In a drab meeting room in West Philadelphia, a group of aging veterans with chronic back pain gathered for a dose of what their teacher called "breath as medicine."
Psychologist Lisa Rambaldo led the mostly male group through a series of gentle yoga positions that improve balance and strengthen muscles that support the spine, along with breathing exercises that free the mind.
While they lay on the floor hugging their knees to their chests, she told them to notice any tension. "Notice the tendency to recoil or bully through," Rambaldo said soothingly. "We breathe through tension and we exhale from it."
As the country struggles with an opioid addiction epidemic that has roots in prescriptions for pain medication, this yoga class at the Cpl. Michael J. Crescenz VA Medical Center is just one part of the multidisciplinary approach the VA uses for pain.
In addition to medications and surgical procedures, veterans can receive physical and occupational therapy as well as a type of cognitive behavioral therapy developed specifically for pain patients. There's a pain school, a program that helps veterans understand and manage their pain. There's exercise, massage, weight-loss counseling, help with sleep, meditation, acupuncture, chiropractic care, and more.
This kind of integrated, whole-body approach to chronic pain is gaining - in truth regaining - visibility as the nation tries to wean itself from years of overreliance on opioids while still trying to help the 100 million Americans who have some degree of chronic pain.
But pain experts say many private insurers are reluctant to cover such programs, making them difficult for patients outside the VA to afford. Some patients may balk at the time - and personal change - that this way of looking at pain requires.
"The whole country is going through a transition right now," said Nancy Wiedemer, a nurse-practitioner who is part of the Philadelphia VA's pain-management team.
"We have a health-care system that is based on what insurance will pay for, visits that span 15 to 20 minutes, care in silos, a culture that is used to quick fixes and a pill to fix everything."
Three of Rambaldo's students stayed after class recently to talk about what yoga has done for them. Dave Beasley, 69, said he is now pain free and sleeping well after 40 years of insomnia. Bill Stewart, 73, said he's gone from three opioid pills a day to one; his wife no longer complains that he's acting like a "slug."
Victoria Partin, 69, an Army veteran who blames her back and knee pain on jumping from trucks, said she still takes opioids, but is more active.
"I'll never give this up," she said of yoga. "It helps me tremendously every day.
She has also tried acupuncture, cognitive behavioral therapy, and aquatic therapy.
Martin Cheatle, a pain psychologist at Penn Medicine, said that patients with chronic pain - pain that's lasted more than a few months - are "extremely complex." Trying to treat them with medications alone ignores the fact that emotions, depression, insomnia, and inactivity can amplify pain.
"Pain management is a team sport," said Sean Mackey, chief of the division of pain medicine at Stanford University School of Medicine and cochair of the National Pain Strategy, released earlier this year by the U.S. Department of Health and Human Services.
Mackey said studies are badly needed to determine how helpful and safe opioids really are in patients with chronic pain. He added that there are more than "200 different medications that can be used for pain. The vast majority are not opioids."
Experts said that doctors were oversold on the idea that opioids, once largely reserved for hospitalized patients or those with cancer, were safe and effective for wider and longer use. The emphasis came at a time when specialists campaigned to make pain a "fifth vital sign," a step some now see as problematic.
The new thinking - and pain patients may not like this - is that doctors may not be able to eradicate chronic pain. Instead, it is for some a condition such as diabetes, which can be managed but not cured. The focus is on helping patients function better with pain, rather than waiting for it to go away, or despairing that it has destroyed their lives. Doctors said pain symptoms abate when people move around more and feel more of a sense of peace.
"Though the pain may be mandatory, suffering is optional," Cheatle said.
He is working to create a coordinated multimodal pain program at Penn so that patients don't have to go to multiple offices to get all the help they need.
Multimodal pain clinics were all the rage in the '90s, but experts said most went out of business because of poor insurance reimbursement. Johns Hopkins Hospital in Baltimore has a surviving inpatient program that helps patients taper off high doses of opioids while receiving other treatments. It attracts people who have suffered from pain an average of 11 years, said Michael Clark, a psychiatrist who directs the program.
Pain experts say the new model is to individualize care using evidence-based treatments. But more research on effectiveness is badly needed, they said.
Insurers typically cover some of the treatments, but not all of them. Therapists well-versed in cognitive behavioral therapy for pain, a mental-health treatment aimed at changing negative thinking patterns, may not accept insurance. A course in mindfulness-based meditation, which insurance typically doesn't cover, can cost $300 to $700, said Daniel Cherkin, an epidemiologist with Group Health Research Institute in Seattle who has studied back pain. He said many of the modalities are about equally effective when tested in groups, but some patients will respond to one and not another.
His study earlier this year found that adding mindfulness-based stress reduction and cognitive behavioral therapy both worked better than usual treatment alone to reduce back pain and improve function. Patients, most of whom used over-the-counter meds, did not reduce their reliance on drugs. "The goal was not to decrease use of medication," he said. "It was to improve people's ability to function in life."
Cutting out drugs isn't realistic for all patients, doctors say, though many do say they prefer to use opioids more sparingly than in the past.
Pain experts say they choose their words very carefully to avoid suggesting that they blame patients for their own misery, or think it isn't real.
"We never challenge the pain experience," Rambaldo said.
Cherkin agreed that wording is critically important. If patients "don't feel you validate and accept their pain, anything you say is going to be totally ignored, and they'll feel abandoned and betrayed," he said.
Two people can have the same injury and end up with different pain and disability levels. Why pain persists in some and not others is a mystery. Genetics plays a part. Women, people with a history of depression and anxiety, and those with stronger inflammatory responses have higher risk for chronic pain.
A new frontier is identifying people at risk before surgery and trying to prevent chronic pain, said Robert Edwards, a pain psychologist at Brigham and Women's Hospital in Boston who is on the board of the American Pain Society.
Many of the nondrug treatments target emotional states that worsen pain, especially depression and fear. Both of those can keep people from moving, leading to weaker muscles, more pain, and, ultimately, social isolation.
At Cooper University Hospital, Basant Pradhan, who trained as a monk before he became a psychiatrist, uses mindfulness meditation (which teaches a nonjudgmental focus on the present) and yoga to help pain patients "detach" from pain and damaging thoughts. He is testing these treatments in combination with the drug ketamine.
Sheldon Norwood, a former probation officer who suffered chronic pain after a stabbing in 2004, is a Christian who said he resisted meditation because of its Buddhist roots. But now the 53-year-old Pennsauken man, a Pradhan patient, meditates daily and said it has helped him cut back on opioids and enabled him to work part time as a substitute teacher and enjoy life more.
"It gave me a sense of calmness," he said. "It gave me the ability not to be afraid or not to be nervous."
Edwards said pain-related catastrophizing is common in chronic pain sufferers, who fear they will always be miserable.
His job is to help them identify unrealistic thoughts and balance them with more reasonable ideas. A better inner dialogue might go like this: "This is an annoying chronic condition that makes certain things in life difficult, but there are ways I can deal with it."
Mackey said patients need to be taught the difference between hurt and harm.
He treated an elderly woman with sciatic pain who would sit up for only five seconds when he met her. She was afraid to sit longer because of the pain. The Stanford team had her add just two seconds each day. Mackey said this patient recently sat through a four-hour opera.
Clark, at Johns Hopkins, said his program is based on examining four domains: the diseases that patients have, what their circumstances mean to them, what they're doing about their pain, and what strengths and weaknesses they bring to the table.
"The most important aspect of an alternative to opioids is that you actually know what's wrong with somebody," he said.
It's "next to impossible" to treat pain unless depression is under control, he said. Otherwise, much of the program teaches coping skills that may not come naturally. The psychological treatments, Clark said, "share a certain sense of trying not to get caught up in wishing that the pain would stop or focusing on the fact that the pain is so terrible."
Patients leave saying much what the VA's yoga patients said. Some are pain free, Clark said. Some have milder, more localized pain. Others still hurt, but say the pain isn't as "intrusive and dominating and impairing."