Editor’s Note: The first-ever North American Pain School (NAPS) took place June 26-30, 2016, in Montebello, Quebec, Canada. An educational initiative of the International Association for the Study of Pain (IASP); Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION); and the Quebec Pain Research Network (QPRN), NAPS brought together leading experts in pain research and management to provide 30 trainees with scientific education, professional development, and networking experiences. Six of the trainees were also selected to serve as PRF-NAPS Correspondents, who provided first-hand reporting from the event, including summaries of scientific sessions and interviews with NAPS’ six visiting faculty members, along with coverage on social media. This is the third installment of interviews from the Correspondents, whose work is featured on PRF and on RELIEF, PRF’s new sister site for the general public.
Francis Keefe, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences; the Department of Psychology and Neuroscience; the Department of Anesthesiology; and the Department of Medicine at Duke University in Durham, North Carolina, US. Keefe is a pain researcher whose work focuses on understanding psychosocial aspects of chronic pain, and developing and testing treatment protocols, such as cognitive behavioral therapy, mindfulness meditation, partner-assisted pain coping skills training, tai chi, and yoga. He is also the editor-in-chief of PAIN. Keefe sat down with PRF-NAPS Correspondent Kathryn Birnie, a PhD candidate in clinical psychology at Dalhousie University and the Centre for Pediatric Pain Research, IWK Health Centre in Halifax, Nova Scotia, Canada, to discuss psychological approaches to understanding and treating chronic pain, his current research interests, and his advice for researchers just starting out in their careers. Below is an edited transcript of their conversation.
How did you get into pain research?
My early interests were in biofeedback and other mind-body approaches. When I came to Duke University, I was hired to work with the clinical biofeedback lab there. I had some pain problems of my own, so working with people with pain seemed natural. I started to look at the psychological literature on pain, at what was working and what wasn't working, and began developing assessment approaches to use with patients we were seeing who had pain—and one thing led to another.
What were some of the psychological approaches you worked with at that time?
The dominant model at that point was the behavioral model that Wilbert Fordyce developed. The notion was to help patients suffering from chronic pain achieve maximum recovery by using reinforcement principles. In essence, this involved providing positive social reinforcement when patients engaged in adaptive behaviors, such as exercising or interacting with others, and minimizing social reinforcement when they engaged in pain behaviors, such as avoiding activities or resting a lot in bed.
The programs were intensive and lasted from two to five weeks, and virtually all of them were multidisciplinary in nature. Key elements included graded increases in exercise and activity levels, time-contingent pain medications with the goal of eliminating these medications, and increasing involvement in pleasant and meaningful activities. Behavioral programs were usually conducted in specialized inpatient or outpatient medical or rehabilitation units where clinicians on the treatment team were trained how to effectively deliver social reinforcement. To facilitate the transfer of benefits from the treatment to the home setting, patients and their family members were also trained how to use these reinforcement principles. Patients involved in these programs often showed substantial progress in terms of increasing the range and level of their activities and decreasing their intake of pain medications.
One of the striking things, considering the current opioid epidemic, is that the early behavioral approach was quite effective in getting people off of opioids. We published one of the early studies on the intake of opioids in patients with chronic pain where this approach was used. The study looked at the medical records of 150 patients who had been in our inpatient multidisciplinary program, and only 16 were found to need continuation of opioids at the end of the program.
There have been many significant developments in the field of pain, but there is still a lot of work to do. From your perspective, where is the field now?
There is growing recognition that how people adjust to chronic pain depends on their learning history. Once maladaptive behavior patterns―such as adopting an overly sedentary, inactive, and dependent lifestyle―become really entrenched, they're very difficult to modify. These maladaptive patterns often are reinforcing in the short run, and over the long haul lead to much higher levels of disability, social isolation, and psychological distress. And, unfortunately, these patterns often become perpetuated in a vicious cycle, and the processes that are involved not only affect overt behaviors but also biological and psychological domains; once established, the patterns are difficult to change. It's like trying to turn around a huge ship—it's very hard to do that.
One implication for the future is the need for early identification of maladaptive patterns; some people call this a risk factor identification approach. Early identification is important because it can lead to timely referrals for interventions, which can involve a stepped approach starting with minimal intervention for those with just a few risk factors, and more intensive approaches for people who have multiple risk factors. The point is that the earlier we can intervene with people who are at risk, the more likely it is that we can begin to turn the ship around. The possibilities for using early identification and treatment for the prevention of prolonged pain, and reducing the suffering of people with pain and of those around them, are incredibly exciting.
What other developments are exciting to you?
There is an opportunity, not only in pediatric pain, but certainly in adult pain management, too, to capitalize on teachable moments for training in pain coping skills. Teachable moments may occur around certain salient and emotionally demanding events like major medical procedures or surgeries. We have found that, at such times, patients and their families are often open to learning new ways of coping and thinking about pain. Focusing more on teachable moments when emotions are high and when there is an openness to learning is a very promising direction for the future.
How have you included members of the patient’s family in your work on pain coping?
Our interest in involving significant others in pain coping skills training began about 20 years ago. It was based on an observation made while we were doing a randomized clinical trial of patients with osteoarthritis. In that study, we brought patients into treatment groups and trained them in pain coping skills. Interestingly, we found that a number of the patients arrived at the treatment groups with their partner. We always asked the partner to sit in the waiting area while we worked with the patient. Many patients asked us if their partner could sit in on the group but, because of our study design, we told them no. But after this happened many times, we got the message that partners really wanted to be involved in the training.
As a result, we decided to conduct a study comparing two approaches to training in pain coping skills. One approach, which is the traditional one, involved training just patients, in groups, who had osteoarthritis pain. The second approach involved training patients and spouses in pain coping skills; this was in groups made up of couples in which one member had pain. We found that the outcome was better when spouses were included in the training groups, compared to when the spouses weren't included.
Another opportunity we had to involve partners in pain coping skills was in research examining pain at the end of life. At such times, caregivers are routinely involved in pain management, and patients welcome their involvement. We did a study where a hospice nurse visited the home and trained patients and their caregivers in pain coping skills that could be used at the end of life. The training produced clear benefits for the partner, including decreased caregiver strain and improved self-efficacy, and some indications of benefits for the patient.
That study led to a series of studies examining the efficacy of a variety of psychosocial interventions for cancer patients and their caregivers. The program of research conducted by Laura Porter, Rebecca Shelby, and Tamara Somers in our lab has involved patients with various types of cancer and has focused not only on training patients and caregivers in skills for managing pain, but also skills for managing other common cancer symptoms such as fatigue and nausea. We’ve been fortunate to have had multiple NIH [US National Institutes of Health] grants to study the efficacy of these kinds of dyadic approaches to training cancer patients in pain and symptom management. It's been a really fascinating area.
What are you working on now?
We’re working in two main areas. In the first, we’re looking at mechanisms that underpin three different, well-validated types of psychosocial approaches for pain, including behavioral treatment, mindfulness, and cognitive therapy. We’re asking whether these treatments work through the specific mechanisms that they're thought to work through—for example, whether cognitive therapy works because it reduces catastrophizing about pain—or whether the treatments work through shared mechanisms—for instance, whether behavioral treatment, mindfulness, and cognitive therapy all work because they decrease pain catastrophizing. This research on mechanisms is important because of its implications for streamlining treatment.
In the second area, we are looking at how we get the treatments that have been developed out to large numbers of people with pain who need them. One of the most disappointing things for me, and for other people who have spent their lives doing efficacy studies and demonstrating that the treatments work, is that many of these treatments are not being used much in primary care or even specialty care. Much of my work now focuses on training people other than psychologists, such as physical therapists and nurses, to deliver the treatments. We are testing whether treatment delivered by other health professionals works, and our data suggest that it does. We are also looking at novel ways of delivering treatment, through telephone or Internet-based programs, that require less involvement from highly trained therapists. We're interested in the full array of possibilities.
We're also very interested in virtual reality approaches as a way of intervening with patients who have trouble disengaging from pain, are having severe pain, and/or who are very disabled. We're developing a range of virtual reality approaches that would include an education portal. The portal would provide a compelling way to change attitudes and beliefs about what pain is and what a patient can do about pain. The portal can provide an entryway to various virtual interventions that could be delivered on smartphones and other devices.
Compared to the rapid changes in technology, the scientific process can seem slow and not agile enough to keep up. How should the pain field deal with that issue?
I would encourage people, such as applied scientists, who have these interests to work closely with those developing the technologies—to really infuse the technologies with the clinical wisdom they've gained from working with many patients, rather than taking a stand-back-and-wait approach. Such an interactive approach will ease translation and heighten our ability to use the scientific process we have, which is the randomized clinical trial, to test and validate the technologies that are developed.
One of the amazing things to me is that there are hundreds of apps for pain out there, usually to help people track their pain, but only a small number have ever been empirically tested in a randomized clinical trial. So, in many cases, we have no evidence that an available app can actually benefit people. In that sense, the technology is ahead of the rest of the field. We need to be more actively involved in educating consumers about which of these apps have data to support their use and might actually help people.
You mentioned pain catastrophizing as a potential mechanism across psychological interventions, and it is a very popular construct right now. Why do you think that is?
There are several reasons to focus on pain catastrophizing. First, from the perspective of a psychosocial researcher who's looked at almost every potential psychological factor related to pain and disability, pain catastrophizing is the single most robust predictor of how people are going to do when they have pain. We talk about reproducibility; this is a finding that is highly reproducible.
The second reason is that pain catastrophizing is potentially modifiable. When people were studying personality and pain in the past, there was a feeling that we couldn’t really do anything to improve outcomes because personality is fairly stable over time. One of the reasons for the interest in pain catastrophizing amongst interventionists is that you can change it, and the changes can have real benefits.
Another reason is that pain catastrophizing is evident across varied medical populations where pain is likely to be a problem. Even studies of the general population show that people vary in their levels of pain catastrophizing, in terms of day-to-day events that might contribute to pain, so there is an opportunity to study it in healthy populations.
I also think there are a lot of myths about catastrophizing.
What are they?
One is that it can't be changed, but there are many studies showing that it can be changed. Another myth is that it only occurs in certain chronic pain populations, but we know that's not true. Another myth is that if a person scores very high on a catastrophizing scale, they're really not going to benefit from any treatment. We actually have unpublished data showing they do well when given training in pain coping skills.
Many of these myths come from the notion that if people score high on a catastrophizing scale, it's almost like a diagnosis—you are now a "catastrophizer." That's unfortunate, because it's a misunderstanding of the concept. We need to educate scientists to make sure they understand that catastrophizing is a process that is part of normal experience. It can vary from person to person and is incredibly dynamic, and it can be decreased. Scoring high in catastrophizing at one time doesn't mean a person is always going to score high or that treatment is doomed to fail.
What advice do you have for trainees who are at the beginning of their careers in pain research?
I’ve thought about this a lot. I mentor a lot of people and really enjoy this work. My advice is that it's very important to become nested in a very active research group—to be surrounded by people doing research, writing papers, and applying for grants. The best settings include not only supportive and effective mentors, but also students, postdocs, and early-career, mid-career, and senior faculty.
Ideally, the trainee is working within a multidisciplinary group—gone are the days of the lone scientist. Given the current funding environment, it's very hard for people to build that type of career and sustain it. The idea that you have your own lab and work on a very restricted problem is tough right now. I'm not sure it's the best strategy.
If someone is nested in an active research group at the moment, my advice is to stay there for a while and get all the advantage you can out of that. But when you do spin out of that group, look for other groups that you can work with. I believe that people who attend to this networking approach are those who end up having the most rewarding and successful research careers. I've also seen that these individuals often have an easier path that enables them to balance work and other life goals much more easily.
You are a scientist-practitioner, but it seems difficult to do both. How have you handled that in your career?
Everybody struggles with it. I went into clinical psychology because it gave me the opportunity to do research, see patients, and teach, and I was able to do all of those. Being in a medical school environment has allowed me to pursue all three in different combinations at different times. There's a lot of cross-fertilization—I get a lot from my students that informs my research; when I work with patients, my research informs what I do; and patients give me a lot of ideas that I can then explore in research. So I think the three work together.
Obviously, times are changing. Some departments in medical schools think you're either a scientist or a practitioner; it's hard for them to conceptualize someone being both. But within psychology, there's been more of a tendency for people to hold onto the scientist-practitioner model because of their training, and to do a bit of both. One of my concerns is that, because of the emphasis on being either a scientist or a practitioner, a number of physicians get pushed into a practitioner track. There are people who could make very important contributions to the science, but that is not being nurtured right now because of the way systems are set up. That's a tremendous lost opportunity for the field.
Thank you so much for your time.
It was good talking to you.
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