A Primer for the Post-Opioid Age.
Last night I woke suddenly from a seizure of sleep paralysis that had made me feel trapped inside my own head. My brain felt drained and sore, like the top of my head had come off and everything was leaking out. I’ve had these episodes many, many times before over the last twenty odd years. The nature of the seizure changed about 4 years ago, but now on rare occasions when I’m all together exhausted, stressed-out, dehydrated, and have had sugar, one will come along and render me useless for a day or two. The episode itself is terrifying, exhausting, and traumatic, but the pain afterward is almost unbearable, as my already acute senses are heightened with the shock, only to be then bombarded with every usually inaudible sound around me. Pain is something every human suffers with at some point in their life – whether it is physical, emotional, mental, or spiritual – it hurts, and it makes us stop in our tracks. We either hold our breath hoping it will pass while our body frantically produces endorphins to try and numb it, or we numb it with external aids like drugs, alcohol, or whatever vice we have on hand. At best this just supresses the pain, and the underlying cause waits for the right conditions to align again when it can scream at us and try once more to get our attention. At worst, we continue to numb it and ignore what it’s screaming and end up either addicted to the drugs or with some degenerative and possibly terminal condition, or both. Some of us are good at ‘relaxing into it’, or ‘breathing into it’, and this is also useful to a degree (it has particular merit during childbirth). But at some point, we just have to sit with it, and to really listen to what it’s actually telling us. Last night, while waiting for the cannabis root balm that I’d applied all over my head to take effect, I did exactly that.
As herbalists, more often than not we prescribe herbs for pain based on the nature of the pain itself – for example if someone presents with cramping in their gut, we may make up a formula with Wild Yam in it – which we call a spasmolytic, because it relaxes the spasms occurring in the gut, to which it has an affinity for. For period pain, we may also prescribe a formula with Crampbark in it – again because as its name suggests, it helps relax spasms and cramping – particularly in the smooth muscle fibres of the uterus. Sometimes we may also prescribe more general anodynes – or pain-relieving herbs – like Jamaican Dogwood, or Willow bark. These are all great and effective, and I use them as well, but we can easily fall into the reductionist trap of ‘here, you have a headache, take this generic pill that I give to everyone with a headache’. In our sometime anxious efforts to relieve the suffering of another, we can sometimes forget to check not only the nature of the pain, but what is actually causing it. Why is the uterus cramping? Why does my head pound at times, yet at other times I have sharp shooting pains radiating through it?
As I was contemplating all of this last night, I realised that the current iatrogenic (man-made) epidemic of opioid addiction, and antibiotic misuse and abuse fed this mindset of prescribing just to numb and supress. If we look at the energetics behind our medicines and the correlating energetics inherent in our physical makeup and the language through which our bodies communicate, both opiates and antibiotics are energetically very cold. Opioid drugs – originally derived from the Opium poppy – are ‘cold in the fourth degree’, according to the ancient Greco-Arabic system of medicine (and across most traditional systems of healing). This ‘cold in the fourth degree’ means that they can sedate someone to the point of death because cold is the absence of heat, or life. This category of medicines should only be used wisely and with great skill, matching with the persons own level of vital reserves. Modern antibiotics are the same energetically – literally the name means ‘anti-life’. So, the flagrant and unskilled use of both of these class of medicines can result in the cold/depression(as in lack of functionality) tissue state. This tissue state then makes a nice environment for opportunistic infections to move in. In the mental sphere, we might equate this with apathy, lack of interest in life, lack of motivation. In this state of apathy, we might lose our ability to discern and so we become more ‘suggestable’ and susceptible to things that in the end, aren’t really in our best interest. Cold is also constricting. In the mental sphere, this can equate with a chronic introspection to the point of narcissism. How well does this tissue state describe our Western culture just now?!
In the practice of holistic herbal medicine, we are in the unique position of having access to a vast materia medica of plants that may not seemingly be related to the nature of the pain itself but can effectively relieve that pain, largely by addressing the underlying cause.The pain, like most symptoms of the body, is the language used by the innate intelligence to tell us and direct us to a more specific and long-lasting remedy. In this regard, we are working with the body, rather than against it or simply ignoring its pleas. Learning to listen to this language, to understand the language of pain in particular, tells us a great deal about what’s actually going on. And, it has a lot to do with the energetics – again something that is peculiar to holistic herbal medicine across all traditions – including the Western tradition. Let me illustrate this concept with the example of processing the language of my own pain.
As I sat with my pain last night and began to listen to it, to really feel it, I felt an ache, a dull but belligerent, all-encompassing draining ache. I instinctively cradled my head in my hands, as if creating a helmet that would hold my brain in. In technical jargon, we might say that my pain was ‘better for pressure’. I reflected on all of the pain that I had suffered through in my life, and for me, it is always relieved by pressure. I began to process why a pain might be ‘better for pressure’, and my thoughts immediately went to the First Aid principle of applying pressure to a bleeding wound. This action not only ‘clamps’ the blood vessel/s effected, but also shunts the now restricted blood flow into the surrounded capillary beds, which can expand up to forty times, thus reducing the flow of blood from the original wound. In the tissue state model, or underlying energetics of the tissues, this free, unrestricted blood flow (in the case above, from an injury), we refer to as damp/relaxation. There is no tone or restriction to hold the blood or the fluid in (until we apply pressure, or an astringent to tighten the tissue, or a circulatory stimulant to diffuse the blood into the surrounding capillary bed). If this damp/relaxation state is left unchecked it can lead to dry/atrophy– or a withered, malnourished state with loss of function. I note that these ‘seizures’ that I have often occur when I am really stressed and dehydrated. Therefore, the pain is worse when dehydrated. Already we can see a pattern; things dry out when there is too much relaxation of the tissue and there is excessive fluid loss that can’t be replenished at the rate that it’s being lost. Instead of just drinking a glass of water, which may help, we also need to address the underlying cause of the relaxed tissue tone. We have a class of herbs here with an Astringent action that work to tone and tighten the tissue, and we also have a class of herbs with Moistening qualities that help to rehydrate the intercellular and intra-cellular fluids throughout the body and help maintain that moisture.
At the same time, as we have damp/relaxation, this can cause pooling in some areas and contribute to damp/stagnation. For example, we often see this manifest as varicose veins. The vein walls lack the tone to effectively allow the blood to move along, and so the vessel may ‘kink’ and the blood begins to pool. The damp/stagnation tissue state can then lead to the cold/depression tissue state because there is no movement. In these tissue states, we need to use herbs that stimulate and move the flow of blood and fluid. These herbs generally also have a very warming quality, thereby returning vital heat to the area. An example of this particular type of pain may be with period pain. The uterus may feel aching and crampy, but also congested and boggy, it feels better for a hot water bottle and a back rub (again, note the need for pressure to diffuse some of that congestion). The cramping is coming from a damp/stagnation and cold/depression tissue state, rather than just spasm. The spasm of the smooth muscle tissue may be seen as a knee-jerk response to these underlying tissue states, as the body tries to create some sort of heat through the movement, as well as responding to a diminished flow of nutrient. We might use ginger here, as a tea, in tincture, or infused in oil and made into a balm to rub onto the abdomen, or added to a nice warm bath.
As our perception of pain is transmitted through nociceptors (or pain sensors) on the end of the nerves, we should be aware that the nerve endings are also influenced by the basic quadrune of life – the meeting point between capillary, extracellular matrix, cell, and lymph vessel. The integrity of this unit, of how well the flow through this inner ocean occurs, I believe reflects the type of pain we feel. For example, if an area of tissue is drying out, the nerve endings here will sense this, and the insulating properties of the myelin sheath will also begin to wither and leave them more exposed and more sensitive. Like a rocky shore at low tide, all of the rocks below the shoreline are now exposed to the elements. They are vulnerable. And over time, as the tides and seasons and climates change, a certain amount of erosion can set in. To me this feels like an ache. One might think a longing of things lost (dry/atrophy – although pain that occurs due to dry/atrophy I find to sometimes also exhibit a sticking like quality, due to a lack of lubrication.), rather than the burning passion of things anticipated – the pain of heat/excitation. The pain of heat/excitation (where there is too much friction or irritation, or too much blood) can be sharp and shooting or tingling, as in nerve pain, when the nerve is either severed or impinged, or pounding and throbbing when the blood is high, thick, and fast. Here I think of a strike of lightning, and the contrast to a hot desert sun beating down relentlessly on hapless explorers. The pain of heat/excitation may also more likely be tender to the touch. In both of these tissue states, we might also see damp/stagnation, or dry/atrophy as contributing factors, although heat/excitation can lead to a literal burning up of the fluids causing dry/atrophy. In the case of heat/excitation, we look to herbs that are cooling, and sedating. Many members of the Rose family find value here.
The last tissue state, which is perhaps partly most familiar, in terms of a general sense of pain, is wind/tension.The wind here denotes symptoms that change suddenly or alternate (such as with the alternating constipation and diarrhoea of Irritable Bowel Syndrome). Tension simply means just that. This is the pain often associated with bloating and gas in the gut. Or a true tension headache after a stressful day at work staring at a computer screen and dealing with uncooperative or demanding colleagues or customers. A pain typifying tension will be one of spasm, as opposed to the tension we create in ourselves when we hold our breath or hold in our emotions. It may also feel stretched, like a guitar string that has been wound too tight, or a belly that has just received a really big meal. It can also arise from the previous tissue states. Oftentimes, wind/tension arises from dry/atrophy as tissues start to dry out and harden or become rigid. For example, recently I supported a woman who needed a knee replacement. The tendon behind the knee that was being replaced was incredibly tight and caused a great deal of pain, in fact it had caused more pain than the actual knee which had, by the time I saw her, become bone on bone! The reason for the knee replacement was due to osteoarthritis, which I assessed was due to the dry/atrophy tissue state, caused largely by damp/relaxation and wind/tension (according to her constitutional pattern and an extensive case history). I gave Solomon’s Seal – a moistening herb that relaxes or tones tendons as needed, and she was able to find great relief, to the point where she noticed a difference when she had run out and needed another bottle. Her recovery from the knee replacement operation was also notably quicker than usual. However, generally speaking in this wind/tension type of pain, we do rely heavily on herbs with direct relaxing qualities, or herbs that directly affect the nerves.
In all of this ‘pain language’ of the six tissue states, we also want to juxtapose it with our individual constitution, as I described in the case above. We may have a tendency to lean in a particular energetic or elemental direction, and this may determine the way we perceive the pain and how it manifests. For example, I am a typically cold person, leaning toward dryness and nervous tension. In the Ayurvedic tridoshic system, I am predominantly Vata (a combination of the elements of air and aether/space). So, my pain will more often than not come from an underlying cold, dry condition. I need warming, moistening, astringent, and nerve nourishing herbs, that are also grounding. Currently, I am taking a formula that I made consisting of:
Agrimony (astringent, relaxing) – my constitutional remedy, Wood betony (circulatory stimulant to the brain, grounding, protective, astringent, relaxing), Skullcap (nerve nourishing, relaxing), Milky Oats (moistening, nerve nutrient), Sage (warming astringent, balances fluids, help assimilate the essential fats).
I also drink a chai or a Tulsi (relaxing, warming, adaptogen) tea with ginger (moistening, warming) every day. And once or twice/week I drink a cold infusion of marshmallow root, which is deeply hydrating. Because hydration should also include how well we use oils in our body, I usually eat a lot of good quality fats and use sesame oil on my skin. For acute situations like last night’s experience, we still want to match the acute remedy with what’s going on (e.g: when some women instinctively reach for the hot water bottle). I used cannabis root infused in olive oil and made into a balm because 1.) it is warming, 2.) it is anti-inflammatory and 3.) it does have relatively immediate analgesic and anxiolytic (anxiety reducing) and sedating properties, and 4) when infused in oil it also takes on the moistening and nerve-insulating properties of the oil.
When we consider pain, not only do we look at the tissue state, the overall constitution, the type of pain itself, but we also consider its: a) Onset – was it the result of an injury? (here we would consider first aid herbs for bruising and wound management, and if it began with an injury then it’s wise to give the herb we would have given at that time), when did it begin? What was happening in our life at the time? (In the example of my situation, I could see that I had been under a fair bit of stress, and had too many late nights, and wasn’t keeping up my hydration levels); b) Palliation/Provoke– that is, is there anything that makes it better (eg: pressure, warmth), or worse (eg: dehydration, stress, cold, touch, etc); c) Quality– what does the pain actually feel like (dull ache, sharp or shooting, congested, hot, cold, throbbing, tight, etc?); d) Radiates– where is the pain actually and does it radiate or travel anywhere else? This tells us a lot about the tissues, organs, or systems effected and helps us choose herbs that have an affinity for these particular areas. For example, this is quite evident with gallstone colic. Gallstones can form due to a number of reasons, such as congestion in the liver, heat in the liver, tension in the ducts, or drying out, and inactivity (remember the six tissue states?). Gallstones caused by dryness (due to too much heat in the liver) can be seen manifested in dry skin and hair throughout the body, and particularly if the skin of the right temple feels a bit rough like fine sandpaper. The pain associated with this may radiate from the area up through the back between the shoulder blades and over the head to the right temple. In this situation we need to cool and decongest the liver, and rehydrate the tissues; e) Severity– how severe or debilitating is the pain on a scale of 1 (mild) to 10 (extreme torture)? This tells us how much the area is affected, as well as providing a good way to measure how effective our treatment is; f) Timing– when, how often, and how long does the pain occur? Does the pain occur at various times of the day? After eating? Is it effected by seasonal changes, or changes in position, movement etc? This can help us determine if the pain is due to allergies or intolerances, as well as contributing food, lifestyle, or environmental factors; g) Concomitant symptoms– what else is going on with the pain? Constipation or diarrhoea, nausea, excessive or scanty urination, bleeding, etc?
Asking good questions and making observation of how we also instinctively respond to the pain (amongst our general observations of the complexion and feel of the skin, looking at the tongue, the eyes, and feeling the pulse) can give us a tremendous amount of useful information for not only being able to understand what the body is trying to tell us about its interior health status, it can also point us to selecting very specific remedies and treatment plans.
The formula that I made for myself, listed previously, will not look like a formula I might make for someone else because I’ve formulated it for my specific needs. None of the herbs I’ve used are specifically pain-relieving. This is the beauty of herbal medicine, that we can really make our remedies specific, not just for the pain but for the person as a whole, and sometimes we don’t need to use blanket pain-relieving herbs at all. Even our acute remedies can be more specific than “here, take a neurofen”. When we combine this with sound dietary and lifestyle habits (something which I fell back on and thus suffered for last night), we can affect positive, lasting change.
To summarise the flow of thought that I’ve written above, I’ve put together a simple chart highlighting the tissue states, the types of pain that may be felt arising from each one, the various virtues that we look for in herbs to remedy these, and some examples of these herbs. It is certainly not a comprehensive chart, just a quick overview to show that we have a range of herbs at our service to help with pain that speaks to us from a multitude of reasons. We might also consider herbs specific for nerve pain itself (sharp, shooting, tingling) such as Saint John’s Wort and Prickly Ash, as well as nervines (herbs that act specifically on the nervous system) for supporting the stress of living with chronic pain. These herbs not only include the more sedative herbs like passionflower, skullcap, and lavender but also adaptogenic herbs (herbs that help the body recover from and handle chronic stress) such as Ashwagandha, Tulsi, Eleuthero, and Reishi.
I hope that in my dull-ached and semi-functional ramblings I have been able to encourage you to see a way beyond the current opioid crisis and the modern view that nothing else can be done. Plenty can be done to alleviate people’s pain! We just need to learn to listen and take a wider view. If you are suffering from pain and would like to explore this way of approaching it, I encourage you to visit a herbalist to help you J
|Tissue State||Types of pain that may typify this.||Medicinal Virtues Needed.||Examples of herbs.|
|Heat/Excitation||Hot, tender, throbbing, pounding, burning, sharp, shooting, intense.||Cooling
|Cold/Depression||Dull, sometimes pins and needles type pain.||Stimulating, warming.||Ginger
Saint Johns Wort
|Damp/Relaxation||Ache, sometimes a bearing down pain, can lead to spasm and twitch.||Astringent (tightening and toning).||Agrimony
|Damp/Stagnation||Congested, boggy, full, sometimes bearing down, sometimes dull and achey especially after sleep. Can be inflamed.||Stimulant, warming, diffusive, circulatory stimulants, alteratives/blood cleansers, cooling diuretics (if hot and inflamed).||Cayenne
|Dry/Atrophy||Sticking, crackling, stiff, a pressure type pain as tissue rubs against other tissue with no lubrication in between.||Demulcent/moistening, emollient (softening and moistening)||Solomon’s Seal
|Wind/Tension||Changes suddenly or may come and go, spasm, cramp, tight, stretched, tension, twisted and unable to relax.||Relaxing, nerve nourishing, carminative.||Agrimony