BEHAVIORAL HEALTH CONSULTATION FOR PATIENTS WITH PAIN. Bridget Beachy, PsyD. David Bauman, PsyD

Transcription

1 BEHAVIORAL HEALTH CONSULTATION FOR PATIENTS WITH PAIN Bridget Beachy, PsyD David Bauman, PsyD

2 TODAY S AGENDA Introductions Case Fast facts on chronic pain The Trident Approach for chronic pain in PCBH

3 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)

4 OUR VALUES

5 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?

6 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.

7 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

8 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

9 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

10 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..

11 TRIDENT APPROACH TO CHRONIC PAIN Direct interventions with patients Supporting/upskilling the PCPs Supporting the entire system

12 TRIDENT APPROACH TO CHRONIC PAIN Direct interventions with patients Supporting/upskilling the PCPs Supporting the entire system

13 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

14 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

15 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

16 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

17 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)

18 INTERVENTIONS Values Do you have pain, or does pain have you? True North Bull s eye 85 th 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?

19 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

20 TRIDENT APPROACH TO CHRONIC PAIN Direct interventions with patients Supporting/upskilling the PCPs Supporting the entire system

21 SUPPORTING/UPSKILLING PCPS Co-visits Shared medical group visits Document functioning of patient Document functional goals of patient on opioids Risk assessment for opioids

22 TRIDENT APPROACH TO CHRONIC PAIN Direct interventions with patients Supporting/upskilling the PCPs Supporting the entire system

23 SUPPORTING THE ENTIRE SYSTEM Crucial role in pain contracts Group visits Risk assessment Pain pathway Initial Annual As requested by patient or PCP

24 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.

25 QUESTIONS/COMMENTS YouTube channel:

26 REFERENCES 1. Elliott AM, Smith BH, Penny KI, et al. The epidemiology of chronic pain in the community. Lancet 1999; 354: 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: Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet 2011; 377: 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: 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 (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 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: 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:h Institute for Clinical Systems Improvement. Health care guideline: Assessment and management of chronic pain. Fourth edition November 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: 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): 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):