Psychological/Behavioral Therapies

The sole use of medically (somatic)-based therapies when treating a patient is rarely sufficient to address the complex nature of chronic pain. The risk of iatrogenic dependence, and compromising adverse events, encourages the use of a more comprehensive and patient-involved process. There are a number of psychologically based therapies applicable to the treatment of chronic pain. The most researched and commonly used are the behavioral-based therapies. They range from simple to complex and from brief to prolonged. While it may be preferable to have these treatments applied by a trained behavioral specialist with a background in chronic pain, many can be adapted for use in the primary care setting. Furthermore, a variety of cell phone apps, self-help books, and YouTube presentations are available for patient and family use.

The Easy but Harmful Solution

This case may represent one of the common problems faced by clinicians involved in treatment patients with chronic pain. There appears to be a growing number of patients with a sense of entitlement, which manifests itself in requests to medications to address a plethora of problems. They often resist, if not resent, suggestions for lifestyle changes, (eg, exercise, diet, smoking reduction, use of nutritional supplements, stress management, etc.). They perceive and prefer pharmacological therapy (ie, chemical coping). This helps to dissolver them of any responsibility for the problems and encourages iatrogenic dependence on the medical system. Sometimes writing a prescription is the most efficient way to end on office-based consultation. This approach, however, may be detrimental to the patient in the long run.

Psychogenic Pain: A Useful Concept?

The term “psychogenic” pain was use liberally during the 20th century. It has been applied in a number of different ways. First, to describe pain originating from psychological/psychiatric (ie, mental) processes. Second, as a way of declaring that, although there may be physical abnormalities, the degree of pain experienced is dictated by psychological states. Finally, to imply that psychological factors co-mingle with physical factors in the experience of pain, especially chronic pain. By its very nature, “psychogenic” implies of separation of mind and body. Most often it has been used as a diagnosis of exclusion—we cannot find the real (ie, medical/physical) cause, so it must be psychological, all but impugning the validity of the patient’s report. In the midst of modern technology and research, and the prevailing philosophical approach to pain (chronic), the term “psychogenic” has exhausted its research, clinical, and practical utility. This chapter provides supporting evidence for this conclusion and research data highlighting the complex and dynamic nature of pain (chronic).

A Broken Life

This case represents an all too frequent, and tragic, example of the devastating effects of chronic pain following an injury. The problem impacts all aspects of the individual’s life, including the family. Repeated failure of various medical/surgical treatments, intending to be corrective, can result in despair, hopelessness, and anger. Even the most stoic are prone to depression. It is important to recognize and address these issues early. There are some simple strategies that can guide assessment and treatment. It can take years for such a person to “reinvent” themselves. The aware clinician can be a great source of solace and hope.

Psychologically Immobilized and Functionally Paralyzed

The role of conditioning in the development and maintenance of fear and avoidance is well-researched and well-established. Learning theory and conditioning principals form the basis of various behavioral therapies. Indeed, even the process of nociception is susceptible to conditioning. Pharmacological therapy is not likely to be effective and may, in fact, be detrimental to the patient. There are a variety of behavioral strategies that can be implemented in a primary care setting as well as in a pain clinician. Utilizing the expertise of a behavioral therapist may be ideal, but most interested clinicians can acquire a basic understanding of the principle and techniques. There are a variety of educational materials suitable for patient use that can be incorporated into treatment. Functional restoration should be considered as a primary outcome, perhaps even more so, than a reduction of subjective pain rating.

The Psychology of Opioid Tapering

The pendulum has swung; in this case, it may be a double pendulum. The double pendulum is a pendulum hanging from a pendulum. It is a simple physical system used in physics to demonstrate mathematical chaos. When the motion of its tip is monitored, it appears very predictable at the outset, but soon reveals a very chaotic and unpredictable pattern. It is very difficult to know where the tip of the double pendulum will be at any given time in the future. This seems to describe the course of the use of opioids, especially for the treatment of chronic pain. Once, all but ignored, then heralded, and then demonized. At every step of the way, pundits will argue the incompleteness, absence, or misinterpretation of existing data. It is important to understand the psychological environment is which the opioid tapering movement occurs and to carefully consider the process in the context of the individual patient. Simply instituting another set of presumptive evidence-based guidelines could have unforeseen, and potentially tragic, consequences for the patient.

The “What If” and “Yes But” Syndrome

Repeated requests for a definitive diagnosis, prognosis, and reassurance as to the positive outcome of a therapy made by some patients with chronic pain can be very exhausting to both patient and clinician—especially when it is clear that no amount of information will be satisfactory. The practitioner can easily feel like be asked to be a psychic or fortune teller. Pain catastrophizing (PC) has emerged as critical area of study. PC has been linked pain intensity, decreased function, and treatment outcomes, including the effect of pain medications such as opioids. It is most effectively addressed by the use of cognitive-behavioral therapy procedures. Learning how to apply these strategies in the context of the typical office visit can reduce the frustration level of the clinician and patient. In more severe cases, referral to behavioral specialist may to advisable.

The Not-So-Perfect Remedy

“But nobody ever died from an overdose of marijuana” has become one of the rallying cries of those who support legalization of marijuana for the treatment of chronic pain and a plethora of other disorders. There is little doubt that the Cannabis Sativa and Cannabis Indica plants produce substances that may well have medicinal value. However, much is yet to be learned. The endocannabinoid system, like the plants themselves, is very complex. Hemp oil and cannabidiol are flooding the market. Unregulated by any federal agencies, the claims and labeling are often unsupported and misleading, if not false. The issue of medical marijuana is here to stay. The clinician treating patients with chronic pain needs to become familiar with the nuances of these products and recognize that they are not without side effects and drug-drug interactions.

No Way That’s My Drug Screen

In the process of treating patients with for chronic pain with opioid type medications, the use of urine drug screens (UDS) is considered the standard of care. The frequency with which a UDS is obtained varies across different guidelines and states/medical boards. It is often associated with dosage, risk for aberrant drug behavior assessment, and ongoing compliance. Most clinicians will obtain a UDS two to four times per year, unless the circumstances require otherwise. In general, the point-of care UDS lacks the sensitivity and specificity of confirmatory testing. The prescribing clinician should (i) be familiar with various types of testing, (ii) create a relationship the testing lab performing the confirmatory testing, and (iii) acquire basic interpretation skills. Clinical decisions should be postponed pending the results of confirmatory testing. False positives, and false negatives, do occur. It behooves the clinician to have “all their ducks in row” before confronting the patient and to accurately document the consultation and decision-making process. In some instances, discontinuation of therapy may be necessary and appropriate. Other cases may be subject to remediation.

The Abandoned Patient

The bane of existence for the clinician who treat patients with chronic pain, especially from a pharmacological perspective, is the “abandoned” patient. The incidence of this has significantly increased according to a 2016 Centers for Disease Control and Prevention report. Indented or not, this report has been used as the foundation for creating, if not imposing, restrictions on the prescribing of opioids The emphasis on total morphine equivalent dosing leaves little room for arguing quality of life issues. Clinicians are encouraged not to fear disciplinary action or prosecution when acting in the usual course of medical practice and offering appropriate documentation. The abandoned patient ranges along a continuum form the person informed that a medication will no longer be prescribed to those from a practice that has been discontinued to those who have committed some egregious violation of the medical agreement. In any case, it is important not to side-step your usual assessment process; prescribe only when you feel comfortable doing so. Under extreme circumstances, a short-term prescription at a low dose to safeguard against catastrophic events may be justified. As always, “trust, but verify.”