No Brain, No Gain When Relieving Chronic Pain

By Dirk Hoffman

Research led by Jeffrey M. Lackner, PsyD, professor of medicine and chief of its Division of Behavioral Medicine in the Jacobs School, is looking to expand upon the possibilities CBT holds for treating chronic pain conditions.

As principal investigator on the Irritable Bowel Syndrome (IBS) Outcome Study (2010), the largest clinical trial for IBS the federal government had awarded at the time, Lackner developed treatments to include practical skills training that leverages our understanding of how the brain contributes to persistent pain and how it can be re-trained to relieve its day-to-day burden.

“Taking control of persistent pain symptoms often comes down to learning to challenge and dispute thinking patterns that can aggravate symptoms,” he says. “People with chronic pain — lower back pain, IBS, pelvic pain and other mechanistically similar pain disorders — oftentimes are just dismissed, labeled as headcases, fragile or unmotivated. The more we learn about the science of pain, we find that these labels are not just cruel, they are wrong … chronic pain is far more complicated.

“The pain disorders that are some of the most challenging are neither psychiatric problems nor problems easily explained by physical damage, but develop when the brain’s pain center loses its bearings, becoming hypervigilant and responds disproportionately to sensory input that would not normally register as painful when pain is acute,” Lackner adds. “When the neural circuitry the brain relies on to modulate pain goes awry, it is called central sensitization.”

Modern medicine is very good at treating acute conditions, Lackner notes.

“However, physicians, despite all the powerful interventions and medications and good intentions, really struggle treating chronic pain. It’s a real challenge to see a patient who seems completely normal, but suffers from very real pain for which there is no simple cure or explanation,” he says.

Funded by the National Institutes of Health (NIH), Lackner and his team’s research started with IBS in 2000, but recently found “that this type of behavioral treatment that teaches people to essentially reset brain circuitry by developing a more flexible cognitive style seems to be really important in tackling other chronic pain problems that cluster together and share features of central sensitization.”

The NIH and U.S. Congress has termed these types of problems as chronic overlapping pain conditions (COPC) which represent a new frontier in pain research because they are so prevalent, but are poorly treated and misunderstood.

For example, someone with IBS might also have fibromyalgia or might also have migraine headaches. They might have temporomandibular joint disorders (TMJ) or pelvic pain, all of which have no identifiable pain generator that is identified through diagnostic testing.

“What we found is that if we effectively target a singular COPC like IBS, we see changes in the severity of other COPCs, which suggests they share underlying mechanisms that drive symptom severity,” Lackner says.

“We found in our IBS patients that if we target IBS, we saw not only a significant reduction in the severity of IBS symptoms, but also a significant reduction in the severity of co-occurring centralized pain conditions like back pain, pelvic pain and jaw pain, even though they were not targeted.

“That is important clinically and scientifically because it means you don’t have to treat all of these conditions separately or sequentially, one after another. There may be a transdiagnostic — or across disorders — approach that allows you to target multiple COPCs in a much more efficient and powerful way,” he adds.

Lackner says the potential population of chronic pain patients affected is enormous.

“IBS is the most common GI disorder seen by gastroenterologists and one of the most common seen by primary care physicians. Migraines are one of the most common neurological problems and one of the top causes of disability in the world.

“Nonspecific low back pain is one of the leading causes of pain and disability in the world. When we talk about COPCs, we’re talking tens of millions of people who suffer,” Lackner adds. “The ability to develop transdiagnostic treatment that is brief, low intensity and convenient has game-changing public health implications particularly when they are delivered in novel delivery systems that are more scalable than treatments delivered face-to-face in outpatient settings.”

Lackner was senior co-author on a 2022 joint study between researchers at the University at Buffalo and UCLA that demonstrated for the first time that a specific type of CBT developed at UB that teaches information processing skills can modulate key components of the brain-gut-microbiome axis in some of the most severe IBS patients for whom medication was inadequate.

The study, conceived by an interdisciplinary UB team, shows how a non-drug, non-dietary treatment for IBS induces changes in brain function and in the microbiome by normalizing ways of information processing, he explains.

“This was paradigm shifting for how we understand the role of the microbiome and therapeutics that can modify its composition to treat and prevent disease,” Lackner says.

“What our research suggests is that it’s not some type of physical deficit that maintains these problems, but it’s a cognitive style, a rigid mindset that makes it difficult to deploy the type of flexible coping response that you need respond effectively in stressful situations that can aggravate symptoms.

“If you can teach people a more flexible coping style so they can read their environment better and deploy a coping response the situation calls for, they are able to modulate the stress response and lower the volume of their pain,” he adds.

Josh Briggs, 45, the owner of Past to Present, a furniture refinishing and repair business in Amherst, is a former IBS patient of Lackner’s. He is living proof that CBT can help IBS patients better manage even the most severe GI symptoms.

As a teenager, Briggs says he started to internalize his anxieties, which manifested in digestive issues, along with pain.

He started seeing a doctor who began treating him for Crohn’s Disease after misdiagnosing his ailments.

Briggs continued the Crohn’s Disease treatments for about five years without experiencing any relief from his symptoms until seeking a second opinion from David S. Garson, MD, at Gastroenterology Associates, LLP.

He underwent Garson’s treatment after going through a series of tests and having his condition diagnosed as irritable bowel syndrome. Briggs started taking medications for IBS and the severity of his gut symptoms decreased.

“It got to the point where I thought this isn’t bad anymore, but then around 2009 I became really symptomatic again,” he says. “I began to become more apprehensive of what I was going to eat, where I was going to go — to the point it almost took me down a reclusive path.”

He continues to be under Garson’s expert care, taking medication, but describes it as “a very conservative route.”

Garson recommended Briggs consult Lackner at UB’s Behavioral Medicine Clinic at the Erie County Medical Center in 2010.

Briggs says when he first met with Lackner, a lot of what he said resonated with him, particularly how contemporary science understands IBS as a problem in how the brain and gut communicate.

“The gist of it was really just needing to take a more relaxed approach to life,” he says. “When something happens, you deal with it and move on.”

Briggs says diaphragmatic breathing is just one of the techniques he learned from Lackner that he uses on a regular basis.

“If I feel myself getting amped up, that’s where I’m going to maybe change the music that I listen to and kind of bring myself back to center, using some of those breathing techniques,” he says. “I just shut my eyes and imagine I am in a different place than sitting in a chair and hating life.”

Lackner says another skill Briggs learned was to read his environment more accurately and then pick coping skills that are best suited for the problem at hand. This is called flexible problem solving, a technique Lackner’s team developed that is now regarded as a staple of evidence-based behavioral self-management treatments for IBS.

“Learning practical skills to alter your mindset in a more flexible way that allows you to be resilient across stressful situations that pose different types of challenges — some of those are controllable problems and some are uncontrollable problems,” he says.

Lackner says the CBT coping techniques he developed are about more than just reducing physical tension through relaxation skills — they also involve identifying what the problem is and whether it is fixable or not and then applying the best possible coping response among ones taught in the UB protocol.

“For those problems that are solvable, you want to tackle them and fix them,” he says. “When Josh says he adopted a more relaxed attitude, he is saying one thing he learned is to do a better job of toggling between is it solvable or is it unsolvable?

“It’s more than just dampening muscle tension through relaxation, but actually being able to read your environment better, asking yourself is there something you can do about it and then deploying the best response based on that situation.

“The stress literature has recently put out a lot of evidence that there isn’t any one single coping response that works across different situations. It really depends on someone reading their environment,” he says.

In 2022, Lackner was awarded a $3.3 million NIH grant to conduct a five-year clinical study of drug-free behavioral treatments for chronic pelvic pain in men and women.

He is principal investigator on the study, called the Easing Pelvic Pain Interventions Clinical Research Program (EPPIC). The interdisciplinary study involves a team of researchers from the Jacobs School’s departments of Medicine, Obstetrics and Gynecology, and Urology, as well as UCLA and the University of Michigan.

Chronic pelvic pain encompasses several common, debilitating conditions including interstitial cystitis/bladder pain syndrome in both males and females, and chronic prostatitis/chronic pelvic pain syndrome in males. The symptoms, persistent pelvic pain, pressure or discomfort, frequent urination and urge to urinate, affect millions of Americans who often suffer silently without relief from medical or dietary treatments.

“EPPIC is a landmark NIH clinical trial that leverages what we know about how people who have these nociplastic disorders — centralized pain disorders — that are fueled by the way the brain processes information about painful stimuli,” Lackner says.

The fact that Briggs considers himself to be essentially free of IBS symptoms for the past 12 years is remarkable and is a credit to both his own hard work and the treatment he underwent, Lackner says.

“What he learned is practical skills to take control of the pain — not just handle the fallout — but actually reduce the symptoms that he had not achieved with medications or dietary changes.”

One area of Briggs’ life where he saw a dramatic improvement is the ability to travel.

He stopped traveling after becoming symptomatic and winding up in a hospital emergency room on several trips.

While he was under Lackner’s care, Briggs was scheduled to visit his mother-in-law in Mississippi.

“I was terrified to get on an airplane. I started to go down that rabbit hole again — thinking I am going to get sick,” he says. “The anxiety was huge, but Dr. Lackner talked me through it.

“I was able to make it to Mississippi and I had a wonderful time. It really started to reignite my love for travel and seeing different places again. My wife and I are going to Ireland in the spring.”

Lackner says it all came down to how Briggs perceived threats to his health and chose the best tool in his pain self-management tool belt. 

“He learned to be more flexible in how he processes information and to toggle back and forth and to pivot between situations and to be able to employ the best coping skills.”

Briggs says he really appreciates Lackner’s “down-to-earth approach.”

“I feel like his approach followed my lead. He met me where I was.”

Briggs says he would recommend Lackner’s CBT treatment to anyone whose symptoms have persisted without relief.

“It all comes down to the ability to be open-minded,” he says. “You have to put thought into it.”

Briggs says after his sessions with Lackner he would often go fishing or for a hike in the woods so he could “really process what we had worked on without being distracted.”

“I needed that time to digest things. Without Dr. Lackner, I honestly think I would be stuck in the same old conundrum,” he says.

“He didn’t just help me. He helped me help myself. It changed my life.”