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transcript
The How and the What of Behavioral Health Intervention for Pain in a Medical Setting
6th Annual Montana Pain Initiative ConferenceUniversity of Montana
5/31/2014
Patrick Davis, PhDMontana Spine & Pain Center
Providence Health and Services St. Patrick Hospital
Missoula, MT
Conflict of Interest Disclosure
Has no real or apparent conflicts of interest to report.
Patrick Davis, Ph.D.
Why
Jenson & Turk (2014) Inadequacy of purely biomedical
treatments Demonstrated efficacy of behavioral
health interventions Behavioral health intervention for
chronic pain is a model for behavioral health intervention for other chronic health conditions
Stranger in a Strange Land
Role Clarity
Specialty Mental Health Professionalor
Primary Care Behavioral Health Consultant
Resources The Primary Care Consultant: The Next Frontier for Psychologists
in Hospitals and Clinics – James & Folen (Eds.) American Psychologist Special Issues
▪ Chronic Pain and Psychology (2014) ,Vol 69, No. 2▪ Primary Care and Psychology (2014), Vol 69, No. 4
When in Rome
Continuing Education A & P, etc.
Treatment Team Meetings Stay above the fray - Don’t form alliances
Documentation Rules: Abbreviations, Content consistent with procedure and diagnostic coding Timely, Legible, Brevity Action Oriented Balance of patient privacy and team need to know (minimum necessary rule)
Flexibility Schedule Practice habits
Ethical Differences Multiple relationships Patient autonomy v. Paternalism/non-maleficence
Laws in the House of God1. GOMERS DON'T DIE.2. GOMERS GO TO GROUND3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE
YOUR OWN PULSE.4. THE PATIENT IS THE ONE WITH THE DISEASE.5. PLACEMENT COMES FIRST.6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED
WITH A #14G NEEDLE AND A GOOD STRONG ARM.7. AGE + BUN = LASIX DOSE.8. THEY CAN ALWAYS HURT YOU MORE.9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.10.IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.11.SHOW ME A BMS (Best Medical Student, a student at the Best Medical
School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.12.IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE
A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.13.THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING
AS POSSIBLE.
But Seriously
1. Schedules are merely guidelines and aspirational.
2. Notes need to be completed on the same day that the service is provided whenever possible and no later than the following business day
3. You may have to provide referring providers with the language they need to ask you meaningful questions
4. If it takes more than one minute to read or explain your clinical impressions you will lose your audience
5. Be prepared for the warm handoff
6. Learn to translate medical jargon to street speak for patients
7. Ask the patient if they understand what the physical medicine provider told them
8. Clarify misconceptions
Primary Care CompetenciesReport of the Interorganizational Work Group
on Competencies forPrimary Care Psychology Practice
March 2013
6 broad core competency domains
Science Systems
Professionalism Relationships Application Education
Health & Behavior Codes
Who is eligible to use these codes? Psychologists, nurses, licensed clinical social workers, and
other non-physician health care clinicians whose scope of practice permits can bill the codes. Physicians performing similar services should use Evaluation and Management codes.
Focus of assessment not on mental health but rather on biopsychosocial factors important to physical health problems and treatment
Focus of intervention is to improve the patient’s health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems
Health & Behavior Codes
96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face with the patient; initial assessment.
96151 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face with the patient; re-assessment.
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual.
96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients).
96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present).
96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present).
PAIN
Relevant Clinical Characteristics Childhood Sexual Abuse Adverse Childhood Experience (ACE) Study Suboptimal Attachment Dynamics Adverse Adult Experience Pain Behavior Attentional Bias/Somatic Focus Anxiety Depression Affective Distress in Response to Pain Catastrophizing Fear/Avoidance Low Self Efficacy Irrational Pain-Related Beliefs Characterological Negative Affectivity/Type D Personality Psychosocial Stress Deficient or Maladaptive Coping Strategies Tobacco Dependency Suboptimal Sleep Neuroplastic Change Posture Muscle Tension
Childhood Sexual Abuse
Norms in the general population 15-25% of females and 5-15% of males
▪ Finkelhor (1994)
Wurtele et al (1990) 39% of women & 7% of men seeking services for chronic pain
Finestone et al (2000) 69% of women in group therapy for survivors of childhood sexual
abuse v. 43% of combined control groups (psychiatric outpatients & nurses) reported chronic pain
Raphael & Widom (2011) Childhood abuse/neglect is associated with future chronic pain only
when PTSD is also present. Recommendation for assessment to “focus on PTSD rather than broad inquires into past history of childhood abuse or neglect”
Adverse Childhood Experience Schofferman et al (1992)
85% of patients reporting 3/5 types of childhood trauma had surgery failure v. 5% of those reporting 0/5 ▪ Sexual, physical, and/or emotional abuse, abandonment, and
parental substance abuse
ACE Study Emotional abuse, physical abuse, sexual abuse,
emotional neglect, physical neglect, parental separation, domestic violence, substance abuse, mental illness, prison
▪ http://acestudy.org/▪ http://www.cdc.gov/ace/index.htm
Attachment
Insecure Attachment Elevated prevalence of chronic widespread pain▪ Davies, Macfarlane, McBeth, Morriss, & Dickens, 2009)
Increased pain reporting and pain-related suffering among individuals with chronic pain ▪ McDonald & Kingsbury, 2006; McWilliams, Cox, & Enns, 2000;
Meredith, Strong, & Feeney, 2007
Higher health care utilization among chronic pain patients▪ Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003
Associated with a proclivity to catastrophize about pain▪ Kratz, Davis, & Zautra, 2011
Adverse Adult Experience
Trauma 66%-88% comorbid chronic pain in war veterans with PTSD ▪ Poundia et al (2006); Shipherd et al, (2007)
As much as 75% of torture victims develop chronic pain▪ Olsen et al (2007)
Trauma Onset FMS, RA▪ Hauser et al (2013): PTSD/FMS▪ Boscarino et al (2010): PTSD/RA
Stress▪ Khasar et al (2009): Cortisol and epinephrine cause intracellular
signal pathway changes in primary afferent nociceptor resulting in enhanced nociceptive signaling
Pain Behavior
Verbal: expressions of hurting; moaning, sighing, etc.
Non-verbal: limping, rubbing, grimacing, use of a cane, etc.
General activity level
Consumption of medications and use of other devices to control pain
Fordyce, W.E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby
Sanders, S.H. (2002). Operant conditioning with chronic pain: back to basics. In D.C. Turk & R.J. Gatchel (Eds.), Psychological approaches to pain management: a practitioner’s handbook. (pp. 128-137) New York: Guilford
Villemure & Bushnell (2009) Attentional Bias/Somatic Focus Anxiety Depression Affective Distress in Response to Pain
Provides a partial review of the literature demonstrating the impact of attention and mood on pain perception
MRI findings suggest that separate neuro-modulatory circuits underlie emotional and attentional modulation of pain
Catastrophizing
Seminowicz & Davis (2005)
Cites studies finding an impact of catastrophizing on pain intensity, disability, difficulty disengaging from pain, and predicting post-surgical pain levels
fMRI results demonstrated negative correlation between catastrophizing scores and activity of prefrontal cortical regions implicated in top down modulation of pain
Fear Avoidance
Vllaeyen & Linton (2012) Fear-avoidance model of chronic
musculoskeletal pain: 12 years on, PAIN, 153 (2012) 1144–1147
Low Self-Efficacy
Bandura (1977) Efficacy expectations determine how much effort people will expend
and how long they will persist in the face of obstacles and aversive experiences
A ‘‘resilient self belief system’’ whereby ‘‘people who believe they can exercise control over potential threats do not conjure up apprehensive cognitions and, hence, are not perturbed by them’’
Nicholas (2007) Brief summary of pain literature relevant to construct of self-efficacy▪ Treatment dropout▪ Pain behaviors▪ Work status▪ Medication use▪ Pain interference in daily behaviors
Author of the Pain Self-Efficacy Questionnaire (PSEQ)
Irrational Pain-Related Beliefs People are helpless to do anything about their pain People should not have to experience pain Pain is unacceptable The healthcare system can and should eliminate pain Pain makes it impossible to have a decent quality of life Life will just have to be on hold until pain goes away People who experience pain and physical limitations are worthless Pain always means the body is being damaged Pain means that it is not safe to exercise Increasing physical activity will cause increased pain Stress and emotions have nothing to do with pain Medication is the only effective treatment for pain Medication is the most effective treatment for pain
Cook & DeGood (2006): Cognitive Risk Profile for Pain (CRPP)
Characterological Negative Affectivity/Type D Personality
A tendency to experience negative emotions (e.g., anger, anxiety, sadness) across time and situations Barnett et al (2009) Type D personality and chronic
pain: construct and concurrent validity of the DS14
Melzack & Wall (1982). The Challenge of Pain
Janssen (2002) Negative affect and sensitization to pain
Negative Emotions
Negative emotions are associated with increased activation in the amygdala, anterior cingulate cortex, and anterior insula
These brain structures not only mediate the processing of emotions, but are also important nodes of the pain neuromatrix that tune attention toward pain, intensify pain unpleasantness, and amplify interoception (the sense of the physical condition of the body).
Thus, when individuals experience negative emotions like anger or fear as a result of pain or other emotionally salient stimuli, the heightened neural processing of threat in affective brain circuits primes the subsequent perception of pain
Psychosocial Stress
McFarlane (2007) Multiplicity of pathways between stress and
musculoskeletal pain▪ Posttraumatic body memory▪ Chronic HPA axis activation▪ Impact on CNS sensitization
Vachon-Presseau et al (2013) The overall portrait is that prolonged pain may
constitute an allostatic load in individuals showing more stress vulnerability, inducing long-lasting plastic changes that in turn instigate a spiraling down of the patient’s condition
Deficient/Maladaptive Coping Strategies
Riley & Robinson (1997) Revision of the Coping Strategies Questionnaire
(CSQ-R) Original CSQ conceived by Rosenstiel and Keefe 6 Scales▪ Distraction▪ Catastrophizing▪ Ignoring Pain▪ Distancing▪ Cognitive Coping▪ Praying
Tobacco Dependency
Behrend et al (2013) 5333 patients with spinal-related pain:▪ “As a group, those who had continued smoking during
treatment had no clinically important improvement in reported pain.”▪ “Compared with patients who had continued to smoke,
those who had quit smoking during the course of care reported significantly greater improvements in pain.”
Suboptimal Sleep
Cooperman et al (1934) Moldofsky et al (1975 & 1976) Roehrs et al (2006) Davies et al (2008) Okfuji & Hare (2011)
Sleep deprivation, and particularly lack of Stage 4 and REM sleep results in▪ Increased pain sensitivity▪ Increased musculoskeletal tenderness▪ Reduced pain tolerance▪ Reduced effectiveness of pain medication
Better sleep is associated with recovery from chronic widespread pain
Sleep Apnea – Epworth Sleepiness Scale
Neuroplastic Change
Seminowicz et al (2013) An 11-week CBT intervention for coping with chronic pain
resulted in increased GM volume in prefrontal and somatosensory brain regions, as well as increased dorsolateral prefrontal volume associated with reduced pain catastrophizing. These results add to mounting evidence that CBT can be a valuable treatment option for chronic pain
Zeidan, F., et al (2012) Reviews the growing literature documenting the benefits of
mindfulness meditation for reducing pain The data indicate that, like other cognitive factors that
modulate pain, prefrontal and cingulate cortices are intimately involved the modulation of pain by mindfulness meditation
Posture
Poor posture creates imbalances in the body in which some muscles are overworking and others are not doing their job
This creates stress on the joints, excessive tension in some muscles, deconditioning in other muscles and over time, leads to pain
Situational/Chronic Muscle Tension
Pretty much a no-brainer, but just for example:
Klinger et al (2010) Classical conditioning model of chronic muscle
tension Found that tension-type headache and low back
pain patients demonstrated a higher number of both conditioned and unconditioned muscle tension reactions in response to exposure to an aversive stimulus (electric shock)
Assessment
Pain
Numerical Analogue Scale (NAS) 0-10
McGill Pain Inventory –Short Form Sensory and Affective Dimensions
Multidimensional Pain Inventory Pain Severity Subscale
Psychosocial Factors Commercial Instruments
MMPI-2-RF Millon Behavioral Medicine
Diagnostic (MBMD) Pain Patient Profile (P3) Battery for Health Improvement -2
(BHI-2) Multidimensional Pain Inventory
(MPI)
Psychosocial Factors Non-Commercial Instruments
Hospital Anxiety and Depression Scale (HADS) Pain Catastrophizing Scale (PCS) Tampa Scale of Kinesiophobia (TSK) Chronic Pain Acceptance Questionnaire (CPAQ) Psychological Inflexibility in Pain Scale – 12 Item version
(PIPS-12) Pain Stages of Change Questionnaire (PSOCQ) Pain Self-Efficacy Questionnaire (PSEQ) Cognitive Risk Profile for Pain (CRPP) Screener for Opioid Addiction in Pain Patients – Revised
(SOAPP-R) Opioid Risk Tool (ORT) Epworth Sleepiness Scale and associated Snoring Scale
Treatment
Wall of Fame
Treatment Models
4 broad model of behavioral health intervention Jensen & Turk (2014)▪ Operant Models▪ Peripheral Physiological Models▪ Cognitive and Coping Models▪ Central Nervous System Neurophysiological Models
The Psychodynamic Perspective▪ Freud▪ Sarno