Welcome back to the Healing Pain Podcast with Dr. David Cosio, PhD
People tend to think that having no pain is normal when in fact, having a little is. While that is the case, there are still some ways that can help us manage pain. Talking about effective strategies for pain management is Dr. David Cosio. He is a pain psychologist in the Pain Clinic and interdisciplinary pain program at the Jesse Brown VA Medical Center in Chicago. He earned his PhD from Ohio University with a specialization in Health Psychology. Starting with his journey, he shares how he got involved in health psychology and then into pain management. He explains the difference between a health psychologist and a clinical psychologist. Having both backgrounds, he gives a holistic look into pain—taking into consideration the environmental aspects as well. He gives us a peek into his book, Pain Relief: Managing Chronic Pain Through Traditional, Holistic, and Eastern practices, by talking about the concept of a fifth vital sign. He shares pain education and the future of chronic pain in the VA.
Effective Strategies For Pain Management with Dr. David Cosio, PhD
It is a pleasure to be with you as we talk about pain care and pain science. On this episode, we’re talking about effective strategies for pain management with Dr. David Cosio. He is a Pain Psychologist in the Pain Clinic and Interdisciplinary Pain Program at the Jesse Brown VA Medical Center in Chicago. He earned his PhD from Ohio University with a specialization in Health Psychology. He completed a behavioral medicine internship at the University of Massachusetts and a Primary Care/Specialty Clinic Post-Doctoral Fellowship at the Edward Hines Jr. VA Hospital. David has given several presentations in Health Psychology at both the regional and national levels. He has also published several articles on health psychology, specifically in the area of pain education. He has published his first book called Pain Relief: Managing Chronic Pain Through Traditional, Holistic and Eastern Practices. If you’d like to access the first chapter of his book for free, all you have to do is go to www.DrJoeTatta.com/110Download. If you’re on your smartphone, you can text the word 110Download to the number 44222. When you go to either one of those links, you can download the first chapter of David’s great book for free. Let’s get started and learn about effective strategies for pain management with Dr. David Cosio.
David, welcome to the show. It’s great to have you here.
Thanks, Joe. I’m glad to be here.
David, you’ve got lots of great stuff going on. You’ve got a book which we’re going to talk about. Before we start to dive into pain, your experience, and pain psychology, you are a health psychologist. I’m curious to know your journey of how you got involved in health psychology and how you then parlayed into pain management.
I got my PhD in Clinical Health Psychology from Ohio University. I started my journey focusing on HIV prevention and sex-related behaviors. As you know, that’s a very stigmatized population. It’s a lot about coping and there are issues of pain within that population. I did an internship at the University of Massachusetts Amherst, I delved further into biofeedback and hypnosis. I did a year-long training in that. Then had a post-doc at Hines VA where I was starting to have a lot of referrals for patients with pain, not knowing what could be available for them. Once I finished my post-doc at Hines, then I was hired to the Jesse Brown VA, which is where I am now. It wasn’t my initial group of the population that I worked with, but a lot of the same skills apply to both populations. I’m passionate about working in this population. That’s what led me to this point.
Explain to us the difference between a health psychologist versus a clinical psychologist.
A clinical psychologist is what we call a generalist. These are people who have a doctoral degree who are able to help people with different mental health conditions. They do treatment for depression, anxiety, insomnia, PTSD, so on and so forth. A clinical health psychologist has the same skill set. I am a clinical psychologist first, but I have a specialization in Health Psychology. The training that I had was how do you apply this same skill set and these same type of treatments in a medical clinic like in a primary care or in a specialty clinic? We look at the biopsychosocial model. We not only understand the biological aspects of pain but then we also learned how the psychological and social components interact with a biological and the different presentations that we have for patients.
You are working at the VA, which I believe is in Chicago?
That is correct.
Are you working with inpatients or with outpatients?
I’m the psychologist in the outpatient multidisciplinary clinic, which means I’m housed within the Pain Clinic but we meet with patients separately. How that’s nice is that when we need to consult with each other, it’s just across the hall. I’m also the psychologist in our CARF-accredited program. That’s a twelve-week intensive interdisciplinary program. That’s when all of the disciplines together meet with the patient in one clinical appointment. Very different models, the same clinic and the same VA.
A good overview of what happens in the VA on an outpatient versus an inpatient basis. I started looking through the book that you have, which is great. In the first chapter of your book, you start talking about the concept of a fifth vital sign, which is interesting to look at from a historical perspective as far as where we were as far as pain and opioids were and where we are now. Can you tell us what the fifth vital sign was, why it was created and what we have now done with that terminology?
Up to this point, when a patient would come into a clinic, they were triaged, there were four different vital signs that were being measured. This was a point of time in where it was believed that providers were not assessing or treating pain. They developed this initiative called the pain as the fifth vital sign. The VA got jumped on board, JCO jumped on board and it was for the purpose of ensuring that we were assessing, diagnosing and treating pain within our patients. What was interesting though is after the initiative was released several years later, they did a study and found that they didn’t make any difference whatsoever. They were very concerned and like, “How did we spend all this money on this initiative and it’s not making any difference?”
They did a smaller study where they looked at a particular primary care clinic. They would stop patients as they were coming out and asked them if they were being treated for pain. When they were treated for pain, they went back on the record to see if it was documented and what they found. It wasn’t that we weren’t assessing or treating it’s that we were doing a very poor job of documenting on what we were doing. A lot of the organizations are looking back and saying, “Maybe we shouldn’t be asking pain as the fifth vital sign. We should be waiting for patients coming in and having the main complaint of pain and then delving into that assessment.” You’re right, the pendulum swings. One moment we’re looking at it, we’re assessing it very closely and then the next moment, we’re taking a step back. We’re saying, “Maybe we don’t need to be asking these types of questions because they might be leading patients in the discussion.”
I know there’s some research on this that probably you can talk about. How did that potentially inform prescriber habits?
If I’m a primary care provider and I’m asking a patient if they have pain, now I’ve asked the question. I need to make sure that I’m addressing it. What happens most of the time is I’ve asked the question. I’m a primary care provider and what I have available in my arsenal are different medications, maybe different interventions, but not a lot of the other holistic or complementary integrative practices that are now available. I would offer what I have available. I would offer what I’m able to give to that patient. What we’re finding is that monotherapy is not showing very good results. It’s when you use a multidisciplinary approach. I think that it was a good intention, which is usually what happens in our past, but it was followed through and it led to a situation that we’re in now.
Primary providers wanted to do the best for their patients. They’re trying to help them. They want to help someone and at times it can be a medication, although they do have something powerful, which is a pen and a prescription pad. They can put other things there. A multidisciplinary care that does help people. Along those lines, in your book, you also talk about stepped care. You have a great little infographic in there. Can you talk about the concept of stepped care and how that helps our system?
In the VA system, they have released the stepped care model. How they want primary care to approach pain patients is by the first step, making sure that the patient is doing their self-management. Is this patient using heat or ice? Are they doing exercise? How’s their nutrition? Are they getting sleep? Once the patient has been doing those things and it continues to have difficulties with pain, then they have a consultation with primary care. That’s when we start introducing pain education. This whole idea for this book, this whole journey that I’ve been in the last years has been about how to give people the information they need. Once we give people the information they need, they tend to make the right choice. Then the problem is reaching out to enough people that have the right information.
I can do that by meeting with patients one-on-one. I can do that by doing talks with providers, but it’s making a small dent in a big tsunami. Going back to your question, the second step is primary care. We introduce the concept of pain education. If the patient needs additional sources or secondary consultation, then that’s the third step. That’s when you start integrating mental health, maybe specialty pain clinic services, maybe rheumatology. Then if they need even further treatment, if it needs to go to a tertiary clinic, then that’s the fourth step. That would be an example like the twelve-week CARF-accredited program. That’s how we do stepped care in the VA.
The VA is interesting because it is its own health system. It’s managed differently than what happens in the rest of the United States. When I look at that step system, the second step is primary care. It’s so interesting to me because I was at the International Association for the Study of Pain, their world conference, and there was a lot of talk that primary care providers are not equipped or not trained to evaluate and on some levels successfully triage a patient to the right type of care after that. I think that stepped model is great. I wonder if we need something to support those steps, so they can act, they could potentially work more effectively. The other interesting thing I’m sure you’re aware of is at the Cleveland Clinic, they have teams now, PTs and psychologists who are in that position of that step before the primary care doctor.
There are two questions there. Let me start with the first. I just came back from PAINWeek, which is a national conference. One of the statistics that threw me out of my chair when I was there was they were throwing out around this statistic that primary care providers on average only have seven minutes with a patient. That is not enough time for the degree of complexity that comes along with pain. I think they’re saying the same kind of messages. Is primary care equipped with the services needed to deal with this complex problem?
Also, the two things that keep coming out is time and access. Do patients have access to these other treatments that are available? Do they have access to mental health? Do they have access to complementary or integrative health? Part of my role as a clinical health psychologist is to fill in that gap, try to help the patient access those treatments, and also the provider to offer those treatments. I work in the VA but I also work in private practice. When I work with my civilian patients, that’s a lot of my time spent educating the patient about what’s available, educating the provider what is available, but then addressing that issue that I was talking about.
When I heard them talking about primary care providers, there was someone there who brought up the topic that they have to know how to evaluate the musculoskeletal system. Which would mean they’d have to know how to evaluate a spine, the neck, the shoulder, the ankle and all of these things. I went to school for seven and a half years to learn how to do that. Asking them to do those types of interventions or the type of evaluation is quite difficult for them, and equally with a behavioral intervention. That’s why I love the Cleveland Clinic’s model of their testing and it’s not proven yet. PT and psychologists, because you get the mind and body together there and they can see as the patient effectively if they then need to go to orthopedics or anesthesiology or some other place. In your book, you talked about opening and closing the gate. Can you explain what that is, opening and closing the gate and how that helps them and what that concept is?
There were two theorists, Melzack and Wall, who proposed the gate control theory. What they said was that there was an imaginary gate somewhere in our spine somewhere in our system where when we have a pain signal that comes from the portal of origin, it goes up the spinal cord to the brain and it is the brain that interprets that signal and sends a signal back to wherever the origin came from. That’s why you lift your hand from the stove or why you lift your foot from the nail. The gate control theory says that there’s an imaginary gate somewhere in that system and when that gate is opened, that signal is free to go back and forth from the spinal cord to the brain. When that gate is closed, it bounces out a signal similar to what it feels like if you go to the zoo. You first walk into the zoo and it smells bad, but then you figure there for a couple of inches, it’s close making you more habituated to this thing. The belief or the theory is that the way that 25 different treatments that they taught in the book. That’s including the psychological treatments, the traditional approaches, the complementary and integrative and the lifestyle imbalances. By addressing those areas, we’re essentially closing that gate.
Everybody wants to learn how to close the gate so that there’s less discomfort, less unpleasantness. Can you tell us some key things, some key factors in closing the gates?
Things that people can do on their own that they don’t need to go and receive a treatment for is keeping a positive attitude. Making sure that they have the support of loved ones, living a valued life, doing things that they find valuable and that they feel they get enjoyment from. Those are all key things that you can do that can keep the gate closed.
As the evolution of this podcast has gone on, people are becoming more and more aware of the concepts of psychology and pain psychology. When you start to look into the different types of treatment, there’s Cognitive Behavioral Therapy for pain. There are acceptance and commitment therapy for pain. There’s Operant Behavioral Therapy. There’s mindfulness and mindfulness-based stress reduction, which technically is not a psychotherapy though it’s psychologically informed care. I want to ask you the difficult question, which one is your favorite right now? Oftentimes these are flavors that we use, but sometimes they’re used appropriately to certain patients based on their learning styles and preferences do better with certain types of treatments. How do you approach that in your care of people?
It is a difficult question, but we did some research because I had the same question. We have the Cognitive Behavioral Therapy, which is probably the strongest treatment out there but then we have this acceptance and commitment therapy or ACT, which is gaining a lot of excitement and it has a lot of potentials. One of the things that I did about years ago is we ran patients through both groups and compared how they on every session would be affected by the treatment in terms of distress. One of the interesting things that I found in my study was, as patients progress through CBT, you saw a very curve or linear relationship in the data and where if they’re distressed would go up and then it would go down and it would go up and it would go down. How I interpreted that was as human beings, we have a lot of difficulties making change. It’s hard to change the way that I think. It’s hard to change the way that I behave. However, when we looked at the acceptance and commitment therapy, you saw a little bit of that up to the fourth session.
Once we reached the fourth session, the distress plummeted straight down and remains down. What we interpreted that was at the moment that people reach a level of acceptance, that’s when they start living a valued life. They start not focusing on the pain and what the pain is not getting in the way of because they’re living their life, the best way they can with what they’ve got. Based on that data, I’ve become an ACT therapist. ACT, I infused in my assessments. I infuse it in my interactions with patients and my pain education. I’m finding that there’s also a need for Cognitive Behavioral Therapy. Both of them address different needs and there are different skill sets that are helpful in different situations. I recommend patients to do both if they’re willing to go through both.
Is there a certain amount of time that you see patients for or is it based on their diagnosis and what you decide together?
Most of the therapy that I do is group therapy. Pain is a very social disease. What I find is that the power of groups is where you see a lot of change occur. They talk to each other, they learn through the discussions that go on throughout the group. When I do group therapy with six or eight patients in a room, usually I try to stay anywhere between ten to twelve sessions, one-hour long sessions. The reason is I could do longer and less number of sessions, but we’re talking about individuals who have pain, who have a very limited amount of attention span, who may be taking medication. The repetition of keeping ten to twelve sessions helps with the repetition but also it’s something that it’s bearable versus doing a two hour, two-and-a-half-hour intervention. That would be too much.
I want to weave in two questions before you start talking about pain education, which is vitally important. It falls under a psychological informed type of care that pretty much every healthcare practitioner should be trained in and should be providing to their patients. One of the biggest challenges that we have as clinicians is we have great training. We have Doctorate degrees, we are involved in research and we are all highly trained at this point. Unfortunately, the health literacy that we have in our country is quite low. It’s not the fault of the patient and the greater pain community.
What’s interesting to me is that the pain in and of itself, the neuroscience of pain is quite complicated. The treatments and oftentimes the discussion and the education that we should be having with patients’ needs to be dialed in. It needs to be concise. At times, you have to learn how to make it very narrow and focused. Other times you have to learn how to make it broader. If other practitioners are reading this, how do they start to make their treatments simple and easy for people to understand and to interact with?
One of my jobs is to do with the pain education school program here at Jesse Brown and that’s been a learning experience for me. What I’ve learned is the population that we work with tends to have a lot of health literacy issues and so the messages need to be short. They need to be clear. They need to be in a way that a layperson can understand. One of the things that I over time have learned and felt very supported by was the Institute of Medicine report that came out in 2011. They said that education is imperative when it comes to pain management. They also said that it had to be a repeated message. What we do well is that we do a lot of education in our first interaction, but then we don’t follow that up every other interaction after that.
One of the things that I do when I do provider education is to talk about the need for education at every encounter. It’s that repetition and it’s that consistency of message that’s going to help as opposed to doing a lot of education on the first encounter and then not mentioning it again. That’s why I think multiple sessions are necessary. It’s important that providers in primary care, every time they see their patients, they do a little bit more education every time they come in. It’s that reputation and that consistency of message where we’re going to start seeing some changes.
Speaking of changes, where do you see chronic pain treatment heading in the future in the VA? How do you see that may be affecting what’s happening in the private healthcare sector?
The VA oftentimes is the leader in trying new things because they have the support of the government. What they’re doing right now is doing a lot of research into the complementary and integrative health treatments, which is great because it’s a $50 billion industry and patients are doing this already. Why not get the data to support whether these things are effective or not? They’re doing that right now. Where they’re also making changes is that every region of the United States has to have an interdisciplinary program. There’s research to support these programs, but they’re ongoing collecting research. Once that data is compiled with complementary and integrative health, I see a push for making changes in terms of coverage from insurance companies, education and incorporating some of these professions into primary care or in subspecialty clinics.
When you say regions, are those regions in the country for the VA itself?
I think there are 23 different regions. The US has broken down into three sections. Each of those sections is required to have an interdisciplinary program like ours. We’re the one for our region. What we’re doing is we’re running those programs and they’re collecting data on those programs, which eventually it will be compiled and put together to show if there’s benefit from having these programs or not. The research supports it. This is more updated data.
It’s a shame that so many multidisciplinary, interdisciplinary programs were cut in the ’80s and early ’90s because when you look at those programs, they were full of therapists. I think that therapies are the way to remedy a lot of what we’re facing here, a lot of our challenges.
What’s exciting is that now there’s a research that they’re trying to put a physiotherapist or physical therapist and psychologist in primary care, which is essentially the interdisciplinary model. I can only hope that that’s going to show a success. If it does, then that might push to start integrating some of those professions in primary care. That would be great.
As a psychologist who works with people with pain, every once in a while, you probably get the question, “Will this pain ever go away?” It can be a tough and challenging question because as a practitioner, we don’t have crystal balls. How do you respond to your patient?
Oftentimes this is my spiel. If I went on the street and asked a million people who do not report pain, what their pain score is on a scale from zero to ten, most people are going to say they’re anywhere between a two or a three, which indicates discomfort. That is normal. When a patient comes in with chronic pain, one of the first things that I try to do is set realistic expectations. If you’re coming in looking for a zero, that’s not what we’re looking to do. We’re looking to improve your function, improve your quality of life and trying to get you as close to that two to three mark. Having some pain is normal. Once you set that reasonable expectation, I see that patients do better because they’re not holding onto that false hope of something that’s going to cure their pain and take it away. Is that possible? May something be discovered in the future? It’s possible. Right now, with what we have in the field of medicine, it’s not the goal of therapy. One of the first things that I try to do is set realistic expectations. If you don’t do that, then the patient’s always going to be disappointed.
You said two things there. You said normal and then you said zero pain. A lot of patients think that normal means zero pain or, “I should have no pain.” From an acceptance and commitment therapy perspective, what does ACT say about a life of having no pain?
ACT would say, it doesn’t matter what it is that you’re feeling, it’s acknowledging whatever your negative experience might be and continuing to live the most fulfilled life that you can. Oftentimes the example I give is someone who’s born without vision. That person is going to have to adapt and make the best they can with the disability that they have. It’s the same thing with somebody who is suffering from pain. It’s not that we don’t care about the pain. It’s not that we’re ignoring the pain, but how can we make you have the best life despite even having the pain? ACT would say it’s not important what you do with the sensation, it’s recognizing it but still moving forward even that is present.
You have your book, I’d like you to tell us all about the title and what the book is about. Where do you see yourself going within this pain management perspective as we move forward?
The book is called Pain Relief: Managing Chronic Pain Through Traditional, Holistic and Eastern Practices. It’s something that I developed over ten years. Part of it is information that I’ve learned in my own training, but it’s also the information that we teach our veterans in our pain education program. As a provider who goes out and does a lot of talks with other providers, especially frontline providers, one of the common things I hear is, “This is great but I don’t have time to sit with my patient and give them all this information.” That was the idea of having something that is affordable and available anywhere that a patient can pick up and start having some of the information. That way, when they go in to see their primary care provider, they have some of the languages and they have some of the understanding. They’re able to have a better communication between the provider and the patient. That was the reason why I wrote the book.
Where I see myself in the future, I think I’m going to keep doing what I’m doing. I love doing education with my patients. I love doing education with providers. I also like hearing from providers about the challenges that they face. Oftentimes, it’s not anything that maybe psychology could be helpful with. A lot of the issues that providers bring up is on communication. A lot of providers talk about difficulties on how to deal with difficult behaviors, and how to deal with mental health that’s not being treated. There’s a section in my book that talks about how to empower providers and how to empower your patients. That’s a good section specifically for providers that talks about some of the challenges that they face. In the next couple of years, I hope I’m doing more of what I’m doing now.
You brought up mental health there, which we should touch on. Having chronic pain does not mean that you have a psychopathology or a problem, but how can optimizing our mental health access help people with pain?
There are two sides to that coin. If there are people who have preexisting mental health concerns that haven’t been diagnosed, assessed or treated, that could be intervening in the pain management treatment plan. That’s one reason why it’s important to assess. It’s also people’s reaction to the pain. How are people coping with the pain? Are they developing depressed mood? Are they developing anxiety? Are they having sleeping problems? The other side is, how can we intervene so that way it doesn’t become a mental health condition? How can we show that patient some coping skills so that way they are better able to live their life? It’s a two-pronged approach.
I just did a study where I looked at all the different mental health diagnoses using DSM-5 because most of the research that’s out there is based on DSM-3. What I found was we saw the same kind of patterns, that anxiety, depression and substance use are concerns that need to be addressed as part of the pain management assessment. What was also interesting is that there is a high level of sleep disorders and there’s a high level of anger. If we start addressing those two things in our interactions with our patients, especially in primary care, you might do a lot of good just by addressing those two things. That was something that I wasn’t expecting to find that I found just using the DSM-5 diagnosis.
You certainly are doing great work both in the clinic and research-wise. Can you tell everyone how they can learn more about you and learn about your book?
I have a website. It’s www.DrDavidCosio.com. I’m also on Twitter, @DrDavidCosio. I’m also on Facebook, @DrDavidCosio. If they want to contact me, I welcome questions. I’m always about collaborating, getting ideas and addressing people’s concerns. They could email me at DrDavidCosio@Gmail.com. I made it easy and consistent.
I want to thank David for being with us on the show. Check out his book and check out his website. He’s got great stuff. At the end of every podcast, I ask you to make sure to share this information with your friends, family and colleagues on your favorite social media handle, whether it’s Twitter, Facebook or LinkedIn. Pop in there and give us a share. We’d appreciate it. Make sure you hop on over to DrJoeTatta.com/Podcasts and on the right-hand side of the page, you’ll see a little box where you can enter your name and email address and I’ll put you on the mailing list. Each week I’ll send you the latest podcast update right to your inbox. I want to thank David and all of you for being here. We’ll see you next time.
- Dr. David Cosio
- Pain Relief: Managing Chronic Pain Through Traditional, Holistic and Eastern Practices
- @DrDavidCosio on Twitter
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About Dr. David Cosio, PhD
David Cosio, PhD, ABBP, is a psychologist in the Pain Clinic and interdisciplinary pain program at the Jesse Brown VA Medical Center, in Chicago. He earned his PhD from Ohio University, with a specialization in Health Psychology. He completed a behavioral medicine internship at the University of Massachusetts and a Primary Care/Specialty Clinic Post-doctoral Fellowship at the Edward Hines Jr. VA Hospital. Dr. Cosio has given several presentations in health psychology at the regional and national levels. He also has published several articles on health psychology, specifically in the area of patient pain education.
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