I had an opportunity to sit down with Geralyn Datz, PhD, past president of SPS, after her session on “Biopsychosocial Approaches to Treating Chronic Pain and Headache” at our recent meeting in New Orleans.

One of the topics you addressed in your talk was how there has been attention to the overemphasis on medications, particularly opioids, to manage pain. Tell us more about how we can be better at teaching patients how to actively cope with chronic pain?

One of the biggest challenges with using a solitary approach such as pharmacotherapy, including opioid therapy, for the patients living with pain, is that chronic pain is best treated through a multimodal approach. This is because pain affects the whole person. Patients and practitioners need to learn techniques to adapt to and manage the pain, not just take it away temporarily. There is a push to teach active self management strategies, such as sleep restoration, pacing, conquering worry and anxiety, and how to minimize depression in the face of pain. Simply taking a pill is a passive strategy and it is does nothing to teach the patient about the very important mind, body, and behavior connections that exist with chronic pain. Many treatment centers and insurers are including psychologists in the pain treatment conversation because of the understanding that this discipline offers time tested ways of dealing with these issues.

Similarly, the first thing to consider when talking about opioids is that they are designed to be a delivery system, a pharmaceutical, which provides analgesic relief for a certain period of time. As a result, medication is time-limited. When patients deal with a medical problem like chronic pain, they have a constant, day-long, often years-long, process of discomfort and limitations. There will naturally be times where the patient has more or less analgesic effects, and in different people these effects vary widely in duration. Furthermore, the data on opioids for long term pain management and relief in non-cancer pain is rather weak. A Cochrane review showed that in some carefully selected populations, there was relief long term. However, for the great majority of patients, adverse effects and side effects were many, and relief was generally poor, and less than 30%. There is also evidence to suggest that opioids can increase pain when taken long term (opioid induced hyperalgesia), which is obviously completely counterproductive to the goal of pain relief.  As a result, multi-modal approaches that teach coping skills and ways to overcome the impact of pain are crucial.

You shared that the biopsychosocial model of treatment is becoming more recognized by providers and insurers, compared to the biomedical model, which dominated for many years. Can you elaborate on that?

For many years the biomedical model of treatment has prevailed in treating patients living with pain. This model is based on some very early research about acute pain. It basically holds that there is a one-to-one correspondence between the extent of injury and the amount of pain experienced. Therefore, large injuries lead to large pains, and small injuries lead to small pains. This model also assumes that surgery and medications can fix pain.  While this is sometimes true, this model fails to appreciate what we now know about the central nervous system. We know that chronic pain is a complex and dynamic process, and it involves a person’s thoughts, beliefs, experiences; and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can intensify pain through interactions of the brain with the body. 

To address chronic pain effectively, we must address the person’s reactions to it and teach ways to overcome it, including retraining the brain away from the unpleasant pain signals. This is a psychological process involving education, training in thinking and new behaviors, and coaching.

We know that there is a very strong co-occurrence between chronic pain and conditions like depression and anxiety. You spoke about in this in your talk. What can you tell our readers?

Chronic pain is an unpleasant physical and emotional experience. The emotional suffering related to chronic pain, as well as the many changes it can bring about to a person’s life—job loss, financial distress, changes to activities of daily living, limitations, and reliance on other people—all can become very discouraging, frustrating and overwhelming. These circumstances frequently result in the development of clinical depression and anxiety. Co-occurrence rates of depression and anxiety in chronic pain patients are very high.

Another psychological diagnosis that is common to patients living with pain is post traumatic stress disorder. Patients with PTSD actually do experience higher rates of chronic pain and generally will not recover with medical approaches alone. It is worth noting that a person can also have a premorbid psychological diagnosis and then develop pain, and the pain in turn exacerbates the psychological diagnosis. It is extremely important to have psychologists involved in pain treatment for these reasons. Psychologists and specialized mental health professionals are experienced in providing evidence based treatments for depression and anxiety, and these can be adapted for patients with pain. Some of these treatments can be delivered in 8 to 16 sessions and are very effective and inexpensive to deliver.

Can you explain the process of treating pain from a psychological perspective?

I will focus on cognitive behavioral treatment of chronic pain because this approach is considered the gold standard for treating chronic pain. The psychological approach to treating chronic pain involves tailoring treatment to the person with chronic pain who is sitting in front of you. By that, I mean that each person has their own set of thoughts, feelings and behaviors related to managing (or not) their pain. This includes assumptions and fears, such as what to do and what not to do, whether they are willing to experience more pain, and whether they perceive the pain as a signal of harm. In addition, patients with pain also typically have strong feelings of resentment and anxiety about pain, because they perceive it as unnatural and unwanted. In the psychological treatment of pain these thoughts, feelings, behaviors, and assumptions are identified, targeted and modified so that the person experiences less distress related to all of these.

We know that cognitive behavioral treatments (CBT) create quantifiable changes in the brain, and that these changes are distinct to CBT. These effects are lasting and result in long term success. Ideally the psychological and medical perspectives work together. They really shouldn’t be independent. The best results are achieved through collaborative care.

In your talk, you discussed Biopsychosocial Laws and other changes in the healthcare landscape. What do you see as essential health care delivery system changes in the treatment of chronic pain?

I see that we need big changes in insurance and reimbursement practices in health care delivery. These will enable better collaboration between medicine and psychology. It should be easier to refer to psychologists and mental health than it is. We need to remove barriers that slow down this process. In addition, mental health is subject to higher copays and deductibles and a greater financial burden to patients. Also, the reimbursement for medical psychology type services should reflect the specialized training that must occur to deliver these types of treatments, and be reimbursed at a higher level. Finally, the stigma of referring to mental health should be addressed. Some providers are hesitant to refer to mental health due to fears of being misunderstood by their patients. Other providers are still ignorant of what psychology can do to help them and their medical patients. Finally, patients themselves are fearful of being labeled or being judged as crazy or weak for attending psychotherapy. These stigmas need to be addressed systematically through education and collaboration. In our clinic, while many people may hesitate to be referred, once they arrive and have an opportunity to be heard, and hear how ‘normal’ what they experience really is, the relief and healing that occurs is truly amazing to watch. We need more approaches that are personalized, and tailored to patients’ needs and presenting problems, because that is the basis of true rehabilitation.