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Learning to Control Pain

Are we entering a "golden age" of pain study?

The greatest evil is physical pain. —Saint Augustine.

Pain is everywhere. According to a 2008 international survey looking at more than 40,000 respondents in 18 countries, the prevalence of chronic pain was about 37.3 percent in developed countries and 41.1 in developing nations. Back pain and headaches were more common in developing countries and chronic pain problems were more often found in females and older adults. In the United States alone, 116 million adults experience some form of chronic pain according to a 2011 survey by the Institute of Medicine.    

More common than cancer, heart disease, and diabetes combined, chronic pain represents a major drain on life quality, mental health, and work productivity. The financial costs associated with chronic pain, whether in terms of direct health care expenses and time lost from work are astronomical. The 2011 Institute of Medicine report estimated health care costs between $560 to  $630 billion dollars annually. This figure excludes costs for people in the military, prisons, psychiatric facilities, and Veterans Administration hospitals. 

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Along with the spiralling demand for pain medications prescribed by medical professionals, street drugs such as heroin are widely abused as much for their use in pain relief as they are for recreational purposes. People with chronic pain are also prone to a wide range of mental health symptoms, including depression and anxiety. And that is just for the people experiencing pain directly. Health care figures tend not to consider the impact that chronic pain can have on spouses and other family members who often bear the burden in caring from long-term pain patients.  

Considering the magnitude of the problems involved in dealing with chronic pain,  and the fact that even the most powerful pain medications bring only moderate relief, it is more important than ever to recognize the psychosocial factors linked to pain. A new review published in American Psychologist presents an overview of  research into the psychological underpinnings of pain. Written by veteran pain researchers Mark P. Jensen and Dennis C. Turk of the University of Washington, the article is one of nine in the "Chronic Pain and Psychology" issue looking at the future of pain research and the direction treatment should be taking to provide real relief for pain patients.

While chronic pain has traditionally been seen as a medical issue requiring medical treatment, many of these treatments have often ended up making the pain worse. Along with the dependency issues linked to many opiate-based pain relievers, actual research into different pain remedies have shown little real proof of their effectiveness. Shifting away from the purely biomedical model of pain towards a biopsychosocial approach, psychological methods of pain relief have become more common in recent years. Along with behavioural pain treatment based on operant conditioning principles, relaxation training and biofeedback also became widely used during the 1970s. Beginning in the 1980s, cognitive behavioural treatments to help chronic patients cope more effectively were also introduced.    

Cognitive behavioural techniques that are effective with chronic pain patients include:

  • Cognitive restructuring to alter negative thoughts about pain and deal with maladaptive beliefs
  • Training in problem-solving to encourage pain patients to work through their problems as testing new solutions and measuring their effectiveness
  • Relaxation training including guided imagery and progressive muscular relaxation
  • Changing structured activities by learning pacing (breaking up activities into smaller chunks during the day) and becoming more physically active
  • Psychoeducation to learn more about pain and coping techniques
  • Supportive counseling to provide guidance and emotional monitoring
  • Other treatment methods including biofeedback, hypnosis and relapse prevention training to retain the gains that have been made

Cognitive behavioural techniques are useful in helping chronic pain patients manage their symptoms and researchers have also focused on understanding the nature of pain in the hope of developing even more effective treatments. One of the critical developments in the history of pain research has been the publication of the gate control theory by Ronald Melzack and Patrick David Wall. First developed in the early 1960s, the gate control theory suggests that the dorsal horn of the spinal cord acts as a sensory "gate" regulating the flow of information between the brain and the rest of the body relating to physical damage or threat of damage. As one example of the gate in action, rubbing a body part sends information to the dorsal horn "closing" the gate which decreases the amount of pain perceived by the brain. Melzack and Wall have argued that different brain processes can influence how "open" or "closed" the pain gate is which leads to altered awareness of pain. 

In recent years, research into chronic pain has focused on the gate control model and brain imaging studies to develop a better understanding of the psychological and neurological factors that control pain. While the dorsal horn in the spine acts as a gate, the complex nature of pain means that many different brain regions are also involved in pain awareness. The effectiveness of psychological treatments in controlling pain is likely linked to the influence of the the different parts of the brain. For example, relaxation and biofeedback can affect the sensory cortex and the limbic system which in turn leads to an increased sense of control over pain. By combining biofeedback techniques with more accurate measures of brain functioning, including EEG and functional magnetic resonance imaging (fMRI), psychological treatments for pain may become far more effective. 

Unfortunately, one of the main drawbacks to research on pain is that it cannot be directly measured. Only the person experiencing the pain is really aware that it is there. Up until now, there was no way of measuring pain except by either asking the patient about their subjective experience or measuring how pain changes behaviour. With the development of better brain imaging methods such as fMRI,  it may become possible to measure changes in the brain linked to pain directly. Along with allowing for more sensitive measures of pain, it may aslo become possible to evaluate the effectiveness of psychological treatments by how they change the brain directly.

As Mark Jensen has pointed out,  there is also a critical shortage in treatment professionals able to help all of the chronic pain patients needing therapy. Along with developing new treatment approaches, pain treatment researchers are also developing new technological solutions to provide this needed treatment. That can include new online treatment systems, smart-phone applications, and software solutions to provide treatment on demand without requiring pain patients to travel long distances or wait for months before a space in a treatment group becomes available.

And online pain treatments are already making a difference. A recent meta-analysis looking at eleven studies involving nearly three thousand chronic pain patients found that Web-based treatment can provide pain relief as well as helping reduce depression, anxiety, and dependence on medication. Even better results can be obtained by combining different treatment methods including psychotheapy, relaxation training and medication to provide patient with better pain relief than they might have received just from one method alone. 

While all pain patients are different, there isn't going to be a single approach that will help everybody. By learning  how to match pain treatments to specific pain patients, researchers can discover why some people get more pain relief than others. Instead of treating all pain patients in the same way, we may be entering a new era of personalized pain treatment that can be more cost-effective and provide better relief than what chronic pain patients often endure now. In treating pain, it is also important to make certain that pain patients have a realistic idea about what to expect from treatment and not to rely on false hopes.

In their review, Mark Jensen and Dennis Turk point out that psychologists and psychological research are playing a stronger role in treating pain than in the past. Chronic pain patients need to learn how to cope effectively and to recognize the misconceptions that make their recovery more difficult. As we learn more about how genetics, neurophysiology, and psychology come together and new methods of controlling pain become available, we may well become able to deal with many of the social and economic problems linked to chronic pain. In entering what Jensen and Turk call the "golden age of pain study", there is more optimism than ever before about providing real relief for millions of chronic pain around the world.

Along with relieving human suffering, many of the same psychological treatments that can help with pain can also be used to treat the various problems linked to pain. That includes insomnia, depression, fatigue, and substance abuse. Learning to control pain may yield dividends that we haven't even begun to appreciate.

Romeo Vitelli, Ph.D. is a psychologist in private practice in Toronto, Canada.

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