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Pain Relief: Putting Pain Management in Your Client's Hands
by David Cosio, Ph.D., ABPP

3 CE Hours - $44

Last revised: 01/01/2019

Course content © copyright 2019 by David Cosio, Ph.D., ABPP All rights reserved.

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Learning Objectives

This is an intermediate level course. Upon completion of the course, mental health professionals will be able to:


The materials in this course are based on the book, Pain Relief: Managing Chronic Pain Through Traditional, Holistic, & Eastern Practices by D. Cosio (2018), published by Cedar Fort. The course contains the most accurate information available to the author at the time of writing. The scientific literature on chronic pain grows daily, and new information may emerge that supersedes these course materials. This course will equip clinicians to be able to advise patients and other providers on the most effective methods for managing the symptoms of chronic pain.

Introduction: State of Pain Management

The public health crisis in the U.S. has led to a call for change in the medical system. In the current system, the patient is defined as the one who suffers. Healthcare was designed with disease at the center, not people. The change to placing people at the center will require teaching people how to be healthier by integrating a variety of modalities. They will need to move away from the mentality of “fixing” enduring diseases such as chronic pain to one of “managing” it.

The current way of thinking about chronic pain management is changing as well. Medical professionals and the general public alike are adjusting to these new models of healthcare. Understanding more about this new approach can help improve treatment and ease the suffering related to chronic pain. This course is laid out in three general sections: pain education, treatment, and assessment. The objective is to put pain management into your client’s hands.

This course aims to empower licensed psychologists, social workers, professional counselors, and marriage and family therapists who work with patients who suffer from chronic pain. It is designed to share basic principles of pain relief and prevention, provide education about conventional interventions, introduce disciplines offering non-pharmacological and alternative interventions for relief of chronic pain, and promote self-management strategies. Thus, mental health providers will be better able to educate others about pain management, screen for chronic pain in their caseloads, and offer help to their clients who may be coming to their practice with distress related to their chronic pain. Once you complete this course, you will begin to understand the strong connection between mental health and pain.

As previously mentioned, this course has been adapted from the author’s recently published book (Cosio, 2018). Since this is an introductory course, there are places the reader will be referred to the author’s book for more detailed information.

Pain Was a Silent Epidemic

Until recently, pain was a silent epidemic. It is estimated that about 100 million people in the U.S. have chronic pain, and an additional 25 million suffer from acute pain. The incidence of chronic pain is higher than heart disease, cancer, and diabetes combined. Approximately 2/3 of people in pain have suffered for more than five years. The most common types of pain include:

We know that 36 million missed work in the last year due to pain. We also know that 83 million indicated pain affected participation in their activities of daily living.

Pain was believed at one time to be undertreated. I have a vivid memory of watching Geraldo Rivera doing an expose on the undertreatment of pain in nursing homes. Approximately 80% of nursing home residents who suffer from pain were found to be undertreated. About four out of 10 people suffered from moderate to severe pain and were unable to find adequate pain relief. We know that pain has a negative impact on an individual’s quality of life and on their mood. Depression is the most common reaction to chronic pain, while anxiety is the most frequent reaction to acute pain.

There are also medico-legal issues that pain-treatment providers have to consider. They must provide timely and effective management of pain. They must adhere to evidence-based and consensus guidelines and policies. Some providers are excessively liberal, while others are extremely conservative in their approach to the evaluation and treatment of individuals with pain. The goal is to have providers practice in a standard way, which is why it is important for them to maintain their knowledge and skills. Providers must also be timely, accurate, and thorough in their documentation while adhering to Health Insurance Portability and Accountability Act (HIPAA) guidelines.

Cultural Considerations

It was once believed that we as human beings differ in some ways in which we experience pain. It was widely thought in the 19th century that racial groups varied in their physiological experiences of pain. In fact, the diagnosis of “Dysaesthesia Aethiopsis" or "an obtuse sensibility of the body" was believed to be a genetic insensitivity to pain attributed to those of African descent. While clinical studies do report an ethnic difference in pain perception and response, and there are indeed differences within and between cultural and ethnic groups, minorities (African Americans, Latinos, Asians, etc.) currently remain at risk for inadequate pain control.

Several factors affect how an individual identifies with their ethnic or cultural group, including:

These factors may mediate the relationship between ethnic background and pain.

In terms of gender differences, we know that women generally report experiencing more recurrent, severe, and longer-lasting pain than men. The research also indicates that women have lower pain thresholds and tolerance to a range of pain stimuli. This is attributed to changes in sex hormones which moderate these differences. Women are more likely to participate in research studies and seek healthcare for pain than men. The research has also shown that men and women respond differently to opioid medications. However, multidisciplinary treatment produces similar treatment gains for both. There is greater female prevalence in painful conditions such as:

Women are also more likely to experience depression and to experience more physical conditions than men.

Advances in History

In 1996, the American Pain Society introduced “pain as the 5th vital sign.” Up to this point, there were only four, including pulse rate, temperature, respiration rate, and blood pressure. These vital signs indicate the state of a person's essential body functions. This initiative emphasized that pain assessment was as important as the evaluation of the other four standard vital signs. It stressed that providers need to take action when their patients report pain. The Department of Veterans Affairs (VA) recognized the value of such an approach and included it in their national pain management strategy. In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced standards for pain assessment and management relevant to multiple healthcare disciplines and settings. These standards stress the persons’ rights to appropriate assessment and management of pain (JCAHO Standard RI1.2.8, 2000) and emphasized that pain should be assessed in all patients (JCAHO Standard PE1.4, 2000).

Interestingly, the quality of pain care remained unchanged between visits before and after the pain initiative. No significant changes were witnessed in subjective provider assessments, pain exams, orders to assess for pain, new analgesics, changes in existing analgesics, other pain treatments, or follow-up plans as a result of this initiative. One study looked at why this may have occurred by comparing the self-report of 79 patients to the documented report about their care in their charts. Approximately 22% had no attention to pain documented in the medical record. Another 27% had no further assessment documented in their chart. About 52% received no new therapy for pain at that visit even though the patient reported pain had been assessed and treated. These findings highlighted that the problem lies in documentation, not in the practice of pain management. We can learn from our past mistakes, so it is important to review a brief history of pain management.

History of Pain Management

The philosophical, political, and religious meanings of pain have defined the suffering of individuals for much of history. Amongst the oldest known religious texts in history, we can find examples of pain, such as flogging, crucifixions, and walking barefoot for miles through scorching deserts. Evidence of pain has been found in carvings on stone tables from ancient civilizations. It was once believed that pain symptoms were manifestations of evil, magic, or demons, and its relief only came from sorcerers, shamans, priests, or priestesses who used herbs, rites, and ceremonies as treatments.

The Greeks and Romans were the first to advance the theory of sensation. The idea that the brain and the nervous system have a role in producing pain developed between the Middle Ages and the Renaissance. During the 17th and 18th centuries, the study of the body and the senses continued, and Rene Descartes described the first pain pathway. The sensations of pain, itch, nausea, and fatigue were believed to be protective.

Pain is the oldest medical problem and the universal physical affliction of mankind. Yet, it has been little understood in physiology until very recently. During the 19th and 20th centuries, medicine witnessed the development of anesthetics. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. This led to the later development of a pill found in your medicine cabinet, aspirin. Before long, anesthesia, both general and regional, was refined and applied during surgery. As the 21st century unfolds, advances in pain research are creating a less grim future, one that includes a better understanding of pain. We also have greatly improved treatments to maintain function and enrich quality of life.

Advances in Theory

Since the 17th century, there have been several different theories of pain perception. These include the Intensity, Specificity, Pattern, and Gate Control theories of pain. Here I will describe the most current one, Gate Control Theory. For information regarding the earlier theories, see Cosio (2018).

Ronald Melzack and Patrick Wall proposed the Gate Control Theory in 1965. The theory proposed that there is a "gate" or control system in the dorsal horn of the spinal cord. All information regarding pain carried by the nerves of the body must pass this gate before reaching the brain. When the gate is "open," the nerves can carry signals from the body to the brain, where pain is perceived. Chronic pain is believed to persistently activate this transmission to the dorsal horn and induces it to “wind-up.” Over time, this phenomenon induces uncontrolled changes that lower the threshold for pain signals to be transmitted. When the gate is “closed,” the nerves stop firing and no pain signal is sent to the brain. The goal of chronic pain management is to help “close” the gate. There are several factors that open and close this gate of pain. These include physical sensations, thoughts, emotions, activity, and social factors.

An example of this theory would be when an adult walks into a playground. At first, the adult may feel overwhelmed by the screaming, laughing, and running around of children in the park. However, after a few minutes, the adult may not notice these behaviors, yet they continue to exist. In this example, the children are analogous to the chronic pain that people suffer. The pain is often “wound-up,” and treatments should aim to help the person cope with and become habituated to the sensation. The treatments offered for chronic pain are able to produce this effect. They create changes in the neural pathways and synapses of the brain, a process known as neuroplasticity. The idea is that by making changes to biological, psychological, and social factors, the individual and pain-care provider are creating alterations to these neural processes. These changes in the neural processes then result in changes in pain perception.

The Role of the Brain in Pain

There are three general areas of the brain that are involved in pain, including the:

These brain regions are involved in learning and emotions and so are important in the development of chronic pain. The brain uses any information it has available to interpret the pain signal. One’s interpretation is a result of how these areas of the brain engage with the injury, which then dictates how one perceives the pain.

The same regions of the brain that regulate pain also control our emotions. That means that emotional and physical pain are interpreted the same way. The brain is unable to decipher which is physical pain and which is emotional pain. Researchers have found that the same areas of the brain are responsible for processing both pain and feelings of depression. Another study showed that the part of the brain that works to diminish pain was sluggish in the depressed subjects.

The brain uses many of the same chemicals responsible for regulating mood, including serotonin and norepinephrine, to transmit pain signals. Chronic pain and chronic depression both have similar effects on the nervous system as well, often intensifying perceptions of pain. It's no coincidence that many medications prescribed as antidepressants are effective in treating pain, too. These medications dull both physical and psychological pain.

There are also rare cases of children who suffer from congenital insensitivity to pain. When these children fall down and scratch their knees, they do not cry or scream with pain. The disease deprives them of such an important natural protection as pain because their pain impulses are damaged. This is just further evidence that without the brain there is no pain. When people say “the pain is all in your head,” what they say is true in that pain is all processed in the brain.

Definition of Pain

In 1996, the International Association for the Study of Pain (IASP) redefined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of tissue damage, or both.” This definition is the culmination of centuries of ideas and work that have explored the concept of pain.

Types of Pain

There are several types of pain, including acute, chronic, cancer, and breakthrough pain. Acute pain has a sudden onset and lasts no more than 3-6 months. It resolves when the underlying cause is treated. Chronic pain persists beyond 3-6 months or beyond the “normal” time of healing. The pain persists even if the trauma, injury, or infection resolves. Chronic pain is affected by both physical symptoms and emotional problems. Cancer pain is pain from the cancer itself as it spreads to organs, bone, or nerves. Cancer treatments can also cause pain. Breakthrough pain is shooting pain that occurs multiple times during the day without an identified cause or pattern. Breakthrough pain can occur when the person is already medicated. These types of pain can be further broken down into two types of pain: nociceptive and neuropathic pain.

Nociceptive pain is the “normal pain” that results from trauma or injury to the body’s tissues. This may include surgery or an injury (sprain, scrape, burn, fracture, etc.). Examples of nociceptive pain include conditions such as osteoarthritis, rheumatoid arthritis, and cancer pain. Persons with this type of pain experience it as throbbing, aching, dull, or sharp. Nociceptive pain usually fades once the injury heals or the painful stimulus is taken away.

Neuropathic pain results from damage or dysfunction of the nerves of the sensory transmission system. Examples of neuropathic pain include postherpetic neuralgia (painful shingles), diabetic neuropathy, and sciatica. Persons with this type of pain experience it as burning, tingling, or electrical shock feelings. Neuropathic pain does not always go away when the person heals or the stimulus is taken away.

Describing Pain

The numeric pain scale measures a person's pain intensity and is typically based on self-reporting. The numeric pain scale is an 11-point scale for adults and children over 10 years old. Scores range from 0 to 10, with “0” meaning no pain. A score from “1 to 3” means the person is in mild pain, described as being nagging or annoying, and interfering a little with activities of daily living. A score of “4 to 6” means the person is in moderate pain, often interfering significantly with activities of daily living. A score of “7 to 10” means they are in severe pain. When a person describes their pain as “severe,” it is understood that their pain is disabling and they are unable to perform the activities of daily living. A person should only report their pain as a “10” when they are in the most agonizing pain they have ever been in their entire life, which is considered an emergency and only treated in an emergency room.

Often, people who suffer from chronic pain hold unreasonable expectations about their treatment outcomes. People feel married to their pain scores. Pain scores alone have no utility. On average, a pain score of “2 to 3” is reported by people in the general population who do not suffer from chronic pain. A person who suffers from chronic pain should not expect their pain score to drop down to “0” after treatment, but reasonably closer to “2 to 3.” In most people, chronic pain cannot be eliminated or cured. We must change the cure-seeking behavior. There are no quick fixes. Rather, the goal of chronic pain management should be to improve quality of life and physical functioning. Pain is the only condition where the patient has a say about the failure of treatment. For example, patients who have been diagnosed with diabetes do not demand insulin or other treatment options and their providers are just expected to comply. Providers have the power to know what people might want, but at the same time, the responsibility to give them what they need.

People who suffer from chronic pain can also be active contributors to their treatment. They can do this by giving more thorough information about their condition to their provider. Pain providers need detailed data to determine the causes and triggers of chronic pain in order to build a treatment plan. Unfortunately, similar language is often used to describe pain caused by different conditions, which does not assist pain providers in their assessment. Common descriptors such as sharp, aching, throbbing, hurting, and tight, tend not to provide diagnostic distinctions between conditions. However, more unique descriptors, such as pinching, shooting, sore, and piercing, may be better labels for a lower back condition. Past research has shown that patients with systemic pain conditions, such as fibromyalgia or arthritis, described their pain as constant, tender, tight, and cramping. Yet, other pain conditions, such as migraines or headaches, may be better described as splitting, pounding, pulsating, and squeezing.

It is best if the individual is ready to provide specifics about their pain when a pain provider asks about their progress. Another way people can assist their providers is by keeping a pain diary, a consistent record of their pain experience. There have been cases when a person’s description of their pain has led to a more accurate pain diagnosis, an improved treatment pain, and a better prognosis of their condition. The benefits from having additional patient information has led to task forces recommending that pain providers engage more in shared decision-making processes.

Providers must also note the pain behaviors of their patients. It is normal for people to make nonverbal complaints, such as signs, gasps, moans, groans, and cries when they are in pain. People may also make facial grimaces or wince by furrowing their brow, narrowing their eyes, clenching their teeth, tightening their lips, dropping their jaw, and distorting their expressions. People in pain will oftentimes brace themselves by clutching or holding onto furniture, equipment, or the affected area during movement. They can also become restless, constantly shifting positions, rocking, making hand motions, and being unable to keep still. They may also rub or massage the affected area and make verbal complaints such as “ouch” or “that hurts.” These behaviors are expected and are considered normal. It is noteworthy that if these behaviors are extreme, it may be an indication of illicit substance use.

What Affects Pain?

We already discussed how someone’s emotional and psychological state can negatively affect their pain. If two patients with the identical pain condition present to the pain clinic and one has an untreated mental health condition, it is unclear how that person will improve without also addressing their mental health. In those cases, seeking professional help would be recommended in addition to their pain management. Thus, mental health clinicians may find themselves receiving referrals from knowledgeable, informed physicians to treat their clients who are experiencing chronic pain. The client may, however, be unclear as to why the referral to mental health was made. In these situations, pain education can be life-changing.

I sometimes ask people if they would feel better if they had a free, all-expenses-paid trip to the Bahamas. When people say “yes,” we discuss how their environment may be adding additional stress to them and how this affects their pain. Oftentimes, people talk about the worst pain they ever had in the past or how they are worried about their future. If someone is focused on their past, they are carrying baggage and need to address their depression. If someone is focused on the future, they are walking around worried and need to address their anxiety.

We know that people who have pain come from families who had pain. These people may have learned behaviors during their upbringing that may be negatively affecting their pain or be in conflict with their treatment plan. Assessing your client’s compliance or noncompliance with the recommended level of activities he or she is engaging in can provide helpful information.

Your patient’s expectations of and attitude toward his pain management can have a direct effect on his pain experience. There are two extreme examples of people who suffer from pain. One type will tell you that “you don’t know me or my pain” and at the same time tell you “the only thing that works is 5mg of this medication.” This person is closed to suggestions and may not see any improvement in their pain. This is different from the other extreme type who may say “I have tried everything and nothing has worked.” This person remains open to suggestions and is more likely to see improvement. The role of the clinician is to assess these types of expectations and attitudes, and devise a treatment plan appropriate for the type of patient. Attitude change through basic education may be a goal for the first client in this example.

There are people with different beliefs and values that will have an impact on their pain. For example, some religions prohibit the use of certain medical procedures due to their “spiritual” conflicts. It is important that you are aware of your client’s beliefs. There are also social and cultural influences that may have an impact on pain. For example, there are some minorities who have a distrust of providers which needs to be addressed before they will engage in any treatment.

Gender differences were discussed earlier, but age changes have not been mentioned yet. We know that as we age, we will slowly experience some pain. When we age, the intervertebral discs between each of our vertebrae lose their jelly and begin to flatten. When this occurs, we begin to shrink and our internal muscular system and nervous system is compressed. This causes pain because the core of the body does not remain the same size and they begin touching each other. So, the bad news is we may feel pain slowly as we age. This type of pain is not the same as in the person who is 80 years old who never had pain but is now experiencing it for the first time. This latter person is an example of someone who could benefit from further evaluation and treatment.

The Pendulum Swings

U.S. attitudes have shifted repeatedly in response to medical observations and events in legal communities. Often providers will describe these changes as a pendulum that swings freely backward and forward. In 1961, the world had its first and only narcotic drug use conference. During that conference, there were two messages that were released. The first was that effective pain management was deemed a human right. The second message was to convince countries who did not allow the prescription of narcotics for pain management to use them. As you may have witnessed recently, we only get parts of the news. This second message led to some people believing they were entitled to opioids for prolonged pain control. Providers would then feel pressured to continue prescribing opioids. The provider compliance reinforced their patient’s beliefs and reliance on medication. This in turn reinforced a bad behavior. The role of providers is not only to reject the sole use of opioids for pain management, but also to redirect people to other options and to use a multidisciplinary approach. The use of opioids as a treatment for non-malignant chronic pain remains a subject of considerable debate (see Cosio, 2018).

Recognized National Guidelines

The modern practice of pain management requires providers to apply evidence-based medicine to the decision-making process used in the care of people. Evidence-based medicine involves the incorporation of the best available research in deciding on chronic pain therapies. The creation of clinical practice guidelines to address specific clinical treatment issues has been one of the most useful and popular applications of evidence-based medicine. Specific pain conditions have guidelines set forth by national task forces. Some of these include treatment of low back pain (American College of Physicians and the American Pain Society), treatment of osteoarthritis and arthritis (American Pain Society) and treatment of migraines/headaches (National Headache Foundation). For details regarding these and other guidelines see Cosio (2018).

Approaches to Pain Management

Traditional Approaches

The traditional approaches to chronic pain management include medications, interventions, and physical medicine and rehabilitation modalities. Most people who suffer from chronic pain are familiar with these treatment options. However, your client’s primary care provider and/or pain medicine specialist can provide additional information, including the risks and benefits of these approaches and information about additional traditional approaches that are not described further here.


Medications will always have a role in pain management. When we discuss medications, we are not only speaking of opioids; there are several other types of medications available for the treatment of chronic, non-cancer pain. Which medication to prescribe depends on the type, length of time, and level of your client’s pain. Each person’s response and tolerance of a pain medication is unique. Use of certain pain medications may be limited or contraindicated due to your client’s:

Therefore, medications are recommended as a part of a multidisciplinary approach to chronic pain management. Medications require constant re-evaluation regarding the risk and benefit for continuation of use. People who suffer from chronic pain should be advised:

Medications used for chronic, non-cancer pain are classified as:

Medication management will continue to be the backbone of chronic pain treatment. A combination of results from several studies have concluded that opioids result in small improvements in pain severity and function compared with placebo.

There are many benefits to the use of opioids for the treatment of chronic pain. Some people believe it is the standard of care. It can also serve as an anxiolytic and can be sedating. It is easily accessible in hospitals or pharmacies, no matter how remote the location. The opioid can be transported in a bottle, insurance companies reimburse for opioid prescriptions, and they are easy to dispense. By looking at these benefits, it is easy to see how we have developed an epidemic in this country.

However, there are serious risks in using opioids for the treatment of chronic pain. We know that 8% to 10% of people will get addicted to opioids. Despite the widely held perception that opioids are the most potent medications available for the treatment of pain, there is little evidence that they are more effective than other therapies discussed in this course.


Intervention approaches are advanced medical procedures that are performed often through penetration of the skin. Interventions include:

The decision of which intervention to use is based on pain severity, persistence, or how bothersome the pain becomes. Your client’s physician will determine which modality to recommend based on these indices and how invasive the therapy will be.

Epidural steroid and facet injections are the most commonly used in the U.S. However, the evidence for epidural steroid injection use as long-term monotherapy is not clear. Facet injections have some evidence for use with facet joint pain, but are not clearly successful for other syndromes. A combination of results from several studies have evaluated the efficacy of Spinal Cord Stimulation (microelectrodes implanted in the epidural space to deliver pulses to the spinal cord). They concluded that there was moderate evidence for improvement in pain with SCS. A more recent systematic review evaluated the success of the Intrathecal Drug Delivery System (delivery of the medication directly into the fluid around the spinal cord), and determined that there were moderate reductions in pain but was unclear regarding long-term success.

Physical Medicine and Rehabilitation

Physical medicine and rehabilitation (PM&R), or physiatry, is a branch of medicine. PM&R aims to enhance and restore functional ability and quality of life to those with physical impairments/disabilities. Chronic pain management is achieved through a multidisciplinary approach involving:

Back pain has been estimated to account for 45% of all physiatry visits and is one of the most expensive injuries to treat. Rehabilitation, specifically for low back pain, occurs in three phases:

  1. Physiatrists make a specific diagnosis, develop a treatment plan, and offer treatment options.
  2. Flexibility and strength are developed to get the body parts into their proper positions.
  3. A total body fitness program is designed to maintain body mechanics and increase endurance.

Evidence suggests that exercise can effectively decrease pain and improve function, but no conclusions can be made about exercise type. Physical medicine approaches are commonly included as components of interdisciplinary pain rehabilitation programs. The use of proper body mechanics and self-care aids is recommended for people who suffer from chronic pain, especially during rehabilitation, (Your client may find it helpful to read the section on good body mechanics and self-care aids in the author’s book, Cosio, 2018.)

Psychological Approaches

Past research has found that psychological treatment, as a whole, results in modest improvements in pain and physical and emotional functioning. There is insufficient evidence to recommend one therapeutic approach over another. Psychological interventions aim to:

The modest reductions in pain witnessed with psychological interventions are similar to those noted with traditional approaches. Thus, it would be recommended that medical providers use the least invasive first, such as a referral for psychotherapy, rather than other options that are more invasive, such as the interventions covered so far.

The field of psychotherapy has witnessed five ways of thinking over time, or “waves.” The first wave was psychoanalysis, emphasizing the unconscious conflicts, early experiences, and transference. The second wave was behavior modification, stemming from learning theories. The second wave was organized into procedures for desensitization and changing contingencies. The third wave was humanistic/experiential psychotherapy, emphasizing emotions, conscious motives, and human potential. The fourth wave is cognitive psychotherapy, emphasizing thoughts and interpretations. The mindfulness-based therapies, which incorporate meditation practices, is the most recent, and is considered the fifth wave of thinking.


Meditation is a devotional exercise of – or leading to – observation. Meditation involves several techniques, including compassion, love, patience, and mindfulness. Mindfulness is a type of meditation. There are other practices which fall under meditation. Practicing short meditation exercises is a great way for your client to break away from pain. It may also reduce anxiety, depression, and sleep trouble. Meditation is an umbrella term that encompasses the practice of reaching ultimate consciousness and concentration to:

You may need to teach your client that mindfulness is not some special mystical state, nor is it a form of relaxation. Mindfulness is an exercise in just noticing, or awareness. There are several types of mindfulness-based interventions available, including:

Acceptance and Commitment Therapy (ACT) is one of the more actively researched approaches among the fifth-wave psychotherapies. It is a style of therapy with a lot of flexibility, and therapeutic process is more experiential than didactic. Therefore, efficacy will depend largely on the level of commitment and participation of the client in treatment. The experiential elements will challenge one to learn and practice new and more flexible ways of responding to pain. The basic idea of ACT is to shift the primary focus from reducing or eliminating pain to fully engaging in life. ACT is about changing how we relate with our internal experiences. It is about living better. A primary goal of treatment is for our clients to suffer less through becoming actively involved in what they really care about. In this way, they will do what matters most in their life despite having and experiencing pain. ACT treatment is difficult, as there are no simple solutions to chronic pain.

Patients report feeling a range of emotions during the intervention, but this response is natural and incredibly human. The role of the therapist is to help a client accept whatever discomfort exists, both physical and emotional. The client learns to live with this while continuing to live life according to his or her values. Doing so can help one to make meaningful changes in one’s life and reduce suffering. ACT applies six core treatment processes through different experiential exercises to create psychological flexibility. The model is best illustrated using a hexaflex. A simplified model may suggest that the intervention helps your client to become more open, present, and take action.

Your client will learn to become more “open” to his experience of pain using two principles: willingness to accept, and cognitive defusion. He/she will learn to become more “present” with the experience of pain using two other principles: contact with the present moment, and observing the self. He/she will also learn to “take action” despite the experience of pain, using two more principles: valued directions, and committed action. (For more discussion of these principles, see Cosio, 2018.)

At the end of the intervention, the client is taught how to maintain his progress by continuing to:

  1. practice mindfulness and acceptance exercises
  2. set short-term goals each week
  3. monitor progress

You will also need to prepare your clients for relapse and setbacks. You can help your clients to identify when they have relapsed or had a setback on their chosen path. The therapist can train the client to recommit to their valued action plan after failure to live up to or keep their valued commitments. One gets back on track by noticing the setback and bringing the awareness back to valued directions.

ACT and traditional cognitive-behavioral therapy (CBT) are among the most utilized interventions in behavioral medicine for pain. Past research has shown that ACT compares favorably with CBT in the treatment of chronic pain among different populations. They tend to overlap in terms of behavioral techniques and strategies. There are specific theoretical differences that exist with regard to the role of cognitions and emotional-regulation strategies. ACT has been shown to have modest support, but CBT has strong, long-standing research support to treat chronic, non-cancer pain, according to the American Psychological Association.


The term biofeedback refers to the function of this modality. “Bio” means body and “feedback” is having information fed back to you. Biofeedback is the use of instruments to mirror psychological and physical processes an individual is not normally aware of and which can then be brought under voluntary control. The fight-or-flight response, as an example, involves all parts of the nervous system, including the sympathetic nervous system. The sympathetic nervous system is also responsible for adrenaline secretion. The response occurs when an individual is subjected to severe stress. When the response is activated by a stressor, the nervous system increases sympathetic activity. This includes an increased heart rate, sweating, and muscular strength, which prepares the individual to face or avoid the stressor. Most people who benefit from biofeedback have conditions that are made worse by stress, which makes internal processes become overactive.

The biofeedback instruments will give immediate information about one’s biological conditions, including:

This feedback enables an individual to become an active participant in the process of health maintenance. Over time, these changes can endure without continued use of the instruments. As clinicians, you may want to recommend biofeedback for several reasons. Biofeedback training may be able to reduce, or even eliminate, the need for medication management of disease states. Biofeedback may also help your client take an active role in their own healing, which is consistent with the self-management model of chronic pain.

Clients often misunderstand biofeedback. Whether or not you as their therapist will provide the biofeedback or refer them to another clinician, the following script may be a helpful way to discuss this intervention with them:

Most individuals have come into contact with common types of biofeedback. For example, people use the following at home to become more aware of their physiology:

  • thermometers
  • bathroom scales
  • mirrors
  • mood rings
  • Fitbits

People use the information they obtain from these to make changes and gain control. They also come in contact with blood pressure and heart rate monitors when they are triaged into medical clinics, which provide information about their heart’s functioning which can be altered.

Similarly, biofeedback instruments do not change or influence bodily processes; they merely monitor or measure bodily functions. Implementing mental exercises is the key. In a typical biofeedback training session, sensors are attached to the skin at the different locations of the body. This, of course, is done only after the therapist has asked for your permission. The area of the skin where the sensor is going to be attached is usually cleaned with alcohol and a dab of electrode gel is applied to each sensor. The biofeedback therapist then leads you in mental exercises. These techniques can range from:

  • listening to pre-recorded audio or other media
  • mindfulness
  • formal relaxation techniques
  • prescribed self-hypnosis practice

(There are several types of instruments that are typically used in biofeedback training, including a thermistor, photoplethysmograph, pnuemograph, electrodermograph, electromyograph [EMG], and electroencephalograph [EEG]. Therapists can find detailed information to provide to clients about these specific instruments in Cosio [2018.])

When successful, the feedback signals from these instruments reflect accomplishment. The signals act as affirmation and encouragement for your continued efforts.

There are three stages that occur during the biofeedback training:

Stage 1: You gain awareness of your problematic physical response. Individuals identify how their bodies respond to stressors and determine their ability to overcome the undesired physical reactions.

Stage 2: You use the signals from the biofeedback to control your physical responses. The individual is coached by the therapist to reach certain goals related to managing a specific physical response.

Stage 3: You transfer control from the biofeedback equipment to yourself. Individuals learn through trial and error to identify triggers that alert them to implement the self-regulation skills learned. You will be encouraged to practice daily the mental exercises at the conclusion of treatment.

Biofeedback should be conducted only by trained healthcare professionals, such as licensed psychologists or masters-level clinicians. There are some contraindications for biofeedback that you must keep in mind. Certain cases are discouraged to pursue biofeedback therapy, including:

  • persons with severe psychosis or neurosis
  • individuals with a pacemaker or other implantable electrical device
  • debilitated patients
  • patients with psychopathic personalities

Biofeedback should only be used as an adjunct to – not a replacement treatment for – depression, diabetes, and other endocrine disorders. Biofeedback is considered to be an otherwise safe, non-medication intervention that does not appear to have any negative side effects. A positive side effect of biofeedback is that you can use self-regulation skills to help manage other life stressors. You can use these skills anywhere, at any time, independently from medications or doctors.

Relaxation Techniques

Relaxation techniques can help facilitate changes in your client. The purpose of these exercises is to decrease autonomic nervous system activity, such as:

Relaxation exercises have been found to be useful for pain caused by:

There are several different types of relaxation exercises, including but not limited to, diaphragmatic breathing, guided imagery, progressive muscle relaxation (PMR), and autogenics. For those clinicians unfamiliar with these techniques, more details can be found in Cosio (2018).

Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is perhaps the most investigated and research supported modality available for chronic pain. CBT is a structured, time-limited, present-focused approach to psychotherapy that helps your client engage in an active coping process. This process is aimed at changing maladaptive thoughts and behaviors that can maintain and exacerbate the experience of chronic pain. Past research has shown CBT to be highly successful in the treatment of different pain disorders, including:

CBT for pain is based upon the cognitive-behavioral model of pain. The cognitive-behavioral model is grounded in the notion that pain is a complex experience that is influenced by the individual’s underlying cognitions, affect, and behavior. In other words, “as I think, so I feel (and do)!”

CBT for pain has three components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills. The goals of CBT with pain clients are to:

  1. Reduce the impact pain has on their daily life.
  2. Learn skills for coping better with their pain.
  3. Improve physical and emotional functioning.
  4. Reduce pain and reliance on pain medications.


Hypnosis is a procedure involving cognitive processes such as imagination in which you guide your client to respond to suggestions. These suggestions are for changes in perceptions, sensations, thoughts, feelings, and behaviors. According to the Society of Psychological Hypnosis (APA Division 30), hypnosis involves learning how to use your mind and thoughts in order to manage:

Your clients can be trained in self-hypnosis, in which they learn to guide themselves through a hypnotic procedure. There are many myths, misconceptions, and misinformation about hypnosis, more than for any other treatment for chronic pain, in fact. This is most likely due to perceptions about hypnosis created by popular culture via movies (Get Out; Office Space; Shallow Hal; Zoolander), books (Manchurian Candidate), television (Doctor Who; Monk), rumors, and stage performers who make no attempt to tell the truth about hypnosis. These types of cultural references to hypnosis tend to embellish in order to make a more dramatic effect for entertainment purposes. In addition, medical hypnosis is not generally taught as part of a proper medical- or health-provider curriculum. This lack of knowledge adds to superstition even in the medical community. Since clinical hypnosis should be conducted only by trained healthcare professionals, you may want to search for trainings or workshops to learn these skills if you do not already have them. You should receive informed consent before beginning the hypnotic process with a client.

Health professionals who conduct hypnosis may not be comfortable providing this type of therapy to all patients. It is important to remember that the working relationship can have an effect on treatment outcomes. The current evidence suggests that hypnosis is increasing in popularity as a modality of interest in the treatment of chronic, non-cancer pain, specifically:

Even though hypnosis will rarely provide a cure for chronic, non-cancer pain, it will help your client self-regulate and influence their pain perception.

Everyone responds to hypnosis differently. Some patients report their experience as a “trance-like” state. Others may experience it as imagery or the soothing of body sensations. Most people describe hypnosis as a pleasant experience, feel focused and absorbed in the experience, more alert, relaxed and comfortable, and peaceful. No matter what the experience, patients consistently report better health and happiness using these techniques. Imaging data has indicated that hypnosis affects cognitive control by modulating activity in specific brain areas.

Hypnotized subjects have shown reduced brain activity in both visual areas and the anterior cingulate cortex, which plays a role in a wide variety of autonomic and cognitive functions. Certain cases are discouraged to pursue hypnosis, including anyone with severe psychological disorders that have gone untreated, persons under the influence of recreational drugs or alcohol, and anyone who is delusional or hallucinatory at the time of treatment. Some patients may object to hypnosis due to their religious beliefs, cultural beliefs, and/or external factors.

Other Holistic and Eastern Approaches

Complementary and Integrative Health (CIH), formerly known as Complementary and Alternative Medicine (CAM), is a group of medical and healthcare systems and practices. It is estimated that more than one-third of adults use CIH in a given year. The top four reasons adults use CIH approaches are to treat back pain, neck pain, joint pain, arthritis, and other musculoskeletal conditions. CIH products can be categorized into four general categories:

There is promising scientific evidence to support the use of CIH for non-cancer pain conditions, such as:

We already reviewed some treatments in the previous section that are considered mind-body modalities, such as biofeedback and hypnosis. I want to spend some time discussing different types of movement programs that have shown to be successful for chronic pain.

Exercise and Movement Therapies

Physical exercise, or movement, is any bodily activity that enhances or maintains physical fitness and overall health and wellness. It is performed for various reasons, including:

Exercise is a successful treatment strategy in various conditions, including neck pain, osteoarthritis, headache, fibromyalgia, and low back pain.

Stretching, or flexibility exercises, can be good tools for managing chronic low back pain and fibromyalgia. Other forms of flexibility exercises to consider are tai chi and yoga. Yoga has been known to help with arthritis, back and neck pain, headaches, and osteoporosis. When practicing yoga, regular benefits include improved sleep, strength and balance, circulation, flexibility, and physical and general well-being. There is promising scientific evidence to support the use of yoga and other movement-based exercises for non-cancer pain conditions such as low back pain. These exercises may provide a good alternative when aerobic or strengthening exercises are not recommended.

Strengthening exercises work on muscles to help give added strength for strenuous activities. Strengthening exercises may help to manage chronic low back pain.

Aerobics, or heart-health exercises, can include walking, biking, and swimming and should be done regularly for a minimum of 30 minutes each. A typical fitness facility should be equipped with a variety of cardio, strength, and conditioning equipment.

Functional restoration is a rehabilitation program for chronic spine-pain sufferers that aims to:

At times, these programs will offer aquatic therapy. The unique physical properties of the water make it an ideal medium for rehabilitation of conditions such as lower back pain. A therapist will typically give constant attention to the person receiving treatment in aquatic therapy.

Balneotherapy is the treatment of disease by bathing, usually practiced at spas. While it is considered distinct from hydrotherapy, there are some overlaps in practice and in underlying principles. Balneotherapy may involve hot or cold water, massage through moving water, relaxation, or stimulation. Many mineral waters at spas are rich in particular minerals such as silica, sulfur, selenium, radium, and medicinal clays.


A resounding concept people with chronic non-cancer pain should embrace is that of “motion is lotion.” It is the idea that a range of movement can improve or maintain function and promote health. It is also an idea rooted in the principles of several medical fields in which the movement of the body promotes health. These fields of medicine include:

All of these forms of treatment are trying to promote motion. However, each is distinct in their own way.

Spinal Manipulation

Spinal manipulation is the practice of manual medicine to promote well-being. When structure is altered via the musculoskeletal system, abnormalities occur in other body systems. This can then produce restriction of motion, tenderness, tissue changes, and asymmetry. In other words, dysfunction in one area of the body is believed to derive from dysfunction from other areas of the body. Therefore, restoration of function in these areas might also help improve the symptoms and motion in area of concern. Some common problems treated by using spinal manipulation include mid-low back pain, neck pain, muscle tightness/stiffness, hip pain, fibromyalgia, muscle injury, scoliosis, some headaches, and muscle spasms.

The goal of spinal manipulation is to improve the natural range of motion of the body by overcoming restrictions to normal motion. To do this, the provider will take an extensive history with the client and review any diagnostic tests that might be helpful. The provider will also use their hands to palpate the body looking for restrictions to normal range of motion while the person remains clothed. The value of the placing of hands on the body is universally acknowledged by health professionals. This essential component of the doctor-patient relationship has a great deal to do with well-being. Therefore, when the provider begins the examination with their hands, the treatment has already begun. The provider will use different techniques to improve motion after some discussion about the options for treatment. Among a diverse group of methods, the three most commonly used techniques include:

Patients will typically have one or two different achievements with spinal manipulation. The first is that they may find instantaneous relief of pain symptoms with the use of spinal manipulation over time. The other is that through motions of spinal manipulation, he/she will gain confidence that motion can be safe and effective for the body. Before the conclusion of a visit, the client and the provider will determine which spinal manipulation techniques worked best and how many follow-up visits might be needed to achieve a desired level of functional improvement. Each person is treated with this shared decision-making perspective in mind.

Traditional Chinese Medicine (TCM)

Traditional Chinese Medicine (TCM) is one of the oldest systems of medicine in history. It is more than 3,500 years older than traditional Western medicine. TCM is a standardized version of the type of Chinese medicine that was practiced before the Chinese Revolution. It is based on several ancient beliefs. The first is the Daoist belief that the human body is a miniature version of the universe. Another belief is that “Qi,” a vital energy that flows through the body, performs multiple functions in maintaining health. Chronic pain results from blockage or imbalance of Qi, and TCM practitioners correct or balance its flow. Other concepts in TCM include the Yin/Yang and the Five Elements Theories. Concepts such as these are of interest in understanding the history of TCM.

TCM addresses a wide variety of health needs besides pain, including immune enhancement/disease prevention, chemical dependency, anxiety, depression, migraines, maintaining health and wellness, and rehabilitation. TCM practitioners utilize five basic methods of diagnosis in their assessments, including:

TCM encompasses several methods designed to help people achieve and maintain health. There are six modern therapeutic methods used in TCM, including moxibustion, tui na massage, cupping/scraping, Chinese herbs, TCM nutrition, and acupuncture.


Acupuncture is one of the oldest and most commonly used complementary and integrative health treatments in the world. It is part of TCM and is not typically considered a stand-alone treatment. Despite having originated in China during the Shang Dynasty in 1600-1100 B.C., it has become popular in the Western hemisphere only recently, since 1971. Acupuncture began with the discovery that stimulating specific areas of the skin affect the physiological functioning of the body. It has evolved into a scientific system of healing that restores and maintains health. In 2007, a study of the National Health Interview Survey estimated that Americans made 14 million visits per year to acupuncture practitioners.

Acupuncture is the practice of inserting and manipulating needles into the superficial skin, subcutaneous tissue, and muscles of the body at particular acupuncture points. In TCM, there are as many as 2,000 acupuncture points on the human body, which are connected by 12 meridians. These meridians conduct the Qi energy between the surface of the body and its internal organs. Acupuncture is believed to keep the balance between the Yin and the Yang, allowing for the normal flow of Qi associated with neural transmission throughout the body. It also restores health to the mind and body. There is promising scientific evidence to support the use of acupuncture for chronic pain conditions such as arthritis and headaches, and limited support for neck pain. Acupuncture also tends to provide a short-term effect when compared with a waiting list control or when acupuncture is added to another treatment of chronic low back pain.

Acupuncture is generally safe when administered using clean needles and practiced by a licensed, trained acupuncturist. Many people express concerns about acupuncture due to their needle phobia. Unlike other needles, acupuncture needles are solid and hair-thin. They are generally inserted no more than a half-inch to an inch depending on the type of treatment being delivered. While each person experiences acupuncture differently, most people feel only a minimal amount of pain as the needles are first inserted. It may take several visits to see significant improvement of the chronic pain condition. Depending on the seriousness and the length of the condition being treated, the traditional acupuncture visit may take between thirty to sixty minutes.

Healing Touch

Healing touch is a bio-field therapy that arose in the nursing field in the late 1980s. It is being used in a variety of settings, including pain centers, with reported benefits. It is an energy-based therapeutic approach to healing that can be used in conjunction with more traditional therapies or as a stand-alone treatment. It is a contemporary interpretation of several ancient laying-on-of-hands healing practices. The practitioner utilizes non-invasive techniques with their hands to clear, energize, and balance the human and environmental energy fields. This is done in order to facilitate healing at the physical, emotional, mental, and/or spiritual levels. It is based on a heart-centered caring relationship in which the client and the practitioner come together energetically to facilitate health and healing. The goal is to restore balance and harmony in the energy system placing the client in a position to self-heal.

Healing touch is based on the assumption that all human beings have the natural ability to heal and to enhance healing in others. It is believed that human beings are an open energy system composed of layers of energy that are in constant interaction with self, others, and the environment. Therefore, illness is considered an imbalance in one’s energy fields, or auras. Energy therapies focus on removing energy congestion that form in the energy tracts and energy centers, or chakras. Once these imbalances and disturbances are cleared, the energy channels resume their task of connecting the body, mind, and spirit to restore health and promote healing. Practitioners may use a number of techniques, including:

Healing touch can influence a person’s response to pain in many ways. It is interpreted by the body as physical, emotional, mental, and spiritual aspects of the self. More studies are needed even though research supports the use of healing touch in improving quality of life in chronic disease. The overall outcomes indicate encouraging results for the use of healing touch for pain management specifically. Healing Touch has been found to decrease pain in acute, chronic, post-surgical, and centralized sensitization pain conditions. There are no contraindications for using energy work to relieve pain. It can be valuable in supplementing traditional approaches or when other approaches are not successful. Healing touch does not require the use of equipment or substances and can be done in any setting. An open heart, a set of hands, and a willing spirit is all that is needed.

Lifestyle Imbalance Management

Chronic diseases are among the most common, costly, and preventable of all health problems, according to the CDC. The incidences of heart disease, diabetes, and cancer, all combined, are lower than that of chronic pain. In the U.S., 86% of all healthcare spending in 2010 was for people with one or more chronic diseases, including chronic pain. Alarming projections suggest future generations may have shorter, less healthy lives. Healthcare costs in the U.S. will rise to $4 trillion, the equivalent of four Iraq wars, in a single year if current trends continue. Specific health risk behaviors cause much of the illness, suffering, and early death related to chronic diseases and conditions. The roadmap to health is simple:

Thus, the solution to our nation’s pain crisis does not seem complicated.

Chronic pain tends to negatively affect one’s level of stress, mood, and substance use, but it also affects the following areas of life:

This section discusses the importance of helping your clients to maintain a balance in their lifestyles. Traditional approaches are often the first option to fix something before we even look at the potential of lifestyle changes. Lifestyle is an area that is often ignored or taken for granted. By addressing these areas, you may also be indirectly addressing your client’s pain. These areas have a mutual relationship with pain.


“Mother Nature is the best pharmacist and food is the most powerful drug on the planet” (Hyman, 2012). A nutritional approach to pain management involves making changes to your diet. This is done to prevent pain or promote the relief of inflammation as part of a comprehensive pain management strategy. Back/joint pain, rheumatoid arthritis, fibromyalgia, and osteoarthritis are affected by your diet.

Researchers have highlighted the advantages of certain foods when added to one’s diet. They have suggested avoiding foods that are thought to contribute to chronic pain. After one month of avoiding these foods, a consecutive reintroduction of each particular food every couple of days can follow. For example, persons diagnosed with gout may need help decreasing uric acid levels in their blood. Limiting their intake of high-purine foods may help to decrease their joint pain.

Nutritional health can also provide relief for constipation caused by opioid pain medications and muscle relaxants.

A basic principle of nutritional health is to eat food from each of the basic food groups every day. The Food Guide Pyramid was introduced by the U.S. Department of Agriculture in 1992. It was then updated in 2005 to because the original pyramid was too misleading and hard to understand. The movement was eventually replaced by MyPlate in 2011. The plate was advised by the first lady’s anti-obesity team and federal health officials.

Weight Loss

According to the CDC, about two-thirds of U.S. adults are overweight or obese and are at increased risk for musculoskeletal disease. The U.S. has witnessed a shift in averages in reference to weight the past few decades. The first lineman in an American football team over 300 lbs. was William “The Refrigerator” Perry (355 lbs.) in 1960. Today, the average weight of every lineman in the national football league is 355 lbs., with a life expectancy of about 57 years. Healthcare claims have estimated the coexistence of pain and obesity to be as high as 30%. These high rates are related to decreased quality of life, emotional distress, increased disability, sedentary lifestyle, and stigma.

Past research suggests that there is a direct relationship between weight and frequency of musculoskeletal pain. Rates of neck, back, hip, knee, and ankle pain have been found to be significantly higher in obese individuals. An underlying relationship remains unclear. Similar to the chicken-or-the-egg dilemma, it is yet unknown whether obesity causes pain or vice versa. Obesity is assumed to lead to knee and low back pain because of excess mechanical stresses. Fat functions much like an organ that secretes chemicals which affect blood pressure and cholesterol. Carrying five lbs. of extra weight feels like ten lbs. on the body’s joints. Ten lbs. feels like 20 lbs. on joints, especially the knees. Obesity has been related to thoracic spine, neck, and upper extremity pain. It has also been linked with conditions such as fibromyalgia, migraines, and headaches due to its pro-inflammatory state.

Chronic pain may also result in obesity because of physical inactivity and emotional eating. The opposite must also be true – weight loss can reduce chronic pain. One study found that more than a 10% loss of body weight from diet alone resulted in a 50% decrease in knee osteoarthritis in obese people. When one reaches a 10% weight loss, the levels of inflammatory substances circulating in the blood drops significantly.

The problem with reducing weight is complicated. Chances are, people who suffer from chronic pain are unable to move or exercise enough to lose weight. Medications, such as opioids, sedatives, muscle relaxants, or antidepressants, may suppress the body’s metabolism and cause weight gain. These co-occurring diseases both respond to behavioral self-management interventions.

An integrative approach that combines nutrition, physical activity, and behavioral strategies appears to provide maximum benefit.

Sleep Hygiene

There are about 10 different sleep disorders, including narcolepsy, restless leg syndrome, obstructive sleep apnea, and insomnia. Excessive daytime sleepiness is a symptom that can occur with several sleep disorders. Excessive daytime sleepiness may include episodes of uncontrolled sleep attacks that occur while in conversation, reading, watching television, or driving. Excessive daytime sleepiness may be caused by not getting enough hours of quality sleep. Adults between 26 and 64 years of age need about seven to nine hours of sleep per day. Disturbed sleep can have many health consequences, including fatigue, decreased focus, altered mood, and can be a potential warning sign for osteoarthritis.

About two-thirds of people who suffer from chronic pain also report poor sleep due to the relationship between these two conditions. The problem of pain and sleep becomes even more complicated because many medications commonly prescribed to relieve pain (oxycodone, morphine, and codeine) can fragment sleep. If one experiences poor sleep due to pain one night, one will likely experience more pain the next night and so on, creating a vicious cycle. Chronic pain frequently is associated with a sleep disorder and these coexisting problems can be difficult to treat.

Sleep disorders are diagnosed through a comprehensive assessment that includes a detailed patient history, physical exam, questionnaires, sleep diaries, and sleep studies. During a typical sleep study, the client will be connected to a variety of testing equipment that measure various biological functions, including:

The temperature of the room is maintained at a comfortable level and the lights are turned off. After the study is completed, the client will follow up with a specialist to review the outcomes and develop a treatment plan.

The most common type of sleep disorder is insomnia. This condition may cause difficulty falling asleep, staying asleep, or awakening. Many people have experienced a period of transient insomnia for less than one week due to stress or environmental changes. If this persists, it becomes acute insomnia (less than one month in duration) or evolves into what specialists call chronic insomnia (more than one month in duration). There are several potential causes of chronic insomnia, including:

In primary insomnia, individual differences in brain function may result in an overactive alerting signal that continues long after a person would like to fall asleep. There are a variety of treatment options available if underlying health issues or environmental factors cannot be identified or changed. Treatments include:

We already reviewed biofeedback and meditation. CBT-I is a psychological intervention typically lasting 8-12 weeks. In CBT-I, you perform a series of sleep assessments, ask your client to complete a sleep diary, and then work with the client in session to help change the way he/she sleeps. CBT-I is a safe and effective means of managing chronic insomnia. This program can help even if the sleep problems have a biological origin. The program does not use sleep medications but instead teaches a person how to improve sleep through behavior change.

Sexual Health

According to the World Health Organization, sexual health is a state of bio-psycho-social well-being in relation to sexuality. Sexual health it is not merely the absence of dysfunction. Most studies of the sexual activity of people who suffer from chronic pain report worsening in sexual health, including frequency and quality. No relationship has been found between pain severity, duration, frequency, and sexual functioning. A relationship has been found between disability status, age, and psychological variables (depression and anxiety) and domains of sexual response cycle (desire, arousal, and orgasm). In order to make a comprehensive diagnosis and a recommendation for treatment, providers must include sexual function in their medical review of patients with chronic pain.

Sexual health also requires a positive and respectful approach to sexuality and sexual relationships that are consensual among adults. Sometimes chronic pain can alter the way people feel about themselves. It may cause them to have low self-esteem or to feel depressed. These feelings can interfere with sexual desire. Some people find that chronic pain strains their relationships with their sexual partners because of their mood. As a result, they tend not to be very attentive to their partners which may cause their partners to become impatient and feel differently toward them. Regardless of the pairing, the relationship is the key to sexuality. If the relationship is in conflict, then the pairing may need some conflict resolution. There are different sexual needs when one person in a pairing has an illness, such as chronic pain. People are taught to take responsibility for their own sexual satisfaction, and worry less about holding their partner accountable. Thus, good communication is essential and the couple may need psychological counseling or enrichment programming.

Chronic pain may hinder a person’s ability to move freely, and thus limit the positions they can get into to have sex. Sometimes chronic pain requires partners to change the sexual positions or acts they’ve grown accustomed to in order to find a position that doesn’t cause pain. There are several different sexual positions with recommendations to prevent people from hurting their back. These recommendations may generalize to all pairings if modified to reflect the sex of those involved. Note what aids are used during the sexual act, such as pillows, and body posture such as proper knee and hip alignment remains important. Again, it’s important that pairings spend time touching, kissing, and hugging as forms of foreplay before, during, and after sex and even when they don’t have sex but want to express affection toward one another.

If a person with chronic pain continues to report sexual dysfunction, a referral to a sexual health clinic may be beneficial. Sexual health clinics may provide various services, including:

Sexual health providers will also evaluate each person to determine what factors or drugs may be affecting their sexual function. There are several factors that affect sexual dysfunction, including:

Sexual healthcare professionals can also provide several different treatment options, including:

Vocational Rehabilitation

Pain is the number one cause of adult disability in the U.S. Approximately 13% of the total workforce reported experiencing a loss in productive time during a two-week period of employment due to pain. Workers who were missing from productive time due to pain lost a mean of 4.6 hours/week. The majority of the lost productive time (77%) was explained by reduced performance while at work and not work absence. A 2010 report by the Institute of Medicine indicated that the annual value of lost productivity ranged between $297 billion and $335 billion. The value of lost productivity was based on three estimates, including days of work missed, hours of work lost, and lower wages. For many people, employment is an essential part of their identity. Work helps people:

Research has shown that work is beneficial while unemployment is associated with poorer physical and mental health and well-being. Work can be therapeutic and can reverse the adverse health effects of unemployment among many disabled people, people with common health problems, and social security beneficiaries. Thus, more and more attention is being paid to preventing disability and promoting return to work in pain management.

Vocational rehabilitation programs have been developed for people with chronic diseases. They consist of a systematic assessment of the problems at work and the development of individual solutions. The aims of vocational rehabilitation are to improve psychosocial skills and/or implement work accommodations. They use several different methods, including:

The most important outcome measures of vocational rehabilitation are:

Demographic, job-related, and psychological factors should be emphasized in the evaluation of vocational potential and the assessment of disability in people with pain. Jobs should be safe and accommodating for sickness and disability. Keep in mind that the beneficial effects of work outweigh the risks of work, the harmful effects of long-term unemployment, or prolonged sickness absence. There is some evidence that interventions that train people in requesting accommodations and feeling self-confident in dealing with problems are successful. Psycho-socio-demographic variables (sex and beliefs in vocational return) have also been found to be powerful overall predictors of failure. They are better predictors of vocational rehabilitation outcome and superior to the signs and symptoms recorded by physicians. There is strong scientific evidence for vocational rehabilitation for musculoskeletal conditions.

Spirituality and Religion

Healthcare systems in the U.S. have begun implementing a new medical care model that is more aligned with a bio-psycho-social-spiritual approach to health. The renewed bio-psycho-social-spiritual approach emphasizes the person’s responsibility for self-management and should include education, wellness principles, and sound interventions. Such a comprehensive approach must be used in chronic pain management. Health professionals should serve their patients’ needs as a “whole,” including their mind, body, and spirit. Chronic pain can be considered a disruption in biological relationships that in turn affects all the other relational aspects of a person. Spirituality concerns a person’s relationship with transcendence, or “whole”-ness. Scholars suggest that many people would like health professionals to attend to their spiritual needs. However, healthcare providers must be cautious and avoid preaching.

The topic of “spiritual healing” or “spiritual acts” is riddled with controversy due to its religious implications. Certain religious groups may believe that these practices are condemned in the Holy Bible, New International Version. For example, Deuteronomy 18 (v. 10-11) states, “Let no one be found among you who sacrifices their son or daughter in the fire, who practices divination or sorcery, interprets omens, engages in witchcraft, or casts spells, or who is a medium or spiritist or who consults the dead.” Others shy away from these practices because they equate spirituality with religion. Spiritual healing is largely non-denominational, and traditional religious faith is not a prerequisite for therapy.

As noted, pain management should treat people as a whole – their mind, body, and spirit. But how do you define spirit? In athletics, spirit may mean excitement or passion. In sacred texts it denotes the breath or life. In modern times, it connotes meaning or purpose. Meaning is a sense of beliefs or values. Purpose is a sense of direction or aim. Spirituality is the aspect of humanity that refers to the way people seek and express meaning and purpose. It is the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred. A chronic illness, however, can cause people to question their meaning and purpose in life. The literature suggests that it is important to discuss spirituality because such efforts:

In 1946, Viktor Frankl described in “Man’s Search for Meaning” how concentration camp inmates’ pain and suffering eased once they found meaning and purpose in their lives. Spirituality matters to many people who experience pain. In addition, people may struggle to make sense of their pain experience. Those who struggle with their spirituality are at risk for inadequate pain management. The relationship between spirituality and healing can be traced back to antiquity. Historically, the priest, the physician, and the psychologist were the same person in some societies. The advent of scientific medicine in the mid-19th century separated the body from the mind and spirit nearly completely. A century later, the direct interrelationship between the body and mind became firmly established. Over the past several decades, there has been a broad revival of interest in spiritual healing and health. Spirituality may have:

There are several practices people in pain can engage in to increase their spirituality. Prayer is the simplest form of self-care and has been found to be the most common medical intervention used in the U.S. Prayer is a reverent petition made to an object of worship. The three largest faith groups in this country are Christianity, Judaism, and Islam. Perhaps providers should encourage their patients from those faiths to use prayer as a form of pain management. Meditation is a devotional exercise of or leading to contemplation. It is perhaps a more secular or neo-sacred approach and/or alternative to this process. A simpler method of introspection may be for people to read words of hope and inspiration.

People may present with barriers to everyday practice of these methods, including sedation from medications, relaxation wariness, unwillingness to look beyond the self, and difficulties in setting boundaries.

Chaplain services have been integrated in most health-care systems They are available to facilitate spiritual healing by providing chapel worship, sacraments and rites, memorial services, inpatient hospitalization visits, and other types of spiritual care. At times, chaplain services may not provide exactly what the person seeks. In such cases, chaplain services may be able to provide alternative choices via a network of other clergy and spiritual leaders within the community, including traditional healers.


I often call recreation therapy the “crown jewel” of comprehensive pain management. Recreation therapy is a treatment service designed to restore, remediate, and rehabilitate a person’s level of functioning and independence in life activities. According to the American Therapeutic Recreation Association, the goals are to promote health and reduce limitations that restrict participation in life. The word “recreation” defines the role of the recreation therapist – to “re-create” a means of activity. Intervention areas vary widely and are based upon the client’s interests, including:

Unfortunately, research has shown that providers tend to give recreation therapies a lower endorsement when compared to other pain management modalities. This is due to their low practical and theoretical exposure to this type of intervention. Theoretically, recreation therapy could be thought of as an adult version of “child play therapy.”

Empowering Those Affected

The purpose of this section is to discuss ways to help people in their efforts to lead healthier lives. Several skills will be covered for you to use to help your clients communicate about their pain with more success. It is important that people who suffer from chronic pain remain engaged in the process of improving their care and maintain their role as the primary investors in the healthcare system.

Selecting Treatments

Health professionals and people who suffer from chronic pain ask me how to determine the best treatment modality to use. Pain patients may have come to the conclusion that most treatments will offer a mild to moderate reduction of pain. The current evidence provides little support for choosing one approach over another. Some people might find this conclusion to be discouraging. However, there are other things to explore with your clients in selecting the best treatment, including:

The Goldilocks Effect

People with chronic pain and their providers try different treatments until they find something that works, a phenomenon referred to as the “Goldilocks effect.” The name is, of course, derived from the children’s tale of The Three Bears. In the story, Goldilocks wanders far from home and stumbles upon the house of the three bears. She tries all their chairs, tastes all their porridge, and lies in all their beds. Goldilocks finds the baby bear’s place the most suitable for her in all three cases.

Unfortunately, many people try different options without giving themselves enough time to see whether they work or not. They move from one treatment to the next treatment. This affects the success rate of each type of treatment. To study the success rate of acupuncture, you would need to first find a representative sample of people with chronic pain (i.e., who have had pain for more than five years). Those people would most likely have tried other treatments in the past which could interfere with the results of the experimental treatment (i.e., acupuncture). This difficulty is why research has shown that the overall success of treatment for chronic pain remains inconsistent and fairly poor. The practice of psychotherapy confronted a similar issue in the past. The field of pain management may be able to glean insight from the psychological research in “common factors.”

Common Factors

References to the concept of common factors began as early as 1936. Research studies at that time found that all psychotherapies were successful – a conclusion later termed the “dodo bird effect.” This is a reference to the character from Alice’s Adventures in Wonderland. In the original story, the dodo bird is the character who proposes that everyone run a Caucus race. The participants were to run in different patterns in order to get dry after a swim. He says this so that everyone wins and “all must have prizes.” Hans Eysenck wrote one of the classic papers in the history of psychology in 1952. He announced that psychotherapy did not lead to improved patient outcomes. In response, mental health providers began conducting research to explain the psychotherapy process and outcomes. A summary of the review of research has shown that psychotherapy is undeniably successful as a treatment.

Two important findings have been noted from those analyses. First, the effect of psychotherapy did not change despite how conservative or rigorous the research study. In addition, all the different types of psychotherapy had the same effects. These conclusions led to the distinction of two possible means of psychotherapeutic change: “specific” and “nonspecific” effects. Specific effects were associated with unique interventions to certain therapy approaches. Nonspecific effects were linked with common factors of the clinical encounter.

Factors common across therapies have been found to contribute more to treatment outcomes than effects associated with specific technical interventions. A summary of the review of research then summarized psychotherapy outcome research and reduced the factors into four areas:

  1. Patient factors – the characteristics of the patient and his/her environment – were found to explain 40% of the change in outcomes.
  2. Therapeutic relationship – the characteristics of the patient and the provider that facilitate change and are present regardless of the type of intervention – were found to explain 30% of the change in outcomes.
  3. Expectancy/placebo/hope – improvements that result from the patient and provider’s belief that treatment is successful – were found to explain 15% of the change in outcomes.
  4. Techniques/models – such as the traditional, holistic, and Eastern practices discussed previously – were found to explain 15% of the change in outcomes.

This research later inspired a book titled The Great Psychotherapy Debate (Wampold, 2001). In that book, the author concluded that nonspecific effects were responsible for more than four times the amount of change in treatment outcomes across various interventions. Using models developed in other professions to inform inquiry in another field is appropriate. There is some precedence in the literature, specifically in physical medicine and rehabilitation. Is it possible that these nonspecific effects are responsible for some amount of change in treatment outcomes in pain management?

Common factors speak to pain management being an art form in addition to a science. From a psychotherapy perspective, specific interventions discussed previously will not be fully successful without adding the other common factors. There is evidence to suggest that these same common factors may be responsible for general effects in pain management.

Manumea Effect

Research studies in pain management have concluded that the diverse treatment interventions currently available all appear to be successful. I propose this verdict be termed the “Manumea effect,” referencing Samoa’s endangered tooth-billed pigeon. The Manumea is similar to the dodo bird, which is appropriate since it is a relative of this famously extinct bird. It is also cryptic, and almost invisible in its nature. Even though a common factors model in pain management is not fully developed, such a model should be considered in order to further advance knowledge and practice in pain medicine.

Patient Factors

Patient factors include several different themes, such as social support, faith, and strengths/abilities. It would appear from the current research that treatment outcomes were better when the patient:

According to the research, it is important for your client to maintain his or her employment while in the process of recovery. If not employed, I would recommend working with a vocational rehabilitation counselor.

Some people may react to that recommendation by saying "I'm not motivated." People tend to get motivated when they hit rock bottom. Unfortunately, motivation for some of us comes from fear or anxiety. The good news is that as a therapist you have the skills to improve motivation in your clients by:

Everything today seems to not be our own fault but rather the result of a disease, addiction, or chemical imbalance. As a society, we need to stop being victims and start taking control of our lives. The good news is that we can help our pain patients take control of their lives by teaching them to:

There is a lot of negativity in this world and it can be easy to fall into it. In fact, when we wake up in the morning, our brains are already set to think negatively. I have learned that there are things we can do to stay positive and live a positive life. The good news is that we can assist our clients to bring more positivity into their lives by:

Therapeutic Relationship

The therapeutic relationship is a psychotherapy common factor. It was identified by Grencavage and Norcross in 1990 and has been validated by strong research support. Research on the power of the therapeutic relationship now reflects more than 1,000 research findings. It has been found to predict treatment loyalty, agreement, and outcome across a range of patient diagnoses and treatment settings. Therapeutic relationship factors include several different themes, such as the patient-provider relationship and encouragement/instruction. It would appear from the current research that:

The patient-provider relationship is the key mediator between perceived helpfulness and patient satisfaction. In reality, the right to effective pain management comes with shared responsibilities between the person who suffers from pain and their provider. However, these relationships can be challenging. People who suffer from chronic pain and their medical providers may have opposing attitudes and goals. One person tries to control the other. Someone asserts control and the other person is left to concede. This leads to tension, power struggles, increased feelings of stigmatization, distrust, and discomfort in treatment. People who suffer from pain want their pain to be legitimized. They perceive providers as lacking in empathy, doubting their pain is real, and being influenced by stereotypes. Medical providers want to avoid feeling powerless – there is no cure, no improvement, and no consolation prize at times. Providers report being more concerned about other urgent health conditions, looking for objectivity within a subjective condition, and not taking ample time to build a relationship of trust. Providers do not engage in more shared medical decision-making because they believe it will increase their workload. They are reluctant to engage with people who appear to lack comprehension. Some providers will even discontinue treatment if the person in pain engages in complementary and integrative health treatments over standard medical care.

Here enters the mental health professional, who can be a bridge between the medical provider and the pain patient. This clinician is trained in just such a supportive, empathic role. The therapist can offer compassion, clear expectations when dealing with difficult behaviors, assistance in receiving adequate explanations from their medical provider, and training of their client in becoming an active participant in decision-making. Finally, the therapist is probably the best-trained team member for instilling hope. People who have rewarding relationships with their healthcare providers have better outcomes and are less likely to seek assistance from multiple sources, which reduces the risk of conflicting treatment plans and further confusion. The success of a working alliance often determines whether a person with chronic pain will adopt self-management strategies.

Understanding Pain

Pain assessment is a cornerstone of pain management. The vast majority of pain practitioners recognize assessment as a valuable part of pain treatment. This is because assessment results help create a complete picture of the person per the chronic pain model. Assessment results cannot precisely predict outcomes but they can assist in patient selection for treatments. We already reviewed aspects of pain assessment in the earlier section, Definition of Pain, including words to describe pain, intensity, location, duration, and aggravating or alleviating factors. However, there is much more information that can be gathered to help develop a treatment plan.

Pain Assessment Tools

There are several formal pain-assessment instruments currently available. They vary by what they measure; decisions on which to use should be based on what you are looking to measure. Here are a few examples of pain instruments that you can use and that are easily accessible through a Google search:

Pain Quality

Neuropathic Pain Questionnaire: A 12-item assessment instrument intended to measure neuropathic pain based on qualities of pain as they are inferred from pain descriptors.

Functional Impact

Brief Pain Inventory: This instrument rapidly assesses the severity of pain and its impact on functioning. It also has a pain body diagram. It has been translated into dozens of languages and is widely used in both research and clinical settings.

Pain Outcomes Questionnaire - VA: A 20-item inventory that functions as a multi-dimensional measure of pain in veterans to keep pace with the emergence of the biopsychosocial model of pain. It has proven to be a reliable, valid, and robust measure of the diverse cluster of symptoms associated with pain.

Sensory, Affective, and Cognitive Domains

McGill Pain Questionnaire: Measures subjective pain experience and consists of 78 adjectives organized into 20 sets covering sensory, affective, and cognitive domains. People select the best descriptor in each set.

Pain Beliefs and Coping

Chronic Illness Problem Inventory: Consists of 65 self-report items related to pain behaviors, physical dysfunctions, healthcare behaviors, finances, sleep, relationships, etc. It assesses coping ability, functioning, and the person’s perception of problems.

Coping Strategies Questionnaire: A 50-item self-report questionnaire designed to assess six cognitive coping responses to pain and two behavioral responses.

Pain Management Inventory: An instrument that assesses specific methods that the individual is currently using for arthritis pain management and the perceived helpfulness of these methods.

Pain Self-Efficacy Questionnaire: A 10-item questionnaire developed to assess the confidence people with ongoing pain have in performing activities while in pain.

Survey of Pain Attitudes: A well-researched instrument that assesses the person’s feelings about pain control, solicitous responses from others, medication, pain-related disability, pain and emotions, medical cures for pain, and pain as an indicator of physical damage or harm.

Sickness Impact Profile: A questionnaire instrument designed to measure sickness-related behavioral dysfunction, developed for use as an outcome measure in the evaluation of healthcare.

Inventory of Negative Thoughts in Response to Pain: A 12-item self-report assessment that includes three subscales: negative self-statements, negative social cognitions, and self-blame.

Level of Functioning

Oswestry Disability Questionnaire: Used to assess the person’s daily functioning and activity level. Contains 10 multiple-choice items that cover nine aspects of daily living plus use of pain medication.

Multidimensional Pain Inventory: A 52-item inventory divided into three sections that assess the impact of pain on the person's life, the response of significant others to the individual's communication of pain, and ability of the person to conduct common daily activities.

Short-Form Health Survey: A 36-item, self-report survey of the person’s health that consists of eight scaled scores, including vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health.

Pain Disability Index: A simple and rapid instrument for measuring the impact that pain has on the ability of the person to participate in essential life activities. This can be used to evaluate the person initially to monitor them over time and to judge the effectiveness of interventions.

In addition to having someone in pain complete some of the instruments reviewed above, there is additional information you can note about their behavior that can help with your assessment. As with other clients, your assessment begins once you meet someone. Do they call you by your first name, having never met before? How do they get up from their chair and walk toward you? Do they leave blanks on the assessment instruments we just reviewed? All these behaviors are notable. You also may want to assess whether the person in pain has normal blood pressure. Do they have a primary care provider? Have they experienced a recent motor vehicle accident, fall, or fire which may have worsened their pain condition? There are also more abnormal behaviors about which you should be informed, including:

A comprehensive pain assessment includes a diagnosis with appropriate differential and an appraisal of pain level and function. It should also include a psychological evaluation and an assessment of risk for addiction.

Psychological Assessments

Chronic pain not only affects an area of the body, but also one’s mood, which in turn affects behavior, which then can result in the body becoming deconditioned, meaning experiencing muscle loss. We know that 1% to 3% muscle atrophy occurs per day for people lying in bed. This creates more pain, which effects the patient’s emotions, and it’s those emotions that drive the experience of chronic pain. As you can see, this creates a vicious cycle.

Psychology has an important role to play in every aspect of pain management, including pain assessment. Behavioral health providers can teach clients ways to better manage stress or other difficult emotions connected to pain. You can help clients create a better multidisciplinary self-management plan to address their pain. In addition, you may even be involved in a procedure, such as a Spinal Cord Stimulation trial, which requires a psychological evaluation. For pain clients, a psychological evaluation is used to assess mental health history and may include a review of the medical file as well as a session to collect the following helpful information about the client:

In 1986, Fishbain and colleagues investigated the co-occurrence of mental health disorders in 283 chronic pain patients at the Comprehensive Pain Center of the University of Miami School of Medicine. They conducted an extensive three-day evaluation period, of which two hours were detailed, semi-structured psychiatric interviews based on the DSM-III. They found that most chronic pain patients suffer from somatic symptom disorder, depression, suicidal thinking, anxiety, post-traumatic stress disorder (PTSD), personality disorders, and substance use disorders.

About 10% to 50% of people with pain have suicidal ideations. Over 30,000 suicides occur each year in this country, and it is now the 10th leading cause of death for all ages in the United States. Acute and chronic pain is a risk factor for suicide. Thus, screening for suicide among people who suffer from pain is critical.

Relative to depression, anxiety disorders have received less attention in the chronic pain literature. Anxiety disorders cause distress in more than 30 million Americans in their lifetime. The direct and indirect costs of anxiety disorders are estimated to be about $42 billion per year in the U.S. Anxiety disorders impair work, social life, and physical functioning. It is easy to mistake symptoms of anxiety for physical illness and become worried that the person is suffering a heart attack or stroke. This, of course, increases anxiety.

In the DSM-5, PTSD is no longer in the section on anxiety disorders but in the section on Trauma and Other Stress-Related Disorders. Pain is the most common physical complaint among people who suffer from PTSD. Research indicates that people with chronic pain related to trauma or PTSD experience more intense pain and affective distress, higher levels of life interference, and greater disability than their counterparts without trauma or PTSD.

Substance Use Disorder and Chronic Pain

In 2005, one study indicated that before the current opioid-epidemic, approximately 32% of chronic pain patients may have comorbid substance-use disorders. In 2008, another study reported that among 5,814 patients with chronic pain who were also prescribed chronic opioid therapy, 19.5% had a current substance-use disorder diagnosis documented in their medical record. Most people reported using alcohol (73%), but there were also reports of cannabis (16%), prescription and/or illicit opioids (15%), and stimulant use (cocaine 11% and amphetamines 8%). In 2011, another review found anywhere from 4% of patients with chronic pain in a primary care setting to 48% of patients with chronic pain in an AIDS clinic had a current substance-use disorder. Overall, persons with a substance-use disorder have been found to be at a greater risk for aberrant medication-related behaviors. For example, if a person with a substance-use disorder is prescribed an opioid, there is an increased risk for prescription opioid misuse and abuse. This is why people with comorbid substance-use disorder (past and present) and chronic pain are potentially more difficult to treat and are at higher risk for other health conditions such as depression, anxiety, and sleep disturbances. For a more in-depth look at the relationship of a variety of other substances of abuse and chronic pain and rehabilitation treatment, see Cosio (2018).

Medicinal Marijuana

I want to start by saying that I am neither for nor against the use of medicinal marijuana. My opinion is that we are just not ready as a field to endorse the use of marijuana for chronic pain treatment. This is a political issue that has been put onto the medical community to decide. I can tell you this for sure, the medical community will not recommend the smoking of marijuana. The lungs are not built as a filter system for foreign substances, but rather for the air we breathe. The medical community learned from their mistakes surrounding smoking tobacco. In addition, we do not know enough about all the components of marijuana. There are about 80 to 100 different types and about 480 components in cannabis and 113 cannabinoids. There are three classes of marijuana that are not psychologically active: CBG, CBC, and CBD. THC, CBN, CBDL, and others are classes that are psychologically active. CBD is the most abundant class and is present in 40% of resin. CBD has been shown to reduce the intensity of THC.

We do not know more about the medicinal use of marijuana because pharmaceutical companies are not getting involved. They are not conducting research into marijuana because it is schedule I and there is no federal approval for clinical trials. Marijuana is still ILLEGAL in the federal government. Federal law surpasses state law. As of right now, there are 29 states and D.C. who have legalized medicinal marijuana. CBD is still schedule I according to the DEA. There are six states that particularly outlaw CBD, including Idaho, South Dakota, Nebraska, Kansas, Indiana, West Virginia. Access to medicinal marijuana varies by state, including laws about cultivation, possession, use of ID cards, diagnosis restrictions, and opened dispensaries.

Interestingly enough, there are already several different legal formulations of marijuana available on the market in the world. For a description of some of these formulations see Cosio (2018).

There are differences between what products you buy from a pharmacy versus a dispensary. Some questions still remain regarding what you buy from a dispensary:

  1. Quality control: Has the product you are using been tested for contaminants? CBD content is real only in Colorado, Washington, Oregon, and Alaska.
  2. Product form: Which is the best route of administration-inhaled, ingested, topical cream, vaping?
  3. No warnings of reported side effects: Adverse events among people with chronic pain include dizziness, lightheadedness, fatigue, muscle spasms, dry mouth, short-term memory impairment, suicide attempts, psychosis or mania, paranoia, agitation, motor vehicle accidents, infectious diseases, recurrent nausea and vomiting, cramping and abdominal pain, and psychological addiction.
  4. No established dose to treat a condition: In the 1970s, the THC level in marijuana was at 3.5%. Today, the THC found in marijuana averages more than 7%. Specific techniques used today can skyrocket the amount of THC to as high as 27%. Anecdotally, we suspect that marijuana helps with sleep, mood, appetite, enhances effects of opioids, and helps offset side effects (constipation or respiratory suppression).

If you are considering recommending the use of medicinal marijuana to someone, there are several clinical practice guidelines of which you should be aware:

Opioid Use Disorder

Opioid Abuse vs. Opioid Misuse

Opioid abuse (9%) and illicit drug use (16%) have been found to be common in people with chronic pain. Many frontline providers are reluctant to prescribe an opioid for chronic pain management among people with a substance-use disorder for fear of misuse, abuse, or addiction. Let’s clarify these terms:

Thus, many providers implement different justification strategies in an attempt to reduce these occurrences. Several prescribers begin treatment by working their way up the “pain analgesic ladder” before prescribing an opioid. Others attempt to identify red flags to predict these occurrences, such as:

Mitigation Strategies

According to the new CDC guidelines for the initiation, selection, and assessment of opioid therapy risk released in March 18, 2016, providers should incorporate into their management plans strategies to mitigate risk, including an assessment and history of substance-use disorder. There are several other mitigating strategies medical practitioners can use against opioid diversion and misuse, including:

Presently, a combination of these strategies is recommended to stratify risk, identify and understand aberrant drug-related behaviors, and tailor treatments accordingly. Unfortunately, only limited data are available regarding the success of any of these strategies.

Coping with Pain

Coping is the act of investing your own conscious effort into the solving of personal and interpersonal problems. The term generally refers to adaptive coping strategies which reduce stress. In contrast, maladaptive coping strategies may increase stress. The success of the coping effort depends on the individual, the type of stress, and the circumstances. Coping responses are partly controlled by personality, but also partly by social environment.

Active Versus Passive Coping

People who suffer from chronic pain tend to seek out passive treatments versus active alternatives. They tend to go for short-term relief at a long-term cost. In pain management, active treatments should be the primary focus, with passive interventions as an adjunct, not the other way around. It is possible that the reason people gravitate to passive treatments is because providers have reinforced that belief. Providers continue to use these passive treatments as the standard of care for chronic pain management.

Active treatments (such as home exercises, relaxation techniques, and mindfulness practices) can be available where and when the person needs to manage the pain. However, they rely on the person to actively participate in these techniques at home, away from the clinic. In addition, active techniques have a synergistic rather than a mere additive effect when combined with other interventions. It has been theorized that the active approach offers the potential to change physical factors (e.g., pain) and psychological factors (e.g., self-efficacy). Past research has shown that active movement and behavioral treatments for chronic low back pain are generally effective.

Passive therapies (such as medications, interventions, and surgery) tend to be discouraged as a primary focus. Passive treatments have the potential of reinforcing feelings of powerlessness in people who suffer from chronic pain. They also put the responsibility for pain management back in the hands of the provider. Passive options require people to be a submissive recipient of treatment. Passive treatment can help with immediate pain relief, but active treatment keeps the individual functional in the long-term. For example, when someone undergoes a surgery and fails to follow a proper rehabilitation program, they may still have pain long after recovering from their operation. Many passive interventions have shown positive effects for acute low back pain. Interestingly, the interventions shown to be effective in acute pain appear less effective in chronic pain. It has been recommended that passive modalities not be employed except when necessary to facilitate participation in an active treatment program. While passive treatments can be successful, it is critical to shift the person into a model of active care.

It may be helpful to think of all the treatments covered in this course as existing on a continuum, with passive treatments being on one end and active treatments on the other. In the middle, one could envision treatments as being “transitional.” For example, a chiropractor may transition from using myofascial release to teaching the person exercises to do at home. This is so the patient is able to increase range of motion at home while still benefiting from spinal manipulation. Thus, the chiropractor would rely on the person to actively participate in the techniques away from the clinic. As a mental health provider, you can suggest to your client that he/she can ask his/her primary physician or pain specialist for instruction on self-care in these areas while explaining the benefit; as part of a multidisciplinary team you can be in contact with the other providers and suggest that they provide instruction to the patient for self-care or share their recommendations with you to teach the patient.

Comparing Treatment Models

The rules about treating chronic pain have changed in the medical field in the past two decades. Remember, acute pain is pain lasting less than three to six months. Acute pain is directly related to tissue damage, is immediate, and usually of a short duration. The cause of acute pain can usually be diagnosed and treated. Acute pain is a symptom of an injury. When the injury heals, pain goes away. Medical providers tend to use the biomedical approach to treat acute pain. They use technology as a diagnostic strategy, are short-term in time span, assess cause, and define pain as a symptom, all of which separates the body and mind.

Governing agencies have suggested that if pain persists beyond three to six months, or the normal time of healing, then the pain is chronic. The person in pain should then be approached using the biopsychosocial method. A biopsychosocial approach rewrites the rules and expectations about treatment. People who suffer from chronic pain are encouraged to take a more active role in their treatment. This is different from the biomedical approach used during the acute phase of pain. Active care can counter-stimulate the pain in the brain. It can teach the brain to move the relentless, persistent, and constant pain signaling toward comfort and pleasure. It is recommended that people move from a passive “disempowering” stance to a more active “empowering” stance.

Burnout occurs among people with pain and may include increased feelings of emotional exhaustion in part from lack of control in their ability to meet their responsibilities, and lack of social support. The following section outlines several strategies for coping that you can teach your pain patients to utilize to combat burnout. Some of these strategies include resilience, distraction, social support, and goal setting.

Strategies for Coping


Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or stress. Resilience is the ability to maintain successful outcomes or to recover in response to a stressor. Resilient individuals are best described as having high levels of pain, but low interference/emotional burden. In fact, about 37% of people reporting high pain intensity have low pain disability. Resilient individuals have more adaptive pain coping, lower catastrophizing, decreased use of prescription pain medication, and decreased healthcare utilization. Resilience factors positively influence pain outcomes. There are both environmental and internal sources of resilience, including the following:

Resilience-based approaches yield benefits in pain and psychological functioning. Developing resilience is a personal journey. Note that an approach to building resilience that works for one person might not work for another. Examples of resilience-based approaches include:

Some or many of the ways to build resilience may be appropriate to consider in helping your client to develop his or her own personal strategy.


Distraction is the process of diverting the attention of an individual or group from an undesirable area of focus and thereby blocking or diminishing the reception of undesired information. In this case, the undesired pieces of information are the pain signals. Distraction requires the mental capacity to concentrate and the physical ability/energy to engage in distracting activities. There are several examples of activities used for distractions, including:

Distraction is useful for brief pain episodes. An example is when undergoing procedural pain, such as needle sticks. Keep in mind that the awareness of the pain may return once the distraction ends. The distraction is more successful if the client chooses something in which he/she is interested. The activity must stimulate one or more of the major senses (hearing, sight, touch, movement, etc.) in order to be engaging. It is also helpful to have the potential to increase the distraction stimulus when the pain increases. An example is when beating a drum or creating music.

Social Support

Social support is the perception and actuality that one is cared for, has assistance available from other people, and is part of a supportive social network. These supportive resources can be emotional, tangible – such as information or companionship, and/or intangible-such as personal advice. Social support can be obtained from a group or from an individual. This person or persons allow your client to express feelings about pain or tell their story; they provide encouragement and reassurance, and discuss problems or other concerns. Support can come from many sources, such as family, friends, pets, neighbors, coworkers, or organizations. The therapy relationship itself, of course, is a major opportunity for receiving support. An example of tangible support may be government-provided and is often referred to as public aid.

Intimacy promotes healing. Intimacy is a close, familiar, and usually affectionate or loving personal relationship with another person or group. There are different types of intimacy and each one can be nourishing.

Setting Goals

Some people might say that humans put all their effort toward setting and achieving goals. Living life to the fullest is one of the most common goals. Goals are part of every aspect of life. It is something by which we measure and motivate ourselves. However, figuring out how to do it is a conundrum that has challenged people throughout the ages. It may not be a difficult problem after all. Everything comes down to priorities, whether you make a conscious choice or go with subconscious preferences. Without setting goals, life becomes disordered and one would lose control. You can teach your client to treat his/her life as a gift, appreciate every little thing, and develop a sense of purpose which in turn will provide a convincing and fulfilling reason to get out of bed every day and to keep going.

The acronym S.M.A.R.T. can be used to provide a comprehensive definition of goal-setting. Instead of vague resolutions, S.M.A.R.T. goal-setting brings structure and a way to track your goals.

S – Specific

M – Measurable

A – Attainable

R – Realistic

T – Timely


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