Pain: The Great Motivator

In this exclusive video, Beth Darnall, PhD, Director of the Stanford Pain Relief Innovations Lab, and Sean Mackey, MD, PhD, Chief of the Division of Stanford Pain Medicine, discuss psychological and behavioral health therapies that can help patients manage their chronic pain. Darnall and Mackey are currently researching ways to improve accuracy and access in pain management practices.

The following is a transcript of their discussion:

Darnall: So, let's start off with a discussion about what pain is.

Pain is defined as a noxious sensory and emotional experience. Most people don't appreciate that part of the definition of pain actually involves emotions and psychology. This is one of the reasons why we have psychological approaches or behavioral medicine approaches or self-management approaches -- we can use these terms somewhat interchangeably -- that are integrated into whole-person pain care.

We want to be sure that we're assessing each person, identifying their needs, and then addressing them in a comprehensive treatment approach, because the data suggests that that's what helps people resolve pain best or learn to manage pain best.

Sean, I know that you've spent decades studying this as well. What do you have to say about the definition of pain and the role of behavioral medicine in pain treatment?

Mackey: The definition, as you said, from the International Association for the Study of Pain, defines it as this sensory and emotional experience. And I think that captures it, but I think there's actually missing components from that definition.

We're leaving out one of the key ones in that definition, which is that pain is the great motivator. Pain causes us to want to get away from something that is causing us potential damage or more damage.

Getting to the point about the need for appropriate assessment, listen, all chronic pain starts with a very thorough history and physical examination. As a physician, that is where everything begins. You have to get a thorough sense of what the person brings into this. What is the cause of this injury? What are the events that led to it, a lot of the mitigating factors?

Then what we need to do is put together a diagnostic plan, and that diagnostic plan or diagnostic workup would be the various causes for it. Then that leads us to a treatment plan.

That treatment plan, as you alluded to, Beth, frequently includes a multidisciplinary approach, a multimodal approach. It could be medications, it could be interventional therapies or procedures, it could be mind-body therapies that you're going to build on (which we'll talk about more), it could be physical and occupational therapy approaches, it could be what we used to refer to as complementary alternative medicine approaches, and it could be more self-empowerment or self-education approaches. Typically, as we know, these all work better when they're all bundled together.

Darnall: So true. And, you know, there are commonalities to treating pain regardless of whether a person is going to be prescribed a medication or they have surgery or they receive physical therapy. I mean, there's a whole variety of treatment approaches that we have to address the individual needs of each person, but there are also some commonalities.

It's important for each person to understand what they can do to best help themselves to alleviate their own distress, because pain is naturally distressing. Each and every one of us are hardwired to want to get away from it, and we can't do that when maybe we have migraines or fibromyalgia or chronic low back pain. You can't just run away from that pain. And so, of course, it's uncomfortable, it's painful, and it's also distressing. It can interfere with our lives, our sleep, our activities, all of these things.

So what's important is to help people understand what they can do on a daily basis to provide themselves with comfort and symptom management to be able to increase their activities, their function, their own health and wellbeing. This realm of pain psychology or behavioral medicine is very much focused on equipping people with a critical skill set, an evidence-based skill set, that helps them understand how to work with mind and body.

People acquire the ability to better regulate stress responses, the responses that we naturally have when we experience pain. These are physiological responses, so this is anchored in the body. Helping people understand what they can do to calm their nervous system, to be able to gain better control over what is a naturally distressing circumstance.

Mackey: Looking at it through, for instance, my lens as a physician and a neuroscientist, one of the things I've learned over the last 20 years or more is that when you hear the word "psychological," a lot of patients react to that term. And they react to that term because they tell me that they think I'm saying it's all in their head.

The reality is, it's not in your head, but it's in your brain. What we're learning more and more is that any type of psychological phenomenon has a neural basis to it. It is, by definition, a brain-related thing. When you think about stress, when you think about anxiety, when you think about anger, when you think about depression, and when you think about pain, all of those exist in our brain. And there are circuits there. There are circuits and connections between different brain regions and they can get out of whack.

I've spent much of my career doing brain imaging and opening up windows into people's brains to help see where those abnormal connections are occurring, and I think if there's one thing that I and others who do this work have contributed, it's providing validation to people. To help show them that, no, this isn't your fault. This isn't something you're making up. It's not something psychological. There's a real neural basis for this.

And the type of techniques, the type of skills that Beth is talking about right now, it's all about controlling brain systems. She refers to it as kind of taking over at a personal level and when I think about it as a scientist, I'm thinking about, "Well, what she's talking about is manipulating brain networks and teaching you how to do that."

The reality is, we learn how to do that all the time. When we learn how to hit a baseball, when we learn how to drive a car, we're learning how to manipulate brain systems. It's not much different when we're trying to learn how to control pain.

Let me build just briefly on this term "psychogenic," which is one of those irritating terms I wish I could just banish, because it's caused a lot of harm. The reason why [people with chronic pain] are frequently labeled this is that as physicians, we don't get much medical training in med school around chronic pain. On average, we get about 7 hours. And so the thing is in healthcare, in medicine, is that if we don't understand something, we have frequently in the past just said, "Well, it's psychological or it's psychogenic," and it's invalidated so many people's symptoms, their complaints, and it's stigmatized them.

The reality is I've treated thousands upon thousands upon thousands of patients; I can't remember the last person I would've thought of giving a label of psychogenic pain. Right? We've gotten so much better at diagnosing pain. We can almost invariably come up with some explanation. It may not be a perfect explanation, but at least it's something that can help them to understand why they have what they have.

Darnall: I really believe that one of the most important messages that I can give people who are living with chronic pain is that your pain is real and it impacts your brain and body in certain ways. So, let's help you move yourself in the direction of being more comfortable. We validate the pain is real, and we also recognize that many people have received these stigmatizing messages, but we have great evidence-based treatments that can really help a lot of people.

There's decades of science supporting the efficacy of various interventions. Just to name a few of those: cognitive behavioral therapy for chronic pain is very well studied. Across different medical conditions and pain conditions, we see that it can help people reduce pain intensity, pain interference, and a variety of symptoms that people are living with on a daily basis. It can help them improve their sense of control and their ability to control various factors in their lives.

We also have mindfulness-based stress reduction, acceptance, and commitment therapy; there's other techniques such as hypnosis, mindfulness principles, pain neuroscience education. All of these various treatments focus on educating people about what they can do on a daily basis to help themselves, and I think that's so critical because so many other approaches within the context of medical care involve a person sort of being a passive recipient to the intervention, the medication, whatever that is. Each of these treatments may not be right for everybody, of course, but there is a portfolio of evidence-based treatments, so people can pick among them what resonates most with them.

I submit, after all these decades of science and showing some moderate treatment effect sizes for these treatments, I think the biggest issue that we're facing in behavioral medicine is access. Because we've been studying for all these decades what works, this efficacy, but most people don't have access to what we know works. So, we are spending a lot of time studying something that means nothing to a person who lives in rural Iowa who is never going to have access to that intervention.

So, one of the most exciting things to happen as a consequence of COVID in the pandemic is that we've moved our treatments online, and so people have better access. Now, my own line of research is focused on compressed, brief evidence-based treatments so that we can really provide people with all of this empowerment, but in a convenient single session, because that's more acceptable and feasible for people at a population level.

We want to be thinking much more broadly, not just about, "Oh, can we get this treatment to people, something that we've been studying forever." It's time to reexamine to, "Can we repackage what we know works well, but put it together in a patient-centered way that allows us to meet the needs of these hundred million Americans?"

Mackey: Building on that, your research is about making these therapies accessible, and a lot of what I'm doing and other people are doing is to better characterize people to better collect high-quality data, high-quality evidence about each individual person's unique experience, and then use that data to predict what is going to be the right therapy for that particular person in that context. That's where the future of this is all going -- to combine that high-quality data capture with the work that you're doing and bring that all together so that we can make this broadly acceptable and precise.

The question comes up, if you're a busy primary care doctor, what do you do with that patient who's in front of you? You've got less than 10 to 15 minutes. Well, because of production pressures, the easiest thing to do is to break out a prescription pad. It's harder to think about these mind-body interventions and in large part, because this gets to what Beth said before, access. If you're a primary care doctor in a community setting, you might not have ready access to a pain psychologist that you can easily send somebody to.

The good news is, I'm seeing greater and greater acceptance amongst my colleagues of this integration of mind-body therapies and of psychological therapies. As we continue to work together to break down barriers to access, I see this becoming more and more commonly used. Beth, what are your thoughts?

Darnall: A hundred percent, and it's included in all of the guidelines now. They involve an emphasis on integration of behavioral medicine. I mean, Sean, you co-led the development of the National Pain Strategy and it was in there, it was in the IOM [Institute of Medicine] report, it was in the 2019 HHS Best Practices for Pain Management [Inter-Agency Task Force] report, the CDC in their guidelines, everybody is putting forward that we need to better integrate behavioral medicine strategies at the outset of pain care and really provide meaningful access.

The problem is we've spent a lot of years talking about what's needed and not enough rubber-meeting-the-road implementation -- really rolling this out with meaningful access to solutions that are evidence-based solutions that are proven to work, and that's changing. This is really exciting. This is the work that I do at the Stanford Pain Relief Innovations Lab, and we're rolling out accessible solutions that are evidence-based that can be applied at the population level to begin to meet the needs of people no matter where they live in the United States.

Until we really solve this issue, we will be studying treatments that only a tiny fraction of people will ever have access to. But it's an incredibly exciting time, I think you would agree, Sean, because the world is finally ready. We're embracing technology and being able to both characterize and deploy evidence-based treatments online.

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