Chronic pain, defined by the U.S. Centers for Disease Control and Prevention (CDC) as pain that lasts longer than 3 months, is the leading cause of disability in the United States, affecting about 1 in 5 adultsopens in new window. One in 14 adults experience high-impact pain that limits their daily activities (NCHS Data Brief, No. 390, 2020opens in new window).
Many people with chronic pain depend on opioids, which temporarily relieve symptoms but also come with side effects and a well-established risk of addiction and overdose. “Opioids are alluring because they act both physiologically and psychologically, basically numbing away the pain,” said Aaron Weiner, PhD, a counseling psychologist in Chicago who specializes in addiction and president of APA’s Div. 50 (Society of Addiction Psychologyopens in new window). “However, the right combination of treatments for chronic pain, which can certainly include behavioral health interventions, can often control pain just as well as opioids.”
While many view pain as a physical experience, psychological research suggests it’s much more complex, also stemming from psychological and social factors. This understanding lays the groundwork for the biopsychosocial model, which identifies the many aspects that can contribute to pain. As a result, effective treatments involve a variety of tools, such as medication, physical therapy, and psychology.
The need for new chronic pain strategies is more urgent than ever due to the covid-19 pandemic. Pandemic-related stress can worsen symptoms, and long covid has brought on many new chronic pain cases, said Ravi Prasad, PhD, professor of anesthesiology and pain medicine at the University of California, Davis School of Medicine.
[Related: With opioid overdoses reaching a record high, how can psychology help? 5 questions for Ravi Prasad]
“Stress is known to exacerbate pain, and the covid-19 pandemic is fraught with tensions that can tax even the most resilient among us,” he said. “The ambiguity associated with the virus, the rich discussions about science and politics that ensue during this period of our lives, and the social isolation and financial impacts linked with stay-at-home orders are just a few of the many pandemic-related stressors that can directly worsen pain.”
The nation’s opioid epidemic has also fueled interest in non-pharmacological options for managing pain. The CDC and U.S. Department of Health and Human Services are now recommending non-pharmacological approaches to chronic pain whenever possible. From creating new treatments to more inroads to access them, an increasing number of psychologists are committed to improving patient outcomes by introducing the right type of care early on.
“Although efficacious, psychology is offered as a last resort for patients who are struggling, but it’s important to be able to offer it sooner rather than later,” said Stacey B. Sandusky, PhD, a clinical psychologist at James A. Haley Veterans’ Hospital in Tampa, Florida.
Training medical professionals
Primary-care providers are often the first to treat patients’ pain, yet many report feeling underprepared to address it, said Alison M. Vargovich, PhD, a clinical assistant professor of psychology at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences in New York.
The average U.S. medical school has 9 hours devoted to pain in the curricula, compared with 19.5 hours in Canadian medical schools and 45 hours in the average veterinarian program (Journal of Pain, Vol. 12, No. 12, 2011opens in new window). New physicians express a lack of preparedness in assessing and managing pain (BMC Medical Education, Vol. 17, No. 33, 2017opens in new window).
Medical providers typically search for a physiological source—but in many people who report pain, there’s no objective evidence of pathology. “You can’t do a scan and find pain in the brain,” said Robert Kerns, PhD, a professor of psychiatry, neurology, and psychology at Yale University. “We rely on what people tell us about their experience.”
Plus, many patients prefer medicine for its immediate effects. “Psychological treatments by their nature take time and effort, which is hard when you are in pain,” said Michael Robinson, PhD, a professor of psychology at the University of Florida and director of UF’s Center for Pain Research and Behavioral Health.
Psychologists play a critical role in helping medical professionals understand how pain works and how to treat it. Rachel V. Aaron, PhD, an assistant professor of physical medicine and rehabilitation at Johns Hopkins University School of Medicine, teaches medical students about the biopsychosocial model, along with internal biases that can impact how they interact with people in pain; research shows Black people, women, and people with obesity, for example, are often subject to providers’ doubts about the validity of their pain. She also teaches about the importance of active listening and empathy.
“If providers believe pathology and pain are perfectly correlated, when they don’t find pathology, they may attribute the pain to factors like the patient’s personality or mental health,” said Aaron. “That can make the patient feel like the doctor’s not taking them seriously, and they may be less open to recommendations that could help them.”
Sarah Buday, PhD, an assistant professor of anesthesiology and pain psychologist at Washington University School of Medicine in St. Louis, teaches physicians about motivational interviewing so they can validate patients even when tests do not indicate etiology of painful sensations.
Along with explaining how statements like “Everything looks good” can feel belittling, Buday encourages physicians to respond to patients with reflective statements rather than potentially invalidating questions.
To promote awareness of treatment options, Vargovich and her colleagues teach medical students about non-opioid options for managing pain. Their workshop at West Virginia University covered the latest developments in pain science, evidence-based treatments that employ a biopsychosocial approach to pain management, and how to talk to patients who may be resistant to non-opioid treatments or unfamiliar with pain science. Afterward, students reported better knowledge and increased confidence in treating chronic pain (Academic Psychiatry, Vol. 43, No. 5, 2019opens in new window).
Building interdisciplinary teams
For many, seeing a psychologist is a last resort when other interventions fail. “That makes it harder for people to be receptive to pain psychology, because they come with the mindset that nothing’s going to help,” said Aaron. In response, many psychologists are helping build teams in which clinicians working with pain patients can integrate psychology into their treatment and refer patients to psychologists when appropriate.
Jennifer L. Murphy, PhD, director of pain management for the Veterans Health Administration (VA), has worked within the administration’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program to enhance and expand pain care and staffing. Her program has funded the implementation of pain management teams at all VA facilities as mandated by the Comprehensive Addiction and Recovery Act—teams that include a physician and rehabilitation therapist with pain expertise, a behavioral provider with expertise in evidence-based pain treatment, and an addiction medicine expert. Her office has also disseminated funding for various VA initiatives, including the hiring and embedding of 60 physical therapist and psychologist duos in pain clinics to deliver integrated, group-based, nonpharmacological pain care grounded in behavioral principles and pain neuroscience education.
Murphy has also led the VA’s Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) Programopens in new window, which has trained more than 1,000 VA social workers and psychologists in the evidence-based intervention. She assisted other VA clinicians in developing an abbreviated CBT-CP manual for mental health providers embedded in primary-care clinics. “We’re trying to move toward adopting a shared pain language across clinics and settings, so that everyone from your nurse and physician to your physical therapist and psychologist talk the same talk and provide consistent foundational messages,” she said.
Kirti Thummala, PhD, an assistant professor of psychology at the Medical College of Wisconsin, is part of the Froedtert and MCW health network clinical neurology team that educates physicians, physical therapists, and behavioral health providers in other departments about chronic pain and the importance of resilience in pain management. “In order for patients to really believe changing their behavior can help them feel better, that message needs to be reinforced by everyone,” Thummala said. By the time patients come to her for therapy, they’re much more open to comprehensive approaches that include psychology.
Better access to care
Patients with chronic pain often have a difficult time getting to and from appointments due to their pain or socioeconomic factors common in those with chronic pain, and psychologists are finding new ways to help.
Beth Darnall, PhD, a professor of pain medicine at Stanford University School of Medicine and director of the Stanford Pain Relief Innovations Lab, created a single-session intervention called Empowered Relief, which includes psychoeducation, mindfulness principles, and cognitive behavioral therapy (CBT) pain management skills to help people manage pain at home with a virtual, 2-hour intervention. “I can make recommendations in a pain clinic about what a patient can receive in their community a hundred miles away, but there’s often no one to provide that service,” said Darnall. “We’re equipping people with a basic skill set so they can help themselves on a daily basis.”
So far, the intervention has been delivered to patients in national and international clinic and hospital settings. A 2021 study found the intervention to be comparably effective to eight sessions of CBT; the intervention reduced pain-related distress, intensity, and interference, along with decreasing depression, anxiety, and sleep disturbance. All the positive outcomes persisted to 3 months post-intervention (JAMA Network Open, Vol. 4, No. 8, 2021opens in new window). Darnall is leading two new national pragmatic trials of online Empowered Relief, one for people with general chronic pain and another for people with chronic pain and prescription opioid misuse. Combined, the trials will study 1,600 individuals and longer-course online CBT for chronic pain.
A digital, on-demand version of Empowered Relief that has been tailored to patients undergoing surgery was shown to decrease opioid use in women undergoing breast cancer surgeryopens in new window, and to reduce pain immediately after orthopedic trauma surgery and up to 3 months later (Anesthesia & Analgesia, Vol. 134, No. 2, 2022opens in new window).
During the pandemic, the Tampa VA also created a virtual, interdisciplinary pain rehabilitation program called the Pain Empowerment Anywhere (PEAK) Program for people with high-impact chronic pain. The 5-week program is rooted in the same evidence-based, active rehabilitation principles as Tampa’s inpatient Chronic Pain Rehabilitation Program but is delivered synchronously. “The intervention casts a wider net, so people who may not be appropriate for, ready [for], or able to participate in traditional, in-person care can access treatment,” said Sandusky.
PEAK is a blend of individual, group, and team-based modalities focused on functional restoration through exercises, skills, and techniques. Because PEAK is conducted on a rolling basis, patients engage with others who are at various time points within the program. “Seeing someone espouse the benefits and reinforce active coping can help people in the earlier weeks buy in,” said Sandusky. Murphy’s office has provided support for the PEAK staffing and expansion.
Psychologists can also train master’s-level clinicians to deliver pain treatment psychotherapies. Risa B. Weisberg, PhD, a professor of psychiatry at Boston University School of Medicine, helped develop three NIH-funded, phone-based interventions for patients with comorbid depression and chronic pain, chronic pain and opioid use disorder, and HIV-related pain and depression. Social workers, mental health counselors, and doctoral students deliver the trials to patients referred by addiction or primary-care providers, focusing on acceptance and commitment therapy and cognitive behavioral therapy principles and incorporating psychoeducation, values clarification, and goal setting, along with lessons on how to talk to providers about pain. Trials are still in progress, but Weisberg said the primary goal is to increase patients’ functioning and engagement in everyday life, with a secondary goal of decreasing pain severity.
Psychology-informed technology
Cutting-edge virtual reality (VR) treatments aim to make learning to practice mindfulness easier by immersing patients in digital worlds where they can practice skills in real time. “It’s even easier to learn mindfulness in VR than in person with a therapist because rather than sitting with your eyes closed imagining yourself on the banks of a river, you go there,” said Weisberg, chief clinical officer for the VR startup BehaVRopens in new window, which is developing digital pain interventions and provides virtual reality pain neuroscience education. The company is creating more content for chronic pain, including one experience that combines pain neuroscience education with mindfulness and gentle movement. BehaVR also has a grant with Eric Garland, PhD, of the University of Utah, to create an intervention to combine mindfulness and craving cue exposure to reduce opioid cravings. The in-person version of this intervention has been shown to reduce patients’ chronic pain (JAMA Internal Medicine, Vol. 182, No. 4, 2022opens in new window).
Darnall helped create an FDA-authorized VR product for low back pain for the company AppliedVRopens in new window. Virtual reality headsets are prescribed and shipped to patients, who can use the device daily at home as needed. The device incorporates evidence-based psychological treatment for low back pain—primarily mindfulness, meditation, deep breathing, and CBT—to help patients manage their pain at home, said Todd Maddox, PhD, vice president of research and development at AppliedVR. The intervention can be prescribed by a doctor and includes 8 weeks of daily VR experiences about 7 minutes long. “Being transported somewhere else through VR activates the brain’s learning systems, which helps you build new habits and change the way your brain deals with pain,” Maddox said.
One randomized controlled trial showed VR-delivered content yielded superior reduction in pain intensity and interference compared with the same clinical content in audio-only format (JMIR Formative Research, Vol. 4, No. 7, 2020opens in new window). A follow-up showed that an 8-week, VR-delivered pain intervention offered extended and clinically meaningful analgesia and reduced pain interference compared with a placebo VR treatment (Journal of Medical Internet Research, Vol. 23, No. 2, 2021opens in new window). A 3-month follow-up also showed sustained benefits across all indices measured (Journal of Pain, Vol. 23, No. 5, 2022opens in new window) and another follow-up was planned at 6 months post-treatment.
Restructuring the brain
Neuroscience research lays the groundwork for new evidence-based treatments. Studies suggest negative emotion and thought about pain can increase the pain signal, leading people to report higher pain intensity and interference. “Pain psychologists can help patients change how their brain is firing in response to pain signals and retrain them how to respond appropriately,” said Amy Wachholtz, PhD, director of the clinical health psychology program at the University of Colorado Denver.
Wachholtz uses a combination of evidence-based psychoeducation and biofeedback strategies. “You start by teaching patients how pain works, and then you give them strategies for controlling sensations in their bodies with tools like meditation and deep breathing,” she said. Over time, this increased sense of autonomy can turn down pain signals in the brain.
Tor Wager, PhD, director of the Brain Imaging Center at Dartmouth College, studies how beliefs about pain treatment can impact how the brain constructs pain. One treatment Wager has studied is pain reprocessing therapy (PRT), a system of psychological techniques aimed at retraining the brain to respond to signals from the body to help break the cycle of chronic pain. PRT integrates cognitive behavioral therapy, mindfulness, and exposure therapy, along with new elements meant to turn down signals in the brain exacerbated by problematic thoughts and emotions about pain. “The belief that pain is dangerous makes the brain hypervigilant to bodily sensations, creating a feedback cycle of mutually reinforcing threat and pain,” Wager said. “But once pain has become chronic, it is no longer a signal of damage to the body. PRT helps people form new beliefs about pain, which can create large, durable reductions in pain and increase functionality.”
In a randomized controlled trial of 150 chronic back pain patients, 66% of those randomized to PRT were pain free or nearly pain free by the end of treatment—in spite of the fact that they had been in pain for an average of 10 years before the study—and gains were maintained through a 1-year follow-up (JAMA Psychiatry, Vol. 79, No. 1, 2022opens in new window).
Pain risk factors
Psychological research on factors that contribute to a person’s experience with pain is an important part of developing new evidence-based treatments and informing provider-patient interactions. Shin Ye Kim, PhD, an assistant professor of counseling psychology at University of Wisconsin–Madison, studies how cultural factors like language barriers can impact people’s pain experiences.
If a patient is only fluent in a language a provider doesn’t speak, providers report difficulty with diagnosis and assessment. Conversely, when patients don’t feel understood by their providers, they may not share as openly about their pain, decreasing their quality of life. Ongoing research about the relationship between culture and pain, Kim said, should continue to shape provider-patient interactions. “When providers understand cultural differences and the importance of communication, they can advocate for better resources for the patient,” she said.
Annmarie Caño, PhD, a professor of psychology at Gonzaga University in Spokane, Washington, studies how people’s response to someone’s chronic pain affects pain intensity and distress. Her research consistently shows that when a partner minimizes or catastrophizes pain, the person in pain experiences poorer outcomes (Journal of Pain, Vol. 18, No. 8, 2017opens in new window).
Emotional validation, on the other hand, can improve people’s mood and emotion regulation, enhancing functionality amid chronic pain and even affecting pain sensation. Caño’s findings suggest that while behavioral activation is important, so is empathy. She developed an intervention that teaches couples in which one or both people have chronic pain how to be emotionally validating and find shared meaningful activities (Cognitive and Behavioral Practice, Vol. 25, No. 1, 2018opens in new window).
Next steps
To continue promoting psychology as a first-line treatment will require several systemic changes to the health care training infrastructure. Kerns recommends all psychology educators integrate pain education into their curricula. To inform more psychologists, APA will provide video training in the biopsychosocial model and evidence-based psychological approaches any clinician can use to help patients with chronic pain (see New continuing education on pain management below).
Advocacy is also important because psychological pain treatments often aren’t adequately reimbursed by insurance, which has resulted in fewer psychologists providing these services. Kerns stressed the importance of the Centers for Medicare and Medicaid Services, which is examining new policy options for the reimbursement and treatment of chronic pain. APA has been actively engaging with the Centers for Medicare & Medicaid Services (CMS) on pain management services and reimbursement issues and is responding to a new chronic pain management and treatment service proposal released as part of the CMS Physician Fee Schedule Proposed Rule on July 7, 2022.
In the process, psychologists should help shape patients’ expectations about their pain. “The most successful providers of care to people with chronic pain conditions have to spend time helping patients broaden their focus of treatment success beyond a sole focus on pain relief,” said Robinson.
Clinicians can also advocate for patients. Weiner said when patients who take opioids disclose they may be struggling with an addiction, doctors are often overly aggressive in discontinuation, increasing both pain and the likelihood patients will turn to illegal or street sources. When a patient of Weiner’s wants to taper off opioids, he contacts the person’s physician.
“I’ll say, ‘We have a mutual patient who’s interested in making a change, and I want to partner with you in this,’” Weiner said. “The doctor feels reassured because I’m seeing the patient on a regular basis, and as such patients can go through the taper process much more gently and successfully.”
