Mental Health – Chronic Pain – And Where They Intersect

Mental Health – Chronic Pain – And Where They Intersect

By Ed Coghlan.

Dr. Geralyn Datz is a leading national mental health expert who has contributed to the National Pain Report. She is a chronic pain advocate. Recently, we discussed how her comments on Twitter about cognitive behavioral therapy can benefit the chronic pain community. Here are her comments:

National Pain Report: “We saw your tweet about Cognitive Behavioral Therapy for pain relief – you seem to indicate that workers comp and other insurers are viewing it not only more positively but may also cover it? Would you like to expand?”

Dr. Datz: “Sure.  Psychotherapy as a whole is technically a covered service under workers compensation, and has been for many years. However, the challenge has been that acknowledging the mental health side of medical problems is something that Workers Comp has traditionally been loath to do. There are many reasons for this, but two of the most prominent have to do with the idea that the mind and body are separate, and that psychological suffering from pain, like depression or anxiety as a result of pain, is not in the realm of a “covered treatment”. Therefore, these services were often denied.  The other challenge has been more legal, in that if a psychological disorder is acknowledged in an injured worker, this opens up liability for the insurer.  Thankfully, these trends are really changing and the treatment of the whole person is now becoming an aspiration of many insurers, as well as recognizing that medical problems like chronic pain take a tremendous emotional toll on a person and require specialized treatment. There are more programs and providers now that are specifically focused on injured worker recovery using cognitive behavioral therapy, and insurers that support them.”

National Pain Report: “Explain what CBT is – how it works?”

Dr. Datz: “Cognitive behavioral therapy (CBT) is a specialized form of psychotherapy, talk therapy, that has a very strong evidence base. Basically, it has been shown to outperform many other types of therapy, and reduce symptoms of distress in people with chronic pain. CBT has worked more effectively than opioids in some patients. In short, it is viewed as a treatment that works. Cognitive behavioral therapy involves a working with a person with chronic pain and teaching them how their thoughts, feelings, and pain-related actions, can work for or against the person with pain. Chronic pain, while felt in the body, is experienced in the brain. Over time chronic pain actually rewires the brain in an unhelpful way, and ends up reinforcing itself over and over, which in turn causes the patient to focus on it more, worry about it more, dread it more, change their behaviors in response to it more. This becomes a vicious cycle that causes a lot of physical and emotional suffering. In CBT a pain patient is taught about the physiology of the pain response, how pain is represented in the brain, and how things like stress, anger, sleep disturbance, and anxiety over pain, all make pain worse. The person is then taught techniques for self-calming, tension reduction, and mental techniques which change thinking patterns, and this all helps to turn down the central nervous systems aggressive response to pain.  CBT is considered very effective because research has shown that people who undergo CBT experience considerable relief, and actually have measurable changes in their brain in response to the treatment. Essentially CBT teaches people how to maximize the healing potential of their own brain.

NATIONAL PAIN REPORT: “For folks who can’t pay for it or their healthcare insurer won’t cover it—are there things they can by themselves?”

Dr. Datz: “Of course! There is always hope! I will say that if an insurance plan covers mental health, then they cover CBT. The main issue would be finding a provider who does CBT for chronic pain. That said, there are many helpful self-help resources like Master Your Pain by Jill Fancher PhD (@masteringpain), Less Pain, Fewer Pills by Beth Darnall PhD (@bethdarnall) both of which use these concepts. There is also an excellent self-help book for people with spine pain that is inoperable called Back In Control by Dr David Hanscom (@DrDavidHanscom), which discusses psychologically informed techniques and delves into the neuroscience of pain as well.  I encourage anyone with pain to take advantage of these resources and seek as much help as they can.”

Dr. Datz was the leader of the Southern Pain Society…one of the few mental health leaders to be so honored. Here are some of her prior contributions to the National Pain Report. (http://nationalpainreport.com/?s=geralyn+datz)

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Authored by: Ed Coghlan

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As a chronic pain patient with CRPS for almost 3 years I was finally approved for cognitive therapy through physical therapy. I have one session left. I will say that I feel if this was taught at the earlier stage that it would save a patient a lot of fear by learning about the endocrine system that ties to pain, emotions, and even the brain. Challenging yourself can be a great mind distraction. I definitely feel the struggles within the brain. I don’t feel cognitive therapy can replace medications/opioids at later stages of a disease. To me it has been more of a mind distraction from pain just the same as reading is for me. It doesn’t stop the physical flare ups, the debilitating pain that causes non use of the limbs. It doesn’t stop the cold feeling or color changes from happening and in some cases cognitive therapy can cause more pain by movements that feel OK at the time. I would certainly recommend this therapy for those in their first few months of chronic pain. It is very educating. Thanks for sharing.

Rachel

I am qualified in psychodynamic therapy and I have severe chronic pain. There is no evidence base for CBT the effects last a few months then patients are back where they were. Insurers will like it because it is time limited and relatively cheap. There is an evidence base for psychodynamic therapy and that its effects are lasting. CBT does not account for intelligence levels – it does not work on people at the upper end of the IQ scale, neither does it account for the fact we all have an unconscious which is responsible for over 95 per cent of our thoughts and actions. Patients should be educated there is no mind body split, sadly many professionals also need to know that and practice with that in mind.

Maureen Mollico

I must add a side note here:
BRAVO TO ALL! I am so very proud of you (us!) for these many strong comments which exhibit just how much we suffer, how strong we are in our suffering,
how fervent and serious we are for giving all that we have to get our points across to those who ought to be learning from us…the Chronic Pain Community, and for the stamina we muster up to stand up for ourselves in the midst of severe suffering. I pray for us to be heard and for positive changes.
Red… Thank you for your never ending research and posts on our behalf.
And As always, I say, keep strong ‘WARRIORS’, for that is what you all truly are!
Merry Christmas, huge healing hugs and Forever proud, Maureen Mollico

Byron

I will post again, for the umpteenth time::

Every chronic pain patient needs to be VERY concerned about HR 4482, the Meadows-Renacci “Opioid Abuse Deterrence, Research, and Recovery Act of 2017” https://www.congress.gov/bill/115th-congress/house-bill/4482/committees?r=6 .

Contact your US Representatives, especially members of the Energy & Commerce Committee https://energycommerce.house.gov/about/ and Judiciary Committee https://judiciary.house.gov/wp-content/uploads/2017/12/115th-House-Judiciary-Committee-Updated-120517.pdf .

Ibin

I have dealt with non stop, moderate to severe pain for almost 24 years after two low back surgeries. I am liike many patients that have been “prescribed’ alternative treatment, regardless of the type pain generating issue and I also took the initiative to try alternative pain mangement treatment as my families’ well being and future was at stake including “talking” to two different psychologists. Both told me I could :manage pain: without medication. i actually listened and, attempted to do so.Psychological treatment simply did not achieve…..pain management for me. I was 37 yeras old. We had two sons in college, two automobile payments, a home mortgage and a small construction business of 14 years to own, operate, and save. I “depended” on surgery and was told that about a 70 percent pain level reduction could be achieved so I could continue to earn…..a living. After 3.5 years and two surgeries complete with surgical metal plates and screws were driven into my lower spine vertebra, I realized after surgery recovery time and then some that, only, prescribed medication,physical movement, and a willfull attitude was going to keep my wife and I from bankruptcy. Continued movement was very important as I quickly realized that with moderate mobility I actually felt….better. I accepted that with prescribed medication through a good provider, would I be able to literally, survive. Though some days the lifelong pain was not adequately managed, I did not request a higher dosage of medication. I have been on the same, one, medication without increase of dosage, for the last 6 years. I was previously prescribed several different medication types along with delivery types, i.e., extended relief, for several years until I could generally manage the pain. For the past 6 years. prior to the :guideline: for opioid prescribing physicians, which is in the “best” interest for me and others like me, I have continued to work, with no adverse physiogical or psychological consequences, thankful to be able to remain active, and satisfied with treatment for lifelong pain. Unfortunatley, my dosage was approximately 3 times greater than the now “legal” dosage of the type “morphine equivalnet” medication that I was titrated to, used responsibly, and almost one year ago told that I can no longer be prescribed. The ability to remain active, rely on myself with family support, along with a physician that really gives a damn, about my “com[lete” overall health wellness which for me included, mobility and the ability to remain self sufficient…….was all the psychological :assistance that I need. Alternative treatment has been considered and used yet, my “best” alternative to success with lifelong pain which now :includes further “governing” is still to be found somewhere down the road ? My spine, pain management specialist along with years of different treatments until an overall successful narrative was achieved, no longer is in my best interest.I fully realize that every, each, patient requires different treatment for personal pain management which may or may not include adequate opioid medication… Read more »

Julie C.

Any clinician, absent a Medical Degree under their belt, should truly think twice before touting, “CBT has worked more effectively than opioids in some patients“. And I take even greater offense when this statement is (a) delivered to an audience that is largely made-up of chronic, intractable pain patients and (b) only serves to exacerbate the War Against Pain Patients, especially when the CDC/DEA/PROP is seeking “ammunition” under any rock they can find…

Now in my 40s I have undergone extensive psychoanalysis, learned all of the skills taught under CBT, DBT and MBT, to name a few. I have received treatment using EMDR and the Trauma Resiliency Model. I am not a clinician, “only” a consumer with vast anecdotal experience in the field of behavioral health coupled with chronic physical illness/diseases.

My CBT therapist, specifically, was trained under its founder, Dr. Aaron Beck. Two simple matters of fact that are conveniently omitted from this article: (a) highly skilled, competent, CBT therapists are an extremely rare find and (b), my treatment has never once been covered under my high-cost PPO health insurance.

Has CBT offered me any relief from “my” chronic pain, caused by severe Rheumatoid Arthritis, an incurable autoimmune disease? Not for one second!

Apparently I am not “some patients”.

Further, I forwarded this article to my private Psychiatrist (of 24+ years consecutively). She is also a Director and decades-long tenured Professor in the medical school at UCLA. The ONLY 3 scenarios where she could ever imagine that “CBT has worked more effectively than opioids in some patients“ is IF “some patients” were exclusively (a) recovering addicts who must maintain sobriety, (b) any cancer and/or chronic pain patients whose organs may be too vulnerable to tolerate synthetic opioid analgesics and lastly (c) simply anyone who has an outright allergy.

So where does this leave the hundreds of millions of chronic pain patients that do NOT fall into one of these 3 acutely limited categories while fending off an anti-opioid government that will immediately manipulate the blank statement: “CBT has worked more effectively than opioids in some patients“ so that it fits their agenda as evidence that all opioids are evil?!

I hate to even think about it.

Respectfully, and in my humble, personal opinion, the content in this article is not helping, it is only furthering the War Against Chronic Pain Patients especially in light of the current climate many are suffering today.

I spent one week in two separate pain clinics, in which I was able to master the ability to slow down my heart rate and relax every part of my body, from my toes to the top of my head. This is biofeedback and relaxation techniques. In all honesty, I continue to practice them and I do use them when I am in the middle of a long episode of severe pain or, especially, when I am experiencing spikes of the most severe and horrific of my pain. In my case, the claim that CBT “has worked better than opioids in some patients” is quite a stretch. Those patients are not suffering from chronic, intractable pain, that’s for sure. But when I am suffering from my worst pain, I do find that I tense up and get very anxious about when it will ease off because I never know when that will happen. So I use these techniques, and sometimes they work well enough for me to sleep, which is the ultimate escape from severe pain. But reducing the pain? Uh, no. That has never happened. And I’ve been using these techniques since 1995.

Tracy Bryan

“TALKING IT OUT” will not treat chronic pain , leaving the patient pain free.

As a non-physician patient advocate, I would reinforce the message offered by StevefromMA.

The US Agency for Healthcare Research Quality is now circulating a draft report for “Noninvasive, Nonpharmacological Treatment for Chronic Pain: A Systematic Review”. Cognitive Behavioral Therapy is one of this class of techniques. Over 4500 published trials were reviewed, and boiled down to ~245 studies that met rigorous criteria for the review. Only 16 studies of CBT were of sufficient quality that they survived the down-selection process for any of the five classes of pain disorders that were studied.

A careful reading of the AHRQ report reveals the following

As a key message of the report: “psychological therapies such as cognitive-behavioral therapy may improve function or pain outcomes for specific chronic pain conditions”

However, the following was also quoted in the summary of findings: “This review updates our previous review on low back pain by incorporating new evidence on nonpharmacological treatments for chronic low back pain. The current review is based on primary literature and gives more attention to describing effects over the short, intermediate, and long terms. Consistent with the prior review, we identified small to moderate effects of exercise, yoga, various psychological therapies, acupuncture, spinal manipulation, and low-level laser therapy. This review suggests that most effects are at short or intermediate term; long-term data are sparse.”

However, supporting details also do not hold out a lot of promise:

“Fibromyalgia: Function improved slightly in the short term with cognitive behavioral therapy (CBT)… Small functional improvement continued into the intermediate term … (Strength of Evidence: Low)”

“Osteoarthritis of the Knee: One fair quality and one poor quality study of pain coping skills training and cognitive behavioral training versus usual care found no differences in function.”

=========================

Thus I would reinforce Steve’s reservation. Exhaustive AHRQ review of the literature found no consistent evidence that CBT can serve as a substitute for opioid analgesics in people for whom medical therapy is otherwise successful. Fair disclosure: this was my own reading of the report, not an explicit finding by the authors.

connie

I totally agree with Steve! While it may be helpful to some like anything else there’s no one size fits all treatment for chronic pain. Some of us ONLY get relief from opiates

After twice trying CBT, I found it to be useless. Perhaps a person that has just started down the pain road may find it helpful. For me, I had already been in a pain state for a long time (centralized) and listening to waterfalls and thinking nice thoughts does nothing. Opioids are much more valuable to me.

Bob Schubring

This is a valuable discussion in many ways. Pain is disabling when it interferes with major activities of daily living. Overcoming pain is at least partly a learning process, of learning not to make the pain worse when one goes about one’s normal activities. Our brains have a pain center, the periaqueductal grey matter (PAG), that sorts out pain signals and forwards some of them to our conscious awareness, where they inform us of reinjury or new injury.

Amplifying on StevefromMA’s point: Since every living person already has endogenous morphine in our brains, we all are on opioid-class pain treatment, 100% of the time. The only difference between endogenous morphine and prescribed opioids, is that the patient whose pain far exceeds what his/her endogenous morphine can relieve, can get greater relief from supplemental prescribed opioids, when the doctor understands that this treatment is necessary and provides the prescription.

That said, Geralyn alludes to an important point, too. The PAG informs us when we re-injure ourselves. Learning to move, in ways that don’t re-injure the existing injury, is essential to our recovery. Getting the proper dose of medication to provide that level of pain control, along with other aids such as canes, crutches, braces, and assistive devices, requires that the doctor actually communicate with the patient and determine what happens when the patient tries to get out of bed or otherwise tries to move. @DrDavidHanscom has written extensively about his experience with Major Depressive Disorder and co-morbid back pain…it’s worth spending a day or two reading what he has written about this, but crudely summarizing, Dr Hanscom was so angry about so many things that his muscles were tense all the time and he constantly was suffering the pain of various pulled muscles while also battling Major Depression. For Dr Hanscom, treating and relieving his depression made his muscles less tense and led to fewer re-injuries and reduced pain over the long term. Over the short term, he too needed pain relief on occasion while he learned to manage his depression.

Not asking patients what they feel, and why, is a guarantee of failed treatment. The patient knows their own pain better than anybody. Insurers who objected to the time spent by primary care physicians in taking a history, were mistaken. Rushing the patient through the appointment, results in further complications and more money spent, not less. Primary care doctors need to apply CBT techniques and engage with their patients to learn the details of how they got hurt, where they hurt now, and how that pain is interfering with major activities of daily living. Doing that will result in smarter prescribing, wiser use of consulting specialists’ time, and empowered patients. Less communication results in worse care, more complications, slower recovery, and higher costs. Insurers need to learn that fact and live with it.

Steven Smith

As chronic, intractable pain sufferers that now have their medication severely limited, CBT does not take the place of the medication that we had just six months ago.Would a person with diabetes have his insulin cut in half? Would we eliminate radiation and chemotherapy as too dangerous for the cancer patient? These two examples are just what the pain sufferer faces! If CBT works for you then may I suggest it is the placebo effect. Consider yourself blessed. Thank you for your well meaning article.

Linda

How utterly absurd to think for one minute that therapy will assist with the underlying condition. It has only the possibility of helping with the lessening of anxiety, certain depression, and stress, that may be CAUSED by the actual pain.

I speak from informed, in-depth experience. The desire is STRONG OUT THERE to want to tie in the world’s of various reasons for chronic pain, to this kind of therapy. It may help a patient who is not in biting pain, learn that their pain is causing them stress and anxiety and thereby “planting the seed”,of knowing something else may or may not be wrong with them, but now that they know something ELSE is wrong with them, the collaborative effort will no doubt be pointed in that direction, one of therapy, and avoiding, dodging a bullet, for the physician to say nope, no opiod pain relief for you!, you need to go to mental health for your pain!

And what gets tangled up and completely twisted in mix? In the brains of our doctors? Is them losing sight, REALLY LOSING SIGHT, that hey, that mental health you’ve been convinced is what your patient needs to treat their chronic pain? YOU FORGOT SOMETHING: The mental health treatment doesn’t treat the underlying reason for the pain remember?

Oh yes. That’s the part where they just turn, well, stupid. They forgot to keep in their mind FIRST, mental health was for what the pain might be causing.

And honestly, the blinders are truly on these days because of these guidelines, or personal profit, or just having tunnel vision.

A person in chronic pain already knows that trying to get things done during the day is causing them stress. Because if not for the pain we’d have the radio on, broom handle as a microphone, singing into it as we flitted around the house dancing and cleaning and happy and stressors-free. Which we do not. Because of pain.

If this therapy helps those who have lessor pain than others, lessen your pain, because the body and mind are still able to let that truly work for you, take it and run! And hopefully never need to look back

Iam with StevefromMA,most ,and that means most ppl can’t convince their mind of anything,much less that they don’t have pain.Iam sure there will be a lot of mind games going on now for us to try.Are these really the alternative therapies that the CDC was thinking about when they wrote the guidelines?No what am I thinking,of course they wanted us all to go to rehab.lol.

Steven Smith

Works just like the Easter Bunny, tooth fairy and Peter Pan. Please people, get real. The biggest risk for mental illness in the Pain Sufferer Cadre is the lack of medicine that he or she had just one year ago.

Maureen Mollico

I agree with Steve. Once again, a comment such as that and also that is ‘has worked more effectively than opioids in some patients’ is truly not in regard to the moderate to severe lifetime suffering chronic pain person, in my opinion.
Most of us suffer greatly due to diseases or traumatic injury to our bodies.
Over my 26 years in pain… I have been exposed to CBT and have surely explored it (out of pocket $) and it certainly has opened my eyes to the possibility that emotional issues due to my conditions may heighten my pain levels, at times, BUT it does not negate the fact that my conditions will forever continue to override the work I’ve done with CBT.
I’ve learned a lot about it and do my best to control the emotional impact on my pain levels, whenever need be. It can be a good tool to use.
But, Chronic Pain is not that easy to control, regardless.

Rick

CBT does help me to a degree but I’d have to agree with SteveMA, pls don’t conflate with a substitute for opiates!!!
CBT definitely helped me learn to ‘try easier’ as I’m so motivated by anger to heal my CRPS that I’d never slow my fight or flight.

Penny R. Rosen, M A , MLS

Really??? Are you suffering from CRPS?? Many times the patient bonds with thetgerapu therapist/doctor and, because the
patient doesn’t want to disappoint, he or she will say what
they think the caregiver wants to hear…which is NOT always
the truth. Think about it!

StevefromMA

As a clinical psychologist with forty years experience, I’m certainly quite familiar with cognitive therapy. While I have found it useful for some patients with severe chronic pain, both personally and professionally, I think it is overreaching to say that it is an opioid-class pain treatment for many.