Psychological/Behavioral Strategies for Pain Management ......CSAM TAPC Webinar Friday February 24,...

2/26/17

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Psychological/BehavioralStrategiesforPainManagement:

ToolsforPCPstoUseina20MinuteVisit

J.AlexisOrtiz,Ph.D.AttendingPsychologist/ClinicalInstructor

StanfordUniversityAddictionMedicineProgramortiza@stanford.eduCSAMTAPCWebinar

FridayFebruary24,2017OrtizCSAMWebinarPsychPainMgmtTools2-24-17

Disclosures/ConflictsofInterest

Thespeakersandplannersofthiswebinarhavenorelevantfinancialrelationshipstodisclose.

OrtizCSAMWebinarPsychPainMgmtTools2-24-17

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Overview• Caseexample• Tipsandtechniquesfromthefollowingmodalities:• MotivationalInterviewing(MI)• CognitiveBehavioralTherapy(CBT)• DialecticalBehavioralTherapy(DBT)• AcceptanceandCommitmentTherapy(ACT)

•Managingproviderburnout• Takehomepoints• Handouts:Resourcelist


CaseExample• Serena,46yearoldmarriedCaucasianfemale,presentingwithchronicpain,depressivesymptoms,insomnia,traumahx,passiveSI• Statessheis“sickandtiredofbeinginpainallthetime"• SocHx: Workedasanurseuntillastyear,has3children,limitedfinances• Dx:FibromyalgiaDepressionOpioidusedisorder(hx ofhydrocodonedependence)InsomniaPTSD


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ToolsfromMotivationalInterviewing


MITools:FoundationalSkills

Open-endedquestions – ”Whatcanyoudothisweektohelpyou,insteadofyourpain,beinthedriver’sseat?”

Affirmations – “You’redoingagreatjobstickingwithyouropioidtaper.”

Reflections – Repeat/Paraphraseesp.pt’schangelanguage- “It’sreallyimportanttoyoutofindotherlong-termsolutionstodealwithpain.”

Summaries – Repeat/Paraphrasekeytakehomepts –”Soyourtopreasonsforwantingtostayoffopioidsare…”


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MITools:Rulers- Importance,Confidence,Readiness

:


MITools:Rulers• “Onascalefrom0to10,howimportant isitforyouto…”• Findwaystolivethelifeyouwantevenifyouhavepain?• Quitopioids?• Adheretoapainmanagementprogram?

• “Onascalefrom0to10,howconfident areyouinyourabilityto...”• “Onascalefrom0to10,howready areyouto…”

• AfterEACHQUESTIONaskfollow-up:“Whya[number]andnot[alowernumber]?”• Canalsoask:Whatwouldhelpgetyoufroma[number]toa[highernumber]?”/“Whatwouldhavetohappen?”


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MITools:Additionaltechniques• Emphasizeautonomy• Askpermissionbeforeprovidingadvice• “DoyoumindifIsharesomethoughts/tools/concernsaboutthat?”

• Endofsessionquestion:• “Whatareyougoingtotakeawayfromtoday’ssession?”• “What’sthenextstepforyou?”• “Whatwillhelpyou,insteadofyourpain,bemoreincontrolthisweek?


Question1:WhichofthefollowingisNOTanMI-consistent(OARS)strategy?

A.“Whywoulditbeimportantforyoutofindotherwaysbesidesmedicationtomanageyourpain?”B.“Ihavetotellyou,youneedtostoptakingopioidsnow.”C.“You’rereallydeterminedtonotletpaintakeawaythejoyinyourlife.”D.”Itsoundslikeyourhealth,wantingtobeagoodparent,andnotwantingtobedependentonmedicationareyourprimaryreasonsforstayingoffofopioids.”


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Answer=B

“Ihavetotellyou,youneedtostoptakingopioidsnow.”


ToolsfromCognitiveBehaviorTherapy


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Persistent Painwork,

CBTTool:PainCycle - Thenaskaboutfitwithownexperience


CBTTools:CBTforChronicPainSkillstoaddressinterrelationshipsamongthoughts,emotions,behaviors

• ActivityPacing– “Sometimeswecangetintoacycleofoverdoingonedayandthenunderdoing(beingwipedout)thenextday,whichdoesn’thelplong-term.Wouldyoubewillingtotrydoingsomeconsistentactivity/walkingtohelpmakemoresteadyprogress?Whatmightbethebenefitsofthat?Howmanydayswouldyoubewillingtodothat?”

• RelaxationTraining– “Extratensioninthebodycanworsenthepain,let’spracticetaking3slowbreathstogether,infor4seconds,hold,thenoutfor6seconds.Good.”


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CBTTools:CBTforChronicPain• SMARTGoals– Helpptsmakegoals:Specific,Measureable,Attainable,Realistic,Time-bound

• CognitiveRestructuring– “Whenyoutellyourselfyou’realwaysgoingtobemiserable,howdoesthatimpactyourmoodandbehavior?Whatwouldyoutellafriendinthesamesituation?”

• BehavioralActivation– ”Itseemslikeyou’vetakenalotofenjoyableactivitiesoutofyourlifebecauseofpain,that’sunderstandable,butlikelynotmakingyoufeelbetterlong-term.Whatwouldyoubewillingtoaddbackinthisweekthatyouenjoy?WhatdoyoumissaboutXactivity?”


Question2:Serena states”Iworkbetterhavingonereallyproductiveday,eventhoughIenduppayingforitlater”,

whichCBTtechniquewouldbemostindicated?A.BehaviorActivationB.ActivityPacingC.ThoughtStoppingD.RelaxationTraining


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Answer=B

ActivityPacing


ToolsfromDialecticalBehaviorTherapy


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DBTTool:Validation• “Findingthekerneloftruthinanotherperson’sperspectiveorsituation;verifyingthefactsofasituation.”(Linehan,1997)• “Acknowledgingthataperson’semotions,thoughts,andbehaviorshavecausesandarethereforeunderstandable.”(Linehan,1997)

• Whatcanwevalidate? (Linehan,1997)•Thefactsofasituation•Aperson’sexperiences,feelings,beliefs,opinions,suffering,difficulties

• VALIDATIONDOESNOTMEANAGREEMENTORREINFORCEMENT• Don’tvalidatetheinvalid


Whyvalidate?Whenptsdon’tfeelvalidated…

• Anger,agitation• Opposition• Defensiveness• Notunderstood• Overwhelmed• Ashamed• Trapped• Uncomfortable• Donotadheretotreatment• DonotreturntotreatmentOrtizCSAMWebinarPsychPainMgmtTools2-24-17

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Whyvalidate?Whenptsfeelvalidated/feelinvalidated…

• Understood• Respected• Engaged• Collaborative• Safe• Empowered• Hopeful• Interested• Wantingtocomebacktotreatment• WillingtotryoutrecommendationsOrtizCSAMWebinarPsychPainMgmtTools2-24-17


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ValidationStems(+)1.)Pt:“Ijustneedpainmeds,that’stheonlythingthathelps.”Pr:“Iknowyouwanthelpmanagingthispain,andIwanttosupportyouinthat.Wedon’tofferopioids,hereiswhatweoffer… haveyoutriedXbefore?…”

2.)Pt:“Youdon’tgetit,I’vebeenthroughallthisstuffbefore,I’mjustexhausted.”Pr:”Itmakessensethatyoufeelexhaustedgivenbeinginpainforsolong,andyetyou’reheretoday,Iseethatthere’sapartofyouthatwantstofindanotherwaytomanagethispain.”

3.)Pt:“Doctorskeeptellingmetojustmeditate,that’snotgoingtomakemypaingoaway.”Pr:“You’refeelinglikethosethingswon’tmakeanydifference.Iunderstandthat,atthesametime,Icantellyoumanypatientsfindthemhelpful.Icanrecommendsomeapps,books,orprogramssoyoucancheckitoutforyourself,whichwouldyouprefer?”


DBTTool:STOP(mindfulness)• STOP• Takeastepback• Observe:use5senses,acknowledgethepain,noticewhatelseispresentbesidespain• Proceedmindfully:Primarygoal?Top3reasonswhyIwanttostayoffopioids?Whatwouldmakethingsbetter/worse(thatisinmycontrol)rightnow?

• Practicewithpt:• “Ok,let’strythistogether,let’sstop,take3breaths,whatdoyounoticeinandoutsideofyourbodyrightnow,whatcanyoudoforyourselfinthismoment?”


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DBTTool:RadicalAcceptance

”Sometimeswecan’tkeeppainfuleventsandexperiencesfromcomingourway.Wecan’talwayscontrolwhathappenstous,butwecanchoosehowwerespond.Wecanfightagainstrealityandthenthat’swhereourtimeandenergywillgo,ORwecandecidetotryandworkwithwhatishappeningrightnow.”

ACCEPTANCEVS.CHANGE


DBTTool:RadicalAcceptance

• “Radicalacceptancemeanscompletelyacceptingtherealitythatweareinpainatthismoment.Itdoesnotmeanwantingorlikingthepain.Itisacknowledgingthatlifecanbeworthlivingevenwithpainfuleventsinit.”• “Whatiswithinyourcontroltochange?”(e.g.,behavior,narrative,meaning-making)• “Whatwouldbehelpfultobringacceptancetoinyourlife?”(e.g.,presenceofatleastsomepainatsomepoint)

ACCEPTANCEVS.CHANGE


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ToolsfromAcceptanceandCommitmentTherapy


#TheStruggleIsReallyReal


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ACTforChronicPain• ACTislessaboutmakingpaingoawayandmoreaboutgettingdisentangledfromthoughts/feelingsandgettingptsmovinginadirectionthatisimportanttothem.• Whereistheirfocus/effort?- Isthept’slifeabouttryingtonotfeelpainoraboutbuildingarich,full,meaningfullife?• Whatthoughts/storiesaretheyfusedwith?• ACTisaboutlivinglifefromthefeetup,nottheheaddown

• “Whathaspainbeenkeepingyoufromdoingthatisimportanttoyou?”• “Howwouldyourlifelookdifferentifyouweremorefocusedonwhatmatteredtoyouinsteadoftryingtofeellesspain?”


Question3:WhatwouldNOTbeanACT-consistentmessagetocommunicatetoSerena?

A.“Let’sconcentrateongettingridofthispain.”B.”Ihearthatyouwantthepaintogoaway,ifyoudidn’thavepainwhatwouldlookdifferentforyou?”C.“Whatdoyoucareabout?”D.“Wouldyoubewillingtohavesomepainintheserviceofpursuingthethingsthatareimportanttoyou?”


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Answer=A

“Let’sconcentrateongettingridofthispain.”


Whataboutus?ManagingProviderBurnout

• Radicalself-care– Whohealsthehealer?• Consultroutinely– Stateyourneeds:problem-solving,validationforyourself,orempathyforthepatient• Mindfulness – STOPbefore/afterseeingthept,takeabreathwhenyouwalkthroughthedoorway,digitaldetox/technologyhiatus• Celebratesmallvictories– Whatare3thingsthatwentwellwithptcarerecently?• (Re)connectingwithvaluesandpurpose– Howisdoingthisworkconsistentwithwhatyouvalueinlife/whatisimportanttoyou?


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ReconnectingwithEmpathy


TakeHomePoints• Useyourresources– Refertobehavioralhealthifavailable• Validatept’s(andourown)suffering/struggle• Empowerthept - whyisthisimportanttoyoutomakechanges?,whatdoyouwanttolookdifferentinyourlife,whatwouldhelpwiththat?• Shiftproblem-solvingonusbacktoptsinconnectionwiththeirownvalues

• Rememberthepowerof(andevidencebasefor)positivereinforcement• CMEs – ConsideradditionaltraininginMotivationalInterviewing,CBTforChronicPain,ACTforChronicPain,DBT


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Thankyou!

Questions?

Feedback?


February 24, 2017

Psychological/Behavior Strategies for Pain Management: Tools for PCPs to Use in a 20 Minute Visit 1

Friday,04/28/2017:TaperingOpioids

Friday,05/19/2017Friday,06/23/2017Friday,07/28/2017Friday,08/18/2017*Friday,09/22/2017

NEXTWEBINAR:Friday,03/24/2017:Managing Acute and Perioperative Pain in Patients on

Medication-Assisted Treatments (MAT)

You can view our previous webinars

for a small fee for CME/CEU on the CSAM Education Center at:

http://cme.csam-asam.org/

OR

Free on the CHCF TAPC Program Resource Page at:https://tapcprogram.com/

February 24, 2017

Psychological/Behavior Strategies for Pain Management: Tools for PCPs to Use in a 20 Minute Visit 2

Save the date! CSAM Addiction Medicine Review Course

and Board Exam Preparation August 24 – August 27, 2017

Hilton San Francisco Union Square

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Psychological/Behavioral Strategies for Pain Management ......CSAM TAPC Webinar Friday February 24,...

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