The following is an article co-authored by NJ Spine Institute psychologist Dr. Steven Weitz on treatment of chronic pain.  It appeared in the March, 2000 issue of New Jersey Medicine.

Treatment of Chronic Pain Syndrome
Steven E. Weitz,^1,2 Ph.D., Philip H. Witt, Ph.D.,³ & Daniel P. Greenfield, M.D., M.P.H.⁴

Abstract:
We address the psychological and pharmacologic treatment of chronic pain syndrome.  The commonly used pain management protocols in each area are described.  Psychological management procedures that are covered include relaxation methods, patient education, cognitive therapy techniques, and patient compliance enhancement.  Concerning pharmacologic management, the World Health Organization ladder analgesic guidelines are described, as well as adjunct medications, such as antidepressants, anxiolytics, and hypnotics.

Introduction:
Chronic pain is a debilitating and demoralizing condition.  Unable to obtain relief, patients frequently become clinically depressed and anxious.  Family members suffer as well, since the impact of chronic pain syndrome affects all who are close to the patient.  A vicious cycle ensues between chronic physical pain and psychological dysfunction, where each condition exacerbates the other.  Comprehensive treatment of chronic pain syndrome requires that both its psychological and pharmacologic management needs be addressed.  In this article, we review the typical psychological and psychiatric treatments for chronic pain.

Psychological Management:
Certain key elements are present in virtually all chronic pain management treatment protocols.  Relaxation training in its many variants – including meditation, mindfulness training, and biofeedback training – is a core element in treating chronic pain.¹  It has long been accepted that there is a relationship between pain and anxiety in that anxiety both increases the experienced intensity of pain and causes chronic physical tension, itself a pain generator.  Consequently, relaxation training is among the most commonly prescribed psychological treatment methods for chronic pain syndrome.  Relaxation training is relatively easy to implement.  The physician, psychologist, or trained nursing staff can provide a guided relaxation induction in the office.  The induction can be tailored to the patient’s particular needs, perhaps focusing upon a physical area in which the patient experiences tension or pain.  The relaxation induction can be audiotaped, and the patient can practice by listening to the tape at home.  Research indicates that conscientious home practice can result in lowered levels of both experienced anxiety and experienced pain.

One frequent complicating factor in chronic pain cases is sleep disturbance.  Insomnia and non-restorative sleep wear patients down, both physically and psychologically.  As such, chronic pain patients often benefit from instruction in proper behavioral sleep hygiene.^2,3  Patients should be counseled to regulate their sleep cycle by keeping the same bedtime and awakening time each day.  To strengthen the association between sleep behavior and the bed, activity in the bed should be restricted to sleeping and sex.  For the same reason, if patients lie in bed awake for more than 20 minutes, they should leave the bed, returning only when they feel sleepy.

Evening alcohol consumption as well as eating meals or large snacks near bedtime should be avoided.  Caffeine consumption should be reduced or eliminated.  Patients should refrain from daytime naps unless unavoidable, in which case they should not nap after 2PM.   And while mid-day physical exercise can facilitate sleep, patients should not exercise within two hours of bedtime.

Educating patients and their families about the nature of chronic pain is a core component of treatment.  First, the healthcare professional must help patients appreciate the distinction between acute and chronic pain.⁴  Acute pain refers to a physiologic response to a noxious stimulus, associated typically with actual tissue damage, over which the patient has little or no control.⁵  In contrast, chronic pain, following Bonica, persists beyond the usual course of a given acute disease or is associated with a chronic pathological process.⁶  Chronic pain, unlike acute pain, has a clear psychological component that is subject to patient control by application of cognitive and behavioral pain management techniques.  Additionally, family members require guidance in their efforts to support the chronic pain patient.  On the one hand, their sympathy and emotional nurturance can diminish the patient's sense of isolation and depression.  On the other hand, too much accommodation to pain-related disability behavior can unintentionally undermine the patient's efforts to be as independent and self-sufficient as possible.  Both the patient and the family should be taught to view chronic pain as a problem exacerbated by passivity and the expectation that doctors are the only source of relief via medication or surgery.  They must understand that the patient can acquire a meaningful measure of control over pain by becoming the doctor's active partner in pain management.

During the last 20 years, cognitive-behavioral therapy has found the strongest empirical support for managing aversive experiences, ranging from depression to anxiety to chronic pain.  A key tenant of cognitive-behavioral therapy is that one’s thoughts (i.e., cognitions) have a strong controlling influence on emotions, behavior, and experience.  By identifying and altering maladaptive thoughts, people can change the nature of their experience.⁷

Chronic pain patients are prone to thinking about their conditions in catastrophic terms (e.g. "I can't stand this any longer."; "There's nothing I can do about my condition.  I must have surgery.")  Such thinking leads to helplessness and despair.  Patients benefit by learning to manage their catastrophic thoughts effectively.  They can be coached both to develop more realistic expectations and to rationally dispute their catastrophic cognitions.  Developing realistic expectations is critical.  Many chronic pain patients have debilitating physical conditions that prevent them from – even under the best of circumstances – achieving a level of mobility they once enjoyed.  For treatment to succeed, patients need to grieve their loss of bodily integrity and be helped to accept their condition without capitulating to it.

Chronic pain patients frequently restrict their physical activity in the belief that activity will inevitably exacerbate their pain.  An insidious process ensues; chronic pain leads to anxiety about engaging in physical activity, which ultimately results in physical deconditioning, a problem which itself complicates the chronic pain syndrome.⁸  The treating healthcare professional must interrupt this cycle by encouraging the chronic pain patient, under proper supervision, gradually to increase his or her physical activity.

The healthcare professional should pay specific attention to enhancing the patient’s treatment protocol compliance.  An extensive literature regarding treatment protocol compliance has developed over the past decade.  Some major principles include:^9,10

1. Use trained para-professional staff to provide educational modules for patients.  Chronic pain patients can readily be taught the difference between acute and chronic pain, the general principles of relaxation training and pain management, and similar matters by a trained and supervised para-professional or even, in part, through video.  The supervising physician or psychologist can consult on difficult cases or to resolve impasses in treatment.
2. Provide a menu of choices for the patient.  Patients cooperate better with treatment protocols when they play a role in choosing their protocol.  Discussing options from which the patient can choose increases the patient’s sense of ownership and commitment to the treatment plan.
3. Understand the patient’s thinking about his or her disorder.  Patients frequently have unarticulated, unexpressed theories of their disorders.  Without understanding the patient’s private explanation for the chronic pain syndrome, the healthcare professional and patient may end up working at cross-purposes.

During the initial phase of treatment, the psychologist should carefully assess any preexisting psychological or interpersonal problems that contribute to or are aggravated by the chronic pain syndrome.  For example, a family history is often useful for assessing how both the marital family and the family of origin have dealt with similar illnesses in the past.  Certain preexisting psychological problems – such as a history of depression or anxiety disorders – can be aggravated by the experience of chronic pain, and a careful history regarding these matters should be taken.  Finally, the presence of a personal injury lawsuit or disability claim can be a complicating factor in treatment, slowing recovery by presenting incentives to remain ill.

Certain psychological disorders, especially anxiety and depression, are so frequently co-morbid with a chronic pain syndrome that a careful assessment will always evaluate for their presence.  It is not at all unusual to find a chronic pain patient presenting with a clinically significant depression, since a loss of functioning associated with chronic pain can so easily precipitate a depression.  Dysphoria, anhedonia, hopelessness, cognitive difficulties, loss of libido, crying spells, and suicidal ideation are depressive symptoms that frequently accompany a chronic pain syndrome.  Consequently, the instigation of reasonable hope, the cultivation of self-efficacy, and the adoption of an action plan are essential with chronic pain patients.  Cognitive-behavior therapy and interpersonal therapy are the two empirically supported treatments of choice for such difficulties.

Pharmacologic Management:
Long recognized as the mainstay treatment modality of physicians in managing chronic pain, pharmacotherapy remains an important element in an interdisciplinary approach to effective treatment.  Medications for chronic pain may be divided into two types: (1) Analgesic agents (to treat the pain itself); (2) Psychotropic agents (such as antidepressants and antianxiety agents, to treat concomitant psychiatric / psychological conditions).¹¹

Analgesic medications for treating chronic pain on a maintenance basis may be effectively prescribed at one of three levels, according to the "Three-Step Analgesic Ladder" model of the World Health Organization (WHO).¹²  The WHO ladder begins with relatively low doses of low-potency analgesic medications and progresses systematically and incrementally to higher doses of more potent medications (specifically, opioids) as pain worsens.  The three steps involve use of non-opioid analgesic medications with or without co-analgesic agents (such as NSAID’s) in Step 1; lower-potency opioids with or without non-opiod co-analgesic agents as pain persists or increases to mild-to-moderate levels, in Step 2; and finally, high-potency opioids with or without non-opioid co-analgesic agents as pain persists or increases to moderate-to-severe levels, in Step 3.¹³  In all of these steps, the treating clinician must realize and accept that chronic pain by definition does not go away.^14,15  Prescribing should be on an ongoing, maintenance basis at a sufficiently high dose level, whatever WHO Step is involved, to treat the patient’s chronic pain effectively.  While use of opioids remains controversial, we recommend that physicians follow the WHO ladder guidelines, prescribing adequate medication at each step.

Adjunct psychotropic medications are also effective in managing chronic pain syndromes.  Two classes of these medication for the treatment of two prevalent associated sets of symptoms deserve mention.  Antidepressants, such as tricyclics (such as Elavil® (Amitryptyline), Tofranil® (Imipramine)) and selective serotonin reuptake inhibitors ("SSRI’s," such as Prozac® (Fluoxetine), Zoloft® (Sertraline), Paxil® (Paroxetine), and Effexor® (Venlafaxine))¹⁶ may be useful for the pharmacologic treatment of depression in patients with chronic pain syndrome.  Antidepressants are especially indicated with those patients with vegetative, or biological, symptoms of depression, including sleep disturbances (early morning awakening , delayed sleep onset, broken sleep, and other variants), anorexia, reduced energy level, anhedonia, and diminished libido.  Anxiolytics, similarly, may be useful both in treating daytime anxiety and primary nighttime insomnia (that is, insomnia not secondary to depression).  The benzodiazepines (on a time-limited basis)¹⁷ and BuSparâ (Buspirone) are the most widely prescribed of these agents, and may be prescribed during the day (for daytime anxiety) or at night (as a hypnotic agent).  The particular anxiolytic can be selected for such desired pharmacologic and pharmacokinetic properties as rapidity of onset, duration of action, or accumulation (or non-accumulation) of active metabolites.¹⁸  Two non-benzodiazapine hypnotics, Ambienâ (Zolpidem) and Sonataâ (Zaleplon), are particularly useful to assist sleep, given their rapid onset and short-half lives, resulting in little or no grogginess upon awakening.

Conclusion:
Since chronic pain syndrome can be a refractory disorder to treat, a multidisciplinary approach, including pharmacologic and psychological interventions, is frequently required.  Pharmacologic treatment has been used for decades with chronic pain treatment, and presently detailed guidelines are available for its use, although controversy still exits regarding opioid use.  Psychological approaches have gained increasing empirical support in recent years, particularly those approaches including relaxation training, cognitive therapy, and treatment compliance enhancement.  Physicians would be well advised to consider both treatment modalities in treating chronic pain syndrome to ensure their patients receive the highest level of care possible.


¹ Steven E. Weitz, Ph.D., Principal in Associates in Psychological Services, P.A., Somerville, NJ & Consulting Psychologist at The New Jersey Spine Institute, Bedminster, NJ.
² Correspondence should be addressed to Steven E. Weitz, Ph.D., Associates in Psychological Services, P.A., 25 N. Doughty Avenue, Somerville, NJ 08876.
³ Philip H. Witt, Ph.D., Principal in Associates in Psychological Services, P.A., Somerville, NJ; Clinical Assistant Professor in the Department of Psychiatry, Robert Wood Johnson Medical School – UMDNJ, Piscataway, NJ; Visiting Lecturer at the Graduate School of Applied and Professional Psychology, Piscataway, NJ.
⁴ Independent practice, Millburn, NJ; Clinical Faculty of Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY; Clinical Faculty of Seton Hall University School of Graduate Medical Education/New Jersey Neuroscience Institute, South Orange, NJ.


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