Spirituality and Chronic Pain: Empirical Research Findings and Clinical Applications

Transcription

1 Spirituality and Chronic Pain: Empirical Research Findings and Clinical Applications Amy Wachholtz, PhD, MDiv, MS University of Colorado Denver Sept 20,

2 Amy Wachholtz, Disclosures The author declares that there are no conflict of interests or financial relationships with any of the information in this presentation The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2

3 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, and Justina Andonian. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3

4 Target Audience The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 4

5 Educational Objectives At the conclusion of this activity participants should be able to: State the empirical evidence of the effect of spirituality on pain Identify the 4 major types of religious or spiritual (R/S) coping Identify how to assess for R/S coping types 5

6 Outline 1. Bio-psycho-social-spiritual model of pain 2. Major questions in R/S and pain research 3. Intervention Studies 4. Clinical Resources 6

7 R/S and Health Regular attendance (2+/month) protects health as smoking is health deleterious (Strawbridge, et al, 1997) Regular worship attendance increases lifespan 7 years (Hummer, et al, 2000) Prayer for health concerns increased from (Wachholtz & Sambamthoori, 2012) Protective effects from faith-based behaviors rather than cognitions (Baetz, & Bowen, 2008) 7

8 What is Pain? Physiological (6+ months) Musclo-skeletal Neuropathic Psychological Stress Depression Social/Relationships Spiritual Spiritual Or 8

9 Influences on Chronic Pain Biological Factors Spiritual Factors Chronic Pain Psychological Factors Social Factors 9

10 Gate/Neuromatrix Theory of Pain Thoughts Emotions Behaviors Gate I feel Ouch! good! Melzack & Wall, 1965 Injury Signals 10

11 R/S and Chronic Pain 35% of American adults report recent use of prayer for health concerns (Wachholtz & Sambamthoori, 2011) 69% report prayer as helpful 61% of pain patients use prayer to cope with pain (Glover-Graf, et al., 2007) 40% of pain patients report becoming more R/S after the onset of the painful condition (Glover-Graf, et al., 2007) 4% report becoming less R/S due to pain (Glover-Graf, et al., 2007) 11

12 Major Questions of R/S and Pain 1. What are the mechanisms that may affect the link between R/S factors and pain? 2. Who uses R/S to cope with pain? 3. When do people choose to use R/S to cope with pain? 4. How do people chose which R/S tools they will use to cope with pain? 12

13 Question 1: What are the mechanisms linking R/S factors and pain? 13

14 Spiritual Beliefs and Practices Positive vs. Negative Public vs. Private Intrinsic vs. Extrinsic Existential vs. Religious Possible Unique R/S Factor Spiritual Support Spiritual Growth Spiritual Meaning Making Attributions Additional Efficacy Beliefs (Wachholtz, Pearce & Koenig, 2007) Psycho-Social Changes Meaning Making Attributions Self-Efficacy Distraction Social Support Instrumental Support Relaxation Physiological/Neurological Changes Altered neurotransmitter levels Changed conduction of pain signals Different threshold for recognizing pain signals Decreased HPA activity levels Altered Pain Perception Increased/Decreased Sensitivity Increased/Decreased Tolerance 14

15 Question 2: Who uses R/S to cope with pain? 15

16 Who? Older (>33 years) Female More Educated (> High School) Have chronic mental or physical health issues: depression, chronic headaches, back and/or neck pain (McCaffrey, et al., 2004, Klemmack, et al, 2007) 16

17 Question 3: When do people use R/S to cope with pain? 17

18 When? The initial R/S pain coping response to acute pain (selfdirective), is the least likely R/S coping response to chronic pain (collaborative) (Dunn & Horgas, 2004) Terminal stage illnesses with co-morbid pain (e.g. cancer) (Ironson, et al, 2002) Long-term chronic pain (Dezutter, Wachholtz & Corevlyn, 2012) Uncontrollable, intermittent pain (OConnell, Edwards, Wachholtz et al., 2009) When other coping mechanisms fail and R/S is efficacious (Keefe, et al., 2001; Pargament, 2002) R/S coping AND secular coping- not either/or 18

19 Question 4: How do people choose which R/S tools to use for coping with pain? 19

20 Religious Coping Techniques Initially thought to be only 1 type (all Positive) Later research: 4 types Religious/Spiritual Coping Deferential-Giving all control of problem to God Collaborative-Joint problem solving with God Independent-God not involved due to no belief Abandoned- God not involved because feel abandoned (Pargament, Smith, Koenig, Perez, 1998; Schottenbauer, Rodriguez, Glass, & Arnkoff,2006) God God Person Person Person God God I m on my own Its because all in God s God has hands abandoned/punished and out of my control me We re in this together. God I will will do do it myself. his/her part, I don t and believe I ll do in mine God 20

21 Common R/S Tools Prayer Hope Meditation Reading faith-based literature Finding spiritual role models for coping Seeking spiritual support/connection Seeking instrumental support Religious reappraisal Church attendance 21

22 Positive vs. Negative R/S Coping Positive Forms Seek spiritual connection Seek spiritual support Religious assistance to forgive others Asking forgiveness Benevolent religious reappraisal Religion as distraction Collaborative problem solving w/god Negative Forms Interpersonal religious discontent Punishing God reappraisal Demonic reappraisal Spiritual discontent Reappraisal of God s power 22 Pargament, et al.,1998

23 Positive vs. Negative R/S Previously R/S individuals have better outcomes when using R/S tools (Pargament, Tarakeswar, Ellison, & Wolff, 2001) Positive R/S coping is associated with positive outcomes among chronic pain patients (Bush, 1999, Wachholtz & Pargament, 2005; Wachholtz & Pargament, 2008; Wachholtz, Malone, & Pargament, 2015) Prayer is #1 or #2 most frequently used R/S coping method in dealing with chronic pain (Koenig, 2001) 23

24 Positive vs. Negative R/S Why chose positive or negative R/S coping tools? May be demographic differences R/S background R/S salience Ethnic background Gender Position in a religious framework (e.g. gender, class) Age 24

25 Bonus Question: What do we do with all of these questions? 25

26 Intervention Studies Comparing spiritual vs. secular interventions on pain Spiritual interventions affect physiological outcomes (Carlson, Bacaseta, and Simanton, 1988; Ironson, et al., 2002, Pargament et al., 2005; Wenneberg, et al., 1997) Increase pain tolerance in healthy, non-chronic pain individuals (Wachholtz & Pargament, 2005) Improved pain tolerance among a chronic pain group (Wachholtz & Pargament, 2008, Wachholtz, Malone, & Pargament, 2015) 26

27 Conversation Fears 1. Fears about getting into the conversation 2. Fears about the content of the conversation 3. Fears about how to get out of the conversation 27

28 But you can overcome it 28

29 FICA F Faith or beliefs Tell me something about your faith or beliefs. I Importance & influence How does this influence your health/well-being? C Community Are you part of a supportive community? A Address or application How would you like me to address these issues in your health care? Puchalski,

30 OASIS Patient-Centered Spirituality Inquiry 1. INTRODUCE ISSUE IN NEUTRAL INQUIRING MANNER Positive-Active Faith Response 2. INQUIRE FURTHER, ADJUSTING INQUIRY TO PATIENT S INITIAL RESPONSE Neutral-Receptive Response Spiritually Distressed Response Defensive/Rejecting Response Kristeller, et al.,

31 3. CONTINUE TO EXPLORE FURTHER AS INDICATED 4. INQUIRE ABOUT WAYS OF FINDING MEANING AND A SENSE OF PEACE 5. INQUIRE ABOUT RESOURCES 6. OFFER ASSISTANCE TO ACCESS RESOURCES (AS APPROPRIATE AND AVAILABLE) 7. BRING INQUIRY TO A CLOSE 31

32 Future Directions Identification of sub-groups that may be at greater risk for using negative R/S coping tools Further exploring potential mediators for R/S and pain relationship (mood, self-efficacy, etc.) Developing and testing of R/S interventions to improve outcomes in pain patients Move beyond self-reported pain levels to include bio-markers and objective outcome measures 32

33 Key Points Spirituality can have a powerful effect on pain and health Both positive and negative Assessing spiritual health is an important component of a health assessment Critical to assess for type of spiritual coping Do not attempt to do spiritual counseling, but know available professional resources in your area 33

34 Thank you 34

35 References Baetz M, Bowen R. (2008). Chronic pain and fatigue: Associations with religion and spirituality. Pain Res Manage, 13(5): Borneman T, et al. (2010). Evaluation of the FICA tool for spiritual assessment. J Pain Symptom Manage, 40(2): Bush EG, et al. (1999). Religious coping with chronic pain. Appl Psychophysiol Biofeedback, 24(4): Carlson CR, Bacaseta PE, Simanton, DA. (1988). A controlled evaluation of devotional meditation and progressive relaxation. J Psychol Theol, 16(3): Dezutter J, Wachholtz A, Corveleyn J. (2011). Prayer and pain: The mediating role of positive reappraisal. J Behav Med, 34(6): Dunn KS, Horgas, AL. (2004). Religious and nonreligious coping in older adults experiencing chronic pain. Pain Mgmt Nursing, 5(1): Ellison C, et al. (2000). Religious involvement and mortality risk among African-American adults. Research on Aging, 22 (6): Glover-Graf NM, et al. (2007). Religious and spiritual beliefs and practices of persons with chronic pain. Rehab Couns Bull, 5(1): Ironson G, et al. (2002) The Ironson-Woods Spirituality/Religiousness Index is associated with long survival, health behaviors, less distress, and low cortisol in people with HIV/AIDS. Ann Behav Med, 24(1): Klemmack D, et al. (2007). A cluster analysis typology of religiousness/spirituality among older adults. Research on Aging, 29(2): Koenig H. (2001). Religion and medicine IV: Religion, physical health, and clinical implications. Intl J Psychiat Med, 31(3): 321:336. Kristeller J, et al. (2005). Oncologist assisted spiritual intervention study (OASIS): Patient acceptability and initial evidence of effects. Intl J Psychiat Med, 35(4): McCaffrey, A, et al. (2004). Prayer for health concerns: Results of a national survey on prevalence and patterns of use. Arch Intern Med, 164(8): Melzack R, Wall PD. (1967).Pain mechanisms: A new theory. Surv of Anesthesiol, 11(2): O Connell-Edwards CF, et al. (2009). Religious coping and pain associated with sickle cell disease: Exploration of a non linear model. J Afr Am St, 13(1): Keefe FJ et al. (2001). Pain and emotion: New research directions. J Clin Psychol, 57(4): Strawbridge WJ, et al. (1997). Frequent attendance at religious services and mortality over 28 years. Am J Public Health, 87(6): Pargament K. (2002). The bitter and the sweet: An evaluation of the costs and benefits of religiousness. Psychol Inq, 13(2): Pargament, K. et al. (1998). Patterns of positive and negative religious coping with major life stressors. J Sci St Relig, 37:

36 References Pargament K, et al. (2001). Religious coping among the religious: The relationships between religious coping and well-being in a national sample of Presbyterian clergy, elders, and member. J Sci St Relig, 40: Puchalski C, Romer A. (2000) Taking spiritual history allows clinicians to understand patients more fully. J Pall Med, 3(1): Schottenbauer M, et al. (2006). Religious coping research and contemporary personality theory: An exploration of Endler s (1997) integrated personality theory. Brit J Psychol, 97(4): Wachholtz A, Pargament K. (2005). Is spirituality a critical ingredient of meditation: Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med, 28(4): Wachholtz A, Pargament K. (2008). Migraines and meditation: Does spirituality matter? J Behav Med, 31(4): Wachholtz A, Pearce M, Koenig H. (2007). Exploring the relationship between spirituality, coping, and pain. J Behav Med, 30(4): Wachholtz A, Malone C, Pargament K. (2015; online ahead of print). Effect of different meditation types on migraine headache medication use. Behav Med, Wachholtz A, Sambamoorthi U. (2011). National Trends in Prayer Use as a Coping Mechanism for Health concerns: Changes From 2002 to Psychol Relig Spirituality, 3(2): Wachholtz A, Sambamthoori U. (2013). National trends in prayer use as a coping mechanism for depression: changes from J Relig Health, 52(4): Wenneberg, SR, et al. (1997). A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure. Intl J Neuroscience, 89:

37 PCSS-O Colleague Support Program and Listserv PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications. PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost to providers. For more information on requesting or becoming a mentor visit: Listserv: A resource that provides an Expert of the Month who will answer questions about educational content that has been presented through PCSS-O project. To join pcss-o@aaap.org. 37

38 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT). For more information visit: For questions pcss-o@aaap.org Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department 38 of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.