Cognitive Behavioral Therapy for Pain Management

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Cognitive Behavioral Therapy for Pain Management

• John D. Otis, Ph.D.
• VA Boston Healthcare System

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Presentation Overview

• A Historical look at Pain Management
• The Problem of Pain
• Cognitive Behavioral Therapy for Chronic Pain

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Images of Pain
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Early 19th Century Pain Relief

• Most pain relievers were made from plants and
  could be deadly when taken in overdose. One of
  the most commonly used substances was opium
  derived from the poppy flower. Other substances
  used included alcohol or wine, mandrake,
  belladonna, and marijuana.

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• Potions that included these substances were
  commonly available around the turn of the century
  and promised to cure a variety of afflictions.

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Cocaine was recognized as being highly effective
in relieving mouth pain
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The Problem of Pain

• Pain is one of the most common complaints made by
  patients to primary care providers in the VAHCS
  (approximately 50 of patients).
• Pain is typically an adaptive reaction to an
  injury and gradually decreases over time.
• However, for some people pain persists past the
  point where it is considered adaptive and
  contributes to negative mood, disability, and
  increased use of healthcare system resources.

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What is Chronic Pain?

• Pain is defined as an unpleasant sensory and
  emotional experience associated with actual or
  potential tissue damage, or described in terms of
  such damage.
• Chronic pain Pain with a duration of 3 months
  or greater that is often associated with
  functional, psychological and social problems
  that can negatively impact a persons life.

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The Financial Costs of Pain

• Current estimates are that the medical costs of
  back pain in the USA exceed 90 billion dollars
  per year (Spine, 2004).
• Chronic pain costs 61.2 billion per year in lost
  productivity (JAMA, 2004).
• One quarter of the people with back pain account
  for 75 of the costs, and 10 account for more
  than half the costs.

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The Role of Emotions

• Henry Knowles Beecher WWII Soldiers Pain
• Observed that soldiers with serious wounds
  complained of less pain than did his
  postoperative patients at Massachusetts General
  Hospital.
• Hypothesis The soldier's pain was alleviated
  by his survival of combat and the knowledge that
  he could now spend weeks or months in safety and
  relative comfort while he recovered. The hospital
  patient, however, had been removed from his home
  environment and now faced an extended period of
  illness and the fear of possible complications.

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The Gate Control Theory
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The Pain Cycle
Muscle atrophy weakness Weight loss/gain
Disability
Pain
Negative self-talk Poor sleep Missing work
Less active Decreased motivation Increased
isolation
Distress
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The Challenge of Pain

• Over time, negative thoughts and beliefs about
  pain, and behaviors related to pain can become
  very resistant to change.

• Thoughts
• My pain is going to kill me
• This is never going to end
• I'm worthless to my family
• Im disabled
• There is nothing I can do
• for myself
• I'm a bad father, husband,
• and provider

• Behaviors
• Staying in bed all day
• Sleeping all day
• Staying away from friends
• Decreasing activities that
• have the potential to
• increase pain
• Taking more medication
• than prescribed

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Cognitive Behavioral Therapy (CBT)

• Research supports the efficacy of CBT for the
  treatment of chronic pain (Morley et al., 1999)
• Components of CBT for pain include
• Identifying inaccurate beliefs about pain
• Reconceptualizing pain as subject to personal
  control through the influence of thoughts,
  feelings, and behaviors
• Teaching cognitive and behavioral coping skills
  (e.g., cognitive restructuring, activity pacing,
  etc.)
• Practice and consolidation of coping skills
  through practice, and reinforcement of their
  appropriate use

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CBT Evidence Base

• A number of studies have identified CBT as an
  effective treatment approach for chronic pain
  conditions, including headache, rheumatic
  diseases, chronic pain syndrome, chronic low-back
  pain, and irritable bowl syndrome (Compas, et
  al., 1998).
• Meta-analyses
• Morley, Eccleston, and Williams (1999) CBT for
  chronic pain is effective, as it resulted in
  significantly greater improvements in pain
  experience, cognitive coping and appraisal, and
  reductions in behavioral expressions of pain when
  compared with alternative active treatments.
• Hoffman, Papas, Chatkoff, Kerns, (2007)
  cognitive-behavioral and self-regulatory
  treatments specifically were found to be
  efficacious for the treatment of low back pain

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Multidisciplinary Pain Management

• Involves the integration and collaboration of
  multiple healthcare disciplines with specialized
  training in the assessment and treatment of pain,
  with the goals of addressing the physical, social
  and psychological components of pain and creating
  an individualized treatment plan for each
  patient.
• This approach for pain management has been shown
  to be highly effective in promoting positive
  cognitive and behavioral changes in individuals
  with chronic pain (Flor, Fydrich Turk, 1992).

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Top objections to seeing a psychologist for pain
management

• Im not crazy
• I've done this before
• The pain is in my back, not in my head
• Does this mean that you are taking away my
  medication?
• The bad handoff Prescriber You must see
  psychology before I prescribe your pain
  medications

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Assessment Questions

• Describe Pain
• Surgery pending?
• Current medications where prescribed
• Is she taking his medications appropriately?
• Seeking to increase SC or litigation pending?
• What are his goals for the future?
• What is her mood like? Psych history?
• Substance abuse - now or in past?
• What kinds of coping skills does he have?
• How does her spouse react when she is in pain?
• What are his beliefs about his pain?
• Did she like her job?
• What are his hobbies?
• Observe pain behaviors

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Case Conceptualization

• Develop a timeline of events.
• Integrate interview and assessment data in order
  to determine events that have led the patient to
  where he/she is today.
• What factors, both external and internal, are
  contributing to the patients pain problem.
• Antecedents and consequences of pain behavior

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CBT for Chronic Pain

• Session 1 Rationale for Treatment
• Session 2 Theories of Pain, Breathing
• Session 3 PMR Visual Imagery
• Session 4 Cognitive Errors
• Session 5 Cognitive Restructuring
• Session 6 Stress Management
• Session 7 Time-Based Activity Pacing
• Session 8 Pleasant Activity Scheduling
• Session 9 Anger Management
• Session 10 Sleep Hygiene
• Session 11 Relapse prevention

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Critical Element of Treatment

• Session 1 The Sell
• If patients are not convinced that the investment
  of their time will pay off they will be less
  likely to follow through with the treatment plan
  more dropouts.
• Set Achievable Therapy Goals
• Goals should be measurable
• Monitor Homework Completion
• Tailor the treatment to your patient
• Dont focus on pain

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Questions discussion
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Managing Chronic Pain Therapist Manual
Managing Chronic Pain Workbook
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