A recent position statement by the Society of Behavioral Medicine (SBM) concludes that patients with persistent pain need better access to psychosocial care in all healthcare settings.1 The SBM offers 10 health policy recommendations for improving such access, including removing system-related barriers, providing referral tools, reimbursing for evidence-based psychosocial approaches, prioritizing generalist-level and specialist pain training across disciplines, and recognizing pain psychology as a specialty. Unfortunately, the authors note, “despite persuasive evidence supporting the efficacy of psychosocial approaches, these interventions are inaccessible to the majority of Americans.”
Rheumatologists see a lot of patients with persistent pain—defined as lasting for six months or more—among the 25.3 million Americans who experience daily pain identified in the 2012 National Health Interview Survey conducted by the National Institutes of Health. Meanwhile, traditional pain management tools, such as opioid analgesics, for chronic, nonmalignant pain are coming under greater scrutiny.
But what is psychosocial pain care, what can it contribute to pain management, who provides it, and how can rheumatologists get more involved?
What Is Pain?
Pain is a highly personal, subjective experience, says Roger Fillingim, PhD, a psychologist and director of the Pain Research and Intervention Center of Excellence at the University of Florida in Gainesville. Biologic processes are important to address in relieving pain—but so are psychological and social factors. “This goes for all pain, regardless of origin,” he says.
In some patients, the psychosocial factors are stronger than for others, but even when the pain is mostly biologic in origin, psychosocial interventions can still prove effective. “For example, we know hypnosis reduces postoperative pain, and deep breathing and relaxation have been shown to be effective in relieving pain,” Dr. Fillingim says. Reducing a patient’s anxiety and increasing feelings of control also have an impact on pain and physical functioning.
In a recent review, Louise Sharpe, PhD, professor at the School of Psychology at the University of Sydney, Australia, highlighted research showing efficacy of psychological therapy for managing pain in patients with rheumatoid arthritis.2 A study in the Journal of Psychiatric Practice found cognitive behavioral therapy an effective alternative to opioids for chronic nonmalignant pain, either as a standalone treatment or in combination with non-opioid medications.3
But sometimes medical providers appear to believe medical approaches are for “real” pain and psychological approaches are reserved for other forms of pain that may be “all in the patient’s head,” Dr. Fillingim says. In reality, patients experience pain in both realms. “It is almost never all psychological in the same way it’s almost never all biologic. I’d encourage providers not to restrict their approaches for those whose pain they have decided is psychological in origin.”