Psychotherapeutic interventions for chronic pain: Evidence,rationale,and advantages

Abstract

Background

Long-term use of opioids to treat chronic pain incurs serious risks for the individual—including misuse, abuse, addiction, overdose and death—as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients.

Method

We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments.

Results

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes.

Conclusion

Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.

Keywords

chronic pain cognitive behavioral therapy acceptance and commitment therapy mindfulness-based therapies opioid abuse. behavioral health and primary care integration

Introduction

Chronic pain is defined as recurrent pain, lasting beyond the usual course of an acute illness or tissue healing time, and/or persisting for more than 12 weeks.¹ It may be accompanied by such somatic symptoms as fatigue, sleep disturbances, decreased appetite, and irritability. In chronic pain, pain intensity is linked less with nociception and more with emotional, motivational, cognitive, and psychosocial factors.² Persistent helplessness and hopelessness experienced by these patients may be the root causes of their suffering.

In addition to impacting individuals, chronic pain has significant social and economic consequences. Reported estimates find that 11.2% of the population of the United States has chronic pain.³ Chronic pain increases unemployment, sick leave, disability claims, physician visits, and length of hospital stays.⁴

The use of opioid pain medications as the primary approach to the treatment of chronic nonmalignancy-related pain has had unintended consequences, leading to what the Center for Disease Control and Prevention (CDC) has classified as an epidemic.⁵ On the other hand, nonpharmacologic treatments including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based programs (MBPs), and occupational and physical therapy have been demonstrated to be effective and durable in the treatment of chronic pain.^6–8 They lack the risks associated with opiate medications, surgical procedures, or interventions.

In routine practice, clinicians and patients often underappreciate these psychotherapeutic interventions in part because their effect size is moderate, they have a relatively slow onset of action and due to economic disincentives that provide differential reimbursement for psychotherapeutic treatments.⁹ In addition, the lack of collaborative care and case management services makes it difficult for patients to access these interventions. However, these nonpharmacological treatments have great potential for addressing chronic pain without the risks associated with opioid prescriptions.

The purpose of this review article is to describe three alternative approaches to the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments. We also discuss the advantages of and current practice gaps in integrating such therapeutic interventions into primary care treatment.

Methods

To identify effective nonpharmacological treatments for chronic pain, we searched PubMed/MEDLINE, PsychInfo, Google Scholar, and the Cochrane Database of Systematic Reviews for studies evaluating such treatment approaches. In this search, we scanned study abstracts, identified relevant studies for review, and extracted data using such keywords as “chronic pain,” “cognitive behavioral therapy,” “alternative treatment,” “acceptance and commitment therapy,” and “mindfulness based therapies.”

Management of nonmalignant chronic pain

Initial assessment

To develop a treatment plan for chronic pain, it is first necessary to undertake a thorough physical and psychological evaluation of the patient, including a focused history, a detailed history of the pain and its impact on functioning, a physical exam, and radiological and other diagnostic tests. Clinicians should understand the various pathophysiological mechanisms in different pain conditions as they have implications for treatment recommendations. For example, neuropathic pain, such as trigeminal neuralgia, which causes a localized pain in response to noxious or nonnoxious stimuli, is different from Complex Regional Pain Syndrome in which neurogenic inflammation and excitation of the sympathetic system cause the pain.^10,11

In the management of nonmalignant chronic pain, complete elimination of symptoms is often not a realistic goal. The treatment approach should be to decrease suffering and increase functioning.

Consequences of reliance on opioids to treat chronic pain

The use of opioid pain medications to treat chronic nonmalignancy-related pain has resulted in a four-fold increase in opioid prescriptions, with no substantial decrease in pain scores.^12,13 Despite this lack of efficacy, almost 20% of individuals with chronic pain in the United States are prescribed an opiate in an office-based setting.¹⁴

Moreover, the reliance on opioids as the primary treatment of chronic pain has led to significant unintended consequences. The number of deaths due to opioid overdose, which consists of both prescription opioids and heroin, has quadrupled since 1999, and almost half of all U.S. opioid overdose deaths involve a prescription opioid.¹⁵ The CDC reports prescription opioids have fueled the increase in opioid overdose deaths over the past 15 years. Prescription opiate use continues to grow, and the CDC has classified it as an epidemic.⁵ This makes it incumbent on clinicians engaged in treating patients with chronic pain—both primary care physicians and psychiatrists—to seek new approaches and new ways to collaborate.

Alternative treatment approaches

One approach to the treatment of chronic pain is to combine multidisciplinary treatment with medications. There is a substantial body of medical literature that supports the use of physical therapy, occupational therapy, acupuncture, massage, yoga, and exercise in the treatment of numerous chronic pain conditions.^8,16 Multidisciplinary rehabilitation has moderate evidence in the reduction of pain and improvement in the functioning of patients with disabling chronic low back pain (CLBP).

Buprenorphine and methadone are frequently used as opioid maintenance therapy in medication-assisted treatment programs, and these medications have potent analgesic effects as well.

Psychological therapies are another excellent alternative to prescription opioids to treat chronic pain. These therapies are efficacious and durable, reduce disability, and also may treat co-morbid psychological illnesses.¹⁷ In the following section, we discuss psychotherapies that can be utilized in combination with medications and other multidisciplinary approaches to treat chronic pain conditions.

CBT for chronic pain

Over the past half-century, CBT techniques have been in practice in the management of chronic pain. CBT helps the patient to decrease catastrophic cognitions about the pain and develop a sense of self as a healthy person with a pain disorder.¹⁸ Reduction in pain catastrophizing mediates the improvement in functioning in chronic pain.¹⁹ The therapist educates the patient about pain as a stressor and helps develop effective coping and adaptation skills to deal with such a stressor.

Initially, patients learn to establish an association between pain and activity throughout the day. In the behavioral part of the therapy, the therapist gradually introduces the idea of engaging in meaningful work projects, pleasurable activities, and family activities to re-establish a better quality of life. Graded task assignments—meaning dividing activities into small tasks with gradual small increases in increments to reach a goal—help patients develop the courage to experiment with increases in day-to-day life pursuits. Progressive muscle relaxation, controlled breathing, imagery, and meditation are used to manage physical distress during activities.¹⁸ Cognitive strategies are employed to teach patients to identify automatic thoughts that occur about pain as well as to use cognitive restructuring and positive coping statements to help to modify negative thoughts.

Chronic Wide-spread Pain (CWP) and fibromyalgia are usually resistant to treatment of pain-relieving medications. On the other hand, CBT is highly effective in the treatment of CWP and fibromyalgia reducing both intensity and perception of pain while having a moderate effect size.^20,21 A Cochrane Database Systemic Review showed a positive effect of CBT for the treatment of chronic pain (excluding headache) in adults. When compared with treatment as usual/waiting list, CBT was effective in reducing disability, treating mood problems, and reducing catastrophizing outcomes six months posttreatment. The authors recommended CBT as a practical tool to treat chronic pain.²²

CLBP is highly prevalent disorder in the adult population. In a meta-analysis of all psychological interventions available for treatment of low back pain, CBT alone showed significant positive effects for pain intensity (d = 0.62, p = 0.00) in the treatment of CLBP.²³ CBT was also found to be helpful in improving the quality of life, return to work, and stabilizing mood.

In other studies and reviews, CBT was found to be efficacious for orofacial pain and specific pain disorders such as dyspareunia.^24,25

ACT for chronic pain

ACT is a form of CBT originally developed in the 1980s by Steven Hayes.²⁶ It is based on an experimental analysis of human language and cognition known as relational frame theory. The premise of ACT is that changing a person’s relationship with thoughts (rather than changing thoughts), and accepting emotional experiences with mindfulness-based strategies can be helpful in managing painful experiences and allow a person to pursue valued actions and have a meaningful life.²⁷

The treatment goal of ACT for chronic pain is to encourage patients to engage in a persistent and flexible pattern of “value-directed behavior” in the presence of pain or discomfort.²⁷ Through experiential exercises, the client shifts from avoiding negative feelings to observing and accepting them, subsequently working toward goals developed by considering his/her own personal values.

There is substantial and continually growing evidence for the use of ACT for chronic pain in adolescents, adults, and the elderly ^28,29 It has a “strong” strength of research support for chronic pain as recognized by the American Psychological Association’s Division 12 (Clinical Psychology). A number of systematic reviews and meta-analysis of trials have supported the utility of ACT for chronic pain.^7,30–32 The most recent systematic review and meta-analysis by Hughes et al. studied 11 trials focusing on ACT for a wide variety of chronic pain syndromes. It concluded that although the results may be overestimated, the current evidence for ACT in the treatment of chronic pain is promising.³³

Mindfulness-based programs

Over the past decade, there has been increased interest and research regarding the therapeutic benefits of “MBPs” including mindfulness-based stress reduction (MBSR) and mindfulness-based CBT.³⁴

Patients practicing MBPs learn to temporarily suspend judgment toward all negative thoughts and sensations. This causes an “uncoupling” of the sensory dimension of the pain experience from the effective alarm reaction allowing for the attenuation of the experience of suffering through cognitive reevaluation.³⁵

There is moderate empirical support for the use of MBPs for the treatment of chronic pain and chronic pain syndromes. A recent randomized control trial involving 342 patients with chronic back pain compared MBSR/CBT intervention to usual care. Patients in the MBSR and CBT group had higher improvement on the Roland Disability Questionnaire (60.5% and 57.7%, respectively) compared to those receiving usual care (44.1%).³⁶ The authors concluded that treatment with MBSR or CBT was effective and resulted in improvement in back pain and functional limitation at 26 weeks. There was no statistically significant difference between the outcomes of those receiving MBSR and CBT.

Recently, an Italian consensus conference on pain in neurorehabilitation extensively reviewed the psychological treatments for chronic pain.³⁷ The experts concluded that CBT has an adequate effect, while MBPs has a strong impact on the treatment of chronic pain with heterogeneous pathology. The consensus group recommended the use of these therapies in the treatment of chronic pain. In a 26-week, randomized, interviewer-blind clinical trial, treatment with CBT or MBSR was significantly better than usual care for chronic back pain in adults.³⁸ CBT and MBSR did not differ in clinical outcome, suggesting that both modalities are effective treatment options.

Mindfulness meditation (MM) reduces pain intensity and unpleasantness by neuroanatomical changes in the brain. Due to neuroplasticity, the results of MM may be durable. A recent novel study determined the neural pathways responsible for the modulation of pain by MM.³⁹ MM activates regions that mediate the cognitive control of pain including anterior cingulate cortex and insula. MM attenuates pain via neural pathways independent of opioidergic, neurotransmitter mechanisms.³⁹

Practice gap and new frontiers

Psychotherapies are often underutilized in the treatment of chronic pain due to lack of access, clinician’s lack of familiarity, poor reimbursement rates, and lack of patient education and receptivity. For these reasons, education and access to these effective modalities should be improved.

Many Individuals with diagnoses of chronic pain also have mental health problems. To obtain optimum care, these individuals must overcome social, financial, and clinical barriers, such as limited mobility, reduced income, poor compliance with multiple appointments, and more co-payments.⁴⁰ Chronic pain treatment and mental health treatment are not always coordinated or integrated.⁴¹ To address this concern, psychiatrists should be actively involved in the treatment of chronic pain in a multidisciplinary team setting.⁴² Alternative psychotherapeutic interventions should be regularly offered to patients with chronic pain issues. There is a need for more systematic coordination and collaboration with primary care providers so that patients have better and seamless access to a variety of treatment options, as well as a more cost-effective way to get treatment for pain, addiction, and medical issues.

Limitations

The limitation of the systematic review of pain treatments is that such studies often include different types, etiologies, and duration of pain. The limitation of alternative therapies is generally their moderate effect size and slow onset of action.^33,36 There are no head-to-head trials to compare these therapies. The training, integration, and dissemination of these therapies may require significant resources, and time and outcomes may depend on the expertise and skill of the individual therapist.

Conclusion

Treatment of chronic pain outside of active cancer treatment, palliative care, and end-of-life care is challenging. There is an intrinsic risk of misuse, abuse, addiction, overdose, and death associated with chronic opiate therapy and a risk of infection, hematoma, and other complications from surgical interventions. Chronic pain places an enormous medical, social, economic, and psychological burden on society; therefore, it is imperative to place greater emphasis on alternatives to opiates. Primary care office-based multidisciplinary and evidence-based approaches such as psychotherapeutic interventions are necessary to treat chronic pain. Integration of primary care and behavioral health therapies will provide better treatment outcomes.

CBT, ACT, and MBPs have moderate empirical evidence supporting their utility in reducing pain, enhancing function, and improving quality of life.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Treede R-D, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain 2015; 156: 1003–1007. doi:10.1097/j.pain.0000000000000160.

Apkarian

Baliki

Geha

PY.

Towards a theory of chronic pain. Prog Neurobiol 2009; 87: 81–97.

Nahin

RL.

Estimates of pain prevalence and severity in adults: United States, 2012. J Pain 2015; 16: 769–780.

Häuser

Wolfe

Henningsen

et al . Untying chronic pain: prevalence and societal burden of chronic pain stages in the general population - a cross-sectional survey. BMC Public Health 2014; 14: 352.

Rudd

Aleshire

Zibbell

et al . Increases in drug and opioid overdose deaths—United States, 2000–2014. Am J Transplant 2016; 16: 1323–1327.

Cherkin

Sherman

Balderson

et al . Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA 2016; 315: 1240.

Veehof

Trompetter

Bohlmeijer

et al . Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther 2016; 45: 5–31.

Deyle

Henderson

Matekel

et al . Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132: 173–181.

Keefe

Abernethy

C Campbell

Psychological approaches to understanding and treating disease-related pain. Annu Rev Psychol 2005; 56: 601–630.

10.

Baron

Binder

Wasner

Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol 2010; 9: 807–819.

11.

Jänig

Baron

Complex regional pain syndrome: mystery explained?

Lancet Neurol 2003; 2: 687–697.

12.

Daubresse

Chang

H-Y

et al . Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care 2013; 51: 870–878.

13.

Chang

H-Y

Daubresse

Kruszewski

et al . Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014; 32: 421–431.

14.

Frenk

Porter

Paulozzi

LJ.

Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS Data Brief 2015; 189: 1–8.

15.

https://www.cdc.gov/drugoverdose/epidemic/ (2017, accessed 31 May 2017)

16.

Chou

Huffman

; American Pain Society, American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007; 147: 492–504.

17.

Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001; 322: 1511–1516.

18.

Majeed

Sudak

DM.

Cognitive behavioral therapy for chronic pain-one therapeutic approach for the opioid epidemic. J Psychiatr Pract 2017; 23: 409–414.

19.

Smeets

RJEM

Vlaeyen

JWS

Kester

ADM

et al . Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 2006; 7: 261–271.

20.

McBeth

Prescott

Scotland

et al . Cognitive behavior therapy, exercise, or both for treating chronic widespread pain. Arch Intern Med 2012; 172: 48.

21.

Glombiewski

Sawyer

Gutermann

et al . Psychological treatments for fibromyalgia: a meta-analysis. Pain 2010; 151: 280–295.

22.

Williams

Eccleston

Morley

Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012; 11: CD007407.

23.

Hoffman

Papas

Chatkoff

et al . Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007; 26: 1–9.

24.

Aggarwal

Lovell

Peters

et al . Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev 2011: CD008456.

25.

Dunkley

Brotto

LA.

Psychological treatments for provoked vestibulodynia: integration of mindfulness-based and cognitive behavioral therapies. J Clin Psychol 2016; 72: 637–650.

26.

Hayes

SC.

Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies—Republished article. Behav Ther 2016; 47: 869–885.

27.

Vowles

Sowden

Ashworth

A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain. Behav Ther 2014; 45: 390–401.

28.

Gauntlett-Gilbert

Connell

Clinch

et al . Acceptance and values-based treatment of adolescents with chronic pain: outcomes and their relationship to acceptance. J Pediatr Psychol 2013; 38: 72–81.

29.

McCracken

Jones

Treatment for chronic pain for adults in the seventh and eighth decades of life: a preliminary study of acceptance and commitment therapy (ACT). Pain Med 2012; 13: 861–867.

30.

Veehof

Oskam

M-J

Schreurs

KMG

et al . Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain 2011; 152: 533–542.

31.

Powers

Zum Vörde Sive Vörding

Emmelkamp

PMG.

Acceptance and commitment therapy: a meta-analytic review. Psychother Psychosom 2009; 78: 73–80.

32.

Smout MF, Hayes L, Atkins PWB, et al. The empirically supported status of acceptance and commitment therapy: An update. Clin Psychol 2012; 16: 97–109. doi:10.1111/j.1742-9552.2012.00051.x.

33.

Hughes

Clark

Colclough

et al . Acceptance and commitment therapy (ACT) for chronic pain. Clin J Pain 2017; 33: 552–568.

34.

Majeed

Ali

Sudak

DM.

Mindfulness-based interventions for chronic pain: evidence and applications. Asian J Psychiatr 2018; 32: 79–83.

35.

Kabat-Zinn

An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982; 4: 33–47.

36.

Turner

Anderson

Balderson

et al . Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain. Pain 2016; 157: 2434–2444.

37.

Castelnuovo

Giusti

Manzoni

et al . Psychological treatments and psychotherapies in the neurorehabilitation of pain: evidences and recommendations from the Italian consensus conference on pain in neurorehabilitation. Front Psychol 2016; 7: 115.

38.

Cherkin

Anderson

Sherman

et al . Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017; 317: 642.

39.

Zeidan

Emerson

Farris

et al . Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. J Neurosci 2015; 35: 15307–15325.

40.

Vanderlip

Raney

Druss

BG.

A framework for extending psychiatrists’ roles in treating general health conditions. Am J Psychiatry 2016; 173: 658–663.

41.

Homes

Behavioral

Centers

APA official actions position statement on the role of psychiatrists in reducing physical health disparities in patients with mental illness, http://apps.psychiatry.org/pdfs/position-statement-role-of-psychiatrists.pdf (2015, ▪).

42.

Majeed

MH.

Strengthening the role of psychiatrists in the treatment of chronic pain. Pain Med. Epub ahead of print 22 November 2017. DOI:10.1093/pm/pnx284. file:///Users/muhammadhassanmajeed/Downloads/Position-2015-Role-of-Psychiatrists-in-Reducing-Physical-Health-Disparities-in-Patients-with-Mental-Illness.pdf