Behavioral Medicine for Pain

Chronic pain is pain that persists beyond the time of healing or is ongoing for at least 3 months (some people use a 6-month threshold). Pain is a cross-cutting symptom that presents in many medical conditions. The causes and sources of chronic pain are varied and can be simple or highly complex. Chronic pain is considered a unique health condition and has its own ICD-10 diagnostic code. While it's important to understand the causes of chronic pain and address those, often chronic pain requires active choices that support pain control. Consider a person who has diabetes and takes insulin daily. Even with insulin, they must be mindful of other health factors to ensure the best control of diabetes, such as nutrition, exercise, and sleep. Addressing chronic pain fully requires a 'whole person' approach to pain management that equips individuals with the information and evidence-based pain relief skills. This is where health psychology can help optimize a person's control over their condition and life.

A key strategy to reduce stigma about behavioral medicine for pain is to make it available to every person early on. Do not wait until medical treatments have failed to recommend it, as this is a backward approach. Behavioral medicine can help people achieve better outcomes for medical treatments. We also want to avoid people feeling singled out. Rather, we recognize that pain is best treated with a whole-person approach, including applying easy-to-use strategies that reduce pain processing in the central nervous system. We have seen the benefit for people with chronic pain and also for surgical patients (https://academic.oup.com/painmedicine/article/20/11/2228/5488546).

Pain is more than just the hurt we feel in the body. Pain is defined by the International Association for the Study of Pain as being a noxious sensory and emotional experience. So, pain is truly a whole-person experience (https://www.nature.com/articles/d41586-018-04994-5), and we should treat it as such (https://www.apa.org/pubs/books/4317497).

Sometimes people do not have a medical diagnosis for their pain, but that makes it no less real. All pain is real. Validation is critical, and it is the most important message for patients to hear. "Your pain is real, and there are things you can do to help gain you some relief." Pain is naturally distressing and something we all wish to escape. Without having the skills and tools to manage this distress, people can begin to feel helpless and at the mercy of their pain. It's important to equip individuals with simple and effective tools, so they know how to help themselves and gain some control.

Our 2016 national study (https://pubmed.ncbi.nlm.nih.gov/26803844/) contributed to the understanding that in the U.S., we lack a number of therapists who are skilled in treating pain. This is especially striking when considering that up to 100 million Americans live with ongoing pain of some type. As was recently cited by the U.S. Department of Health and Human Services (https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf), we need scalable and accessible interventions to address a population's needs. While 8-session cognitive behavioral therapy (CBT) is the gold standard behavioral pain treatment for chronic pain, it is resource and time intensive and infeasible for many patients. Furthermore, not all patients require the intensity of 8 treatment sessions (16 hours total treatment time. A range of evidence-based behavioral treatments with varying treatment intensities are required so our treatments can be matched to patient wants and needs.

I have worked to help address the accessibility and scalability issues. I created a single-session 2-hour class ("Empowered Relief") that rapidly equips individuals with evidence-based pain relief skills. "Empowered Relief" 'compresses' key elements and skills from pain CBT and mindfulness into a single-session. The class format and name reduce stigma and enhance patient engagement. Based on its early success, we conducted an NIH-funded 3-arm randomized controlled trial (https://pubmed.ncbi.nlm.nih.gov/29510735/) in 263 real-world people with chronic back pain. Our results manuscript is in review, so I cannot give away the whole story, but at a high-level, we found relative equivalence for a single-session pain class to impart lasting symptom control (3 months later) compared to 8-sessions. We are now training clinicians (https://empoweredrelief.stanford.edu/) to be certified Empowered Relief instructors and are scaling the efficient intervention worldwide. To date, 300 instructors have been certified. It is delivered in seven countries and is available in five languages.

The word "psychology" is the problem. We need to reverse the messaging and make pain education and management ubiquitous to all health professions. Decentralizing behavioral pain management strategies is a critical part of this. Every profession can help educate patients about the role of individual factors in modulating the central nervous system and pain and teach patients how to adaptively self-regulate. Psychology is one profession that can help, but pain is not a psychological disorder. Integrating pain education and behavioral treatment at the front end of treatment and ensuring all patients receive it—will help de-stigmatize the profession's role in pain treatment. I also think that removing the word "psychology" and "therapy" from our treatments' names may enhance patient receptivity. Lastly, psychological treatment should not be offered as a replacement for medical care. This is a disserve to patients and also the profession of psychology. Psychology should be encouraged alongside medical treatment and other modalities that may be appropriate for the individual patient, such as physical therapy.

Solving the illicit drug crisis will require a coordinated effort from professionals who are focused on that space. I focus my energy on addressing the needs of people who have pain. The most pressing issue for people with chronic pain is retaining access to opioid medications and not being forced off (https://academic.oup.com/painmedicine/article/20/3/429/5218985) of them as this increases health risks, including mortality. I have spoken to the U.S Congress twice on this issue and to the U.S. Food and Drug Administration about the need for patient-centered opioid prescribing and to protect patients from iatrogenic harms from forced opioid tapering. I am leading a 4-state voluntary opioid reduction study that seeks to partner with patients who wish to gradually their opioid doses over one year. It's called the EMPOWER study (https://empower.stanford.edu/), and it is funded by the Patient-Centered Outcomes Research Institute. EMPOWER is also a comparative effectiveness test (https://academic.oup.com/painmedicine/article/21/8/1523/5687295) of evidence-based behavioral medicine treatments to support opioid and pain reduction.

Catastrophizing is a term that was first created many decades ago and applied within the context of pain about 3-4 decades ago. It describes one's cognitive and emotional experience and response to pain – or pain coping. Many patients experience the term 'pain catastrophizing' as pejorative, insulting and blaming. Even if it's a minority of patients who experience the term negatively, we must address it and ensure our language is patient-centered. The terms and language we used can impact patient engagement in needed treatment. I have been working with pain leaders internationally (https://renamepc.stanford.edu/) to better understand patient needs and wants around the term pain catastrophizing. Last year we surveyed more than 5,000 patients and clinicians worldwide. We hope to share some results this year. It is important to listen and attend to the needs of the people we intend to help. By including patients in the discussion and attending to their needs and wants, we will support them in achieving their best outcomes.