The other day I heard someone make the claim that psychological interventions for persistent, or chronic, pain are at best modestly effective. She went on to rhetorically ask why the field should promote such therapies when the empirical support for them is so unimpressive?
I’ve heard such statements countless times before.
It would be an important point if the field of pain management was filled with effective therapies. Pain management has many offerings in terms of therapies and procedures and, were it the case that these offerings were highly effective, it would make little sense to recommend behavioral therapies that are only modestly effective.
But it is not the case that there are many, highly effective therapies and procedures for the management of persistent pain. With one possible exception, there are actually no highly effective therapies for chronic pain.
Twenty some odd years ago, the American Academy of Pain Medicine and the American Pain Society, two large pain-related professional organizations, teamed up to agree upon what it means to have both chronic pain and be addicted to opioid pain medications at the same time.1 They did it because addiction to opioid medications when patients are prescribed them for legitimate health reasons seems different than addiction to other substances like alcohol, cannabis, cocaine, or even illegally obtained opioid medications when not used for pain. The difference involves the phenomena of tolerance, physical dependence, and withdrawal, which in part serve as criteria for the diagnosis of addiction when it comes to all other substances.
I am nearing the end of a forty-five minute initial evaluation for our interdisciplinary chronic pain rehabilitation clinic and my patient is an amiable woman in her late forties from the suburbs. She drove a minivan to the clinic and attends the evaluation while her three children are at school for the day. Her primary care provider had referred her to us because of her chronic and disabling low back pain, which over the years had become progressively worse and more widespread.
We live in an interesting time within the field of pain management. We literally have two competing ways of understanding the nature of pain – what it is and how it works and what to do about it.
There’s a divide between chronic pain experts and their patients that rarely gets crossed. The divide centers on the issue of fear-avoidance of pain.