4.6 Empowered Relief: An Evidence-Based One-Session Pain Relief Skills Intervention

By Beth D. Darnall, PhD (The creator of Empowered Relief®, which is owned by Stanford University, California (trademarked and copyrighted). Stanford receives fees from Empowered Relief® clinician certification workshops.)

The Problem of Pain. Chronic pain impacts more people than diabetes, cancer, and heart disease combined. Across health conditions, pain is the primary reason people seek medical care and costs Australia about $144 billion each year. (Pain Australia) Across disease conditions, chronic pain (>3 months) is the leading cause of work-related disability. Moreover, people often have more than one chronic pain condition (i.e., chronic overlapping pain conditions), which compounds suffering, disability, and treatment needs. Pain and disability rates are rising despite increased use of surgery and pharmaceuticals, which can have adverse effects. Minorities, women, older adults, and those of lower socioeconomic status are disproportionately not only impacted by ongoing pain but also experience the greatest barriers to effective pain care. Equitable access to effective pain treatment is an urgent national need.

Thinking Beyond Surgeries and Medications Only: The Need for an Integrated Pain Treatment Approach. The International Association for the Study of Pain (IASP) defines pain as “a negative sensory and emotional experience.”  This is true for all pain conditions, including facial pain and specified conditions such as TN. The definition recognizes that, across varied medical diagnoses, all pain is processed in the central nervous system, where it is also influenced by many factors, including our thoughts, mood, behavior, history, and expectations for pain and treatment, to name just a few. Because pain is influenced by so many factors, it is important that pain treatment address these various factors and “dial down” the intensity of pain. Indeed, although we cannot control our medical diagnoses, we can address some of the factors that influence the severity of our pain, its impacts, and our suffering. This is the opportunity presented by treatments that are referred to as behavioral pain medicine, pain self-management, or pain psychology. With each of these approaches, the treatment focuses on helping people gain an understanding of what they can do to best control their pain and reduce its impacts. In so doing, people gain confidence in their ability to live with greater comfort and control, even within the context of an ongoing painful medical condition. It is important for people to have their pain addressed from an integrated perspective, one that does not rely on medications and surgeries alone but rather considers and targets various aspects of the person and their life (see Figure 4-3).

Figure 4-3. Biopsychosocial model of pain.

Behavioral Pain Treatments: Evidence and Access Barriers. Indeed, decades of clinical science show that evidence-based behavioral pain treatment can reduce chronic pain impacts, improve medical outcomes, and reduce the need for medical treatments for pain. Owing to the benefits and low risk profiles of behavioral treatments, multiple agencies in the U.S. have called for broad integration of such treatments into national pain care pathways. Cognitive Behavioral Therapy (CBT) for chronic pain is the best studied behavioral treatment for chronic pain and is sometimes referred to as the “gold standard” behavioral pain treatment. Over the course of eight or more 2-hour individual or group sessions (16 hours of total treatment time), CBT attendees learn a variety of pain management skills and information. Attendees apply the information and skills by setting personal goals and creating daily action plans. Research suggests clinically meaningful benefits across a range of symptoms (pain intensity, physical function, pain-related distress, depression, sleep disturbance), with positive results lasting 6 months or more, There are other evidence-based behavioral pain treatments, including Acceptance and Commitment Therapy (ACT) (a variant of CBT), emotional awareness and expression therapy, and Mindful-Based Stress Reduction (MBSR). Although often effective and low to no risk, these treatments can be infeasible for many people because of time, costs, and lack of availability. In addition, some patients neither want, nor require, 16 or more hours of treatment time. As a clinical psychologist, I grew tired of seeing patients unable to conveniently access the care they needed and wanted. I created Empowered Relief® to provide broad patient access to effective, low-burden behavioral pain treatment.

Empowered Relief®: One-Session Pain Relief Skills Intervention Improves Patient Access. Empowered Relief® is a one-session pain relief skills intervention for people with acute and chronic pain of all types. The 2-hour intervention is delivered by certified clinicians to groups of patients either in person or online via Zoom or another conference platform. Empowered Relief® is not therapy; it is a class. Its content includes pain neuroscience education; participants acquire three core pain management skills and complete a personal plan for empowered relief (Table 4-1). These pain relief skills are rooted in mindfulness principles and CBT skills.

Table 4-1. What Is Empowered Relief?

• One-session pain relief skills class
• Delivered by a certified clinician
• Can be received online or in person
• 2 hours in duration
• Class content includes pain neuroscience education, experiential exercises, three core pain management techniques, development of a personalized plan for empowered relief, and a free binaural app for daily use
• Published data from four randomized controlled studies showed efficacy for pain and symptom relief 3 and 6 months after completion of the class

A U.S. randomized controlled trial of 263 adults with chronic low back pain revealed that single-session Empowered Relief® was of comparable benefit (i.e., not inferior) to 16 hours of CBT at 3- and 6-months posttreatment for reducing pain catastrophizing, pain intensity, pain interference, pain bothersomeness, depression, anxiety, fatigue, physical function, and sleep disturbance. A second U. S. study compared Empowered Relief® received online to usual care in 105 patients with chronic pain receiving care from a pain clinic.  The results revealed high patient engagement and satisfaction, in addition to a similar pattern of reductions in pain intensity, pain interference, pain catastrophizing, pain bothersomeness, anxiety, and sleep disturbance at 3 months posttreatment.

Empowered Relief® for Surgery. Empowered Relief® has been studied in two surgical studies. For these studies, Empowered Relief® was tailored to the surgical context, and a digital version was created to allow patients to receive the intervention conveniently from home or in the hospital after surgery.

Empowered Relief® was first studied in women undergoing breast cancer surgery to compare the digital intervention (then called “My Surgical Success”) to a health education control intervention that involved no active pain relief skills. Women who engaged with My Surgical Success were found to require about one week less of opioids after breast cancer surgery relative to women in the control group, suggesting that Empowered Relief® helped speed the cessation of opioid use after surgery.

We next studied the Empowered Relief® digital intervention in 84 patients receiving orthopedic trauma surgery. The majority of patient participants received their assigned treatment on an iPad in the hospital on postoperative days 1 through 3. Patients who received the digital version of Empowered Relief® reported significantly less pain after surgery relative to controls, and the analgesic benefits lasted up to 3 months later, the last time point of the study. The results suggested that Empowered Relief® imparted clinically meaningful and sustained pain relief after surgery. Moreover, the results underscored the potential for low-cost, low-burden, brief education and pain self-regulatory skills to improve surgical recovery. We are partnering with health care organizations to embed digital and on-demand Empowered Relief® for Surgery into surgical pathways broadly.

Scaling Access to Empowered Relief®. Because its low-burden format requires only one session, Empowered Relief® can help many patients receive behavioral pain care, often conveniently from the comfort of their own home. Brief and home-based pain care can overcome many disparities that prevent people with the least means, and those in rural areas, from receiving the pain care they need.

Since the rollout of certifications in 2019, 1000 certified clinicians are delivering Empowered Relief® in 27 countries, and 8 languages (French, Spanish, German, Dutch, Danish, Italian, and English), with expansions underway. Separate and tailored versions of Empowered Relief® exist across the continuum of care and across the lifespan (Table 4-2). Versions of Empowered Relief® exist for chronic pain and acute/surgical pain, and certification flexibly allows clinicians to deliver either or both versions.

Table 4-2. Tailored Versions of Empowered Relief®

• Adult chronic pain
• Acute and post-surgical pain
• Adults with pain having challenges taking prescription opioids as prescribed
• Active Service Members and Veterans with pain
• Youth with chronic pain

Empowered Relief® is being delivered as “standard care” at multiple health care organizations, meaning that it is offered to every person who reports having ongoing pain. This addresses a common problem in the field: we tend to wait too long to provide behavioral pain care. Now, rather than waiting until people suffer and offering behavioral pain treatment as a last resort when most treatments have failed, Empowered Relief® as standard pain care makes it possible for people to receive this class earlier in their pain journey. Thus, people will become equipped to best help themselves as they navigate the challenges of their diagnosis and the medical system. Organizations that have adopted Empowered Relief® as standard care include The Queen Elizabeth Hospital, Adelaide; Gold Coast Health; Hunters Hill Medical Practice, Sydney; Mother Nature Psychology, Bowral;  Flexible Minds Therapy, Parkwood & Robina QLD and Brite Psychology, Sunshine Coast.  Another benefit of the standard care approach is that it allows organizations and clinics to emphasize the applicability of this intervention to all patients, thereby destigmatizing it and boosting patient interest and engagement.

Research and New Directions. Various investigators are studying Empowered Relief® in different patient populations, such as individuals with chronic migraines and individuals who have experienced an acute back pain episode, to name just two. At Stanford, we are conducting a national comparative effectiveness trial of online-delivered one-session Empowered Relief® versus online-delivered eight-session CBT for individuals with chronic pain of any type (called the PROGRESS study). PROGRESS is a six-site national trial launched in January 2023 that is enrolling a total of 1650 adults from across the United States.  We aim to be able to say which behavioral treatment works best and for whom. The focus of this research is the inclusion of a diverse patient sample, including individuals from different regions, of varied races and ethnicities, with varied pain conditions, and of different economic and educational levels.

How Can I Access Empowered Relief^®?

• Check with your health organization to see if they offer Empowered Relief® within your clinic or at a nearby location. Many organizations offer it at no cost to you; others may bill your insurance company.
• Visit the Empowered Relief® website (https://empoweredrelief.stanford.edu) and check under the “Find a Provider” tab to see if there are certified clinicians in your area.
• Several certified clinicians offer Empowered Relief® online, and you can register for these class offerings regardless of your location.
• If you are a clinician or health care leader who would like to adopt Empowered Relief® in your care setting, please visit the Empowered Relief® website (https://empoweredrelief.stanford.edu) and learn about the clinician certification process.