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T M C » P U L S E | N O V E M B E R 2 0 1 8 30 H elen Brindell is not thrilled about taking pain medication. "I want to manage the pain on my own," Brindell said. "I like to keep my mind in focus rather than take the drugs and not know what happens." To watch Brindell on the job at a landscaping office or to converse with her, it's hard to tell that behind her bubbly personality and distinct Louisiana accent is a woman who plans her day around the possibility of physical discomfort. Treatment for a tumor at the top of her spine and fusion surgery on her lower back left Brindell in chronic pain. In the current health care environment, where providers are increasingly hesitant to prescribe opioids, doctors and startup companies are finding innovative ways to help patients manage chronic pain without relying on high doses of medication. Among the problem solvers is Rex Marco, M.D., vice chairman of the department of orthopedics and sports medicine as well as chief of reconstructive spine surgery at Houston Methodist Hospital. He said the opioid epidemic started 20 years ago when "pain" became the fifth vital sign monitored by hospitals. Since then, preventing pain with medication has become a standard practice. As an alternative, Marco now recommends digital health appli- cations, including Stop, Breathe & Think for mindful meditation and The Back Doctor for daily exercises—as a way to avoid taking B y C h r i s t i n e H a l l Finding Opioid Alternatives Doctors and startups are proposing new ways to manage chronic pain without heavy medication medication or, at least, to take less. Brindell tried both apps after going to Marco for her back surgery. "It's amazing. The app takes in the information and gives you med- itation homework," she said. "I had 20 minutes of meditation yesterday because my day was not so good." Brindell explained that stress exacerbates her pain, but combining meditation and back exercises at night often leaves her feeling better by the next morning. "Do I feel 100 percent? No, I'm never going to feel 100 percent, but it is enough to get me through the day until I get home and do the meditation and Back Doctor again. It's like exercising," she said. Recently, the meditation tech- niques got Brindell through a partic- ularly painful medical examination during which a sudden move nearly caused her to jump off the table. Rather than react with anger, she asked for a moment to refocus her mind so she could better tolerate the pain. Your brain on stress Being more mindful is not only something Marco recommends to his patients, but a discipline he practices himself. About three years ago, he started using meditation apps and practicing yoga following some life-changing experiences, including a divorce, one of his children almost dying from a fall and substance abuse problems in the family. "I didn't know this about myself, but my brain didn't ever really stop," Marco said. "Just sitting there or lying there and being present was a completely new concept to me." He has learned that being present is difficult for humans, who are often thinking about the future. While that kind of mental prepa- ration can be helpful in finding success, the same mental acuity can lead people to dwell on what they could have done differently in the past. "When we think about the future, we are really in a state of anxiety, and when we think about the past, we are often in a state of sadness or depression," Marco explained. "I was trained to think about how to prevent problems. If you do this, this, this and this, then this horrible thing won't happen. The people I revered the most were able to avoid problems and complications by having that approach." When someone is anxious, the brain tells the body to be stressed out. The amygdala, the part of the brain involved in experiencing emo- tions, triggers the pituitary gland to signal the adrenal gland to release stress hormones, Marco said. I want to manage the pain on my own. I like to keep my mind in focus rather than take the drugs and not know what happens. — HELEN BRINDELL Houston Methodist patient