LAS VEGAS—The “three-legged stool” of pain treatment comprises injections and surgery, medications, and self-care skills; in other words, what patients can learn to do for themselves.
“But access is usually a problem,” said Ted W. Jones, PhD, CPE, of the Behavioral Medicine Institute at Pain Consultants of East Tennessee in Knoxville and Oak Ridge. “Most pain practitioners do not have access to a complete range of educators, psychologists, counselors, and the like who can teach these [self-care] skills,” he added, and “very few have such practitioners inside their own practice.”
Furthermore, patients with chronic pain, as a rule, “generally don’t like making additional appointments at another location to access these educators.”
Faced with these challenges, Dr. Jones said his institute tried a traditional model to teach patients pain coping skills, which consisted of 6 weeks of 1-hour sessions.
However, as it turns out, “very few patients wanted this,” leading the practice to ask several questions: “How hard to you push? Do you ‘mandate’ treatment? Do you discontinue opioids if a patient does not come? Do you build on each session, or is each independent? What if a patient misses a session? How do you make it up?”
To overcome these challenges, they decided to offer a single session to patients, not only because it was an easier “sell,” but because attendance would be easier to mandate by expecting each patient “to put in at least a minimal investment in his/her own care.”
Faced with what to include in one session, Dr. Jones and colleagues decided to focus on teaching the five key pain coping skills: understanding, accepting, calming, balancing, and coping.
- Understanding focuses on providing information for patients about pain as well as their pain condition and treatment options.
- Accepting recognizes the role of cognitive behavioral therapy and acceptance and commitment therapy as well as catastrophizing, a key variable in outcomes.
- Calming emphasizes that decreasing stress can take many forms, such as Tai chi, progressive muscle relaxation, medication, and biofeedback; a good and easy start is, simply, a focus on breathing.
- Balancing assists patients in achieving routines to decrease pain flares; issues include sleep hygiene, saying “no,” time management, and “the biggie,” activity pacing, Dr. Jones said.
- Finally, coping explains, in simple terms, that there are three kinds of pain: nerve, joint (inflammation), and muscle. The first step is for the patient to ask, “What kind of pain am I having?” and “What can make this better?”
The benefits of a single group session are that it demonstrates to patients that “it’s not all about injections and pills;” is cost-effective; is able to fit into most pain practices; and can effectively transform a pain practice into a multidisciplinary pain program, Dr. Jones said.
He outlined one treatment delivery option his group offers, “Pain Pearls” or “Pain 101,” a 2-hour, single-session group (CPT 96153, 8 units), in which all five key pain coping skills are reviewed.
A 2013 study published in Pain and Therapy by Dr. Jones and colleagues reviewed the effects of this single session group intervention for pain in which 53 patients were asked how helpful it was. The patients were administered the Pain Catastrophizing Scale (PCS) at baseline and at 3 months.
At follow-up, 96% of patients said the sessions helped “a great deal” or “a little” (the other choices were “not at all” or “worse”) and 85% would recommend the group to other patients with pain. Also asked were what coping skills helped them the most, both after the session and at 3-month follow-up (see Table); patients were provided blank lines to fill in their response.
Scores on the PCS decreased significantly from baseline to follow-up, as did scores on the rumination and helplessness subscales; however, the magnification subscale did not change significantly.
Dr. Jones said comments from the patients put the session in perspective:
- “It helps to hear from other people about their pain and how they deal with it.”
- ‘‘Wish I would have taken it years ago. I have been through all the emotions dealing with disability. It would be excellent for new patients.”
- ‘‘I believe any doctor’s office prescribing any pain medications should by law require classes such as this. People with chronic pain have the right to be educated as to options we have to not only pain medication but pain education.”
The single session group need not be led by a psychologist; in fact, the skills needed are basic and any interested healthcare practitioner can teach these, he concluded.