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10 Articles in Volume 21, Issue #3
Chronic Pain in Patients with Hemophilia: A Clinical Assessment and Treatment Primer
Analgesics of the Future: ASIC Inhibitors and IGF for Migraine Relief
Behavioral Medicine: How to Deliver CBT for Pain in Primary Care Settings
Case Chat: Evolving Treatments for Chronic Headache and Migraine
How to Manage an Acute Pain Crisis in Sickle Cell Disease: Practical Recommendations
Occipital Neuralgia: The Importance of Taking a Patient’s Full History
Research Insights: Data Builds the Case for Acupuncture in Pain Management
The Complex Intersection of Pelvic Pain and Mental Health in Women
Treating Amplified Musculoskeletal Pain Syndrome with Photobiomodulation
Utilizing CGRP Antagonists for Non-Migraine Indications

Behavioral Medicine: How to Deliver CBT for Pain in Primary Care Settings

Brief, group-based psychological interventions have the potential to maximize limited clinical resources while providing interpersonal support for patients with chronic pain and reducing the systemic burden on specialty mental health services.

Cognitive behavioral therapy (CBT) for pain management is based on the cognitive behavioral perspective of pain.1 The cognitive behavioral model is grounded in the notion that pain is a complex experience that is influenced by underlying pathophysiology and the patient’s thoughts, feelings, and behaviors (see Figure 1).2 Thus, CBT interventions can work to engage patients in an active coping process aimed at changing maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of their chronic pain.

The American Psychological Association recognizes the long-standing effectiveness of CBT for the treatment of chronic, noncancer pain.3 Traditional CBT has been shown to be highly efficacious, particularly in the treatment of:

More specifically, research has shown that CBT for chronic, noncancer pain:

  • decreases
  • pain intensity9,10
  • pain severity and interference12
  • functional disability4,6
  • catastrophizing13,14
  • evels ofdistress4,9
  • increases readiness to adopt a self-management approach11
  • creates changes in coping15

 

 

Standard Cognitive Behavioral Therapy

CBT is a structured, time-limited, present-focused approach to psychotherapy. It asserts that distorted thinking has a significant, adverse impact on pain symptoms and behaviors, and that there is a reciprocal relationship among thoughts, feelings, and behaviors. CBT aims to help patients first develop awareness of their dysfunctional thinking patterns and maladaptive behaviors. Then, through Socratic questioning and psychoeducation, the patient learns to ask disputing questions in response to dysfunctional, automatic thoughts. Dysfunctional thought patterns are slowly replaced with adaptive, rational thoughts. Rational thoughts in turn result in positive feelings and adaptive behaviors. CBT is traditionally a time-limited intervention comprised of 12 to 16 sessions over 3 to 6 months delivered in specialty care settings.

Some efforts have been made in the healthcare system to reduce patient mental health biases, improve patient outcomes and access to behavioral healthcare, and reduce the systemic burden on specialty mental health services by providing these treatments in primary care. As an example, CBT for chronic pain has been disseminated nationwide by the VA Office of Mental Health Services and National Pain Management Program Office. Unfortunately, evidence suggests that CBT for chronic pain is underutilized in healthcare settings despite its apparent benefits.16 In response, brief psychosocial approaches targeting pain-related disability are ideally suited to address the concerns outlined in more integrated care settings – including primary care, further described below.

Some efforts have been made to reduce mental health stigma, improve access to behavioral healthcare, and reduce the systemic burden on specialty mental health services by providing these treatments in primary care. Brief interventions may make this path easier. (Image: iStock)

 

Brief CBT Interventions Versus Lengthier Therapies

Brief interventions are informed by research that has shown that improvement occurs very early in treatment.17 Practically speaking, brief interventions minimize use of patients’ and providers’ time and allow for greater accessibility to services.  Treatments that require less of a time/length commitment from patients may gain a higher level of engagement and improve retention. 

Brief interventions have demonstrated efficacy compared to lengthier therapies whose effectiveness may be not incremental.18 Brief interventions have also been shown to bring about clinically significant patient improvement,19,20 leading to reduced symptoms, improved functioning, and social integration, in as few as two sessions when delivered in an integrated primary care setting.21

These changes have been shown to be robust and stable over a 2-year follow-up period.22 Furthermore, group-based formats of brief interventions have been found to provide an additional source of support for patients with chronic pain23-25 and significantly reduce wait times for pain management services.26         

Evidence for Brief CBT for Chronic Pain

It is only in the past decade that abbreviated, modular forms of CBT treatment have been developed and demonstrated for use in primary care settings. The earliest mention is found in a 2009 handbook of cognitive behavioral approaches in primary care, which provides patient encounter guidelines, basic skills for evaluation, and lessons in CBT for primary care physicians.27

In 2012, Cully and colleagues published a protocol in an article exploring the implementation of brief CBT in a primary care setting for symptoms of depression and anxiety in a sample of medically ill patients with chronic cardiopulmonary disease.28

In 2019, Beehler and colleagues explored the relative impact of each of six brief CBT for chronic pain (bCBT) treatment modules (30 minutes each) on patient outcomes in primary care to both improve treatment decision-making and inform future research efforts.29 They found that a composite measure of pain intensity and functional limitations (as measured using the Pain, Enjoyment of Life, and General Activity scale, or PEG) showed statistically significant improvements by the third appointment. Pain-related self-efficacy outcomes also showed a similar pattern of improvements.29 Furthermore, the research team assessed patients’ perceptions of the acceptability and utility of the bCBT intervention. Patients’ responses suggest the intervention is viable and acceptable in a primary care setting.30

More recently, Martinson and colleagues examined the effectiveness of a bCBT group (6 sessions, 50 minutes each) for patients in primary care with mixed idiopathic chronicpain conditions. They investigated the impact of treatment on patients engaged in differing levels of opioid medication use.31 Results demonstrated no significant treatment-related differences between patients taking opioids compared to their counterparts. They also found that participation in the treatment group resulted in statistically significant improvement across several variables, including pain symptoms, physical functioning, sleep problems, pain-related anxiety, pain catastrophizing, and depressed mood. They concluded that a bCBT group can be effective in a real-world setting and aligns with the primary care model.

Delivery of CBT by Frontline Providers

The question still remains whether a certain type of professional degree, level of training, or expertise is required to deliver CBT efficaciously to patients with chronic pain. Studies have investigated the delivery of CBT by non-mental health, licensed professionals, including dental hygienists,32 nurses,33 and physical therapists.34 There is also evidence to show that psychologists are more effective than therapists with less training.23,35

Nicholas and colleagues noted that CBT facilitated by interventionalists who were non-psychologists appeared not to be superior to the usual care.23 This finding could be due to a number of different factors, including lack of knowledge about CBT, reimbursement problems, time constraints, and/or patients' reluctance to participate in the intervention. Main and colleagues also highlighted the momentous practical and philosophical shift required of non-psychologists delivering CBT for the treatment of chronic pain.34 Both research teams suggest that gaps in treatment outcomes between psychologists and other licensed professionals can be addressed through further training in CBT.23,34

For example, a mixed group of treatment providers including nurses and physical therapists trained to deliver CBT to a sample of patients with low back pain produced outcomes demonstrating significant patient gains across disability functioning, pain self-efficacy, physical, and mental health.6 Further, these gains were maintained at 3, 6, and 12 months.

A Brief CBT Group Intervention: A Recommended Protocol

Given the research supporting the effectiveness of bCBT group interventions, an experimental intervention was designed and delivered by the author to a sample of patients with chronic pain. The current intervention consisted of four 90-minute sessions, delivered once a week. The pain bCBT group intervention was adapted from a manualized “Treatments That Work” protocol.36

The protocol includes:

  • reviewing with the patients pain education topics, such aschronic pain syndrome and theories of pain
  • introducing cognitive concepts, such as automatic thinkingand cognitive restructuring
  • introducing behavioral strategies, such as relaxation techniques (diaphragmatic breathing, progressive muscle relaxation, and visual imagery), time-based activity pacing, and pleasant activity scheduling
  • revieweing themes related to anger management and stress management as these have been deemed especially important within the veteran population (see Table I).

 

 

Group therapy for chronic pain management has become a common treatment format.37 Using a group format makes the intervention more time efficient for providers and provides a mechanism for patients to learn coping skills from others, helps patients realize they are not alone, and gives them valuable social support.

Methods and Materials

A sample of 45 veterans ranging from 18- to 89-years-old who suffered from chronic pain were recruited from the pain education program at a midwestern VA Medical Center for the Pain bCBT Group. Veterans voluntarily participated in the groups and were free to withdraw at any time. As part of the introduction to the pain bCBT groups, all participants completed quality assurance outcome measures, which included:

  • Pain, Enjoyment of Life, and General Activity scale (PEG) – this scale score is the average of three separate numerical scales, each one ranging from 0 to 10. Individuals rate their pain level concerning three areas: pain (on average), pain interference with enjoyment of life, and interference with general activities over the past week.38
  • Perceived Global Distress (PGD) – this scale is a 10-cm line from 0 to 10, with 0 representing no problems and 10 representing the worst possible situation.39
  • Coping Strategies Questionnaire-Catastrophizing scales (CSQ-CAT) – this score is the sum of the ratings on six statements that measure negative self-statements, catastrophizing thoughts, and ideations about their pain using a 0 to 5 Likert scale.40
  • Chronic PainCoping Inventory-Short Form (CPCI-SF)– this scale produces two scores: one is for illness-focused coping (guarding, resting, and asking for assistance) and another for wellness-focused coping (exercise/ stretching, relaxation, task persistence, seeking social support, and coping self-statements).41 Participants were asked to describe how many days in the past week they used each strategy to manage pain. The scores are the sum of days they used those coping skills.

Of note, measures that assess the outcomes of psychotherapy have the potential to inform quality improvement efforts and bring greater accountability to the delivery of mental health care. Those patients who received the group psychotherapy completed the same set of outcome measures at the end of the intervention to determine whether they experienced any improvements in their symptoms and functioning. Quality assurance data were analyzed with paired samples t-test (one-tailed) using the Data Analysis ToolPak Excel Add-On.

Recommended Protocol: Findings and Discussion

Pain Interference Scores Decreased

Current findings from the above protocol study indicate a significant decrease in pain interference scores as measured by PEG. This finding is consistent with previous research studies investigating the effectiveness of CBT with individuals suffering from chronic pain12 but an inconsistent finding among veterans.14,42

Pain Catastrophizing Decreased

In addition, there was a significant decrease found in pain catastrophizing (maladaptive thinking) scores as measured by CSQ-CAT. This finding is consistent with previous research studies investigating the effectiveness of CBT with veterans suffering from chronic pain.14,42

Increased Coping Behaviors, Pain Global Distress Maintained

A significant increase in wellness-focused coping scores was found at post-intervention compared to pre-intervention as measured by CPCI-SF. This finding is consistent with previous research studies which have found that CBT creates changes in coping.15 These findings are not surprising, as the aim of the CBT intervention is to decrease catastrophizing thoughts and increase wellness-focused behaviors (such as relaxation).

However, the current quality improvement effort did not find significant differences in pain global distress, which is consistent with previous research.14 A potential reason for this finding may be that veterans who suffer from chronic pain may be a unique group of individuals due to the dualism of active duty and civilian life.43

Impact on Frontline Providers in Primary Care

Every day, frontline practitioners in integrated care and primary care settings are tasked with effectively treating and managing complex biopsychosocial symptoms in a growing number of patients with chronic pain. At the same time, they are experiencing an increased need to make services more accessible and to cut down on appointment wait times. Thus, brief biopsychosocial interventions are needed to optimize clinicians’ time without sacrificing outcomes.

Group-based formats such as brief cognitive behavioral therapy (bCBT) have demonstrated the potential to maximize limited resources while providing an additional interpersonal support factor, which has been found to be valuable for patients with chronic pain. The bCBT intervention for chronic pain described herein shows promise for treating the biopsychosocial symptoms of chronic pain in an overburdened healthcare system.

Editor's Note: See a special report on gaps in current mental health screenings in primary care, including overlap with chronic pain disorders, on our sister clinical site Psycom Pro.

More research is needed to better understand the change mechanisms in group-administered bCBT interventions. More research is also needed to explore how bCBT treatment outcomes vary as a function of treatment provider and specific CBT training. Lastly, research investigating the impact of telehealth delivery of bCBT would extend its application, especially within underserved populations.

Practical Takeaways

  • Traditional CBT has been shown to be highly efficacious, particularly in the treatment of several different chronic pain conditions.
  • Abbreviated, modular forms of CBT treatment (bCBT) have been developed and demonstrated for use in primary care settings over the past decade.
  • A bCBT group intervention may be effective in a real-world setting and aligns with the primary care model.
  • CBT requires that non-mental health care providers – such as those in primary care – significantly shift their traditional approach to chronic pain treatment and requires additional, specific training to achieve outcome effectiveness.
  •  Preliminary data suggests that a bCBT group intervention may make significant improvements in pain interference, maladaptive thinking, and coping in the chronic pain population in as few as four sessions.

 

Last updated on: May 14, 2021
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Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
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