What Can Pain Psychology Provide for your Patients

Transcription

1 What Can Pain Psychology Provide for your Patients Catriona Buist, Psy.D. Assistant Professor Department of Anesthesiology & Psychiatry Oregon Health & Science University Headache Management Symposium OHSU, Portland, OR March 17, 2018 Chronic pain touches many parts of life, and each piece affects others The interaction between each circle shown here impacts how you feel overall. The good news is that while some factors May increase or turn the volume up on pain, Other factors may decrease it and you can Decide how to manage many of these factors (VA) Biopsychosocial Model Because Pain is Complex! Anxiety Depression PTSD Catatrophizing Fear of Movement Trauma history oregon.org/ What Are We Often Really Medicating With Opiates??? 1

2 Screening Tools Body map BDI-II or PHQ-9 Pain Anxiety Symptom Scale Pain Catastrophizing Scale PEG pain, function, QOL STOP-BANG (sleep apnea) Opioid Risk Tool What is CBT for Chronic Pain? Widely researched and shown to be effective with many mental and behavioral issues Time-limited psychotherapeutic approach Encourages active, problem solving approach, self-management Focuses on the relationship between cognitions (thoughts), emotions (feelings) and behaviors Improves function and quality of life Objectives of CBT-CP the negative impact of pain on daily life pain intensity physical and emotional functioning effective coping skills for managing pain 2

3 Adapted from Wenzel, Brown, Karlin 2011 Ex. If back pain is experienced standing up from a chair a person may feel discouraged and frustrated (emotion) And think, if I try to do anything today I m going to hurt more (thought) which may lead to staying in their recliner and avoiding moving for the rest of the day (behavior) Their Shrinking World Neuroplasticity The ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury. Our goal is to help people get their life back Acceptance of pain & Selfmanagement approach Negative thoughts about pain can lead to maladaptive coping and increased suffering and disability Thought: I have DDD. My back is crumbling Emotion: fear Behavior: seek additional medical treatment 3

4 Hurt vs Harm & Fear of Movement (kinesiophobia) Thought: pain means I am hurting myself. Emotion: fear (of pain) Behavior: stop all activity, guard, protect, hold breath Activity and Pacing: Strategies Pacing to Return to Activity Get support and encouragement With a professional, community group, or a friend Getting moving is more important than "exercising" Normalize discomfort Ideas: - Aquatic exercise - Gentle therapeutic yoga - Tai Chi - Simple whole body movement, focusing on breathing comfortably Click here for assessment, or in resources or in OPMC website Pacing is an active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities Expect Flare Ups and teach flare up management strategies to build selfefficacy and increase sense of control The Activity-Rest Cycle in Chronic Pain (Gil, Ross, & Keefe, 1988) in Psychological Approaches to Pain Management: A Practitioner s Handbook. Edited by Robert J. Gatchel and Dennis C. Turk (1996) Tracking headaches and identifying triggers Rebound headaches Sleep Skipping meals Alcohol, caffeine, and other substances Bright lights or sounds Hormonal changes Weather changes Stressors eep: Sleep Hygiene Strategies Consistent sleep/wake cycle Paced exercise and limited napping Relaxation/mindfulness training Cognitive behavioral therapy for insomnia (CBT-I) (CBT-I Address sleep apnea 4

5 Anxiety & PTSD Thought: I feel overwhelmed. I feel out of control nobody understands or believes me. Catastrophizing = magnifying the negative and anticipating the worse case scenario Emotion: fear, anxiety Behavior: shut down Thought: my pain will never stop or nothing can be done to improve my pain. If this pain continues I will end up in a wheelchair like my mother Emotion: feel helpless and overwhelmed, anxiety Behavior: stop all activity What Happens When Stress Continues Pain becomes the lion following you around Diaphragmatic Breathing - Increased pain - Depression - Mood swings - Cell death in the hippocampus - Memory changes - Poor tissue healing - Weight gain - Altered immunity To learn deep breathing: com/videosfeatures/videos/bre athing-exercises breath/ Headspace.com Calm.com (From Explain Pain, 2003) Mindfulness Mindfulness means paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. Jon Kabat-Zinn Mindfulness Exercise: ACT Exercise for handling stressful thoughts leaves on a stream Free Mindfulness Based Stress Reduction site: 5

6 Biofeedback Diaphragmatic breathing Stress management through relaxation Muscle tension reduction Heart rate variability I phone apps: Breathe2Relax Breath Pacer Depression or negative affect can turn up dial on pain Thought: I can t do anything that I enjoy Last time I went to the park with my kids I had a flare up I feel guilty I can t take care of my kids, spouse, contribute to the family like I want to. Emotion: depression, sadness Behavior: withdrawal from activity Loss of self and identity Thought: I ve always worked so hard to be the best. Who am I now? I have lost my independence. Emotion: sadness, grief Behavior: stop activity, socializing, getting dressed, doing things enjoy doing Role of the family and others? May require setting boundaries, education about pain, and improving communication skills Black and white thinking Thought: If I can t like I did before, I am not going to do anything at all. Emotion: anger, sadness Behavior: stop all fun activity People don t hurt if they have something better to do. W. Fordyce, Ph.D 6

7 Getting back to living life in a valued direction ACT Values Exercise Tobias Lundgren Mary s short term CBT Mary continued Session 1 Pacing Sleep hygiene Flare up management Believes medications only thing helping her Hurt vs. harm and stress response Teach deep breathing Refer to rest of the team homework Session 2 FU on homework Downloaded Calm.com app Walking to mailbox Trying to stick to schedule More aware of pacing Address cognitive distortions catastrophizing, black and white thinking Values exercise Leaves on a stream mindfulness exercise homework Session 3 FU on homework Starting to walk more Getting dressed and in shower Calling friend Took out sewing Neuroplasticity exercise Engaging in rewarding activities Biofeedback Homework Session 4 FU on homework Sleep improved Joined warm pool Ready to work with tapering opiates Feeling more activated and wants to lose weight Ready to get into MH for trauma work New issues arise When to Refer to CBT-CP When patient would benefit from learning additional coping skills to self-manage pain Patient is not progressing as expected with current treatment Patient presents with a negative, exaggerated, emotional or behavioral reaction to pain Patient is experiencing pain-related impairment in various domains of functioning Framing the Role of Mental Health in Pain Management Their role is to help you find ways to cope better with the pain as well as to reduce the negative impact pain has on your life. Their focus will be to help you develop tools to manage the pain so that you can improve your quality of life. 7

8 You don't have to do this alone: The Team Superstars Required Pain Management Education Licensed Acupuncturists Health Coaches Peer Support Groups Nurses Chemical Dependency Counselors Pharmacists Dentists Primary Care Providers Physical/ Occupational Therapists Chiropractors Behavioral Health Providers Licensed Massage Therapists Pain Management Specialists Yoga Instructors Case Managers Physicians Physician Assistants Nursing Acupuncture Psychologists Physical therapists Occupational therapists Chiropractic physicians Naturopathic physicians Pharmacists Dentists Endorsing the team members is a critical part of the care plan Prioritizing Care: Key Domains Key Concepts Strategies Resources Connecting with your patient Knowledge of pain Nutrition Activity Sleep Mood Pain Tool Kit Where to start with a complex presentation: shared decision making helps patients engage and enhances motivational interviewing towards positive behavior change. Available by link here and in Resource section and OPMC website. Providence Tool kit is available Videos Tame the Beast Providenceoregon.org/pain toolkit 8

9 #PainMed2018 AAPM 34th Annual Meeting April 26-29, Save the date for the Oregon Conference on Opioids, Pain + Addiction Treatment: Pioneering Change Ending the Opioid Crisis Starts Now This is a must-attend event for everyone committed to ending the opioid crisis, improving pain management and providing better access to addiction treatment health systems, clinicians and providers, and community leaders. Together we will spark transformation for lasting change. May 17-19, 2018 Hilton Eugene Eugene, Oregon For more information about this conference, please contact: Elizabeth White, MPA, Project Manager, Oregon Coalition for the Responsible Use of Meds (OrCRM), a service of Lines for Life or elizabethw@linesforlife.org Catriona Buist, Psy.D. buistc@ohsu.edu Thank You #PainMed2018 AAPM 34th Annual Meeting April 26-29, Talking Tips: Effects of pain and what you can do! BELIEFS: you may believe that it is better to try and restrict your movement CBT-CP: You will learn about your body and make some changes that will show moving is helpful ACTIVITY: cutting back on activity can make your muscles stiff and cause you to lose strength CBT-CP: We will focus on slowly introducing activities to get you back to things you enjoy PHYSICAL: not moving may have lead you to gain weight or to feel fatigue and tired much of the time CBT-CP: Starting to move and walk will improve your physique and give you more energy MOOD: the effects of chronic pain may make you feel down, frustrated, anxious, angry CBT-CP: Beginning to engage in pleasant activities and resuming regular activities will help improve your mood and self esteem SOCIAL LIFE: you may have withdrawn from others and feel irritable or guilty from your pain and its effects CBT-CP: We will focus on interacting more with others and having positive social experiences THOUGHTS: you may spend a lot of time worrying about your pain or thinking negative thoughts CBT-CP: We will help you learn how to change your thinking so that you can manage your outlook Talking Tip: Hurt vs Harm and the CP Cycle chronic pain lasts beyond 3 months and persists after all the healing has happened. Although you are still hurting, the pain is no longer alerting you of additional injury or damage. Often when people have chronic pain they decrease their level of activities because it hurts to move. the inactivity actually makes the pain worse over time. Deconditioning leads to decreased flexibility and stamina, increased weakness and fatigue and spasms from tight muscles. All this can lead to increased risk of injury, weight gain and feelings of sadness, frustration, or boredom, making you feel worse and encouraging further avoidance of people and places. 9

10 Talking Tip: Negative Thoughts Today we will talk about how your thoughts can affect your pain and how changing them can help improve your satisfaction with life. When you are in pain, what kinds of thoughts go through your head?..we find that as pain gets worse, thoughts often become more negative and negative thoughts increase pain and get in the way of doing things that we know help make pain better. everyone has negative thoughts and often these thoughts are automatic such as my pain is never going to get better.. Embracing these thoughts may lead to avoiding activities and people, and make it less likely to use the pain management skills you have. The chain reaction of negative, unhealthy thinking, feeling upset, avoiding others, and not using active coping skills is the cycle that we are trying to break. Self-monitoring of automatic negative thoughts What was going through my mind just before or just after I started to feel this way? What is the thing I am most afraid might happen? What is the worst things that could happen? What memories does this lead me to experience? What does this mean about my future, my life, my health? Is this 100% true? Is there a different way to look at this issue? What would I tell a close friend if they just had this thought? Is this thought helpful to me? Is there evidence that I am not taking into account? Talking Tip on Value of Relaxation: Relaxation is a skill that can help people better manage stress and muscle tension that increase pain. There are many relaxation skills that are easy to use and we want to find some that work for you. It s important to make them part of your daily routine and they can help you when you have a pain flare up. The goals of relaxation is to reduce the effects of stress on your health. Chronic pain taxes our body and creates increased muscle tension so even if you don t feel stressed emotionally, it is likely that your body is impacted. While we can t avoid all stressors or pain, we change how we respond. Relaxation is more than resting ore enjoying a hobby. It involves taking a break and reducing tension in your body and mind. Talking Tip: Exercise Tight muscles, decreased stamina, fatigue and extra weight can worsen your chronic pain and make it harder for you to do different activities. Adding exercise and walking to your life has been shown to help your body combat chronic pain and improve mood. Physical activity helps: increase endurance and strength return muscles to normal size helps you have less pain when you move While starting something new is tough for all of us, as you practice walking and engage in more activities, things will get easier each day as your muscles are strengthened. Remember: Motion is lotion! Talking Tip: Pacing Pacing involves taking breaks at regular times, not just when the task is done. By resting regularly, you can actually get more done in the long run and not pay for extended periods of activity. Pacing helps you maintain a constant activity level over time, which is good for you body and mind. Remember: Take breaks based on how much time you have worked not on how much you have accomplished Take breaks before the pain begins to increase, or after it gets bad Practice makes perfect your body must learn how to respond This is about working smarter not harder! 10