In 2014, a movie was released in the United States which showed both the relentless daily emotional and physical toll of chronic pain and the switches in emotions and attitude that often precede a patient improving.

Like so many real chronic pain patients recovering from car and work accidents or living with pain that has no clear cause, Claire has become addicted to opioids and her entire life revolves around getting drugs and hiding her addicted state from others. One scene shows how she manipulates and charms a doctor into writing a prescription that does not have authorization; another scene follows Claire and her housekeeper Silvana as they drive all the way to Tijuana to procure Claire’s drugs which she then hides in a statue as they cross back into the United States.

Anyone who has had chronic pain or treated it will recognize Claire’s cluster of psychological and behavioral responses to her condition that make her pain worse not better: overriding focus on the pain, a narrowing life and isolation, “pain behaviors” that are rewarded by others and a feeling of being an innocent victim who has been wronged.

Cake also demonstrates a treatment precept we have stressed repeatedly in this book: long-term opioid treatment for chronic pain is almost never indicated; it will not relieve pain on a long-term basis and can worsen a patient’s pain through opioid-induced hyperalgesia. In treating chronic pain patients, opioid therapy is only valuable when used to help a patient participate in the therapies, especially physical therapy, that address the pain—and not to just cover it up, as we discussed in Chap. 6. Claire’s downward spiral on long-term opioids, both worsening her pain and her mental state, are clearly portrayed.

At the beginning of the movie, Claire does not identify with others in a chronic pain support group and unleashes sarcastic remarks that get her banned from the group. She embraces fear, remains in isolation and takes her anger out against others. However, later in the movie, viewers became aware that it is not just physical pain but emotional pain that is driving Claire’s suffering. Once she is able to get “in touch” with the emotions behind her pain, her anger begins to dissipate.

Following the suicide of another woman in the chronic pain group—which is replayed through flashbacks and dreams—Claire befriends the widower husband who is now raising the son alone. By spending time with the husband and son, Claire comes to get “out of herself” as she symbolically fills the place of the lost mother and wife. She sees she has something to offer, loses her self-focus, and “reframes” her pain.

Toward the end of the movie, Claire gets another “lesson” in the existence of others’ pain besides her own. Her housekeeper, Silvana, loses her temper at Claire’s self-centered self-pity after having to save Claire from a suicide attempt in which she lies down on train tracks. You “treat me like a dog” and “pay me like a dog,” too screams Silvana in Spanish, though it is not clear that Claire understands the language. The tirade seems to be a wake-up call to Claire.

Families and friends of patients with chronic pain will no doubt relate to Silvana’s outburst from spending months or even years exhibiting patience and compassion to increasingly irascible pain sufferers. Strained family relations are a hallmark of chronic pain conditions—yet they change for the better when patients adopt newer attitudes.

Cake’s dramatic conclusion in which Claire finds new meaning in her life after wishing for death clearly shows the power of acceptance in chronic pain patients. Toward the end of the movie, Claire allows herself to feel the emotions she has been covering up with opioids. Most recovery programs whether for addiction or previous trauma focus on processing unpleasant emotions rather than “pushing them down.”

Several scenes in Cake also demonstrate the “hurt versus harm” dichotomy that we have stressed in this book. Claire predictably clashes with her physical therapist over her unwillingness to do exercises that hurt her in the short-term even though they will help her in the long run. But, in the last scene in the movie, Claire signals that she is willing to endure the “hurt” to recover from pain. She enacts an effort-filled and successful attempt to finally sit up in the car for this first time. It serves as a visual metaphor for her resolution to face her pain, reframe it and not let it control her life.

In Chap. 2, we looked at the book The Promise: Never Have Another Negative Thought Again by Graham Price (Pearson 2013) which chronicles this acceptance process—a phenomenon that Price calls “pacceptance” (for positive acceptance) that is, arguably, the single biggest predictor of improvement in chronic pain patients. The process of acceptance is often linked to the patients’ realization that their pain and the events that caused it cannot be undone and will not go away.

When patients finally accept that their pain cannot be “cured,” it can be a bittersweet moment in which they surrender both their dreams and their battle and wave the white flag. In 12-Step recovery programs from addiction, this is the moment when a person has hit a “bottom” and is “sick and tired of being sick and tired.” This moment of “enough” causes a shift in perspective in which a patient often reframes his situation and becomes willing to try a new attitude and a new path for the first time. Often patients also accept at this point that their pain and situation are no one’s particular “fault”—whether an employer, doctor, motorist, or surgeon. Renouncing anger, resentment, remorse, and even anger at themselves greatly help patients control their pain as we explored in previous chapters.

After hitting a “bottom” in which they admit they are powerless over their chronic pain, patients often become open-minded and “come to believe” that a new and different treatment path could work. They proceed to place their trust in a multidisciplinary approach or their physical therapist and psychologist for the first time—despite their doubts that the recommendations of these clinicians will work. In a sense, patients have become so frustrated and discouraged with their current path, they have become open-minded and “teachable.”

There is another change that occurs when pain patients undergo this acceptance process: they became active participants in their pain rehabilitation. Most current unimodal pain treatment reduces patients to passively taking a pill or submitting to injections or surgery; with a new, acceptant attitude, a patient now partners with his clinicians—actively working his treatments. Exhorting patients to act as their own “healer” (in conjunction with other medical professionals) can be disarming to patients because it is at variance with much current medical practice. But self-management, self-efficacy, and self-care are the foundation of the multidisciplinary approach to chronic pain—and why it works so well.