Clinical considerations for behavioral pain management in co-occurring acute and chronic pain presentations.

Abstract

Objective: Behavioral pain management treatments are typically provided after a multidisciplinary assessment determining whether the nature of pain is expected to be short-term (i.e., acute) or whether the pain is persistent (i.e., chronic). However, many of the standard ways clinicians approach pain management are challenged by the presentation of co-occurring acute and chronic pain experiences, such as can be the case in sickle cell disease (SCD), headache management (migraines and daily persisting headaches), chronic musculoskeletal pain with reinjury, and juvenile idiopathic arthritis, among others. Such overlapping pain presentations can involve conflicting treatment approaches for pain management. Currently, there is burgeoning, yet still limited, understanding of the complexity of co-occurring acute and chronic pain presentations. Methods: Given the unique pain presentation common in SCD, among other conditions, we review how behavioral pain management strategies can utilize complementary approaches to address the experience of co-occurring acute and chronic pain. Results: This commentary provides a brief historical review of the evolution of our understanding of pain perception and psychological treatments for pain. We propose an innovative clinical framework for behavioral pain management of co-occurring acute and chronic pain. Conclusions: We hope to enhance the current dialogue around pain perception and pain burden to address the unique needs of cooccurring acute and chronic pain presentations. Ongoing areas for research and clinical considerations are also discussed. Implications for Impact StatementThere is increasing awareness of the heterogeneity of pain conditions involving both acute and chronic pain. This commentary proposes a new care model for behavioral pain management for individuals experiencing co-occurring acute and chronic pain. Behavioral pain management strategies should consider complementary and flexible approaches that address the cumulative experience of both acute and chronic pain.

Feasibility and preliminary efficacy of the Balance Program to reduce pain‐related disability in pediatric sickle cell disease

“…50 Approaching the treatment of pain in SCD from a biopsychosocial rather than a biomedical perspective 54 is gaining momentum with increased appreciation for behavioral interventions that address the unique pain presentations seen in SCD. 55 Behavioral pain interventions are particularly important in addressing pain interference, as there is the variability of the extent to which even disease-modifying therapies (e.g., hydroxyurea) impact pain interference, if at all. 56,57 Even in studies where objective measures of hydroxyurea adherence were associated with worse pain interference, the difference between groups with high versus low adherence was approximately 1.4 SDs in patients with HbSS.…”

“…As individuals with SCD may experience both acute and chronic pain, the program focuses on teaching strategies to reduce or manage acute pain (CBT) and strategies to continue participating in meaningful activities even when dealing with persistent or chronic pain (ACT). 20 The Balance Program also incorporates a caregiver training module to teach strategies for effectively responding to their child's pain, as caregiver knowledge and behavioral responses play a critical role in pain-related outcomes. 27,28 Session 1 of the Balance Program focuses on goal setting with the caregiver and child and providing education about SCD, pain, and pain perception using developmentally appropriate terms and analo- Staff also communicated with families using their preferred method (e.g., phone call or email) to remind them of appointments and confirm that ClinCard payments had been received.…”

“…As we have described elsewhere, SCD presents unique pain management challenges as certain recommendations for the treatment of chronic pain may be contraindicated for acute pain and vice versa. 20 There have been decades of noteworthy efforts to develop and evaluate nonpharmacological interventions in pediatric SCD. A systematic review determined that although there were few randomized controlled trials in SCD, there was sufficient empirical evidence to suggest that CBT was probably efficacious for treating SCD pain.…”

“…Importantly, the program incorporates both CBT and ACT strategies to address acute and chronic pain presentations in SCD. 20 The current study aimed to determine the feasibility, acceptability, and preliminary efficacy of a novel telemedicine-based pain management intervention for youth with SCD. It was hypothesized that (1) the Balance Program would demonstrate a high level of feasibility, as measured by 80% of the participants completing all four sessions; and (2) participants would rate the Balance Program as acceptable, as defined by self-reported satisfaction with the treatment on the Treatment Evaluation Inventory-Short Form (TEI-SF).…”

“…Furthermore, behavioral pain management approaches developed for general chronic pain populations may not be analogous or transferable to SCD due to the potential for patients to experience intermittent and severe acute pain episodes in addition to chronic pain. As we have described elsewhere, SCD presents unique pain management challenges as certain recommendations for the treatment of chronic pain may be contraindicated for acute pain and vice versa 20 …”