Defining the Role of Cognitive Behavioral Therapy in Treating Chronic Low Back Pain

THIEME 496 Narrative Review GLOBAL SPINE JOURNAL

Deﬁning the Role of Cognitive Behavioral Therapy in Treating Chronic Low Back Pain: An Overview

David A. Hanscom1 Jens Ivar Brox1 Ray Bunnage1

1 Swedish Medical Center, Seattle, Washington, United States Address for correspondence David A. Hanscom, MD, Swedish Neuroscience Institute, Swedish Medical Center, 550 17th Avenue, Seattle, Global Spine J 2015;5:496–504. WA 98122, United States (e-mail: [email protected]).

Abstract Study Design Narrative review of the literature. Objectives Determine if the term cognitive behavioral therapy (CBT) is useful in clinical care and research. What literature supports these variables being relevant to the experience of chronic pain? What effects of CBT in treating these factors have been documented? What methods and platforms are available to administer CBT? Methods Chronic low back pain (CLBP) is a complex neurologic disorder with many components. CBT refers to a broad family of therapies that address both maladaptive thoughts and behaviors. There are several ways to deliver it. CLBP was broken into five categories that affect the perception of pain, and the literature was reviewed to see the effects of CBT on these variables. Results The term cognitive behavioral therapy has little use in future research because it covers such a wide range of therapies. CBTshould always be defined by the problem it is Keywords intended to solve. The format and method of delivery should be defined because they ► cognitive behavioral have implications for outcomes. They are readily available even at the primary care level. therapy The effectiveness of CBT is unquestioned regarding its effectiveness in treating each of ► insomnia the variables that affect CLBP. It is unclear why it is not more widely implemented. ► structured care Conclusions CBT represents a family of therapies that are effective for a wide range of ► catastrophizing problems, many of which coexist with and influence CLBP. Each of the variables can be ► chronic pain improved with focused CBT. Early, widespread adoption of CBT in treating and ► expressive writing preventing CLBP is recommended. Future research and clinical care should focus on ► CBT implementation strategies to operationalize these well-documented treatments utilizing a public health ► presurgical screening approach.

Introduction psychological interventions on the treatment of CLBP. CBT was noted to be particularly effective.10 Cognitive behavioral therapy (CBT) is a form of psychotherapy The literature contains many studies that compare CBT that has been documented to be effective in treating anxiety, with isolated treatments for CLBP such as physical therapy insomnia, depression, addictions, and other mental disor- and surgery.1,2,11,12 The problem from a research perspective – ders.1 8 It has also been utilized in the treatment of chronic is that cognitive behavioral therapy is a general term that low back pain (CLBP).9 Hoffman et al conducted a detailed encompasses many variations and subentities under an um- meta-analysis demonstrating a strong therapeutic effect of brella term9; in addition, multiple factors affect the

received DOI http://dx.doi.org/ © 2015 Georg Thieme Verlag KG August 27, 2015 10.1055/s-0035-1567836. Stuttgart · New York accepted after revision ISSN 2192-5682. October 1, 2015 Cognitive Behavioral Therapy to Treat Chronic Low Back Pain Hanscom et al. 497

Table 1 Variables influencing the perception of chronic low more focused on the present situation rather than the influ- back pain ence of the past on your current experience. One premise of CBT is that thoughts create a physiologic 38 Sleep response that usually includes adrenaline and cortisol. Stress Thoughts may represent cognitive distortions that have little Anxiety to do with reality. The result may be unpleasant in that it includes a physical sense of alertness and tension to enable a Fear avoidance13,54 “fight or flight” response. CBT aims to create an awareness of 3,5 Catastrophizing these distortions and resultant maladaptive behaviors (i.e., to Anger49 identify automatic negative thoughts). CBT has been reported Injury conviction50 to be effective in treating anxiety and depression as well as other mental health conditions.6,8 CBT is particularly relevant Depression43 to the treatment of chronic pain,9 in that different stressors Medications and states of mind have an adverse effect on the perception of Compliance63 pain and functional outcomes.13 Physical conditioning1,2 Ehde et al summarized the literature regarding the goals of CBT to reduce pain and psychological distress and improve Life outlook physical and role function in the treatment of chronic pain by 27 Forgiveness decreasing maladaptive behaviors, increasing adaptive behaviors, identifying and correcting maladaptive thoughts and beliefs, and increasing self-efficacy for pain management.9 perception of pain (►Table 1). Therefore, looking at CBT in the treatment of CLBP may provide limited clinically useful Background of Cognitive Behavioral Therapy information. The origins of CBT began with Albert Ellis in the 1950s. He is Indeed an extensive Cochrane review concluded: “There is considered one of the most influential psychologists in history, no need for more general RCTs [randomized controlled trials] publishing over 800 peer-reviewed papers. His term for this reporting group means, rather, different types of studies and treatment approach was rational emotive behavior therapy.He analyses are needed to identify which components of CBT founded the Albert Ellis Institute in 1959, which continues to work for which type of patient on which outcome/s, and to try disseminate these principles.14 Interestingly, he gave credit to to understand why.”7 the Stoics who were influential in Roman times for the The purpose of this article is to delineate the factors that formation of basic cognitive concepts. He particularly recog- have been reported to affect the perception of pain and what nized Epictetus (55 to 135 BC), a Greek philosopher who was role the different types of CBT might have in addressing them. exiled by the Romans, who stressed that human beings cannot The manner and setting in which CBT is delivered will also be control life, only their responses to it.15 considered. Aaron Beck, an internationally renowned psychiatrist who is considered the father of CBT, modified the concepts devel- Methods oped by Albert Ellis and conducted extensive research regarding the role of thoughts in creating emotions. His work became This study is a narrative educational review, and we note the influential beginning in the 1960s. The Beck Institute, founded potential for bias or omission of important articles. We sought to in 1994, actively promotes CBT concepts through research, perform a formal systematic literature review at the onset of this clinical care, and training health care professionals.16 project and after a midpoint review decided to base this article David Burns, a Stanford psychiatrist, popularized Beck’s primarily on the conclusions of systematic reviews and meta- work in a best-selling book, Feeling Good, published in 1980.17 analyses instead. Individual studies are presented to illustrate He also is actively engaged in research as well as teaching and promising areas for further research and clinical applications. In training. light of the vast nature of the literature regarding CBT for a multitude of different medical conditions, we decided to reframe Types of Cognitive Behavioral Therapy our project with the intent to clarify the basic CBT concepts that are applicable to CLBP and to suggest a direction for further “Cognitive Behavioral Therapy” studies. Our intent was to educate spine providers about the A more traditional psychological approach to pain is operant options of selectively using elements of CBT for the various conditioning, with which the various forms of CBT are often clinical scenarios that occur in the presence of CLBP. compared. This approach focuses on extinguishing maladaptive behavior and reinforcing positive reactions to pain. It is Results traditionally based on reward and punishment of behaviors in contrast to addressing the cognitive component of pain.13 Defining Cognitive Behavioral Therapy CBT addresses both the cognitive and behavioral elements CBT describes a category of therapies that address the effect of a given problem. It is important to realize that there is no that thoughts have on behavior, emotions, and symptoms. It is standard CBT protocol, and indeed many different techniques

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are used to administer it. CBT may be perceived as a specific psychomotor therapy. This group had improved functional treatment paradigm but is really a descriptor for a “family” of disability, self-efficacy, outcomes expectancy, and less fear of treatments. Mansell proposed seven areas of CBT that need to movement/reinjury.22 be clarified to improve the delivery of CBT. The three most important are clarity (shared definitions of CBT and its Modes of Delivery terminology), coherence (shared therapeutic principles and theory), and cohesion (integration of individuals and sub- Individual Therapy groups using CBT).18 CBT is frequently administered in a one-to-one setting, which One problem when evaluating CBT is that the information is ideal if there is a good fit of the patient with the mental learned is limited unless the type of CBT is clearly defined and health professional. Such an arrangement provides guidance, the intended outcome of treatment is measured. therapeutic alliance, and support. Unfortunately, there is limited access to mental health Third-Wave Cognitive Behavioral Therapy resources, especially individual therapists. Access is limited CBT can be combined with treatments that calm the nervous because of both the availability of therapists and insurance system such as mindfulness and meditation. Instead of con- coverage. Despite the federal government mandating that fronting and addressing the content of the thoughts, the mental health be placed on even par with physical health, not participant learns to watch and disassociate from them. Tools much has changed to allow easier access to these resources. include relaxation, mindfulness, meditation, acupuncture, Nonetheless, this variable should be noted in directing pa- medical hypnosis, play, among others. The general term being tients to CBT. used for this more eclectic approach is Third-Wave CBT.19 With proper training, CBT can be administered by all who One review regarding the role of Third-Wave CBT in treat patients with pain such as family physicians, rehabilita- treating depression described seven different approaches.19 tion physicians, surgeons, physical therapists,11,12 nurses, Again, the term describes a family of therapies that include and occupational therapists.23 various relaxation techniques. Meaningful data regarding its efficacy would still have to focus on the specific variable being Group Treatments treated. Social isolation is a significant issue for many patients suffer- For example, Acceptance Commitment Therapy or adap- ing from chronic pain. Unfortunately, in this state, the brain is tive CBT was developed in the 1980s. Instead of challenging spending more time on pain pathways and obsessing about intrusive thoughts, patients learn to accept and separate from the problems. People in pain may not have the energy to them rather than judging or reacting to them. It is comple- associate with others and eventually lose interest if they mentary to core CBT, which is cognitive identification, cogni- become depressed. They are also not that enjoyable to be tive reappraisal, and behavior modification. As meditation with and they may drive friends and family away. and mindfulness have already been shown to be effective in Social isolation causes the same part of the brain to light treating pain, it is felt that this combination should be helpful, up on functional magnetic resonance imaging (MRI) as in but the evidence regarding the efficacy of this combination of physical pain; the pattern of responses are similar and therapies is limited.20 reproducible. Social pain and physical pain are essentially An extensive Cochrane Review regarding its applicability one and the same. This adaptation may be part of the to depression concluded that the data is promising but not evolutionary process that allowed the more social species robust enough to specifically recommend it compared with to survive.24 treatment as usual.19 The interaction with other people is a powerful way of creating a shift out of pain pathways as well as diminishing Problem-Focused Cognitive Behavioral Therapy the activity in the pain center.23 One study reported that By definition, all CBTs are problem-focused. The treatments teacher-administered CBT could decrease depression, anxi- are always targeted for specific issues and outcomes. Al- ety, and impulsivity in high-risk students.25 though anxiety is universal, CBT focuses on specific thoughts and behaviors around anxiety. Phobias would require an even Self-Administered more-specific approach.21 Bibliotherapy is the use of reading materials to learn and Brox’s group conducted a randomized prospective study implement CBT without the guidance of a mental health comparing a focused CBT for physical activation compared professional. Studies have reported a high success rate in with a spine fusion for low back pain. CBT was comparable to treating anxiety and depression with just this approach fusion surgery but at 1-year follow-up, there was less fear alone.26 Without access to mental health care, a self-admin- avoidance in the CBT group.2 A longer-term follow-up (4 istered approach can be considered as an option. years) of the same protocol confirmed these findings.1 Another platform for self-directed CBT is the Internet. A A prospective randomized study compared early rehabili- systematic review looked at how a computerized format tation after a lumbar fusion. One group was placed into a might be accepted in rural areas. The authors concluded it structured exercise program and the other into exercise plus was a viable and effective platform and that rural patients CBT geared toward modifying maladaptive pain conditions, might be more open to it than to face-to-face contact with behaviors, and motor control. This combination was termed practitioners.6

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For a patient, taking responsibility for the present situation • Mental and physical pain is sensed in close proximity with would logically be helpful for a successful long-term outcome. similar reaction patterns on functional MRI.24 One way of assessing this responsibility is the “locus of control” • Back pain circuits shift from the nociceptive center to the concept. Patients with an external locus of control look to the emotional center within 12 months of onset.34 environment as their source of happiness; patients with an • The neuroexcitatory effect of prolonged cytokine immune internal locus of control look inward for life satisfaction.27 When response leads to a “wind-up” increased pain response. using screening tools, determining the patient’s locus of control • With sustained pain, patients feel trapped and angry. The may be helpful. If a given patient refuses to engage in these tools resultant chemical hypersensitivity and inflammatory re- and still demands treatment, it is a clear indication that he or she sponse create a multitude of physical symptoms in addi- has an external locus of control. This scenario is a catch-22 of self- tion to magnifying the pain.35 directed care in that one of the aims of CBT is to develop a sense • Pain pathways, mental and physical, are structurally im- of responsibility and internal locus of control.28 bedded (central sensitization), and it takes neuroplastic reorganization to recover from chronic pain.36 Expressive Writing—with or without Cognitive Behavioral Therapy To successfully treat chronic pain, interventions that stim- An approach that has been studied extensively in 200 pub- ulate neuroplasticity to rewire the brain and also to calm lications since 1982 is the use of expressive writing. The original down the nervous system are warranted. All the factors that study by Pennebaker reported the course of volunteers who affect pain should be addressed to optimize the outcome were asked to write about an adverse life experience in detail.29 (►Table 1). CBT can be helpful in treating each of these They were asked to write for 20 minutes, 4 days in a row. The variables either directly or by improving compliance with control group just recorded the day’s events. A 2005 review care. article of the impact of this simple exercise reported improved immune system function, fewer stress-related visits to the Cognitive Behavioral Therapy and Sleep doctor, reduced blood pressure, improved lung function, fewer Poor sleep quality is common in patients suffering from inpatient days in the hospital, improved mood/affect, feeling of chronic pain. It is debated whether lack of sleep exacerbates greater psychological well-being, less depressive symptoms the pain or the pain prevents sleep.37 Regardless of the source before exams, reduced absenteeism from work, quicker reem- of insomnia, it is important to address it as part of the ployment after job loss, improved working memory, improved treatment program. One study suggests that poor sleep sporting performance, higher student grade point average, and quality is a better predictor of disability than the actual altered social and linguistic behavior.30 There was also improve- severity of the pain.38 ment in chronic pelvic pain as well as a decrease in sleep latency. A small prospective study looked at the effect of expressive Effect of Cognitive Behavioral Therapy in Addressing Sleep writing on the effectiveness of physical therapy. There were There are various stepwise approaches to address sleep 20 patients in each group. The writing cohort showed signifi- disturbance. Sleep hygiene refers to a set of strategies that cant improvements in pain, posture, and overall sense of well- improve the chances of falling asleep, such as avoiding being. Pain continued to decrease 6 months later only in the caffeine in the afternoon, not having a clock in the bedroom, writing group.31 only going to bed to sleep when you are tired, among other. CBT may be combined with expressive writing. There is However, it is more difficult to obtain adequate sleep when some evidence that it is more effective when combined with experiencing pain. Sleep medications may be required for a positive expression. Some advocate just writing a stream of defined period of time to break the cycle. CBT can be directed consciousness. Although expressive writing is often used with at insomnia or the depression and anxiety that may be the CBT, it is a different entity. CBT is based on challenging cause of insomnia. CBT-I (CBT-insomnia) is an example of a disruptive thought patterns and beliefs. The writing increases problem-focused therapy intended to improve the quality of the awareness of the negative thoughts, which is increasingly sleep.4 One study suggests that patients who have a successful seen as important for mental health.30,32 resolution of their depression have a much lower relapse if they are sleeping well.39 Cognitive Behavioral Therapy’s Role in Treating the Factors Affecting the Perception of Chronic Low Back Managing Stress: Role of Depression and Catastrophizing Pain in Exacerbating Chronic Pain The emergence of sophisticated functional MRI has allowed Linton did a meta-analysis of the link between psychosocial researchers to describe the neurologic basis of chronic pain. stress and chronic pain.40 He collected 913 articles, with the The nervous system is involved in the transition from acute to resultant meta-analysis utilizing 37 studies. Linton reported a chronic pain. Several basic changes have been reported: significant association between stress and pain and poorer outcomes of spine surgery in stressed patients.40 A review • There are changes in both gray and white matter in pain documented the relationship between depression and cata- processing regions. The pain brain map grows and the strophizing with rheumatologic disorders.3 Catastrophizing motor cortex map shrinks. Fortunately, these maps can be is reported to increase pain and decrease the effectiveness of reversed with treatment.33 biomedical interventions. Prolonged stress has a profound

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effect on almost every organ system including the immune Richmond et al conducted a meta-analysis comparing CBT system and inflammatory response.3 to usual care/wait list and guideline-based treatment for Carragee et al conducted a 5-year prospective study in CLBP. They included any duration of low back pain and all volunteers with persistent back pain.41 The researchers age groups. The significant benefits in decreasing pain and documented MRI findings and performed diskography in disability and improving quality of life were maintained at 25 patients. He demonstrated that psychosocial variables longer-term follow-up. Although the various types and ad- strongly predicted both long- and short-term disability ministration of CBT were documented, the results were events. He used the DRAM index, which is a combination of reported for the general category of CBT.65 a depression and somatization scale and the fear avoidance questionnaire. There was no correlation of the disk pathology Life Outlook—Cognitive Distortions with the development of disabling pain, except for a mild CBT identifies various common cognitive distortions that in correlation with the presence of Modic changes.41 chronic pain may become deeply ingrained and evolve into an Multiple studies have reported the poorer outcomes reinjury conviction and anger. Unrelenting anger may create a garding pain and function in the presence of coexisting hypervigilant state of arousal and adds to the magnitude of depression, catastrophizing, and fear avoidance belief.5,42,43 the pain. Eventually it evolves into rage.49 One study reported some improvement in mental health if Whether the original series of events that created the the surgery is successful.44 chronic pain were valid or become distorted over Several studies have reported that the use of presurgical time makes no difference. The ongoing bodily reaction of psychological screening can help predict surgical outcomes. anger creates a series of undesirable sequelae. One of The Texas Back Institute reported 82% accuracy in predicting those is “blame,” also referred to as an “external locus of a positive surgical outcome.45 Chou and Shekelle did an control.” Possibly one of the most important factors in extensive literature review (1966 to 2010) on the predictors determining long-term success in addressing chronic for developing persistent low back pain. The most effective pain is achieving a transition from an external to an internal components were maladaptive pain coping behaviors, non- locus of control.27 organic signs, functional impairment, general health status, A 2003 study reported a link between the hyperarousal and presence of psychiatric comorbidities.46 state of being angry and increased levels of pain. A majority of Most surgeons currently are not routinely evaluating patients remained angry with the person or situation that psychosocial risk factors and they may have a limited ability created the pain.50 Interestingly, one study showed that to do so.47 Daubs et al64 prospectively administered a DRAM patients were commonly angry at themselves. It was sug- index to a cohort of orthopedic spine patients in a clinical gested that CBT could improve pain by addressing the de- setting. However, the overall sensitivity for detecting patients pression around pain and anger.51 with high levels of distress was low. Using CBT to treat One prospective study concluded that there was a higher depression and catastrophizing was felt to be a meaningful external locus of control in treated patients versus those who intervention. were waiting to be treated with physical therapy. It raised the A meta-analysis compared the effectiveness of treating question of the providers reinforcing this belief system.52 anxiety compared with a psychological placebo and a waiting The locus of control can be switched in a multidisciplinary list group. There was moderate evidence that CBT was effec- pain clinic setting. This setting usually includes a form of tive in treating anxiety. The study suggests that the beneficial psychological intervention, but it is unclear whether CBT effect in the treatment of pain is mediated through decreased alone can accomplish this shift.53 pain catastrophizing.8 Interestingly, one study showed that In a review article, Vlaeyen and Linton wrote that fear of engaging patients in a graded physical conditioning program pain was more of a problem than the actual pain experience. could decrease catastrophizing without the use of CBT. CBT The resultant fear avoidance behavior reinforces chronic pain alone was also effective in reducing it. As patients gained and disability.54 more confidence in their ability to move, they were able to One foundational concept of CBT is to systematically calm themselves down.5 identify and challenge these distortions in thinking. Then the next steps of substituting more rational thoughts Cognitive Behavioral Therapy and Physical Health versus engaging in mindfulness or other options depends Edwards et al summarized the effects of depression and on the therapist’s approach. Catastrophizing is one of the catastrophizing on diminishing efforts to engage in healing cognitive distortions that has been associated with a poor behaviors.3 There was a strong effect in blocking positive self- prognosis.3 directed interventions. They cited references regarding knee If a patient has deep anger or rage, the capacity of the arthritis, medication noncompliance, lack of weight control, patient to listen and understand may be compromised. The and insufficient exercise among other self-destructive role of anger in creating depression and pain catastroph- behaviors. izing is beyond the discussion of this article. CBT is one Another prospective study demonstrated that an Internet- tool but, for example, if a patient has a history of severe based CBT program could be helpful for patients with residual trauma, more sophisticated and focused strategies must be symptoms after physical rehabilitation.48 utilized.

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A Framework of How Cognitive Behavioral Therapy Chronic Pain—Multidisciplinary Approach May Be Implemented for Patients with Chronic Low Should a patient’s pain persist more than 3 months, a Back Pain multidisciplinary approach is preferable. At this point, there As part of this review, we evaluated different types of CBT, as are almost always more substantial issues that require pro- well as methods and formats of delivery. A multipronged fessional assistance. CBT can be administered either in a rather than a multidisciplinary approach is suggested. group or an individual setting. Ideally, all the aspects of pain are addressed in these sessions.60 Possible Treatment Paradigm Finally, the ultimate goal for long-lasting successful The need for early identification of (and intervention for) at- outcomes is for the patient to develop an internal locus risk patients with chronic pain has been documented in the of control. Although the above-mentioned approach may literature for decades. Waddell reported a return to work rate work for a while, it is not sustainable unless the patient of less than 5% if a patient was disabled for more than takes full responsibility for his or her care. A challenging 2 years.55 Therefore, the goal of care for any patient in pain paradox arises when patients who have a strong external is to quickly treat the acute phase and prevent it from locus of control, such as a strong injury conviction, will not becoming chronic. It is noteworthy that in one study 50% of engage in any of the strategies needed for healing. CBT may the acute group progressed to CLBP.34 help shift the locus of control but alternate approaches may From a human suffering and cost perspective, patients at be needed. risk for developing chronic pain can actually be identified at In general, it seems desirable that a methodological the time of presentation. A small percentage of patients are approach that addresses mental health factors is utilized responsible for over half of all health care costs.56 Fear in every patient prior to the use of any invasive elective avoidance is consistently identified as a risk for disability.57 procedures. Distressed patients are more vulnerable to A 2008 meta-analysis also showed that worker expectations adverse events when undergoing procedures.61 The United have significant impact on return to work for nonspecificlow States Preventive Services Task Force recommended the use back pain.57 Early identification is important, and examples of of routine presurgical psychological screening if resources validated questionnaires to accomplish this task include the are available to address the identified problem.62 To date, DRAM index,44 Fear Avoidance Behavior Questionnaire only a minority of surgeons have implemented this (FABQ),42 and the Battery for Health Improvement (long practice.47 and short form).58 This process could be accomplished at the primary care level. Interestingly, one study showed that Future Research to Better Specify the Effectiveness of primary care physicians who expressed a special interest in Cognitive Behavioral Therapy for Treating Chronic Low musculoskeletal care were more likely to have faulty belief Back Pain systems regarding the management of low back pain.59 It is The evidence that psychosocial factors negatively affect out- also important to understand that mental and physical pain comes of any treatment is irrefutable.40 Yet few surgeons are processed in the same part of the brain and should be assess or treat these issues.47 Methodologies should be treated in a similar manner.24 developed and documented to ensure that every patient has mental health disorders defined and treated before Acute and Subacute Pain—Multipronged Approach undergoing elective procedures, especially in more invasive If a patient has acute pain and is at low risk for developing procedures such as spine fusions. The utilization of mental chronic pain, then simple symptomatic care should be health screening and follow-up therapy might be of interest sufficient. However, if there are risk factors and/or the from a public health perspective. pain persists for more than 6 weeks, then additional The term cognitive behavioral therapy used in isolation interventions should be implemented targeting all the should probably be discarded. Future research should always relevant factors affecting the situation. Linton, in a system- identify what aspect of a person’s problem is to be addressed atic review, found that psychological factors influenced by what type of CBT. By definition, CBT always targets a development of chronic neck and back pain for acute, specific set of behaviors and/or thought patterns. Many of subacute, and persistent pain.40 these affect the perception of pain. The questions should be, Linton also demonstrated a ninefold decrease in long-term “Did the CBT successfully treat a given variable? If so, how did disability with a six-session CBT intervention in acute and the resolution of that specific problem affect the CLBP? How subacute patients with spinal pain compared with patients many issues need to be solved before the pain resolves? Are only given information in pamphlets. This approach can be there core problems that are more important to address applied to primary care settings.40 first?” Only by breaking CBT down to specific focused out- Resources to address the cognitive and behavioral issues comes will we better understand its role in treating CLBP. are easily available and do not require a full pain clinic setting One important challenge is the development of resources to implement. Treatment can be accessed through books and and pathways to enable early identification and treatment of the Internet. Delivery can be given in a group setting, self- at-risk patients. Different validated questionnaires exist to administered, or administered individually by nontraditional profile this risk, and treatments could be made readily providers such as nurses, occupational therapists, and physi- available. We recommend that future research focus on cal therapists. methodologies to implement and sustain known effective

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treatments, which would hold true for focused CBT as well as 8 Zhu Z, Zhang L, Jiang J, et al. Comparison of psychological placebo addressing other aspects of chronic pain. Questions include: and waiting list control conditions in the assessment of cognitive behavioral therapy for the treatment of generalized anxiety • Who can develop these systems and tools and sustain disorder: a meta-analysis. Shanghai Arch Psychiatry 2014;26(6): them? 319–331 • What payment model must be developed to make these 9 Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and direc- types of nonprocedural treatments equitable? tions for research. Am Psychol 2014;69(2):153–166 • What percent of money spent on procedures with poorly 10 Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of documented outcomes should be spent on strategies that psychological interventions for chronic low back pain. Health are effective? 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Global Spine Journal Vol. 5 No. 6/2015 504 Cognitive Behavioral Therapy to Treat Chronic Low Back Pain Hanscom et al.

Editorial Perspective

Our reviewers were appreciative of the attention placed on development of chronic pain to facilitate early interven- the topic of CBT by Hanscom and colleagues, as use of these tion rather than requiring late and costly interventions. In forms of therapy should be very important to spine care light of the high direct and indirect costs of low back pain professionals and have been largely unappreciated in the care, the integration of such mental health and distress past. The initially submitted idea for a Systematic Review of screening programs into the basic primary care evalua- CBT regarding CLBP management turned out to be impos- tions would be of high public health interest. sible to perform in light of the magnitude and diversity of • CBT is not one single entity but an array of therapeutic the literature on this subject. After discussions with the interventions directed at speciﬁc aspects of patient dys- authors, Evidence-Based Spine-Care Journal (EBSJ)/Global function. This distinction is important as future research in Spine Journal (GSJ) agreed to a resubmission of the study as spine using CBT-type intervention can be rightfully a Narrative Review on the topic of cognitive behavioral expected to provide more differentiated details on the health in the management of CLBP. Hopefully, the reader- type of therapies administered and the timing and ship will agree that the authors provide a helpful introduc- duration of such interventions. tion and overview of this area of care. There are several • Attempts at comparing surgical treatment for CLBP and valuable take-home points from this article: CBT are probably misguided. There is little reason to not • Concepts of pain, and especially chronic pain, are probably make some form of CBT part of routine elective spine care not adequately taught in medical schools around the and utilize screening tests to better identify patients at risk world. These subjects are certainly not part of the curricu- for poor outcomes based on psychosocial comorbidities. lum in the training of most spine surgeons. Similarly, identifying risk factors for the emergence of chronic pain EBSJ/GSJ thanks the authors for their efforts at educating are also not part of routine medical practice. This article spine surgeons around the world on this important topic and highlights that in the future, primary care providers ideally hopes that they will use this platform for more in-depth would be trained to identify patients at risk for the studies on this topic.

Global Spine Journal Vol. 5 No. 6/2015 October 1, 2016

Southern Pain Society New Orleans - 2016 Non-opiates for Chronic Pain Management

Harry J. Gould, III, M.D., Ph.D. Department of Neurology LSU Health Sciences Center, New Orleans Director, Pain Mastery Center of Louisiana

Disclosures

Speaker has nothing to disclose

1 October 1, 2016

Initial Considerations

• What is your first thought?  Is this person a drug seeker or drug addict?  What am I going to give him/her for the pain? • Medications are the easiest form of treatment for physicians and are often their first thought  when considering pain the analgesics are the logical choice  “pain meds” the opioid and non-opioid analgesics  most familiar, greatest training  BUT – many times ‘pain meds’ are the most problematic Will I be able to treat at all?

Initial Considerations

• In many cases pain is acute, incidental, simple to assess and readily treated by any healthcare professional without difficulty. • Unfortunately, simple complaints presenting with acute pain may result from more significant problems that if not adequately assessed, accurately diagnosed or effectively treated may become a life-long problem affecting the patient, the family, and society as a whole. • Important to conduct an unbiased and comprehensive assessment • Important to consider alternative options, non-pharmacological options and adjuvant medications early in the treatment plan • Important to get the patient involved

2 October 1, 2016

Objectives

• Be able to identify essential elements of a comprehensive pain evaluation that are often overlooked yet important in developing an effective treatment plan • Understand the importance of the multidisciplinary approach to pain care • Be able to list non-opioid pharmacologic treatment options and alternative therapies • Be able to develop a rationale treatment plan that may eliminate the need or minimize the amount and duration of opioid use

Pain Evaluation

• Quality, intensity, location, distribution, temporal pattern, and duration

• Consider known pain syndromes and pathophysiology

Verbal Pain Intensity Scale

No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain

0–10 Numeric Pain Intensity Scale

0 1 2 3 4 5 6 7 8 9 10

No Moderate Worst pain pain possible pain

3 October 1, 2016

Pain Evaluation

• Pain quality helps determine which of the major classifications of pain might be involved in the presenting complaint • A place to start for selecting pharmacologic options  nociceptive, neuropathic, psychogenic, idiopathic • Since many common painful conditions include pain of both neuropathic and nociceptive quality and may also include a psychogenic component, it is important to at least consider the use of alternative treatments and adjuvant medications early in the management of any pain problem

Pain Evaluation

• Results of previously attempted treatment options  What has worked in the past for this and other pains? • Exacerbating and ameliorating conditions  Are there things you can do to make the pain better?

4 October 1, 2016

Pain Evaluation

• Comorbid medical conditions, previous and current level of functioning, and psychosocial situation  What would you like to do most that your pain keeps you from doing?  How much pain relief would make that possible?  Are you employed? At what? How does pain affect your work?  Do you have any hobbies? What are they?  Do you have a spouse, children, pets? How does pain affect them?  How well do you sleep?  Provide a baseline for developing a reasonable treatment plan, for establishing rational expectations and evaluating treatment success.

Stratifying Risk

Low Risk Moderate Risk High Risk • No past/current • History of treated • Active substance history of substance substance abuse abuse abuse • Significant family • Active addiction Noncontributory history of substance • Major untreated abuse • family history of psychological substance abuse • Past/comorbid disorder psychological • No major or untreated Significant risk disorder • psychological to self and disorder practitioner

• (Webster and Webster , Pain Med 2005)

5 October 1, 2016

Treatment Considerations Comprehensive Therapeutic Strategy

• Where possible treat the underlying cause • Choose appropriate treatment modality – pharmacologic (non-opioid, opioid, adjuvant), surgical, anesthetic, stimulation, psychological, physiatric • Address co-morbid conditions and psychosocial situations • Assess risk and apply Risk Evaluation and Mitigation Strategies (REMS)

Non-pharmacologic Options Non-invasive

• Training in alternative forms of coping and pain control, e.g., meditation, guided imagery, self-hypnosis and relaxation • Physical modalities – topical ice/heat, massage • Physical evaluation to determine a routine regimen for improving strength, range of motion and endurance. Gradual steady progress – NOT “no pain, no gain” • Consider work and living environment. Tailor to minimize but not necessarily eliminate ergonomic stress and over-exertion; eliminate high risk conditions • Plan for participation in social activities and encourage participation in hobbies and things enjoyed

6 October 1, 2016

Non-pharmacologic Options Non-invasive

• Regular healthy diet with a goal to optimize BMI • Encourage daily activity. Regular progression of activity from baseline to 30-60 min/day tailored to patient’s ability to tolerate activity without backward slide • Schedule time for self • Encourage good sleep hygiene • Offer patient the opportunity to suggest possible options in their treatment plan • Education of patient, family members, care-givers about the treatment plan, condition being treated and the importance of monitoring response

Pharmacologic Options

• Previous approach utilized analgesic medications to treat painful syndromes, e.g. low back pain, trigeminal neuralgia, cancer pain, post- herpetic neuralgia. • Current approaches employ symptom identification and management through the multimodal modification of presumed mechanisms underlying the transduction, transmission, modulation, perception, interpretation and behavior associated with nociception, and the ability to match the mechanism of action of potential treating agents with the condition to be treated. Using this approach several options for pain management have been introduced had heretofore not been considered.

7 October 1, 2016

Pharmacologic Options Sites Affecting Signal Transmission

• Alter stimulus transduction or neuronal firing thresholds • Modify action potential generation and conduction • Alter the release of neurotransmitters from primary afferent terminals • Reduce the dedicated transmission of signal through the central nervous system • Modifiable mechanisms  sodium channel modulation, intracellular calcium augmentation, central inhibition, modify membrane sensitivity and correction of underlying patholophysiology of disease

Non-opioid Pharmaceuticals Weak Analgesics

• Acetaminophen, aspirin, NSAIDs, Cox-2 selective NSAIDs • Generally the first choice for nociceptive pain • Use lowest effective doses for limited periods of time  prudent pre-emptive dosing may be help in reducing overall dose • Remember weak analgesics have an analgesic ceiling. Dosing above the analgesic ceiling significantly increases the risk of adverse events without improving analgesia. Counsel patient to beware of over the counter medications that frequently contain doses of weak analgesics as part of the combination formulation.

8 October 1, 2016

Non-opioid Pharmaceuticals Adjuvant Medications

• Adjuvant medications have analgesic properties although they were designed and approved for treating conditions other than pain • Generally the first choice for neuropathic pain • Adjuvant medications frequently produce analgesia at doses below those recommended for treating the condition for which the drug was designed • The selection of adjuvant medication is guided by an understanding of how nociceptive processing is altered by injury and disease and the ability to match the adjuvant’s mechanism of action to be able to modulate the change

Non-opioid Pharmaceuticals Adjuvant Medications

• Most adjuvant medication have similar efficacy. Thus, selection is frequently based on desired adverse effect profile that can be beneficial in managing a co-morbid condition or avoided if potentially problematic  anti-epileptic medications – neuropathic adjuvants that also treat seizures  tricyclic anti-depressants – neuropathic adjuvant that produce somnolence and help with insomnia • We should keep in mind that direct modification of one pathway may significantly affect other aspects of pain processing indirectly. Give sufficient time to determine the extent of drug effectiveness.

9 October 1, 2016

Non-opioid Pharmaceuticals Adjuvant Options

• Anti-convulsants – older formulations  gabapentin, pregabalin, oxcarbazepine, carbamazepine, lamotrigine, lacosamide, topiramate, levetiracetam, zonisamide, clonazepam, phenytoin • Anti-convulsants – newer possibilities  vigabatrin, ezogabine, clobazam, perampanel, eslicarbazepine, brivaracetam • Anti-convulsants have been associated with an increased risk of suicidal ideation

Non-opioid Pharmaceuticals Adjuvant Options

• Anti-depressants  tricyclics – amitriptyline, nortriptyline, doxepin, desipramine  SNRI – duloxatine, milnacipran, venlafaxine, desvenlafaxine  SSRI – fluoxetine, paroxetine, sertraline, citalopram, escitalopram • Anti-spasmodics – tizanidine, baclofen • Anti-hypertensives – clonidine • Local anesthetics – lidocaine, mexilitine • Anti-anginal agents – ranolazine • NMDA-agonists – memantine, dextromethorphan, ketamine • Miscellaneous – capsaicin, cannabanoids, ziconotide

10 October 1, 2016

Non-pharmacologic Options Interventional/Invasive

• Minimally invasive  percutaneous electrical nerve stimulation (TENS), acupuncture, cryotherapy, epidural/intrathecal infusion • Surgical intervention  surgical decompression, deep brain/motor cortex stimulation, lysis of the dorsal root entry zone, myelotomy • Timing for invasive therapies depends on diagnosis, functional impairment and prognosis for survival

Principles of Pain Management Study Case

• A 56 year old male presents to clinic with a complaint of “severe” back pain. The patient had been experiencing daily low back pain that began approximately 6 years ago after a lifting injury at work. The pain was generally deep and achy and was initially managed with OTC analgesics at an intensity level averaging 3/10. Over the last 5 years the intensity of pain had increased, now requiring daily dosing of “maximum” doses of ibuprofen to maintain a level of 3/10. Three days ago the patient experienced an episode of coughing and sneezing during which he felt a sharp, stabbing pain and spasms his the low back.

11 October 1, 2016

Principles of Pain Management Study Case

• The patient’s pain levels spiked to 9/10 in intensity with best levels reaching only 6/10. Only with great difficulty was he able to move and ambulate. He has been treating the pain unsuccessfully with ibuprofen – 2 tabs every 3 hours, extra strength acetaminophen – 2 tabs every 4 hours and warm water soaks. He called for an appointment because yesterday he noticed a new burning pain that extends into his left leg.

Principles of Pain Management Study Case

• His wife died of cancer about 5 years ago. • He now lives alone with his Labrador retriever, his companion for 12 years. They enjoyed going for walks but this recent pain has kept that from happening. • He runs a local hardware store with his son who has begun to take over the business; fortunate because he has needed to miss some work. • He enjoys being outdoors and working in his garden; not in last 2 years. • He usually sleeps 6-8 hrs per night but now that is interrupted by pain. • ”What else would you like to know?”

12 October 1, 2016

Pain Evaluation What Do We Need to Know?

• Why does the patient have pain? Why now? • Is it a new problem or an exacerbation of a pre-existing condition? • How might the patient’s current condition, planned diagnostic testing, treatment or clinical intervention affect any pre-morbid pain condition or management protocol? • What is the likely underlying cause and how it is being and/or has been managed? • Are there complicating medical co-morbidities or psychosocial situations that may affect the pain complaint or treatment? • What was the patient’s baseline prior to the current problem?

Principles of Pain Management Study Case – Past Medical History Current Medications

• Medical Conditions • Medications  Hypertension  Lisinopril  Hypercholesterolemia  Atorvastatin  Esophageal reflux  Furosemide  Father died of MI  ASA 81mg  Mother died of breast cancer  Lorazepam  30 pk/yr smoker  OTC analgesics, Cold/Flu preps as needed

13 October 1, 2016

Principles of Pain Management Study Case – Physical Exam

• Restless, agitated and demonstrates dyspnea at rest • Antalgic gait with difficulty getting onto exam table • Mildly obese with dyspnea exacerbated when getting onto exam table • Subcutaneous petechia and ecchymotic patches • Mild dependent edema • Palpation of spine reveals lumbar tenderness with paraspinal spasms • Remainder of exam normal with the exception of  heart sounds: RRR, S3; lungs: diminished breath sounds mild wheezing; neurologic: guarding, normal strength, sensation, reflexes  allergies: NKA  BP: 157/88 (RA, sitting); HR: 105; RR: 22; T: 98° F; BMI: 32

Principles of Pain Management Study Case – Diagnostic Evaluation

• MRI of lumbosacral spine – mild left L4/L5 disc bulge • Chest X-ray - normal • Abdominal CT – normal • Consider EMG/NCS and sleep study • Serum chemistry – Cr: 1.7

14 October 1, 2016

Principles of Pain Management Study Case – Setting Goals

• What are we treating?  acute herniated nucleus pulposus  chronic low back pain strain  depression and possible unresolved grieving issues  polypharmacy medication duplication  addressing co-morbidities  hypertension  mild renal insufficiency  insomnia  current smoker; possible COPD  GI reflux

Principles of Pain Management Study Case – Setting Goals

• Treatment goals  manage acute pain  improve function – increase activity, reduce work absences  address psychosocial concerns  address co-morbid pathology – hypertension, renal insufficiency, possible COPD, insomnia  address concerns about polypharmacy and medication duplication

Goal – ”First, do no harm” – reduce pain levels, increase psychosocial functioning, and improve quality of life

15 October 1, 2016

Principles of Pain Management Study Case – Treatment Plan

• Consider intervention with epidural steroid injection for acute pain management • Pharmacologic considerations – check prescription monitoring program and risk assessment  D/C ibuprofen, OTC Cold and Flu, acetaminophen, lorazepam  zonisamide 100 mg at bedtime (AE – weight loss); consider topiramate or gabapentin pending response  add tizanidine 4 mg at bedtime for spasm and sleep • Non-pharmacologic treatments  warm water soak 30 minutes after ibuprofen 200 mg, 2 tabs  liniment of choice topical  walking daily, increase duration and distance slowly as tolerated

Principles of Pain Management Study Case – Treatment Plan

• Additional assessment  psychiatric evaluation for mood, unresolved grief and coping status  consider sleep study and pulmonary function test • Patient education  discuss the dangers of self-medication and the use of multiple medications that can produce additive or antagonistic effects  OTC combination drugs with ‘hidden’ ingredients • Keep a daily pain record • Return to clinic in 2 weeks with family member if possible

16 October 1, 2016

Monitoring Treatment Four “A’s” of Pain Reassessment

• Analgesia “Faces” Scale  monitor pain intensity  pain rating scales  patient diary 0 1 2 3 4 5  brief pain inventory including perceived improvement  mood rating  how much relief and how long does it last? • Activities of Daily Living  determine functionality and quality of life, including interpersonal relations and work disturbance

Monitoring Treatment Four “A’s” of Pain Reassessment

• Adverse effects – when do they occur?  decreased functionality and quality of life  lead to systemic side effects  interfere with compliance, resulting in increased pain intensity  increase psychological morbidity  impede progress toward rehabilitative goals, affect work habits • Action  continue or modify treatment  change, titrate, adjust medication, manage side effects  discontinue treatment

17 October 1, 2016

Principles of Pain Management Study Case – 2 Week Follow-up

• Analgesic assessment  pain better controlled – range 2-6/10, average 4/10  burning pain has decreased but is still disturbing  sleeping better without morning hangover; awakened less by pain • Pharmacologic assessment reveals no adverse effects • Non-pharmacologic assessment  walking daily, 15 minutes at a slow pace without pain exacerbation or shortness of breath

Principles of Pain Management Study Case – 2 Week Follow-up

• Physical assessment  patient appears more comfortable with minimal agitation and no dyspnea at rest  BP: 142/84 (RA, sitting); HR: 85; RR: 18; T: 98° F; BMI: 32; Cr: 1.2  lumbar tenderness and paraspinal spasms have improved • Is scheduled for counseling to address depression • Son is present and reports that his father has been less irritable at work, has missed fewer days and has not exhibited excessive drowsiness

18 October 1, 2016

Principles of Pain Management Study Case – 2 Weeks Follow-up

• Pharmacologic treatments  increase zonisamide to a max. of 400 mg at bedtime as tolerated  continue tizanidine 4 mg at bedtime  naproxen 200 mg at bedtime • Non-pharmacologic treatments  continue daily walks and warm water soak regimen  physical therapy evaluation for routine exercise program to improve strength, endurance and range of motion  elicit patient thoughts on treatment needs and progress to goal • Family education on current status, reducing fall risks in home (throw rugs, cane support) and how to support and monitor progress • Follow-up in 4 weeks