Renewed Interest in Biopsychosocial Tx for Chronic Pain

— Insurance coverage still a battle, but that may change given the country's opioid crisis


There was plenty to blame: the car wreck that broke his back. The job pouring concrete that shattered his spine a second time. The way he tore up his insides with cigarettes, booze, cocaine, and opioids.

It all amounted to this: Carl White was in pain. All the time. And nothing helped -- not the multiple surgeries, nor the self-medication, not the wife and daughter who supported him and relied on him.

Then White enrolled in a pain management clinic that taught him some of his physical torment was in his head -- and he could train his brain to control it. It's a philosophy that dates back decades, to the 1970s or even earlier. It fell out of vogue when new generations of potent pain pills came on the market; they were cheaper, worked faster, and felt more modern.

But the opioid epidemic has soured many patients and doctors on the quick fix. And interest is again surging in a treatment method called biopsychosocial pain management, which trains patients to manage chronic pain with tools ranging from physical therapy to biofeedback to meditation. It helped Carl White, a 43-year-old social worker from Leroy, Minn.

The catch? It can take weeks and cost tens of thousands of dollars -- and thus remains out of reach for most patients with chronic pain.

"We've been banging our heads on the wall, and banging our fists on the door, trying to get insurers to pay for this," said Bob Twillman, PhD, executive director for the Academy of Integrative Pain Management. "For the most part, they will not."

When Pain Is Not Just Physical

Chronic pain affects nearly 50 million Americans, according to the American Pain Foundation. The largest drivers include migraines, arthritis, and nerve damage -- but in many cases, emotional trauma also contributes to the sense of misery.

"We have a lot of people in this country who are unhappy, isolated, and hurting," said Jeannie Sperry, PhD, a psychologist who co-chairs the division of addictions, transplant, and pain at the Mayo Clinic in Rochester, Minn. "Depression hurts. Anxiety hurts. It's rare for people to have chronic pain without one of these comorbidities."

Indeed, chronic pain has a substantial psychological element: Being in pain often leads to self-imposed isolation. That loss of a social network then leads to anxiety, depression, and a tendency to catastrophize the pain -- so that it's all a patient can think about.

So even if the initial cause of the pain is treated medically -- with opioids, surgery, steroid injections, or physical therapy -- it's unlikely to go away entirely. That may be why just 58 percent of patients who routinely take prescription painkillers say the drugs are effective in managing their chronic pain, according to the American Academy of Pain Medicine.

"In the past, pain was viewed just as a physical issue," said Robert Gatchel, PhD, a pain management researcher and professor at the University of Texas at Arlington. "The thought was, if you cut something out, the pain will go away -- but lo and behold, it doesn't in many cases, and sometimes [the pain] gets worse."

Acute pain is generated in the peripheral nervous system, which conducts danger signals to the brain. From there, the brain determines whether it'll experience the pain signals or ignore them, Sperry said. "In the case of chronic pain, that system has gone awry," Sperry said. "Without training your brain to turn down the alarm system, the alarm keeps going off all the time."

So although the pain may have originated in the foot, patients end up with headaches, chronic nausea, chronic fatigue, and back pain -- developing a host of other symptoms as the brain short-circuits.

"Focusing solely on a pain generator in the body," like a herniated disc or nerve damage, "utterly and completely misses the chronic, complex, changing nature of chronic pain" as it's processed and experienced in the brain over time, said Tracy Jackson, MD, an associate professor of anesthesiology and a pain specialist at Vanderbilt University.

Bracing for 'New Age-y nonsense'

The second time White broke his back, he decided to shift gears: He left the cement pouring business and got first his high school diploma, and then a college degree. He began working at Mayo Clinic as a neurosurgery coordinator -- but still relied on alcohol and painkillers to get through the day.

It's tough to estimate how many people with chronic pain develop a dependence on medications, but in 2014, about 2.5 million adults had opioid addictions -- and many of those addictions started with a prescription for potent pain pills.

White soon found that unless he distracted himself with intense physical labor, he focused obsessively on the pain, and his thoughts spiraled into darkness. "If it's a 1-to-10 pain scale, a chronic pain patient will say, 'Mine's at a 12 or 13,'" White said. "A 1-to-10 scale isn't even sufficient. When I was at my worst, all I know is that my pain was on my mind 24/7."

By then, White had run out of medical options. No one would operate on him, and the pills were making him feel worse, not better. Finally, in 2009, Mayo referred him to its pain management clinic.

White went in with a great deal of skepticism. He recalls sitting in the back of the meeting room, arms crossed, waiting for the pain rehabilitation specialists to tell him some "New Age-y nonsense."

Instead, in that short, intensive program, White learned tools that worked for him -- some of them very simple instructions, like how to lift heavy objects with his legs instead of his back. The program also helped him process some traumas from his childhood, White said, such as when he was orphaned at age 10 when he found his abusive, alcoholic father dead.

The psychological component also helped White learn to be kinder to himself -- easing a great deal of self-imposed pressure to overexert himself.

These days, White's baseline pain stays at a 4 -- meaning, it's always there, but it's manageable. On the bad days, he considers small things, like getting out of bed in the morning, to be victories. "Instead of lying in bed, I gotta get my butt out of bed -- otherwise it becomes a tomb, and the 'stinkin' thinkin' comes back," White said.

He's now working at the Minnesota Adult and Teen Challenge, a faith-based addiction therapy program in Rochester. And he's working on launching a pain management program for his clients.

Plumbing Psychology to Deal with Pain

There used to be hundreds of integrated pain management centers all across the country. But in the '90s, the insurance market shifted; more patients joined managed care plans that limited them to a narrow network of doctors. Then in 1996, the powerful opioid OxyContin hit the market. It quickly became the tool of choice for controlling pain.

Soon, there were just four major integrated pain management centers left: Mayo Clinic, Johns Hopkins University, Cleveland Clinic, and Stanford University.

The Mayo Clinic's outpatient pain program runs for three weeks and keeps patients busy from 8 a.m. and 5 p.m.

They do physical and occupational therapy -- learning, for instance, how to go shopping or do yard work in ways that won't aggravate their pain. And the program includes four to five hours of lessons each day on how to understand pain. Patients learn to relax, breathe slowly, and meditate to mitigate some of the anxiety-related pain flare-ups. Entire sessions are dedicated to understanding the psychological underpinnings of their own pain.

"By the time people get here, they have a lot of functional disability," said Sperry, who helps run the program. "They're fearful, because they're getting such strong signals in the brain -- so we offer a very structured increase in activity, where we're retraining the brain to soothe the central nervous system to not process these signals as danger."

The program is not cheap. It costs $37,000 to $42,000 for three weeks. Gatchel, who is affiliated with several pain management programs in Texas, said that price is an "exception to the norm," and less intense versions of the treatment can run between $4,000 and $10,000.

Studies suggest the programs can be quite effective. The Brooks Rehabilitation pain program in Jacksonville, Fla., reports that six months after intensive treatment, 9 out of 10 patients reported improvements in quality of life and 3 out of 4 felt decreased levels of pain. The center reported that just 6% of patients who were weaned off of opioids during the program resumed taking them afterwards.

Another study, published in the journal Pain, followed 339 patients who completed a three-week program at the Mayo Clinic Pain Rehabilitation Center. Some 70% responded to questionnaires six months after their treatment, and reported significant improvements in pain severity, depression, social functioning, and other metrics. The gains held both for patients who had been taking opioids before entering the center and for those who had not.

Renewed Interest in Alternative Treatments

Such results, and anecdotal reports from patients like White, have spurred renewed interest in biopsychosocial pain management.

Insurance coverage is still a battle: Many plans will pay for medical treatments such as surgeries, pills, and steroid injections that can run $2,000 apiece. They're not as keen to cover therapy, massage, and meditation. "It's much more efficient for insurers to pay for a pill in a 15-minute office visit," Twillman said, "instead of a pill, plus a psychologist, plus a chiropractor, plus acupuncture, plus yoga and massage."

Slowly though, that's changing, in large part because of the opioid crisis.

The FDA just changed its provider education guidelines to urge doctors to learn about alternative strategies for managing pain.

Some insurers are open to new approaches, too. Oregon's Medicaid system, for instance, recently began covering more physical therapy and chiropractor visits for people with back pain, so as to help them avoid painkillers and surgery. Cigna, too, has increased its coverage for back pain physical therapy.

Veterans Affairs, meanwhile, is taking steps to reach out early to chronic pain patients, often through their primary care physicians, to coax them into increasing physical activity, sitting through cognitive behavior therapy, and meditating.

Sperry has appealed to Congress to accelerate the shift with more funding -- not just for chronic pain and addiction treatment, but also for medical education. She conducts a workshop at Mayo Clinic to teach medical students how to say no to patients who ask for opioid refills -- and how to help them instead train their brains to manage their chronic pain.

"We need a cultural shift," Sperry said. "There's an implication that there's a pill for everything -- and that's not accurate. It's very dangerous."

This article originally appeared on STAT News.