Are you using the best tools to treat chronic pain?

Pain can be manufactured in your head and in your body

Our society needs to get over this concept that either the pain is real or “it’s all in the head”. The truth is much more complex: pain can have both physical and psychological components. But the psychological component is often dismissed. 

This dualistic thinking that continues to pervade our understanding and response to illness leaves patients feeling misunderstood. The pain that is experienced by patients is often very real and can be a source of huge distress.

We’re taught, by evolution and by our experience, that the sensation of pain means there’s something physically wrong with our bodies. But sometimes, a one-time injury or illness triggers years of chronic pain. Indeed, the World Health Organization has just defined pain as a disease in its own right where it’s a disorder of the pain messaging system in the body, a little bit like a fire alarm going off even though there is no fire.

“Imagine this pain system is like the alarm system of your house,” says Andrea Furlan, a leading chronic pain physician and researcher at the University of Toronto. “The alarm system can break; it can malfunction.” 

Our thoughts, personalities, and learned behaviors can also influence whether our pain alarms get tripped. So do our emotions. “If you get an on-the-job injury and you hate your job, you’re much more likely to become disabled by the pain,” says Roger Chou, a professor of medicine at Oregon Health & Science University who has studied chronic pain.

Counselling and Other Nonpharmacological Treatments as Alternatives

Liaison Psychiatry

Patients with chronic pain are often referred to liaison psychiatrists when their physical health colleagues feel stuck – all the relevant investigations have been done but they cannot find any bodily damage to account for the patient’s pain. 

In liaison psychiatry, doctors conduct a biopsychosocial assessment to explore the patient’s health and life circumstances as a whole. Where they find factors for which effective interventions are available, this is where treatment can then be focused: these factors can include obesity, insomnia, inactivity, anxiety, depression, malnutrition or poor housing.

Cognitive Behavioural Therapy

The most common psychological treatment for pain, and the most well-studied, is cognitive behavioral therapy, or CBT. CBT trains patients in behavioural techniques to help modify situational factors and cognitive processes exacerbating pain. 

Several studies have shown that CBT can help patients who have chronic non-cancer pain reduce pain and associated distress, disability, depression, anxiety, and catastrophizing, as well as improve coping, functioning, and sleep (Turner, Mancl, & Aaron, 2006; McCracken, MacKichan, & Eccleston, 2007; Thorn et al., 2007; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009).Most recently, a JAMA Internal Medicine systematic review published in early May found it effective in treating chronic pain in patients over age 60. There’s also some evidence that CBT can lead to brain changes believed to correspond with people being in more control of their pain. 

Multimodal Approach and Multidisciplinary Therapies

Multimodal and multidisciplinary therapies combine exercise therapies with psychologically-based approaches. These therapies involve coordination of medical, psychological, and social aspects of care.

Motimodal strategies can reduce long-term pain and disability compared with single-modality care and compared with physical treatments (e.g., exercise) alone.

If opioids are used, nonopioid medication and nonpharmacologic treatment should also be prescribed as appropriate. Treatment combinations should be tailored depending on patient needs, cost, and convenience. 

The best pain treatment centers have psychologists, physical therapists, and physicians on staff who consult with one another and decide on the right course of medication and therapy. But these centers are hard to find and their waitlists can be months long. It can be hard to convince patients who are looking for a quick fix to try psychotherapy.

Holistic approaches still have a long way to go

CBT, like Multimodal and multidisciplinary therapies, are not easily available or reimbursed by insurance and can be time-consuming for patients.

It is far easier to prescribe an opioid than to explain to a patient why they are not getting one. That makes a physician’s job harder. “There are many options to consider when offering treatment for chronic pain that go beyond pharmacological management such as physical therapy, cognitive behavioural therapy, mindful meditation, yoga, and tai chi,” Dr. Michael Ashburn and Dr. Lee Fleisher of the University of Pennsylvania wrote.

“However, explaining these options to patients can be difficult and time-consuming for clinicians and helping patients access these treatment options even more difficult.”

Patients who have complex health needs fall between the cracks of the health system, which is designed with policy in mind rather than pathology: primary versus secondary care, mental versus physical. We need to find ways to work together more collaboratively, as complex problems demand comprehensive solutions.

With each decade that passes, we see modern medicine develop increasingly sophisticated and effective treatments, creating an expectation that we will have solutions to all problems. Given that we have effective treatments for acute pain, the public perception is that this must also be true for chronic pain. Sadly, this is not the case. The question, then, is how we shift our understanding of pain so that psychotherapy is the opposite of a last resort.

woman with chronic pain

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