PSPI Live is a series of 60-minute live events highlighting recent or upcoming articles published in the APS journal Psychological Science in the Public Interest (PSPI). Speakers include the authors, policymakers, or representatives of important stakeholder groups.
Chronic pain has broad negative consequences beyond causing physical suffering. It also affects well-being, emotional functioning, and overall quality of life, and its high prevalence—combined with its undertreatment and societal burden—makes it a serious public-health concern. What prevents the broader use of psychological interventions for treating chronic pain? In a PSPI Live webinar on June 28, four experts explored the issues related to the application and uptake of psychological interventions for the management of chronic pain in real-world settings.
The speakers were Mary A. Driscoll, PhD, and Robert D. Kerns, PhD, coauthors of “Psychological Interventions for the Treatment of Chronic Pain in Adults” (Driscoll, Edwards, Becker, Kaptchuk, & Kerns, 2021); Shari M. Ling, MD, deputy chief medical officer of the Centers for Medicare & Medicaid Services (CMS) in its Center for Clinical Standards and Quality; and Christin Veasley, cofounder and director of the Chronic Pain Research Alliance and an advocate for increased awareness of chronic pain and its consequences.
After introductions from Andy DeSoto, PhD, director of government relations at APS, and APS Fellow Nora Newcombe, PhD (Temple University), the editor of PSPI, Driscoll and Kerns summarized their 2021 article, which addressed the disconnect between evidence for the effectiveness of several psychological interventions and their availability and use in treatment in the real world.
In that article, Driscoll and colleagues aimed to:
- Summarize contemporary perspectives on chronic pain;
- Review theoretical and empirical foundations for psychological intervention for chronic pain;
- Review the evidence for specific interventions and evaluate the factors that may influence their effectiveness;
- Identify scientific and clinical gaps that limit the uptake of these interventions; and
- Discuss strategies to advance the science and practice of psychological interventions for chronic pain.
Research has indicated that several psychological factors play a role in chronic pain—not only what causes it but also what perpetuates and exacerbates it. Psychological interventions, in turn, can be used to treat it. “The demand for psychological interventions for chronic pain is largely fueled by pain’s role as a staggering public-health problem,” said Driscoll in the webinar. Moreover, she noted, the National Pain Strategy, published by the U.S. Department of Health and Human Services in 2016, asserted that biopsychosocial factors are relevant for chronic pain and called for integrated evidence-based, multimodal, and interdisciplinary treatments that address these factors and include psychological interventions. In their article, Driscoll and colleagues reviewed several evidence-based interventions that aim to attenuate psychological risk and/or augment psychological protective factors. These interventions include cognitive-behavioral therapy, which identifies and seeks to change maladaptive thoughts about pain that cause distress and unhelpful behaviors, such as isolation and withdrawal, and promotes the development of helpful behavioral coping strategies (e.g., relaxation).
Reiterating recommendations from the 2021 article, Driscoll argued that health-care plans should include psychological interventions, patients should be empowered to engage with whichever intervention appeals to their interests and needs, and providers should feel confident that recommending psychological interventions to patients will improve pain-related outcomes and quality of life.
Kerns spoke about barriers to accessing psychological interventions for chronic pain, including patients not recognizing their benefits, providers misunderstanding their rationales and mechanisms, and insurance coverage not being adequate to ensure timely and equitable access to them.
Outlining future directions to improve the use of psychological interventions for chronic pain, Kerns suggested studying the implications of comorbidities for the interventions’ effectiveness, optimizing existing interventions, and establishing the effectiveness of newer interventions and in special populations. Mobile technologies, he added, should be evaluated for delivering psychological interventions.
The policy perspective: Research can inform programs and policies
Ling, a geriatrician, gerontologist, internist, and rheumatologist, discussed the importance of research to inform programs and policies involving chronic pain. She noted that the CMS Behavioral Health Strategy, which includes some of the barriers that Kerns mentioned, drew from interviews with people who have lived experience of pain and people who provide care services to beneficiaries living with acute or chronic pain. These interviews identified evidentiary gaps as well as the importance of an integrative, comprehensive, multimodal approach to care that can include cognitive interventions.
Curious to learn more about CMS rules and policies? Ling noted that all are published in the Federal Register, a daily compilation of a wide variety of proposals and other documents issued by U.S. federal entities, and that citizens are free to comment on CMS proposals. “And the CMS is obliged to listen and [to] acknowledge each and every comment,” and to consider adapting its proposals in response to better “meet the needs and the intent of the original proposal,” she added.
The lived experience: Inclusion and language matter
Veasley has advocated for the acceleration of rigorous multidisciplinary pain research and the translation of research findings into meaningful change for people with chronic pain—with a special emphasis on pain conditions that are common in women and frequently co-occur.
Speaking from her personal experience as someone who has lived with chronic pain for 30 years, Veasley explored two impediments to the adoption of evidence-based psychological interventions in clinical settings: lack of stakeholder engagement in the planning and execution of research and the language used when talking about psychological interventions.
To address the first impediment, Veasley called for the early inclusion of end users, including patients with chronic pain and their caregivers, in planning studies. “It’s really beneficial to bring people in from the beginning and get their perspectives on how they will use that data” to inform their decisions, she said. (Relatedly, Ling noted that Medicare considers interventions only when supporting studies include the relevant beneficiary populations.)
Regarding the second impediment, Veasley noted the importance of language in educating patients about how biological, psychological, and social factors affect the brain and its health. Language can also help patients understand that the suggestion of psychological interventions in no way means that patients are to blame for their pain. This last point is particularly important because many chronic pain patients must wait a long time before being diagnosed and are told, either directly or indirectly, that “their pain is in their head, or they’re making it up, or they’re malingering,” explained Veasley.
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