Non-drug pain management is on the rise

The Centers for Disease Control and Prevention changed its prescribing guidelines in 2016, and several states have implemented legislation restricting their use. Opioid prescriptions fell 22% between 2013 and 2017 as doctors' awareness of the medications' dangers grew.

According to 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 Pain," these changes have created a powerful new incentive for doctors to look for non-drug treatments for pain, including psychological treatments.

Darnall adds, "We've always understood that pain is best treated biopsychosocially, with an integrated approach." "When we talk about treating pain in the safest way possible, we have to talk about behavioral and psychological treatment."

The opioid crisis has sparked renewed interest in these long-established treatment alternatives, as well as some additional financing. A collaboration of three government agencies—the National Institutes of Health (NIH), the Department of Veterans Affairs (VA), and the Department of Defense (DOD)—has invested $81 million to explore nonpharmacological pain remedies for veterans.

Sean Mackey, MD, PhD, an anesthesiologist and director of Stanford's division of pain management, says, "There's a growing respect for the psychosocial components of pain." "It's gaining popularity for two reasons: One is simply a deeper understanding of the psychological variables that influence pain. The opioid crisis is the second. The opioid crisis will have the unfortunate benefit of bringing attention to pain psychology."

Treatments that are based on evidence

Pain psychology and behavioral treatment has been studied for decades. Cognitive-behavioral therapy is the most prevalent psychological treatment for pain (CBT). Patients can learn to steer their thoughts away from "catastrophizing" pain and toward thinking of pain as a manageable problem that can be addressed through treatment and self-care, according to Darnall. CBT-based programs educate patients about pain, teach self-management techniques, and provide psychological tools to help them control symptoms, become more active, and live better in the face of pain.

CBT can lead to long-term benefits in individuals with lower back pain and fibromyalgia, according to a new thorough literature evaluation published by the Agency for Healthcare Research and Quality (AHRQ, 2018). (The review also looked at neck pain, osteoarthritis, and hip pain, but found no long-term benefits from CBT or insufficient evidence to form a conclusion.)

Acceptance and commitment therapy, hypnotherapy, and mindfulness-based stress reduction (MBSR) are some of the additional psychological and behavioral treatments available. In a recent randomized clinical trial, for example, researchers discovered that two months of mindfulness training or cognitive behavioral therapy (CBT) improved symptoms and functioning in 342 individuals with chronic lower back pain compared to conventional care (Journal of the American Medical Association, 2016).

Furthermore, unlike the known hazards of opioids and other pharmacological treatments, no studies have revealed verified problems from psychological therapy.

According to Darnall, who gives continuing-education presentations to national physician groups, physicians are willing to prescribe behavioral pain therapies as a result of these findings. "Physicians are very interested in learning how to connect behavioral pain treatment to their patients," she says. "Their questions are, 'How can I put this into practice?' And to whom do I refer them in my neighborhood?"

Challenges

Those questions aren't always easy to answer. "Implementation, access, and insurance are the impediments," Darnall says.

For starters, there aren't nearly enough psychologists educated in pain psychology, a problem Tennessee pain psychologist Ted Jones, PhD, sees on a daily basis at a Knoxville medical pain clinic. Although the clinic has 1,600 active patients, there are just two psychologists on staff to help them.

Jones, who examines possible candidates for medication treatments and delivers psychological treatments such as CBT in group and individual sessions, adds, "We're seeing more and more patients here, and we'd like to offer more services." He'd want to hire another psychologist, but hasn't been able to discover a suitable applicant.

"We haven't yet created the incentives that would entice enough psychologists to enter this profession," says Robert Kerns, PhD, a Yale University professor and former national program director for pain treatment at the Veterans Administration.

Kerns, Darnall, Mackey, and their co-authors emphasized the need for expanded pre- and postdoctoral training programs in pain psychology in an article published in Pain Medicine, with the objective of establishing it an APA specialist (Pain Medicine, 2016).

Another issue, in addition to training, is reimbursement. Some insurance companies and government-run health-care programs don't cover behavioral pain treatment or reimburse it at a lower rate than physical pain therapies like pills or injections, making it more difficult for some patients to get these treatments.

The problem isn't ubiquitous, and it varies by geography; Jones, for example, claims he hasn't had any issues with reimbursement, including from TennCare, Tennessee's Medicaid program.

However, according to Mackey, the Stanford pain center loses money on the services provided by its five psychologists. "I could make them cover their costs by giving them less time to visit patients," he says, "but then they won't be able to deliver the services that the patients deserve." "So, for the greater good, I've decided to lose money on it." "We'd want to see reimbursements go up."

While those structural concerns will take time to overcome, research on improving access to behavioral pain treatment continues. The $81 million NIH-VA-DOD collaboration, for example, will support 11 large-scale "pragmatic clinical trials" to see how military and veteran health-care providers may include nonpharmacological treatments, such as mindfulness and CBT, into their care.

Meanwhile, Darnall is designing shorter sessions and treatments that may be provided online in order to bring behavioral pain treatment to more individuals inside the present health-care system. She's created a two-hour, single-session CBT-based pain psychology lesson and is putting it through a randomized controlled study to see how beneficial it is compared to a regular eight-week CBT course. In another clinical experiment, she's looking into whether an online CBT-based lesson might help surgical patients with recovery discomfort.

Overall, the goal is to reach as many patients as possible with the benefits of pain psychology treatment. Darnall explains that "pain is both a negative sensory and a negative emotional experience." She continues, "Psychology is already integrated into the notion of pain." "It is a primary treatment for pain, not a 'alternative' treatment."