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Living Well with Chronic Living Well with Chronic PainPain
Steve Overman, MD MPHSteve Overman, MD MPHThe Seattle Arthritis ClinicThe Seattle Arthritis Clinic
Northwest Hospital & Medical CenterNorthwest Hospital & Medical Center
DisclosuresDisclosures
• No vested interestsNo vested interests• I brought my back-upI brought my back-up• Contrasting perspectives – public Contrasting perspectives – public
health, PCP, ER doc, health, PCP, ER doc, rheumatologist, insurance medical rheumatologist, insurance medical director, disability advisor, cost-director, disability advisor, cost-containment director, optimist, containment director, optimist, chronic pain & illness manager chronic pain & illness manager …… ……
What’s the evidence?What’s the evidence?
• How should we respond to our How should we respond to our patient’s complaints of pain?patient’s complaints of pain?
• How should we respond if we How should we respond if we perceive our patient manifesting perceive our patient manifesting ‘pain language’ & ‘pain ‘pain language’ & ‘pain behavior’?behavior’?
One StoryOne Story
• My professorMy professor
• Patient storiesPatient stories
• ‘‘Coaching-ship’Coaching-ship’
• Illness as a Illness as a journeyjourney
• Illness as an Illness as an opportunityopportunity
• Phases that recurPhases that recur
Who are our Patients?Who are our Patients?USA PopulationUSA Population
• Pain is the #1 reason for patients Pain is the #1 reason for patients seeing their doctorseeing their doctor
• 20% of population have chronic pain20% of population have chronic pain• 20% of population have arthritis20% of population have arthritis• Musculoskeletal problems accounts Musculoskeletal problems accounts
for 65% CDC reported disabilityfor 65% CDC reported disability
Katz WA Clin Rheum (2002) Katz WA Clin Rheum (2002) (Supple 1) S2-S4(Supple 1) S2-S4www.cdc.gov/arthritiswww.cdc.gov/arthritis
Pain Behaviors?Pain Behaviors?
• What are they?What are they?
• What influences?What influences?
• What do they mean?What do they mean?
““Living Well”Living Well”
•Is this an important goal for Is this an important goal for youryour care? care?
•What does this mean to you and your patient?
•How do we help patients live well?
How do we help our How do we help our patients ‘Live Well’?patients ‘Live Well’?
•UnderstandUnderstand each patient as a each patient as a personperson
•Treat and teach based on Treat and teach based on their their illness dimensions & illness dimensions & phasephase
•Build a systemBuild a system around you around you for managing chronic illnessfor managing chronic illness
Sir William OslerSir William Osler
““It is more important to know It is more important to know
what sort of patient what sort of patient
has a disease has a disease
than what sort of diseasethan what sort of disease
a patient has.”a patient has.”
My OfficeMy Office
• SurveySurvey: : 160 consecutive patients 160 consecutive patients from our community-based, 100% from our community-based, 100% referral practice of rheumatology referral practice of rheumatology were given the one page were given the one page questionnaire asking their interest in questionnaire asking their interest in 12 topics. Patients were not required 12 topics. Patients were not required to complete or sign.to complete or sign.
• Result:Result:Living well with your illness – 75%Living well with your illness – 75%
Managing fatigue - 65%Managing fatigue - 65%
Managing pain - 63%Managing pain - 63%
Why does a person with Why does a person with FMS come to the doctor?FMS come to the doctor?
• Design Design – Comparison of 79 FMS patients to 39 Comparison of 79 FMS patients to 39
community persons with FMS by community persons with FMS by questionnairesquestionnaires
• Assessments - 14 measures that Assessments - 14 measures that produced 6 domains of variables: produced 6 domains of variables: background demographics and pain background demographics and pain duration; psychiatric morbidity; and duration; psychiatric morbidity; and personality, environmental, cognitive, personality, environmental, cognitive, and health status factors.and health status factors.
Kersh BC, .Arthritis Rheum. 2001 Aug;45(4):362-71.Kersh BC, .Arthritis Rheum. 2001 Aug;45(4):362-71.
What ‘predicted’ physician What ‘predicted’ physician visits?visits?
• Predictive VariablesPredictive Variables– High recent stressful events High recent stressful events – Low self-efficacyLow self-efficacy– Negative affect Negative affect – High perceived painHigh perceived pain
• Biology did not predict Biology did not predict – Low resting state functional activity in Low resting state functional activity in
the thalamus and caudate nucleus was the thalamus and caudate nucleus was not influenced by presence or absence of not influenced by presence or absence of above variables, and was similar in both above variables, and was similar in both groups.groups.
“ “It struck me that they didn’t It struck me that they didn’t understand pain”understand pain”
• Patients with chronic musculoskeletal Patients with chronic musculoskeletal pain from a specialist pain clinic.pain from a specialist pain clinic.
• Asked patients about their beliefs and Asked patients about their beliefs and attitudes via in depth interviews ( not attitudes via in depth interviews ( not predefined questionnaires )predefined questionnaires )– Understanding of painUnderstanding of pain– Expectations for providersExpectations for providers– Impacts on livesImpacts on lives
Harding G. Arth Rheum Care Res 2005 Oct; 53(5):691-696. Harding G. Arth Rheum Care Res 2005 Oct; 53(5):691-696.
Pain Patient PerceptionsPain Patient Perceptions
• Unmet expectations of providersUnmet expectations of providers
• Frustrations making sense of pain Frustrations making sense of pain
• Perceptions of spoiled identityPerceptions of spoiled identity
• Difficulties living with pain & Difficulties living with pain & planning for the futureplanning for the future
..
How we make decisions?How we make decisions?
clinical expertise
research evidence patient preferences
“Clinical expertise in the era of evidence-based medicine and patient
choice.”
clinical expertise
research evidence patient preferences
clinical state and circumstances
research evidencepatients’ preferencesand actions
clinical expertise
R. Brian Haynes, etal, McMaster University, Hamilton, Ontario, Canada
ACP J Club. 2002 Mar-Apr;136(2):A11-4.
--->
Clinical CircumstancesClinical Circumstances
•Illness DimensionsIllness Dimensions
•Illness PhaseIllness Phase
Illness Dimensions Illness Dimensions
• BiologicalBiological
• PsychologicalPsychological
• SociologicalSociological
Phases of Chronic IllnessPhases of Chronic Illness
•Crisis Crisis (Getting Sick)(Getting Sick)
•StabilizationStabilization (Being Sick)(Being Sick)
•ResolutionResolution (Grief)(Grief)
•IntegrationIntegration (Living Well)(Living Well)
Jason LA, Fennell PA. J Clin Psychol. 2000 Dec;56(12):1497-508Jason LA, Fennell PA. J Clin Psychol. 2000 Dec;56(12):1497-508
Selak J, Overman S. Selak J, Overman S. You Don’t LOOK SickYou Don’t LOOK Sick. 2005 Haworth. 2005 Haworth
CrisisCrisis
Life full ofLife full of
Stress EventsStress Events
&&
Unmet CareUnmet Care
ExpectationsExpectations
Crisis – “Getting Sick”Crisis – “Getting Sick”
• Medical Medical – Unexplained symptoms & dysfunctionUnexplained symptoms & dysfunction– Diagnosis & treatment Diagnosis & treatment
• Psychological Psychological – Denial, fear, shame, death ideationDenial, fear, shame, death ideation– Provide understanding & hope Provide understanding & hope
• Social Social – Loss of support, isolationLoss of support, isolation– Build a teamBuild a team
Helping Patients not to WorryHelping Patients not to Worry
““I am an old man and have I am an old man and have known a great many known a great many
troubles,troubles,
and most of them never and most of them never happened.”happened.”
Mark TwainMark Twain
StabilizationStabilization
Low confidence Low confidence in inSelf-managementSelf-management
& &
Frustrations Frustrations making sense making sense
of pain of pain
Stabilization – “Being Stabilization – “Being Sick”Sick”
• MedicalMedical– Symptom management Symptom management – Monitoring & adjusting medicationsMonitoring & adjusting medications
• Psychological Psychological – Confusion, searching, rejection of limitations Confusion, searching, rejection of limitations
– Coaching to improve confidence and Coaching to improve confidence and
effectiveness in self-careeffectiveness in self-care
• Social Social – Increased conflict at home & work Increased conflict at home & work – Vocational & marital counseling & assistanceVocational & marital counseling & assistance
““Words are, of course, Words are, of course,
the most powerful drug the most powerful drug used by mankind.”used by mankind.”
Rudyard KiplingRudyard Kipling
Cognitive Behavioral Cognitive Behavioral Therapy Therapy
A willingness to experience A willingness to experience pain and focus on pain and focus on
functioning is better than functioning is better than avoiding activities while avoiding activities while focusing on pain control.focusing on pain control.
McCracken LM. Eur J Pain. 2005 Feb;9(1):69-78.McCracken LM. Eur J Pain. 2005 Feb;9(1):69-78.
Does everyone respond to Does everyone respond to CBT type counseling?CBT type counseling?
• Multidisciplinary trial with Multidisciplinary trial with exercise, education and CBT for exercise, education and CBT for Fibromyalgia patients. Fibromyalgia patients.
• Outcomes Outcomes – Reductions were observed in pain, Reductions were observed in pain,
affective distress, perceived affective distress, perceived disability, and perceived disability, and perceived interference of paininterference of pain
Turk DC, Turk DC, Arthritis Care Res. 1998 Jun;11(3):186-95. Arthritis Care Res. 1998 Jun;11(3):186-95.
Who Responded to CBT?Who Responded to CBT?
YES, someYES, some MEDICALMEDICALAdaptive copersAdaptive copers - those with low - those with low pretreatment levels of affective pretreatment levels of affective distress and disability distress and disability
YES, a lotYES, a lot PSYCHOLOGICPSYCHOLOGICDysfunctionalDysfunctional – those with poor – those with poor coping skills and a high level of coping skills and a high level of pain pain
NONO SOCIOLOGIC SOCIOLOGICInterpersonally distressedInterpersonally distressed - those - those with interpersonal difficultieswith interpersonal difficulties
““Awareness is the first step in healing, Awareness is the first step in healing, for individuals and society. for individuals and society.
Sometimes the brain needs to be Sometimes the brain needs to be satisfied satisfied
before the heart begins to open.” before the heart begins to open.”
Dean Ornish, MDDean Ornish, MD
Resolution - Resolution - “Acceptance”“Acceptance”
• MedicalMedical– Worsening symptoms disproportionate to Worsening symptoms disproportionate to
disease indicatorsdisease indicators– Focus on function & depression treatment Focus on function & depression treatment
• Psychological Psychological – Grief - “Can’t Go Home Again” Grief - “Can’t Go Home Again” – Acceptance through finding the “New You” Acceptance through finding the “New You”
• SocialSocial – Separations & Losses, experiences of Separations & Losses, experiences of
stigmatizationstigmatization– Group interaction & supportGroup interaction & support
Acceptance of PainAcceptance of Pain
Acceptance of painAcceptance of pain correlated with a shift correlated with a shift away from a search for a cure and away from a search for a cure and acknowledging that pain may not change.acknowledging that pain may not change.
Acceptance of chronic painAcceptance of chronic pain was associated was associated
with a shift towards non-pain aspects of life.with a shift towards non-pain aspects of life.
Acceptance of painAcceptance of pain correlated with mental correlated with mental well-being but did not associate with well-being but did not associate with physical functioning. physical functioning.
Viane I. Pain. 2003 Nov;106(1-2):65-72. Viane I. Pain. 2003 Nov;106(1-2):65-72.
““We suffer not We suffer not
because we’re in pain. because we’re in pain.
The real suffering The real suffering
is that we feel we are in pain is that we feel we are in pain ALONE.”ALONE.”
Rachel Naomi Remen, MDRachel Naomi Remen, MD
IntegrationIntegration‘‘Learning to Live Well’Learning to Live Well’
High PainHigh Pain
&&
Difficulties Difficulties LivingLiving
&&PlanningPlanningwith pain with pain
Integration – “Living Integration – “Living Well”Well”
• MedicalMedical– Need for comprehensive integration & Need for comprehensive integration &
adjusting medication – up & downadjusting medication – up & down– Rehabilitation & monitoring Rehabilitation & monitoring
• Psychological Psychological – Redefining personal values & a new lifeRedefining personal values & a new life– Life change counseling & personal caringLife change counseling & personal caring
• Social Social – New friends, partner, job, health careNew friends, partner, job, health care– Resources & referralsResources & referrals
““HealingHealing may not be may not be
so much about getting better, so much about getting better,
as about as about letting goletting go
of everything that isn't you of everything that isn't you - all of the expectations, all of the beliefs -- all of the expectations, all of the beliefs -
and and becoming who you arebecoming who you are.”.”
Rachel Naomi Remen, MDRachel Naomi Remen, MD
OFFICE VISITOFFICE VISITWhat are your goals?What are your goals?
• Getting out quickly?Getting out quickly?• Looking for a procedural opportunity?Looking for a procedural opportunity?• Doing what you enjoy?Doing what you enjoy?• Solving problems and prescribing Solving problems and prescribing
treatments?treatments?• Helping reduce your patient’s pain?Helping reduce your patient’s pain?• Helping your patient achieve her goals?Helping your patient achieve her goals?• Do no harm?Do no harm?• Enhance hope, confidence, acceptance or Enhance hope, confidence, acceptance or
meaning?meaning? • Helping your patient “live well”?Helping your patient “live well”?
Domains & GoalsDomains & Goals
MEDICALMEDICAL PSYCHOPSYCHO SOCIALSOCIAL
I – CRISISI – CRISIS HOPEHOPE
II -II -STABILIZATIONSTABILIZATION
CONFIDENCCONFIDENCEE
III - III - RESOLUTIONRESOLUTION
ACCEPTANCACCEPTANCEE
IV - IV - INTEGRATIONINTEGRATION
MEANINGMEANING
TO YOUTO YOU YOU FOR YOU FOR YOUYOU
YOU & YOU & OTHERSOTHERS
““Patient’s Perspective on Ideal Patient’s Perspective on Ideal Physician Behaviors”Physician Behaviors”
• ConfidentConfident - - assured manner engenders trust and assured manner engenders trust and calmcalm
• EmpatheticEmpathetic – tries to understand what I am feeling– tries to understand what I am feeling
• HumaneHumane – caring, compassionate and kind– caring, compassionate and kind
• PersonalPersonal – – remembers me as an individual remembers me as an individual
• ForthrightForthright – tells me with plain language – tells me with plain language
• RespectfulRespectful – takes me seriously and lets me – takes me seriously and lets me participateparticipate
• ThoroughThorough – is conscientious and persistent– is conscientious and persistent
Bendapudi N., Mayo Clin Proc. March 2006; 81(3):338-344
Your Behavior Your Behavior to to
Change BehaviorChange Behavior
• ASSESSASSESS - Pre-visit form- Pre-visit form• ADVISEADVISE - Discharge form - Discharge form (to me)(to me)
• AGREEAGREE - Menu of options - Menu of options (for (for me)me)
• ASSISTASSIST - Nurse visits- Nurse visits
• ARRANGEARRANGE - Referral data-base- Referral data-base
How confident are you in managing How confident are you in managing your health problemsyour health problems??
Not al all 0---2---4---6---8---10 CompletelyNot al all 0---2---4---6---8---10 Completely
Crossing the Quality Chasm: A New Crossing the Quality Chasm: A New Health System for the 21Health System for the 21stst Century Century
National Academy Press: Institute of Medicine. 2001National Academy Press: Institute of Medicine. 2001
Rules to Redesign and Improve Health Care:Rules to Redesign and Improve Health Care:
1.1. Care based onCare based on continuous healing relationshipscontinuous healing relationships..2.2. Customization based onCustomization based on patient needs and patient needs and
valuesvalues..3.3. TheThe patient as the source of controlpatient as the source of control..4.4. Shared knowledgeShared knowledge and free flow of informationand free flow of information..5.5. Evidenced-based decision making.Evidenced-based decision making.6.6. Safety as a system priority. Safety as a system priority. 7.7. The need for transparency.The need for transparency.8.8. Anticipation of needs.Anticipation of needs.9.9. Continuous decrease in waste.Continuous decrease in waste.10.10. Cooperation among clinicians. Cooperation among clinicians.
Patient-CenteredPatient-CenteredChronic Illness Care Chronic Illness Care
Systems Systems World Wide Pursuing Perfection World Wide Pursuing Perfection
www.WWPP.orgwww.WWPP.org
Improving Chronic Illness CareImproving Chronic Illness Carewww.ImprovingChronicCare.orgwww.ImprovingChronicCare.org
““The Bell Curve”The Bell Curve” New YorkerNew Yorker (November 23, 2004)(November 23, 2004)
What is the meaning of our What is the meaning of our patient’s pain behavior? patient’s pain behavior?
How do we respond?How do we respond?
Help your patient “Live Help your patient “Live Well”Well”
bybyunderstanding the understanding the dimensionsdimensions
of his illness of his illness
and in what and in what phase of recoveryphase of recovery
he is in, he is in,
and then use the 5 A’s of and then use the 5 A’s of
behavior changebehavior change
to her manage better.to her manage better.