At least 100 million Americans are living with ongoing pain of some type. How do we meet the needs of a population and best treat pain? And what does psychology have to do with it?
Treating pain best means addressing pain comprehensively, at the lowest cost and risk, and ensuring that treatments are broadly accessible to patients (Darnall 2018a). To be sure, we need the full tool kit of pain treatment options available for all patients: pain medications (including opioids for some), self-management classes, procedures, physical therapies, and psychological and other supportive therapies. We need clinicians trained in the best practices of pain management, so they can discern the individual needs of each patient, and tailor treatment to their specific needs. There is no one-size-fits-all in pain care (Darnall 2018b).
That said, everyone can benefit from understanding how to help themselves best manage pain and reduce suffering. This is the realm of behavioral medicine for pain—or pain psychology; pick your term. Behavioral medicine for pain works alongside medical treatments. It is what I call empowered pain relief.
The Fallacy: Pain is Either Medical or Psychological. Pain is an integrated biopsychosocial experience. It is defined as a negative sensory and emotional experience. This means that to best treat pain, we must acknowledge that pain is distressing and, for many people, life-altering. Medical evaluation and care are important, and other approaches are also needed to address the full definition of pain. Individuals can become equipped with information, skills, and strategies that help them better manage the negative impacts of pain. This can help them reduce aspects of suffering, alter the trajectory of pain, and for some patients can even help reduce the need for medical care. This is "whole person" pain care.
Of course, what’s best and what’s accessible are two different things. In the realm of behavioral medicine for pain, the biggest problem is poor access to evidence-based care. Indeed, people who want whole-person pain care often have difficulty finding it. For instance, we documented a variety of barriers that prevent patients from working with a skilled pain psychologist (Darnall, Scheman, Davin et al 2016). Here’s where brief and digital treatment options come in.
Scaling Treatment to Meet the Needs of a Nation
Empowering Patients Who Are Receiving Surgery or Hospitalized
Patients often lack access to information on what they can do to help manage distress, pain, and symptoms that may naturally arise before and after surgery. Scheduling treatment visits with a health psychologist is often impractical or impossible. Digital interventions can help fill the void in surgical behavioral medicine. For instance, “My Surgical Success” is a fully automated, online (digital), pain education and skills-based intervention. It consists of three 15-minute video learning modules that patients can access from home or the hospital, and it includes pain relief skills and downloadable materials. Patients can engage with the content on-demand and at their own pace.
Our first randomized controlled pilot study revealed that patients who engaged with My Surgical Success required almost 7 fewer days of opioid medication after breast cancer surgery than patients who received digital general health education (Darnall, Ziadni, Krishnamurthy et al 2019). Importantly, My Surgical Success does not direct patients to alter their pain medication use; rather, we found that patients simply needed less of the opioid medication that was prescribed and available to them. My Surgical Success is being studied at Stanford Hospital, the Cleveland Clinic, and at La Tour hospitals in Switzerland.
Virtual reality is another digital behavioral pain management tool for pain management in the hospital and at home. Researchers studying hospitalized patients with pain found that virtual reality was most beneficial for hospitalized patients reporting severe pain (Spiegel, Fuller, Lopez et al 2019). Virtual reality (VR) is more than just distraction from pain. New VR programs include pain education and active pain management skills and relaxation response training for on-demand learning and longer-term relief. The beauty of digital pain treatments is they require no in-person clinic visits, and in many cases, these treatments can be received in one’s own home.
Empowered Relief for People with Chronic Pain
In 2019 the U.S. Health and Human Services Interagency Pain Task Force issued a report on what’s needed in national pain care. The task force specifically cited the need for scalable behavioral pain treatment and highlighted our single-session skills-based class as one promising option. Now called “Empowered Relief,” the 2-hour class offers compressed behavioral pain medicine and actionable evidence-based pain management skills training in one efficient visit (Darnall, Ziadni, Roy et al 2018; Darnall, Sturgeon, Hah et al 2014). Empowered Relief is scalable because: (1) it requires only one in-person visit; (2) it can be offered within clinics and healthcare organizations free of charge or at very low cost; (3) family members are welcome to attend and learn about pain management and how to support their loved one; (4) any healthcare clinician can become a certified instructor; and (5) as many as 100 patients can be treated in a single class if the room size allows it.
Empowered Relief is the subject of major NIH research awards and is embedded into healthcare systems and clinics throughout the U.S., Canada, the U.K, Denmark, and Australia. In Canada, Empowered Relief is available in French and English in primary care and pain clinics. The idea is to empower patients as early as possible – ideally before pain becomes an ongoing problem. Scalable treatments like this do not eliminate the need for medical care; rather, they work alongside medical treatments and support patients in achieving best outcomes. Scalable options provide rapid access to pain treatment and stand to support intensive work with an individual therapist that some patients desire.
Ultimately, we need healthcare to focus on prevention and optimizing symptom management early in the process. To accomplish this, we need scalable behavioral treatments and digital supports that meet patients where they are. To be truly patient-centered, patients need options that are effective and accessible.
This is empowered relief.
Darnall B. To treat pain, study people in all their complexity. Nature 2018 May; 557 (7703):7. PMID: 29717254.
Darnall BD, Scheman J, Davin S, Burns JW, Murphy JL, Wilson AC, Kerns R, Mackey SC. Pain Psychology: A global needs assessment and national call to action. Pain Medicine. 2016; 17(2): 250-263.
Darnall BD, Ziadni MS, Krishnamurthy P, Mackey IG, Heathcote L, Taub CJ, Flood P, Wheeler A. “My Surgical Success”: Effect of a Digital Behavioral Pain Medicine Intervention on Time to Opioid Cessation After Breast Cancer Surgery—A Pilot Randomized Controlled Clinical Trial. Pain Med. 2019; 20(11): 2228–2237.
Spiegel B, Fuller G, Lopez M et al. Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial. PLOS One. Sept, 2019.
U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations.
Darnall BD, Ziadni MS, Roy A, Kao MC, Sturgeon JA, Cook KF, Lorig K, Burns JW, Mackey SC. Comparative Efficacy and Mechanisms of a Single-Session Pain Psychology: Protocol for a Randomized Controlled Trial in Chronic Low Back Pain. Trials 2018; 19:165. PMID: 29510735
Darnall BD, Sturgeon JA, Hah JM, Kao MC, Mackey SC. ‘From Catastrophizing to Recovery’: A pilot study of a single-session treatment for pain catastrophizing. J Pain Research. 2014; (7):219-226. PMID: 24851056
Monitor on Psychology covers scalable behavioral pain medicine options in the September 2019 issue (author: Deborah Bailey)