Integrated Treatment of Co-morbid

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1 Opportunities and Challenges in Integrated Treatment of Co-morbid Chronic Pain and Substance Use Disorders Mark Ilgen, PhD Ann Arbor VA, HSR&D Center of Excellence; Serious Mental Illness Treatment and Resource Center (SMITREC); Department of Psychiatry, University of Michigan Daniel Kivlahan, Ph.D. Acting National Mental Health Program Director, Addictive Disorders Office of Mental Health Services, VACO Department of Psychiatry, University of Washington

2 Disclosure Statement No conflicts of interest to disclose Research funding from: VA Health Services Research & Development National Institute on Drug Abuse 1

3 Overview Brief review of CBT for pain in those with and without SUDs Provide overview of new VACO directives/ initiatives State Prescription Drug Monitoring Programs Discuss your questions/concerns related to pain management in at-risk patients 2

4 CBT for Pain and Substance Use Disorders Psychological interventions such as CBT have demonstrated efficacy for reducing pain and improving functioning in persons with a broad spectrum of painrelated conditions (McCracken and Turk 2002;Turk and Okifuji 2002). Prior studies have typically excluded those with substance use disorders. Only one existing study has explicitly examined the effects of CBT for pain in those with substance use disorders (Currie et al. 2003) and found significant reductions in pain, pain-related interference, medication misuse and more general measures of maladaptive coping from baseline to 12-month follow-up. 3

5 Case Example Older male patient Axis I: MDD, Cocaine Dependence, History of Alcohol Dependence, and Opioid Abuse. Problems: Chronic Pain (knees and back) Unemployed, inadequate income Feelings of inadequacy Medication noncompliance Poor relationship with prescriber Poor relationship with children and grandchildren How do you conceptualize treatment in this patient? Where do you begin??? *Patient information disguised to protect confidentiality. 4

6 Where to Begin: Gate Control Theory Of Pain Thought Center Emotion Center Pi Pain Center Situation/ Behavior/ Physical State Skills: Attention Diversion, Pacing, Activity Rest Cycle, Behavioral Activation, SAS, Hurt vs. Harm, Sleep Hygiene Gate (open/closed) Thoughts Skills: Thought Monitoring, Catastrophic Thought Cycle, Nonjudgmental Thinking, Cognitive Restructuring, SOLVE Emotions Skills: Acceptance, Thoughts Feeding Emotions, Progressive Muscle Relaxation Site of Injury 5

7 Conceptualizing Treatment: Fear Avoidance Model Pain Perpetuation and Exit Strategy Ilgen et al.,

8 Ongoing Studies of CBT for Pain in Those with SUDs Two ongoing studies of group CBT versus group SPC in adults treated for SUDs VA study total of 128 patients to be recruited from VA SUD treatment programs We have recruited the full sample and are conducting the final series of groups NIDA study total of 452 patients (226 male and 226 female) patients t recruited from a large residential SUD treatment program We have recruited 50 participants (year 2 of 5) 7

9 Steps to Improve Pain Management in Any Treatment Setting Ask about pain ask about prescription pain medications. How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? (Smith et al., 2010). 8

10 Ways to Assess for Pain Medication Misuse Past 30 day pain medication misuse Current Opioid Medication Misuse (COMM; Butler et al., 2007) How often have you needed to take pain medications belonging to someone else? How often have you had to go to someone other than your prescribing physician to get sufficient pain relief from your medications? How often have you taken your medications differently from how they are prescribed? How often have you had to take more of your medication than prescribed? How often have you borrowed pain medication from someone else? How often have you used your pain medication for symptoms other than for pain? 9

11 Steps to Improve Pain Management in Any Treatment Setting Ask about pain ask about prescription pain medications. How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? (Smith et al., 2010). Try to understand patients motivation for using pain medication what are their beliefs about pain medications? Reinforce the message that managing pain does not always have to involve using a substance. Discuss hurt versus harm 10

12 State Prescription Drug Monitoring i Programs Discussion of new guidelines for the use of State Prescription Drug Monitoring Programs 11

13 VHA National Pain Management Strategy t Infrastructure t Pain Management Program Office; Patient Care Services; National Pain Management Strategy Coordinating Committee VISN Pain Points of Contact Facility Pain Points of Contact Primary Care Pain Champions Pain Resource Nurses VISN and Facility Pain Management Committees 12

14 Discussion i Topics How well is your site doing in terms of managing pain in those with and without SUDs? What is working well? What isn t working well? What is needed in terms of additional guidance? Use of Urine Drug Screens Coordination between service providers Other comorbid conditions (TBI, PTSD, etc.) Interactions with outside providers Dialogue between psychologists and prescribers What could improve the VHA National Pain Management Strategy? 13

15 Thank You! 14