Integrating Medical and Psychological Treatments for Cancer Pain

Karen L. Syrjala, Pain and Toxicity Research Program, Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington 98104 and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195

Where do psychological treatments belong in the management of cancer pain? Most clinicians and researchers now acknowledge the importance of emotional, cognitive, sociocultural, and behavioral factors in the experience of pain and the success of treatment for the cancer patient. But after we acknowledge the importance of these psychosocial factors, there are few examples to guide us in how to integrate these recognitions into a medical practice with busy nurses and physicians, limited financial resources, varying ages and sociocultural norms of the patient environment, fatigued and ill patients, and protective, worried families.

Certainly, psychological treatments never take the place of medical treatment; they are not alternative pain management methods, but they are always, in some form, an adjunct to pharmacologic or other medical interventions. The question is not whether we ``should'' use these techniques, but rather how we can use them with clear intent, not arbitrarily or by coincidence, or even to the patient's disadvantage.

In this chapter, I will review the psychological methods all health care providers can use in management of cancer pain. I want to focus particularly on communication and educational methods that can be integrated into any medical practice by any professional treating the cancer patient with pain. Then I will provide more detail on specific cognitive-behavioral approaches psychologists and other behavioral medicine specialists use.

OVERVIEW

The role of psychology in cancer pain treatment is not only to eradicate pain. In a sense, the role of psychology is as an observer: to notice what has not been fully or consistently addressed; to remind the physician, the nurse, sometimes the family and even the patient, that there is more to the patient than the disease or the pain, more to the treatment than the drugs.

Other chapters in this book describe in detail the theoretical, physiologic, and observable relationships among the constructs of sensation, emotion, cognition, and behavior in the experience of pain and suffering. We can demonstrate the empirical validity of these constructs. Based on research results, we can prescribe effective models of psychological treatment, incorporating cognitive-behavioral methods as adjuncts to pharmacology for the management of cancer pain. To some extent I will do this. But prescribing an optimal model for psychological treatment will not change day-to-day practice or improve comfort for the majority of patients who are followed by physicians and nurses but do not have access to psychological specialists trained in cancer pain. Thus it is necessary to think not only about what works given all the resources possible, but what can be accomplished given the resources most settings have accessible.

What can be accomplished when the physician or nurse understands basic tenets of communication about pain management? What can be accomplished by a psychologist or social worker who knows about cancer patient issues but may not be a pain expert or know cognitive-behavioral skills like hypnosis, imagery, or cognitive restructuring? And in those situations where pain experts are available or cognitive-behavioral skills are known, what is effective for psychological specialists to provide? This chapter will review interventions at several levels of expertise and training. The goal is that these will be useful to you at the level of resources and skills available in your setting or in those settings where you teach others.

There are two important additional issues to address in discussing these interventions. First, since all patients will not have access to all resources, we need to define the most important interventions that can be provided in the course of ``standard'' medical practice. Second, not everyone benefits from the same psychological intervention any more than everyone benefits from the same pharmacologic intervention. We need to know more about who benefits from what; and we need to define adequate evaluation of the patient and the patient's needs.

Goals of Treatment

What do we attempt to do in most cancer pain treatment and where do psychological methodologies apply? In optimal situations, our treatments:

• make the patient free of pain,
• add no side effects from treatment (especially constipation, sedation, and mental confusion),
• enable the patient to function physically and socially,
• free the patient from fear of future suffering,
• maintain high quality of emotional and social life (without depression, anxiety, withdrawal, or alienation from family).

When these optimal goals are not met, we strive to select treatments that provide the greatest physical comfort possible while causing the fewest possible side effects and least disruption of function. We try to provide treatments that allow patients to meet their expectations for quality of life at their present point in the course of the disease. We assure patients that suffering can be treated and that they can have some control over discomforts. Thus our practical goal is to help patients believe that their symptoms are manageable while they maintain the best possible quality of life.

Standard Medical Practice

Pain treatment usually proceeds in the following stages:

1. Evaluation indicates a pain problem.
2. The first line of treatment after assessment is medical: radiation; chemotherapy; surgery; medication by various routes, beginning orally; neuroinvasive procedures.
3. Nurses, physicians, physical therapists, patients, and family members may add some physical treatment methods of their own: ice or heat; massage; positioning; movement.
4. If assessment identifies problems of anxiety, depression, sedation, delirium, or other mental status change, psychotropic medications may be considered.

In many cases, antidepressants, antianxiety agents, antipsychotics, or stimulants are prescribed by the treating physician. Evaluation by a psychiatrist is underused in most settings. Consequently, an inadequate number of psychiatrists are trained in the unique medical problems and psychological issues of cancer patients. At the same time, oncologists or cancer pain specialists often are not entirely familiar with psychotropic medications or their proper indications, thus these drugs may not be given optimal trials.

INTERVENTIONS TO INTEGRATE INTO STANDARD MEDICAL PRACTICE

Having recognized the role of standard medical practice, the following communication tools should be understood by all practitioners:

Multidimensional assessment

Information provision

Education about pain management

Reframing

These tools must be learned because they will be used in the course of standard treatment-related communication. Without understanding their use, practitioners are more likely to assess, inform, or educate inadequately or in forms that enhance anxiety or helplessness. Nurses and physicians convey information at the bedside, they listen, they reassure patients and family members, and they actively educate patients about both the pain and potential treatments. Each of these interactions can enhance patients' beliefs in their ability to cope with the symptoms they have, can foster adherence to the medical plan, or can escalate patient anxiety or helplessness.

Assessment

Regular assessment is the cornerstone for determining when pharmacologic and nonpharmacologic treatments should be introduced. Far from feeling burdened by reporting pain and other symptoms, patients are often relieved that staff ask specific questions. Cancer patients are reluctant to complain and do not know what experiences are ``normal'' or what should be reported. They will often answer ``fine'' or ``OK'' if asked only ``How are you doing?'' A pain score, rated on a scale from 0 to 10, can be used as an objective quality-assurance tool to determine the need for further evaluation or change in treatment. Pain above a score of 3 indicates a need to assess more dimensions of the pain experience than just pain severity. These moderate or severe pain reports above 3 suggest the need to use higher doses or a different medication or, alternatively, a different intervention. Even temporary pain should not exceed 6 on a scale from 0 to 10 without mandating further evaluation or additional pain treatment methods (7).

In addition to identifying the level of unrelieved pain, assessment must evaluate patient functioning. When patients do not require further treatment, the following factors apply:

Sleep includes uninterrupted hours adequate to feel rested;

Basic self-care is adequate to maintain necessary health, self-esteem, and adherence to medical treatment;

Daily activity maintains lung and cardiac function and muscle flexibility and strength.

Interactions with family and medical staff meet needs for assistance, information, and emotional support;

Mood is mostly hopeful or neutral, with manageable fear or discouragement.

Thoughts are overall neutral or positive regarding ability to handle pain and the demands of treatment;

Attitude is accepting of treatments as needed to maintain comfort and health care; opioids, if needed, are not rejected out of fear of addiction, tolerance, side effects, or sense of personal weakness.

Concepts Related to Psychological Interventions

Thoughts, emotions, and behaviors are the observable targets of psychological interventions for managing cancer pain. Interactions with medical staff provide options for cognitions or thoughts about symptoms or sensations. Illness-related concerns become the focus of a patient and family's thinking. Interactions with the medical staff are given enormous significance. Words and behaviors are repeated, overinterpreted, and scrutinized for covert messages. Most often, the family models their unspoken and spoken rules, beliefs, and behaviors on the medical team (27). One of the valuable contributions a physician, nurse, or social worker can make to the long-term mental health of the family is to model, by example, the acceptability of talking about and planning for pain management, disease progression, and dying.

Patients turn the words of the medical team into internal cognitions that can increase fear or provide reassurance when they have pain or unfamiliar experiences. Properly provided information assists patients in maintaining adaptive thoughts and reducing or eliminating maladaptive thoughts. Maladaptive thoughts increase patients' beliefs that an experience is out of control.

As noted above, emotions are closely tied to and influenced by thoughts. Cognitive-behavioral methodologies are built on the recognition that how people think affects how they feel and, if you change how they think and behave, their feelings, and even their experience of sensations, will change also (2). Originally developed for treating depression, these methods have been adapted for the treatment of chronic pain and of cancer pain (35,38,39). Over time, unrelieved pain can engender feelings of helplessness and hopelessness. At the extreme of hopelessness, cancer patients with severe, unrelieved pain are more likely to commit suicide (5). The recognition of helpless feelings and the introduction of alternative experiences of self-control or joy counter these helpless feelings. For example, a patient may be tired and uncomfortable, with very limited activity possible. A family member may help the patient to bathe, reassure her of the success of the effort she is making, no matter how small the result may seem, and then talk with her about an activity she has done before or one she would like to do when she is better. These behaviors and discussion remind the patient that she is not totally helpless. Acknowledging the effort involved in small accomplishments can bring a sense of control back to the patient. Remembering positive events evokes feelings of pleasure. In addition, the memories of the past and anticipation of the future remind the patient that there is more to her existence than the present pain.

Coping behaviors are all of those actions (or inactions) patients take to try to manage their pain. These might be helpful or counterproductive. In the broadest sense, these include verbal and nonverbal communications about pain such as reporting pain, withdrawing, and other behaviors that indicate suffering or might initiate efforts to help from others. These certainly include taking medications to relieve pain as the most common coping strategy used by cancer patients. Other behaviors are used by nurses or experimented with by patients or families, including physical methods such as the use of ice or heat, rest, and physical positioning (for details, see ref. 22). Additional coping methods that influence cognitive and emotional responses to pain can be incorporated into treatment. These include the use of cognitive modifications, active distractions such as hobbies, massage, exercise, physical activity, and relaxation, imagery, or hypnosis.

SPECIFIC COPING INTERVENTIONS

Table 1 lists the coping interventions all medical professionals use in regular practice that will either help or hinder patient and family coping efforts.

Information

Chapter 24 Table 1:Coping interventions used by all health care providers

To the extent possible, we make the unfamiliar more predictable by informing patients of what is going to happen. This in itself is reassuring, since uncertainty is known to increase distress and threaten perceptions of ability to cope (25). The in formed consent process used in many hospitals emphasizes provision of medical information that patients often cannot fully comprehend (26). The process forces patients to recognize the limits of their own (or the medical staff's) control over the outcome of treatment. Although this process is necessary, it emphasizes the negative and makes it more difficult for patients to maintain positive or hopeful cognitions.

Some of the effects of this informed consent process and the overall uncertainty about what will happen can be countered by providing specific information about what is known. Information helps patients to ``label'' their sensations with familiar, less frightening terms. Information also gives patients a way of ``reframing,'' or thinking about their situation from a less threatening or less helpless perspective.

There are three kinds of information that can be helpful to patients' labeling and reframing efforts. The most important is temporal information. Telling patients when something is likely to happen and, even approximately, how long it will last is the most useful information we can provide (19). For all of us, if we know something will end, we can tolerate much more than if we think it might go on forever. To facilitate coping, it is helpful to break the timing of events into the smallest time frames possible. So, for instance, we do not talk about a bone marrow aspiration as taking ``only 20 minutes.'' We break the aspiration down into sections. The local anesthetic numbing section might take 30 sec; the pressure of the needle going into the bone marrow might take 5 sec; the pull might take another 10 sec. Although the overall procedure might take 20 min including preparation, we help patients recognize that the painful sections last about 2 min, and most of the procedure is not painful at all. For any of us, our belief that we can tolerate 2 min of intense discomfort is much greater than our belief that we can tolerate 20 min of physical discomfort.

Sensory information is helpful to patients because it tells them exactly how they will feel. Using descriptors other than pain or hurt helps patients to label what they feel with familiar, known terms. Vague terms are uninformative and can only leave patients worrying about what an experience will be like and whether they will be able to stand it. Anything familiar is less threatening than the unfamiliar, even when it is unpleasant. Thus we would describe sensations as stinging or hot or pressure. These terms do not deny discomfort, but they also allow patients to prepare themselves for specific sensations and reassure themselves when sensations fit those predicted. Use of a simile can be very helpful when describing a sensation and reminding the patient that the experience is tolerable.

Procedural information informs the patient of specifically what will happen or is happening. This gives the patient an overview of what the nurse or doctor is doing. The patient can then remind himself that what is happening is expected. This reduces uncertainty, which in turn maintains the belief that the situation is under control. As a general rule, procedural information is the most frequently provided form of information, but it is less useful for assisting positive appraisals than temporal or sensory information (20,37). For most patients, once the procedure has been reviewed, the focus can turn to other forms of information provision.

The exception to this guideline is the patient who is extremely anxious and needs a great deal of control; otherwise he or she will feel totally out of control. For these patients, procedural information is equally as important as temporal and sensory information. At its extreme, these patients may be terrified to the point of phobia or refusal to continue care. For the small number of patients who are phobic of procedures and cannot tolerate distraction away from the procedure, we recommend systematic desensitization and/or anxiolytics (13). These patients need to receive constant feedback from the person doing the procedure and need opportunities to be in control where possible.

Ideally, patients receive all three types of information. Procedural and sensory information are provided prior to beginning any new process, and then the focus moves to temporal information and active distraction so thoughts focus away from discomforts that cannot be alleviated. When changes in treatment are required, new procedural and sensory information may be needed. But, as a rule of thumb, when medical treatment cannot further reduce discomforts, rather than focus on the pain, it is more helpful to remind patients that they are coping well, that this phase will not last forever, and then move attention to areas where control is an option.

Education

Barriers to Adequate Pain and Symptom Control-Targets for Education

Barriers to effective pain management have been identified for both physicians and patients. In a recent survey of 1,177 oncologists who had cared for more than 70,000 cancer patients in the previous 6 months, inadequate pain assessment was identified most frequently as the number-one reason patients are undertreated (41). Patient reluctance to report pain, patient reluctance to take opioid medications, and physician reluctance to prescribe opioids were other key factors identified as barriers to adequate treatment.

Mounting evidence supports the observation that patients and their families not only fear cancer pain but believe that pain cannot be effectively controlled without unacceptable consequences. A recent survey in Wisconsin (9) found 72% of the respondents agreeing that cancer pain can get so bad that a person might consider suicide; 39% agreed that strong painkillers are an indication that a patient is close to death. In cancer patients with metastatic disease who were on opioids for pain, 63% said they would wait until pain was moderate to severe before asking for analgesics, rather than taking them ``before the pain returns'' (8). Nearly 70% endorsed the statement ``I feel I should not take narcotic medications on a regular basis but only when the pain is extreme.'' In relation to effects of opioids, 70% expressed concerns about tolerance; 70% expressed concerns about mental confusion; 63% identified addiction as a concern. Spouses were more often concerned about tolerance (80%) and less often concerned about addiction (58%).

In research on cancer patients' beliefs about cancer pain, Ward and colleagues (42) reported that 79% endorsed beliefs that addiction is a danger with pain medication; various side effects were concerns for 61% to 85% of the patients; 60% endorsed beliefs that a choice might be needed between treating the disease or treating the pain; 59% agreed that pain medication should be ``saved'' for when pain is severe, otherwise it might be ineffective; 50% expressed concern that complaining about pain might annoy their doctor. These data indicate that a majority of cancer patients do have concerns that their pain will not be controlled during the course of their disease. Furthermore, the majority have misperceptions about tolerance, side effects, and addiction and, perhaps because of these concerns, believe that they should postpone taking pain medications until pain is extreme. When patients who return home to treat themselves believe that opioids are dangerous, they will not adhere to their physicians' prescriptions of oral medications no matter how proper these prescriptions are.

Education Methods

Information presents facts; it provides patients with labels for sensations and helps reframe a situation from a less threatening perspective. Education provides information that patients can then use to modify their own coping behaviors. This implies not only being told facts, but also having the opportunity to adapt the facts to fit their own situation and to plan their own responses. Beliefs about which patients need to be educated related to medication use are listed in Table 2.

General medical care research has noted that patients who desire information about their medical care nonetheless do not engage in information-seeking behaviors with their doctors or nurses (3,4). Patients tend to regard their doctors as the appropriate decision makers, even about what to discuss, and do not initiate communication about problems (3). Patients and their family members are unlikely to raise questions addressing beliefs and fears about pain.

Messerli and colleagues (24) surveyed postmastectomy patients and surgeons regarding education needed and sources of education important to these patients. While surgeons identified talking with a sensitive, understanding doctor as the most important resource, with written materials as second most valuable, patients identified written pamphlets as most important in both first- and second-place rankings. Discussion with other patients ranked third; counseling with a nurse or other health care provider ranked fourth; videotapes ranked fifth. Patients identified talking with a sensitive, understanding doctor as eighth in ranking.

Chapter 24 table 2: Barriers to patient use of appropriate pain medication

These results suggest that physicians will have to specifically ask about symptoms and request questions if they wish to communicate with and educate patients. With time demands on practice, it is equally important to note that written materials and communication with nurses and other patients can be more than adequate substitutes for education directly from the physician as long as the information is reinforced by the physicians' communications.

Chapter 24 table 3: Topics of medication-related education needs of patients and family members

Rimmer and colleagues (29) found that cancer patients who received medication-related education demonstrated higher compliance with analgesic prescriptions and had reduced concerns about taking opioid analgesics. These patients who received training also had a tendency to report lower pain levels compared to the untrained control group.

Concerns about negative effects of educating patients sometimes arise from fears that discussing possible side effects will oversensitize patients to symptoms. Available research indicates that informing patients about possible side effects of therapy does not increase the occurrence of side effects or have other adverse effects (17,43).

Specific medication education needs of patients and their family members are listed in Table 3. These targets for education of patients and their families should be addressed when pain is mild and when opioids are first needed. We also educate patients in an abbreviated form about the gate-control theory so they understand that nonpharmacologic methods may be effective and that this does not mean that the pain is ``not real.''

Reframing by Health Care Providers

Physicians and other health care providers can assist patients and families by remembering that these listeners will retain and repeat exact words over and over to themselves and one another. These include both negative and positive information, but most people look for statements that offer hope. When providing day-to-day feedback about the patient's condition, including statements about what is going well, that are not misleading, can be very helpful. It is always possible to find positive points, even if the point is that the patient is doing a good job of managing a very difficult situation. We first address the symptoms, problems, and patient concerns. Next we ask what the patient has been doing and ask about symptoms we believe they do not have. Finally, we comment on those areas of functioning that are not problems and on the many accomplishments of the patient and family. Thus we acknowledge the problems and then recognize that, no matter how difficult, there are things that are not problems and the patient and family are doing a good job of managing the situation. This simple, positive perspective can make a large impact on feelings of control, self-efficacy, and overall good feelings within and among family members.

COPING STRATEGIES REQUIRING SPECIALIZED TRAINING

Chapter 24 table 4: Coping interventions used after specialized training

Many cognitive-behavioral and psychological interventions can be used to treat cancer patients with pain (13). Table 4 lists coping strategies used most often by psychologists, social workers, nurses, or psychiatrists after specialized training. These are skills that can be taught to the patient so that a method can be used when the therapist is not present.

Self-Statements

When patients receive information and education, they are as prepared as possible to cope with threats to health or well-being. They can then use this information in self-statements or affirmations to remind themselves that the experience is expected and temporary and that they can cope. We help patients prepare ``I can cope'' statements prior to a major stressor, specifically to address the fears of the individual patient.

We prepare these statements by first exploring the conversations a person has with himself or herself. Many patients initially deny any helpless or self-defeating thoughts. With an accepting approach, exploration, and some provision of examples from other patients, most people acknowledge specific fears or concerns that sometimes enter their minds about what might go wrong. Patients then develop alternative phrases to remind themselves of areas where they have control. Finally, we work out statements to reinforce that they are doing as well as possible in this exceptional experience. It is important to emphasize that this approach is only effective when it is adapted to, and developed with, the individual patient.

In discussing any cognitive modifications, it is essential to assure both patients and families that they will not kill themselves or cure themselves by having the ``right'' thoughts or by maintaining only positive thoughts. Fears and helpless thoughts are normal and should be understood and tolerated as normal; at the same time, we encourage patients not to stay in these thoughts. At times, awareness of these thoughts can help patients identify when they need more information or when they need reassurance from someone else whose knowledge or support they value.

Reframing

In addition to providing reframes to the patient as a part of regular communication, we teach patients to learn to reframe for themselves. After teaching them to identify negative self-talk, times when they expect the worst, or situations that really bother them, we teach four forms of reframing:

Focus on what they have done or can do instead of what they cannot do or have not done;

Find something positive that they will gain from the situation and focus on that;

Look at the situation from the perspective of an uninvolved observer to try to find a more balanced, neutral view;

Focus on the temporary nature of what is difficult.

Active Coping and Distraction

Distraction is a normal part of coping when we have exhausted our abilities to solve problems or simply want a break from problems or preoccupations. Distraction is not the same as denial, which implies an inability to recognize reality, or avoidance, which implies an unwillingness or inability to cope with reality. Denial can be beneficial in situations where nothing can be done to change the circumstances and focusing on fears may just increase anxiety (21). Avoidance, on the other hand, seems unhelpful as a coping strategy and is related to greater levels of distress (40). When coping with cancer pain, getting through the day comfortably is often the greatest problem and one that may be hard to totally solve. In this case, focusing attention away from discomforts can be one of the better coping strategies. Individuals each have their own preferred distractions. We work with patients to plan when, where, and how they will use specific distractions.

Some distractions involve focusing on thoughts or mental activity. Imagery is one such focus. Others include self-statements, prayers, reading, listening to someone read, and listening to music. Other activities focus on active behaviors such as working on a hobby, using deep breathing, and relaxation. Many patients report talking with family and friends as the most effective distractor. Often the best way to focus attention away from discomfort is to create more pleasant sensations. Massage and exercise such as walking are commonly used. We encourage patients to set a goal each day for one thing they want to do for their own comfort or pleasure, regardless of how small or what else has to be done. This then becomes a focus and provides a sense of achievement that reminds patients of their control over their own experience.

Relaxation and Imagery/Hypnosis

Relaxation with imagery is one of the most easily accepted, most useful noninvasive methods for managing cancer pain. Progressive muscle relaxation can be provided either by tensing and relaxing each muscle in turn (4) or by deep breathing and relaxing muscles without first tensing (33). Knowledge of the physical sensations of tension and relaxation in the various parts of the body can be helpful to patients so that they can easily notice tension and relax muscles when stressed. Once patients understand relaxation and deep breathing, we explore goals or wishes for the future. We develop images of places where they felt relaxed, healthy, strong, and capable. Nearly all patients enjoy and respond to these ``pleasant place'' images. With some patients we incorporate suggestions for increased general comfort or for numbness in the painful area. An understanding of the use of suggestion is one of the primary distinctions between relaxation and hypnosis (1,16). For the purposes of pain management, research does not yet allow us to clearly distinguish effects of hypnosis from those of relaxation and imagery. Because of the negative connotations of hypnosis for some patients, we usually use the term relaxation with imagery (15).

Brief imagery can be used to counteract the sensory qualities of pain. When in-depth imagery is not possible because the patient is not interested or does not have the needed attention span, brief images can still provide a time-out from pain and illness. We take the patient's description of sensation and create an image to match. In cases such as severe, paroxysmal pains, we use a brief image that counteracts the sensory quality of the pain. For burning, stabbing pain we might have the patient focus on deep breaths while imagining blowing arctic air through the sensation; for extreme pressure in the abdomen, we might use an image of a heavy weight lifting off the painful area, lifting higher with each exhalation.

For less excruciating pains, but where patient attention or participation in receptive imagery is impaired, we simply have patients tell us a story about a place they have been. With questions, we help them to expand on the story in the same way we would do with imagery. Storytelling is nearly always more effective with children than formal relaxation and imagery. The nurse or family member can tell a story or have the child tell the story. When possible, having the patient tell the story will be more absorbing and distracting than listening to a story.

Structured Support

Support is clearly one of the essential needs for patients and family members. Most people actively seek support as the most frequent coping strategy of cancer patients (10). Men tend to be more reluctant than women to seek out supports and to provide emotional support rather than problem-solving. Including education in support efforts can be an effective enticement for men who otherwise might resist supports.

The value of support is being increasingly recognized in numerous studies. Recent research demonstrates that cancer patients who receive active psychological support, with or without skills training, from groups or individuals, report less pain and live longer (11,31,32,35). These supports are not alternatives to traditional medicine, but the expression of feelings and the sharing of experiences may help patients to participate more fully in medical treatment. Researchers are exploring whether these support interventions have neuroendocrine or immunologic effects (12,28,31).

Controlled Clinical Trials of Psychological Interventions for Cancer Pain Relief

Although there has been considerable interest in the use of psychological interventions for cancer pain management, few controlled clinical trials have examined the utility of these techniques. Spiegel and Bloom (32) randomly assigned breast cancer patients to three groups: a support group, a support group plus hypnosis training, and a no-treatment group. Support groups for the two treatment conditions lasted more than 1 year, but outcome assessment was completed at 1 year. Both support groups reported significantly less pain and suffering than the untreated group, with the hypnosis group reporting lowest pain levels after 1 year. A recent study by Fawzy and colleagues (11) did not look specifically at pain, but did randomly assign cancer patients to an untreated control group or a group that received coping skills training consisting of four components: brief education, support, training in problem-solving, and relaxation with imagery. The advantage of this study was its short duration, six weekly sessions. These researchers found that the intervention significantly reduced patient reports of fatigue and distress while increasing patient use of active cognitive and behavioral coping methods. Results remained at 6-month follow-up. Even though this study did not look directly at pain, the methodology indicates that relatively brief, cost-effective (e.g., group) interventions can have long-lasting results.

We have completed two studies testing the efficacy of cognitive-behavioral skills training for pain related to bone marrow transplantation for cancer. In both clinical trials, we found that patients can learn these skills with brief training and can use the methods to reduce severe pain even when opioids are used concurrently, as long as the training occurs before treatment begins. In a pilot study, we randomly assigned patients to four groups: a no-treatment control; an untreated attention control where patients spent time with a therapist but no psychotherapeutic support was provided; a group that received hypnosis training; and a group that received cognitive-behavioral training without imagery or hypnosis (34). Patients received two sessions of training and had two half-hour ``booster'' sessions per week in the hospital to help them use the skills. The hypnosis group reported significantly less pain than all other groups, without using more opioids. Results suggested that hypnosis or imagery may be the most potent of the interventions. In our second study, we modified the interventions somewhat: (a) the untreated control group remained the same; (b) the cognitive-behavioral group included relaxation with imagery and simplified cognitive skills; (c) we called the hypnosis group ``relaxation with imagery''; and (d) we changed the attention control to an active psychotherapeutic support group that also received education and reframing from the therapist, although no coping skills were taught (35). All patients were treated individually in the same format as in the pilot study. Consistent with the Spiegel and Bloom study (32), we found that patients in all three treatment groups reported less pain than the untreated group.

Results of these four studies indicate that psychological intervention from trained therapists helps cancer patients to manage disease-related pain and treatment-related pain. Structured support is effective, but there may be an additive effect from the inclusion of coping skills in the intervention. Further research is needed to more clearly define the effective components of these interventions. Possibly the specific content is less important than providing the patient with some skills for self-management of symptoms and conveying that the patient has the ability to cope with the pain. Our research and that of Fawzy and colleagues clearly indicate that long-term treatment is not needed, that brief, focused interventions can be effective (11,34,35).

Pediatric Considerations

Most of these methods need little adaptation for use with children. Information is important for children, but of course must be phrased with words the child will understand. Otherwise the child may be frightened by unfamiliar terms. As with adults, education should be oriented to reinforce areas where the child has some control, such as asking for medication or understanding rewards for self-care activities. Children can plan for their own active distractions and can be engaged in play even when quite ill. Active storytelling play can be even more engaging than storytelling imagery while lying in bed. Children frequently enjoy art projects and drawing, whereas adults may be intimidated by perceived performance expectations with art.

Assessing children's pain is as feasible as with adults and should be the cornerstone of any pain treatment. In most cases, children as young as 7 years old are able to report pain on a 0-to-10 scale if the scale is explained and practiced briefly (23,36). Children between age 3 or 4 and 7 can use scales of faces where ``no pain'' is indicated by a smiling face and ``extreme pain'' is indicated by a tearful face. Under age 3 we rely on observation to inform us of pain intensity, although pain cannot be distinguished from general distress by the observation measures available (18,30). Other areas of assessment should be included as described above.

Who Benefits When?

Prior to moderate or severe pain, patients are most open to opportunities to enhance their control over symptoms. Once pain is moderate, patients may benefit from imagery done by a therapist but are less likely to be able to use any new cognitive-behavioral skills on their own. Attention span, concentration, and energy are necessary for learning new coping skills. When patients are sedated or confused from medical treatments or the disease, or when patients are exhausted and frustrated because all other treatments have been inadequate, we have a very difficult time teaching cognitive techniques for relieving pain. Information and education are always useful, but again are best provided when the pain problem is in early, mild stages. Physical methods such as massage or active distraction can be introduced at any point.

Although we do not have strong data yet on which patients benefit most from psychological methods of cancer pain control, clinical experience with patients in pain is quite similar to reports of cancer patients who have chemotherapy-related nausea and vomiting. Thus we can extract some general principles. Patients who are most anxious, or who expect the physicians and nurses to be in control, have difficulty learning cognitive coping skills. These patients may initially need supportive listening and identification of specific areas where they have some control (6). Cognitive-behavioral skills may be introduced after anxiety has decreased and after patients believe they have the ability to participate in managing their symptoms. At the other extreme, for patients who cope actively and manage anxiety well, it may be hard to tell whether the skills benefit them. Patients with moderate anxiety and those who have not evaluated their coping plans may benefit the most from cognitive-behavioral methods (6). These patients are often motivated to learn skills that help them to feel like participants in their care. They feel more in control of their physical reactions when they learn the skills, and they respond well to the additional support provided by the trainer.

For several categories of patients, it is particularly useful to have psychiatric or psychological evaluation in advance of a crisis to permit a baseline assessment and to plan for management if pain becomes a problem. Patients with difficult personality styles may respond very well to the structure of a medical setting if the treatment team understands the patient's needs and is consistent in their approach. These patients may use cognitive-behavioral methods appropriately as long as their other psychological needs are recognized.

Patients with histories of alcohol, long-term opioid, benzodiazepine, or other substance abuse may have greater difficulty with opioid management and achieving acceptable pain control. Anxious staff may raise questions as to whether medication is being used to treat pain or emotional needs. We have seen patients use opioids very appropriately when their history of substance abuse is more than 1 year old, although these patients may still need higher doses of drug to achieve pain relief. Patients with active histories of drug misuse are more difficult to evaluate for adequacy of pain treatment. In these cases, we work with medical staff to set external criteria for assessing pain control. With some of these patients, we establish contracts for minimum behaviors that must be adhered to if medication is maintained or increased. Again, these patients may respond well to cognitive-behavioral methods as long as the treatment plan also incorporates recognition of their unique psychological and medical needs.

CONCLUSIONS

Integrating Psychological Methods with Medical Treatments

Standard medical practice in cancer pain management can easily integrate cognitive and behavioral skills. All health care professionals can provide:

Assessment of pain and related quality of life;

Information in a manner that uses familiar descriptions of expected sensations and indicates the situation is manageable;

Education that (a) responds to common beliefs about cancer pain and opioid use; (b) conveys that cancer pain can be controlled; and (c) provides specific behaviors, including taking medication, that the patient can use to manage his or her own pain;

Reframing that reminds the patient of what is going well and acknowledges the beneficial coping efforts the patient is making;

Support for expression of emotions such as fearful or helpless thoughts about the disease or pain experience.

Psychological specialists may be needed in two roles:

To train other cancer pain specialists in methods of information provision, patient and family education, support, and cognitive reframing;

To provide structured support or patient skill training in self-statements, reframing, active coping and distraction, relaxation with imagery or hypnosis, and ways to communicate with medical staff or gather needed information.

What Works?

Research indicates that psychological interventions, when integrated with standard medical care, do reduce cancer pain. Data support the efficacy of the following methods: education, information, support, imagery, and coping skills packages that include active cognitive and behavioral coping.

Feasibility

These interventions need to be made available to more patients. Widening availability requires developing methods that take less time and do not depend only on professional resources. The following modes of delivery would expand the availability and efficacy of these methods:

Early information, education, and coping skills training prior to severe pain;

Multimodal training using videotapes, written materials, audiotapes, and brief one-to-one contact with follow-up;

Including a family member as a coach when providing information, education, or training in coping skills;

Use of group rather than individual formats for training or support.

Cancer pain experts all acknowledge that physical mechanisms interact with thoughts, behaviors, emotions, and environment to determine how patients respond to cancer pain and pain treatments. Yet many nurses, physicians, social workers, psychologists, and psychiatrists do not know what psychology can offer or how to integrate this area of expertise into the medical management of the cancer pain patient. At the same time, many nurses and physicians believe they can meet the psychological needs of patients themselves. Results of research available today inform us of how to improve patient pain relief both by expanding the knowledge of nurses and physicians and by including more social workers, psychologists, and psychiatrists in active treatment of cancer pain problems.

ACKNOWLEDGMENTS

This work was supported by grants from the National Cancer Institute (CA38552 and CA57807-01). The author thanks Dr. Janet Abrams for her editorial contributions.

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