A new research paper highlights the psychological distress seen in people who have chronic pain, and discusses different ways by which support from nurses and other people in the patients’ lives can reduce this suffering (Mil Med 2014;179:1-26).

Lead author Marianne Matthias, PhD, told Pain Medicine News that the value of the nurses in particular lies in both the delivery of the study intervention, including cognitive-behavioral therapy (CBT), and in the human contact and caring involved.

“So many of the participants really clung to the support, motivation, encouragement and listening they got from the nurse care manager,” said Dr. Matthias, a research scientist at the VA Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis. “The participants talked about how the nurse was so valuable, not just in terms of the CBT, but because she listened and was empathetic and she cared. That meant a lot to them because you don’t always get that from your health care professional.”

Patricia Bruckenthal, PhD, president of the American Society for Pain Management Nursing and chair of the Department of Graduate Studies in Advanced Practice Nursing, Stony Brook University’s School of Nursing, Stony Brook, N.Y., said her own research reflects these results (Clin J Pain 2011;27:315-322). She commended the VA team for their work and said this model should be extended to treatment of all Americans who have chronic pain.

“Our work shows that nurse practitioners are as consistent as psychologists in delivering coping-skills strategies in patients with osteoarthritis, and this new research is supporting that also. The nurses have good teaching skills and provide an important human connection to the patients,” Dr. Bruckenthal said. “One of the real barriers we’ve had in getting these interventions to patients is the shortage of people to deliver it, and this is a way to reduce that shortage.”

Dr. Matthias’s paper is one of several being published from the ESCAPE (Evaluation of Stepped Care for Chronic Pain) study. It involves 242 American veterans of recent military conflicts in Afghanistan and Iraq, and was funded by the Department of Veterans Affairs.

In 2010, a U.S. Army Pain Management Task Force made recommendations on the best approach to helping the more than 50% of soldiers returning home with chronic pain. The recommendations included promoting a culture of proactive intervent ion, making sure support is available to the veterans, and creating a spectrum of best evidence-based practices for the continuum of care for acute and chronic pain (http://www.pdhealth.mil/​education/​2011_​Presentations/​AFPCH%20​11%20​Pain%20​Management%20​Across%20​the%20​DoD.pdf). The randomized controlled study is part of those efforts; its methods were described in a paper published in June 2012 (J Pain 2012;13:571-578).

The veterans were randomized to either usual care or a nurse-led pain management intervention that involved pain medication management, and 12 phone conversations. During the first six phone calls, the nurses provided information on medication management and pain self-management instruction. In the next six calls, they delivered brief CBT, focusing on how to overcome cognitive barriers to reducing activity limitation and pain severity.

The 2012 paper focused on in-depth interviews with 26 of the patients aged 24 to 62 years, and explored how CBT helped the patients understand the connection between their thoughts and emotions and their experience of pain, as well as other aspects of how they were learning to manage their pain. The January 2014 paper delved more deeply into the pain’s emotional toll on the 26 patients and their perceptions of need for support.

One veteran said his pain was “a burden on my soul.” Another said, “In Iraq we did so much, and then come back and you have to fight to get out of the chair. The pain was just overwhelmingly a sense of helplessness.”

Some of the men and women found it best to not talk to people in their lives about the pain. “Guys always wanted to do something for me instead of letting me do it. … I had to tell people, ‘It’s OK, I’m not crippled…. I’m still part of this team,’” said one veteran. Another said, “I usually handle it if I’m in pain. I usually keep it to myself.”

Others said they found it important to have someone to talk to about their pain, whether a partner, other veterans or co-workers. “Dr. [name deleted] didn’t resolve anything. The meds didn’t resolve anything. And my friends at the VA resolved the problems, because … when you know you’re not the only one, this isn’t just you the world’s picking on.”

—Rosemary Frei, MSc


Drs. Bruckenthal and Matthias did not disclose any relevant conflicts of interest.