as for number 1, I think that's impossible to de-confound, because I don't think it's just a question of comorbidity or that untreated mental health "causes" fibromyalgia
Chronic pain, even when it's unquestionably somatic in origin, can always be a cause of a number of mental illnesses, the main one I'm thinking is depression. And there appear to be mechanisms for cause-effect beyond "oh hey now that I've got chronic pain I'm just really bummed how that affects my life and I'm just not coping well."
That isn't to say that all chronic pain leads to mental illness, but it certainly can a primary cause in some individuals.
I'm coming to think a lot of chronic pain or other "functional" neurological issues are very real, and real in the sense that there's nothing that anyone can control voluntarily to completely reverse what's going on (not in every case, of course). If a patient can't do anything to make it go away, and I can't do anything to make it go away, then I see no purpose to what I think is a lot of a "blame game," so that in the face of powerlessness to solve a super sucky yet real issue where no one is a bad guy, we don't have to feel bad because it represents some failure on the part of the patient or isn't "real." The hardest problems to deal with emotionally are the ones we can't do anything to solve. There are different ways providers cope with their own distress about these things, to "not care."
90% of the patients that are a massive pain in the ass don't want to be. Are they all maximizing what they could to maximize functionality and minimize the issue? Many aren't. Sure, that's true of anyone, we all cope with things more or less well and almost never perfectly. Are there some patients that just can never be bothered to enact solutions that would end their suffering? Yeah, but even then I think overall it's more complicated than that.
Basically, I don't think most of these patients are lying. I don't think it's just "in their head." I don't think it's something that would just be sorted out with psych or mental health treatments. I think there is some other basis to it, it could be something that we could one day understand, and at that point I'm not sure that means we could better treat it, but hopefully it would. Until then....
That said, and I say this all day every day to any one that will ever listen, is that 1) no, we actually can't fix everything, and that doesn't make the problem less real and 2) that doesn't mean that improvement isn't possible. There is ALWAYS room for improvement. That could be APAP, it could be placebo, it could be prayers and mint tea. Note that I don't recommend those things as first line for your stomach cancer. Exercise could help, it might not. Even if it didn't, you'd still be better for it. That's true for a lot of things you could improve.
I also point out that opiates are not a treatment nor a cure. They are only limited time only band aids that end up frakking you in the butt in a not nice way. It sucks, but life is pain. One of the first sensations to evolve in living beings was pain, it's a powerful motivator of behaviour. So with our pills we get people closer to dead before we ever really root out pain, which in some ways is why so many people have to medicate themselves into unconsciousness to get on top of the pain depending on how bad it is. We know that pain can wake us from sleep, so of course sometimes the point at which pain ceases is also the point at which consciousness does as well, and even then. They're wrapped up together. In general, to be conscious or alive is to be capable of feeling pain. That is how I explain that life is pain, and any expectation to live and not feel pain, is probably very unrealistic.
We have an enormous capacity to live with and cope with pain. Back in caveman days, if it didn't kill you, and you didn't kill yourself, you'd just *have* to live with it, no choice. So you absolutely can live with huge amounts of pain and no opiates. Man has done it for thousands of years. Maybe not live well, but live without nonetheless. Which brings me to my next point.
And even when pain is unquestionably not central in origin, like EVERY signal being filtered by the brain, it is subject to the brain interpreting the signal. So you might have moments where you "forget" the pain or it isn't that bad. Again, that doesn't make it less real. It does give us a powerful angle for dealing with it, though.
This all adds up to, in my mind, you have to basically just frakking suck it up. Adjust your life. Do what you can to maximize your function and ability to cope with pain, and that might not actually = less pain. Sometimes living better is having MORE pain, not less.
This is my little speech that I've used with almost every chronic pain patient I have ever encountered. It's not a magic wand as far as speeches go. I've never not had something good come of it, though. Does it mean these patients quit taking opiates or their pursuit of them? No. Does it make me less of a bad guy, someone empathetic, and in the same book if not on the same page? Yes. And that can create a therapeutic alliance, and it frequently will get a patient to consider at least one other thing they could possibly do to improve their lives, and often even DO such a thing. And that's a win in my book. Because I believe my speech, it's not about cure/fix/is it real blah blah, it's about the room for improvement.
