Optimal Cancer Pain Management Means Understanding Pain Psychology

Interview with Dr Beth Darnall

Lidia Schapira, MD

Disclosures

July 30, 2018

Editor's Note:
The opioid crisis has had a significant impact on opioid access for patients; this year saw the largest annual decline in opioid prescriptions in 25 years. And as part of this decline, cancer patients and survivors have also been significantly affected by more restrictive prescribing habits.

In this interview, Lidia Schapira, MD, an associate professor of medicine at Stanford University School of Medicine, talks with her colleague Beth Darnall, PhD, about the psychology of pain, particularly among cancer patients, including basic behavioral and cognitive interventions for patients who are experiencing pain.

Dr Darnall is a clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine.

Pain Psychology

Lidia Schapira, MD: How should clinicians working with cancer patients think about pain?

Beth Darnall, PhD: One of the most important things for clinicians to appreciate is that pain is defined as both a negative sensory and emotional experience. And recognizing that definition, psychology is integral to the experience of pain. Emotions, thoughts, and whatever may be affecting the moment are going to influence our experience of pain. When we would ask patients to give us a number, a "pain score," that we used to quantify pain, that self-reported number is necessarily subjective, and much of the person's life goes into that number. When we appreciate the highly influential role of psychology in the experience of pain, we have the opportunity to treat pain better.

Rather than treating pain purely as a number, the opportunity exists for us to then further assess the patient. We can assess how the patient is experiencing pain, the thoughts they have associated with pain, the emotional experience they associate with the experience of pain, their belief about the pain, and what it means in the context of their condition and in the context of cancer. Those data that we collect around the individual's psychological experience reveal opportunities for us to apply low-risk pain treatments that are actually going to allow patients to gain better control over their experience of pain and the distress that it's causing them.

Helping Patients Control Their Pain: Low-Risk Strategies 

Schapira: When you talk about "low-risk pain treatments," what exactly do you have in mind?

We want to help patients be able to reduce their own pain and suffering as much as possible, not to the exclusion of medication.

Darnall: I'm a pain psychologist, so I consider pain from behavioral and psychological perspectives. We are not passive recipients of a pain experience; we are constantly participating with our pain. The attention we give pain—what we attribute to pain and our feelings of control or helplessness around pain—can either help or contribute to its worsening. Low-risk pain strategies involve helping patients feel and be in more control over their thoughts, their emotions, or the meaning that they are getting from their pain. This is fundamentally a psychological behavioral self-management strategy that allows patients to have control over the "volume dial" of pain, either turning it up or turning it down.

We want to help patients be able to reduce their own pain and suffering as much as possible, not to the exclusion of medication when medication is deemed appropriate. Science shows us that applying these low-risk and evidence-based psychological approaches contribute to medical treatments working better for patients.

We can use strategies to help patients who are highly reactive to pain and have a lot of fear around their pain. We can equip them with relaxation strategies so that they have a fundamental understanding and gain the ability to calm their nervous system in the face of pain and distress. We can work with the individual to really allow them to understand how some of their thoughts may be unhelpful and unwittingly contributing to their suffering. We can help patients apply techniques to extinguish some of those thoughts and to cultivate patterns of thoughts that are adaptive and help them steer their brain toward pain relief.

There is clear science behind cognitive-behavioral strategies and treatments to help the mind and body in the context of pain[1] and help cultivate a nervous system that is primed for relief. It is a disservice to give patients a pill bottle only, when additional low-risk relief exists. But again, it's not to the exclusion of medicine. If we only give patients a pill bottle, then we are missing the opportunity to empower them to best control their own pain and symptoms. We want to set our patients up for success for living, because this is a long-range situation. We're not just interested in helping them feel better in the moment; we want to set them up with skills for a lifetime.

Schapira: Is this similar to what we learned decades ago about using a relaxation response for stress?

Darnall: The science goes back decades and decades. Essentially, we train the nervous system. Relaxation responses counteract these negative mind-body responses that are known to amplify pain. We teach our patients self-soothing skills that they can use in the moment, not only to help themselves feel better but to help extinguish some of those negative thoughts over time. Science on cognitive-behavioral strategies has been available for decades. Literally 30 years of science supports the efficacy of these techniques within the context of pain. The more recent literature on neuroimaging[2] teaches us that these skills have the ability not only to change brain functioning, but change the structure of the brain in just a course of weeks, so that patients' brains are optimized for pain relief rather than for pain and suffering.

Treating the Family System

Schapira: I find that caregivers or loving family members may get in the way of the patient's ability to manage pain in the ways you suggest. Sometimes the patient may be led to take a pill or call the doctor because there's so much distress in their circle of caregivers. How do psychological interventions address the feelings of loving and well-meaning caregivers?

To create the most healing environment for the individual, it's important to consider and address the stress and anxiety of those around them.

Darnall: Great question and great point. In the pediatric realm, we know that children's pain levels and their functioning are heavily influenced by the parents' distress levels. When parents catastrophize their child's pain, which is defined as focusing on the worst-case scenario, fearing the pain worsening, or feeling helpless about pain, those children also catastrophize their pain and tend to have more pain and disability. Humans are influenced by their environment. In adults, we're not just treating the individual who has the medical condition, pain, or cancer. We need to focus on treating the family system, because the individual with the medical condition is going to be highly influenced by their environment, including the stress and the anxiety of their loved ones.

To create the most healing environment for the individual, it's important to consider and address the stress and anxiety of those around them. For this reason, I developed a 2-hour pain psychology class[3] for individuals who have chronic pain of any type. It could be any type of ongoing pain. Attendees learn the most important information skills that they can use immediately to begin providing themselves with psychological pain relief. They learn to calm their own nervous system. They learn how to extinguish unhelpful thoughts. They learn how to begin cultivating a pain relief mindset and how to self-soothe in the long run.

I strongly encourage attendees to bring family members or friends with them to this class—ideally the most important person in their life—because that gives us the opportunity to provide the caregiver or the loved one a similar plan to help them self-soothe their own distress about their loved ones' medical condition. We can also provide the loved one or caregiver a fundamental understanding of the importance of these skills so that they can encourage the patient to use them.

Coming to the class in and of itself is not going to change a person's life. It's the daily application of the information and skills that is going to help rewire their nervous system over time. Humans need a lot of support and encouragement to continue with those types of daily plans.

Pain Catastrophizing

Schapira: In your writing and scholarly work, you have used the term "pain catastrophizing" to denote the associations and negative feelings that are often triggered by unpleasant painful sensations.

Darnall: The term "pain catastrophizing" actually arose in the late 1980s and is probably one of the best-studied constructs within the context of pain. It's a psychological construct, and it's defined as magnification or illumination of feelings of helplessness about pain. This can occur while the patient is currently experiencing pain, but it can also occur when an individual is considering future pain. You don't even have to have pain in the moment to be catastrophizing. If patients have chronic pain or even just a painful medical condition, they can be worrying and catastrophizing about pain they think they will experience tomorrow.

These are some examples of how a person could begin to engage in some catastrophizing around future pain.

  • "What if I have a bad pain day tomorrow and I have to cancel the outing with my friends? I already feel guilty about how my medical condition has affected this relationship. What if it never gets any better?"

  • "My pain is terrible, and there's nothing I can do."

Literature and science have brought the concept and construct of pain catastrophizing to the forefront of pain treatment, because the scientific literature has revealed it to be one of the most important prognostic indicators for pain outcomes of all types, whether acute, postsurgical, or ongoing chronic pain. It has an incredibly influential role on pain intensity in the moment; response to pain treatment; trajectory of pain; recovery from pain; and chronification, a long-standing pain condition that is intractable or unresponsive to pain treatment.

I am not suggesting that everybody who has persistent pain is at fault for their pain. It is simply that the science tells us that how we think and feel about pain has a very large impact on the trajectory of the pain. Focusing on this psychological construct and treating it early on in the process allows patients to cultivate a mindset of pain relief, so that they are most likely to have the best response to their cancer treatments going forward.

Help for Cancer Survivors

Schapira: A large number of cancer survivors still have pain, even a year or two after treatment. Can these interventions be used to harness the power of the mind to help these patients manage their physical symptoms?

Darnall: Absolutely. Every step of the way, there is a wonderful opportunity for us to optimize our psychology and nervous system functioning so that it's working to our advantage. When I work with clinicians, I recommend to assess these factors on day one, whether patients are coming in soon after a diagnosis, whether on active treatment, or whether they are living their lives post-treatment. Wherever you are on the continuum of cancer care, there are fresh opportunities to examine an individual's psychology and optimize the power of mindset for health and healing.

You can administer the Pain Catastrophizing Scale any time, much like you can assess other factors, such as anxiety or depression. And the more that we bring psychology into the primary treatment of each patient, the better served that patient is going to be. We can no longer afford to separate psychology from patient management, because it's so powerfully influential on each patient's response to medical treatments and so highly predictive of future needs.

These psychological strategies are not helping patients simply cope with their medical conditions. They actually can alter the trajectory of the medical condition itself.

Let's say we have a patient or an individual who has pain and a lot of anxiety about their pain. They have a negative pain mindset or pain catastrophizing. This person has pain due to a clear medical condition, but they don't know the right information and skills to be able to calm their nervous system and self-soothe. They are unwittingly amplifying their own pain and suffering simply because they don't have that skill set. Thus, their pain is increasing, and they are being prescribed more and more opioid medication and prescribed more and more treatments for pain.

But we are missing this low-hanging fruit, where we can help the patient suffer less by applying some of these low-risk behavioral treatments that are really targeting the underlying problem. We can no longer afford to consider psychology as something on the side or as an "alternative" treatment, or to just think of it as referring a patient for "coping skills."

These psychological strategies are not helping patients simply cope with their medical conditions. They actually can alter the trajectory of the medical condition itself. Thinking of the strategies and the psychological treatments as primary treatments will serve patients, and all of us, better. Patients will be more receptive to psychological treatments because they will understand that they are part of the primary medical treatment.

Identifying Opportunities

Schapira: For clinicians who have patients with such illnesses as cancer but are not trained in psychological techniques and interviewing, what questions could they ask to try to get at this experience of pain and maybe identify opportunities to discuss psychological repercussions? How can they open up the dialogue in that direction with the patient?

Darnall: For clinicians, it can be less about asking questions and more about giving information to all patients. It is vitally important for clinicians, even nonpsychologists, to educate patients about the role of psychology and the experience and treatment of pain. This powerful information needs to come from a medical provider. A physician can say to a patient, "Psychology is part of the definition of pain, and for that reason, we want to be sure that we are recognizing the full range of factors that influence the pain that you are experiencing. This is the best science. I want to give you some information and resources so that you can learn more and begin applying some of these low-risk evidence-based methods. I will also give you some tools so that you can start treating your pain, not to the exclusion of the medication, but in a way that targets the pain from all angles, because we know that that works best."

Then, if you suspect that a person has heightened distress about pain, you can administer a measure such as the Pain Catastrophizing Scale,[4,5] a very simple questionnaire. The results can provide the clinician with information about whether referral to a skilled clinician is necessary, or whether to reflect back to the patient and say, "It's clear that you are experiencing a lot of distress about your pain, so I'm going to prescribe some reading and a brief video to you so that you can learn more about this and what you can do to help yourself feel better."

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