Millions of Americans suffer from moderate to severe chronic pain, ranging from headaches, low-back pain and arthritis to fibromyalgia, jaw disorders and various forms of neuropathic pain. The psychological and social toll of chronic pain is enormous, and pain specialists estimate its cost in medical expenses and lost income and productivity to be between $50 billion and $100 billion annually.
In the past 20 years, the medical community has increasingly recognized psychosocial interventions--such as cognitive-behavioral therapy, coping skills training, hypnosis and biofeedback--as an important component of effective chronic pain treatment. And recently, psychologists have made progress in persuading third-party payers to reimburse patients for psychosocial pain treatment programs.
Despite these gains, however, chronic pain remains poorly understood, and researchers and clinicians have been discouraged to find that many patients' pain does not respond well to any treatment.
The challenge now, many researchers say, is to develop a more fine-grained understanding of why cognitive-behavioral therapy and other psychosocial approaches work better for some chronic pain patients than for others, and to refine treatment to reflect that understanding. Here are a few emerging avenues of research.
Tailoring treatment to patient characteristics
One reason that many chronic pain patients do not show significant improvement in pain treatment programs may be that chronic pain patients have for too long been treated as though they were a homogeneous group, suggests Dennis Turk, PhD, a psychologist in the University of Washington's department of anesthesiology and director of the university's Fibromyalgia Research Center.
His and others' research, however, indicates that nothing could be further from the truth. There is now voluminous research indicating that people with chronic pain are not all alike. Instead, studies indicate, chronic pain sufferers who seek treatment from pain specialists tend to fall into one of three subgroups.
Those Turk terms "dysfunctional"--30 to 60 percent--have severe pain, tend to be depressed, feel they have little control over their pain and are very inactive. Patients who are "interpersonally distressed"--about 20 to 35 percent--experience severe pain and feel they get little support from those around them. The most fortunate of chronic pain patients are the "adaptive copers,"--20 to 35 percent--who experience significant pain but are reasonably well-adjusted and feel in control of their pain.
Although the percentages of patients who fall into each category vary among different chronic pain disorders, studies in many pain centers in the United States and Europe have shown that the same three patterns of response appear consistently. Further, in studies of patients with fibromyalgia or temporomandibular joint disorders, people who were interpersonally distressed did not benefit from standard pain treatment programs that provide information, exercise and stress-management training, whereas those in the dysfunctional and adaptive-coper groups did.
In a large, prospective study funded by the National Institutes of Health, Turk and his colleagues are investigating whether matching patients to specific treatments, depending on whether they are interpersonally distressed, dysfunctional or adaptive copers, will boost treatment effectiveness.
The researchers are recruiting more than 300 fibromyalgia patients for a six-week pain-treatment program tailored to their pain-response profile. Patients who are interpersonally distressed, for example, will receive information and exercises that are standard treatment for fibromyalgia, as well as training from psychologists in interpersonal problem solving, communication and assertiveness.
The research, Turk hopes, will help distinguish patients who respond well to standard treatments for chronic pain from those who require more individualized treatment.
A family affair
One commonly neglected facet of chronic pain is that it envelops not only pain sufferers, but often their spouses, friends and family members as well.
"Persistent pain is a couples issue," argues pain researcher Francis J. Keefe, PhD, a professor of medical psychology at Duke University. "It affects the relationship between the patient and partner and their daily activities, goals, how they divide tasks up, what they hope to do as a couple."
When patients' spouses practice coping skills such as relaxation, imagery, goal-setting and communication with their partners, Keefe believes, they are less likely to undermine patients' own coping strategies or to feel depressed, anxious or guilty about their partners' pain.
In a recent long-term investigation of pain in patients with osteoarthritis, Keefe and colleagues found that patients whose spouses were included in a coping-skills training program experienced less psychological distress, reported better marital adjustment and felt greater self-efficacy, or ability to control their pain, than did patients whose spouses did not take part in the training. Further, arthritis patients who reported greater self-efficacy had larger decreases in pain and disability than did those who reported less self-efficacy.
Following up on these studies, Keefe's team is examining the effects of providing coping skills training to family members of cancer patients at the end of life. Although the results of that study won't be available until at least next year, Keefe says the preliminary findings are promising.
"We're finding that when the partner's a lot more confident, the patient is doing better physically and the partner is doing better in terms of mood and strain," he says.
Keefe and his co-workers are also planning a study with patients in the early stages of lung cancer. They hope that by beginning to work with spouses and other caregivers early, they can substantially enhance patients' and spouses' confidence that skills such as relaxation, imagery and goal-setting will have positive effects.
Motivational interviewing aims to help patients make the first step
For most chronic pain patients, recovery requires substantial lifestyle changes, including beginning to exercise, learning to pace activities appropriately and practicing relaxation and stress-management skills. But making those changes, behavioral scientists agree, is often a major hurdle. Attendance in rehabilitation programs and compliance with therapists' instructions are persistent problems, with about half of all patients dropping out of therapy prematurely.
One promising avenue of treatment is an approach known as motivational interviewing, developed for treating problem drinking by University of New Mexico psychologist William R. Miller, PhD.
The goal of motivational interviewing is to help patients overcome ambivalence about behavior change and boost their motivation to change. Rather than providing specific behavioral skills, therapists monitor patients' readiness to change their behavior, guide them to examine the costs and benefits of change, affirm their freedom of choice and selectively reinforce statements about their desires, intentions and ability to change.
Psychologist Mark P. Jensen, PhD, of the University of Washington has been using motivational interviewing with his chronic pain patients for about five years. The approach has been very successful, he says.
"When I started using motivational interviewing, my relationships with my patients improved dramatically," Jensen remembers. "I found that I spent much less time arguing and much more time acting as a coach."
Following up on Jensen's clinical experience, psychologist Akiko Okifuji, PhD, of the University of Utah, is planning studies with fibromyalgia patients who vary in their readiness to change their behavior. She plans to compare the effectiveness of three approaches: motivational interviewing, cognitive behavioral therapy and provision of educational materials.
The research may provide new hope for patients who have traditionally fallen through the cracks, Okifuji believes. In the past, she says, when patients dropped out of their rehabilitation therapy, "We used to just say, 'Well, it's their problem--they failed the treatment.' Now, we're asking ourselves what we can do to help patients stick around."
Examining ethnicity and pain
What does the tale of John Henry have to do with pain? According to Christopher Edwards, PhD, a psychologist at Duke University's Pain and Palliative Care Center, Henry's story is perhaps indicative of many African Americans' style of coping with pain, and understanding that link might lead to more effective pain treatments.
Legend has it that John Henry, a railroad worker, could crush more rock than a steam drill. But the effort Henry expended in competing with the machine killed him, just after he hammered his last spike. "John Henryism"--the term coined by Sherman James--describes some African Americans' "aggressive, single-minded, goal-oriented behavior--often to the exclusion of overall health," says Edwards.
His work with Francis Keefe has revealed differences in the way African Americans--in research involving patients with osteoarthritis and prostate cancer--experience, cope and report on the severity of their pain. "Studies have found that African Americans have a lower pain tolerance, post-surgically, for example," Edwards explains. "Sometimes more medications are required. The variances associated with being black or a woman or an immigrant alter experiences with pain."
Edwards believes that pain is a biopsychosocial experience. In order to truly manage and treat pain, he says, many factors, such as experience with racism and discrimination, socioeconomic status, access to health care and stress reactivity, must be examined. "Pain assessment and treatment must integrate these factors, in contrast to the clinical model that mainly treats biology," he says.
But little research has been focused on the area of ethnicity and pain, Edwards notes. For instance, he cites his most recent Medline search that yielded 60,000 articles on pain but only 227 on pain and blacks. "Less than 1 percent of the pain research is devoted to ethnic issues," he says.
He'll continue to look at coping styles in African Americans and whites in an ongoing study involving patients with lung cancer. The work, he says, is immediately applicable in the clinic. "It enables us to develop a target for intervention--one that's more flexible and less goal-oriented."
Palm-top computers portend changes in pain research and therapy
Chronic pain research has relied for decades on patients' retrospective reports of how much pain they felt that day, or how much they thought about their pain, or what activities they engaged in during the course of a given day. These days, there's a new technology on the block: palm-top computers that patients can use to record their pain levels, stress, thoughts, feelings and activities at pre-set times.
The palm-top technology, quickly gaining popularity among researchers, is affording pain experts a fresh look at pain and how therapeutic strategies and daily thoughts, emotions and events affect--and are affected by--pain.
For example, psychologist Judith Turner, PhD, also of the University of Washington, has recently begun research using palm-top computers to study people who have temporomandibular joint disorders. Three times each day, the computers signal patients to record their pain intensity, stress level, mood, feelings of control over their pain and "catastrophizing" thoughts about pain. Collecting such data in real time, rather than retrospectively, will allow Turner to examine "process" questions, such as whether greater pain intensity leads to catastrophizing beliefs about pain, or the reverse.
"The beauty of these electronic diaries, as opposed to paper-and-pencil diaries, is that you know when people are answering the questions--it's date- and time-stamped," says Turner. She speculates that in the future, the palm-top computers could be deployed not only in research, but as an extension of cognitive behavioral therapy. For example, the computers could be programmed to remind patients to engage in particular coping strategies depending on what information they enter into the computers.
Dennis Turk agrees. "The use of this technology holds promise for helping us to better understand the inter-relationships of thoughts, mood and behaviors for people with different chronic pain syndromes and may give guidance in how we customize treatments to the pattern of these inter-relationships," he says.
In research using palm-top computers with fibromyalgia patients, Turk and his colleagues have found that people's retrospective ratings of their pain, activities, mood, fatigue and sleep quality are discrepant from their online assessments. If these preliminary findings hold true in further research, Turk argues, they will challenge scientists' reliance on retrospective reports.
But as in any research that involves patients making frequent pain assessments, cautions psychologist Glenn Affleck, PhD, of the University of Connecticut School of Medicine, researchers using palm-top computers to assess patients' pain should avoid undermining patients' efforts to cope with pain through distraction.
Further, he adds, researchers must be sensitive to the possibility that "by asking people to concentrate so intently on their pain and other experiences...we might even create or consolidate the very relations [between pain and other factors] that we then 'discover.'"
Monitor Senior Editor Jennifer Daw contributed to this story.
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