Relieving chronic pain with behavioral strategies

Behavioral strategies that relieve the physical and emotional burdens of chronic pain are becoming more commonplace, not just as alternatives or adjuncts to problematic opioid analgesics, but as effective means to restore daily functioning.

While analgesics can provide welcome relief in acute pain conditions, pain reduction is only temporary and does little to remedy the distress and disabilities that emerge when pain persists.

In fact, a recent study published in the Journal of Pain, examining populations in two large health systems, indicated that increasing the dose and duration of opioids for unrelieved chronic pain was associated with worse health outcomes.

Behavioral interventions can successfully interrupt the cycle of treating heightened perception of pain with ever more analgesics. They have also empowered patients to shift the focus from their pain and impairment to reclaiming function and activities, despite residual pain.

What strategies can physicians use to change pain behavior? And why are these treatments not widely adopted in the medical profession?

Calls for implementing evidence-based behavioral strategies in managing chronic pain have been issued by various agencies, including the National Institutes of Health (NIH) and the Institute of Medicine in the United States.

The principal interventions for relieving the psychological symptoms of chronic pain are cognitive behavioral therapy (CBT) and mindfulness treatments.

CBT includes several different strategies, with acceptance and commitment therapy (ACT) as one of the newest iterations. Each focuses on maladaptive or dysfunctional thinking and responses to stress, with ACT emphasizing acknowledgment and acceptance of these without requiring their resolution before progressing.

Key targets of CBT are reducing "catastrophizing," which is when the patient is feeling helpless and overwhelmed, and identifying "secondary gains" from the impairment of pain, which may undermine motivation to resume work or interact with family or peers.

CBT can also increase both self-efficacy and the capacity to accept social support, as both are associated with greater tolerance of pain and reduction in perceived pain intensity.

Mindfulness treatments, including mindfulness-based stress reduction, mindfulness-based cognitive therapy, and mindfulness meditation, foster an awareness of the sensation of pain without judgment or emotional response. v In one assessment of the putative mechanisms underlying pain control from mindfulness meditation, published in Annals of the New York Academy of Sciences, the authors conclude that "analgesic effects of meditation can be developed and enhanced through greater practice, a critical consideration for those seeking long-lasting narcotic-free pain relief."

Dawn C. Buse, Ph.D., an associate professor in the Department of Neurology at Albert Einstein College of Medicine of Yeshiva University in New York City, NY, explained to Medical News Today the value of behavioral strategies in treating patients with chronic pain.

"Behavioral treatment strategies for chronic pain have strong, proven efficacy, are cost-effective, and do not have side effects or interactions," said Prof. Buse.

When referring a patient for treatment, Prof. Buse cautioned that the physician should not just "hand off," but they should instead maintain a pivotal role in providing integrated care.

She also discussed the importance of choosing the type of intervention that is likely to be acceptable and effective for a particular patient.

The latest research shows that ACT can improve functioning in chronic pain patients.

"For people with higher levels of disability, depression, anxiety disorders and/or uncontrolled stress along with chronic pain, mindfulness training, alone, may not provide sufficient therapeutic outcomes," Prof. Buse said. "However, it can be successfully combined with CBT strategies in programs such as MBCT [mindfulness-based cognitive therapy]."