The cornerstone of a unified approach to chronic pain syndromes is a comprehensive behavioral program. This is necessary to identify and eliminate pain reinforcers, to decrease medication use, and to use effectively those positive reinforcers that shift the focus from the pain. It is critical that the patient be made a partner in the effort to manage and function better in the setting of ongoing pain symptoms. The clinician must shift from the idea of biomedical cure to ongoing care of the patient. The patient should agree to discuss the pain only with the clinician and not with family members; this tends to stabilize the patient’s personal life, since the family is usually tired of the subject. At the beginning of treatment, the patient should be assigned self-help tasks graded up to maximal activity as a means of positive reinforcement. The tasks should not exceed capability. The patient can also be asked to keep a self-rating chart to log accomplishments, so that progress can be measured and remembered. Instruct the patient to record degrees of pain on a self-rating scale in relation to various situations and mental attitudes so that similar circumstances can be avoided or modified.
Avoid positive reinforcers for pain such as marked sympathy and attention to pain. Emphasize a positive response to productive activities, which remove the focus of attention from the pain. Activity is also desensitizing, since the patient learns to tolerate increasing activity levels.
Biofeedback techniques (see Somatic Symptom Disorders, above) and hypnosis have been successful in ameliorating some pain syndromes. Hypnosis tends to be most effective in patients with a high level of denial, who are more responsive to suggestion. Hypnosis can be used to lessen anxiety, alter perception of the length of time that pain is experienced, and encourage relaxation. Mindfulness-based stress reduction programs have been useful in helping individuals develop an enhanced capacity to live a higher quality life with persistent pain.
A single clinician in charge of the comprehensive treatment approach is the highest priority. Consultations as indicated and technical procedures done by others are appropriate, but the care of the patient should remain in the hands of the primary clinician. Referrals should not be allowed to raise the patient’s hopes unrealistically or to become a way for the clinician to reject the case. The attitude of the clinician should be one of honesty, interest, and hopefulness—not for a cure but for control of pain and improved function. If the patient manifests opioid addiction, detoxification may be an early treatment goal.
Medical management of chronic pain is addressed in Chapter 5. The harms of opioids generally outweigh the benefits in chronic pain management. A fixed schedule lessens the conditioning effects of these medications. SNRIs (eg, venlafaxine, milnacipran, and duloxetine) and TCAs (eg, nortriptyline) in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes. Both duloxetine and milnacipran are approved for the treatment of fibromyalgia; duloxetine is also indicated in chronic pain conditions. The antidepressants impact the endogenous analgesic pathways independent of their effects on depression. In general, the SNRIs tend to be safer in overdose than the TCAs (although venlafaxine may be more arrhythmogenic in overdose than other SRNIs but less than TCAs); suicidality is often an important consideration in treating patients with chronic pain syndromes. Gabapentin and pregabalin, anticonvulsants with possible applications in the treatment of anxiety disorders, have been shown to be useful in neuropathic pain and fibromyalgia.
In addition to medications, a variety of nonpharmacologic strategies may be offered, including physical therapy and acupuncture.
Involvement of family members and other significant persons in the patient’s life should be an early priority. The best efforts of both patient and therapists can be unwittingly sabotaged by other persons who may feel that they are “helping” the patient. They frequently tend to reinforce the negative aspects of the chronic pain disorder. The patient becomes more dependent and less active, and the pain syndrome becomes an immutable way of life. The more destructive pain behaviors described by many experts in chronic pain disorders are the results of well-meaning but misguided efforts of family members. Ongoing therapy with the family can be helpful in the early identification and elimination of these behavior patterns.
In addition to group therapy with family members and others, groups of patients can be helpful if properly led. The major goal, whether of individual or group therapy, is to gain patient involvement. A group can be a powerful instrument for achieving this goal, with the development of group loyalties and cooperation. People will frequently make efforts with group encouragement that they would never make alone. Individual therapy should be directed toward strengthening existing coping mechanisms and improving self-esteem. For example, teaching patients to challenge expectations induced by chronic pain may lead to improved functioning. As an illustration, many chronic pain patients, making assumptions more derived from acute injuries, incorrectly believe they will damage themselves by attempting to function. The rapport between patient and clinician, as in all psychotherapeutic efforts, is the major factor in therapeutic success.
et al. An overview of pharmacologic management of chronic pain. Med Clin North Am. 2016 Jan;100(1):65–79.
et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659–66.
et al. Multimodal treatment of chronic pain. Med Clin North Am. 2016 Jan;100(1):55–64.
et al. An umbrella review of the literature on the effectiveness of psychological interventions for pain reduction. BMC Psychol. 2017 Aug 31;5(1):31.
et al. Identification and management of chronic pain in primary care: a review. Curr Psychiatry Rep. 2016 Feb;18(2):22.
et al. Off-label antidepressant use for treatment and management of chronic pain: evolving understanding and comprehensive review. Curr Pain Headache Rep. 2019 Jul 29;23(9):66.