Biopsychosocial Aspects of Chronic Pain:

515. Managing and Counseling the Chronic Pain Patient: What is the Role of the Pain Doctor?

Rob Edwards, Ph.D.BWH Department of Anesthesiology

Disclosure

Financial Disclosure:

Robert Edwards has no financial disclosures

Drug/Product Off-Label Use Disclosure:

No discussion of off-label drug or product use

Variability in Pain is the Rule Rather than the Exception

AppraisalAppraisal

CopingCoping

PersonalityPersonality

MoodMood

Self-efficacySelf-efficacySocial ContextSocial Context

SleepSleep

CultureCulture

IncentivesIncentives

Pain

Self-efficacySelf-efficacy

EducationEducationAcceptanceAcceptance

ConditioningConditioning

Catastrophizing

Magnification Rumination Helplessness

A set of negative cognitions, emotions, attitudes, and beliefs related to pain

PCS (13 Items)- Examples:I worry all the time about whether the pain will end.

I feel I can't stand the pain anymore.

I wonder whether something serious may happen.

Male and female monozygotic (n= 206) and dizygotic twins (n= 194) completed the PCS and performed a cold pressor test. As expected, PCS scores were significantly heritable and were strongly predictive of several cold pressor outcomes, including Pain Tolerance, and Painful Aftersensations.

PCS Correlations:Dizygotic: r=.04Monozygotic: r= .45

Genetics

GeneticUnique/Nonshared Environment

37%63%

Intra- and Inter-Sample Individual Variability

Healthy, Pain-Free Controls

Nonspecific LBP

Knee OA Patients

Catastrophizing Reduces Analgesic Responses

Patients with DPN, PHN, or persistent post-operative pain in trials for topical preparations including amitriptyline & ketamine

What Does A Catastrophizing Brain Look Like?

CNS Manifestations

Catastrophizing in Fibromyalgia

Functional MRI assessment of 43 Fibromyalgia patients. Cuff (mechanical) stimuli applied to the calf, tailored to a pain intensity of 50/100 (much lower pressures used for patients relative to controls). Assessment of catastrophizing using the PCS.

Catastrophizing & Brain Responses

Positive relationship between PCS scores and pain-related activation in medial thalamus and anterior insula, even with a standardized pain intensity.

Medial Thalamus Anterior Insular Cortex

Medial thalamus and anterior insula are strongly associated with affective component of pain.

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Functional Connectivity: Insula and S1

CBT and Related Self-Management Approaches:

Reducing catastrophizing and improving pain and psychosocial

functioning

Cognitive Behavioral Therapy

Gatchel et al. Psychol Bull 2007

“The term CBT varies widely and may include self-management instructions … relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain, and goal setting …

“Data Synthesis: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (4 weeks’ duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point VAS pain scale . . .”

2014 Review

“The primary goal of CBT for pain is to promote the adoption of an active problem-solving approach to tackling the many challenges

associated with the experience of chronic pain.”

Specific Objectives:

1) Change patient’s views of their problems from totally overwhelming to manageable.2) Re-conceptualize personal views from passive to competent and resourceful.3) Teach patients to monitor maladaptive thoughts.4) Demonstrate how/when to employ pain-coping skills.

Improvement maintained at 9 months and 12 months

CBT Reduces Neuropathic Pain

Nearly 100 fibromyalgia patients randomized to CBT, CBT + Hypnosis, or standard pharmacologic treatment.

Reduction in catastrophizing on the order of 40%, maintained at 6-month follow-up . . .

CBT Effects on Catastrophizing

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Dental Management

CBT for Pain

Lasting CBT Effects

Opioid Weaning

Uncontrolled study of CBT (6 sessions) for pain patients with problematic use of codeine (asking

for early refills, obtaining medications from multiple providers, etc). While weaning patients from opioids often exacerbates pain, CBT may

help to buffer this effect.

Nilsen et al.

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CBT Reduces Catastrophizing & “Normalizes” Brain Responses in FM

Fibromyalgia with high PCS scores were enrolled in a treatment study and randomized to 4 sessions of CBT (n=8) or 4 sessions of an educational control treatment (n=8).

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changes in S1-a/mINS connectivity4 weeks

CBT patients showed reduced resting state connectivity between S1 and anterior/medial insula, and the reduction in connectivity correlated with changes in PCS scores:

Brief Interventions Can be Effective

Satisfaction ratings are around 95%, and PCS scores are reduced by nearly half at 1-month follow-up:

A single 2-hour educational group course, taught by a clinical psychologist via Powerpoint. The course involves: education on mind–body science, brief training in skills such as diaphragmatic breathing and progressive muscle relaxation, and education about catastrophizing (including how to identify it and how to reduce it via reframing and thought restructuring). Participants write out a catastrophizing cessation plan and get a relaxation CD for home use.

282 pts with acute nonspecific low back pain were followed for 1 year to determine predictors and consequences of bed rest . . .

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Prolonged Bed Rest*

Physical Activity / Exercise

CBT Encourages Exercise, Which Benefits a Variety

of Pain Conditions

Pain after TKA

Rooted in the principles of Buddhism, mindfulness meditation is based on increasing intentional self-regulation. Goals include the attainment of both relaxation and greater focus of attention. The focus is on fully experiencing sensory phenomena in the moment. In pain management, meditation helps to separate the sensation of pain from the thoughts about pain. In so doing, the individual can begin to accept the pain as it is without the negative cognitive and emotional connections that typically serve to make the experience of pain worse.

Mindfulness Meditation

“ACT adopts a pragmatic approach to knowledge . . . Thoughts or feelings are not deemed helpful or unhelpful from their form, frequency, or appearance alone.”

“Within ACT, a set of broadly applicable and integrative treatment processes is proposed, the core being psychological flexibility. Psychological flexibility is the capacity to continue with or change behavior, guided by one’s goals, in a context of interacting cognitive and direct non-cognitive influences.”

One of the foundations of ACT

Mindfulness Meditation

Comparison with WL in patients with failed back surgery

Mindfulness- Rapid Effects

Study in eighteen healthy subjects (with no prior meditation experience). Subjects received a total of four days of training in “mindfulness-based attention to breath”

Meditation reduced pain intensity, pain unpleasantness, and activation in primary somatosensory cortex

Mindfulness & CBT Reduce Daily Catastrophizing

143 RA patients randomized to CBT, Mindfulness Meditation, or Education. Daily assessments using electronic diaries showed that CBT and MM reduced catastrophizing, with MM having larger effects on high pain days.

50 female patients with high anxiety scores randomized to receive either 1,200 mg gabapentin or placebo prior to major surgery.

Pharmacologic Treatment May Also Have

Psychosocial Benefits

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NRS Anxiety Catastrophizing Fentanyl

Gabapentin Placebo

Other Benefits: Improvement in Symptoms of Sleep

Disruption/Insomnia

Chronic Pain

~ 35%50% - 90%

CDC (2009): Approximately 1/3 of

US adults obtain insufficient sleep

Chronic Insomnia

~20%

Slide courtesy of Michael Smith at Johns Hopkins

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Treating Insomnia Improves Pain

• Catastrophizing varies widely across individuals, and influences many aspects of the pain experience.

• There may be multiple pathways by which catastrophizing exerts its deleterious effects.

• A variety of approaches (CBT, Mindfulness, Exercise, etc.) may help to reduce catastrophizing and improve pain-related outcomes.

• Future Directions: Optimal treatments may involve personalized/tailored multi-modal interventions.

Conclusions

Thanks to Colleagues

BWH& MGH:Bob Jamison, Ph.D.

Kristin Schreiber, M.D.Marco Martel, Ph.D.

Vitaly Napadow, Ph.D.Marco Loggia, Ph.D.

Johns Hopkins:Jennifer Haythornthwaite, Ph.D.

Michael Smith, Ph.D.Claudia Campbell, Ph.D.

Gayle Page, DNSc

Ajay Wasan and Inna Belfer at UPMC