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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
Appraisal
Incentives
Coping
Personality
Culture
Pain
Acceptance
Education
Mood
Sleep
Social
Context
Self-efficacy
Conditioning
Catastrophizing
A set of negative cognitions, emotions,
attitudes, and beliefs related to pain
Magnification
Rumination
Helplessness
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.
Genetics
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.
Unique/Nonshared Environment
Genetic
37%
PCS Correlations:
Dizygotic: r=.04
Monozygotic: r= .45
63%
Intra- and Inter-Sample
Individual Variability
Healthy, PainFree 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
CNS Manifestations
What Does A Catastrophizing Brain Look Like?
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.
Functional Connectivity:
Insula and S1
CBT and Related SelfManagement Approaches:
Reducing catastrophizing and
improving pain and psychosocial
functioning
Cognitive Behavioral Therapy
“The term CBT varies widely
and may include selfmanagement instructions …
relaxation or biofeedback,
developing coping strategies,
changing maladaptive beliefs
about pain, and goal setting …
Gatchel et al. Psychol Bull 2007
2014 Review
“Data Synthesis: We found good evidence that cognitivebehavioral 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 . . .”
“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.
CBT Reduces
Neuropathic Pain
Improvement maintained at
9 months and 12 months
CBT Effects on
Catastrophizing
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 . . .
Lasting CBT
Effects
% with zero catastrophizing
30
25
20
15
Dental Management
10
5
CBT for Pain
0
Baseline
Post-Tx
6 Month
12 Month
Opioid Weaning
Nilsen et al.
350
9
300
8
250
*
200
150
100
*
*
Pain Intensity
mg of codeine
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.
7
6
5
4
3
2
50
1
0
0
Pre-Tx
4 Weeks
8 Weeks
3 Months
Pre-Tx
4 Weeks
8 Weeks
3 Months
CBT Reduces Catastrophizing &
“Normalizes” Brain Responses in FM
CBT
40
35
30
PCS Score
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).
EDU
*
25
20
15
10
5
0
Pre-Tx
Post-Tx
S1-a/mINS
CBT patients showed reduced resting
state connectivity between S1 and
anterior/medial insula, and the
reduction in connectivity correlated
with changes in PCS scores:
1.5
1
0.5
0
-0.5
-1
-1.5
CBT
EDU
changes in PCS (4wk-baseline)
5
0
-6
-4
-2
0
2
-5
-10
-15
-20
-25
changes in S1-a/mINS connectivity
-30
4 weeks
4
6
Brief Interventions
Can be Effective
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.
Satisfaction ratings
are around 95%,
and PCS scores are
reduced by nearly
half at 1-month
follow-up:
Physical Activity /
Exercise
282 pts with acute nonspecific low back pain were followed for 1 year to
determine predictors and consequences of bed rest . . .
No Bed Rest
25
PCS
20
15
10
5
0
*
Prolonged Bed Rest
CBT Encourages Exercise,
Which Benefits a Variety
of Pain Conditions
Pain after TKA
Mindfulness Meditation
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.
One of the foundations of ACT
“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.”
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.
Pharmacologic Treatment
May Also Have
Psychosocial Benefits
Gabapentin
50 female patients
with high anxiety
scores randomized
to receive either
1,200 mg
gabapentin or
placebo prior to
major surgery.
Placebo
30
25
20
15
10
5
0
NRS Anxiety
Catastrophizing
Fentanyl
Other Benefits: Improvement in
Symptoms of Sleep
Disruption/Insomnia
Chronic
Insomnia
~20%
CDC (2009):
Approximately 1/3 of
US adults obtain
insufficient sleep
Chronic
Pain
50% - 90%
~ 35%
Slide courtesy of Michael
Smith at Johns Hopkins
Treating Insomnia
Improves Pain
Pre-Treatment
18
Post-Treatment
Symptom Intensity
16
14
*
12
10
8
*
6
4
2
0
Control
CBT Pain
CBT Pain + Insomnia
Conclusions
• 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.
Thanks to Colleagues
Johns Hopkins:
BWH& MGH:
Bob Jamison, Ph.D.
Kristin Schreiber, M.D.
Marco Martel, Ph.D.
Vitaly Napadow, Ph.D.
Marco Loggia, Ph.D.
Jennifer Haythornthwaite, Ph.D.
Michael Smith, Ph.D.
Claudia Campbell, Ph.D.
Gayle Page, DNSc
Ajay Wasan and Inna
Belfer at UPMC