About 100 million Americans live with some form of chronic pain—more people than are affected by diabetes, heart disease and cancer combined. For nearly two decades beginning in the late 1990s, the first-line treatment for many of these patients was opioid drugs. But over the past several years, as physicians and health officials realized that opioid overprescription had spiraled into an addiction crisis, the tide has turned. The Centers for Disease Control and Prevention altered its guidelinesopens in new window for prescribing the drugs in 2016; several states have passed laws limiting their use; and opioid prescriptions decreased 22 percentopens in new window between 2013 and 2017 as physicians’ awareness of their risks increased.
These changes have wrought a powerful new incentive for doctors to look for non-drug treatments for pain, including psychological treatments, says psychologist Beth Darnall, PhD, a clinical psychology professor in the department of anesthesiology, perioperative and pain medicine at Stanford University and author of the new APA book “Psychological Treatments for Patients With Chronic Painopens in new window.”
“We’ve always known that pain is best treated biopsychosocially, with an integrated approach,” Darnall says. “When we talk about treating pain in a way that has the lowest risks, it necessarily involves behavioral and psychological treatment.”
Now, the opioid crisis has spurred new interest in these long-standing treatment options—as well as some new funding. That includes an $81 million investmentopens in new window by a collaboration of three government agencies—the National Institutes of Health (NIH), the Department of Veterans Affairs (VA) and the Department of Defense (DOD)—to study nonpharmacological pain treatments for veterans.
“There’s a growing appreciation for the psychosocial aspects of pain,” says Sean Mackey, MD, PhD, an anesthesiologist and director of the division of pain medicine at Stanford. “It’s growing for two reasons: One is just a greater awareness of the psychological factors that play a role in pain. The second is the opioid crisis. It’s going to be a tragic benefit of the opioid crisis that it will bring attention to pain psychology.”
Evidence-based treatments
Research into psychological and behavioral treatment for pain dates back decades. The most common psychological treatment for pain is cognitive-behavioral therapy (CBT). Through CBT-based programs, Darnall says, patients can learn to steer their thoughts away from “catastrophizing” pain and toward thinking of pain as a manageable problem that they can address through treatment and self-care. CBT-based programs provide education about pain, self-management skills and psychological tools to help patients manage symptoms, become more active and live better within the context of pain.
In a new comprehensive literature review, the Agency for Healthcare Research and Quality (AHRQ, 2018) found that CBT can lead to long-term improvements in patients with lower back pain and fibromyalgia. (The review also looked at neck pain, osteoarthritis and hip pain, but found either no long-term improvement due to CBT or insufficient evidence to make a determination.)
Other psychological and behavioral treatments include acceptance and commitment therapy, hypnosis and mindfulness-based stress reduction (MBSR), among others. In one recent randomized clinical trial, for instance, researchers found that two months of either mindfulness training or CBT could improve symptoms and functioning in 342 patients with chronic lower back pain, relative to usual care ( Journal of the American Medical Associationopens in new window , 2016opens in new window).
And importantly, no studies have found documented harms from these psychological treatments, as opposed to the definite risks of opioids and other pharmacological treatments.
Armed with these results, physicians are eager to prescribe behavioral pain treatments, says Darnall, who offers continuing- education lectures to national physician groups. “Physicians are intensely interested in how to connect their patients to behavioral pain management,” she says. “Their questions are: How do I implement this? And who do I refer them to in my community?”
Challenges
Those questions often have no easy answers. “The barriers are implementation, access and insurance,” says Darnall.
First, there are simply not enough psychologists trained in pain psychology, a problem Tennessee pain psychologist Ted Jones, PhD, sees daily at a medical pain clinic in Knoxville. While the clinic has an active patient load of 1,600 people, it has only two psychologists to provide services to them.
“We’re seeing more and more patients here, and we’d like to offer more services,” says Jones, who evaluates potential candidates for drug treatments and provides psychological treatments like CBT in group and individual sessions. He would like to hire another psychologist—but he can’t find a good candidate.
“We haven’t yet built the incentives that would encourage enough psychologists to go into this field,” says Robert Kerns, PhD, a professor at Yale University and former national program director for pain management at the VA.
In an article in Pain Medicine, Kerns, Darnall, Mackey and their co-authors cited the need for more pre- and postdoctoral training programs in pain psychology, with the goal of making it an APA specialization ( Pain Medicine , 2016 opens in new window).
In addition to training, another challenge is reimbursement. Some insurance companies and public insurance programs don’t cover behavioral treatment for pain, or they reimburse for it at a lower rate than physical treatments such as medications or injections, which makes it more difficult for some patients to access these treatments.
The issue is not universal and varies by location—Jones, for example, says that he generally has not had problems with reimbursement, including from TennCare, Tennessee’s Medicaid program.
But Mackey says the Stanford pain clinic loses money on the services that its five psychologists provide. “I could force them to cover their expenses by giving them less time to see patients, but then they can’t provide the services the patients deserve,” he says. “So I’ve made a decision to lose money on it for the greater good. We would like to see reimbursements increase.”
Those structural issues will take time to address, but in the meantime, research continues on expanding access to behavioral treatment for pain. For example, the $81 million NIH-VA-DOD collaboratoryopens in new window will fund 11 large-scale “pragmatic clinical trials” to look at how military and veteran health-care providers can add nonpharmacological treatments, including psychological treatments like mindfulness and CBT, to the care they provide.
Meanwhile, Darnall is working to bring behavioral pain treatment to more patients within the framework of the current health-care system by developing shorter treatments and treatments that can be delivered online. She has developed a single-session, two-hour CBT-based pain psychology class and is conducting a randomized clinical trialopens in new window to compare its effectiveness with that of a standard eight-week course of CBT. In another clinical trialopens in new window, she’s investigating whether an online CBT-based class can help reduce recovery pain in surgical patients.
Overall, the aim is to bring the benefits of pain psychology treatment to as many patients as possible. “Pain is both a negative sensory and negative emotional experience,” Darnall says. “Psychology is already integrated into the definition of pain,” she adds. “It is not an ‘alternative’ treatment, it is a primary treatment for pain.”
