Applying CBT and Mindfulness Effectively in Pain Management

Mindfulness-based stress reduction is effective when teaching critical skills for self-modulation of pain.
Mindfulness-based stress reduction is effective when teaching critical skills for self-modulation of pain.

LAS VEGAS — The role of psychosocial factors in the development and maintenance of chronic pain is now widely accepted. Developing and implementing treatment prevention strategies and leveraging that knowledge has become critical in the face of the chronic pain epidemic.

At PAINWeek 2016, Beth Darnall, PhD, clinical associate professor and Clinical Pain Advisor board member, presented studies that identified factors leading to the development, maintenance, and progression of chronic pain.1 Identification of these factors has been essential for determining appropriate treatments, as well as for anticipating a patient's response to those treatments.

“What we know is that [pain] is individual,” stated Dr Darnall. “We need to focus on the whole person.” As an advocate for a personalized approach to pain management, she believes that the recent emphasis on limiting access to opioids fails to “address the fundamental problem in this country, which is one of pain and how to best treat it.”

The Guideline for Prescribing Opioids for Chronic Pain—released earlier this year by the Centers for Disease Control and Prevention—as well as the National Pain Strategy have focused on the concept of a comprehensive treatment of pain, to address the pain and opioid crises occurring in the United States (US).2,3 These documents stress the importance of using a biopsychosocial approach to chronic pain management and delivering targeted and individualized therapies.

A major focus has been on cognitive behavioral therapy (CBT), although Dr Darnall points out that mindfulness-based stress reduction (MBSR) has recently taken center stage. A clinical trial comparing MBSR and CBT for the treatment of low back pain demonstrated equivalent pain reduction with the 2 treatments.4

“Self-management strategies and MBSR are effective in teaching people these critical skills to learn how to self-modulate their experience of pain, to learn how to calm their nervous system,” she added. Convincing evidence shows that learning psychological skills over 8 CBT sessions, either in group or individual treatment, modulates a patient's brain function, both in the context of pain and at rest.

Functional magnetic resonance imaging (MRI) has shown that CBT leads to volumetric increases in brain regions associated with pain control.5 “You can tell your patients: ‘You are actually growing your brain and training your brain away from pain,'” continued Dr Darnall.

Treatment around catastrophizing has appeared as the key driver of CBT and MBSR in reducing pain. “It goes back to the concept that pain is our ‘harm alarm,' and in view of individual differences, this alarm is going to ring more loudly in some people than in others,” Dr Darnall explained.

To explain the effect of psychosocial interventions to her patients, Dr Darnall tells them “your brain and your nervous system are working to protect you, but if we just let it do what it is trying to do, it can take what is essentially your pain and amplify it.”

She teaches patients how to stop catastrophizing, but cautions them that this will help reduce pain levels, not stop the pain. Pharmacologic interventions are more likely to be effective in such a context.

“We need to help people learn the critical skills to move into the direction of decreasing and dampening pain processing in their nervous system,” Dr Darnall added. “Pain is not a passive process and cannot be best treated by pills alone – and that is why we are in this problem right now in the United States. We have not communicated this message effectively enough and we need systems to better treat pain. We have to connect patients with this evidence-based treatment that we know works,” she concluded.


References

  1. Darnall B, Mackey SC. In the wake of the CDC opioid guidelines and the National Pain Strategy: leveraging pain psychology and platforms to address the national pain and opioid crises. Presented at: PAINWeek 2016. Las Vegas, NV; September 6-10, 2016.
  2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
  3. Department of Health and Human Services: National Pain Strategy: a comprehensive population health strategy for pain. Available at: https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed September 8, 2016.
  4. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240-1249.
  5. Holzel BK, Carmody J, Vangel M, et al.  Mindfulness practice leads to increases in regional brain gray matter density.  Psychiatry Res. 2011;191(1):36-43.

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