Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain

Introduction

Pain is a common complaint of people living with serious illnesses. The meaning and impact of pain varies for patients depending on their abilities to acknowledge, understand, remember, and express pain adaptively in various contexts. Contemporary models of pain often recognize pain as a network or matrix of biopsychosocial processes, including thoughts, emotions, and behaviors. On the one hand, the biopsychosocial network of pain sets up a framework for complex cycles of suffering and loss—distant traumatic memories, poor sleep, and conflict can make pain worse. On the other hand, many factors can be addressed to improve pain management.

Behavioral pain management refers to evidence-based psychosocial interventions developed to reduce pain intensity and enhance functional outcomes and quality of life in individuals with malignant and nonmalignant pain. These programs conceptualize the experience of pain based on learning theories. Tissue damage can automatically elicit pain (e.g., somatic and visceral) and pain-related behaviors (e.g., wincing and tension), thought processes (e.g., worry and memories), and emotions (e.g., fear and anger). Many people learn to attend to conditions associated with pain, to remember and fear such situations, and avoid them. Modern medicine and other technological advancements mean that many individuals live with chronic malignant and nonmalignant pain syndromes that are not acutely life-threatening. Over time, chronic tension, avoidance, and vigilance to pain can erode function and quality of life. Easing stress, promoting safety and calm, and encouraging better communication can alleviate pain or at least make it less disruptive.

Pain varies in many ways, including its causes, maintaining factors, and duration. Acute pain may last moments to days. Chronic pain may last many months or even years. In the case of serious and life-threatening illness, a medical professional should assess new experiences of pain as changes in pain may signal a shift in the disease process or response to a treatment. As summarized in Figure 1, this review provides 10 tips for behavioral pain management. These tips are provided as suggestions for the management of persistent or chronic pain. While some tips such as good communication are also clearly useful for the treatment of acute pain, other tips such as stretching and activity may depend on the nature and causes of acute pain.

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FIG. 1.

Summary of the top 10 tips for behavioral pain management.

Tip 1: Conceptualize Pain from a Biopsychosocial Perspective, Attending to the Emotional, Social, and Cultural Aspects of Pain and Encouraging Use of Behavioral Approaches as Adjuncts to Medication Treatment

Pain is a complex multidimensional experience that not only has a biological basis but also affects and is affected by behavioral, psychological, and social factors.^1–4 Psychological factors such as self-efficacy for pain management and nonjudgmental attitudes toward pain tend to help people adjust to and manage pain, whereas people tend to have more trouble managing pain when they view it as a catastrophe and/or become anxious.^1,3–5 Social support is often important; for example, family caregivers often play a key role in helping individuals manage pain by providing emotional support and helping them monitor symptoms, deal with treatment side effects, and communicate with health care professionals.^1,2,4 The broader social context and access to resources—including race, ethnicity, and socioeconomic status—can also influence how pain is treated.^1,4 For example, people with pain who have difficulty paying for medications may take medications less frequently or not use them at all.

Taking a biopsychosocial perspective to assess pain, clinicians might consider asking about the contextual factors (e.g., emotions, thoughts, behaviors, and social contexts) that impact pain as being better or worse.^1–4 Attending to context can help increase patients' awareness of important associations between their thoughts, feelings, behaviors, and their pain experience. In formulating a treatment plan, the biopsychosocial model points to the importance of integrating medical and behavioral approaches. Although medication is often the mainstay of pain management, thoughtfully applied behavioral approaches have several important advantages. First, unlike medications, they can address psychosocial and behavioral factors that both impact and are impacted by pain. Behavioral approaches can also address many individuals' primary goals for pain management, which include performing valued tasks and activities, maintaining important relationships, and preserving a sense of control and independence.

Tip 2: Activity Pacing Can Create a More Sustainable Activity Profile for Those with Chronic Pain by Offering a Series of Strategies to Avoid the Boom/Bust Cycle of Overexertion When Feeling Well Followed by Limited Activity When Recovering

People with pain often have difficulty regulating their activity levels, and should pursue establishing routines with moderate physical activity.^6–8 Individuals may engage in periods of overactivity that exacerbate pain, which then lead to underactivity as they rest and recover. This period of rest then allows overactivity upon healing, perpetuating boom-and-bust cycles.^6,7

Activity pacing seeks to regulate participation in activities and disrupt cycling between over-/underactivity to promote a more consistent sustainable level of engagement.^6,8 This form of behavior modification provides structure to implement change while also allowing for individualization based on each patient's abilities, pain severity, and needs. ⁹ Ultimately, pacing allows people to resume typical functioning without increasing their likelihood of pain. ⁸

When advising activity pacing, clinicians may wish to help individuals set realistic activity goals and develop action plans for gradually reaching those goals. ⁸ Such strategies may be flexible and include activity scheduling, breaking down tasks over time, switching between types of activities, or engaging in some level of activity despite pain. ⁷ Clinicians should be aware of commonly cited obstacles to activity pacing, such as frustration with stopping an activity before completion, and aim to address these obstacles through psychoeducation. ¹⁰ Activity pacing is self-driven mainly, so this discussion is essential for obtaining patient “buy-in” and improving effectiveness. ⁹ By promoting these behavioral modifications, clinicians can help people improve their self-efficacy, manage their symptoms, and provide empowerment to complete activities again, leading to meaningful improvements in functioning.

Tip 3: Suggest Low-Intensity Stretching Exercises That Can Relieve Tension, Increase Mobility, and Reduce Pain Over the Short and Long Term

Stretching and other forms of movement therapy are a valuable and noninvasive treatment option for individuals experiencing chronic pain.^1,11 Patients with chronic pain who use stretching exercises tend to experience less pain and better quality of life.^12–14 The use of stretching exercises can also reduce risk of injury, especially after sedentary phases. ¹¹ Stretching programs commonly used for pain management include low-impact or sitting yoga, Tai Chi, and Qigong.^11,13,14

Stretching exercises commonly focus on movement, flexibility, and relieving tension without overexertion of the muscles. Stretching positions are low-intensity and typically held for a few seconds to a few minutes to relieve tension and increase mobility. Stretching should cease if people begin to feel any pain. ¹⁵ Stretching exercises can be useful for short- and long-term pain management. Clinicians can prescribe specific individually tailored stretching activities to relieve pain. ¹⁶ Physical therapy referral can also be beneficial for helping people develop a safe home stretching routine. ¹⁵

Tip 4: Suggest Specific Relaxation Techniques, Such As Meditation or Breathing Training, and Help Patients Identify Those They Can Use on a Consistent and Frequent Basis

Relaxation is a well-studied and beneficial nonpharmacological treatment for pain management and coping. ¹⁷ Many individuals find relaxation techniques enjoyable and effective in reducing pain and tension. The goal of relaxation is to replace a stress response with a relaxation response. ¹⁸ Regular use of relaxation exercises is associated with improvements in psychological responses ⁸ as well as physiological responses that include lower cortisol, reduced blood pressure levels, and improved heart rate variability. ¹⁹

Relaxation skills can take various forms, which include among others diaphragmatic breathing, meditation, visual-guided imagery, low-impact yoga, stretching, and use of progressive muscle relaxation^18,20 In highlighting relaxation techniques, it is important to encourage frequent and consistent use to maximize benefits. Patients may wish to test out several options to determine what method can be maintained with consistency because continued use of relaxation for three months or longer has been shown to sustain improvements in pain management. ¹⁷

Tip 5: Assess Sleep Concerns and Assist People Who Are Experiencing Pain and Sleep Disturbance to Access Cognitive Behavioral Therapy for Insomnia

Sleep disturbance and pain are commonly intertwined, with ∼75% of patients with chronic pain reporting clinically significant levels of sleep disturbance. ²¹ Patients with comorbid pain and sleep disturbance are more likely to report more severe pain, longer pain duration, greater levels of depression and anxiety, as well as greater impairments in physical and psychosocial functioning relative to patients only experiencing pain. ²² People with cancer who report sleep difficulties also tend to have more difficulty with pain.^23,24 Although sleep and pain are bidirectionally related, evidence suggests that sleep disturbance is a stronger and more consistent predictor of pain than the other way around. ²⁵ Assessing and treating sleep disturbance represents an important but clinically overlooked avenue for reducing pain.

Pharmacological treatments for insomnia are common and may be associated with adverse side effects such as sedation and fall risks, especially when used with opioids. ²⁶ Cognitive behavioral therapy for insomnia (CBT-I) is the recommended frontline treatment. ²⁷ Commonly delivered in four to six sessions, CBT-I consists of sleep hygiene education, stimulus control, sleep restriction, cognitive therapy, and relaxation training. CBT-I targets thoughts and behaviors that inadvertently perpetuate sleep disturbance, such as use of electronics before bed, spending prolonged periods awake in bed, frequent daytime napping, and worrying about sleep. By the end of treatment, many individuals sleep better and find their sleep more restful and restoring. CBT-I produces moderate to large improvements in sleep among individuals with comorbid pain. People also report small improvements in their pain and depressive symptoms after receiving CBT-I. ²⁸

Tip 6: Screen for Mental Health Concerns and Refer Patients to Mental Health Professionals as Psychological Distress Can Exacerbate Pain Symptoms

Seriously ill patients with pain often experience simultaneous mental health symptoms that can be overlooked and undertreated.^29,30 Patients experiencing pain are more likely to meet diagnostic thresholds for major depression and generalized anxiety disorder. ³¹ Even those experiencing clinically mild pain symptoms can experience increased anxiety and reduced functioning. ³¹ Pain interference with social, occupational, and leisure roles is also associated with depression as patients struggle to engage in daily activities that promote meaning-making and well-being. ³⁰

An interdisciplinary approach can improve the diagnosis and treatment of pain and mental health concerns among seriously ill patients. Clinicians should consider the routine query of both physical and emotional symptoms; however, they should also be aware of the overlap between somatic symptoms and depressive symptoms to provide appropriate patient care. ³⁰ Poor patient–clinician communication about pain and emotional concerns can be a barrier to patients seeking treatment. ³² When clinicians validate experiences with pain, acknowledge the common occurrence of pain and emotional distress in serious illness, avoid stigmatizing language or attributing pain to mental illness, and convey optimism regarding treatment to reduce pain and distress, people are more likely to seek treatment. ³³

In addition, an exploration of the interplay between emotional distress and physical pain may increase the willingness of patients to address that distress. In facilitating screening^34,35 and conversations regarding pain and resultant emotional distress, clinicians can refer patients to services that simultaneously provide pain management, assist with meaning-making, and treat mental health symptoms to improve quality of life.

Tip 7: Promote Mindfulness Exercises So Patients Can Be Aware of Their Physical and Emotional Pain Without Judging It or Avoiding Healthy Activities

Coping with pain and pain-related problems can feel challenging and reduce perceived control. Mindfulness, defined as purposefully paying attention to the present moment with acceptance, is one strategy that can reinforce an internal locus of control. ³⁶ Mindfulness-based interventions appear to be promising tools for pain management in palliative care settings.^37,38

The utility of mindfulness for pain management lies in its focus on encouraging people to connect to present feelings and experiences of pain, with avoidance of strong negative reactions. Central to mindfulness is breath control. Pacing one's breath facilitates awareness of internal negative thoughts and emotions and disrupts the cycle of rumination and anxiety that comes with pain. This allows negative experiences related to pain to be noticed by the patient and shifted to the present moment without judgment. The act of connecting to the “here and now” provides patients with perspective about the pain–mind connection and fosters greater sense of control to invite thoughts and emotions that counteract negative reactivity.

In the context of dealing with pain due to serious illness, mindfulness may enhance personal sense of control, modify responses to pain, reduce distress, and enhance quality of life.^38,39 Clinicians can serve as a referring resource, offering patients access to mindfulness-based resources, including text-messaging services, consultation with mental health clinicians, and enrollment in mindfulness-based intervention studies and programs.

Tip 8: Encourage Patients and Families to Attend to Their Communication and Set Routines Like a Morning “Huddle” to Check In on Pain and Treatment Adherence

Chronic pain poses several challenges for communication. Patients often experience fluctuations in their pain, emotion, and function. These fluctuations mean that patients' abilities, resources, and needs can change rapidly within and across days, which can create a sense of confusion for the patient and their caregivers. ⁴⁰ Pain can also lead to deficits in patients' attention and memory. Further communication problems may emerge when pain, side effects (e.g., pharmaco-/chemo-/radiotherapy), and comorbid conditions (e.g., mild cognitive impairment, dementia, depression, and post-traumatic stress disorder [PTSD] ⁴¹ ) interfere with attention, concentration, memory, and executive function. As a result, patients may need additional supports to effectively attend to, understand, recall, and act on everyday perceptions of pain and medical information.

Patients and family members often benefit from training in basic communication skills such as active listening, which is reflecting on what the speaker said rather than reassuring or problem-solving. Some may need assistance in expanding their emotional vocabulary and assertive expression. The setting and process of communication may be as important as the focus of discussion, and so important conversations can be scheduled around times of peak energy and limited distraction. For example, a morning “huddle” at breakfast may be ideal for many patients whose pain and medication side effect profiles are lowest early in the day.

Cognitive screening to identify subtle changes in cognition and use of memory aids may also support good conversation surrounding pain and other concerns. Written, visual, and recorded memory aids may be of assistance for enhancing use of pain management strategies. Patients and family may appreciate permission to record important medical instructions, including those for pain medication use for later review. For example, patients may forget to appropriately pace activities, and so a provider can record the instruction that a walk or gardening session should end before pain is exacerbated. Likewise, patients may prefer hearing instructions for mindfulness in their providers' familiar voice. The teach-back technique can help assess comprehension and allows patients to rehearse and remember medical advice. Finally, some patients with cognitive complaints may be unable to discuss or describe their pain. Providers and caregivers may need to attend to the patient's potential nonverbal expressions of pain.^42,43

Tip 9: Diffuse Family Tension Surrounding Pain Management and Enhance Problem-Solving by Labeling and Resolving Anger, Frustration, and Conflict

Pain can be a source of conflict for patients and families, and anger, criticism, and hostility can exacerbate pain and erode social supports.^44,45 Effective anger modification and conflict resolution strategies can help interrupt the cycle of anger, conflict, and pain. ⁴⁶ Effective emotional regulation involves acknowledging, reappraising, and respectfully expressing emotions to supportive others. ⁴⁷ Patients, families, and clinicians often benefit from a reminder that anger is a valid, powerful, and yet fleeting signal of underlying threat and vulnerability. By discussing anger and its triggers, we can aid in reestablishing comfort and safety while appreciating patients' individuality, pride, and agency. Helping patients discuss and process their anger can ease tension and physical pain.

The act of verbally labeling a patient or caregiver as experiencing anger, frustration, and conflict can be helpful in and of itself. As strong emotions subside, the patient and caregiver can be encouraged to jointly use problem-solving strategies to (1) identify problems, (2) set goals, (3) identify feasible solutions, and (4) track outcomes. ⁴⁸ Trauma-informed strategies often mitigate frustration to the degree that they empower patients to assert their needs and autonomy.

Tip 10: When Patients Are Nonadherent to Pain Management Recommendations, Explore the Obstacles to Adherence Rather Than Responding with Judgment

Challenges related to treatment adherence are common among people living with both malignant and nonmalignant pain.^49,50 Nonadherence can take on many forms—from the under- or overuse of prescribed medications to low follow-through on behavioral recommendations. Low adherence can reduce functioning and quality of life in those living with pain.^49,50 Clinicians involved in treating pain may, therefore, experience frustration when faced with ongoing nonadherence despite persistent efforts to provide information on the benefit of a treatment.

Clinicians should meet nonadherence with nonjudgment and focus on exploring patients' preferences, perceptions, and barriers related to the treatment of their pain. The nature of communication between clinicians and patients is likely a key modifiable factor impacting adherence. ⁴⁹ Components of “good” communication include an emphasis on shared decision making, normalization of patients' experiences, and approaching conversations in an open, warm, and empathetic way. ⁴⁹ This patient-centered approach may uncover barriers to adherence previously unknown to the clinician. Such barriers may be cognitive in nature—that is, fears around addiction or beliefs that pain cannot be helped—or related to practical concerns, self-efficacy, or incompatibilities between a treatment and a patient's values.^49,51

Motivational interviewing may also be helpful in the context of nonadherence given its emphasis on taking a collaborative nonjudgmental approach to exploring self-efficacy, confidence, and overall readiness for change.^52,53 Clinicians should be careful to use nonjudgmental language. For example, “opioid use” may be less stigmatizing than “opioid addiction.” Within this framework, jumping ahead to solutions without first pausing to explore patients' readiness and barriers related to treating their pain may have a counterproductive effect.

Conclusion

This review summarizes the top 10 tips for behavioral pain management in the context of a serious illness. Palliative care clinicians should use these tips as a part of an ongoing multidisciplinary framework to implement practices to support patients in pain and their families. Although time and individual clinician expertise may be barriers to personally implementing many of these interventions, we encourage all palliative care clinicians to partner with or embed skilled behavioral health providers within their teams to ensure their patients' biological, psychological, and social drivers of pain receive comprehensive treatment.