain medications and more.

The landscape of pain management is changing rapidly, as legislatures and federal health agencies seek to more tightly control and monitor opiate pain medication prescription practices. These changes are in response to an increase in prescription pain medications – which quadrupled nationally between 1999 and 2014, according to the Centers for Disease Control and Prevention. Pain remains one of the leading reasons that people seek medical care.

“When we’re treating people with pain, are we treating suffering, or are we treating pain? The expectation of being pain free is an unrealistic expectation for the patient and the doctor,” says osteopath Doug Jorgensen, DO, founder of Patient360, a physician registry firm. Jorgensen observes that for the past 2 decades the trend has been to try to provide medication that would mask pain as much as possible.

“What medicine has done is, we keep throwing simplistic solutions at a complex problem. As the awareness of the complexity of pain grows, we believe in treating every aspect simultaneously,” says Dr. Hanscom, who lived with intense chronic pain for 15 years before developing his multilayered approach to pain management. Dr. Hanscom is in private practice with Swedish Neuroscience Specialists in Seattle.

The complexity of Hanscom’s program reflects the recommendations for non-pharmaceutical pain management outlined by the American College of Physicians clinical practice guidelines and in the Academic Consortium for Integrative Medicine & Health Pain Force White Paper published in 2017.

People with chronic pain might still need medications or surgery. These 8 strategies can be used on their own or with other medical treatments to reduce pain:

  1. Acupuncture. Nurse practitioner Elizabeth Spokoiny, DPNC, RN, on staff at the University of Washington Medical Center in Seattle, found relief from pain with acupuncture after a car accident in 2015, and then was able to tackle 20 years of pain caused by an autoimmune condition. In addition to acupuncture, she uses dietary change, meditation, bodywork and yoga to manage pain. Her experience with acupuncture is mirrored by clinical data. A research review published in a 2017 issue of Programme Grants for Applied Research showed acupuncture to be more effective than a placebo or no treatment.
  2. Massage therapy. At least an hour a week of massage therapy or other soft tissue manipulation could improve your experience of pain. Massage is recommended by the American College of Physicians Clinical Practice Guidelines for acute, subacute and chronic pain.
  3. Meditation, relaxation and biofeedback. These are practices that connect your mind and your body despite pain, and are recommended by the ACP. “My first experience with chronic pain was 40 years ago, when I was 25 years old,” recalls biofeedback practitioner Cindy Perlin, LCSW, author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free, in private practice in Albany, N.Y. “I also use exercise, nutrition, homeopathy, energy psychology, occasional massage, self-massage and, most recently, low-level laser therapy to deal with pain challenges that come up.”
  4. Yoga, tai chi and Pilates. Although pain can make you want to be still, movement can also reduce pain. “Movement causes us to produce endorphins, which are naturally occurring opioids,” says integrative medicine pain specialist Heather Tick, MD, associate professor of anesthesiology and pain management at the University of Washington in Seattle.
  5. Nutrition. Make sure your plate offers a rainbow of fruits and vegetables. “Most people don’t know that everything you eat can impact your body chemistry,” says Dr. Tick, lead author of the Consortium’s white paper. She recommends giving up sugary, fatty, processed foods. Instead, aim for the anti-inflammatory eating pattern outlined by the Academy of Nutrition and Dietetics. This approach emphasizes eating produce, whole grains, heart-healthy fats, plant-based proteins or fish, and fresh herbs as seasoning. Dr. Tick also advocates certain supplements, such as magnesium, vitamin D, fish oil and turmeric (curcumin).
  6. Hands-on manipulative therapies. Massage, osteopathic treatment and chiropractic treatments all are evidence-based approaches to pain management.
  7. Challenge your thoughts. CBT is an approach that helps identify harmful thought patterns and provide alternative thoughts, while also identifying and supporting your resilience. CBT has been shown to help with many aspects of pain management, according to a review of research published in the February issue of Physical Therapy.
  8. Sleep better. The relationship between pain and sleep is dynamic: Pain interferes with getting the sleep you need, and sleep deprivation makes pain feel worse. Taking steps to improve the quality of your sleep will be part of your pain management strategy. Pavlosky stresses the value of being more mindful about quality sleep habits. “I don’t look at screens for at least an hour to 2 to 3 hours before sleep. I dim the lights after sundown, so my body can slowly start preparing. I don’t have any coffee or caffeine after noon and no alcohol late at night,” he says.

Finally, whether you opt for any of these approaches, or medication or surgery, make sure your expectations for pain relief match up with the reality of the treatment, advises Sal Raichbach PsyD, LCSW of Ambrosia Treatment Center. Raichbach recommends a substantial conversation so that you and your physician understand both your hopes for pain relief, as well as what you might expect from any given mix of therapies.

Insomnia? Skip the Meds for Other Therapies Without Side Effects

Prescription and over-the counter (OTC) sleep aids are among the most widely used medicines. Their popularity has been spurred by aggressive marketing over the last decade — almost every adult knows what Ambien is — but also by changes in our culture that have disrupted good sleep habits (TVs, computers, smartphones, the Internet, etc.) and exacerbated things for people prone to clinical insomnia (work and life stress, economic displacement).

Much has been written about this issue and the drugs themselves, with lots of hand-wringing and popular advice. But for the past 2 decades, physicians and public health officials mostly went with the societal flow — acceding to the growing demand for and use of prescription and OTC sleep aids.

That’s now beginning to change, and fast. More and more research and data show that these medicines are being abused, overused, and unwisely prescribed — and there are better solutions.

The latest research to reach this conclusion comes from the Agency for Healthcare Research and Quality (AHRQ), a federal government entity. Researchers contracted by AHRQ to probe all the recent studies on insomnia treatment found cognitive behavioral therapy (CBT) to be a more consistently effective way to combat chronic and intermittent insomnia — especially over the long term — compared with any insomnia or sleep medicine. (More about CBT below.)

The problem is that both the prescription and OTC sleep drugs are intended for short-term use — a week to 10 days — but are being widely used over longer periods. An analysis by Thomas Moore of the Institute for Safe Medication Practices found, for example, that two-thirds of people taking zolpidem (generic Ambien) used it for weeks, months or even years.

While that analysis focused on Ambien, the same problem likely exists for Ambien’s competitors Lunesta (eszopiclone) and Sonata (zaleplon).

Such long-term use has been associated with psychological addiction and a heightened risk of morning drowsiness, falls and accidents. These effects have been highlighted in numerous court cases surrounding fatal and non-fatal auto and other kinds of accidents.

In addition, Moore’s analysis found that 1 in 5 people who took Ambien combined it with an opioid. That combination vastly increases the risk of dangerous side effects and even potentially fatal depression of the central nervous system.

The good news: Prescriptions for these medicines are declining amid attention to their downsides and risks. But they are still prescribed way too often. Here are some numbers, compiled from IMS Health, which tracks drug sales worldwide:

  • Prescriptions for Ambien declined from just above 3 million in December 2014 to 2.6 million in May 2016.
  • Prescriptions for Lunesta declined from 249,000 in December 2014 to 240,000 in May 2016.
  • Prescriptions for Sonata declined from 71,900 in December 2014 to 63,200 in May 2016.
  • Prescriptions for Belsomra (suvorexant), the newest prescription sleep aid (approved by the FDA in August 2014 but not sold until early 2015) rose from 7,258 in February 2015 to 44,466 in March 2016, but declined to 39,914 in May 2016.

OTC Insomnia Drugs

As for the OTC sleep drugs, they can hook you as well, according to medical experts and Consumer Reports. There are dozens of kinds, but the big sellers are Advil PM, Nytol, Simply Sleep, Sominex, Tylenol PM, Unisom SleepMinis, and ZzzQuil, from the makers of NyQuil.

The active ingredient in all these drugs is diphenhydramine, a decades-old antihistamine used as a remedy for seasonal allergies. It works by blocking the histamine receptors in the brain that control wakefulness, so drowsiness is a side effect for most people.

The packaging on these medicines suggests they are “non-habit-forming” when used as directed — that is, for short periods. And the FDA requires the package inserts to tell consumers to see their doctor if insomnia persists for more than 2 weeks.

But a 2015 Consumer Reports survey of 4,023 adults found a troubling trend: Of the 20% who took an OTC sleep aid within the past year, 1 in 5 said they took it on a daily basis and 40% said they used the drugs for a year or longer.

That’s a problem for many reasons. Diphenhydramine can cause constipation, confusion, dizziness, and next-day drowsiness, according to the FDA. Also of concern: the “hangover effect”— impaired balance, coordination, and driving performance the day after you’ve taken the drug, heightening the risk for falls and accidents.

Diphenhydramine can also create psychological dependence, says Carl W. Bazil, MD, PhD, director of the Epilepsy and Sleep Division at Columbia University’s Department of Neurology. “The pills are not ‘addictive’ in the physical sense,” he says, “but there can certainly be a risk for a psychological dependency.”

So, What to Do?

If your sleep problems persist beyond 14 days or so, it’s time to see your doctor. If he or she is up on the latest research, you’ll be cautioned to minimize the use of prescription and OTC sleep medicines. Instead, he or she may direct you to a sleep clinic or therapist (usually a psychologist or clinical social worker, not a doctor) who does CBT.

CBT aims to change the way you think about and approach sleep, and your habits of going to bed and getting to sleep. Various techniques are used. Typically, after a full assessment, you’ll be prohibited from watching TV in bed, coached to go to sleep and get up at the same time every day, and taught relaxation and meditation techniques.

Related emotional and life problems will also be discussed, but usually just as they relate to your sleep patterns and troubles. If your insomnia has been triggered by a life event or by depression or anxiety — as is common — you’ll typically be referred to a counselor or psychotherapist. CBT involves, initially, 3 to 6 one-hour sessions.

The AHRQ analysis found that CBT helps 70 to 80% of people with chronic insomnia — shortening the time people fall asleep by 12 to 40 minutes, and adding 20 to 45 minutes of total sleep time.

And CBT is not restricted to people with chronic insomnia. Sleep specialists and clinics these days routinely use CBT to treat people who have intermittent bouts of insomnia as well. In addition, a recent review of 37 studies involving 2,189 people found that CBT was effective in those with co-existing illnesses and psychiatric conditions, including alcohol dependence, depression, post-traumatic stress disorder, cancer, chronic pain, and fibromyalgia.

The biggest benefit of all: No side effects or risks.

If you still decide to take insomnia drugs, do so for only a few days at a time, at the lowest recommended dose. Never drink alcohol while taking them, and don’t take an extra pill to get back to sleep — doing either can worsen the drug’s side effects.

Also, pay close attention to pill labels and, above all, avoid mixing narcotic painkillers with any kind of sleeping pill.

How to Correct Poor Sleep Habits



Watching TV in bedDon’t. TV viewing is not conducive to calming down.
Computer work in bedDon’t work on a computer at all for at least an hour before going to bed. A tall order for many people, to be sure, but the light emitted from computers, mobile devices and smartphones (so-called “blue light”) signals daylight to the brain even more than ordinary light bulbs and has been shown in studies to delay falling asleep.
Drinking alcoholic or caffeinated drinks or chocolate at nightAlcohol often leads to sleep disruption later in the night and may contribute to awakenings. If you have an insomnia problem, caffeine in drinks and foods like chocolate should be consumed only in moderation and not after midafternoon.
Taking medicine late at nightMany prescription and nonprescription medicines can delay or disrupt sleep. If you take any on a regular basis, check with your doctor about this.
Big meals late at nightNot ideal, especially if you are prone to indigestion or heartburn. Allow at least 3 hours between dinner and going to bed.
Smoking at nightDon’t smoke for at least 3 hours before going to bed. (Better yet, quit.)
Lack of exerciseJust do it! Regular exercise promotes healthy sleep.
Exercise late at nightA no-no. Allow at least 4 hours between exercise and going to bed. It revs up your metabolism, making falling asleep harder.
Busy or stressful activities late at nightAnother factor that will raise your alertness. Stop working or doing strenuous housework at least 2 hours before going to bed. The best preparation for a good night’s rest is unwinding and relaxing.
Varying bedtimes and wake-up timesGoing to sleep at widely varying times – 10pm one night and 1am the next, for example – disrupts optimal sleep. The best practice is to go to sleep about the same time every night, even on weekends, and wake up about the same time every day, with not more than an hour’s difference on weekends.
Spending too much time in bed tossing and turningSolving insomnia by spending too much time in bed is usually counterproductive; you’ll only become more frustrated. Don’t stay in bed if you are awake, tossing and turning. Get up and do something relaxing, such as reading, until you are ready to go to sleep.
Late-day nappingNaps can be wonderful, but should not be taken after 3pm because they can disrupt your ability to get to sleep at night. If you have sleeping problems, it may be best to avoid napping altogether.
Poor sleep environmentNoise, a room that’s too hot or not dark enough, an uncomfortable bed, covers, or pillow – all can prevent a good night’s sleep. Solve those problems if you have them.

Source: Consumer Reports

Therapy, Meditation, Sleep and Exercise Can Help Lessen Anxiety

When Lisa Jones was in college, her once-manageable anxiety became overwhelming.“I was having three or four panic attacks a day,” she says. “My hands were shaking. I felt I needed to run and hide. I would hyperventilate sometimes to the point of blacking out. I knew I needed help.”

Lisa’s doctor referred her to Frances P. Thorndike, PhD, an Assistant Professor in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia Health System, in Charlottesville, who also has a private practice. Lisa’s doctor had prescribed medication, and Thorndike recommended that she also start a program of Cognitive Behavioral Therapy (CBT), a technique that gives patients tools to control their own anxiety. Lisa also began meditating, starting with 10 minutes a day, on her own.

Lisa very quickly started to see results. “Even though the treatment didn’t immediately cut down the number of panic attacks, I felt better,” she says. “I felt like I had control, and I didn’t have to let the panic attack take over my life.”

Lisa, who wasn’t opposed to medication, decided to hold off and try the therapy alone first. Still, knowing the medication was available gave her comfort. “It was helpful to know that it was OK to take it if I needed it,” she says. There is ample evidence that techniques including CBT, meditation, sleep strategies and exercise can help people with anxiety disorder. People who try these techniques may still need medication, however, to manage extreme symptoms, help get them through the first stages of therapy, or, like Lisa, to keep on the shelf for a “break-glass-in-case-of-emergency moment.”

CBT: Tools for Living

Many studies show that Cognitive Behavioral Therapy (CBT) can teach people with anxiety disorder to manage their condition. Recently, a November 2013 study, published in Behavior Research and Therapy, tracked 361 people with panic disorder as they completed an 11-session course of CBT. The study showed “strong evidence” that CBT reduced panic symptoms. “Medications for anxiety disorder can certainly be helpful,” explains Thorndike. “But CBT actually changes thought patterns and behaviors that cause anxiety and keep it going.”

If you choose this type of therapy you will learn techniques to cope with your situation and feelings, and those techniques will be tailored to your unique situation, Thorndike says. You will learn techniques to deal with anxiety, including relaxation and deep breathing, as well as cognitive tools – things you can say to yourself to challenge and control your fears. Eventually, you will practice using these techniques when exposed to your trigger, the situation that produces anxiety. “We start gradually,” Thorndike says. For example, if someone is afraid of dogs, “we may start by looking at pictures of dogs, and then going to a park and watching them from a distance,” she says.

To find a therapist who practices CBT ask your doctor or the Therapist Directory of the ADAA. While one-to-one therapy is ideal, you can also try to learn some of these techniques on your own. Thorndike recommends starting with The Anxiety and Phobia Workbook by Edmund J. Bourne (New Harbinger Publications, 2011). In addition, a review in the January 2014 issue of Current Opinion in Psychiatry found that “recent studies have confirmed the utility of computerized psychotherapy for anxiety” although more research is needed. If you want to try an online program, Thorndike recommends you use Beacon 2.0, to search for the right program.

Mindfulness Meditation: Living in the Moment

Another technique that has been proven to control anxiety is mindfulness meditation. This is a type of meditation that teaches you to be aware of the present moment—your thoughts, emotions, and sensations—with an attitude of acceptance.

Elizabeth Hoge, MD, an Assistant Professor of Psychiatry at Harvard Medical School in Boston, is a psychiatrist with a specialty in anxiety disorders. Her study on mindfulness meditation was published in the August 2013 issue of the Journal of Clinical Psychiatry (view a summary here). For this study, 93 people were asked about their symptoms and put through a stress test both before and after training. Half had training in mindfulness meditation, and half attended an education class. Those who learned to meditate had less stress on the second test than those who didn’t, says Dr. Hoge, who is also affiliated with the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital.

Why does meditation help? “Mindfulness meditation starts with a practice of focusing on your breath,” says Dr. Hoge. “As your thoughts arise, you are taught to just notice them there, like a cloud passing in the sky, and not react to them.” With practice, people with anxiety disorder can use these techniques to control their reactions to negative thoughts in daily life.

While any form of meditation will help, she says, her research study used mindfulness meditation, which is derived from Vipassana or Insight, meditation. You can find information on Insight meditation at the website of the Insight Meditation Society, www.dharma.org. There are also many books on meditation technique, including Wherever You Go, There You Are by Jon Kabat-Zinn (Hyperion, 2005).

Get Your Rest

Sleep and anxiety are intertwined, says Thorndike. “People who are anxious may struggle with falling asleep or wake up during the night,” she says. Being overtired can make people more prone to anxiety and less able to cope with its symptoms as well, she adds.

Try some simple steps to improve your sleep at night. “Your bed should be saved only for sleep or sex,” she says. “If you are awake for more than 15 or 20 minutes, leave the room. Don’t lie in bed and worry.”

It is also important to keep screens, phones, and TV out of the bedroom, maintain consistent bed and wake times, avoid caffeine in the afternoon and avoid exercising late in the evening. If you want help doing this, consider trying an online program. A 2013 study in the Journal of Clinical Psychology, co-authored by Thorndike, found that adults using an online sleep program saw improvements in both sleep and anxiety. Thorndike has helped develop one called SHUTi.

Get Moving

Exercise can help as well, Thorndike says. Researchers at Princeton University recently found that mice who exercised were calmer than those who were more sedentary — and had developed more new brain cells as well. Even if you are out of shape, “start wherever you can, depending on your fitness level,” Thorndike says. “It is only important to do it regularly and consistently.” Eventually, try to build to a program of exercise of at least 30 minutes 3 times weekly.

For Lisa, a little more than a year of therapy gave her the tools she needs to manage her anxiety daily. Today, she meditates daily, practices yoga, and uses the skills she learned from Thorndike. “I still get the symptoms of panic attacks,” she says. “I still have all the same triggers. But when I feel the attack coming on, I can use these tools to squash it.“

Ellen Wlody is a writer who specializes in health and parenting topics. She lives in upstate New York with her husband, children, and two dogs.