A Six-Session Evidence-Based Protocol for the Treatment of Individuals with Chronic Pain in a

Primary Care Setting

Abigail Lockhart, PsyD, Postdoctoral Psychology Fellow

Laurie Ivey, PsyD, Clinical Psychologist

Samantha Monson, PsyD, Clinical Psychologist

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #A3aFriday, October 17, 2014

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe a brief six-session individual treatment intervention that can be implemented by Behavioral Health Providers in integrated care settings.

• Describe how to facilitate improved communication with the patient’s PCP and other PCMH treatment providers in order to promote collaborative models of care.

• Identify strategies for recruiting patients in primary care.

• Describe how to support patients develop sustainable life changes after the six sessions are complete.

Bibliography / ReferencesCarlson, M. (2014). CBT for Chronic Pain and Psychological Well-

Being: A Skills Training Manual Integrating DBT, ACT, Behavioral Activation and Motivational Interviewing. John Wiley & Sons.

McCracken, L. M., Sato, A., & Taylor, G. J. (2013). A trial of a brief group-based form of acceptance and commitment therapy (ACT) for chronic pain in general practice: pilot outcome and process results. The Journal of Pain, 14(11), 1398-1406.

McCracken, L.M., & Vellman, S.C. (2010). Psychological flexibility in adults with chronic pain: A study of acceptance,

mindfulness, and values-based action in primary care. Pain, 148: 141-147.Vowles, K.E., & Thompson, M. (2011). Acceptance and Commitment Therapy for chronic pain. In L.M. McCracken (Ed.)

Mindfulness and acceptance in behavioral medicine: Current theory and practice (pp. 31-60). Oakland: New Harbinger Press.Wetherell, J.L. et al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive- behavioral therapy for chronic pain. Pain, 152: 2098-2107.

Learning Assessment

• A learning assessment is required for CE credit.

• Question and answer opportunities will be incorporated throughout this presentation.

Condition Number of Sufferers Source

Chronic Pain 100 million Americans Institute of Medicine of The National Academies (2)

Diabetes 25.8 million Americans(diagnosed and estimated undiagnosed)

American Diabetes Association (3)

Coronary Heart Disease(heart attack and chest pain)Stroke

16.3 million Americans

7.0 million Americans

American Heart Association (4)

Cancer 11.9 million Americans

American Cancer Society (5)

Prevalence of Chronic Pain

American Academy of Pain Medicine, Get the Facts on Pain - http://www.painmed.org/patientcenter/facts_on_pain.aspx

Pain is a significant public health problem that costs society at least $560-$635 billion annually

Institute of Medicine Report: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011

Worldwide, up to 22% of primary care patients suffer from chronic debilitating pain*

53% of chronic pain patients treated on an ongoing basis are treated by primary care physicians*

* By the Numbers: Pain Management and Primary Care Published Online: Wednesday,

June 27th, 2012. www.painlive.com

Stats

Nearly 15,000 Medicaid patients in Colorado had one or more of those traits in the year analyzed, which put them at a risk of overdose from 9- 14 times higher, depending on the trait exhibited

At least 1 of those traits showed up in 174 Medicaid patients who overdosed in the year studied

556 beneficiaries, 15 of whom overdosed, had all 3 traits

Colorado Medicaid Study

Evidence Base• “When added to usual care, both ACT and CBT can improve pain

interference, depression, and pain-related anxiety in individuals with chronic pain.”

Wetherell, J.L. et al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. PAIN, 152:

2098-2107.

Standardized instruments

1. Brief Pain Inventory (Short Form)

2. PHQ-9

3. GAD-7

Intra-patient data collection

Collaborative Model of Pain Management

CULTUREPATIENTPAIN

PARTNERS

PROVIDER

Perspective of letting the patient be the guide to ensure productive outcome

Facilitation of communication amongst the team

PATIENT PARTNERSHIP

PATIENT

PROVIDER

Helpful when providers partner (decreases dread) Co-consult with patient beginning, middle, end Intervention most effective if physician partners Reinforcing skills AMAP Checking in with patient on what is most helpful Supportive partnership/stance in

decreasing/maintaining medications or eliminating opiates—holding the Rx line!

PROVIDER PARTNERSHIP

1. What do you think caused(s) the pain (problem)?2. Has anyone else helped you with this pain (problem)? How so?3. Are there things that help you that our doctors don’t know

about?4. What kind of treatment do you think you should receive?

Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2)

CULTURAL PARTNERSHIP

CULTURE

Through attuned questioning, you may find…

…pain = distress (e.g., trauma response).

CULTURAL PARTNERSHIP

CULTURE

Introduce 6 session outline Partnership Goals, including goals of the intervention: To develop

a curiosity for engaging with pain in an alternative way Screening Tools

1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-74. Culture Questions5. Assess physician/team relationships & lay framework for team

Review BPI with patient, focus on how pain is interfering with the patient’s functioning

Discuss difference between acute pain and chronic pain Homework – Complete Valued Living Questionnaire

Session 1

Introduce 6 session outline Partnership Goals, including goals of the intervention: To develop

a curiosity for engaging with pain in an alternative way Screening Tools

1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-74. Culture Questions5. Assess physician/team relationships & lay framework for team

Review BPI with patient, focus on how pain is interfering with the patient’s functioning

Discuss difference between acute pain and chronic pain Homework – Complete Valued Living Questionnaire

Session 1

1. Relay culture question answers

2. Medication goals (maintenance, decrease, other)

Shared Pain Management Plan:

Session 1

Review Valued Living QuestionnaireDevelop functional goals based on individual responses on

Valued Living Questionnaire

MIND/BODY CONNECTIONNegative emotions and pain – pathways intersect in the

brainA-B-C Model

How you think about pain, it is the way you are going to feelWhat are your beliefs about pain?

What can you do to help?Keep your mind busy, Self-talkExplore thoughts and emotional reactions to sensations in

the body – Introduce body scan Homework – Body scan

Session 2

Review Valued Living QuestionnaireDevelop functional goals based on individual responses on

Valued Living Questionnaire

MIND/BODY CONNECTIONNegative emotions and pain – pathways intersect in the

brainA-B-C Model

How you think about pain, it is the way you are going to feelWhat are your beliefs about pain?

What can you do to help?Keep your mind busy, Self-talkExplore thoughts and emotional reactions to sensations in

the body – Introduce body scan Homework – Body scan

Session 2

1. Values

2. Functional goals

Shared Pain Management Plan:

Session 2

Screening Tools1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-7

Gate Control Theory of Pain Current stressors that may exacerbate pain Role of sleep in the management of chronic pain

Discuss Sleep Hygiene and provide handout Adaptive vs. Maladaptive Coping Skills

Evaluate beliefs about medications, opiate use, illicit drug use What adaptive coping skills are you already using? Review “A-B-C’s” (Adding Pleasure, Building Mastery, Coming Back to

the Present Moment) Homework - Pleasant and unpleasant events calendar

Session 3

Screening Tools1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-7

Gate Control Theory of Pain Current stressors that may exacerbate pain Role of sleep in the management of chronic pain

Discuss Sleep Hygiene and provide handout Adaptive vs. Maladaptive Coping Skills

Evaluate beliefs about medications, opiate use, illicit drug use What adaptive coping skills are you already using? Review “A-B-C’s” (Adding Pleasure, Building Mastery, Coming Back to

the Present Moment) Homework - Pleasant and unpleasant events calendar

Session 3

1. Barriers Identified

2. Plan to address

Shared Pain Management Plan:

Session 3

Review pleasant events scheduling homeworkDiscuss barriers

Increasing Positive ExperiencesNutrition

What foods should be avoidedDrink recommended amount of waterAvoid alcohol and nicotine

ExerciseDiscuss current activity level and explore barriersWhy exercise helps Alternative ways to be active

Homework – Build in at least one new activity to pleasant events calendar

Session 4

Review pleasant events scheduling homeworkDiscuss barriers

Increasing Positive ExperiencesNutrition

What foods should be avoidedDrink recommended amount of waterAvoid alcohol and nicotine

ExerciseDiscuss current activity level and explore barriersWhy exercise helps Alternative ways to be active

Homework – Build in at least one new activity to pleasant events calendar

Session 4

1. Gains/Positive experiences to date

Shared Pain Management Plan:

Session 4

Review new activity homework, address barriers

RELAXATION Why relaxation helps Review and practice relaxation strategies

Diaphragmatic breathing Guided imagery CALM exercise

BUILDING NETWORK OF SUPPORT Tree of support exercise

Homework – Schedule time to practice relaxation strategies

Session 5

Review new activity homework, address barriers

RELAXATION Why relaxation helps Review and practice relaxation strategies

Diaphragmatic breathing Guided imagery CALM exercise

BUILDING NETWORK OF SUPPORT Tree of support exercise

Homework – Schedule time to practice relaxation strategies

Session 5

1. Additional gains

2. Ongoing support team & plan for future

Shared Pain Management Plan:

Session 5

Review homework Final session screenings

1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-7

SUSTAINING CHANGE Create plan for addressing barriers to sustaining change

(e.g., flare-ups and bad days) How to involve your network of support How to utilize your PCP

Homework – Talk to at least one person in your support network about how they can help you stay on track

Session 6

Review homework Final session screenings

1. Brief Pain Inventory (Short Form)2. PHQ-93. GAD-7

SUSTAINING CHANGE Create plan for addressing barriers to sustaining change

(e.g., flare-ups and bad days) How to involve your network of support How to utilize your PCP

Homework – Talk to at least one person in your support network about how they can help you stay on track

Session 6

1. Additional gains

2. Ongoing support team continued….

Shared Pain Management Plan:

Session 6

I have worked with a number of different mental health providers and no one has ever asked me about my pain.*

By asking me to participate in this intervention, you really validated my pain and how much it impacts my health.*

• Paraphrased from patient interactions

Pearls combat Dread

Patient Pearls

Managing Pain Before It Manages You, 3rd Edition by Margaret Caudill, MD, PhD, MPH

Get Out of Your Mind and into Your Life: The New Acceptance and Commitment Therapy by Steven Hayes, PhD

Resources for Patients

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!