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4 Articles in this Series
Introduction
Individualizing Pain Treatment: Start with Gender?
Simplifying Pain Self-Management for Patients
The Interactions of Emotions and Chronic Pain
To Treat Pain Better, Underlying Mechanisms Are Key

Simplifying Pain Self-Management for Patients

with Beverly Thorn, PhD, ABPP, and  Burel Godin, PhD

With medication being discouraged as a first-line treatment of many chronic pain cases, physicians are under growing pressure to help their patients self-manage their pain. That may often mean helping them to learn such strategies as cognitive behavioral therapy (CBT) or providing education about pain management, said Beverly Thorn, PhD, ABPP, professor emeritus at the University of Alabama, Tuscaloosa, at the March 2018 American Pain Society (APS) Scientific Summit in Anaheim, California.

While her research and that of others has shown both approaches to be effective, Dr. Thorn says that communicating the strategies has at least two obstacles: many of the 116 million Americans with chronic pain are low-income with lower than average education levels, resulting in potential difficulty with comprehending standard medical educational materials; and not all healthcare providers are familiar with CBT or pain education approaches.

Meeting the Unique Needs of Low-Income Patients with Chronic Pain

Simplified pain management can be easily taught, Dr. Thorn told those attending her presentation on “Simplifying Evidence-Based Self-Management Therapies for Chronic Pain: Rationale, Efficacy, and Implementation.” The talk recapped her research and provided concrete suggestions for getting through to patients of any education and income level.1

Dr. Thorn has been active in helping disadvantaged populations deal with pain for 15 years. During that time, she has simplified CBT techniques and education approaches that apply to this unique population. In one of her recent studies,2 she found that simplified CBT and pain education combined provided better pain relief and improved physical function compared to standard of care. CBT may have had a slight edge, she said.

A workbook that her team put together, LAMP, which stands for Learning About Managing Pain, is available as a free download. The overall message for healthcare providers, according to Dr. Thorn: “If you present relevant information that is meaningful to patients in an interactive way so they can feel like part of the process, and do it in a motivational way, we have discovered that information can change behavior.”

Inside the Proposed LAMP Program

According to the National Pain Strategy, quoted by Dr. Thorn, ‘‘pain self-management programs address the systematic provision of education and supportive interventions by healthcare providers to strengthen patients’ skills and confidence in medical management, role management, and emotional management of their health problem, including regular assessment of progress and problems, decision-making, goal setting, self-monitoring and problem solving.” Patients must be given information about pain and how to build skills to prevent, cope with, and reduce it.

Self-Management and Cognitive Behavioral Therapy

The LAMP program describes self-management education as:

  • providing patients with information about how the brain processes pain
  • giving patients information about the importance of stress management, communication, and physical activity
  • using simplified workbook materials with audio summaries.

Of note, no specific skill-building exercises were taught. The LAMP’s proposed CBT program further includes:

  • training patients in stress management and assertive communication, as well as in CBT techniques such as motivational reinforcement, cognitive restructuring and activity pacing.
  • using simplified workbook materials with audio summaries as well as relaxation exercises.

In the CBT model tested by Dr. Thorn’s team, researchers reduced the reading level of the materials given to patients, reduced the amount of text, and increased the illustrations. They compared approaches in 290 patients—giving 95 CBT, 97 pain education, and 98 usual medical care only.2 The CBT and education groups attended 10 weekly 90-minute sessions. “That interaction was crucial,” Dr. Thorn said. “People with chronic pain feel isolated. If they are learning things and interacting and discussing, that’s a powerful medium.”

Eighty-three percent of the patients completed a post-treatment assessment, and 75% participated in a 6-month follow-up interview. Of the 290 patients, 67% were African American; 36% were reading below a fifth-grade level; and 72% were at or below the poverty level. Ages ranged from 19 to 71; all were Alabama residents.1,2 On average, the participants’ chronic pain had been diagnosed more than 15 years prior and the patients had, on average, more than six pain sites and more than four etiologies. The results:

  • Both CBT and education, but not usual care, reduced pain intensity, interference, and depression at six months.
  • For clinically meaningful improvement, more than a 30% change, CBT and education worked better than usual care.
  • Compared to usual care, CBT and education resulted in better improvement in pain intensity post-treatment. At follow-up, treatment gains (compared with usual care) were not maintained for CBT but were still present for the pain education group.

Barriers Remain

Insurance reimbursement and overcoming patient skepticism remain barriers in providing patients with education about their pain and techniques for self-managing their pain, explained Dr. Thorn. Yet, she is optimistic that a simplified approach may produce results. She pointed to a quote from one of her past participants, featured in a New York Times article that mentioned her program: “It’s about triggering your brain to go to something else, other than the pain.”3

Perspective

Dr. Thorn’s research with lower income pain patients and what ‘‘speaks’’ to them is eye-opening, commented Burel Goodin, PhD, a clinical psychologist at the University of Alabama at Birmingham, who attended the APS presentation (Editor’s note, Dr. Goodin works in a different institution from Dr. Thorn at the university.) In his opinion, ‘‘a lot of healthcare providers are not aware of the literacy issues.”

At this time, he adds, ‘‘it is important to think of these therapies [CBT, pain education] as front-line care.”

Healthcare providers who feel unfamiliar with the approaches may easily access resources, he said, such as Dr. Thorn’s downloadable workbook. Her work is also detailed on the Patient-Centered Outcomes Research Institute site.

Sources

1. Thorn BE, Simplifying Evidence-Based Self-Management Therapies for Chronic Pain: Rationale, Efficacy, and Implementation. Presented at: American Pain Society Scientific Summit. March 4-6, 2018, in Anaheim, California.

2. Thorn, BE et al. Literacy-adapted cognitive behavioral therapy versus education for chronic pain at low-income clinics. Annals of Intern Med. ePub February 26, 2018. Available at http://annals.org/aim/article-abstract/2673506/literacy-adapted-cognitive-behavioral-therapy-versus-education-chronic-pain-low. Accessed March 6, 2018.

3. Goodnough A. Finding good pain treatment is hard. If you’re not white, it’s even harder. New York Times. August 9, 2016.

Next summary: The Interactions of Emotions and Chronic Pain
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