Dr. Regina Koepp  0:00  
For better or for worse, most of us associate chronic pain with getting older. We assume that as we age, our bodies naturally break down and that pain is quote, just a part of getting older. According to a report put out by CDC in 2016, close to 30% of adults in the US experience chronic or high impact chronic pain, and adults 65 And older make up the majority of people living with chronic pain. There are a lot of things that we can do and we're going to talk about it today to effectively manage chronic pain. And here's why it's so important one we don't want people living, you know, with pain and suffering, but to when people do experience chronic pain, their risk for depression goes up. And so today I'm delighted to bring to you an expert in the field of effective brief treatments for chronic pain. Let me introduce you to our guest today. Dr. Beth darnel is associate professor at Stanford University School of Medicine Department of Anesthesiology, perioperative and pain medicine, where she directs the Stanford Pain Relief innovations lab. Her team's pain treatment research is funded by the National Institutes of Health and the Patient Centered Outcomes Research Institute. Dr. Darnell has twice briefed the US Congress and the FDA on the need for patient centered pain care and opioid stewardship. She is a scientific member of the NIH interagency pain research Coordinating Committee, and has served as a scientific member of the CDC opioid workgroup. She's chief science advisor for Applied VR and serves on the board of directors of the American Academy of pain medicine. Her work has been featured in outlets such as Scientific American, NPR, radio, BBC, radio and nature. She's authored five books for her patients and clinicians and is the creator of empowered relief, which is a single session evidence based pain relief skills class that's available in 12 countries and in six languages. I am delighted to be interviewing Dr. Beth Darnell. Today she's going to talk to us a lot about this empowered relief program and how you can be helpful to people living with chronic pain. Let's jump into today's interview. Thank you so much for joining me today and sharing your your wisdom and knowledge about pain management and and really accessible treatment models for pain management. Will you share a little bit about how you got interested in pain management and behavioral treatment for for pain and chronic pain?

Dr. Beth Darnall  2:39  
Sure, no, I'm pleased to say I have a doctoral degree in clinical psychology. And when I was going through my program, clinical psychology program, there, there wasn't any education, about chronic pain, pain management, how to help people living with this particular health burden. But interestingly, when I went on to my internship at a VA hospital, everything was about pain management. I mean, veterans are older adults, and they have a lot of pain issues and medical comorbidities. And then from there, I did a postdoctoral fellowship at Johns Hopkins University where I was working with people with spinal cord injury, amputations, catastrophic burn and major medical conditions. And while these are wildly disparate health conditions, there's one commonality pain management was crucial to each and every type of condition it was really a foundational area in which I was working with patients. And I found that I really enjoyed being with people who were suffering and and helping them helping to alleviate their burden. I it's just so gratifying to see people get better and do better. So I naturally gravitated towards this area. And I also share that I think one of the reasons why I've had great comfort with it is that I had chronic pain when I was younger myself and so my own experience of chronic pain has definitely informed my understanding of both the patient experience at but you know, patient needs and also the development of the treatments that I have designed.

Dr. Regina Koepp  4:39  
I so value Yeah, your own personal journey and then your professional journey. Why do you think there is such a disparity between what you learned in the classroom in graduate school and what happened in real life with the VA and astray with at the VA Health Care System and worked there for many, many years and 10 years at the Atlanta VA, and you're right Veterans are by and large, older adults, one in two veterans is 65 and older. And, and we have so many similarities. Beth, I also had had worked in spinal cord injury for 10 years at the Atlanta VA. And yeah, we have so many overlaps. I know before this, we were talking about our overlap at at Stanford. But why do you suppose there is that disconnect, or was that disconnect in graduate school and then in real applied practice,

Dr. Beth Darnall  5:27  
I think there has been a conceptual bifurcation between mind and body and that, you know, pain has always been perceived as a physical and medical condition, a biomedical phenomenon. And for that reason, there has been far less emphasis on evaluating and treating pain with an integrated approach. And this has been a true disservice to both clinicians and patients, because it has left patients untreated. From a fully comprehensive integrated approach, they they have not had good access. And similarly, clinicians have often felt under resourced, under educated, really unskilled to to address pain in their patient population. We conducted a study on this topic in 2016. And we surveyed almost 1000 patients in the United States and 1000 health care clinicians about the needs for pain education, access to psychological approaches to the management of chronic pain. And what we observed among psychologists is that the majority said that they felt that they were lacking education skills, knowledge about how to appropriately address pain in their patient population. And Regina, we're not even talking about, you know, making people pain psychology experts, but let's be real, if you're a clinician working with patients in any capacity, you're you're treating people who have pain. And so each and every patient encounter that all of us have is an opportunity to bring awareness and some level of education and resources to our patient population. But what we were hearing from clinicians is that they these, they were saying that they lacked the competency that wasn't included in their programs, and it hasn't been well integrated into continuing education or licensure requirements. Now, a lot of this has been changing with a greater focus on pain management, and a huge focus on treating pain, non pharmacologically. So there's been a big push now in a greater understanding that pain is not just a biomedical condition or phenomenon. The International Association for the Study of pain defines pain as both a noxious sensory and emotional experience. And so psychology is actually baked in to the definition of pain. But that is not widely appreciated. But this is, you know, this is our opportunity to to better appreciate that pain is a whole person experience that requires a whole person approach. Because if we only treat the biomedical aspects of pain, if we only treat half of anything, how can we be surprised when the results are suboptimal? And this is what we see, to a very large extent. And when this second half of the definition definition that involves psychologists, social workers, behavioral health professionals, this is really exciting because this is where we can empower individuals to know what they can do on a daily basis to best help themselves so that they're making the right choices every day because some of the best choices for pain management aren't intuitive, left to our own devices. It's natural for us to be making choices that are not actually helping us manage our pain.

Dr. Regina Koepp  9:47  
Oh, yeah, that withdraw the sort of sedentary not wanting to move for fear of agitated with it. Yeah.

Dr. Beth Darnall  9:54  
Great example. Great.

Dr. Regina Koepp  9:57  
So that you mentioned in that 2016 In study, you surveyed 1000 patients and 1000 health care clinicians or, or health clinic mental health clinicians. What did the patient say? Yeah,

Dr. Beth Darnall  10:09  
so the patients told us a lot of people did not know about pain psychology or the role of psychology and the treatment of pain. So one of the things we learned is that we just need to better educate the public about the whole person pain experience and the role of psychology. And but many people did know about it in and what they said was that there, there are many barriers to accessing behavioral health for pain management. And some of those include just not knowing where to find a skilled or trained provider. So you know, Regina, you know, that, you know, there's, there's a difference between just finding a psychologist or a therapist in the community, versus a clinician who's really expert or specializes in, in pain management in some of these deeper issues. And, you know, there are few of these trained professionals. And, and then even when there are even when we have some local trained professionals, patients don't know how to find them, the clinicians, the doctors, other clinicians, don't know how, who to refer to how to refer to them. So there's a broad lack of understanding about how to find these few professionals. But even when people are able to find these professionals, what we see is that the the need vastly outweighs the availability. So these are highly sought after clinicians because their their specialized skill set, there can be six months of a waitlist, there's insurance barriers, a lot of people live outside of urban areas, and these specialized clinicians are often absent in these broader communities in the United States where the vast majority of patients reside. So those are just some of those some of the key issues, you know, there's travel burdens, there's copay issues. And then one last point that I'd like to mention is that often with behavioral health, we have an evaluation. And then we have treatment that often involves multiple follow up treatment sessions, and that can be a 1012 or more sessions. So we're not just talking about the burden of finding a provider and getting the evaluation. But each and every follow up session imparts additional burden on a patient population that often has mobility challenges, financial restrictions, all types of the issues with with travel, and so really trying to access these multisession treatments can impart a substantial burden on our patients who are often the most vulnerable and have the greatest health burdens on them already.

Dr. Regina Koepp  13:35  
That is an incredibly important to talk about. So not only is pain itself, the barrier, there are all of these systemic barriers, like financial restrictions, and it's hard to work full time, if you're in chronic pain or living with disabling pain, it's, you might be using your money for multiple types of treatment and then not have money elsewhere just to basically pay the bills and we know that people living with disabilities, you know, tend to have more socio economic challenges. And the than that insurance and those barriers and and trying to find a provider, where do you even look? And how do you even vet them? I want to back up, you know, you were talking something so important that you said, pain is a whole pain affects the whole person and it deserves a whole person approach. And for so long, we were only looking at the bio medical sort of model and not including a more holistic, biomedical, psychosocial, spiritual approach. And I want to just talk for a minute about the downfall of only looking at the treating pain from a biomedical approach and I really appreciate what you said that if we only treat part or from one perspective, which is the biomedical perspective, we're going to fall short of full success because of only going to treat part of the problem. And so I want to just talk for a minute about the downfall of only treating a part, which is that biomedical part and what's coming to my mind is, how much of that approach then just sort of fueled the opioid crisis? And that, then if it's only that approach, then we have that kind of treatment, which is a medical treatment. And I'm curious, well, I'm not a pain specialist. But since you are, I'm curious what your thoughts are about that the downfall of only treating part?

Dr. Beth Darnall  15:32  
Yeah, well, it's, it's a really great point. And, you know, as I mentioned, if we only treat half of anything, we're going to fall short. And we have really fallen short, when it comes to pain management, we have over emphasized the biomedical

Dr. Beth Darnall  15:53  
to, to the almost to the exclusion of the whole person behavioral health. And, and I really want to mention that I speak with so many physicians and prescribing providers, and they are on board with behavioral health, what they have lacked is accessible options to refer their patients. So what we're seeing are these environmental contingencies that have maintained a biomedical approach, we do not have great reimbursement models. We do not have enough trained providers. And so, of course, your average primary care physician in rural America is going to see Mrs. Smith, who's 75 with limited mobility, and this physician does not have good options for her. And so Mrs. Smith is more likely to get prescriptions, she's more likely to get interventions, injections, pain procedures, these types of, you know, treatment approaches that may be indicated. But what we know is that those are riskier options for pain management. And one of the core philosophies that we want to bring forward is to apply the lowest risk treatments first always. So for instance, the lancet convened an expert consensus panel and review scientific review and consensus panel. And they concluded based on the evidence that pain education and cognitive behavioral therapy should be first line treatments for chronic low back pain. So this, this consensus panel was specific to chronic low back pain, which is the number one pain, chronic pain condition worldwide, regardless of the country. And so CBT and pain education were recommended as first line treatments for chronic low back pain, and let's be real, we all know that that's not happening. And, and so at the end of the day, we can we can, we can talk all day long about what the evidence is and what's best practices. But until we make this accessible, meaningfully accessible to clinicians and to patients, the prescribers, physicians and clinicians are going to default to whatever is available to them. And historically, that has been medications, procedures, things that people can get in house and on demand. And the reason why this is problematic, is that let's say Mrs. Smith, you know, I mentioned she, she has chronic pain, she has mobility issues, she's not very active because her pain is preventing her from engaging in her daily activities. And so she goes to a doctor for pain and the doctor may just prescribe a type of pain medication and they may prescribe certain types of procedures such as injections that she starts receiving regularly. But what's absent from this approach? is really understanding who Mrs. Smith is and what are her barriers and how can we best help her so we don't just want to treat the pain we want to treat the person who has pain. When we look at Mrs. Smith from a whole person perspective, we see that she has she does not understand all of these elements around pain and how to best treat it. She does not understand she'd nobody has provided her with the information that it's it's actually best for her and her type of pain to move more to engage in movement on a regular basis. But because she hasn't had that information she has become deconditioned. She's sedentary, this is now contributing to new onset pain, which has, is interfering with her sleep. So she now has insomnia, which is one of the the most the biggest predictors for increasing daytime pain. So her insomnia is now contributing to worsening pain during the day, which may be adding to her impetus to take more medication during the day. She is becoming increasingly anxious and distressed with her deterioration in her condition. She's worrying more about what's going to happen if her pain continues to get worse. She's feeling helpless about her pain. And she now has some symptoms of depression, feeling isolated, because she's not able to get out and engage with her friends and her family as she used to she's not seeing her grandchildren. So all of these meaningful connections and pleasurable activities are falling to the wayside. And what is increasing in size is her focus on pain. And so her her life is now focusing on her pain, the restrictions and going to these medical appointments. And this is highly problematic, because what Mrs. Smith really needs is a whole person approach. Where we're looking at her from the whole person perspective, we are engaging her with physical therapy evaluation so that she knows what's the safe and appropriate movement for her type of pain. And then we need the psychological or behavioral health approach, so that we can help her feel and be less anxious. She engages in these days in this daily movement, so that she can better manage the distress that may naturally arise when she thinks about engaging inactivity or when she worries about the possibility of her pain worsening. So we need to equip Mrs. Smith with a foundational skill set, so that she can understand how to calm her nervous system, and be able to steer herself away from these types of behaviors and thoughts that we know amplify pain. And instead, we're steering her more towards rehabilitation or engagement in meaningful activities, while being able to self soothe so that she can get a better night's rest. Now, I want to be really careful, these are not binary, it's not all medical, it's not all behavioral health, she may need those medications, and she may need some of those pain procedures. But if we integrate in a behavioral health approach, especially early on in the process, we can help Mrs. Smith have a better response to the medical treatments that her doctors will try. And in many cases, we can obviate some of those medical treatments because pain is just simply better managed at the outset. Similar to the lancet recommendations. If we apply education, cognitive behavioral therapy, these skills based self management approaches early on, we can help a substantial fraction of patients learn to engage in the right actions early on with a goal of obviating some of the more invasive or riskier treatments for some patients.

Dr. Regina Koepp  24:11  
As you were talking, I started to reflect on my own patients. This example of Mrs. Smith is so helpful because it for those of us who who work with folks with a lot of pain. One of the things I hear from my patients is I'm tired of being a patient, I'm always a patient, I don't have any other role in my life now but being a patient like you were describing Mrs. Smith's world narrowing into being very pain oriented. And back to that, as you were talking I was thinking about this and applying it to my own clinical population and thinking Oh right. So if we only focus and that that to me is one of the fallouts of the biomedical only approach is that then the the, the complementary relationship is or the relay kinship of the patients, the biomedical approach is that there a patient, and that it disempowers them and their whole self, right. And so as you were talking, I was thinking, Oh, yes. So this approach that you're talking about, and Lance it said is the first line with education, and cognitive behavioral therapy invites a more holistic frame for the persons that that they can bring all of themselves and not just their pain, living in pain, self. And I really appreciate that, because I hear so often with this biomedical approach, and this is for pain, this is for cancer, this is for dementia. This is for all sorts of conditions. I hear I'm so tired of being a patient. And I think the patient role gets reinforced if we're only looking at biomedical.

Dr. Beth Darnall  25:44  
Yeah, yeah, absolutely 100%.

Dr. Regina Koepp  25:47  
And so I so appreciate this. And I also hear that only looking at biomedical really disempowers the person because it puts them in the role only a patient. And if we look at the holistic frame of the person that empowers them. And I think this is a helpful maybe segue to your program. So I know, You've been very passionate and focused on creating some of that. What can we do that's low risk and high impact for for helping reduce pain and provide education? And what do you think that this is a good place to talk about what you're creating or what you've created?

Dr. Beth Darnall  26:27  
Yeah, sure. Thanks, Regina. Well, you know, I've been working with patients with chronic pain for 15 years. And what I would see in the clinic is that, you know, I would evaluate patients once. But in so many cases, the recommended form of treatment was inaccessible to them, I could say, well, you know, you you would really benefit from learning this information about self management, or these cognitive behavioral skills, you know, pain management skills would benefit you greatly, you can apply these in your daily life and begin steering yourself towards recovery, towards engaging in meaningful activities and having less distress. But regardless of what I would recommend, this was not feasible for the majority of people who didn't have access to it. So what recognizing this and in this vast need to connect people to this information, I essentially took the skills based evidence based ingredients from multiple different treatments that exists today, cognitive behavioral therapy for chronic pain, self management principles, pain, neuroscience, education and mindfulness principles. And I took these key ingredients and compressed them into a single session intervention called empowered relief. And the reason I did this is what I observed is that while I couldn't see most people for multiple sessions, I could see most people for one session, they could attend once treatment session. And so it was really born from the great need for accessible, accessible ways for people to acquire this these critical skills. So empowered relief is a two hour skills based class that is broadly applicable to anybody living with pain, it could be acute pain, or even chronic pain. But I first developed the intervention for people with chronic pain. And over the course of two hours, people learn all of that all about pain, what it is, how it can be best managed by integrating in these behavioral medicine, approaches and skills. People learn three core skills which facilitate self regulation of pain of the distress that and stress that pain naturally causes us. So people learn about how stress and pain impact the central nervous system, and then they learn these core skills to best control these factors so that they are steering themselves towards relief and towards having greater control over their experience so that they're not just the lying on the doctor, and on these medical treatments, which are, you know, can be vitally important. But if we if we don't know what we can do to help ourselves then we're missing a key operator tunity to unpowered relief is all about equipping individuals with effective pain management skills that they can use on a daily basis to best control their own experience and steer themselves towards relief. And this occurs over a single session to our class, a people leave the class, having tailored the information to themselves, they leave with a completed personalized plan for empowered relief. So as you know, information is only useful to the extent to which we apply it to ourselves on a daily basis. So we move people from just education, to applying it to themselves. And we really set themselves we really set people up with the understanding of what they can do each day, people leave the class with a 20 minute binaural audio file. So they also have a standardized tool that they can use on a daily basis to to calm their nervous system. This is a guided deep relaxation audio file that has been tested in multiple randomized controlled trials now. And it facilitates basically this encoding of the relaxation response. So the nice thing is people can receive empowered relief online. So with online delivery of empowered relief now we can access these patients who live in rural areas, people, but you know, we can transcend many of these pre existing barriers that have prevented people from receiving effective behavioral health for chronic pain.

Dr. Regina Koepp  31:57  
So it's a two hour class that you have built the curriculum based on evidence. And I think you've you're a researcher and I know you have done a lot of research with various organization in imH. Am I Am I remembering that right?

Dr. Beth Darnall  32:13  
So in CCIE, ah, yeah, with the National Institutes of Health. So it's a National Center for Complementary and Integrative Health, funded our primary research, this was a $4 million grant that we received in 2015. To study the comparative efficacy of two hour impair empowered relief, compared to 16 hours of standardized cognitive behavioral therapy for chronic pain, both skills based treatments, but obviously one much briefer than the other. And we just, we finished this randomized controlled trial this year and just published our results in JAMA Network open in August. And I have to tell you, this was a really rigorous trial. We studied this in chronic in community based individuals with chronic low back pain. So this was a specific pain condition. But we aimed to understand whether whether to our empowered relief would be comparatively effective to 16 hours of CBT, three months after completion of the treatments, and we were very pleased to have our hypothesis met we we showed and published in JAMA Network open that indeed, to our empowered relief was compatibly effective to eight sessions CBT for reducing pain catastrophizing, pain, intensity, pain, interference, and a whole host of other secondary outcomes such as sleep disturbance, fatigue, depression, anxiety, pain, bothersome Ness, and all of this three months later. And while we have not yet published his data, we are showing durability of effects for comparable efficacy of the two hour class six months after receipt of treatment. This is really a breakthrough in understanding that brief treatment can be effective as effective as longer course treatment. It leads to empowered relief. This is the only treatment we have studied, but we're so excited about it because what it suggests is that we have an evidence based pathway that could truly broaden access to behavioral health for crime. onek pain. Now this NIH study we can I mentioned that we conducted that and chronic low back pain. But about half of the sample had multiple pain conditions. And we also conducted a second randomized controlled trial in mixed etiology chronic pain, meaning people with any type of pain condition, and we studied online delivery of empowered relief. And we found similar multi-dimensional benefits for empowered relief, three months after people received the single session, class online. And so again, we have several data points now suggesting that the classes broadly affect has broad efficacy. But what we haven't yet shown is effectiveness of empowered relief. And so to prove effectiveness, you need to study the treatment really broadly in the wild in community based settings. And I'm really excited to share Regina that just this month, we received major funding from the patient centered outcomes research institute, this is McCory, they awarded us $10.3 million Research Award to conduct a national comparative effectiveness study of online empowered relief, compared to online eight session CBT. And what's especially exciting about this is that we it's a six site national study, and we are enriching our sample for people who live in rural areas who are black, African American, who are on Medicare and Medicaid, older adults, and in really underserved populations. So we're taking this way outside of Stanford way outside of research environments, and we are going to conduct the effectiveness science nationally, to be able to give clinicians and payers and patients broadly, the information they need to make informed decision making about which treatment is best for

Dr. Regina Koepp  37:28  
them. Congratulations on that big new grant. I think that's so incredibly important, especially with all of the health disparities that we know exist for underserved ethnic minority populations, like black African American populations, Latin X populations, older adults or underserved population. So I just congratulations, and thank you for doing this and in applying your work more broadly, and integrating it more into the community. Now, have you looked at all add? Pairing the benefits are the effects of pairing empowered relief with CBT?

Dr. Beth Darnall  38:11  
No, we have not looked at sort of stacking it the way that I sort of envision this and I have some data to speak to this. Is it empowered relief is a fantastic first session, people learn why they why behavioral health is important. They learn these core skills, what we find for a lot of people who take empowered relief, is that they ask for more afterwards, they say how do I get? You know, Can I can I take another class? Is there more that I can learn? And so it's almost like that, that first entry into into more extensive treatment. So a lot of so we have to date empowered relief is in health care organizations throughout the United States. We've certified about 350 clinicians, and they're delivering empowered relief broadly, it has been delivered in 12 countries, it's available in six languages. So it's it's all over and we hear from people that that enhances patients receptivity to further engagement in behavioral health. I think one of the things that we have is a bit of a, a crisis or a problem of branding. One of the issues with branding is even the word psychological so to medical people who are going to their doctor for medical treatments to be referred to a psychologist people don't understand that and they'll say but my pain isn't psychological. Why are you sending me to a psychologist? And then next, the term cognitive behavioral therapy people will say, Well, why do I need therapy? I have have a medical problem. So the terminology has really itself his has contributed to some stigma, some misunderstandings, and it has served as a barrier to patient access to behavioral health, where as empowered relief as a class is designed to be less, stigmatizing accessible, the family can attend, you can attend anonymously, you do not even have to say your name, you don't have to talk about your history, it is not therapy. And once we get people in the door, and they learn more about all of these other pieces, they become more interested in in engaging further. So what we have seen is that some people naturally will take empowered relief and then want to go on to CBT. But we have not conducted a study as such, although I am aware of other researchers who are currently studying what you know, this exact, you know, the question that you're asking, like, have you looked at empowered relief and then CBT. So there are people who are doing that?

Dr. Regina Koepp  41:15  
Oh, great. Earlier, you also mentioned that one of the goals with empowered relief is to reduce some of the medical, more invasive medical interventions in my recalling that correctly.

Dr. Beth Darnall  41:27  
So we believe we we believe, and the data suggests we haven't studied this directly, we're going to we will get the data in this new large Pokorny funded effectiveness study, we're going to be able to collect direct data to be able to say whether empowered released online empowered relief and online CBT reduce health care utilization long term. So what we have now are more data points from prior work that have shown that if we effectively address some individual factors in patients, then they have a better response to medical treatments, and they require less medical intervention. So we've seen that in prior work, but we have not directly studied it for empowered relief proper.

Dr. Regina Koepp  42:25  
Yeah. And you mentioned, you're with a new study going to be applying it to more underserved populations, has empowered relief been studied with older adults? Or is there data that gives us information about older adults? Or who empowered relief is more beneficial for is it? What do you notice?

Dr. Beth Darnall  42:45  
You know, great questions. And we have conducted multiple randomized controlled trials. And we have found no baseline predictors for treatment response. And what I mean by that is, there's you know, it's not just for higher education or lower education, or one type of pain versus another to date. Our information suggests that this is broadly applicable to all individuals, we have not restricted to older adults or younger adults, we have looked at the data for older adults. And there, there was one element that that was both interesting and surprising to me is that the highest treatment satisfaction ratings come from older adults. So so they really like the information. They're very pleased with being given access to this treatment pathway. Humana neighborhood, I don't know if you're familiar with Humana neighborhood, but this is an offshoot of Humana than the national payer, and Humana Neighborhood Services, Medicare and Medicaid patients. And they deliver online education to this patient population. And they integrated empowered relief into their member portfolio. So in October of 2021, I delivered several online classes to the Humana neighborhood membership nationally. And so virtually everyone is an older adult and it was really well received and Humana is now expanding, empowered relief in their treatment portfolio to members. They're certifying many different clinicians within their system to be able to scale out empowered relief and they are also one of the side dates for this new McCory multi site research award that we're starting in 2022. So we are hoping to really expand access to older adults. Also, the Phoenix VA is one of our study sites, and that's predominantly older adults. And we are hoping to receive some preferred designation to be able to put forward empowered relief as an as an evidence based treatment for specifically for older adults, because there is such a huge need. I mean, as you know, about three quarters of older adults report living with persistent pain, three quarters, and a majority describe having pain that's moderate, or, or severe. And so we really untruly need to provide accessible Behavioral Health Options to this patient population to help decrease their suffering, and increase their quality of

Dr. Regina Koepp  46:08  
life. Yes, and decrease risk with so many medications because medication interactions are one of the biggest risks for older adults. If you're on heavy duty pain meds, that's pretty, pretty tough, especially with the impact on cognitive functioning. Absolutely. Oh, that's great. And congratulate Oh, I just am so delighted to hear about this multisite study and your your the results of satisfaction coming from older adults has been, by and large my experience as a as a Jarrow psychologist, that my I have such wonderful experiences working with older adults. And I think that is one of in terms of their satisfaction, my satisfaction as a clinician, their satisfaction in receiving the care and that it's available to them. I think there's a lot of gratitude that I really appreciate. I also wanted to say that like one of the one of the things I see in health care systems is, is that because I wonder if it's because I think there's ageism is a part of this. But if about 75% of older adults experience some level of persistent pain, its providers might hear about it commonly. And because it might be a common concern, I wonder if it gets minimized, and then doesn't get the treatment options it deserves. And I really just so appreciate that. There's something that now with empowered relief that providers can use and can provide. And I think by and large health providers and pain, health pain medical providers want to be helpful, you don't want to alleviate suffering and want to address the pain and, and want something to offer. And I think since the focus for so long has been my biomedical medications and interventions have been one. And what you're saying is, but actually we can do more we can include the whole person with programs like empowered relief and cognitive behavioral therapy, I think there's some act for chronic pain that also has evidence. And, and that actually, we can do more. And now we're giving more resources for health professionals to offer in the moment and I saw and that's that's accessible to the patient with just a two hour course. I so appreciate that. And that it can help reduce also the stigma for older adults and talking about chronic pain, it can increase awareness of a medical provider on even though it's common, it doesn't mean it's any less important for older adults to get pain managed. And another tools for older adults for doing that. So it's just great. Now I'm I need to step down from my soapbox because I'm a pretty anti aging Indian. And then also there's an ableism component too, because we conflate age with ability quite often,

Dr. Beth Darnall  48:58  
you know, and all great points, Regina. And I just want to add one additional point, which is that the person people older adults tend to minimize their own pain. And it especially older populations, where it's like well, this is just part of aging and this is just the way it is and they were raised with such an you know, an ethic to suck it up and you don't go to the doctor. So as clinicians, we have the opportunity to check in with our clientele and really understand what they're experiencing how they're feeling. And then give them access to Low risk, low cost, low burden, skills based treatment that has shown to reduce pain intensity, reduce pain, interference, reduce the burden of multi dimensional symptoms, help them sleep better, help them live better. So that's another Part of it because I agree with you that because pain is so common, it just, you know, it gets minimized in everyone's mind. But sometimes the patient won't even bring it forward to discuss. And so there's truly needless suffering and living with pain. And if we can help reduce that burden for our clientele, that's just, it's really something tremendous that we can offer them. And then as you said it, and also our selves, because helping our patients, our clientele, seeing them get better is and live better is it's why we do what we do. And that is the gratification of being a clinician truly.

Dr. Regina Koepp  50:48  
Yes. And to your point, older adults have had a lifetime of internalizing ageism, you know, like what's expected as we age. And, and I and you were pointing to that exactly that that ageism gets internalized that of course, I'm experiencing pain, I'm old, and and then they get reinforcements of that message in society, and sometimes by their own providers, by their family members, by movies and media. And And actually, what you're saying is we have to help dispel that myth, that pain is manageable, we can help you better manage it, and improve your quality of life and alleviate some of that suffering. And you deserve it, too. Absolutely.

Dr. Regina Koepp  51:34  
I am so curious about your certification, so and how this actually does get applied. So how do you who can get certified? And how does one apply it in practice? Like, is this certified at a medical provider level at a mental health provider level? A little bit about that? Sure. We offer

Dr. Beth Darnall  51:59  
clinician certification, through Stanford University CME. And any type of clinician health clinician can become a certified empowered relief instructors. So we certified physical therapists, physicians, nurses, psychologists, mental health therapists, you name it. But this is we certify clinicians to deliver the Empowered relief intervention to patients or clientele. The certification process involves participating in a two day online certification workshop that involves about 11 hours of contact time or face to face learning. And so we offer those certification workshops every couple of months at Stanford. So we have an empowered relief website, you can go to the website, see what our training schedule looks like. But once clinicians are certified, they receive all of the information needed to immediately begin implementing empowered relief with patients. So I mean, you can start the very next day, if you wish. We do recommend that people kind of build up in in being an instructor because, you know, I hope, because empowered relief is a class, you're not limited to traditional sizes. So the largest group patients, a group of patients that I have treated has been 85 patients at once. When we deliver online classes you can have, you could have hundreds of people in a single class. So it's really up to you. But certified instructors receive all of the instructor materials and all of the patient facing materials. So there isn't a standardized instructor PowerPoint slide decks, the information is delivered via slide deck that is a very highly structured, there's an instructor manual. And then there are the patient facing materials, including the personalized plan for empowered relief, the binaural audio file, you get everything that you need to begin implementing the class right away. There are no ongoing licensing fees. There are no additional fees ever. You have access to all of the language translations, et cetera. We there is a fee for becoming a certified so for that 11 hours the two day certification workshop. We do offer continuing education for that based on your discipline, so you'll have to visit our website to see that we offer if you're a psychologist, we offer APA CEE Use, there's, you know, various disciplines have various continuing education credit for it. So it's just the one time education fee. And then ongoingly, there's no, there's no additional fees for empowered relief ever.

Dr. Regina Koepp  55:15  
And people can use it. So from what you're saying people can use it in their private practice, people can use it in their hospitals based system, people could use it in there, wherever they'd like after they get certified.

Dr. Beth Darnall  55:27  
Yeah, that's right, exactly. And for live online delivery, and also in person delivery, we do have a terms of use, and there is there is one restriction where, let's say if somebody wanted to deliver it online inside of some other national program, like a coaching program, or something like that, you do have to receive approval through Stanford University for that type of very broad dissemination, but for local clinicians, within your within your clinic within your healthcare organization. There are no restrictions on on delivery, we want empowered relief to be accessible to clinicians, healthcare organizations, and patients do people bill for this? Some do they do, and we offer a through the certification workshop, we offer example, billing that may people may choose to use, we do not restrict billing, we have, you know, we empowered relief, we only certify and we don't, we don't restrict whether people charge or not, whether they bill insurance or not. So people have utilized different models. So at Stanford, if you are a patient in the Stanford Pain Management clinic, you have access to empowered really for free, we offer it on a rolling basis. And people can attend that class for free. Other clinicians charge a flat rate for patients to join, they offer national online classes and let's say for $20 patients can go on, it's about the same as a copay, they go on they register and and they and their family can attend the class online. Other clinicians choose to bill insurance. And so they're, they're, you know, treating their patients at the local level, and going through the billing process. So it's it's variable. And again, we we do not restrict what how people choose to, to bill or not.

Dr. Regina Koepp  57:47  
What's been the reception from people are who are using empowered relief in their clinics and practices,

Dr. Beth Darnall  57:55  
we have received a tremendous feedback, you know, pain, I'm just thinking of one pain clinic in Canada in particular, they I love what they're doing this is this is the way I believe it should be done is that everybody should have access to empowered relief on day one. So as soon as you join a clinic, you you report having pain, you're invited to the next empowered relief class where you can learn about, you know, all of this information. And so that further D stigmatizes that, because everybody is encouraged to attend, we're not singling people out based on any type of a profile. But their what they tell us is representative of what we're hearing from others, that patients are just so grateful for the information, they love, the participatory focus in learning what they can do to help themselves, and they come away with actionable information that nobody else has presented to them. So they say that patients both really appreciate the class and are benefiting from the class, which you know, is really critical. So it dovetails with what we see in our research as well. So the the community sort of the pragmatic implementation, and the feedback that we're receiving from that matches what we have seen in the research settings as well.

Dr. Regina Koepp  59:39  
I provide psychotherapy, that's kind of what I do. That's my clinical practices with psychotherapy, and I so often will think I wish I had time to just give the person a class I wish it was like I just want to impart some basic information that everybody comes to psychotherapy with and and it seems like that's what empowered relief Does it get it kind of lays the foundation of pain management and treatment and using the I believe you said there were three, there was the neuroscience, mindfulness, and CBT, for chronic pain principles to develop your empowered relief program. And I just think it to your you had mentioned that your wish or how you envision it is that it's used in conjunction with as a sort of conjunction with long term or cognitive behavioral therapy or other evidence based therapies. Are there other evidence based therapies for chronic pain outside of CBT? And what you're doing with empowered relief?

Dr. Beth Darnall  1:00:47  
Yes, excuse me. And in 2018, I published a book on this topic through the American Psychological Association press. It's called psychological treatments for patients with chronic pain. And I overview in that text, all of the evidence based treatments, so we've touched on several of them today, there is self management, that can be peer lead, or expert lead. We've talked about multisession, structured cognitive behavioral therapy for chronic pain, act based treatments for chronic pain act, of course, being a variant of cognitive behavioral therapy, mindfulness based skills. Treatment is also evidence based, really nice evidence there. And then there are various techniques such as hypnosis, or biofeedback, all of these treatments, typically requiring multiple sessions and working with a trained therapist or clinician, but I review sort of the broader scope of evidence based treatments for chronic pain and that text. 

Dr. Regina Koepp  1:02:08  
oh, great, thank you, I just want to also give a disclaimer, I have no affiliation with empowered pain, and, and so and neither does the Center for Mental Health and Aging. But I'm just delighted to hear of a program that has evidence based, that's a sort of classroom accessible option for people living with pain, and some clinics are offering it for free like Stanford, some, I'm really excited to see what comes of the Phoenix VA, part of your study, because so many programs get rolled out at the VA. And so will, you know, for some mental health and behavioral health programs, when the VA approves them, you know, lots of people within the VA system can get trained, and I hope since this has evidence, and it's so accessible, that that that happens for you all. Thank you. Thank you, and especially for a veteran population that has high need and is 50% older adults. Well, I want to just thank you so much, Dr. Darnell, for your time and your expertise and your willingness to just come here and share all of this. With us. Where can people learn more about empowered relief? And you?

Dr. Beth Darnall  1:03:22  
Oh, thank you, yes, empowered relief, you can visit our website. This is four. This is the clinician certification website, so you can learn about the workshops if you're interested. And that's it. unpowered relief.stanford.edu are pretty easy to find online. And I'm also pretty easy to find online. I do welcome questions from people. So you can ask you can find me at Beth darnell.com. And there is a contact Beth field there that comes to me. So if you have questions about anything that we talked about today or anything else about chronic pain and older adults, I definitely welcome the contact.

Dr. Regina Koepp  1:04:12  
Thank you one last question, any harm or downside with empowered relief?

Dr. Beth Darnall  1:04:18  
Not that we know of we have conducted multiple randomized controlled trials and we do not have any adverse events recorded. Nor have I heard of any adverse events with the clinical implementation. 10s of 1000s of patients have been have received empowered relief now. Again, from about 350 certified instructors and I've been delivering the intervention for about close to 10 years now without any without us recording any adverse events.

Dr. Regina Koepp  1:05:01  
Well congratulations. And thank you so much again for being here and sharing this wisdom and research with us. So for empowered relief, the links that you shared your your APA book and some of the references that you cited, we'll link to those in the show notes as well.

Dr. Beth Darnall  1:05:20  
Terrific. Thank you. Well, it's really been delightful and I've really enjoyed sharing my work with with you and your audience. So thank you for the opportunity.