Teaching Patients to Regulate Emotions May Ease Chronic Pain

April 09, 2019

MILWAUKEE — A novel primary care–based behavioral intervention designed to recalibrate the negative emotions that can perpetuate chronic pain is beneficial for older adults with varying levels of cognitive function, new research suggests.

Preliminary results from a randomized controlled trial of 100 older patients showed that those who underwent the 8-week PATH-Pain program had greater improvement in pain intensity and depressive symptom scores compared with their peers who received education only.

Key components of PATH-Pain include psycho-education about the relationship between pain and emotion, problem solving techniques to address everyday situations, behavioral activation, the scheduling of pleasant activities, and skills training for emotion regulation.

"To our knowledge, this is the first study to use emotion regulation techniques as a self-management tool for older adults with chronic noncancer pain with a wide range of cognitive functioning," co-investigator Dimitris N. Kiosses, PhD, associate professor of psychology in clinical psychiatry at the Weill Cornell Institute of Geriatric Psychiatry, New York City, told Medscape Medical News.

"The take-home message is that using strategies that help patients decrease negative emotions while simultaneously increase their positive emotions, which is what most positive psychology interventions attempt to do, is a practical pain management approach," Kiosses said.

The findings were presented here at the American Pain Society (APS) 2019 meeting.

Dearth of Behavioral Approaches

"Our goal with this therapy is to reduce negative emotions associated with pain and pain-related disability and treatments and other problems that routinely affect quality of life in older adults," co-investigator Cary Reid, MD, PhD, associate professor of medicine and director of the Cornell Translational Research Institute on Pain in Later Life, Cornell University College of Human Ecology, New York City, told meeting attendees when presenting the study results.

"We also seek to increase positive emotions and shift attention during experiences of pain away from pain to help reduce intensity," Reid said.

Following the 8 weekly sessions, which can be delivered by a trained social worker and include one group educational session, there are four booster sessions delivered monthly to help sustain the improvements.

The intervention has been evaluated primarily in older adults with intact cognition, but the researchers sought to evaluate the effects in those with a broader range of cognitive function.

"Behavioral approaches are needed that can produce meaningful treatment effects and are appropriate for individuals with wide ranges of cognitive functioning because we know that those with mild to moderate cognitive impairments tend to have the more negative emotions with pain," Reid said.

For the study, which was funded by the National Institutes of Health, 100 patients (mean age, 75.5 years) were recruited at a primary care practice in New York City serving older adults. All had noncancer-related pain present on most days for 3 or more months and a Montreal Cognitive Assessment (MoCA) score of 16 or above.

The majority (80%) of participants were women, 68% were non-Hispanic white, and the mean pain intensity on a scale of 0 to 10 was 4.7.

While 44 patients had intact cognition (MoCA score, 26 or higher), as many as 56 had mild to moderate cognitive impairment (MoCA score, 16 to 25). There were no significant differences in the measures between the treatment and control groups.

The therapy was delivered at the primary care practice for 74.3% of patients and by telephone for 25.7%; 73% of patients completed all eight of the treatment sessions.

Decreased Pain Intensity

Short-term data available on patients from the week 5 and week 10 time points in the 24-week trial showed significant improvements in pain intensity for the treatment group. The score was 3.9 at both 5 weeks and 10 weeks compared to 4.7 at baseline (P = .04).

On the other hand, after adjusting for age, gender, and marital status, the control group showed an increase in pain intensity — from 4.5 at baseline to 4.8 at weeks 5 and 10.

Pain-related disability, as assessed on the Roland Morris Disability Questionnaire (RMDQ, range 0 - 24), also declined in the PATH-Pain group at 5 weeks (10.9) and 10 weeks (10.1) compared with baseline (12.9; P = .003). There was no significant adjusted change from the baseline RMDQ score of 13.8 in the control group.

Furthermore, improvements in depression, as assessed on the Montgomery-Åsberg Depression Rating Scale (MADRS, range 0 - 60) were found in the treatment group at weeks 5 (9.6) and 10 (9.2) compared with baseline (11.7; P = .009). Again, the control group showed no significant differences from baseline (11.3).

Further 10-week findings showed that 37% of the patients in the treatment group vs 26% in the control group had a 30% or greater reduction in pain intensity, 41% vs 20% had a 2.5 point reduction in RMDQ score, and 32% vs 18% had a MADRS score of 7 or lower.

Although those differences did not reach statistical significance, Kiosses noted that that may have been a result of the small number of patients included in the study.

"We believe that the effects on reducing pain-related disability are real and not due to chance — and that the failure to achieve significance, using a 2.5 threshold cut off score, is due to a small sample size," he said.

The majority of patients in the study had back pain (68%), followed by osteoarthritis (45%), neuropathic pain disorder (32%), and other pain types (24%), such as fibromyalgia, headache, or pelvic pain. The patients had a mean of 2.6 types of pain.

Approximately 21.6% of patients in the study were taking opioids at the time of enrollment, 25.3% were taking anticonvulsants, 24.4% were taking oral nonsteroidal anti-inflammatory drugs, 16.8% were taking acetaminophen, and 15.6% were taking a serotonin–norepinephrine reuptake inhibitor.

Different From Standard CBT

Kiosses noted that the strategies that appeared to be most effective included attentional deployment, or the shifting of attention from the negative emotions and pain; behavioral activation; and a change of perspective.

A notable study limitation was that use of cotherapies besides the use of pain medication were not assessed. Also, some of the participants in the treatment group expressed difficulty in remembering to employ the emotion regulation techniques in everyday life.

"Methods to promote routine adoption of the techniques are needed," Kiosses said.

The findings are particularly important as researchers struggle to find nonpharmacological treatments that are effective for pain, the researchers add.

"Nonpharmacological approaches are strongly recommended, but treatment effects in this population tend to be small to moderate," Reid noted.

The PATH-Pain approach is unique from standard cognitive behavioral therapy (CBT) because it focuses specifically on emotional responses.

"We believe that focusing primarily on emotions rather than on one's thoughts, like CBT, is easier for this population," Reid said.

Furthermore, the program is designed to be provided in the primary care setting, where most older adults present with chronic pain, he added.

Reid consulted on a Johnson & Johnson pain-related project in 2018. Kiosses has disclosed no relevant financial relationships.

American Pain Society (APS) 2019. Presented April 4, 2019.

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