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A recent position statement by the Society of Behavioral Medicine (SBM) concludes that patients with persistent pain need better access to psychosocial care in all healthcare settings.1 The SBM offers 10 health policy recommendations for improving such access, including removing system-related barriers, providing referral tools, reimbursing for evidence-based psychosocial approaches, prioritizing generalist-level and specialist pain training across disciplines, and recognizing pain psychology as a specialty. Unfortunately, the authors note, “despite persuasive evidence supporting the efficacy of psychosocial approaches, these interventions are inaccessible to the majority of Americans.”
Rheumatologists see a lot of patients with persistent pain—defined as lasting for six months or more—among the 25.3 million Americans who experience daily pain identified in the 2012 National Health Interview Survey conducted by the National Institutes of Health. Meanwhile, traditional pain management tools, such as opioid analgesics, for chronic, nonmalignant pain are coming under greater scrutiny.
But what is psychosocial pain care, what can it contribute to pain management, who provides it, and how can rheumatologists get more involved?
What Is Pain?
Dr. Fillingim
Pain is a highly personal, subjective experience, says Roger Fillingim, PhD, a psychologist and director of the Pain Research and Intervention Center of Excellence at the University of Florida in Gainesville. Biologic processes are important to address in relieving pain—but so are psychological and social factors. “This goes for all pain, regardless of origin,” he says.
In some patients, the psychosocial factors are stronger than for others, but even when the pain is mostly biologic in origin, psychosocial interventions can still prove effective. “For example, we know hypnosis reduces postoperative pain, and deep breathing and relaxation have been shown to be effective in relieving pain,” Dr. Fillingim says. Reducing a patient’s anxiety and increasing feelings of control also have an impact on pain and physical functioning.
In a recent review, Louise Sharpe, PhD, professor at the School of Psychology at the University of Sydney, Australia, highlighted research showing efficacy of psychological therapy for managing pain in patients with rheumatoid arthritis.2 A study in the Journal of Psychiatric Practice found cognitive behavioral therapy an effective alternative to opioids for chronic nonmalignant pain, either as a standalone treatment or in combination with non-opioid medications.3
But sometimes medical providers appear to believe medical approaches are for “real” pain and psychological approaches are reserved for other forms of pain that may be “all in the patient’s head,” Dr. Fillingim says. In reality, patients experience pain in both realms. “It is almost never all psychological in the same way it’s almost never all biologic. I’d encourage providers not to restrict their approaches for those whose pain they have decided is psychological in origin.”
What Is Psychosocial Care?
Dr. Janke
Psychosocial care focuses on psychological, behavioral, cultural and social contributors to the pain experience, especially when a purely pharmacologic (or physical) approach has failed to relieve a patient’s pain. “When we talk about psychosocial care, we’re talking about treating the whole person,” says Amy Janke, PhD, the SBM report’s lead author and interim chair in the Department of Behavioral and Social Sciences at the University of the Sciences in Philadelphia.
Psychosocial interventions for pain can include cognitive behavioral therapy, a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem solving and skills teaching. Its goal: To change patterns of thinking or behavior behind people’s difficulties and, thereby, change the way they feel.
Other techniques to enhance the mind’s impact on the body include mindfulness meditation, yoga, guided imagery, biofeedback, hypnosis, tai chi and prayer. The multidisciplinary approach to psychosocial, whole-
person care can be integrated with a variety of opioid-sparing complementary and alternative therapies. Support for this approach comes from a study in Arthritis Care & Research that demonstrated benefits of self-administered acupressure in osteoarthritis, which was shown to be superior to usual care in pain relief and for physical function improvement.4
“One thing we’ve learned through the current opioid public health crisis is that if we take one approach only in treating pain, we can fail a lot of patients. It’s critical that we think about the individual in pain from a more whole-person perspective,” Dr. Janke says. What are their coping methods, their social circumstances? What is their state of mind? What are they thinking about their pain? Not all of those factors may be in play for every patient, but caregivers should address all in every patient encounter.
“On one hand, we want to encourage a psychosocial mindset by medical providers. But the responsibility for psychosocial care shouldn’t land solely on the rheumatologist,” Dr. Janke adds. “Too often, we put providers in a position of having to do everything in their 10–17 minute encounter with the patient. But we can ask them to think more about their patients’ pain from a psychosocial standpoint,” she says.
“Rheumatologists already do this, but our report is saying it should be named and systematized,” she says. “If my patient is struggling with comorbid stress or anxiety, which can exacerbate pain, maybe they need more help managing that—and in getting a psychosocial intervention.”
Rheumatologists, who try so hard to relieve suffering, are now seeing the demonization of what has been at times a useful tool—opioid analgesics—while other tools of demonstrable value are not necessarily accessible, depending on the setting, the resources of their health system or medical group, and what is reimbursed, she said.
Can Patients Participate in Their Own Care?
A greater emphasis on psychosocial care starts with a change in treatment philosophy to require the patient’s active participation, Dr. Fillingim says. “That may be news to many patients.”
The physician’s challenge is to educate the patient and talk to them about how they can participate in their own care and pain management: “‘I as a provider will help you any way I can. But this will only work if you help yourself.’ So you have to get buy-in from the patient,” he says.
If patients are not disposed to engage with these approaches in their own care, perhaps they need a referral to a pain psychologist with expertise in psychosocial pain management. “But if you don’t have access to resources such as that, you’re back to working with the patient yourself,” Dr. Fillingim says. An alternative: Another member of your rheumatology group, such as a physical therapist or nurse practitioner, could obtain additional training in psychosocial pain modalities and take on such cases.
Dr. Janke says it is helpful to recognize a range of resources exist that you can offer to patients, including referrals to disease- or pain-specific websites, online support groups or evidence-based workbooks to help patients manage their pain. Patients can also download mindfulness apps on their smartphones. “But this requires the rheumatology practice to cultivate a list of resources.”
Some patients, such as those who show signs of depression, may require more extensive interventions, such as referral to a behavioral medicine specialist, which could be a psychologist with a background in behavioral medicine and pain medicine. “One of the challenges, of course, is that there are far too few psychologists in this field,” Dr. Janke says. “Access is a problem, undeniably. In an ideal world, wouldn’t it be nice to have an expert right there in the practice who could be pulled in?”
Dr. O’Mahony
Sean O’Mahony, MD, is a hospice and palliative medicine specialist at Rush Medical Center in Chicago whose practice includes treating pain in patients who present with underlying life-threatening conditions, often with concurrent mental health issues. “There are a limited number of clinicians with the required training to support psychosocial interventions. Here we work closely with psychologists and social workers, and we have an occupational therapist [who] provides detailed instruction to patients on how to do mindfulness meditation. I refer about a third of my pain patients to a social worker or psychologist,” he says.
Dr. O’Mahony recently found, in surveying house staff at Rush, that 80% could not recall receiving didactic training on safe pain management prescribing at the undergraduate level. Now all medical interns at Rush get a week of pain training, including psychological modalities. “We also reached out to the oncology community to provide education about palliative care and psychosocial pain care. I could see developing similar collaborations with rheumatologists, to raise their comfort level with these techniques.”
Dr. Gerhart
His colleague James Gerhart, PhD, a clinical psychologist at Rush, is also involved in education of medical providers. “Everyone says we need to treat the whole patient. Of course it’s important, but okay, how do you actually do that in your practice? The first thing is to empower clinicians to say: I hear you. You’re in pain. I want to help you.”
The patient evaluation is itself an intervention—an opportunity to really hear patients, validate their symptoms and address their fears, he says. “If somebody is in pain, I also want to know about their sleep, about their level of functioning.” He encourages rheumatologists to be attentive and curious about these issues. Standardized screening tools should be integrated into the electronic medical record. He also encourages a warm hand-off to the pain psychologist with as much specific information as possible.
An Interdisciplinary Approach
Dr. Fillingim says the conversation about psychosocial pain care could be broadened to include advancing interdisciplinary care overall for pain. That goal is supported in the federal government’s 2016 National Pain Strategy, which endorsed comprehensive, interdisciplinary pain care delivered by integrated, patient-centered teams using a disease management model.5 “That means patients are getting all of the treatments that could benefit them, coordinated across disciplines,” he says. “We’re talking about psychosocial interventions designed to improve outcome, including quality of life and functional status.”
Unfortunately, when the doctor doesn’t have time to conduct a psychosocial intervention, it can be easier to just write a prescription for opioids Dr. O’Mahony says. “Paradoxically, insurance companies will pay for these medications that can have limited benefit and significant risk, but they won’t pay for proven psychosocial interventions,” or they charge prohibitively high copays.
Larry Beresford is a freelance medical journalist in Oakland, Calif.
References
- Janke EA, Cheatle M, Keefe FJ, et al. Society of Behavioral Medicine (SBM) position statement: Improving access to psychosocial care for individuals with persistent pain: Supporting the National Pain Strategy’s call for interdisciplinary pain care. Transl Behav Med. 2018 Mar 1;8(2):305–308.
- Sharpe L. Psychosocial management of chronic pain in patients with rheumatoid arthritis: Challenges and solutions. J Pain Res. 2016 Mar 14;9:137–146.
- Majeed MH, Sudak DM. Cognitive behavioral therapy for chronic pain—One therapeutic approach for the opioid epidemic. J Psychiatr Pract. 2017 Nov;23(6):409–414.
- Li LW, Harris RE, Tsodikov A, et al. Self-acupressure for older adults with symptomatic knee osteoarthritis: A randomized controlled trial. Arthritis Care Res (Hoboken). 2018 Feb;70(2):221–229.
- National Institutes of Health. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. 2016.
