Chronic pain management guide for therapists and nurse practitioners

Chronic pain management represents one of the most complex clinical issues that therapists, clinicians, and nurse practitioners encounter. 

Unlike acute pain that signals injury and resolves with healing, chronic pain persists for months or years, fundamentally altering patients' physical functioning, psychological well-being, and quality of life.

Summary

• Chronic pain management requires multimodal approaches combining pain psychology interventions, medication when appropriate, coping strategies, and integrated care between mental health providers and medical teams to address both physical and psychological dimensions of persistent pain.

• Understanding when to address depression and anxiety is critical, as these conditions commonly co-occur with chronic pain and can significantly hinder treatment progress if left untreated.

• Effective chronic pain management involves teaching patients evidence-based coping strategies including mindful breathing, meditation, appropriate exercise, sleep hygiene, and cognitive reframing techniques that help patients regain control over their quality of life.

• Family impact is an essential consideration, as chronic pain affects relationship dynamics, role distribution, and emotional well-being for both patients and their support systems.

• Therapists and nurse practitioners can measure client and patient progress using validated assessment tools like the PEG scale, PROMIS, and Roland-Morris Disability Questionnaire to track functional improvements beyond pain intensity alone.

Understanding chronic pain

The International Association for the Study of Pain (IASP) originally described chronic pain as pain exceeding normal healing time. 

However, this definition proved ambiguous because healing timelines vary significantly based on individual factors. 

The IASP subsequently adopted a more practical definition: chronic pain is persistent or recurring pain lasting longer than three months.

Chronic pain is multifaceted and can drastically affect an individual's ability to perform activities of daily living, work obligations, and social commitments. 

Pain serves an essential biological function—it signals disturbance or injury and promotes healing. 

However, with chronic pain, these signals persist long after any tissue damage has healed. The pain becomes the disease itself rather than a symptom, causing both physical suffering and significant psychological distress.

Evidence-based pain psychology interventions

Contemporary chronic pain management recognizes that psychological factors play a crucial role in how individuals experience and cope with persistent pain. 

There is no single unifying psychological model; rather, treatment plans must be individualized based on each patient's unique presentation, comorbidities, and goals.

Research has identified four primary pain psychology interventions with strong evidence bases: operant-behavioral therapy, cognitive-behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and acceptance and commitment therapy (ACT).

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Operant-behavioral therapy

Operant-behavioral therapy focuses on modifying pain-related behaviors through systematic reinforcement principles. 

The fundamental premise is that behaviors—including pain behaviors like grimacing, guarding, or activity avoidance—can be modified by reinforcing desirable actions while discouraging maladaptive responses.

Key techniques include:

• Positive reinforcement for adaptive behaviors such as activity engagement

• Extinction of pain behaviors that reinforce disability

• Discrimination training to differentiate between protective pain signals and safe discomfort

• Systematic goal-setting based on observable, measurable behavioral changes

Individuals who have benefited from operant-behavioral therapy include those with complex regional pain syndromes, mixed chronic pain conditions, and lower back pain.

Cognitive-behavioral therapy for chronic pain management

Cognitive-behavioral therapy (CBT) represents the most extensively researched pain psychology intervention, focusing on the interconnected relationships among thoughts, emotions, and behaviors related to chronic pain. 

CBT helps patients develop effective problem-solving strategies to cope with persistent pain challenges.

Core CBT techniques include:

• Cognitive restructuring to identify and modify pain-related catastrophic thinking

• Behavioral activation through activity scheduling and pacing

• Stress reduction strategies and relaxation training

• Assertive communication skills for managing healthcare interactions

• Behavioral response regulation to prevent pain flare-ups

Research demonstrates CBT’s effectiveness for diverse chronic pain populations, including individuals with cancer pain, chronic orofacial pain, complex regional pain syndromes, fibromyalgia, and mixed chronic pain syndromes.

Mindfulness-based stress reduction

Mindfulness-based stress reduction (MBSR) emphasizes acceptance of present-moment experience rather than attempting to control or eliminate pain sensations. 

This approach recognizes that chronic pain signals are persistent and often intractable, so changing one's relationship to pain may prove more effective than pursuing pain elimination.

MBSR strategies include:

• Daily mindfulness meditation practices focusing on body awareness

• Mindful movement such as gentle yoga or walking meditation

• Non-judgmental observation of pain sensations without reactivity

• Present-moment awareness to reduce rumination

• Acceptance practices that acknowledge pain without struggle

Unlike CBT, MBSR does not emphasize specific goal achievement or pain reduction. Instead, it cultivates openness and curiosity toward all experiences, including painful ones. 

Research supports MBSR effectiveness for cancer pain, chronic back pain, complex regional pain syndromes, fibromyalgia, and chronic neck pain.

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) emphasizes psychological flexibility and values-based living despite pain.

 Rather than attempting to change or control thoughts and feelings about pain, ACT helps patients develop different relationships with these internal experiences.

Core ACT principles include:

• Acceptance of pain as a present reality

• Cognitive defusion to create distance from pain-related thoughts

• Present-moment awareness similar to mindfulness practices

• Values clarification to identify what truly matters

• Committed action toward values-based goals despite pain

The goal is not pain reduction but rather living a meaningful life aligned with personal values.

Individuals who have benefited from ACT include those with musculoskeletal pain and whiplash-associated disorders.

How to integrate with medical care

Effective chronic pain management requires seamless integration between mental health providers and medical teams. 

Mental health therapists and nurse practitioners in private practice must develop collaborative relationships with primary care physicians, pain specialists, physical therapists, and other healthcare providers.

Integrated care combines mental health services with primary medical care, recognizing that physical and psychological aspects of chronic pain are inextricably linked.

Key components include:

Coordinated treatment planning

Regular communication among all providers to ensure consistency and avoid contradictory recommendations.

Shared decision-making

Involving patients as active participants in treatment decisions.

Holistic assessment

Evaluating not only pain intensity but also functional capacity, psychological well-being, sleep quality, social relationships, and overall quality of life.

Proactive psychiatric care

Recognizing that treating underlying psychiatric conditions can significantly improve chronic pain outcomes.

Mental health provider roles in integrated chronic pain management

Mental health therapists and nurse practitioners contribute essential expertise/

Psychological assessment and treatment: Providing evidence-based pain psychology interventions including CBT, MBSR, and ACT approaches.

Psychiatric medication management: For nurse practitioners, managing psychotropic medications that address both mood symptoms and pain, such as serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and gabapentinoids.

Behavioral health coaching: Teaching practical skills for pain management, stress reduction, activity pacing, and sleep hygiene.

Care coordination: Facilitating communication among providers and ensuring treatment continuity.

When to address depression

Depression and anxiety represent the most common psychiatric comorbidities in chronic pain populations, with bidirectional relationships that complicate both conditions. 

Understanding when to address depression is not simply a matter of timing but rather an ongoing clinical priority.

The pain-depression connection

Research consistently demonstrates that chronic pain and depression exacerbate each other through multiple mechanisms:

Neurobiological overlap: Both conditions involve dysregulation of neurotransmitters and inflammatory processes.

Functional impairment: Pain limits activity and social engagement, leading to isolation and loss of pleasurable experiences.

Cognitive patterns: Both involve negative thinking, catastrophizing, and hopelessness.

Sleep disruption: Pain interferes with sleep, and poor sleep intensifies both pain perception and depressive symptoms.

Screening and assessment

Proper depression and anxiety screening should occur at initial evaluation and regularly throughout treatment. 

These assessments should not be viewed as optional but rather as essential components of comprehensive chronic pain management.

Recommended screening approaches include:

Standardized instruments: Using validated tools such as the Patient Health Questionnaire-9 (PHQ-9) for depression and Generalized Anxiety Disorder-7 (GAD-7) for anxiety.

Clinical interviews: Conducting thorough psychiatric assessments that explore mood symptoms, anxiety presentations, trauma history, and substance use patterns.

Functional assessment: Evaluating how mood symptoms impact daily functioning and treatment engagement.

Suicide risk evaluation: Recognizing that chronic pain populations have elevated suicide risk, particularly when complicated by depression.

Treatment approaches for comorbid depression

When depression is identified, it must be addressed as a priority. Untreated depression significantly hinders chronic pain management progress and worsens overall outcomes.

Evidence-based approaches include:

Psychotherapy: CBT and behavioral activation specifically adapted for depression in chronic pain.

Pharmacotherapy: For appropriate candidates, antidepressants with dual benefits for mood and pain, including SNRIs and tricyclic antidepressants.

Lifestyle interventions: Exercise programs, sleep hygiene protocols, and social engagement strategies.

Collaborative care: Ensuring coordination between mental health providers and medical teams.

What coping strategies work best

Teaching effective coping strategies represents a cornerstone of chronic pain management, empowering patients to actively manage their condition. 

While no single strategy works for everyone, research and clinical experience have identified several approaches with broad applicability.

Breathing and relaxation techniques

Diaphragmatic breathing activates the parasympathetic nervous system, reducing physiological arousal associated with pain flare-ups.

To practice diaphragmatic breathing:

1. Sit or lie in a comfortable position

2. Place one hand on your chest and one on your abdomen

3. Breathe in slowly through your nose, allowing your abdomen to expand

4. Exhale slowly through pursed lips

5. Aim for 6-10 breaths per minute rather than the typical 12-20

6. Practice for 5-10 minutes during calm periods and pain flare-ups

Progressive muscle relaxation involves systematically tensing and releasing muscle groups to reduce overall tension.

Meditation and mindfulness practices

Meditation doesn't require special settings—patients can practice in their own homes with guidance from apps, recordings, or therapist instructions.

Effective meditation approaches include:

Body scan meditation: Systematically bringing non-judgmental awareness to each body part.

Guided imagery: Visualizing peaceful, safe places that promote relaxation.

Loving-kindness meditation: Cultivating self-compassion.

Mindful movement: Gentle, awareness-based movement practices.

Movement and exercise strategies

Regular physical activity represents one of the most effective interventions for chronic pain management, yet many patients avoid movement due to fear. Mental health providers play a crucial role in addressing these fears.

Key principles include:

Start low, go slow: Begin with very gentle, brief activities and gradually increase.

Pacing strategies: Alternating activity and rest to prevent boom-bust cycles.

Professional guidance: Working with physical or occupational therapists.

Functional focus: Emphasizing improvements in daily function rather than athletic performance.

Regular practice: Consistency matters more than intensity.

Sleep hygiene optimization

Chronic pain and sleep disturbance frequently co-occur, creating a vicious cycle. 

Addressing sleep must be a priority.

Evidence-based sleep hygiene recommendations include:

Consistent schedule: Maintaining regular sleep and wake times.

Bedroom environment: Optimizing temperature (cool), light (dark), and noise (quiet).

Pre-sleep routine: Establishing calming rituals 30-60 minutes before bed.

Screen limitation: Avoiding electronic devices 1-2 hours before bedtime.

Timing considerations: Eating dinner at least 3 hours before bed, avoiding afternoon caffeine, and limiting alcohol.

Cognitive reframing and attention shifting

How individuals think about and attend to pain significantly influences their pain experience.

Attention shifting techniques

Engaging activities: Directing focus toward absorbing tasks, hobbies, or social interactions.

Positive reminiscence: Consciously recalling pleasant memories.

Future-oriented thinking: Planning for meaningful activities and maintaining hope.

Sensory alternatives: Focusing on pleasant sensory experiences—music, nature, pleasant scents.

Cognitive restructuring for pain

Identifying catastrophic thinking: Recognizing thoughts like "This pain will never end" or "I can't handle this."

Evidence evaluation: Examining whether thoughts are factually accurate.

Alternative perspectives: Developing balanced, realistic thoughts.

Self-compassion: Replacing harsh self-judgment with kindness.

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How to handle medication concerns

Medication management represents a complex aspect of chronic pain management, requiring careful consideration of benefits, risks, and alternatives. 

For nurse practitioners and mental health therapists collaborating with prescribers, understanding medication options is essential.

Pharmacological options in chronic pain management

Several medication categories play roles in chronic pain treatment:

Non-opioid analgesics: NSAIDs, acetaminophen, and COX-2 inhibitors for inflammatory pain.

Antidepressants: SNRIs (duloxetine, venlafaxine) and tricyclic antidepressants (nortriptyline, amitriptyline) that address both pain and mood.

Anticonvulsants: Gabapentinoids (gabapentin, pregabalin) for neuropathic pain.

Topical medications: Lidocaine patches, capsaicin cream, or compounded topical preparations.

Muscle relaxants: For specific conditions involving muscle spasm.

Opioids: Reserved for carefully selected patients when other treatments have failed.

Risk-benefit discussions

Before initiating any chronic pain medication, providers must engage patients in thorough discussions covering:

Potential benefits: Realistic expectations about pain reduction (typically 30-40% improvement) and functional gains.

Common side effects: NSAIDs can cause gastrointestinal bleeding and kidney problems; antidepressants may cause drowsiness or weight gain; gabapentinoids can cause dizziness; opioids carry risks of constipation, tolerance, and addiction.

Monitoring requirements: Regular laboratory monitoring, functional assessment, and screening for problematic use patterns.

Alternative approaches: Ensuring patients understand that medications work best when combined with pain psychology interventions and lifestyle modifications.

Special considerations for opioid therapy

Opioid prescribing for chronic non-cancer pain has become increasingly controversial. 

Current guidelines emphasize:

Restrictive indications: Opioids considered only after non-opioid treatments have been tried.

Informed consent: Detailed discussions about addiction risk and overdose prevention.

Dose limitations: Using the lowest effective doses.

Monitoring protocols: Prescription drug monitoring programs and urine drug screening.

Tapering strategies: Slow, patient-centered tapering when appropriate.

What about family impact

Chronic pain profoundly affects not only patients but also their families, intimate partners, and social networks. 

Addressing family dynamics represents an essential but often overlooked component of comprehensive chronic pain management.

Chronic pain disrupts established relationship patterns.

Role changes

Physical limitations force redistribution of household responsibilities, creating feelings of guilt or resentment.

Communication challenges

Pain can make patients irritable or withdrawn, straining communication.

Intimacy concerns

Pain affects physical intimacy, potentially creating distance in romantic relationships.

Social isolation

Many patients withdraw from social activities due to pain, fatigue, or embarrassment.

Financial strain

Medical costs and lost work productivity create significant financial stress.

Family members often experience:

Emotional distress: Watching a loved one suffer creates anxiety and helplessness.

Physical exhaustion: Providing practical assistance can be physically demanding.

Social limitations: Caregivers may sacrifice their own activities to support their loved one.

Relationship ambivalence: Feeling torn between compassion and frustration.

Therapeutic interventions for families

Mental health providers can support both patients and families through:

Family therapy: Addressing communication patterns and relationship dynamics affected by chronic pain.

Caregiver support groups: Providing validation and practical strategies.

Psychoeducation: Helping families understand chronic pain as a legitimate medical condition.

Boundary setting: Teaching healthy limits on pain-focused discussions.

Shared activities: Encouraging families to maintain enjoyable experiences.

How to measure progress: Assessment tools and outcome tracking

Traditional pain assessment focusing solely on intensity provides limited information about treatment effectiveness. 

Comprehensive chronic pain management requires multidimensional outcome measurement addressing function, mood, and quality of life.

Validated assessment instruments

The Pain, Enjoyment of Life and General Activity (PEG) scale represents a brief, efficient tool for evaluating pain's impact. 

This three-item measure assesses:

1. Pain intensity (average pain in the past week)

2. Pain interference with enjoyment of life

3. Pain interference with general activity

The PEG takes less than one minute to complete, making it ideal for busy private practices.

PROMIS (Patient-Reported Outcomes Measurement Information System) offers computerized adaptive testing across multiple domains including physical function, pain interference, sleep disturbance, fatigue, anxiety and depression, and social role participation. PROMIS measures are freely available and psychometrically sound.

The Roland-Morris Disability Questionnaire specifically assesses physical disability caused by lower back pain through 24 yes/no questions about pain-related limitations.

Comprehensive outcome tracking

Beyond standardized measures, effective progress monitoring includes:

Functional goals: Tracking specific, measurable behavioral goals such as walking distances or completion of household tasks.

Medication use: Monitoring changes in pain medication consumption.

Healthcare utilization: Noting emergency department visits and hospitalizations related to pain.

Work and productivity: Assessing work attendance and performance.

Psychological symptoms: Regularly screening for depression and anxiety.

Quality of life: Evaluating overall life satisfaction and engagement in valued activities.

Using assessment data to guide treatment

Regular outcome assessment enables:

Treatment adjustment: Identifying which interventions are helping and which need modification.

Motivation enhancement: Helping patients see gradual improvements they might not notice otherwise.

Goal refinement: Adjusting treatment targets based on progress and evolving patient priorities.

Communication facilitation: Providing objective data for discussions with patients, families, and other providers.

Quality improvement: Tracking practice-level outcomes to identify areas for enhanced training.

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Conclusion: A holistic approach to chronic pain management

Chronic pain management requires a comprehensive, multimodal approach that addresses biological, psychological, and social dimensions of persistent pain. 

For mental health therapists, clinicians and nurse practitioners in private practice, this means developing competency in pain psychology interventions, fostering collaborative relationships with medical providers, understanding medication management principles, and supporting patients and families through the multifaceted challenges of living with chronic pain.

While no cure exists for most chronic pain conditions, evidence-based treatments can significantly improve function, reduce suffering, and enhance quality of life. 

Success requires patience, persistence, and individualized treatment planning.

By integrating pain psychology interventions with comprehensive medical care, teaching effective coping strategies, addressing comorbid psychiatric conditions, involving families in treatment, and systematically measuring outcomes, healthcare providers can help patients reclaim meaningful, satisfying lives despite chronic pain.

Sources

• Raffaeli, R., Tenti, M., Corraro, A., Malafoglia, V., Ilari, S., Balzani, E., & Bonci, A. (2021). Chronic pain: What does it mean? A review on the use of the term chronic pain in clinical practice. Journal of Chronic Pain, 14, 827-835. https://doi.org/10.2147/JPR.S303186

• Ólöf Anna Steingrímsdóttir, O. A, Landmark, T., Macfarlane, G. J., & Sivert Nielsen, C. (2017). Defining chronic pain in epidemiological studies: a systematic review and meta-analysis. Pain, 158(11), 2092-2107. https://doi.org/10.1097/j.pain.0000000000001009

• Lim, J., Choi, S., Lee, W. L., Jang, J. H., Moon, J. Y., Kim, Y. C., & Kang, D. (2018). Cognitive-behavioral therapy for patients with chronic pain. Medicine (Baltimore), 97(23), Article e10867. https://doi.org/10.1097/MD.0000000000010867

• Sturgeon, J. A. (2014). Psychological therapies for the management of chronic pain, Psychology Research and Behavior Management, 7, 115-124. https://doi.org/10.2147/PRBM.S44762

• Leasure, W.B., & Leasure, E.L. (2017). The role of integrated care in managing chronic pain. Focus (The Journal of Lifelong Learning in Psychiatry), 15(3), 284-291. https://doi.org/10.1176/appi.focus.20170014

• University of California Davis Medical Center. (2025). Pain self-management strategies. https://health.ucdavis.edu/nursing/Research/INQRI_Grant/Long-Term%20Non-Surgery%20Pain%20Management%20Strategies%20Booklet%20WebFINAL082311.pdf

• Foster, M. (2023). Pathways through persistent pain: Tips for managing chronic pain. Mayo clinical health systems. https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/8-tips-for-managing-chronic-pain 

• Mayo Clinic. (2025). Chronic pain: Medication decisions. https://www.mayoclinic.org/diseases-conditions/back-pain/in-depth/chronic-pain-medication-decisions/art-20360371

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