A smiling woman next to the words, “First, I’ll teach you how pain is affected by — and how it affects — your actions, feelings, and thoughts.”

A screenshot shows the painTRAINER® program, which teaches people how to manage their pain. Image courtesy of painTRAINER®.

“Hi, and welcome to your first session.” Kelly, a friendly-looking woman, appears on a computer screen.

“First, I’ll teach you how pain is affected by — and how it affects — your actions, feelings, and thoughts,” she says. “Then I’ll teach you the first pain coping skill.”

Kelly is a virtual guide on painTRAINER®, a free web program that teaches people scientifically proven strategies to improve their daily lives by managing their own pain.

Lynn DeBar, Ph.D., a psychologist and behavioral researcher at Kaiser Permanente Washington Health Research Institute in Seattle, and her colleagues are testing whether painTRAINER® or a similar treatment delivered by telephone could be effective ways to help people live better by managing their own pain. Her research is part of the Pain Management Effectiveness Research Network, which seeks to evaluate the effectiveness of a broad range of therapies for a variety of pain conditions, within the Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM. The initiative is fighting the opioid crisis from many angles, including by finding new ways to enhance pain management through clinical research.

Retraining thoughts about pain

In 2016, an estimated 1 in 5 U.S. adults — tens of millions of people — experienced chronic pain, which is defined as pain lasting at least three months.1 When pain is caused by a recent event, such as an injury or surgery, treatment often involves pain relievers and rest. But when pain turns into a long-term problem, treatment gets complicated and often does not work.

“Things really shift when people have more persistent pain,” DeBar said.

Opioids may be helpful to relieve acute pain but are often less effective when used to treat long-term chronic pain. People may need increasing doses over time to get the same relief, raising their risk for dependence and overdose. For some people, using opioids can make them even more sensitive to pain.

The painTRAINER® program is based on the principles of cognitive behavioral therapy (CBT), a kind of psychological therapy shown to be effective in treating mental health and other conditions. CBT has long been used to treat chronic pain, with good results. Although negative thoughts do not cause pain, DeBar said, they can make pain worse. CBT can teach people new ways to think about their pain, to better cope with it and get back to their lives even if they are hurting.

“It’s skills training,” DeBar said. “It’s giving people the confidence that they can do things in real time in their lives to manage their condition.”

Advances in understanding of the brain have shown that regions involved in pain are closely linked to thinking and emotion. With CBT, many people are able to retrain their thoughts and emotions.

“The ability to manage thoughts and behavior and really look at making modest behavioral changes in your day-to-day life might make you less disabled and may even decrease the pain over time,” DeBar said. “As you’re able to get more active and you’re not as fearful, you aren’t as reactive to the pain.”

Scaling up and reaching out

In an earlier study, DeBar and her colleagues found that CBT could be integrated into the usual medical care of people with chronic pain. However, the researchers also noticed that patients, especially those with severe pain, often had challenges in getting to their appointments. So, for the NIH HEAL Initiative study, DeBar’s team is exploring ways for patients to access CBT remotely.

One of those ways is painTRAINER®. The software was developed by Christine Rini, now at Northwestern University, together with Frank Keefe and his team at Duke University. Just as a live therapist would, Kelly walks people through learning about chronic pain and practicing skills that can make living with pain easier. For example, Kelly leads participants through a technique called progressive muscle relaxation, which helps people recognize tension in their bodies and consciously relax their muscles.

The program is divided into eight sessions, meant to be completed over about eight weeks. The first session includes education on pain and relaxation. Later, Kelly talks about topics such as how to ease into physical activity and return to activities the person used to enjoy.

DeBar expects the study to recruit about 2,300 people with all kinds of chronic pain conditions and from across the country, including rural areas where treatment options can be scarce. A third of participants will use painTRAINER®; another third will be given similar sessions by phone with a coach in Seattle who has been trained in using CBT for chronic pain; and the final third will be given written information on how to live well with chronic pain, as a control group.

Other HEAL-supported projects are also testing painTRAINER® for specific pain conditions. One research group is testing painTRAINER® along with medication treatment for people who have knee pain from arthritis; the idea is that people may be able to avoid surgery if they can cope with the pain better. Another group is planning to test painTRAINER® with cancer patients who also have chronic pain. These groups are all part of the Pain Management Effectiveness Research Network, an NIH HEAL Initiative program to evaluate how different pain therapies work for a variety of pain conditions.

Looking forward to results

DeBar and her colleagues will check whether participants’ pain improves and how much the pain continues to interfere with daily life. The team also plans to ask about each person’s quality of life, such as how well they are sleeping (pain often prevents a good night’s rest), and will compare the costs of painTRAINER® and therapy by phone.

The researchers hope that by learning to deal with pain, people will need fewer visits to the doctor or emergency room and other expensive interventions; patients may even be able to reduce the amount of pain medicine they take. DeBar’s team will follow up with study participants after a year to see whether the effects of the therapy have lasted.

“We’re saying, if this doesn’t last up to a year out, that’s not a potent intervention,” DeBar said. “The idea is, you learn these things and then you use them in your day-to-day life, and you should get enduring benefits.”

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1. Dahlhamer J, Lucas J, Zelaya, C, Nahin R, Mackey S, DeBar L, Kerns R, Von Korff M, Porter L, Helmick C. Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016MMWR Morb Mortal Wkly Rep. 2018;67:1001–6.