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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 163-167

The psychobiology and management of chronic pain


1 Department of Anaesthesiology and Critical Care, Command Hospital (Western Command), Chandimandir, Haryana, India
2 Department of Psychiatry, Command Hospital (Western Command), Chandimandir, Haryana, India

Date of Submission20-Jul-2021
Date of Decision29-Jul-2021
Date of Acceptance02-Sep-2021
Date of Web Publication10-Jan-2022

Correspondence Address:
Shibu Sasidharan
Department of Anaesthesia and Critical Care, Command Hospital, Chandimandir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_50_21

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  Abstract 


Introduction: The objective of this review is to advance our understanding on the biolecial and psychological perspectives of Chronic Pain. Methods: For research, a PubMed search was conducted on 01.05.2021 using the systematic review filter to identify articles that were published using MeSH terms Chronic Pain, Pain, Psychology of Pain. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Results: Depression is more common in chronic pain patients (CPPs) than in healthy controls as a consequence of the presence of CP. At pain onset, predisposition to depression (the scar hypothesis) may increase the likelihood for the development of depression in some CPPs. Because of difficulties in measuring depression in the presence of CP, the reviewed studies should be interpreted with caution. Little attention, however, has been given to the development of a comprehensive model that integrates both biomedical and psychological variables in the etiology, maintenance, and exacerbation of chronic pain. The purpose of this article is to propose a dynamic psychobiological model of chronic pain that emphasizes the interaction among psychological and biomedical variables. The experience of pain is viewed as a complex response that incorporates subjective-psychological, motor-behavioral, and physiological-organic components. Moreover, we postulate that there are varying degrees of synchrony among responses measured on these levels determining the development and etiology of chronic pain syndromes.

Keywords: ACT, Coping, Opioid, Cognitive behavioural therapy, Somatic Anchoring


How to cite this article:
Sasidharan S, Dhillon HS. The psychobiology and management of chronic pain. Hamdan Med J 2021;14:163-7

How to cite this URL:
Sasidharan S, Dhillon HS. The psychobiology and management of chronic pain. Hamdan Med J [serial online] 2021 [cited 2022 Jan 26];14:163-7. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/163/335383




  Introduction Top


Chronic pain is an emotional experience with humanitarian dimensions and is defined as pain lasting greater than six months. It is important to understand the neurophysiology of pain in order to treat it. Nociceptors in the periphery travel to the substantia gelatinosa of the spinal cord while secondary and tertiary afferents transmit information from the dorsal horn to the brain. Modification of pain information may take place in these ascending pathways or in descending pathways. Treatment of chronic pain is most successful when it is approached in a multidisciplinary fashion with the focus not only on treatment of underlying etiology, but also on the secondary impacts of pain on the patient's life. The management of chronic pain requires special expertise. Most of the experts in chronic pain assessment and management organize themselves into pain treatment centers. These centers vary widely in their approach to the problem. The most sophisticated is a multidisciplinary center that is university-based and includes teaching and research.

Chronic pain (CP) has a significant debilitating impact on an individual's life. Pain is labelled chronic when it persists for more than 3 months and has significant emotional distress and functional disability.[1] CP is a highly prevalent condition, with an estimated 20% of the worldwide population suffering from it, and is responsible for 15% to 20% of visits to the physician.[2],[3] In an international survey (18 countries, 42,249 respondents), the 12-month prevalence of CP was 37% in developed countries and 41% in developing countries.[4] CP has a significantly negative impact on psychological state, physical health and social functioning.[5] Since CP is a complex medical condition, it requires a broad array of healthcare professionals for optimum management. 'Active self-management' is a crucial factor, along with targeted psycho-social and medical support.

In an attempt to systematically classify, CP has been coded into the international classification of diseases (ICD), 11th revision as chronic primary pain, widespread chronic pain, chronic primary visceral pain, chronic primary musculoskeletal pain, chronic primary headache or orofacial pain and complex regional pain syndrome.[6]

Historically, pain was viewed as a medical symptom, which should respond to physical treatment (pharmacological, surgical management). However, due to inadequate response to conventional treatments, a shift in perspective and biopsychosocial effect and cause model were proposed.[7] The experience of CP is designed by a multitude of biological, psycho-social (e.g., patients' beliefs, affective state, expectations) and behavioural factors (e.g., circumstances, the behaviour of significant others). CP impacts all ages and socio-demographic groups in a multi-dimensional manner, and hence, management of CP entails a multi-disciplinary approach.[8],[9] In this article, the authors have tried to understand the magnitude, psychology, implications and management of CP, emphasising cognitive behaviour therapy (CBT).


  Psychology of Chronic Pain Top


Various psychological models have been applied to advance our understanding of causation, perpetuation and management of CP.

The operant model advocates that the frequency of any behaviour is contingent upon the response that it elicits from the environment. A favourable response (affection, sympathy, support, sanctioned time out) increases the frequency of particular behaviours, while unfavourable (neglect/aversion/punishment) responses reduce the frequency. Pain behaviours tend to sustain or even increase in frequency when they elicit favourable responses. However, if such favourable responses are substituted with alternate behaviours (or better known as 'well behaviours'), it can lead to a reduction in the frequency of pain behaviours. These 'well behavior' includes graded physical exercise, active lifestyle, activity tolerance, focus on self-efficacy and independent functioning despite chronic pain. On the other hand, maladaptive pain behaviours contribute to the maintenance of pain and prolonged disability. Hence, management of CP as per the operant model involves identifying factors that precipitate, perpetuate and relieve pain with the final aim to reduce the reinforcing behaviours and boost the 'well behaviours'. It involves educating the patient and significant others to identify and practice the well behaviours while ignoring the reinforcing behaviours.[10]

The peripheral muscle relaxation-training model with the help of biofeedback was initially advocated for the treatment of stress and anxiety disorders. However, certain CP conditions (chronic low backache, tension-type headache) are also attributable to persistent and excessive muscle tension. Hence, it is worthwhile to educate CP patients to regulate their autonomic nervous system through relaxation training and biofeedback. Relaxation training coupled with biofeedback thus forms an essential component of multi-disciplinary CP management.[11]

The cognitive and coping model argues that the pain behaviours of an individual can be better predicted and influenced when his cognitions (beliefs, motivation, attribution, intentions, etc.) are taken into account. Thus, during the management of CP, patients are educated to become more aware of their thoughts accompanying the pain, maintain a log and identify the adaptive/maladaptive thoughts based on their overall helpfulness/unhelpfulness. They are then instructed to focus and strengthen the adaptive thoughts and avoid/ignore the unhelpful ones. There is extensive literature supporting CBT efficacy in reducing CP and improving overall physical and psychological function.[12]


  Assessment Top


An inherent problem in assessing pain is that there are currently no objective measures to determine/validate the extent of an individual's pain except the subjective self-reporting by the patient. However, CP affects not only the patient but also the significant others (partners, friends, relatives, employers and co-workers) around him and thus necessitates evaluating a comprehensive biopsychosocial profile of the patient, including physical, psychological and financial implications. The healthcare providers need to conduct a thorough clinical examination and diagnostic investigations to locate any biological aetiology of pain while concurrently assessing the patient's cognitions and coping, emotional impact and dysregulation, expectations, responses of significant others (caregiver burden) and functional as well as financial disability.[13]

The psycho-social and behavioural factors can be screened with the acronym 'ACT-UP' (activity, coping, think, upset and people's responses) to guide a brief screening interview for clinicians. This can be summarised as follows:

  1. Activities: How is your pain affecting your life (i.e., sleep, appetite, physical activities and relationships)?
  2. Coping: How do you deal/cope with your pain (what makes it better/worse)?
  3. Think: Do you think your pain will ever get better?
  4. Upset: Have you felt worried (anxious)/depressed (down, blue)?
  5. People: How do people respond when you have pain?


The standardised CP assessment tools available to assess the sensory and affective qualities of CP are Numerical Rating Scales; Visual Analogue Scales; Faces Scale; Verbal Descriptor Scales; Brief Pain Inventory; Graded Chronic Pain Scale, McGill Pain Questionnaire; Pain Detect; Neuropathic Pain Scale; Neuropathic Pain Symptom Inventory; Leeds Assessment of Neuropathic Symptoms and Signs and Douleur Neuropathique-4 Questions. These are easy to use in routine clinical settings.[14]


  Implications of Chronic Pain Top


CP has a significant association with psychological states and psychiatric disorders. CP poses a greater risk for having depression, and also up to 75% of depressed patients reports CP.[15] The incidence of depression amongst patients with CP is estimated to be 30%–45% compared to 5%–7% in the general population.[16] Furthermore, depressed patients with CP report worse sleep disturbances, fatigue, psychomotor retardation, impaired concentration and poor quality of life than people without CP. Moreover, depressed patients with CP respond poorly to antidepressant therapy.[17]

There has been an increase in the use of opioids to manage chronic and acute pain because the effect of opioids tends to wear off following prolonged use, necessitating increased dosages. There has been a 198% increase in hydrocodone prescriptions, a 588% increase in oxycodone prescriptions and a 933% increase in methadone prescriptions from 1997 to 2005.[18] More than 10 million Americans aged more than 12 years were using opioid analgesics without medical prescription in 2014.[19] Although opioids are effective for short-term management of acute and cancer pain, the evidence for long-term management of chronic non-cancer pain is lacking.[20],[21] Second, unregulated long-term use amplifies the risk of addiction and severe side effects. Moreover, patients with existing psychiatric comorbidities (anxiety, depression) tend to experience higher pain intensity, thus demanding higher doses of opioids and an increased likelihood of developing opioid dependence.[22]


  Management Top


The World Health Organization for Cancer Pain recommends a “three-step analgesic ladder” approach for pain medication so that medications with the fewest side effects and the least addicting potential are prescribed first. We believe this approach is appropriate for medical management of noncancer pain as well. While many physicians may question the use of opioids for noncancer pain, current opinion favors this consideration on an individual basis. Additional medication is added to the first step of the ladder as needed. Non-opioid analgesics, such as the non-steroidal agents and acetaminophen, are useful agents to treat acute and chronic pain. They are nonaddictive, have a ceiling analgesic effect (more drug does not offer improved benefit), and are antipyretic. Except for acetaminophen, they are believed to act in the peripheral nervous system by preventing the formation of prostaglandins. They may be administered orally, rectally, or intravenously. Long-term administration does have recognizable toxicity. Renal and hepatic injury should be assessed with regular monitoring every six months. Centrally acting agents, such as the weak opioids, should be considered next if the non-opioid therapies are not adequate. Weak opioids, such as hydrocodone, codeine, and propoxyphene, work at the mu receptors. Many of these opioids are administered in compound formulations with acetaminophen, which limits their dosing, secondary to the risk of liver toxicity from the acetaminophen (greater than 4 g per day). If weak opioids are not effective, or the required dose exceeds that allowable with the acetaminophen, a change to a stronger opioid (morphine, methadone, or dilaudid) is appropriate. The opioids can be delivered intravenously, orally, transdermally, or rectally; it is cheaper and easier, however, to administer opioids orally. All of the opioids work at the mu receptor, and they all have the same side-effect profile, including the risk of respiratory depression, pruritis, nausea, and constipation. Side effects usually decrease with use, except for constipation. A bowel regimen is always indicated for patients on chronic or short-term opioids. Organ-system toxicity with chronic opioid use is not described. Concern over physical and psychological dependence, as well as tolerance and withdrawal, warrant careful consideration. Our recommendation would be to prescribe potent opioids with the intent to achieve specific (not general) goals that can be measured (i.e. walk a certain distance each day, go to work each day, decrease emergency room visits). Epidural and intrathecal opiates can be offered to patients who escalate their opiates to levels that cause respiratory depression and sedation while seeking pain relief.[23] The non-pharmacological interventions include acupuncture, tai chi, reiki, prayer, graded physical exercise, CBT, magnetic stimulation, relaxation training, biofeedback and mindfulness-based stress reduction.They are classified as complementary alternative medical therapies.

CBT has been primarily utilised in psychiatric disorders such as depression, anxiety and post-traumatic stress disorder; however, it is effective in patients with CP. The principle behind CBT is to identify and change thought patterns accompanying maladaptive behaviours into adaptive ones. The success of CBT techniques in the management of CP is attributable to its ability to alter brain function and connections in nociceptive and non-nociceptive areas of the brain, reduction in posterior cingulate cortex activity, pain-related cognition and anxiety related to pain.[24] Multiple randomised controlled trials demonstrate that CBT successfully improves CP across a broad spectrum of syndromes, including headaches, arthritis, cancer and fibromyalgia.[25] The various CBT techniques available for CP are summarised [Table 1].
Table 1: Overview of cognitive-behavioural therapy techniques

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The impact of positive psychological factors (individual adjustment to persistent pain, pain acceptance, hope and optimism) has been studied in patients with CP. Hope has been associated with reduced chronic pain, functional disability, psychological distress and physical weakening in multiple sclerosis and cancer patients.[26],[27] Acceptance-based behavioural interventions recommend engaging in meaningful activities despite the pain and has been shown to significantly lower pain levels, pain-associated distress and disability.[28]

Occupational therapists, through their partaking in everyday activities, can assist patients in their well-being. Nutritionists can educate patients about the role of food and its effect in regulating chronic inflammation. Therapies based on naturopathic nutrition and diet are widely being researched. They can also give suggestions on effective weight management. Social workers can assist by advising patients about available public health services, healthcare plans and benefits of each. They can also help improve the practice and ethical standards of the multi-disciplinary team approach.


  Recommendations Top


  1. More training: Clinicians, including (but not limited to) those working in primary care, may lack sufficient teaching and training about the treatment and management of chronic pain. This lack of good teaching and training can result in poor treatment choices.[29] Coding CP into ICD-11 has allowed us to devise uniform treatment guidelines. In addition, the primary assessment, evaluation and management of CP should be included in the basic medical education teaching curricula
  2. Expand management team framework. Include psychologists, psychiatrists, social workers, nutritionists and occupational therapists in the treatment of chronic pain
  3. Extending follow-up periods. Chronic pain, in many cases, is a prolonged disability. This protracted agony can cause psychological, behavioural and financial repercussions. Hence, a long-term follow-up is suggested to track these changes
  4. Relaxation Techniques: Techniques customised to help the patient to relax both mentally and physically are effective in CP. While mental relaxation eases mental stress, physical relaxation techniques can ease the tense muscles consequent from pain
  5. Somatic anchoring (SA): SA has been found useful in somatic, visceral and neuropathic pain. It involves cognitive restructuring and mindfulness meditation as a tool in cases where medications have been ineffective
  6. Acceptance and commitment therapy (ACT): Mindfulness, along with ACT, is a branch of CBT. It focuses on training the individual on accepting the things that are out of one's control and committing to psychological interventions targeted at improving the quality of one's life.



  Conclusion Top


Chronic pain is a significant public health problem with massive health resources and suboptimal outcomes. Psycho-social factors and biological factors play a significant role in patients with chronic pain; therefore, therapeutic interventions must include psychological therapies, especially CBT. CBT, SA and ACT are effective in alleviating chronic pain across a broad spectrum of chronic pain syndromes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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