Fall 2023
Pain Reprocessing Therapy as an Emerging Non-Pharmacologic Treatment for Chronic Pain: An Interview with Dr. Yoni Ashar
Mariel Emrich, BS1; Katherine Gnall, MS1; & the Pain SIG
The Pain SIG interviewed Dr. Yoni Ashar, a clinical psychologist and Assistant Professor at the University of Colorado Anschutz Medical Campus about Pain Reprocessing Therapy (PRT), an emerging non-pharmacologic treatment for chronic pain. Dr. Ashar and colleagues recently published a trial of PRT in JAMA Psychiatry with promising results and we were eager to hear his perspectives on PRT’s potential as a chronic pain treatment.
Pain SIG: Thank you, Dr. Ashar, for speaking with us. Can you give us a brief overview of PRT?
Dr. Ashar: First, PRT utilizes subtyping of chronic pain patients into different categories (e.g., primary/secondary; or nociplastic/neuropathic/nociceptive). There is a subtype of pain driven predominantly by neural circuits and mind/brain processes, and you can diagnose patients as belonging to that category based on certain indications (e.g., spatial spread of symptoms; initiation of symptoms during a stressful life event). Then you can help them recover (i.e., no longer meeting criteria for chronic pain). We do that with personalized education about how the brain can drive chronic pain.
One of the signature techniques is called somatic tracking, a sort of interoceptive exposure that includes elements of safety reappraisal (i.e., these symptoms are a false alarm, the pain is real but there is not a problem with your body). Somatic tracking is directly working with sensations, similar to a guided meditation, to try to change how you relate to them to reduce or eliminate fear of those sensations.
The last piece I’ll mention is understanding the relationship between stress, emotions, and pain. Helping people [make those connections] and then helping them reduce stress, address difficult relationships, be kinder to themselves…this all interacts with pain.
Pain SIG: What makes PRT unique from other common non-pharmacological interventions, such as CBT for Chronic Pain (CBT-CP)?
Dr. Ashar: I love that question. We are currently running a trial comparing PRT to CBT-CP. I think the first question is: is it unique and if so, what is unique about it? Empirically, we don’t have data on that yet. I can tell you from a theoretical perspective what seems to be unique:
- The subtyping diagnostic step. In CBT or ACT, pain is pain is pain. All pain is due to a complex interaction of biopsychosocial factors. We are not putting people into buckets. In PRT, we are. And a lot follows from that, such as the understanding that if someone has nociplastic pain, then recovery is possible. You can get out of pain because the brain has learned it, so it can also unlearn it.
- In approaches like CBT and ACT, the focus is often more on the suffering around the pain -- helping people live their values along with the pain or not letting the pain interfere too much – rather than directly targeting the pain. I think CBT and ACT are wonderful for chronic pain and in many ways, they are most appropriate for secondary pain where the pain is medically driven (e.g., fracture), and helping individuals live their lives with the pain. When it is nociplastic, I think we can do more. That is what PRT aims to do. PRT also has similarities to a few other treatments like Emotional Awareness and Expression Therapy or Pain Neuroscience Education, all of which utilize the subtyping and trying to get people out of pain.
Pain SIG: Which patients are ideal candidates for PRT?
Dr. Ashar: Anyone with nociplastic (i.e., primary or neuroplastic) pain is a great candidate for PRT, we think. Of note, the trial in which PRT was studied had a relatively White, well-educated, high functioning sample, and so in our ongoing trial, we are aiming to recruit a more diverse population.
Pain SIG: What future directions do you envision for PRT in research and clinical settings?
Dr. Ashar:
- Is PRT different from other treatments and how?
- What are the psychological mechanisms and are they unique to PRT?
- E.g., pain reattribution: a person’s beliefs about the causes of their pain. In PRT, we are directly targeting people’s attributions. At the start of treatment, when asked, “what is driving your pain?” in our data, 90% responded with “bulging disc, bad posture, etc.,” …something physiological. And if PRT succeeds, people will then respond by saying “it’s neural pathways, anxiety, my brain’s overactive alarm system, etc.”
- Who is a good candidate for PRT?
- Use in diverse populations?
- Is it moderated by culture? (E.g., cultural intersections of how people relate to somatization and emotions).
- Scalability of PRT: How do we get this in a group format, and/or primary care settings where most patients with pain show up?
- Our first trial had really good results, but replication is a next step.
Pain SIG: What advice would you have for trainees who are interested in chronic pain research?
Dr. Ashar: Go for it! There is so much to do here and it is a really exciting time. There is such a fruitful dissection between fields (clinical psychology, medicine, neuroscience) and there’s a huge unmet need – both in terms of patients’ unmet needs and the research questions. We are learning about how far psychological treatments could potentially go in treating pain as most people recover following psychological treatment.
Pain SIG: Is there anything that we didn’t ask that you want to add?
Dr. Ashar: I see PRT as one of a wave of “brain-first” pain treatments. There’s other treatments that I didn’t mention: Cognitive Functional Therapy, virtual reality, psychedelic therapies recognize the brain as the center of the equation in the treatment of chronic pain. I’m very excited to see where this takes us.
To learn more about PRT:
- Treatment outline
- Training opportunities
- “The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain” book by Alan Gordon and Alon Ziv
Affiliations
- Graduate Student, University of Connecticut