Beyond invasive therapy: Chronic nonmalignant pain and the cognitive-behavioral perspective

The complexity of pain involves sensory stimulation and an intricate combination of psychological factors. Chronic nonmalignant pain (CLAMP) is pain over time which is directly influenced by affective, cognitive, and behavioral components (Turk & Rudy, 1986).

The role of psychological factors affecting patient outcomes clearly must be evaluated during patient assessment. This process will allow a quality clinical experience based on a multidisciplinary assessment.

Patients with chronic nonmalignant pain differ from other patients. Potentially, within their psyche, there are underlying traits predisposing these patients to a chronic pain state.

In the past, research drove pain assessment as a solely sensory experience. The development of sophisticated surgical interventions ablated pain pathways and potent analgesic therapy was used to treat pain. Sadly, this unidimensional assessment process proved unsatisfactory in the treatment of chronic nonmalignant pain (Tollison, 1989).

In the mid-1960s, this changed dramatically with Melzack and the onset of the Gate Control Theory. Psychological factors influencing pain were viewed as part of an integrative process of pain evaluation (Melzack & Casey, 1968).

Another point of view came from Fordyce's model which described pain more from a subjective report evaluated from the patient's subjective pain experience (Melzack & Wall, 1983). This presentation evaluated "pain behaviors" which communicated pain without words. This nonverbal presentation received positive reinforcement from family, friends, and health care providers.

Fordyce's operant conditioning model defined pain as a perception, not a pain stimuli. This was observable in the low-back pain population and affected the outcomes achieved (Fordyce, 1976).

Turk and his colleagues further advanced the process and discussed a comprehensive intervention model with a multitude of pain syndromes (Kerns, Turk, Holzman, & Rudy, 1986).

Paul Arnstein conducted research published in 2000. It clearly supported the positive effect of a cognitive-behavioral program on chronic pain. Coping skills improved significantly with a decline in disability and pain levels continuing beyond 1 year (Arnstein, 2000).

It is important to make certain assumptions regarding cognitive-behavioral treatment approaches to chronic nonmalignant pain (see Table 1).

It must be assumed that CNMP behavior is influenced by the individual and his/her surroundings. The barriers to integration of these techniques lie in the culture for health care providers in their clinical care setting. The argument of subjective versus objective evidence in evaluation is key. Chronic pain patients were demoralized and labeled as "frequent flyers" in the health care system.

Pain perception from the patient's perspective is a dynamic process involving many factors. These factors are categorized as physiological, psychological, and behavioral-functional. Suffering, disability, and selfimage affect the whole picture. Assessment parameters must include:

* History and physical exam with specific neurologic focus

* Objective information

* Psychosocial and behavioral data with testing (MMPI, McGill Questionnaire)

This process better defines classifications of patients and suggested treatment modalities related to diagnosis.

Psychological Testing

Once the physiological and objective evaluation is complete, the components of psychological and behavioral assessment must begin. Evaluation via testing as well as education regarding patient knowledge of these components is critical. Skills must be acquired to promote self-help/wellness techniques to provide strategies to assist in the pain treatment process. The patient is not looked at as a helpless victim but as interactive in the treatment techniques. Critical to the cognitive-- behavioral approach are therapy sessions with homework via support groups or one-on-one therapy. This helps the patient and the support system better interact and treat pain issues.

Depression is the most common co-morbid diagnosis in the CNMP population: it is diagnosed in greater than 50% of patients in the primary care setting.

In addition, depression is under-recognized and under-treated. The history and physical exam need to include questions regarding depression, routine screening, and treatment.

Suicidal patients have seen their primary providers close to the actual suicide attempt (Barnes, Gatchel, Mayer, & Barnett). Clearly this issue needs to be treated to prevent serious ramifications such as suicide.

Treatment includes antidepressant medication such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI) in conjunction with pain treatment. Side effect profiles are important to monitor and patient education is critical to long-term compliance.

Some of the medications used are:

Amitriptyline (Elavil(R)). Atalapram (Celexa(R)). Clonazepam (Klonopin(R)). Paroretine (Paxil(R)). Sertraline (Zoloft(R)). Venlafaxine (Effexor(R))