Consensus on Pain and Insomnia

Representatives from medicine and psychology endorsed a biopsychosocial approach for treating pain and insomnia over the traditionally used biomedical model at a recent consensus conference held at the National Institutes of Health.

At the technology assessment conference October 16-18 titled “Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia,” a 12-member panel examined the practicality and effectiveness of integrating behavioral and relaxation approaches into traditional biomedical interventions to improve the treatment of chronic pain and insomnia.

“The suffering and disability from these disorders result in a heavy burden for individual patients, their families, and their communities,” concluded the panel in a draft of the conference statement. “There is also a burden to the nation in terms of billions of dollars lost as a consequence of functional impairment. To date, conventional medical and surgical approaches have failed- at considerable expense- to adequately address these problems.”

Convened by the Office of Alternative Medicine and the Office of Medical Applications of Research, the conference was cosponsored by agencies including the National Institute of Mental Health, the National Institute on Aging, the National Cancer Institute, and the National Institute of Nursing Research. Panel members included experts in the fields of family medicine, epidemiology, public health, health policy, nursing, psychiatry and psychology.

Among the psychologists on the panel was APS Charter Fellow Stanley Krippner.

“There has been some hesitation to use procedures that demand specialized training and that do not primarily employ medication,” said Krippner. “I think that one of the effects of the conference will be to stimulate more hospitals, more managed care groups, more private practitioners, and more clinics to start using these approaches. I personally think they are underused at the present time and I think that we now have the data demonstrating their effectiveness.”

The panel’s conclusions were based on two days of presentations and the review of extensive literature on the subject. While the panel agreed that available data indicated that behavioral and relaxation techniques are effective interventions, it also agreed that further study is needed. According to the conference statement, “the state of the art of the methodologies in this field indicates a need for thoughtful interpretation of the findings as well as an urgency to translate them into programs of health care delivery.”

The Path to Successful Treatment

In examining the effectiveness of behavioral techniques in treating chronic pain and insomnia, the panel ‘s analyses addressed five questions:

• What behavioral and relaxation approaches are used for conditions such as chronic pain and insomnia?

• How successful are these approaches?

• How do these approaches work?

• Are there barriers to the appropriate integration of these approaches into health care?

• What are the significant issues for future research and application?

The most frequently used techniques discussed were relaxation, meditation, hypnosis, biofeedback, and cognitive-behavioral therapy. The evidence of the success of each technique in treating chronic pain and insomnia was ranked as strong, moderate, fair, or weak. The evidence was strong for both relaxation and hypnosis in treating chronic pain, but the panel agreed that for any given patient, one approach may be more effective than another. For alleviating insomnia, relaxation and biofeedback were found to be effective, but, as with chronic pain, the panel concluded that more evaluation is needed.

“One barrier to the integration of behavioral and relaxation techniques in standard medical care has been the emphasis on the biomedical model as a basis of medical education,” read the statement. “The biomedical model defines disease in anatomic and pathophysiologic terms. Expansion to a biopsychosocial model would increase emphasis on a patient’s experience of disease and balance the anatomic/ physiologic needs of patients with their psychosocial needs. For example, of six factors identified to correlate with treatment failures of low back pain, all are psychosocial factors. The integration of behavioral and relaxation therapies with conventional medical procedures is necessary for successful treatment of such conditions.”

The panel cited certain issues that needed future research and determination including: establishing reliable and standardized outcomes; studying the influence of race, gender, religion, and socioeconomic status on treatment; determining how and when behavioral and relaxation techniques should be used; and investigating advances in neurobiological sciences and psychoneuroimmunology.

Just a Beginning

Krippner characterized the conference as a starting platform in the combination of pharmacological and non-pharmacological techniques for more effective treatment of chronic pain and insomnia, as well as potentially many other conditions.

“Behavioral medicine has been around for a long time but, in my opinion, it has not been adequately utilized,” he said. “You take a look at editorials in some of the medical journals over the last 10 to 15 years and you see the statement coming up time and time again that a person’s thoughts and emotions have very little, if any, effect on the treatment of medical problems. While that conclusion could have been justified at one time, it cannot be justified any longer.”

According to APS Charter Fellow Richard Bootzin, who has researched the application of stimulus control principles to the treatment of insomnia, the integration of behavior and relaxation techniques could provide more long term, success than traditional treatments.

“I think it is a real plus that there was this technology conference to bring this to the attention of people,” he said. “I think the literature, with regard to behavioral techniques on insomnia, justifies it and there is a lot to draw on. I think you will see both procedures being used more as alternatives to medication. My guess would be that they probably can be integrated to the extent that medications may work faster initially, but cognitive and behavioral procedures will have a longer lasting effect.”

Krippner said in order for behavioral and relaxation techniques to become both an effective and widely used part of treatment, some measures will have to be taken including integrating training programs in medical and psychological programs, and publishing supportive research in medical journals. He cited the recent articles and news reports continuing the popularity of alternative medicine.

“People had no idea that Americans, for better or for worse, were spending so much money on alternative procedures,” he said. “Now we’ve got some documentation that there is a family of procedures that we call ‘behavioral and relaxation approaches’ that are effective for many people and many problems.”

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