ACT for PAIN

05/06/2024

About one in five people globally live with chronic pain, and it is a common reason for seeing a doctor, accounting for one in five GP appointments in the UK.

There is growing caution around prescribing opioids – given their potential for addiction – many doctors are looking to prescribe other drugs to treat long-term pain. A popular option is antidepressants.

In the UK, doctors can prescribe the following antidepressants for “chronic primary pain” (pain without a known underlying cause): amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine and sertraline. Amitriptyline and duloxetine are also recommended for nerve pain, such as sciatica.

A recent review of studies investigating the effectiveness of antidepressants at treating chronic pain found that there is only evidence for one of these drugs: duloxetine.
The review found 178 relevant studies with a total of 28,664 participants. It is the largest-ever review of antidepressants for chronic pain and the first to include all antidepressants for all types of chronic pain.

Forty-three of the studies (11,608 people) investigated duloxetine. The review found that it moderately reduces pain and improves mobility. It is the only antidepressant that was found to be reliably beneficial. Further, the review found that a 60mg dose of duloxetine was equally effective in providing pain relief as a 120mg dose.

The review also looked at studies involving amitriptyline, citalopram, fluoxetine, paroxetine and sertraline and found that that the evidence for benefit was very poor, and no conclusions could be drawn about their ability to relieve pain.
This suggests that millions of people may be taking an antidepressant to treat pain even though there is no evidence for its usefulness.

In light of these findings, which were published in May 2023, the UK’s National Institute for Health and Care Excellence (Nice) recently updated its advice to doctors on how to treat chronic pain.
The updated Nice guidance now suggests 60mg of duloxetine to treat [chronic primary pain] and the same drug and dose to treat nerve pain.

Comment - we are increasingly seeing the limited benefit of medicines in the management of chronic pain and that is why we believe it is so important for sufferers to learn to live better with their pain condition.

01/03/2023

https://www.pnas.org/doi/10.1073/pnas.2215192120

Chronic pain, such as arthritis, cancer or back pain, lasting for over three months, raises the risk of cognitive decline and dementia, a new study found.

The hippocampus, a brain structure highly associated with learning and memory, aged by about a year in a 60-year-old person who had one site of chronic pain compared with people with no pain.

When pain was felt in two places in the body, the hippocampus shrank even more — the equivalent of just over two years of aging.

The risk rose as the number of pain sites in the body increased, the study found. Hippocampal volume was nearly four times smaller in people with pain in five or more body sites compared with those with only two — the equivalent of up to eight years of aging.

Researchers said “Asking people about any chronic pain conditions, and advocating for their care by a pain specialist, may be a modifiable risk factor against cognitive decline that we can proactively address,”

The study analysed data from over 19,000 people who had undergone brain scans as part of the UK Biobank, a long-term government study of over 500,000 UK participants between the ages of 40 and 69.

The study controlled for a variety of contributing conditions — age, alcohol use, body mass, ethnicity, genetics, history of cancer, diabetes, vascular or heart problems, medications, psychiatric symptoms and smoking status, to name a few.

The study provides a quantitative understanding of the impact of chronic pain on cognitive function and the risk of dementia, laying an important foundation for future research into the relationship between chronic pain and cognitive impairment.

Numerous studies have investigated the impacts of common types of chronic pain (CP) on patients’ cognitive function and observed that CP was associ...

01/03/2023

Radically Accepting Chronic Pain | Psychology Today United Kingdom



This is a very good article from a psychologist and a chronic pain sufferers explaining how to apply Acceptance and Commitment Therapy.

There is a focus on letting go of the struggle in your life, and reflects on the ACT metaphor, “Tug of War with the Pain Monster”.



The article says,

“Radically accepting chronic pain involves fully acknowledging the present moment without fighting it.
Practicing radical acceptance helps us “drop the rope” in the game of tug-of-war with chronic pain and frees up energy.
We can then put our focus on things we can control, are grateful for, or are meaningful to us.
It is natural to fight against chronic pain. It is physically unpleasant and uncomfortable, making certain activities more difficult or less enjoyable. And, the more we fight against pain, the stronger it gets and the more depleted and exhausted we feel.

Radical acceptance is defined as being willing to fully accept the present moment as it is. Radically accepting chronic pain does not mean you like it or are resigned to it. You can practice tools to improve your quality of life even with pain. Radically accepting chronic pain simply means you completely acknowledge what is happening in the moment without struggling against it.

This can feel like a tall order. I have been living with a physical disability for over 40 years and I continue to fight against my chronic pain. Often this fight comes from wanting the pain to go away. My body hurts and it can feel like a slog to get through the day. And, by fighting my pain, I am ultimately fighting myself and increasing my distress. Deep down, I know spending my mental and physical energy in a tug-of-war with my pain is futile. It does not make the pain better.

Living with chronic pain is tiring and can make us feel physically and emotionally stuck. Radically accepting pain frees up energy as we are not using energy fighting pain and helps create options. You could spend your time and energy struggling against pain. Or, you could take a few slow, deep breaths. Or, you could go for a walk outside. Or, you could call a loved one. There is power in or, in knowing there are options and that you have the power to choose how you respond to pain.

So, how do we “drop the rope” and stop playing tug-of-war with pain?

Acknowledge How You Are Feeling

Ignoring, or trying to suppress, our emotions and physical sensations just make them stronger. If your lower back is killing you, for example, and you feel frustrated and tired, acknowledge this. You may simply say, “My lower back is hurting right now and I feel exhausted.”

Pause and Breathe

Next, pause for a few moments and take some slow, deep breaths, focusing on lengthening the exhale portion of the breath. For example, you may inhale to a count of 3 and exhale to a count of 5. Living with chronic pain is stressful and is often associated with muscle tension. Taking some slow breaths eases physical and emotional tension and may make it a bit easier to practice other coping skills.

Practice a Radical Acceptance Coping Statement

Use a coping statement. These statements are meant to remind you that there are things you cannot control and that it is unhelpful to fight against what is outside of your control. Here are some examples:

This moment is what it is even if I don’t like it.
I accept this moment as it is.
Fighting my current reality only increases my distress.
Although this moment is unpleasant, I can cope with it as it is.
Although my pain is unpleasant, the intensity ebbs and flows. This specific sensation will not last forever.
Shift Your Focus

When I notice that I am caught in a tug-of-war with my pain, I practice pausing and reminding myself that I have a choice in where I put my attention and energy by asking myself, “Jen, how do you want to be spending your mental and physical energy right now?” Then, I aim to focus on things I can control, am grateful for, or are meaningful to me.

For example, maybe I put in a load of laundry as this is a specific task that I can control. Or, I remind myself that I am grateful that I can go for a walk even if my legs hurt. Or, I make a plan to go out to eat with my partner as I value taking time to nurture my relationships.

So, pause and ask yourself, “What is something I can focus on right now that is under my control, I am grateful for, or is meaningful to me?” and do your best to let the answers guide your behavior.

Your pain will still be there. And, by dropping the rope and not playing an endless game of tug-of-war with it, you will create more space to live your life.”

08/02/2023

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews | The BMJ

Despite it being a frequent practice, there is limited evidence supporting the prescription of antidepressant drugs to help treat pain conditions.

In new data from an overview of systematic reviews conducted by an international team of investigators, approximately only 1 in every 4 comparison trials showed an efficacy of antidepressants in the treatment of pain conditions including back neuropathic and fibromyalgia pain.

The findings highlight a need to improve guidance and rationale behind the use of drug classes including serotonin-norepinephrine reuptake inhibitors (SNRIs) in matters of pain management.

Key Highlights

Antidepressant drugs are frequently prescribed to treat pain conditions, but limited evidence supports their efficacy.
The findings showed that only 11 out of 42 trial comparisons had at least moderate evidence of efficacy, including SNRIs for forms of chronic pain.
The rest of the comparisons (74%) showed either inefficacy or inconclusive evidence on the efficacy of antidepressants for pain.
As antidepressant use has doubled in OECD* countries from 2000 to 2015. Investigators stressed these findings show how little is understood behind the prescription of antidepressants for chronic pain conditions.

( *OECD Organization for Economic Cooperation – currently 36 Member countries in the OECD which spans the globe, from North and South America to Europe and Asia-Pacific including the US)

They said, “We found evidence of efficacy of antidepressants in 11 of the 42 comparisons included in this overview of systematic reviews,” they concluded. “For the other 31 (74%) comparisons, antidepressants were either inefficacious or evidence on their efficacy was inconclusive.”

The investigators went to comment, “This overview adds to mounting evidence challenging the use of medicines for pain,” they wrote. “In consequence, a real opportunity is emerging to focus more on what living with pain means for individuals and to change how we think about pain. Effective care and research can only grow from new, more equal partnerships between clinicians, people living with pain, and researchers.”

The research was commented upon in an editorial in the British Journal of Medicine (BMJ) who stated

“In its most recent guidance on chronic pain, the UK National Institute for Health and Care Excellence (NICE) evaluated the benefits and harms of medicines used for chronic primary pain (pain not adequately explained by any underlying condition). Antidepressants are the only drugs where this balance proved favourable, and NICE recommended clinicians “consider” their use because of the current gaps in evidence.”

They went onto say,

“Clinical guidelines are not rules but valuable aids to decision making. Clinicians continue to prescribe medicines for which the evidence is poor because they observe that some people respond to them, albeit modestly. But all medicines carry risk of harm and there are other, less potentially harmful options more likely to help people to live well with pain.”



There is growing evidence for the use of psychological therapies for the management of Acceptance and Commitment Therapy which also currently features prominently the UK NICE guidance.

We believe that our program ACTforPAIN represents an evidence based, affordable and sustainable alternative to “tablet” based approach to managing chronic pain.



References

Ferreira GE, Abdel-Shaheed C, Underwood M, et al. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ. 2023;380:e072415. Published 2023 Feb 1. doi:10.1136/bmj-2022-072415
Stannard C, Wilkinson C. Rethinking use of medicines for chronic pain. BMJ. 2023;380:p170. Published 2023 Feb 1. doi:10.1136/bmj.p170

01/02/2023

Does pain keep you awake at night? A new survey found that a surprising number of Americans are unable to get a full night’s sleep because of “painsomnia.” This Sleep Foundation survey was conducted online in June 2022. Results are from 1,250 participants aged 18 and older who lived in the United States.

Almost 98% of U.S. adults surveyed by the Sleep Foundation say they experience pain at least one night a week. About 85% said pain costs them at least two hours of sleep each night, with the average respondent losing six hours of sleep per week.

Back pain was the most common reason for painsomnia (56%), followed by neck pain (41%), head pain (32%) and knee pain (29%).

Adults who live with pain average just 6.7 hours of sleep per night, below the recommended 7 to 9 hours. A recent meta-analysis of 31 studies found that sleep loss increases our perception of pain and creates a vicious cycle. Poor sleep leads to more pain and vice versa.

When asked to rate their pain on a zero to ten scale, 73% of respondents with chronic pain said their nightly pain was at level 5 or higher. Over half (57%) said they wake up at least three times during the night, and 41% say they wake up earlier than they’d like. Experts say fitful sleeping is less restorative and heightens pain sensitivity.

What are people doing about their poor sleep? Over half of respondents (56%) who lose sleep to pain have taken sleep aids in the past month. Melatonin was the most popular (49%), followed by Benadryl (diphenhydramine) (23%).

A surprising number said connecting with others in pain support groups helps them sleep. Although only 1 in 5 pain sufferers say they’ve participated in support groups, 91% of those who did say interacting with other painsomniacs helped them learn how to better manage, understand or improve their sleep.

In our program we look at how to manage sleep better. Mindfulness has been shown to be an effective way to manage insomnia.

We believe that pain and insomnia may be helped by our ACTforPAIN program

11/01/2023

https://lnkd.in/emw5uNSm

STUDY CASTS DOUBTS ON EFFICACY OF SPINAL CORD STIMULATION

This is an interesting paper published in JAMA Neurology. It reports on a large study comparing spinal cord stimulation with conventional medical management and suggests a lack of clinical benefit for spinal cord stimulations but also reports that the latter is associated with higher costs and potential for harm for some patients.

The study found that the use of spinal cord stimulators was not associated with reductions in opioid use or nonpharmacologic pain interventions, including epidural and facet corticosteroid injections, radiofrequency ablation, and spine surgery. Nor was it found to be more effective than conventional medical management of chronic pain.

Spinal cord stimulators have seen an increase in use in recent years for chronic pain. About 50,000 are implanted annually in the United States at a cost of roughly $3.5 billion. Some experts have recommended more widespread use of these devices to lower the risks of medications, including opioids and gabapentinoids.

Despite their growing use, the study's authors stated that the evidence supporting spinal cord stimulators over usual care has limitations. They contend that the US Food and Drug Administration (FDA) authorized most stimulators without sufficient clinical data. They pointed out that the manufacturers provided funding for an estimated 85 percent of large studies (involving more than 100 patients) using these stimulators (and therefore there is propensity of bias in any publication).

The study stated found benefit in pain relief at six months from spinal cord stimulators compared with conventional medical management but the benefits were often depleted after 12 to 24 months.

Also the study reported that SCS was also associated with potentially serious side effects. An FDA letter addressed to health care professionals noted that more than 107,000 medical device adverse-event reports related to spinal cord stimulators had been filed between July 2016 and July 2020. The incidents included patient injury, device malfunction, and 497 deaths.


At ACT for PAIN, we re-state that whether patients in chronic pain are managed with physiotherapy, tablets, pain injections or advanced treatments such as SCS, or a combination of all these, it is likely that they will continue to experience daily intrusive levels of pain. This is likely to lead to mental health issues of anxiety, low mood and depression which can worsen the perception of pain. Our online program represents an affordable way of managing the psychological component of living with chronic pain.

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04/01/2023

IS THERE AN IMMUNOLOGICAL BASIS FOR FIBROMYALGIA?

https://www.jci.org/articles/view/144201/

This was recent paper presented at the Faculty of Pain Medicine annual study day in the UK.

Dr Andreas Goebel, a chronic pain researcher from the Walton Neurological in Liverpool presented his recent collaborative work with centres in London and Sweden looking at whether there is a immunological element to Fibromyalgia.

Fibromyalgia – a poorly understood condition that causes widespread pain throughout the body and extreme tiredness – may be caused by be an autoimmune response that increases the activity of pain-sensing nerves throughout the body.

The findings, published in the Journal of Clinical Investigation, challenge the widely held view that the condition originates in the brain, and could pave the way for more effective treatments for the millions of people affected.
Fibromyalgia affects at least 1 in 40 people worldwide, although some estimates suggest nearly 1 in 20 people may be affected to some degree. It is characterised by widespread pain and crippling fatigue – often referred to as “fibro fog” – and usually develops between the ages of 25 and 55, although children can also get it. Similar to many autoimmune conditions, the vast majority of those affected (80% are women).

The development of new therapies has also been hampered by a limited scientific understanding of what causes the condition in the first place, but this could change with the discovery that the immune system is involved.
Researchers harvested blood from 44 people with fibromyalgia and injected purified antibodies from each of them into different mice. The mice rapidly became more sensitive to pressure and cold and displayed reduced grip strength in their paws. Animals injected with antibodies from healthy people were unaffected.

Prof Camilla Svensson from the Karolinska Institute in Sweden, who was also involved in the study, said: “Antibodies from people with fibromyalgia living in two different countries, the UK and Sweden, gave similar results, which adds enormous strength to our findings.”

The mice recovered once the antibodies had been cleared from their systems, which took a few weeks. This suggests that therapies such as plasma-exchange, which are designed to reduce antibody levels and are available for other autoimmune disorders, such as myasthenia gravis, may be effective in fibromyalgia patients.

The next step will be to identify what factors the symptom-inducing antibodies bind to, said Svensson: “This will help us not only in terms of developing novel treatment strategies for fibromyalgia, but also of blood-based tests for diagnosis, which are missing today.”

Here we demonstrate that several key features of FMS can be induced in mice by IgG from individuals with FMS. Transfer of hypersensitivities from patients to mice was reproducible across all tested FMS subjects, strongly suggesting that antibody-dependent processes typically underpin the characteris...

02/11/2022

Two recent studies cast doubt on the benefit of Spinal Cord Stimulation therapy in chronic pain.

Spinal cord stimulation works by sending small electrical impulses to your spinal cord. An electrode is placed over the spinal cord and is powered by a battery which is implanted in the buttock or abdomen. Stimulation helps to block the pain signals travelling to the brain. It may feel like a tingling sensation which may help reduce your pain. You may not feel any tingling sensation. The amount your pain may be reduced varies from person to person.

There are many different forms of stimulation which have evolved using different modes of stimulation. The main differences in stimulation. They fall into the following categories.

i. Conventional or low frequency stimulation – approximately 40-60HZ
ii. Hight frequency stimulation- 10 KHZ or greater
iii. Dorsal root ganglion stimulation – targeting individual nerve roots
iv. Burst stimulation – intermittent or closely spaced stimulation

The effectiveness and long- term outcomes of spinal cord stimulation (SCS) are not fully established.

Two recent studies one from Israel and on from Norway have both questioned the effectiveness of these treatments.

The study from Israel looked at conventional spinal cord stimulation in patient with chronic pain from peripheral neuropathic pain (63 out of the 176 patients, 35.8%), failed back surgery syndrome (64, 36.4%), lower back pain (24, 13.6%), complex regional pain syndrome (18, 10.2%) and headaches or other types of pain (7, 4%).

They concluded “that in summary, after controlling for natural variations over time in the outcome measures, the results suggest that although SCS offers a short-term pain relief to the majority of chronic pain patients, only about 40% of them experience adequate pain relief in the long run (7-month post-implantation).

The study form Norway looked at chronic pain after lumbar spine surgery using burst stimulation.

They concluded “Among patients with chronic radicular pain after lumbar spine surgery, spinal cord burst stimulation, compared with placebo stimulation, after placement of a spinal cord stimulator resulted in no significant difference in the change from baseline in self-reported back pain–related disability.”

Both studies have come in for criticism from various quarters especially those who would be considered SCS implanters or enthusiasts.

Many of the studies which show benefit from SCS treatment have been criticised for
i. Relatively small samples (median of 38 participants)
ii. Relatively short follow-up (median of 12weeks, although it ranged between 0 and 208weeks)
iii. The majority of the studies were sponsored by the devices' manufacturers, a potential bias towards higher likelihood of positive outcome

At ACT for PAIN we believe is a treatment which can be applied to a tiny proportion of chronic pain problems. At best it provides partial pain relief (average about 50% reduction) for about 2 years.

There is no published data about its effectiveness after 2 years. In our experience many patients say it stops working with time.
We believe even for successfully implanted patients with SCS, chronic pain has ongoing intrusive impact on their lives and remains important to develop psychological coping strategies to help them in their daily struggles with chronic pain.

09/07/2022

This a very interesting study which showed that practising mindfulness can alleviate pain. It was carried out by a research group at the University of California.

https://lnkd.in/ei2vurD6

On the first day of the study, 40 participants had their brains scanned while painful heat was applied to their leg. After experiencing a series of these heat stimuli, participants had to rate their average pain levels during the experiment

Participants were then split into two groups:

i. Mindfulness group – were required to complete four separate 20-minute mindfulness training sessions. During these visits, they were instructed to focus on their breath and reduce self-referential processing by first acknowledging their thoughts, sensations and emotions but then letting them go without judging or reacting to them

ii. Control group - spent their four sessions listening to an audio book.

At the completion of the study groups had their brain activity measured again, but participants in the mindfulness group were now instructed to practise mindfulness during the painful heat, while the control group rested with their eyes closed.

They found that people in the mindfulness group had 32 percent reduction in pain intensity and a 33 percent reduction in pain unpleasantness.

They were able to track the changes in the brain scans in both groups which showed a change in the processing of painful sensory information processing. It appears to relate to reduced synchronisation with the thalamus (area of the brain associated with sensory neural processing) and relaying information to areas of the brain involved in how we evaluate life experiences.

The decoupling of synchronisation between the thalamus and these areas seems to lead to reduction in pain.

The lead researcher, Professor Zedain said "For many people struggling with chronic pain, what often affects their quality of life most is not the pain itself, but the mental suffering and frustration that comes along with it. Their pain becomes a part of who they are as individuals -- something they can't escape -- and this exacerbates their suffering."

By relinquishing the appraisal of pain, mindfulness meditation may provide a new method for pain treatment.

Professor Zedain hopes trainings can be made even more accessible and integrated into standard outpatient procedures.

"We feel like we are on the verge of discovering a novel non-opioid-based pain mechanism in which the default mode network plays a critical role in producing analgesia. We are excited to continue exploring the neurobiology of mindfulness and its clinical potential across various disorders

At ACTforPAIN, we have developed a comprehensive easy to follow online self-management chronic pain program which embodies mindfulness with an acceptance and commitment approach. We have recently had our 1st NHS contract.

Mindfulness meditation is effective in reducing pain relief; a new study reveals the underlying neural circuitry.

15/06/2022

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9145501/
This is an exciting study to see if Magnesium supplements can be helpful to manage stress and pain in fibromyalgia.

Patients suffering from fibromyalgia often report stress and pain and are often refractory to usual drug treatment.

Magnesium (Mg) supplementation seems to improve fibromyalgia symptoms, but the level of evidence is still poor. Mg appears to enhance and support the nerve cells of the spinal cord brain to better cope with stress.

In this study patients diagnosed with fibromyalgia were randomly allocated to one month of taking Mg supplements or to take a placebo (i.e., a control sugar coated pill).

This study was a randomized, controlled, double-blind. This means that the participants did not know whether they were taking a Mg pill or a placebo sugar coated pill and the researchers did not know either until the end of the trial when all the results were evaluated.

They identified two subgroups of fibromyalgia based on a pre study questionnaire widely used to assess stress levels called the DASS-42.

The mild/ moderately (m/M) stressed group
The severely/ extremely severely (S/ S+) stressed group.

The researchers looked for the effect on the level of stress on the DASS-42 scale, and also on a variety of other parameters including overall pain levels.

They found that in the mild/ moderately (m/M+) stressed group, their stress and pain levels significantly reduced in comparison to those taking the placebo (sugar coated pill).

In those that were severely/ extremely severely (S/ S+) stressed group, there was also a reduction in the stress and pain levels but it was not considered statistically significant.

This the first study to show that Mg supplementation can reduce stress and pain to significant levels in people with fibromyalgia who are deemed to be mild to moderately stressed.

The researchers suggested that the dosage of Mg used in the trial may have been too low for the stressed/ extremely severely (S/S+) stressed group to make the statistically significant results shown in the mild / moderate (m/ibsM) group.

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