I recently attended the annual meeting of the American Pain Society, in Pittsburgh, PA. Aside from eating at “Primanti Bros,” where they put the fries and coleslaw inside each and every delicious sandwich, I also learned a few things about chronic pain.
Robert R. Edwards, Ph.D., Associate Professor at Brigham & Women’s Hospital, reviewed several effective treatments (aside from meds) for persistent pain; CBT, physical therapy, exercise, mindfulness meditation, and acupuncture, among others. He noted that catastrophizing and its correlates (negative expectations, pessimism, rumination, magnification) all play an important role in perpetuating pain. In medication outcome studies, a patient’s catastrophizing (as well as that of their significant other) accounts for as much as one-third of the variance (Toth et al., 2014). But Edwards emphasized, in contrast to what many believe, catastrophizing is not a symptom of depression. They are statistically independent. Amidst concerns over opioid use, chronic pain patients with these factors (referred to as “negative affectivity”) experience only about half as much symptom improvement as those with positive affectivity, and have about five times the rate of misuse (Campbell et al., 2015). While many therapists understand and expect CBT to help reduce catastrophizing, Edwards said exercise, yoga, and acupuncture – by themselves – have also been shown to reduce pain through a reduction in catastrophizing (Combs & Thorn, 2015). Finally, mindfulness-based stress reduction (MBSR) – along with yoga – can be as effective as CBT in helping chronic low back pain patients achieve higher functionality (Cherkin et al., 2016).
Patrick H. Finan, Ph.D., Assistant Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine, addressed how many chronic pain patients deviate from their opioid prescription: 25% by some estimates (Vowles et al., 2015). Finan noted that it is not just patients who are to blame. While chronic pain base rates are similar state-to-state, prescribing patterns differ significantly, indicating “up stream” factors such as prescriber behaviors and distribution strategy. He reported on his own research suggesting that patients on long-acting opioids (e.g., MS-contin, oxycontin, methadone, fentanyl patch) vary their daily use about half as much as those on short-acting opioids. However, patients on all types of pain meds will adjust their pattern of medication use based on their emotional experience during the day.
Eric L. Garland, Ph.D., Associate Dean for Research, University of Utah College of Social Work discussed his development of a type of MBSR technique he calls Mindfulness-Oriented Recovery Enhancement (MORE). In MORE, he applies mindfulness, cognitive reappraisal, and savoring. Savoring has been included because Garland found that in his experiments, chronic pain patients attend more quickly to negative stimuli than to neutral or positive. Evidence from fMRI studies suggests those with chronic pain end up with applicable brain circuits that have become wired for making these quick connections. In short, he suggested, if you can train them to attend to and savor the positive, and to reinterpret the negative as neutral, their overall functioning improves. For example: a patient who labels their pain as “awful” or “terrible” is encouraged to deliberately, repeatedly focus on the more neutral sensory aspects such as the temperature, the tingling sensations, and the spaces between the sensations. Garland said that eight sessions of MORE was effective in smokers as well as addicted “gamers.” See Garland et al., 2017 for more.
One very intriguing presentation was made by Rosalind Picard, Sc.D., on the use of wearables to measure electro-dermal activity (EDA, also known as Galvanic Skin Response). Professor Picard is founder and director of MIT’s Affective Computing Research Group, as well as co-founder of Empatica, Inc., a wearables and analytics company. She noted that EDA wearables are already being used to help predict seizures in epileptics (Poh et al., 2012), stress in pre-verbal infants, and “meltdowns” in autistics, whom may appear calm on the outside while roiling with emotion internally. The skin, she noted, is innervated entirely by the sympathetic nervous system, whereas the heart is connected to it and the parasympathetic nervous system. Picard said that the current technology can detect subtle changes: one’s palms don’t need to sweat in order to indicate stress. Since EDA rises as pain increases, she hopes that patients may be able to use EDA to help pick the right times to take their medications or engage in other interventions. Incidentally, she noted that EDA spikes just before the needle pierces your skin during injections, supporting the finding that a large part of pain is negative anticipation.
Marom Bikson, Ph.D., Professor of Biomedical Engineering, City College of the City University of New York was one of several who presented on Transcranial direct current stimulation (tDCS). Bikson said that while tDCS has been around since the 1960s, recent advances in integration have put us in the U.S. on the cusp of having devices that can be sent home with patients to help them with pain. tDCS devices for take-home use are available in Canada and the EU. However, here there are still lingering safety concerns among some in the FDA. What’s interesting is that there are several cosmetic devices – such as those that purport to reduce wrinkles – that have more power than those proposed for tDCS, but which do not require FDA approval since they do not address any medical condition. (No, despite what you may think, wrinkles are NOT a medical condition.) Bikson noted that tDCS can reduce migraine pain intensity by a third (DaSilva et al., 2012) and that it is now simple and safe enough for patients to use at home with minimal supervision by providers via tele-health applications. Presently, the main federal regulatory concerns for tDCS are the reliability of electrodes, their positioning, limiting the dose, and ensuring patient compliance (Fregni et al., 2015). Bikson concluded by emphasizing that tDCS should be considered safe in that there are now over 200,000 recorded sessions among over 10,000 patients with no serious side-effects outside of tingling, itchiness or redness at the placement sites. (For more on a company seeking to register their tDCS device with the FDA for research and treatment purposes see.)
On the last day of the APS meeting, Thomas Novotny, MD, MPH, Deputy Assistant Secretary for Health (Science and Medicine) at the Health and Humans Services spoke briefly about the National Pain Strategy (NPS). He noted that under the Trump administration they are looking at all the old goals and plans. With regard to the opioid epidemic, he is hopeful that a balance can be struck between concerns for the deaths associated with opioid overdose and their potential analgesic effects.
Secretary Novotny indicated there remained unanswered questions about exactly who is dying from opioid overuse. Were they previously misusing or using ever-increasing dosages, or at increasing frequency? Or is anyone who uses opioids at risk? He hopes the NPS will address these issues, such as by improving how opioids are prescribed, making them safer (such as through development of abuse-deterrent or non-addictive formulations), or by designing alternatives, like newer cannabinoids that come without the oft-reported cognitive impairment side-effect. Or, he said, the NPS may be helpful in advocating for insurers to reimburse for complimentary and alternative treatments so that we are not totally reliant on opioids. (For more on the NPS see here). For more on the HHS Opioid Initiative see here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
David J. Reynolds, Ph.D., is the Deployment Behavioral Health Psychologist at Malcolm Grow Medical Clinics and Surgery Center (MGMCSC) located on Joint Base Andrews, Maryland.
Campbell, C. M., Buenaver, L. F., Finan, P., Bounds, S. C., Redding, M., McCauley, L., Robinson, M., Edwards, R. R., & Smith, M. T. (2015). Sleep, pain catastrophizing, and central sensitization in knee osteoarthritis patients with and without insomnia. Arthritis Care Research, 67(10), 1387-96. doi:10.1002/acr.22609
Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., Hansen, K. E., & Turner, J.A. (2016). Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain a randomized clinical trial. JAMA, 315(12), 1240-1249. doi:10.1001/jama.2016.2323
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