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BEHAVIORAL HEALTH CONSULTATION FOR PATIENTS WITH PAIN Bridget Beachy, PsyD David Bauman, PsyD
BEHAVIORAL HEALTH
CONSULTATION FOR PATIENTS
WITH PAIN
Bridget
Beachy,
PsyD
David
Bauman,
PsyD
TODAY’S AGENDA
Introductions
Case
Fast facts on chronic pain
The “Trident Approach” for chronic pain in PCBH
WHO WE ARE
Bridget Beachy, PsyD
Director of Behavioral Health for Community Health of Central Washington
Roles include: PCBH clinical, admin, and faculty for FM residency residents and psych interns
David Bauman, PsyD
Behavioral Health Education Director for Central Washington Family Medicine
Roles include: PCBH clinical, core faculty for FM residency, RTD of PCBH psychology internship,
We both live and breathe PCBH and contextual approaches (e.g., Acceptance and Commitment Therapy)
OUR VALUES…
THE WHY
Our why?
To serve patients, providers and the system in a
dignified way using the most up-to-date
behavioral science
Who you are?
Is there anything that you want us to make sure
to address today?
JANE – SOUND FAMILIAR?
Jane is 42 y/o, married mother of 4 children. She and her husband have a strained relationship. Two oldest kids are out of the home, and she has twin 13 y/o boys who both have ADHD. Husband is sole breadwinner. Jane’s parents divorced when she was young, and she grew up having to fend for herself. She met her now husband when she was just 17 y/o and they had their first two kids. After separating and reconciling several times, they had their twins. Although they have problems, she doesn’t see the use in splitting up. She has a few girlfriends, but rarely feels well enough to meet up with them. She does have a dog she adores, but it’s hard to walk him d/t her pain. Jane’s weight has been rising, and now her BMI is in the “severely obese” category. She deals w/chronic low back pain and knee pain. After repeated tests, there does not appear to be structural damage. Jane continues to report she is greatly impaired. She was started on Percocet (opioid) two years ago, with only some relief in her ability to sleep. She is on an SSRI for depression and anxiety symptoms, with little relief. She feels increasingly overwhelmed and is in pain constantly. Denies etoh or drug use; however, she does smoke. She reports it helps her to deal w/her stress.
WHAT IS CHRONIC PAIN?
Acute vs Chronic Pain
Pain lasting longer than 3 – 6 months
Chronic pain
Usually no clear etiology
Musculoskeletal disorders
Muscles, ligaments/tendons, bones and nerves
Localized or generalized
Low back pain
Most common disability
Lumbar degenerative disc disease
30% of people (30-50 y/o)
May or may not cause discomfort
W/o structural abnormality, can still have pain
MORE COMMON FORMS
Joint disease
Arthritis
Rheumatoid arthritis – immune system attacks own cells
Other forms of chronic pain
Chronic fatigue syndrome
Endometriosis
Fibromyalgia
Lupus
Inflammatory bowl disease
Interstitial cystitis
Temporomandibular joint dysfunction
Headaches
Migraines
OTHER FAST FACTS:
Influence of CP on the PC system1,2:
CP is the most common reason for seeking medical attention
Estimated 20-50% of patients seen in PC
Think about that… 20-50%
Current treatments: only about 30% reduction in pain levels3
However, partial reduction in pain can significantly improve patient’s QOL4
Demand for opioid intervention
Lacking of long-term benefit and sx/QOL improvement; increase in serious risk of harm5,6
Recommended CP tx by multidisciplinary team7
Medications should NOT be sole focus of treatment8
LIFESTYLE FACTORS ASSOCIATED
W/ CHRONIC PAIN
Tobacco use
Higher levels of smoking = higher level of pain & less
physical involvement9
Depression (similar pathways – emotion & pain)
4x’s higher rate of having disabling pain
Greater pain intensity10
Overweight or Obese11
What came first?
About that comorbidity thing..
TRIDENT APPROACH TO CHRONIC PAIN
Direct interventions with patients
Supporting/upskilling the PCPs
Supporting the entire system
TRIDENT APPROACH TO CHRONIC PAIN
Direct interventions with patients
Supporting/upskilling the PCPs
Supporting the entire system
INTERVENTIONS
Before we get into interventions…
Philosophies of treating chronic pain
Focus on symptom reduction
Medications
Lifestyle changes
Focus on reengaging in life while having pain
Maybe we can do both…
Also, importance of validating someone’s experience
Need to develop the patient’s perspective
Contextual Interview
CONTEXTUAL INTERVIEW LOVE, WORK, PLAY & HEALTH BEHAVIORS; 3 T’S
LOVE Living Situation
Relationship
Family
Friends
Spiritual, community life?
Work/School Work/school situation
Play Fun/Hobbies
Relaxation
Health Behaviors Exercise
Sleep
Substance use (alcohol, drugs, cigarettes, caffeine)
Sex
Diet, supplements, medications?
3 T’s Time, Trigger, Trajectory
YOUR CHRONIC PAIN
TOOL BOX
BH interventions aiming to reduce pain
Pacing activities
Lifestyle changes
Sleep
Diet
Reducing substance use
Losing weight
Improving physical activity
Addressing emotional comorbidities
Gate control theory of pain
Relaxation/mindfulness exercises
Paradox of trying to stop feeling pain
NEEDS WHEN WORKING WITH CHRONIC
PAIN
Nutrition Encourage fresh foods, four light meals per day, avoid eating while watching
television
Exercise Short walks throughout the day, on a regular basis; gentle stretching exercises
twice daily
Enjoyment Encourage social activities, exploration of hobbies, participation in activities
that provide a sense of accomplishment
Don’t smoke or drink Avoid, reduce or stop use of tobacco and alcohol; cultivate other relaxation
activities
Sleep Learn to relax intermittently throughout the day and prior to bed; keep a regular
wake and sleep time; learn to soften / relax when experiencing pain in bed
INTERVENTIONS
BH interventions Re-engagement in life
Determining workability of solely focusing on pain
reduction
Developing a list of how you tried to control/rid self of pain
Short-term success
Long-term success
Where does their life fit in?
Can we invite pain to be part of our story?
(Willingness)
INTERVENTIONS
Values – “Do you have pain, or does pain have you?”
True North
Bull’s eye
85th Birthday/Retirement party
Mindfulness
TEAMS are ever changing
Leaves on the stream
Clouds in the sky
Data on the computer
Defusion
Who’s in charge – your TEAMS or “you?”
ADDITIONALLY…
The impact of pain on the individual…
When we ask patients with pain to describe
themselves…
Worthless… burden… broken…
We need to emphasize compassion/kindness/love
to these patients
Love isn’t everything, it is the only thing. – Steven
Hayes
Intentional acts of kindness and compassion… tap on
chest…
TRIDENT APPROACH TO CHRONIC PAIN
Direct interventions with patients
Supporting/upskilling the PCPs
Supporting the entire system
SUPPORTING/UPSKILLING PCPS
Co-visits
Shared medical group visits
Document functioning of patient
Document functional goals of patient on opioids
Risk assessment for opioids
TRIDENT APPROACH TO CHRONIC PAIN
Direct interventions with patients
Supporting/upskilling the PCPs
Supporting the entire system
SUPPORTING THE ENTIRE SYSTEM
Crucial role in pain contracts
Group visits
Risk assessment
Pain pathway
Initial
Annual
As requested by patient or PCP
SO, THINK ABOUT WHAT YOU’D DO WITH
JANE…
Jane is 42 y/o, married mother of 4 children. She and her husband have a strained relationship. Two oldest kids are out of the home, and she has twin 13 y/o boys who both have ADHD. Husband is sole breadwinner. Jane’s parents divorced when she was young, and she grew up having to fend for herself. She met her now husband when she was just 17 y/o and they had their first two kids. After separating and reconciling several times, they had their twins. Although they have problems, she doesn’t see the use in splitting up. She has a few girlfriends, but rarely feels well enough to meet up with them. She does have a dog she adores, but it’s hard to walk him d/t her pain. Jane’s weight has been rising, and now her BMI is at 39. She deals w/chronic low back pain and knee pain. After repeated tests, there does not appear to be structural damage. Jane continues to report she is greatly impaired. She was started on Percocet two years ago, with only some relief in her ability to sleep. She is on an SSRI for depression and anxiety symptoms, with little relief. She feels increasingly overwhelmed and is in pain constantly. Denies etoh or drug use; however, she does smoke. She reports it helps her to deal w/her stress.
QUESTIONS/COMMENTS YouTube channel:
https://www.youtube.com/channel/UCR_hf_LGVtUOoLa_KFvqvtQ
REFERENCES
1. Elliott AM, Smith BH, Penny KI, et al. The epidemiology of chronic pain in the community. Lancet 1999; 354:1248.
2. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA 1998; 280:147.
3. Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet 2011; 377:2226.
4. Farrar JT, Young JP Jr, LaMoreaux L, et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001; 94:149.
5. Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
6. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015; 162:276.
7. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015; 350:h444.
8. Institute for Clinical Systems Improvement. Health care guideline: Assessment and management of chronic pain. Fourth edition November 2009. http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline_.html (Accessed on December 09, 2010).
9. Weingarten, TN, Moeschler, SM, Ptasynski, AE, Hooten, WM, Beeebe, TJ, Warner, DO. An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain. Pain Physician 2008; 11: 643-653.
10. Arnow, BA, Hunkeler, EM, Blasey, CM, Lee, J, Constantino, MJ, Fireman, B, et al.. Comorbid depression, chronic pain, and disability in primary care. Psychosomatic Medicine 2006; 86(2): 262-268.
11. Janke, EA, Collins, A, Kozak, AT. Overview of the relationship between pain and obesity: What do we know? Where do we go next? Journal of Rehabilitation Research and Development 2007; 44(2): 245-262.
