Can primary care physicians change the way they treat patients with chronic pain?
While analgesics can provide welcome relief in acute pain conditions, pain reduction is only temporary and does little to remedy the distress and disabilities that emerge when pain persists.
In fact, a recent study published in the Journal of Pain, examining populations in two large health systems, indicated that increasing the dose and duration of opioids for unrelieved chronic pain was associated with worse health outcomes.
Behavioral interventions can successfully interrupt the cycle of treating heightened perception of pain with ever more analgesics. They have also empowered patients to shift the focus from their pain and impairment to reclaiming function and activities, despite residual pain.
What strategies can physicians use to change pain behavior? And why are these treatments not widely adopted in the medical profession?
Addressing components of chronic pain
Calls for implementing evidence-based behavioral strategies in managing chronic pain have been issued by various agencies, including the National Institutes of Health (NIH) and the Institute of Medicine in the United States.
The principal interventions for relieving the psychological symptoms of chronic pain are cognitive behavioral therapy (CBT) and mindfulness treatments.
CBT includes several different strategies, with acceptance and commitment therapy (ACT) as one of the newest iterations. Each focuses on maladaptive or dysfunctional thinking and responses to stress, with ACT emphasizing acknowledgment and acceptance of these without requiring their resolution before progressing.
Key targets of CBT are reducing "catastrophizing," which is when the patient is feeling helpless and overwhelmed, and identifying "secondary gains" from the impairment of pain, which may undermine motivation to resume work or interact with family or peers.
CBT can also increase both self-efficacy and the capacity to accept social support, as both are associated with greater tolerance of pain and reduction in perceived pain intensity.
Mindfulness treatments, including mindfulness-based stress reduction, mindfulness-based cognitive therapy, and mindfulness meditation, foster an awareness of the sensation of pain without judgment or emotional response.
In one assessment of the putative mechanisms underlying pain control from mindfulness meditation, published in Annals of the New York Academy of Sciences, the authors conclude that "analgesic effects of meditation can be developed and enhanced through greater practice, a critical consideration for those seeking long-lasting narcotic-free pain relief."
Dawn C. Buse, Ph.D., an associate professor in the Department of Neurology at Albert Einstein College of Medicine of Yeshiva University in New York City, NY, explained to Medical News Today the value of behavioral strategies in treating patients with chronic pain.
"Behavioral treatment strategies for chronic pain have strong, proven efficacy, are cost-effective, and do not have side effects or interactions," said Prof. Buse.
"They can be used through all stages of life where pharmacologic interventions may not be available or may be contraindicated, such as in childhood, pregnancy, or lactation. They can also help improve adherence to pharmacologic interventions, and can be used independently or combined with pharmacologic treatment interventions."
Dawn C. Buse, Ph.D.
When referring a patient for treatment, Prof. Buse cautioned that the physician should not just "hand off," but they should instead maintain a pivotal role in providing integrated care.
She also discussed the importance of choosing the type of intervention that is likely to be acceptable and effective for a particular patient.
"For people with higher levels of disability, depression, anxiety disorders and/or uncontrolled stress along with chronic pain, mindfulness training, alone, may not provide sufficient therapeutic outcomes," Prof. Buse said. "However, it can be successfully combined with CBT strategies in programs such as MBCT [mindfulness-based cognitive therapy]."
Implementing integrative care
Behavioral strategies are also at the foundation of the pain management programs (PMPs) specified in the Core Standards for Pain Management Services by the Faculty of Pain Medicine at the Royal College of Anaesthetists in the United Kingdom. The PMPs are a system of methods to promote behavior change and improve well-being in people with pain.
Based on systematic reviews, the Core Standards credit PMPs with significantly reducing distress and disability, enhancing coping, and improving various measures of physical functioning.
According to the Core Standards, the PMPs are "directly and indirectly producing behavior change, including methods based on cognitive and behavioral therapy, learning and conditioning processes, skills training, physical exercise, and education."
The Core Standards specify that the PMP interventions include:
- graded activation guided by participant goal setting, identifying barriers to activity and means to resume activity
- cognitive therapy methods to identify and change restricting thoughts and beliefs
- graded exposure to reduce fear and avoidance
- methods to enhance acceptance, mindfulness, and psychological flexibility through a process called "psychological flexibility"
- skills training and activity management to practice acquired skills for changing behavior and dealing with barriers in pursuit of goals
- physical exercise directed at changing behavior patterns around physical sensations, including pain, increasing movement, and activity
- education to improve understanding of goals and the effort necessary to attain them
- lifestyle and lifestyle change issues for improving or maintaining general health
- interventions to facilitate return to work
The Core Standards recommend that PMPs should be considered as treatment of choice when persistent pain adversely affects quality of life and significantly impacts physical, psychological, and social function.
How can physicians implement these strategies when they treat patients with chronic pain?
Although traditional medical training may not have been adequate preparation for the challenge and complexity that patients with chronic pain present, recent changes in curricula are joining best practice statements such as the Core Standards to foster the health of integrative medicine.
Preparing the practitioner for integrative care
Heather Tick, M.D., a professor for integrative pain medicine at the University of Washington in Seattle, explained to MNT that "pain education for most medical graduates is abysmal, yet pain is the main driver behind the majority of healthcare visits."
"The conversation around pain is mainly around drugs," Dr. Tick added. "It was all opioids before, now we know the dangers so it is about drugs to limit opioids. But all the non-pharmacological approaches rarely get discussed."
Dr. Tick and colleagues work in a multidisciplinary task force to develop core competencies in pain care for entry-level primary care physicians, and to provide a basis to develop curricula to build those competencies.
In an article published in the journal Pain Medicine, Dr. Tick indicates the need for pain education to change to "meet patients' pain care needs."
"Giving specific focus to integrative approaches using inter-professional team-based, patient-centered care using the full spectrum of evidence-based traditional and integrative disciplines and therapeutics could create positive influences on the future of healthcare and improve service for the large numbers of patients seeking solutions for living with pain."
Heather Tick, M.D.
In the light of the opioid crisis and the mounting evidence for successful behavior strategies for pain management, there is hope that non-pharmaceutical approaches will soon become firmly embedded in integrative pain care.