Integrating Psychological Interventions Into Chronic Pain Management

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Clinicians should opt for the lowest risk option when initiating treatment and encourage patients to play an active role in the management of their pain.
Clinicians should opt for the lowest risk option when initiating treatment and encourage patients to play an active role in the management of their pain.

The following article is part of conference coverage from the PAINWeek 2018 conference in Las Vegas, Nevada. Clinical Pain Advisor's staff will be reporting breaking news associated with research conducted by leading experts in pain medicine. Check back for the latest news from PAINWeek 2018.

LAS VEGAS — In a presentation titled “The psychological science of pain relief and opioid reduction,” during the 2018 PAINWeek conference, held September 4-8, Beth Darnall, PhD, clinical professor of anesthesiology, perioperative and pain medicine at Stanford University School of Medicine in California, gave an overview of the role played by psychology and behavioral interventions in the management of chronic pain.1

Behavioral interventions aim to address and treat the “full definition” of pain, stated Dr Darnall. Clinicians should opt for the lowest risk option when initiating treatment and encourage patients to play an active role in the management of their pain by giving them the means to “control their experience of pain,” she advised. Such interventions should complement pharmacologic treatments, contribute to improving outcomes, and facilitate opioid tapering.

Pain and psychological disorders (eg, anxiety, depression, and posttraumatic stress disorders) are often comorbid and have been found to have a bidirectional relationship. Pain is a complex phenomenon, and parameters ranging from its context and meaning to its relationship with cognition, emotion, affect, mood, and attention should be taken into consideration when managing patients.

Expectancy — both positive and negative — has been found to play a role in opioid-mediated analgesia, according to a 2011 study published in Science Translational Medicine. In this study, positive and negative expectancy of the effects of the μ-opioid agonist, remifentanil, on constant heat pain were associated with increased activity in endogenous pain modulatory systems and in the hippocampus, respectively, as assessed with functional magnetic resonance imaging. These results led the study researchers to conclude “An individual's expectation of a drug's effect critically influences its therapeutic efficacy and … regulatory brain mechanisms differ as a function of expectancy. We propose that it may be necessary to integrate patients' beliefs and expectations into drug treatment regimens alongside traditional considerations, in order to optimize treatment outcomes.”

Pain catastrophizing, which comprises magnification, rumination, and helplessness, is another psychological phenomenon that has been implicated in the modulation of pain. Literature indicates associations between pain catastrophizing and pain intensity, pain treatment efficacy, pain-related disability, and the development of chronic pain and prolonged opioid use.

The efficacy of a number of behavioral approaches for the management of chronic pain is supported by a growing body of evidence. These include cognitive behavioral therapy and acceptance and commitment therapy, delivered on an individual or group basis; group mindfulness-based stress reduction; and programs teaching chronic pain self-management to groups. Cognitive therapy aims to teach individuals with chronic pain the neuroscience of pain, the relationship between mood and pain and sleep and pain, and ways to leverage social support, pleasant activities, and movement in order to better cope with their pain. This approach also aims to help patients identify goals and improve their problem-solving skills. Other techniques employed include biofeedback, diaphragmatic breathing, and cognitive restructuring.

“Which treatment is best?” asked Dr Darnall, rhetorically. The answer is the one the patient will be committed to. Other factors, such as resources available to patients, referral options, and medical insurance coverage should be considered. Mindfulness-based stress reduction and chronic pain self-management programs are generally not covered by insurers. In addition, behavioral interventions should be conducted by psychologists trained in this field.

Dr Darnall suggests referring patients who show pain catastrophizing or preoccupation with pain, as well as individuals who may go through mood or relationship changes, have an impaired quality of life, or resort to medications to cope with psychological comorbidities. In order for clinicians to “set their patients on the path to success,” she recommends introducing the role that psychology can play in the management of chronic pain at the first consultation, giving patients “homework” to teach them key concepts of behavioral interventions for pain and setting goals and positive expectations for such interventions.

Pain in psychosensory in nature and “psychological factors are strong determinants of the pain trajectory,” emphasized Dr Darnall. A patient's psychopathology may have a predictive value for their response to treatment, as well as for pain intensity and duration. Therefore, a patient's expectations and beliefs are important considerations when devising a tailored pain management program, and clinicians should aim to treat the “whole person” vs solely relying on analgesics. Such behavioral treatments, which were shown to ameliorate factors ranging from pain catastrophizing to stress responses, are low-risk and may be used as part of a strategy to lower opioid consumption. “Engaging the patient as an active participant in their pain care is the secret to improvements,” she concluded. “Help your patients engage in behavioral treatment by explaining [its] critical role in pain relief — normalize it — encourage it — and expect it.”

References

1.      Darnall B. The psychological science of pain relief and opioid reduction. Presented at: PAINWeek 2018, September 4-8, 2018, Las Vegas, Nevada. Presentation BHV-03.

2.      Bingel U, Wanigasekera V, Wiech K, et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med. 2011;3(70):70ra14.

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