relapse prevention


A couple of days ago I mentioned the satisfaction I feel when a person I’ve been working with faces a setback and manages it successfully on their own for the first time.   Someone replied saying that we all face pain setbacks alone, so what did I mean really – and I thought today I’d quickly expand on what I did mean!

Chronic pain persists (goes without saying) but its pattern is to fluctuate from time to time and often without clear provocation – so it’s not very helpful to try and look at what ’caused’ the pain to change.  Yet this is so often what we as clinicians ask about, and more often what the person experiencing the pain tries to do.  Flare-ups happen irrespective of how hard we try to avoid them, so it’s useful IMHO to group flare-ups alongside other ‘set-backs’ and think of them instead as ‘things that make it hard to use my coping strategies’.  The reason being? Our focus in pain management isn’t the pain intensity, it’s about having effective coping strategies so we can sustain working towards our valued goals.

When we start thinking of living life irrespective of pain fluctuations, then it’s much easier to look at the vast range of factors that influence whether we successfully use coping strategies that help move us towards goals, or whether we revert to actions that take us away from achieving values.  We can start to see that living well with chronic pain is mainly about changing habits of a lifetime (which is why it’s so hard!).  This means some of the literature we can draw on to help us help our patients includes not only goal setting and action planning, cognitive behavioural therapy and self regulation, but also relapse and relapse prevention.  Marlatt and Gordon have written extensively about relapse prevention in alcohol and drug rehabilitation (here’s a brief overview of their model), and I’ve found it useful to use their model when I work with patients to review what lead to them reverting to ‘old habits’ in the face of challenging times.

Most of us know that when we start to change a habit, we don’t deliberately choose to slip up and go back to old ways.  Instead, the ‘old ways’ just seem to slither in and before we know it, we’re back doing just the thing we said we’d never do again.  The reality is that it’s a whole series of seemingly irrelevant decisions, or small events that lead up to the slip up where we forget to use the new behaviour.  Just think of your exercise plan, or your decision to never eat that much again, or even to study well before the exam!  We all do it – slide back into those old habits.

A high risk situation is one in which the chances of us reverting to old habits is much more likely – a bit like the difficulty a quitting smoker has when sitting with friends who are all smoking at a bar, or failing to go out for a walk on a day when we’re late back from work and the weather is chilly.

What happens if we go back to old habits?  Firstly, the new habit seems pretty difficult to do, it does require more effort and the old habit probably has some short term payoffs.  That first drag on a cigarette hits the cortex so quickly that the horrible smell, the cost of cigarettes, the effects on health and even the aging effects on skin are simply forgotten.  We have to remember that old habits probably have something about them that makes them ‘work’ – at least in the short term.  So it’s helpful to recognise both the good and not so good about the old ways, and plan to make the not so good a little more evident during high risk situations.

Secondly, if we were feeling a little shaky about the new habit, perhaps not quite trusting that it will work out in the long run, then revert to the old ways, the embryonic confidence we were developing in the new habits will be sorely tried.  It’s much harder to stay strong in a new habit when we’re still newbies at using it.  It’s helpful to practice the new habit with support, or avoid very challenging situations initially when learning a new way of coping.

Thirdly, if we have slipped up and used the old way of coping, the risk of the ‘what the hell effect’ is much higher.  The technical name for this is ‘rule violation effect’ and it basically means that if we’ve set up a new rule then break itjust a little, we’re much more likely to then completely break the rule than to return to the new habit.  Think of a bar of chocolate – one tiny piece is a slip up, then we might remember that we were going to ‘never eat chocolate again’ – having broken the rule, I know I’m likely to say to myself  ‘Oh what the hell, I’ve broken my diet today already, might as well eat the whole bar and start again tomorrow’.  Whoops.  Reframing broken rules into ‘slips’ or ‘lapses’ rather than ‘relapses’, recognising that slips do occur and congratulating yourself on recognising that you have noticed that you’ve slipped makes it much easier to feel good about returning to the original intention.

I’m sure you can see how difficult it is for people with chronic pain who may be faced with not just one habit to change, but many.  Not only do they need to work with their own thoughts and feelings about making these changes, many of the people around them – even health care providers! – can unwittingly place obstacles in the way of the person remaining focused on the new habits.

An example might help.

Allan is a guy who has a very painful hand after sustaining a crush injury and developing a CRPS.  After about three years of unhelpful surgeries and fairly high doses of various medications, he was referred for pain management and started to use things like activity regulation, cognitive reframing, coping statements, breathing and so on.  He even weaned himself of all medication and eventually returned to work, but over Christmas, took a break for about a month to have a summer holiday with his family.  When he returned after his vacation, he had about two weeks working where he had more jobs to do than he’d had for a long time.  Then work slowed down.  His pain increased and he said it was the most painful it had been since before he came to Pain Management.

His wife’s first instinct was that he’d done something to his hand and she went with him to the GP to ‘find out what’s going on’ and maybe have another scan ‘just in case you’ve broken something’.  His GP suggested he go back onto tramadol for a while, and would he like to have some physiotherapy.  Allan decided not to do any of this – he got out his folder of pain management strategies, reviewed his setback plan and started back on the things that he’s found work well.  But his confidence was shaken and so he called me to see if we could review his setback plan and check that he hadn’t forgotten anything.  We went through all the various factors that are, for Allan, high risk situations where he may fail to use his coping strategies – and there they all were.  Changes to routine, a long time where his pain had been quite low then a sudden increase in pain, family stress and social cues from his wife and GP, and he was beginning to feel a lot less confident in his skills – all of these are Allan’s high risk factors.

I’m pleased to say that I got a call from Allan a week ago – he’s back working full time again, didn’t have a scan, didn’t start taking medication again, is regularly playing squash and using his coping statements, and feeling in control.  His confidence has been boosted, and his mood has returned to normal.

That’s what I call ‘managing a setback successfully by yourself’.  Well worth an hour’s follow-up appointment, I think, and a whole lot less costly than having another (useless) scan, more (expensive) medications, stopping work (and feeling stressed because of financial woes), and being a patient (again).

This is a recording…this is a recording…

Preventing relapse has to be one of the most difficult parts of pain management – what do you do to keep someone going with their new skills while at the same time not allowing them to become dependent on your encouragement?

Some strategies have included spacing the final few sessions some time after the bulk of the intervention; providing access to a support group; providing explicit instruction on ‘ways to manage high risk situations’; periodic telephone consultations – and now, ‘an automated, telephone-based tool for maintenance enhancement’ (Naylor,MR., Keefe, FJ., Brigidi, B., Naud, S., Helzer, JE., 2008).

Therapeutic Interactive Voice Response (TIVR) has four components: a daily self-monitoring questionnaire, a didactic review of coping skills, pre-recorded behavioral rehearsals of coping skills, and monthly personalized feedback messages from the CBT therapist based on a review of the patient’s daily reports.  The first three components are pre-recorded and all four can be accessed remotely by patients via touch-tone telephone on demand.

Sounds great – and the response looks favourable.  Maybe this is one way to maximise outcomes, while minimising cost and therapist time? My only concern is the need for participants to be (1) adherent to completing questionnaires on a very regular basis, and (2) comfortable with auditory-only feedback and using a telephone.  Both of these aspects require high levels of commitment to the process – and good literacy.

Nevertheless, it does demonstrate that technology can provide a way for therapy to maintain input with lower costs, which can only be good for our patients.

Naylor MR, Keefe FJ, Brigidi B, Naud S, Helzer JE, (2008). Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention. Pain. 134(3):335-45. Epub 2008 Jan 4.