A critical component in the treatment of chronic pain is teaching patients strategies for coping with the pain, and an approach focusing on five essential coping skills offers beneficial, cost-effective results, attendees heard in Las Vegas at PAINWeek 2013.
The teaching of coping skills is in line with the suggestion of medicine as a "three-legged stool" that was established by Massachusetts General Hospital cardiologist Herbert Benson, MD, said Ted Jones, PhD, a clinical psychologist from the Behavioral Medicine Institute, Knoxville, Tennessee, during a Pain Educators Forum here.
"The idea of the three-legged stool is that one leg of the stool is interventions — pharmaceutical treatments, et cetera; the other leg is surgeries and procedures; and the third leg is the mind/body connection, which is largely controlled by the patient him- or herself, and without that third leg, the stool can't stand on its own — it falls over," Dr. Jones said.
While behavioral therapy for pain can involve a commitment to multiple sessions that can be costly and time-consuming, Dr. Jones recommends starting by simply asking patients to commit to one two-hour group session, in which much can be accomplished.
If there is not a psychologist on staff at the pain clinic, Dr. Jones recommended renting space in the practice to a pain therapist, which is how he operates in his pain clinic.
"Consider finding a psychology practice and rent space to them," he suggested. "Then you're not having to make a capital outlay and hiring someone on staff, but you can still work together."
"In our practice, the pain clinic has become a multidisciplinary program even though we are two separate organizations. It's a model that we really like and it works well."
Either way, the five steps can be taught simply by the pain specialist to patients in two-hour group sessions. Dr. Jones recommended capping sessions at no more than about nine patients each.
The five coping steps each involve various relative simple tools and tasks that can allow patients to look beyond the narrow focus of their pain and gain a broader, better perspective.
The five steps are:
1. Understanding: "In order to get a better perspective, patients need information about their pain and their treatments options," Dr. Jones said. "They need information — they wonder if opioids are safe, if they are going to become addicted, are there alternatives — what are the pros and cons."
This involves describing to patients how pain works — explaining nerve pain, inflammation, and muscle pain, and the distinctions among the three.
Dr. Jones teaches patients about the 'gate control' theory on pain, proposed by Ron Melzack and Patrick Wall in 1965.
"I explain to patients how pain signals go to the brain and to think of the gate control as a volume control that amplifies or turns down the pain, and that there are at least 6 pain gates — depression, anxiety, anger, poor sleep, a focus on pain, and changes in pain."
2. Accepting: Dr. Jones urges patients to try to regard pain as not necessarily equated with suffering, which can help prevent one of the most powerful exacerbations of pain — catastrophizing.
"I suggest patients consider the pain associated with childbirth — there is the physical pain, but there doesn't necessarily have to be this all-encompassing suffering that permeates every aspect of their life," he said.
Patients may reject the idea of acceptance, feeling it suggests they are "giving in" and giving up, but ultimately acceptance allows for progress in a direction away from the anger that can come with resisting the pain, he said.
"Patients should also be encouraged to move from 'Why me?' to 'What now?' Dr. Jones suggested.
3. Calming: Soothing stress can have a significant effect on easing pain, and the options for finding meaningful stress relief are extensive, ranging from tai chi and/or progressive muscle relaxation to meditation, biofeedback and just simply breathing.
"Breathing is the only part of the stress response that you can control," Dr. Jones said. He noted that while most adults breathe with their shoulders, more air can be taken in by breathing with the diaphragm.
4. Balancing: Patients on a burnout track who push on until the job is done or the pain is too much commonly wind up with pain flares and the need for "breakthrough medication."
Balancing activities, trying to get enough sleep, and time management can prevent such situations, Dr. Jones said.
Remind patients to pace themselves, that slow and steady wins, he suggested.
"I tell patients to remember that the turtle wins in the tale of the turtle and the hare — 'Become the turtle,' I suggest."
"You'll get more done and won't have as much pain," he added.
Recommend patients to be mindful of having "up time" and "down time" and to stop activity earlier than usual, with the level of pain as the guide.
5. Coping: Equip patients with plentiful tools to cope with their pain without having to reach for the painkiller, Dr. Jones suggested. Aside from standard heat packs and massage for muscle pain or an ice packs for joint pain, suggest distracting devices.
"All pain patients need a distracting device — it's an excellent pain reliever," he said.
Video games are particularly effective distractions, he said. "In burn units, when they're changing the bandages, they don't sock people with a lot of morphine — they give them a video game and it's in 3-D and it can be so engaging that patients don't feel it when they're pulling the bandages off."
He cautioned that TV doesn't work as well, however. "You need something that engages you — not just any old stimuli. TV can go in one ear and out the other."
When patients feel they need to resort to breakthrough medicine, suggest they first take the breath mint technique.
"Have them simply pause for a second and focus on the dissolving breath mint and by the time it is finished, they may be able to get through the flare up and go without the medication," Dr. Jones also recommended.
Finally, provide patients with hand-outs that outline the advice and recommendations from the session for reference — chances are good they may otherwise forget some of the techniques, Dr. Jones suggested.
He noted that in a climate of increasing concerns of opioid overuse, the strategies can be highly effective alternatives.
"We need focus on more than opioids and adjuvants and injections — those help too, but giving patients skills that they can do themselves is very important."
"We're giving them a toolbox of skill that they can take home to allow them to not be completely reliant on you for medicine and injections."Coping Often Overlooked
Pain specialist Gary Reisfield, MD, said the approach of engaging patients in taking a proactive role of coping with their pain is something that is too often overlooked.
"Most physicians still think in terms of the biomedical model of pain, rather than the biopsychosocial model, that is, the pain, rather than the person with the pain," said Dr. Reisfield, an assistant professor and chief of Pain Management Services in the University of Florida College of Medicine's Divisions of Addiction Medicine and Forensic Psychiatry and Department of Psychiatry, in Gainesville.
Current models of reimbursement don't help the situation, either, he told Medscape Medical News.
"[The system] pays handsomely for procedures, but pays little for time spent speaking face to face with our patients. Also, it's a lot faster and easier to simply write a prescription than to spend time with our patients."
Dr. Reisfield said he has, however, found such efforts to be a "crucial component" in the interdisciplinary management of his patients' complex chronic pain problems.
"These techniques can help our patients reduce their pain, but also to change their relationship with their pain," he said.
"Our pain psychologists address 'automatic thoughts' and their connection to pain, medication-taking, and function in foundational life spheres; cognitive restructuring; stress and anger management; sleep hygiene; and self-help techniques, such as mindfulness meditation, guided imagery, and progressive relaxation."
What successful treatment often comes down to, he said, is how the person handles it.
"It's not so much the type of pain that a person has as the type of person that the pain has."
Dr. Jones has received grant/research support from Ethos Labs and AFTS Labs and honoraria from Alere Labs. Dr. Reisfield has disclosed no relevant financial relationships.
PAINWeek 2013. Presented September 5, 2013.
Nancy A. Melville • Medscape Medical News © 2013 WebMD, LLC