PALM SPRINGS, CALIF. – Physicians who doubt that chronic pain patients need and deserve cognitive-behavioral therapy as an adjunct to other treatments need to take an honest look at how well modern medicine treats pain, Dennis C. Turk, Ph.D., said at the annual meeting of the American Academy of Pain Medicine.
Opioids reduce severe, chronic pain by only about a third. Moreover, up to 50% of patients discontinue opioid therapy because of a lack of efficacy or because of side effects.
At the end of interventional pain trials, the vast majority of patients have improved so little they would still qualify for a new trial. Even surgical procedures that sever neurologic pathways believed to be responsible for a patient's pain often fail to alleviate the symptoms.
“Our best efforts still by and large don't cure people,” said Dr. Turk, professor of anesthesiology at the University of Washington, Seattle.
Pain is real, but it is a subjective perception “resulting from the transduction, transmission, and modulation of sensory input filtered through a person's genetic composition and prior learning history and modulated further by [the person's] current physiological status, idiosyncratic appraisals, expectations, current mood state, and sociocultural environment,” he said. In other words, “that arm or neck or shoulder is attached to a human being with a social context and with a history.”
Underlying physical pain are emotional responses: fear, uncertainty, demoralization, and worry about the future. A family is involved, suffering as well.
Offering or referring patients for cognitive-behavioral therapy (CBT) acknowledges that pain may not be curable in every patient and that life must go on around it. It also gives patients credit for being capable of actively processing information and learning adaptive ways of thinking, feeling, and behaving, Dr. Turk said.
The exact CBT technique used is less important than the characteristics of the approach in general, according to Dr. Turk. All CBT should be:
▸ Problem oriented.
▸ Time limited.
▸ Educational.
▸ Collaborative (between patient and provider, perhaps family members as well).
▸ Practical, using clinic and home exercises to consolidate skills and identify problem areas.
▸ Anticipatory of setbacks and lapses and able to teach patients to deal with these.
In the context of pain, CBT can be particularly effective in helping patients reconceptualize their problems, making seemingly overwhelming hurdles become manageable.
It can help patients to believe they have the skills necessary to solve problems, transforming them from being passive and helpless to being “active, resourceful, competent,” Dr. Turk said.
By utilizing real examples in a patient's life, CBT can help individuals recognize unhelpful thinking patterns such as overgeneralization, catastrophizing, seeing things in all-or-none terms, jumping to conclusions, selectively focusing on details rather than the big picture, and mind-reading the thoughts of others.
A CBT therapist then helps a patient learn to recognize problems associated with a life of pain and then propose his or her own adaptive solutions. Examples might include feeling bored and restless because of diminished activities, experiencing disharmony in family members due to altered roles, or suffering diminished self-esteem when a patient in chronic pain can no longer work.
A good CBT therapist guides the patient to set realistic solutions approached with step-by-step goals, practiced in sessions and during homework sessions tracked with diaries and charts.
Dr. Turk said he makes success highly attainable from session to session. For example, if increased mobility is a goal and the patient already believes he can walk 1 block, he sets the bar at walking 8/10 of a block every few days for the first week.
Monitoring, reinforcement, listening, and adapting to changing realities are all key to CBT success. Perhaps most important is the anticipation of nonadherence. Right from the start, a therapist can tell patients to expect flare-ups in pain and “slip-ups” in behavior, and a plan can be devised to deal with those situations before they occur.
To illustrate how CBT can work, Dr. Turk recounted the case of an elderly woman with chronic neck pain so severe that her husband retired from his job to care for her. During CBT she identified inactivity as a problem and set a goal of beginning to cook again. A plan was established for her to prepare one meal a day.
During her next visit, the patient's checklist revealed that she had not kept her goal. It seems her husband became nervous when she would begin to cook, telling her she should rest because she “didn't look too good.” He would then prepare the meal.