Spokane Pain Conference October 27, 2017 Patty Bullick, MSW, LCSW Riverwood Counseling, LLC Coeur d Alene, Idaho

Spokane Pain Conference October 27, 2017 Patty Bullick, MSW, LCSW Riverwood Counseling, LLC Coeur d Alene, Idaho

Good afternoon. My name is Patty Bullick, and I'm speaking on the Psychological Treatment of Chronic Pain. I own a private counseling practice and have no relevant financial or nonfinancial relationships to disclose.

The Three Areas of Treatment for Chronic Pain What is Pain Management Psychotherapy? Chronic Pain vs. Chronic Pain Syndrome Intake and Assessment Tools Cognitive Behavioral Therapy and Mindfulness Mindfulness-Based Stress Reduction Treatment Outcomes and Case Studies

Approximately 72% of people presenting to pain clinics are of working age The majority of people attending pain clinics reported they were unable to work or had to cut their hours When reporting on quality of life, the inability to work and loss of enjoyment of life were the highest scoring problems associated with pain when using the Brief Pain Inventory (Finlayson)

Psychological Approaches to unexplained or resistant pain have been shown to improve reported well-being and function by between 25% - 45% (Finlayson) Up to 70% of people suffering with Chronic Pain will also suffer from depression and/or anxiety disorders (Bridges and Goldberg; Nimnuan et al)

Interventional Treatments - Surgery, Injections, RFA, Kyphoplasty, Nerve Blocks, SCS, Scrambler Therapy Pharmaceutical/Medical Management - Medications, Topical Creams, Physical Therapy, Chiropractic Active Patient Approaches - Pain Psychotherapy, Pain Support groups, Home Exercise

Chronic Pain: Physical sensations without depression Positive pain coping behaviors Continued normal activity and lifestyle Active, constructive pain control Proper medication management Functional and motivated Chronic Pain Syndrome: Depression, anger, anxiety and fear Seeking medical treatment without success Reduced activity, unemployment and disability Social withdrawal and relationship problems Medication, drug and/or alcohol abuse Helplessness, suicidal ideation, impaired sleep

An effective and clinically based Biopsychosocial and Mind/Body approach An adjunctive therapy after a thorough medical workup The goal is to improve the physical, psychological, emotional and social dimensions of quality of life for people with persistent pain, using a multidisciplinary team with clinically proven treatment Primarily used for patients in a Chronic Pain Syndrome vs. having a chronic pain diagnosis Assesses beliefs about pain; risk factors; self-efficacy to manage pain; cognitive and physical functioning; social and psychological history; personality factors; coping skills; and factors such as depression, anger and anxiety

Pain Management Psychotherapy (Eimer & Freeman) Cognitive Behavioral Therapy (CBT) Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-Based Cognitive Therapy for Chronic Pain (CBT-CP) Mindfulness-Based Stress Reduction (MBSR) Neural Path Therapy (McKay) HeartMath Heart Rate Variability Biofeedback Acceptance & Commitment Therapy (ACT) Guided Imagery Hypnosis

Review of Medical and Psychological Records; Mental Health Evaluation; Assessment Tools - Brief Pain Inventory and/or Pain Rating Scale - Pain Beliefs Inventory to rule out Somatoform Disorders (Hypochondriasis, Somatization, etc.) - Pain Patient Profile Assessment (P-3) - PDQ-9 or Beck Depression Questionnaire - GAD-7 Anxiety Scale - Motivation for Change Assessment (Prochaska & DiClemente)

The Gold Standard of care for Pain Psychology A process of changing negative thoughts and behaviors which complicate the experience of chronic pain and increase pain perception Guided by empirical research, CBT focuses on the development of personal coping strategies to solve current problems and change unhelpful patterns in cognitions (e.g. thoughts, beliefs, and attitudes), behaviors, and emotions Patients learn to pace activities, practice relaxation exercises, focus on pleasant activities, reframe negative thoughts and beliefs, and improve sleep hygiene skills

The practice of maintaining a nonjudgmental state of awareness of one's body sensations (pain, numbness), thoughts (what if s, why s, past, future), and emotions (depression, worry, anger) on a moment-to-moment basis Increase activities that create meaning and purpose Be more physically and socially engaged Increase acceptance of pain and disability Practice stress reduction Decrease Fear/Avoidance Behaviors

A program that incorporates mindfulness to assist people with pain, illness and stress Developed at the University of Massachusetts Medical Center in the 1970s by Jon Kabat-Zinn MBSR uses a combination of mindfulness meditation, body awareness, and yoga exercises In recent years, meditation has been the subject of controlled clinical research. This suggests it may have beneficial effects, including stress reduction, relaxation, and improvements to quality of life, but that it does not help prevent or cure disease (Kabat-Zinn)

Increases the level of pain acceptance (Veehof ) Decreases the Fear/Avoidance behaviors (Schutze) Improves overall mood regulation (Gatchel) Improves Quality of Life factors (McCracken) Decreases catastrophizing (Gatchel) Decreases pain related opiate use (Gatchel) Improves subjective wellbeing (Grossman)

Treatment outcomes can be compromised when both pain and a mental disorder are present and only one of them is targeted for treatment (Co-ocurring Disorders) (Renner) Higher levels of depression and/or anxiety have been shown to be predictive of poorer treatment outcomes for chronic pain patients (Finlayson) Psychological interventions yield improvements in health-related quality of life, work-related disability, interference of pain with daily living and depression (Kerns)

For headache pain, MBCT patients reported significantly greater improvement in selfefficacy (P=0.02, d=0.82) and pain acceptance (Clin J Pain, 2014 Feb;30(2):152-61) Evidence suggests that CBT-CP improves functioning and quality of life for a variety of chronic pain conditions (Hoffman, Papas, Chatkoff, & Kerns, 2007; Morley, Williams, & Eccleston, 1999; Turner, Mancl, & Aaron, 2006)

Mary is a 37 year old healthy female diagnosed with CRPS in a lower limb seven months ago. There is no history of mental illness and she is currently on short-term disability from full time work. Her mood is anxious and depressed. She tends to catastrophize which increases her anxiety and fear states. She is going to physical therapy twice a week and is taking Gabapentin 1500 mg., Hydrocodone 7.5 mg. TID, and Cymbalta 60 mg. Pain ratings are 7/10 consistently. After five weekly sessions of CBT, MBSR and HRV biofeedback, her pain ratings range between 4/10 and 7/10. She has learned to tolerate her pain more effectively, is back to work part time and has better control over her mood. She now knows how stress, depression and anxiety increase the sensations of pain and how to decrease her stress response, as well as increase pleasures. She has been successful in greatly limiting her catastrophizing.

Mike is a married 54 year old unemployed male with chronic low back pain from a past work injury who has an active Workers Comp claim. He has Failed Back Surgery Syndrome with treatment that has included three surgeries, Opiate medications, injections and extensive physical therapy. He rates his pain during the initial evaluation at a 8/10 and states that it ranges between 4-10/10 depending on his activities. He has been depressed since the accident and drinks alcohol nightly to excess. He is taking Oxycontin 20mg. every 12 hours, Oxycodone 5 mg. every 6 hours, Ambien CR 6.25mg. nightly and Methocarbomol 500 mg. TID. He has lost his motivation and drive to be involved in his ADL s. After 10 weeks of authorized visits from Workers Comp, Mike is more involved in his ADL s, he has drastically cut back on alcohol intake, his depression has decreased approximately 40% and he rates his pain at a range of 3-7/10. He is learning to accept his pain and disability. His marriage, which was previously strained, is much better. Mike stated, I didn t realize how bad I was doing and feel like there is hope now. He learned to use the coping skills rather than alcohol to manage the depression and pain, and feels he has a much better quality of life.

Janet is a 42 year old married woman who has suffered from Migraine Headaches since her teen years. The only treatment she has sought were medications including Imitrex and Demerol. She quit working and had never sought counseling, biofeedback or Botox injections. She was referred to the pain clinic and started Botox injections and pain counseling. We started with MBSR skills and HRV Biofeedback to calm her Sympathetic Nervous System. We worked on CBT skills to change her negative reactions to her pain, increase social functioning and improve overall quality of life. A major component of her suffering was depression, a lack of acceptance of her chronic illness and social isolation. After six weeks of therapy Janet slowly started planning a few pleasurable activities and she was able to change her relationship to her pain from one of aversion to one of acceptance. This process helped Janet start living with her chronic pain rather than having her headaches rule her life. After another four weeks of therapy Janet started applying for flexible part time positions that could accommodate her migraine headache flairs. She eventually stopped therapy stating, Even though I still have migraine headaches, I can cope with them much better and I feel that they are not as severe. My depression complicated my chronic pain condition.

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