An estimated 100 million Americans suffer from chronic pain, which by definition lasts longer than 12 weeks.1,2 Chronic pain is not limited to physical discomfort; it is a biological, psychological, and social disorder that in many cases persists long after the initial cause has been resolved.2,3
“Unlike acute pain that warns the body of an injury, chronic pain is no longer a reliable indicator of anything. Even after an injury has healed, chronic pain may trigger reflexive behaviors such as protecting, guarding, and resting that are counterproductive,” Thomas J. Rostafinski, PhD, told Clinical Pain Advisor. Dr Rostafinski is a pain psychologist and clinical associate professor of psychiatry at the Stritch School of Medicine at Loyola University Chicago in Maywood, Illinois.
Cognitive Behavioral Therapy: A Nonmedical Approach
Chronic pain is difficult to treat by nature. Opioids that are effective for acute pain are not appropriate first-line therapy and should be reserved for patients with intractable pain.3 Anticonvulsants that treat neuropathic pain (a common cause of chronic pain) are only effective in a minority of patients, Dr Rostafinski pointed out.
Cognitive behavioral therapy (CBT) is a safe and effective way to treat chronic pain, either alone or in conjunction with other pain therapies. Although mainstream use is supported by decades of research, most patients are never exposed to CBT as a treatment option.1
For many patients and primary care providers, the suggestion that “talk therapy” can help chronic pain is the first hurdle; the typical response is that chronic pain is not imaginary. Patients may resist, saying, “My pain is not in my head, how is talking going to help me?”
“I would love to ban the term ‘talk therapy’,” Dr Rostafinski emphasized, explaining, “All pain is — literally — in your head. It is real pain that registers in your brain and is processed though the way you see the world. That does not mean it is imaginary.”
Changing the Way Patients Think About Pain
CBT comprises a group of psychotherapy methods focused on changing thoughts, emotions, and behaviors. There is no standard protocol; techniques may include relaxing activities, meditation, setting behavioral goals, and activity pacing.1,4
“CBT is the psychotherapy of choice for many conditions. It is a collection of techniques and approaches based on the specific needs of the patient. The cognitive and behavioral components are distinct parts of treatment. One goal is to counter reflexive but counterproductive reactions to pain,” Dr Rostafinski said.
Chronic pain may cause a person to withdraw from life. Symptoms may include fatigue, depression, mood changes, and sleep disturbances. Some patients dwell on the pain, mourning the loss of the life they formerly enjoyed.
“Many of these people have lost a lot. The goal is to regain as much as possible. The first step is to get over the misconception that hurt means harm. Distraction is a powerful coping skill. My mantra for patients is get active physically, mentally, socially, and — for those who choose to — spiritually,” Dr Rostafinski said.
Effective for a Wide Range of Syndromes
CBT can be used for a wide range of chronic pain syndromes and is the most useful psychological treatment for arthritis, headache, low back pain, orofacial pain, and fibromyalgia.1
“The etiology of the pain may be different, but all pain is experienced psychologically and processed in similar ways. The only type of pain that may not respond as well to CBT is migraine headache. That one seems to be a different type of animal,” Dr Rostafinski noted.
How Long Does Treatment Last?
CBT is often described as a short-term treatment, involving as few as 6 sessions or as many as 20. In many cases, CBT skills can be learned quickly and used indefinitely.4
“The length of treatment is hard to predict. A standard answer may be about 3 months of weekly sessions. In that time, you will know if the treatment is working or not. CBT is no different from physical therapy or a pain injection. As long as CBT is helpful, some people will benefit from returning over time,” Dr Rostafinski said.
How Effective Is CBT?
Although CBT has been evaluated in many studies, concepts of pain and its social and psychological byproducts are not easily measured. The research is also plagued by variations in protocol quality and therapist abilities.
Most studies and meta-analytical reviews conclude that there is significant evidence of efficacy, though the benefits are modest.1
“It’s not like taking a pill. CBT takes work and commitment,” Dr Rostafinski said. “The patient and the therapist need to have realistic expectations. The benefits are subtle, not dramatic.”
Additional research is needed to learn more about why CBT works, what components work best, and which patients benefit most. Future studies may also be able to refine CBT protocols and determine ways to integrate techniques into primary care.1
How to Find a CBT Practitioner
Not all psychotherapists are trained in how to use CBT for chronic pain. According to Dr Rostafinski, good resources for primary care providers include:
- University medical center pain management clinics;
- Private, multidisciplinary pain management clinics;
- State psychological association; and
- The American Psychological Association website, which includes a feature to find psychologists practicing in your area. Pain psychology can be specified in the search.
For many patients living with chronic pain, learning how to live as well as possible is a huge benefit. Chronic pain may be inevitable, but chronic suffering may not have to be.1
Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain. Am Psychol. 2014;69(2):153-166. doi: 10.1037/a0035747.
National Institutes of Health. MedlinePlus: Chronic pain: symptoms, diagnosis, and treatment. Available at: www.nlm.nih.gov/medlineplus/magazine/issues/spring11/articles/spring11pg5-6.html. Accessed April 25, 2016.
American Academy of Pain Medicine. Use of opioids for the treatment of chronic pain. February 2013. Available at: www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf. Accessed April 25, 2016.
Association for Behavioral and Cognitive Therapies. What is cognitive behavioral therapy (CBT)? Available at: http://www.abct.org/Information/?m=mInformation&fa=_WhatIsCBTpublic. Accessed April 25, 2016.
This article originally appeared on Clinical Pain Advisor