Behavioral treatments are commonly employed in conjunction with medical and rehabilitation modalities to optimally manage chronic pain. Unfortunately, while the importance of addressing psychosocial factors and increasing pain self-management is widely recognized as being crucial to successful outcomes, too often, behavioral treatment options are limited or absent in the overall care plan. Further, even when such approaches may be available, factors such as patient motivation or setting-specific limitations may interfere with implementation. Thus, clinicians and researchers are increasingly seeking pain management approaches that are scalable and that can be deployed in a short timeframe.
While there is limited literature regarding the optimal dose of behavioral interventions for pain, brief treatments may be helpful in a variety of ways. Evidence suggests that options such as cognitive behavioral therapy (CBT) for pain are underutilized,¹ thus treatments that require less commitment by patients may garner a higher level of engagement and retention. More desirable options may require less time in sessions or offer technology-based platforms that are highly accessible and flexible. Primary care or inpatient medical settings (eg, perioperative), in particular, often call for therapies that are time-efficient due to limitations around the mode of delivery and competing healthcare needs. Shorter-lasting interventions may be easier to implement and, therefore, present less of a burden to individual providers and patients as well as healthcare systems at large.
In addition, treatment that requires less initial investment may serve the important purpose of priming patients for more intensive care. Even when clinically indicated, it is not unusual for patients to be resistant or ambivalent to engaging in more time-intensive treatments. Introducing some of the foundational elements of behavioral pain medicine through brief options may facilitate openness to other needed treatments. There are a limited number of brief behavioral interventions available for chronic pain treatment, but several with promising data have recently emerged, as described below.
Increasing CBT Access in Primary Care Settings
Since 2012, the Department of Veterans Affairs (VA) has trained hundreds of clinicians in its full CBT for Chronic Pain (CBT-CP) evidence-based protocol and therapist manual.² The need was evident, however, for an abbreviated option that could better serve those providers integrated in primary care settings. In 2018, Gregory P. Beehler, PhD, associate director for research at the VA Center for Integrated Healthcare, led the effort to develop a manual that reduced the number of sessions from 11 to 6 with several key differences.3 Specifically, brief CBT-CP implements 30-minute modules with the premise that an evaluation has already occurred and established that the intervention is appropriate. The first and last modules are anchored, but the order of delivery for the others is flexible, based on patient and provider preference and need. Dr. Beehler and his team conducted a clinical demonstration project of Brief CBT-CP which revealed promising results; patients (n = 118) showed statistically significant improvements in pain-related activity interference and self-efficacy.⁴ Information from patients and providers indicated high satisfaction and suggested a decrease in the number of modules used. A randomized clinical trial (RCT) is currently underway to formally assess the feasibility of the VA’s Brief CBT-CP.
Another investigator, Lisa Miller-Matero, PhD, psychologist at the Henry Ford Health System in Detroit, MI, is examining an integrated eclectic behavioral intervention for primary care, offering a unique combination of different behavioral options. A small feasibility trial assisted in honing the protocol by soliciting feedback from patients and providers.⁵ Dr. Miller-Matero is evaluating the efficacy of five 60-minute sessions that include mindfulness as well as cognitive behavioral and acceptance-based therapeutic approaches. This novel integration of various evidence-based components into a single protocol, shaped with the input of healthcare professionals and patients in the primary care setting, may offer another helpful option as a first-line treatment.⁶
Digital and Single-Session Behavioral Therapies
Beth Darnall, PhD, associate professor of anesthesiology, perioperative, pain medicine, and psychiatry & behavioral sciences at Stanford University, has introduced two brief treatments to optimize the use of behavioral pain medicine. My Surgical Success (MSS) offers a fully automated, online self-management treatment for surgical patients, with a goal of maximizing treatment outcomes. Dr. Darnall and her team completed an RCT with women undergoing breast surgery (n = 68) and found benefits for the MSS group, including briefer duration of postoperative opioid use.⁷ Another RCT to be completed later this year is exploring the use of MSS with orthopedic trauma surgery patients.
A second ultra-brief option is a single, two-hour behavioral pain medicine class. Focused on pain catastrophizing, a pilot study found feasibility and preliminary efficacy for the approach, as well as large effect sizes for reducing pain catastrophizing at 4 weeks post-treatment (see also this issue’s Mental Health column on catastrophizing and malingering).⁸ The single-session class is now the subject of an NIH-funded, 3-arm RCT that will complete enrollment later this year.⁹ Stanford University will begin to offer certification workshops for clinicians who wish to administer the two-hour class and embed it into their healthcare systems.
More Access = More Relief
While additional data is forthcoming regarding these approaches, what is known suggests the promising potential for offering briefer approaches across the continuum of pain care. This availability is particularly relevant in the changing healthcare landscape, one that necessitates improved connection with behavioral medicine for pain. Implementing such options more widely is likely to decrease barriers to access and enhance the early availability of behavioral principles in a patient’s pain journey. Briefer options may also play a significant role in providing accurate messaging about chronic pain to increase patient understanding and appreciation of the biopsychosocial nature of pain, facilitate greater uptake of essential behavioral strategies, and minimize pain chronification and suffering.
When facilitating behavioral medicine:
Address early and often: Recognize the importance of self-managed, behavioral strategies from the very first visit.
Refer when possible: If there is a clinician with behavioral pain medicine expertise in your practice setting or community, enlist their support.
Take small steps: Brief treatment options highlight the many strategies that can be implemented now.
Connect with tech: Many apps, videos, and websites can help patients learn about chronic pain and implement self-management approaches.