An Integrated Understanding of Chronic Pain

Abstract

Pain as an interdisciplinary field is nearly 40 years old. Its founder, Professor John Bonica, envisioned pain as an interdisciplinary and translational domain of inquiry that would generate unprecedented research and improve patient care. In 1973, he convened a meeting at Issaquah, Washington that brought together scientific and clinical thought leaders from around the world and produced the blueprint for the International Association for the Study of Pain (IASP). Today, the IASP has 88 national chapters spread across the globe. Its biennial Congresses assemble scientists and clinicians from many disciplines to address all aspects of pain and its management. A vast literature provides evidence for pain management practice and steadily advances knowledge of pain mechanisms. The biggest challenge we face as clinicians and researchers is chronic pain—pain that persists despite treatment for an indefinite period of time, often without an identifiable cause. Despite substantial progress in the scientific understanding of pain and advances in technology that make new interventions possible, we have made little progress over the past four decades in eliminating chronic pain or preventing the disability that it causes. A 2011 report by the Institute of Medicine, “Relieving Pain: A Blueprint for Transforming Pain Prevention, Care, Education and Research,” estimates that up to 116 million adult Americans suffer from common chronic pain conditions. This makes chronic pain more widespread than heart disease, cancer, and diabetes combined. A few months ago, a colleague asked me to recommend a book that offers a coherent, comprehensive perspective on chronic pain. He had no interest in edited volumes that offer narrowly focused chapters from many authors. He said, “Give me something I can read from front to back that will allow me to gain an overall understanding of the field.” I at first thought, with dismay, that such a resource does not exist. Although we produce vast amounts of information on chronic pain, we come up short on knowledge. We compile facts very well but cannot deliver a comprehensive, integrated understanding of chronic pain. But then I recalled that Herta Flor and Dennis Turk had recently produced a book, Chronic Pain: An Integrated Biobehavioral Approach, and decided to examine it. I had wrongly assumed this to be an edited volume. Instead, it is a single narrative that combines the shared understanding of two authors, designed to integrate conventional and behavioral medicine perspectives on chronic pain. This book is a resource that I can recommend to my colleague. The authors of Chronic Pain: An Integrated Biobehavioral Approach are highly accomplished academic psychologists who have worked in the pain field for decades. Professor Herta Flor serves as Scientific Director for the Department of Neuropsychology and Clinical Psychology at the Central Institute of Mental Health, University of Heidelberg. The defining theme of her work over the years has been the interaction of brain and behavior: how behavior and experience influence neural processes and, conversely, how neural processes determine behavior and experience. Professor Dennis Turk is the John and Emma Bonica Professor of Anesthesiology and Pain Research at the University of Washington and Director of the Center for Pain Research on Impact, Measurement, and Effectiveness. Dr. Turk has made chronic pain the focus of his career. He has worked tirelessly to integrate the biobehavioral perspective with medical approaches to chronic pain, and he is a major figure in the development of cognitive-behavioral assessment and therapy in the chronic pain area. The two authors harmonize well, and the narrative seems to speak with a single voice. The first section of the book provides background on pain mechanisms, both physiological and psychological, including basic principles. It contains a number of valuable definitions and constructs, including stress. Recognizing that neither purely somatic nor purely psychological models, of themselves, provide an adequate explanation of chronic pain and associated disability, Flor and Turk assert that chronic pain is a learned response comprised primarily of pain memories rather than immediate noxious signaling. In this book, they seek to integrate current psychological principles and evidence with current biomedical principles and evidence to achieve a level of understanding that neither perspective alone can reach. The second section of the book addresses patient assessment. The authors articulate their concept of multiaxial assessment and describe the process necessary for differential diagnosis. This section includes a review of assessment procedures: interviews, self-report questionnaires, behavioral observation schemes, and psychophysiological methods. In short, the second section provides a guide for comprehensive patient evaluation. A CD accompanying the book provides many useful assessment instruments and treatment protocols. The third and final section describes three well-validated treatment approaches, each of which has substantial empirical support: biofeedback and relaxation training, operant group treatment, and cognitive-behavioral pain management. Recent evidence indicates maladaptive plastic reorganization of the brain in patients with chronic pain, and the authors review this area as well. For each approach, the authors provide the indications for these interventions, information on how to implement the interventions, and a review of evidence supporting each approach. Overall, this book is easy to read and well organized. The illustrations are modest but informative and appropriate. The authors have taken care to minimize psychological jargon that could pose a barrier to medical readers. Importantly, the authors do not indulge in speculation or untethered opinion. They have grounded the content in published evidence. I cannot think of a medical area of chronic pain management—nerve blocks, surgery, pharmacotherapy—that is as solidly based in theory and evidence as the biobehavioral approach put forward in this book. What this book does not cover merits mention. The authors do not attempt to offer an encyclopedic overview of chronic pain, and several important topics receive only nominal mention or are absent altogether. Genetic contributions to pain receive only one paragraph. Molecular neurophysiology is missing. Neuropathic pain receives no attention except for a scale designed to assess it. Depression receives little attention apart from a review of instruments designed to assess it. Discussion of the placebo effect, an area that exemplifies brain-body interaction, is conspicuously absent. I do not assert that these topics are errors of omission on the part of the authors. The purpose of the book is to articulate a biobehavioral framework, show the reader how to implement it, and provide a solid evidence base for their approach. I mention them because the potential reader should be aware that the book does not address several areas of current interest in the pain field. Hopefully, the next edition of this book will extend its scope to include at least some of these areas. Who should buy this book? Clearly, this is a valuable resource for physicians managing chronic pain and an excellent didactic resource for those in pain fellowships. Medical education predisposes physicians to think of psychological factors in chronic pain as mood disorders. Few can conceptualize a cognitive-behavioral perspective as a viewpoint complementary to their own. This book provides the resource they need to expand their understanding and knowledge. It is also a good book for pain clinic psychologists because it defines the state of the art in patient assessment and provides a current evidence base for a biobehavioral practice. Nonphysician clinicians such as nurses, physical therapists, and pharmacists also can benefit from this book. Researchers interested in chronic pain will find this book valuable both as a guide to the field and as a resource for measurement tools. In summary, Chronic Pain: An Integrated Biobehavioral Approach is a unique offering that meets several pressing needs in the field. It provides a comprehensive, integrated narrative on chronic pain, including its assessment and therapy. It also provides a solid articulation of the biobehavioral approach to chronic pain, making this accessible to clinicians working within the conventional medical model. The materials on assessment tools and treatment protocols are an excellent resource that can save interested clinicians and researchers dozens of hours of literature searching. The quality of the writing is high, and the book succeeds in holding the reader’s attention. This affordable book is a solid investment for everyone working in the chronic pain area. C. Richard Chapman, PhD, is Professor, Pain Research Center, Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA.