Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting Empowered Relief for Pain Psychology. Joining me is Dr. Leah Flaherty. She's a clinical pain psychologist and the Clinical Director of the Empowered Relief Program at Allegheny Health Network.

Dr. Flaherty, it's a pleasure to have you with us today as we get into this really interesting topic. I'd like to talk about the current state of pain today. What have you been seeing in the trends? Because as we were talking a little bit off the air, pain management is such a burgeoning field right now, and pain is somewhat subjective. So, how do we measure it? What is the scope of the pain issue that we're seeing in the country today?

Leah Flaherty, PsyD: Yeah. Thank you for having me, Melanie. I'm so excited to be here today. We know that in our country today, one in three people is living with some type of ongoing pain condition. So, that can be pain from so many different aspects of our lives, right? So, we can be talking about whole body pain with something like rheumatoid arthritis. We can be talking about an injury like low back pain that has had difficulty healing and that has been persisting past the expected time of healing, is what we talk about with chronic pain.

We know that chronic pain is the fastest growing health condition in our country today. Incidences of chronic pain are growing faster than incidences of hypertension, incidence of diabetes. This is a field that's growing in response to patients asking us for help. What I'm doing as a pain psychologist is working with folks on the way that the brain and the body work together with response to pain. So, the question that I hear most as a pain psychologist is, "So, you're saying it's all in my head," right? That's something that I answer a lot. And my response to that is always, well, our heartbeat doesn't go without our brain. Our lungs don't work without our brain, right? Our brain leads the charge for everything. This is not an entity that is apart from the body. And so if we can learn more about pain's impact on the brain and how the pain and the brain work together, we can lead people towards relief. And that's my hope here today, to talk more about that and bring that to the lives of more of our patients.

Melanie Cole, MS: That's fascinating. It really is. It's such an interesting topic to begin with. And because people have such different pain tolerances, we're going to talk about something called pain catastrophizing. What is that and how does that impact outcomes? Because I know that I've heard over the years as an exercise physiologist, when people tense up when they're in pain, maybe they've hurt their knee or something, that pain increases, right? So, stress, tensing, muscle tension, all of these things can increase that pain tolerance as it was. What is pain catastrophizing?

Leah Flaherty, PsyD: Yeah. So, pain catastrophizing, importantly, I'm remiss if I don't say that patients don't like that word, and reasonably so. Because pain catastrophizing lends itself to thinking about making a mountain out of a mole hill or something like that. And there's no mole hill when your life is dealing with chronic pain.

Generally, that's an antiquated term that's been around for decades at this point. So, it's really solidified in the research, but I try to move away from it in my clinical work. And so, we talk about our negative pain mindset or pain coping or negative pain thoughts. So, they're all really words that describe the same thing. And that's the way that our thoughts and behaviors change with regard to our pain. So, we talk about magnification. So say I am running and I turn my ankle. And the thoughts that come to me immediately are, "Is this it? Am I not going to be able to run anymore? Am I not going to be able to play with my kids anymore? What does this mean for my life, right? Pain itself doesn't exist in a vacuum. Pain has both an emotional and physical component. So, it's not just the wear when I turn my ankle, it's the whole host of other thoughts that come along with it. Those catastrophic thoughts, that pain catastrophizing is related to the whole host of thoughts that come along with it. So, there's the magnification piece.

The next piece is the rumination. I have a lot of patients say that their brain kind of gets stuck on the pain channel. That it's really difficult to shift away from those pain thoughts, the thoughts about "How long is my life going to be like this? How much worse is this going to get?" these really big, really scary thoughts. And pain and fear live in a similar place in our brain. They share similar real estate in our brain. So when we have those fearful thoughts, they lead back into the pain and the painful thoughts lead back into the fear and it becomes a really vicious cycle.

And the last component of pain catastrophizing is the helplessness. And so by the time I meet with someone, they've usually been through a whole host of other docs, right? They've been to so many physicians. What is going to be the answer? Looking under every rock? Who is going to be able to solve this for me? Pain psychology is usually kind of thrown in as a last-ditch effort. So, my hope is that if we can offer pain psychological interventions at the beginning of someone's care, rather than at the end of it, we can prepare them to have better treatment outcomes. And so, there's a lot of research that shows the links between decreases in pain catastrophizing. So, decreases in those negative thoughts about pain absolutely predicts positive treatment outcomes, whether it's post-surgically, whether it's for our pain physicians, the treatments that they're having working with patients on. So, all of this has to do with the fact that the mind and the body are together and not separate.

Melanie Cole, MS: Wow, that really is so interesting to me, and it can really apply through all aspects as we think of those catastrophic thoughts that go through our head. And as you say, fear and pain share that same space, but fear and those negative thoughts, especially for women, the things we think about. And so, it would only make sense that pain would sit right next to that. Fear and those thoughts of all the worst things that could happen to us. My goodness. That's just really all of us. So, tell us, what is empowered relief and how does that target those pain thoughts specifically? And tell us about the Empowered Relief Program at Allegheny Health Network.

Leah Flaherty, PsyD: I was originally working at the West Penn Institute for Pain Medicine as a pain psychologist doing both individual and group psychotherapy for chronic pain. And I found myself with this giant wait list. And I was always thinking about how I wasn't able to see patients as often as I wanted to see them. And so, I might be able to see somebody once a month, which isn't evidence-based care for chronic pain. We want to see people more often than that if we're doing something like cognitive behavioral therapy for chronic pain, which is the gold standard at this point. I just wanted to be able to cast a wider net and I wanted to be able to impart evidence-based treatment to folks.

So, I started looking to see, has anyone done this before? Has anyone created a program that I'm looking for? And it turns out they did. So at Stanford University, Beth Darnall and her colleagues created this program called Empowered Relief. So, they created a clinical certification program for it. And so I took that clinical certification class, and I'm a certified instructor in Empowered Relief.

So, I started teaching it as a side gig, as a part of what I was doing with my patients at the West Penn Institute for Pain Medicine. And then, I found that patients were loving it. We wanted to get more and more people this treatment. And so, what it does is it takes 16 hours of cognitive behavioral therapy for chronic pain, and it boils it down to kind of like the greatest hits of CBT for chronic pain. It's a two-hour class, it's a one-time thing. And folks come in, they gain all of this information. It's really the first half of the class is like a health literacy intervention. So, teaching people about pain in the brain, what happens with our neural networks, what's going on with the neuromuscular patterns that change with regard to pain, and how can we fight that change and lead our brains towards growth, towards relief? We teach that for the first hour of the class. And then, the second hour is skills and tools and teaching folks how to make this part of their life, whether it's restructuring cognitions related to the pain as well as increasing pleasurable activities, fighting back with that kinesiophobia that, you know, goes along with living with chronic pain as an exercise physiologist, right? So once we start getting afraid of movement, we end up leading ourselves towards more pain.

So, what we're doing is really working together on the skills and tools that folks can have. So, two-hour class, one-time thing, teaching people 16 hours of cognitive behavioral therapy. So, Stanford researchers started looking at how Empowered Relief rated up against what was generally delivered care and found that empowered relief is equally as effective at reducing pain intensity, pain catastrophizing, the sleep disturbance that we all know goes along with experiencing chronic pain, just as well as 16 hours of cognitive behavioral therapy for chronic pain. So, the evidence is really leading up there and is really showing folks that this is working.

So three years ago, I said all of this that I'm saying to you, to the West Penn Hospital Foundation, and they agreed that this is something that more folks should have in front of them. And so, we received a generous donation from them. And now, I've been able to teach a thousand people for free for the past three years, because of this donation from West Penn Hospital Foundation. It's really been beautiful what they've been able to do for our community.

Melanie Cole, MS: That is amazing. Thank you for sharing that story. And as you're telling us that there's really strong evidence base for Empowered Relief, tell us about your published qualitative data, what that analysis reveals. I mean, I'm guessing what it did reveal, but tell us.

Leah Flaherty, PsyD: So, Empowered Relief has an enormous evidence base in the literature with quantitative metrics, right? So, being able to show reductions in things like depression screeners as well as anxiety and pain intensity. So, all these sort of, as you talked about before, the subjective reality of being in pain. And that part can be really difficult to get on the same page as patients with, right? And so, we're trying to get patients into these check boxes of how are you doing today, right? And that can be very difficult for folks who are living with chronic pain.

So, what I wanted to do was see what patients were telling us. So after the class, we send out these surveys and patients are able to write their feedback on the class, what they got out of it. So, we had all of this really beautiful patient data that we didn't know what to do with. And so, with a colleague of mine, we entered patient feedback into a large language model, so OpenAI, de-identified of course, and asked the chat bot to bring us themes from what patients were telling us, and they found themes of empowerment of growth, the benefit of use of learning about their body. My favorite quote from a patient is "Considering meditation like medication has helped me immensely." I couldn't have come up with that. That was her beautiful words. And so, being able to get the patient feedback explicitly like that.

The analysis came with seven themes. One of my favorites is that even after a two-hour class, patients felt like they were part of a community. They felt like they weren't alone in their experience of pain, because they met people who were going through something similar to what they were going through. And I think chronic pain can be an incredibly isolating experience. And so, when we're able to bring people together in what it's been like and how they can cope in a different way, that's been really beautiful to see.

Melanie Cole, MS: I love that. That's just such a cool way to go about this. Now, tell us about some of the exciting collaborative partnerships that you are entering into with other institutions. Because I really think that this nationwide could change the scope of this field of pain management.

Leah Flaherty, PsyD: Yeah. Thank you. What I've been doing in trying to gain as much excitement over this, you can feel my excitement is palpable, but I wanted to get other docs, as excited as I was. So, I started small meetings and then getting invited to grand rounds and faculty meetings and staff meetings, and being able to spread the word on how impactful this program has been from a small sample size to now a large one, to be able to help as many patients as we can.

In attending a lot of these faculty meetings and staff meetings, just started to meet like-minded physicians who also wanted to collaborate and wanted to bring as much care to their patients as possible. And so, I have open IRB projects now with Neurology, with the Headache Institute, with the Neuroscience Institute, as well as with OB-GYN, Anesthesiology, and Autoimmunity and Rheumatology. And so, we're all just trying to see if we can work together. If we can bring this to our patients on the front end of their care, can it help what they're going through down the line? And so, trying to see if this can help with migraine, trying to see if it can help with rheumatoid arthritis. So, it's been really wonderful meeting so many different providers who are also interested in mind-body medicine and whole body care.

Melanie Cole, MS: Wow. Headaches. What a big field that is. There's so much potential here, Dr. Flaherty. It really is amazing. And as we get ready to wrap up, tell us a little bit about how the Stepped Care Model can increase that health literacy of patients toward that goal of improved outcomes. Because really that is the goal, is to be maybe not pain-free, but look at your pain in a different way. Be able to compartmentalize it and kind of bring it apart around in your life so that it doesn't stop your life and really decrease the quality of life. Isn't that what we're talking about?

Leah Flaherty, PsyD: Absolutely. And so, I say that a lot to people, is that a zero on the pain scale is an expectation we can't live with, right? That's what got us in trouble with the opioid epidemic in this country in the first place. That life is going to be inherently painful. There are parts of life that will hurt and it does not have to be the loudest, most important part of our life.

And so, what can we do to make sure that pain is a part of our life, not the most important part of our life. So as we kind of work through these skills and strategies to be able to turn the volume down on the pain, it makes people be able to get back to living more and suffering less. And when we do that, the pain will continue to decrease in line with that.

And so importantly, I'm working with physicians all the time to make sure that are these patients cleared to be doing a kind of therapy like this? Do we know that they have pain that's persisting past the expected time of healing? Do we know that there is this psychological component to their pain? And, for most people, we're going to see a yes on this answer, right? There are always going to be ways that we can help folks turn the volume down on their pain through understanding more about it.

My belief in increasing people's health literacy is people want to know more about their bodies. People want to know more about what they can do. We have these video clips that we've made with Highmark to be able to show in 30 seconds what's going on with your brain and your body when you're experiencing a new pain signal. And hopefully, maybe that helps somebody. And then if not, then they can go up the next step on the ladder, which would be empowered relief.

And then, we can continue up the ladder by talking to pain physicians and potentially psychotherapy. The whole point here is to be able to guide people through this journey of their healthcare. And so, that's my hope, is that we can meet people where they are in that journey.

Melanie Cole, MS: What an eye-opening, enlightening episode this was, Dr. Flaherty. Just such an interesting topic, and I'm sure that other providers really want to learn more. I know that I do. So, thank you so much for joining us today and sharing your expertise in something that not everybody knows about. But I certainly hope that they do after this. Thank you again.

And to learn more or to refer your patient to Dr. Flaherty, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole