People living with HIV/AIDS have higher rates of chronic pain than the general population does, mainly because of neuropathy but also partly because people with HIV are largely an aging population. And with the opioid epidemic that has taken root all over the country and helped fuel hepatitis C rates, new, nonaddictive methods for helping people cope with chronic pain are much needed. Often, we think that medication or surgery is the only answer for chronic pain, but a new study out of the University of Alabama (not restricted to HIV-positive people) shows how some basic pain education or cognitive behavior therapy (CBT) techniques may help patients get a grip on pain, if not alleviate it entirely.
The study involved almost 300 people with chronic pain in rural areas who were mostly women, nonwhite, living below the poverty level, and reading below a fifth-grade level -- not a group that, research shows, would normally access cognitive behavioral therapy. They were divided into two groups, one of which received pain education plus CBT.
"We explained that the brain processes pain and one's emotions and thoughts and that prior experience influences how pain is processed," says Beverly Thorn, Ph.D., lead researcher on the study and author of Cognitive Therapy for Chronic Pain. "Then, we taught them deep belly breathing -- a handy, three-minute exercise teaching people how to elicit a relaxation response."
Related: Why Did the Opioid Epidemic Develop and How Do We Stop It?
People in this group learned to tie their thoughts to their emotions and behaviors. According to Thorn, "If someone said, 'I stormed out of the house in a fight,' we asked them, 'How did that influence your pain?' Or, if people had a pain flare-up, we'd get them to realize that they then said to themselves, 'This is pointless, it's never going to get better.' They learned to recognize what they were saying to themselves, which is often really negative self-commentary. Then, we got them to ask themselves: 'Is that really true? Am I definitely going to end up in the ER again because I'm having a migraine?' Then we'd get them to replace it with a more realistic statement, like: 'This is really inconvenient for me. Of course I don't want a migraine. I'm scared. I don't like the pain. I have too much to do. But this is a signal from my body that I need to do my deep-belly breathing and go from there.'"
Participants also learned, in a conflict, to say calmly, "I'm upset -- can we talk?" instead of lashing out, which often lead to a pain increase. "We incorporated mindfulness training to teach people to sit with their feelings without having to react to them," explains Thorn. "People came back and said things like, 'I realized last week during a fight with my spouse that I was about to take a pain pill, not because of pain but to avoid emotions, and instead I said, 'Maybe I don't need that pill.'" (The study did not ban people from taking pain medication, however.)
Participants also learned expressive writing, in which they sat down and wrote themselves a letter describing their feelings -- or wrote a letter to others that they did not send.
The study's other group got the same information about how the brain processes pain but no CBT skills. They were, however, allowed to talk about their pain and come up with their own CBT techniques. "We were trying to find out what's the secret sauce of these psych treatments for pain," says Thorn. "Is it being in a group? Giving people the right kind of information they can discuss? Or the skills training?"
Ultimately, the study found, folks in the CBT skills group had a slight but not significant edge. The real takeaway? Over time, says Thorn, "Nobody came in and said, 'I don't have any pain.' They said, 'I still have pain but it doesn't control my life the way it used to.'"
So, what can we learn from the study? "One thing," stresses Thorn, "is that we know that pain isn't an issue of mind over matter." She says: "You need both biological and psychological treatment. What's going on in the brain with pain is a physical thing. And there's absolutely a role for medication and surgery, but they're not the only tools in the toolbox that we can use."
Thorn says that people with chronic pain should ask their primary care providers where they can access CBT treatment. "There are psychologists who are experts in pain management all over the [United States]. Patients need to start being more self-informed, which makes providers start to go 'Hmmmm.' ... They learn that when patients learn to use these techniques, they start to come in much less needy."
You can also help patients find a cognitive therapist near you by looking here.