Nonpharmacologic Treatment of Chronic Pain—A Critical Domains Approach

Once a new habit of increased physical activity has been established, the strategy of branching out into new physical activities (or even more formal exercise) is usually more successful especially if they are enjoyable and feasible (ie, affordable, not too time consuming). The need to engage in more physical activity could be the impetus to encourage Lisa to do more activities with her children—walking to the park, flying a kite, and exploring the science museum are all activities that can provide physical, emotional and social benefits simultaneously.

• What interventions are helpful in addressing psychiatric comorbidity?

Psychological Distress

Comorbidity with mood and anxiety disorders is often observed and complicates treatment in patients with chronic pain states [21–23]. Patients with centralized pain conditions like fibromyalgia tend to have even higher rates of psychiatric comorbidity than those with other pain conditions like arthritis alone [24–26]. While estimates vary widely, we have recently reported that 36.2% of patients evaluated in our tertiary care setting meet case criteria for depression [27]. Such psychiatric comorbidity has been shown to be associated with increased pain, worse functioning, higher costs and increased use of opioids [27–30]. Further, suicidal ideation is common in chronic pain populations, especially those with depression and anxiety, and should be carefully evaluated if suspected [31]. The presence of psychiatric comorbidity takes a toll on the individual and society. One study found that pain patients with comorbid depression utilized twice the resources that other patients without depression utilized [32]. Perhaps the most troubling element is that psychiatric comorbidity is too often not adequately addressed in medical settings [33].

Assessing for depression using a standardized measure like the PHQ-9 [34] or anxiety using the GAD-7 [35] can provide a sense of the severity of the psychiatric symptoms. More severe forms of depression and anxiety may require referral, but more mild depressive and/or anxiety symptoms may be treated by the medical personnel the patient already knows and trusts. Nonpharmacologic strategies that can be used to address depression, anxiety, and even pain in chronic pain populations include cognitive-behavioral therapy, exercise/physical activity, regulating sleep and behavioral activation (ie, getting patients engaged with valued activities, social support).

Perhaps the most effective strategy to address depression, anxiety, and pain in chronic pain populations is cognitive-behavioral therapy (CBT) [36–38]. CBT for pain consists of both cognitive and behavioral therapy interventions. Cognitive therapy proposes that modifying maladaptive thoughts will result in changes in emotions and behavior [39]. Thus, errors in thinking like catastrophizing, overgeneralizing, and minimizing positives are confronted and changed to more realistic and helpful thoughts. This results in less emotional distress and fewer self-defeating behaviors. In cognitive therapy for chronic pain, catastrophic thoughts such as “My pain is terrible and nothing I do helps” are replaced by more adaptive thoughts like “Although my pain is severe, there still are a few things I can do to make it a little better.” Several behavioral techniques are also employed such as behavioral activation (getting patients moving again), activity pacing (not overdoing it on days patients feel good and remaining active on days they feel bad), sleep hygiene (identifying then changing behaviors know to disrupt sleep), and relaxation skills (eg, breathing, imagery, progressive muscle relaxation). Meta-analyses have shown that CBT has empirical support for its effectiveness in treating patients with chronic pain [40,41].