Guest article - Treating chronic pain in primary care settings

by Chad Morrow, Psy.D.

Over 70% of people suffering from psychological and behavioral disorders are treated in a primary care facility by their primary care provider (Gatchel & Oordt, 2003).  These statistics suggest that psychology has a primary role in integrating into primary care settings. Recently, psychologists have started to work in primary care settings and have begun to conduct studies to support the use of modified psychological interventions for depression, anxiety, sleep difficulties, and even PTSD (Bryan, Morrow, & Appolonio, 2009; Corso, Bryan, Morrow, Appolonio, Dodendorf, & Baker, 2009).  The purpose of this post is to discuss an empirical study that focuses on the use of modified behavioral/psychological interventions in a primary care setting with a population of patients suffering from chronic pain. 

Current empirical literature is robust with examples of how psychological and/or behavioral difficulties can impair the ability to cope with chronic pain.  The potential impact of chronic pain is great and may involve the following; negative self-talk and/or cognitions, sleep disturbances, and lost time at work. Also, these associated problems/difficulties can lead to increased distress, decreased activity, loss of motivation, and increased isolation. Further, this cycle can be predictive of higher pain intensity, lower tolerance of painful procedures, higher analgesic use, and greater psychological distress and psychosocial dysfunction (Thorn, 2004; Thorn, et al, in press; Nicholas et al, 1991). Simply put, when people who suffer from chronic pain also experience psychological and/or behavioral difficulties, it can significantly worsen their quality of life (McCracken, MacKichan, & Eccleston, 2007).    

Current literature demonstrates the effectiveness of psychological/behavioral treatments in alleviating this suffering through the delivery of “standard” behavioral health or psychological services (e.g., 4-12, 50 minute appointments) (Dahl, Wilson, & Nilsson, 2004. ; McCracken, MacKichan, & Eccleston, 2007 McCracken, Vowles, & Eccleston, 2005, Nicholas et al, 1991;Thorn 2004; Thorn, et al, in press; Wicksell, Dahl, Magnusson, & Olsson, 2005).  Few studies have investigated the effectiveness of treating chronic pain and its associated psychological/behavioral difficulties in other types of settings (i.e., primary care settings) with briefer interventions/appointments.  Given the difficulties that  many chronic pain patients face and the significant number of chronic pain patients  seen in primary care settings, this study’s purpose was to examine the effects of brief, behaviorally-oriented treatment  on  negative mood and functioning associated with chronic pain.

Mental health professionals in this study served as Behavioral Health Consultants (BHCs), who were embedded consultants within the primary care clinic, allowing for true integration of health care. Patient contact with a BHC is brief and problem-focused, typically meeting with patients for one to four appointments, 15 to 30 minutes in duration. Patients were referred to the BHC by their primary care physicians (PCPs) when psychosocial health issues were identified during medical appointments. This study included 71 primary care patients referred for chronic pain and subsequent psychological/behavioral difficulties.  Patients participated in 1 to 4 brief, behaviorally-oriented appointments in primary care.

We hypothesized that patients with chronic pain would demonstrate clinically meaningful improvements in psychological symptoms and life functioning in 2 to 4 BHC appointments. Patterns of symptomatic and functional change were measured through the Behavioral Health Measure-20 (BHM) (Kopta & Lowry, 2002).  The BHM-20 was completed at each appointment. Follow-up appointments were determined collaboratively by the patient and BHC based on current level of functioning, clinical judgment, and patient preference, and typically occurred in two-week intervals. Modified interventions included, but were not limited to, a biospsychosocial explanation of chronic pain, behavioral activation, mindfulness skills, relaxation skills, environmental manipulation skills, and simple cognitive restructuring.

Results of this study suggest that patients improve on measures of subjective well-being, emotional symptoms, and global mental health. In other words, patients appear to improve on psychological measures and experience less emotional distress after 2-4 brief BHC interventions.  Interestingly, patients do not appear to improve in life functioning from 2 to 4 brief, behavioral interventions.  In other words, brief interventions do not appear to immediately result in changed lifestyles or increased functioning.

It is important to note that this study has several limitations that include the following; small total sample size (N=71), smaller sample size of patients who attempted multiple appointments (N=31), limited ability to generalize findings to specific pain populations (e.g., headache versus back pain), and the lack follow up to determine if improvements are maintained over time.

Despite these limitations, the patterns of clinical improvement lend initial support for the effectiveness of BHC interventions with chronic pain patients. Future research topics could include investigating the long-term outcomes of BHC intervention for patients with chronic pain, investigating if life functioning improves overtime as patients’ mental health continues to improve, investigating analgesic use of patients who receive BHC interventions to see if use decreases over time, determining/tracking if 1 appointment patients were immediately referred for more intensive evaluations (e.g., Clinical Health Psychology services/standard behavioral medicine interventions) or improved after 1 session (e.g., 1 appointment patients may represent a sub-population of less severe patients who immediately improve after initial visit), and determining if engagement in brief, BHC services increases the likelihood patients will follow up with more intensive behavioral medicine interventions.

Overall, the patterns of clinical improvement lend further support for the effectiveness of BHC interventions with chronic pain patients on subjective well-being, emotional symptoms, and global mental health (i.e., patients feel less psychological distressed).  Results also support future research in the area of treating chronic pain in primary care settings with brief, BHC-type interventions.

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The views expressed in this study are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, the Department of the Air Force, or the U.S. Government.

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Chad Morrow is a captain in the United States Air Force and the chief of the mental health clinic and ECAC/SERE psych services.  He also contributed the September 2009 Psychotherapy Brown Bag featured article.