Single-session interventions for pain

Traditional approaches for psychological or health symptom management require multiple treatment sessions. These can bring challenges for access and uptake, and so innovative approaches are needed…

I had chronic pain as a teen and young adult. No accessible behavioral options were offered to me, and my suffering was extended needlessly. Decades later, as a Stanford pain psychologist, I'm investigating promising treatment approaches which are beginning to address this issue by equipping people with the understanding of how to best help themselves – enabling them to favorably shape the trajectory of their health.

Multiple treatment sessions – which have long been a default for many physical and psychological issues – can impart major burdens on patients. There's the cost, travel, and often a lack of skilled providers (Darnall et al., 2016). Even when 8-session group-based health psychology treatment is available, patients often attend about half of the sessions (Malins et al., 2020; Fernandez et al., 2015; Thorn et al., 2011). Accordingly, the fields of mental health and health psychology are trending towards a population-health approach that applies targeted single-session interventions (SSIs).

The brevity and convenience of online SSIs could bolster health equity by ensuring people at greatest risk for poor outcomes have quicker and better access to needed care.

Here, I will review findings from several studies and emphasise clinical pain research, discuss how SSIs may be effectively integrated into care, and offer cautions against moving entirely to an SSI approach. Applied wisely, SSIs should expand access to care and not restrict access to more intensive treatment when it is needed or desired.

Do SSIs work?

Generally SSIs target a specific condition, are 1-2 hours in duration, and include symptom management skills acquisition. Depending on the specific SSI, the intervention may be received in-person or online, with delivery formats ranging from individual to small or large groups. In some cases, fully automated and on-demand e-formats are possible. Collectively, SSIs and their flexible options for delivery open avenues for efficient home-based healthcare. Moreover, the brevity and convenience of online SSIs could bolster health equity by ensuring people at greatest risk for poor outcomes have quicker and better access to needed care. SSIs hold promise for offering the greatest treatment reach at lowest cost and burden for patients. But do they work?

SSIs have shown efficacy in diverse populations and health conditions such as youth major depression (Schleider et al., 2020a, b), adolescent mental health (Bermudez et al., 2020), life stress in treatment-seeking patients (Ziadni et al., 2018; Carty et al., 2019), general health behavior (Barreto et al., 2019), and insomnia (Ellis et al., 2015). For instance, in that last study Jason Ellis and colleagues tested a sleep skills SSI that was delivered to individual patients with acute insomnia and found 60 per cent remission for acute insomnia at one-month post-treatment.

Importantly, automated online SSIs (no therapist contact) have efficacy for reducing depressive symptoms in youth. Indeed, in those studies led by Jessica Schleider, a fully-automated intervention for youth with depression was only slightly less effective than in-person treatment that requires up to 16 hours of treatment time and is constrained by small treatment group sizes.

These relatively recent studies suggest, then, that SSIs for various mental and physical health concerns may indeed yield meaningful and lasting symptom reduction. It's inspiring to imagine how early application of targeted and online SSIs might prevent symptom progression and help steer youth and adults toward greater control over their health and wellbeing.

While SSIs lend themselves well to flexible delivery options (e.g. online with a live instructor or in-person, individual or group-based formats, or fully automated and on-demand) a specific SSI may not be offered in the format that is desired by the individual patient. For instance, many patients may lack motivation to engage in a fully automated SSI. Others may wish to avoid groups. Still others may not be receptive to an in-person SSI delivered by a therapist but might be more likely to attend an online 'class'. While SSIs typically offer accessible, highly standardized and evidence-based curricula, assessment of individual needs and wants can best assure treatment engagement. As with any treatment, follow-up is recommended after SSIs are received to understand the patient experience and the next steps in their care.

While SSIs typically offer accessible, highly standardized and evidence-based curricula, assessment of individual needs and wants can best assure treatment engagement.

As such, a key focus of our research at the Stanford Pain Relief Innovations lab is developing and investigating the efficacy and effectiveness of standardised SSIs for acute and chronic pain, and what works for whom.

An SSI for acute and chronic pain

Pain is ubiquitous across diseases and health conditions, the primary reason people seek medical care, and the leading cause of work-related disability. Estimates from the 2011 Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research report suggested that up to 1 in 3 individuals live with ongoing pain of some type. Minorities and people with the least economic means are most likely to develop chronic pain, and they suffer disproportionately because they are the least likely to receive good pain care. Pain is most often treated with reductive biomedical treatment approach (Darnall, 2018a) that ignores the latent factors that influence pain and treatment outcomes. Accessible solutions are desperately needed to ensure equitable access to best practices 'whole-person' pain care.

Psychological and behavioural treatments for pain include options such as cognitive behavioral therapy for chronic pain (CBT), mindfulness-based stress reduction (MBSR), chronic pain self-management, and acceptance and commitment therapy (ACT), along with techniques such as hypnosis and biofeedback (Darnall, 2018b; Driscoll et al., 2018). While effective, such treatments typically involve 6-12 individual or group sessions with a trained therapist or instructor and 16-24 hours of total treatment time. As with other conditions, associated costs and time burden can render these treatments inaccessible or infeasible, thus leaving pain to be suboptimally managed with medical interventions and passive approaches.

Enter 'Empowered Relief', an instructor-delivered 2-hour pain management SSI that rapidly equips individuals with active pain relief skills. ER is rooted in pain-CBT theory and incorporates pain education, self-regulatory skills (i.e. relaxation, cognitive reframing, and self-soothing), and mindfulness principles that boost self-regulation and reduce symptoms. Certified instructors guide participants to self-tailor the information into a personalised plan for empowered relief. This includes identifying automatic and unhelpful thoughts that amplify pain (e.g. My pain is terrible and is never going to get better, and using skills to reframe unhelpful thoughts into statements that provide self-support and comfort (e.g. While my pain is severe now, there are several things I can do to soothe myself. Participants receive a guided relaxation audiofile with binaural integrated into it. Binaural tones stimulate each hemisphere of the brain in rapid alternating succession; the binaural tones enhance the listener's relaxation response, making it a preferred tool for daily use over standard relaxation audiofiles. Because Empowered Relief is didactic (vs. 'therapy') large class sizes are possible. One hundred or more patients may be treated in a single class, and family members may attend.

We conducted a large randomised controlled comparative efficacy study that included Empowered Relief and was funded by the National Institutes of Health (Darnall et al., 2018). Adults with chronic low back pain were enrolled and randomised to receive one of three treatments: (1) 2-hour Empowered Relief; (2) a 2-hour Health Education class that involved no actionable pain-relief skills; (3) 8-session CBT for chronic pain (16 hours total treatment time). We hypothesised that the 2-hour Empowered Relief SSI would be comparably effective to 16 hours of CBT for reducing pain catastrophising (primary outcome), pain intensity and pain interference (priority secondary outcomes), and other secondary outcomes at three months post-treatment. We also hypothesised that the Empowered Relief SSI would be superior to the no-skills Health Education intervention.

Three months after receiving the 2-hour chronic pain SSI, significant and clinically important reductions were found for pain catastrophising, pain intensity, pain interference, and secondary outcomes: sleep disturbance, depression, anxiety, pain bothersomeness [see below] and fatigue (but not for physical function) (Darnall et al., 2021). The results suggested that an SSI can be broadly effective, including for those with complex presentations and moderate to severe symptoms (about half of the study sample had two or more chronic pain conditions and on average participants reporting having chronic pain for at least five years).

Why measure pain bothersomeness?

A primary treatment goal is helping people reclaim aspects of their lives that have been lost to pain. Following multidisciplinary treatment for persistent pain, many patients will say, 'My pain is still there but it doesn't bother me as much, and I'm able to do more'. Reducing pain intensity is important, but we recognize that other factors, such as pain bothersomeness are crucial – and potentially more achievable. Pain bothersomeness is measured with a question that asks people how bothersome their pain was during the previous seven days, from 0 (not at all bothersome) to 10 (extremely bothersome).

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Do the treatment effects last? We analysed data at six months post-treatment and found clinically meaningful and enduring effects for 2-hour Empowered Relief that were similar to 16 hours of CBT treatment for all outcomes previously tested, and newly for physical function (Darnall et al., in review). In fact, Empowered Relief SSI showed superiority over 8-session CBT for reducing pain catastrophising, pain bothersomeness, and anxiety at six months posttreatment. While these results provided good evidence that a chronic pain SSI might provide meaningful pain relief and broad symptom reduction, testing in diverse pain conditions was needed.

Taking SSIs further

Recognising the importance of online access to treatment, particularly during the pandemic, we next conducted a randomised trial that tested the efficacy of online-delivered Empowered Relief in different types of chronic pain conditions compared to usual care. Results mirrored those of the NIH-funded trial in that participants who received online Empowered Relief reported broad symptom reduction at 3 months post-treatment whereas the usual care group did not (Ziadni et al., 2021a, b).

Whole-person acute pain treatment is also needed in surgical settings, though implementation has been more challenging than in chronic pain treatment settings.

Combined, results for in-person and online-received Empowered Relief trials suggest that a 2-hour single-shot pain intervention can have enduring and clinically meaningful impacts across a range of symptoms that are superior to control and comparable to longer course evidence-based psychological treatment for back pain.

Interestingly, to date, we have no patient characteristics, either demographic or clinical, that predict treatment response to the chronic pain SSI. Even when interventions are effective for many, we can often learn the most from exploring the unmet needs of non-responders. So in 2022 we are launching a national pragmatic comparative effectiveness trial in 1,200 real-world patients with mixed etiology chronic pain that will compare online-delivered Empowered Relief vs. online-delivered 8-session CBT (funded by the Patient Centered Outcomes Research Institute). In this effectiveness trial we aim to understand for whom the SSI is effective, as well for whom it is not effective. Which patients benefit from longer course 8-session CBT treatment, and who requires something else altogether? Brief and online treatment will be insufficient for many, particularly those who require individual high-touch care. Patient response to SSIs should be assessed, and higher levels of care applied as needed.

SSI for post-surgical pain

Whole-person acute pain treatment is also needed in surgical settings, though implementation has been more challenging than in chronic pain treatment settings. Indeed, psychological approaches to perioperative pain management have been largely absent due to a lack of feasible, accessible, and economically viable options. So, we adapted the Empowered Relief SSI to the surgical setting, digitised it, and created a fully automated online SSI that patients could receive on-demand at home or in the hospital after surgery. This tailored and digital treatment is called 'My Surgical Success'.

To date, we have conducted two randomised controlled trials testing the efficacy of My Surgical Success. The first study was conducted in women undergoing surgery for breast cancer. Participants were randomized to either receive My Surgical Success or a digital health education intervention (no pain management skills) (Darnall et al., 2019). We aimed to understand whether My Surgical Success might impact pain and opioid use after surgery. We analysed data for women who began opioid use after surgery, and found that those assigned to My Surgical Success reported using almost one week less opioids than women assigned to the health education intervention. This result was highly significant because we only examined the 14-day window after surgery when women are likely to take prescribed opioids for post-surgical pain management.

Our second trial of My Surgical Success was conducted in orthopedic trauma surgery patients who were randomised to receive either My Surgical Success or a digital health education intervention (no pain management skills). We aimed to understand how My Surgical Success might impact pain and opioid use up to three months after surgery. As expected, both treatment groups were reducing their opioid use after surgery, and we did not find any between groups differences in opioid reduction. However, My Surgical Success participants reported significantly less pain after surgery – and their superior pain control was sustained 3 months after surgery (relative to the health education control group) (Ziadni et al., 2022). Similar to the chronic pain research, to date we have found no baseline demographic or clinical characteristics to predict treatment response to the SSI.

SSIs can help answer the call for truly integrated pain care, and integrated healthcare, in which psychological approaches are embedded into medical pathways to optimise outcomes for all patients.

As an SSI that is suitable for chronic and acute pain generally, Empowered Relief is being delivered in 18 countries (including the UK) and in 7 languages. Cleveland Clinic Spine Surgery has integrated Empowered Relief into standard care for spine surgery patients, and for patients with chronic pain. A recent publication describes the clinical implementation of integrating the Empowered Relief SSI into standard care across these two patient populations (Davin et al., 2022).

The future of SSIs and integration into psychological treatment

SSIs can help answer the call for truly integrated pain care, and integrated healthcare, in which psychological approaches are embedded into medical pathways to optimise outcomes for all patients. Expect to see patient-specific or disease-specific SSIs in the future: for instance, others have developed and tested a chronic pain SSI for multiple sclerosis with feasibility and preliminary efficacy shown for online delivery in this patient population (Alschuler et al., 2020).

Viewed from the other lens, SSIs are equally applicable within the context of treatment with psychologists and mental health professionals. For instance, psychologists could apply in-person or online SSIs to bolster the care of their patients, offer skills-based symptom management, and provide 'between-session' treatment extenders. For clients who desire or require individual care, SSIs may provide a useful complement that free up face-to-face session time to discuss the SSI content, problem solve any barriers, and celebrate successes.

While evidence suggests that several SSIs are effective, they are not meant to replace longer course treatment entirely. The reason is simple: some people need and/or want longer-course personalised psychological treatment. With SSIs, we lose the ongoing therapeutic alliance that comes with individual care. Also lost is the social support that accompanies group-based interventions. For some people, these critical psychosocial elements shape treatment outcomes, possibly more than anything else. Let's not apply a binary approach (all SSI vs. all longer-course treatment). Instead, we can begin to see how an SSI population-health approach might offer the greatest initial reach, while 'non-responders' may need a higher level of care, and more costly and intensive treatment.

The promising evidence to date invites us to envision a pathway where SSIs might help achieve the vision of integrated and evidence-based care that is available to everyone at low or no cost, regardless of location or financial means. We may reduce health and pain care disparities by connecting our most vulnerable patients to high-quality needed care that they may receive in the comfort of their own home. Let's work towards a future where we may reduce human suffering at scale, by meeting patients where they are.

About the author

Professor Beth Darnall is Director, Stanford Pain Relief Innovations Lab, Stanford University School of Medicine. [email protected]

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