Integrated Models of Integrated Models of Care: Care: Pain Management Pain Management Robert D. Kerns, PhD Robert D. Kerns, PhD National Program Director for Pain National Program Director for Pain Management, VACO Management, VACO Chief, Psychology Service, VA Connecticut Chief, Psychology Service, VA Connecticut Professor of Psychiatry, Neurology and Professor of Psychiatry, Neurology and Psychology, Yale University Psychology, Yale University
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Integrated Models of Care: Pain Management Robert D. Kerns, PhD National Program Director for Pain Management, VACO Chief, Psychology Service, VA Connecticut.
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Integrated Models of Care:Integrated Models of Care:Pain ManagementPain Management
Robert D. Kerns, PhDRobert D. Kerns, PhDNational Program Director for Pain Management, VACONational Program Director for Pain Management, VACO
Chief, Psychology Service, VA ConnecticutChief, Psychology Service, VA ConnecticutProfessor of Psychiatry, Neurology and Psychology, Yale Professor of Psychiatry, Neurology and Psychology, Yale
UniversityUniversity
Integrative care Integrative care
Psychology, psychologists, and pain Psychology, psychologists, and pain managementmanagement
Primary models of pain perception emphasize the central Primary models of pain perception emphasize the central role of psychological factorsrole of psychological factors
Role of psychological factors in the development and Role of psychological factors in the development and perpetuation of persistent pain is universally acceptedperpetuation of persistent pain is universally accepted
Psychological interventions for pain management are Psychological interventions for pain management are accepted as efficacious and cost-effective accepted as efficacious and cost-effective
Approximately 20% of members of IASP and APS are Approximately 20% of members of IASP and APS are psychologistspsychologists
Current president of APS is Dennis Turk, a psychologist Current president of APS is Dennis Turk, a psychologist
Goal of VHA National Pain Management Strategy is to Goal of VHA National Pain Management Strategy is to incorporate an interdisciplinary, multimodal approach to incorporate an interdisciplinary, multimodal approach to pain managementpain management
Efficacy of psychological Efficacy of psychological interventions for chronic paininterventions for chronic pain
Meta-analysis of RCTs of psychological treatments for clbpMeta-analysis of RCTs of psychological treatments for clbp
Effect sizes were calculated from 22 RCTsEffect sizes were calculated from 22 RCTs
Positive effects of psychological interventions, relative to Positive effects of psychological interventions, relative to numerous control conditions, were noted for pain intensity, numerous control conditions, were noted for pain intensity, interference, quality of life, and depressioninterference, quality of life, and depression
Cognitive-behavioral and self-regulatory treatments were Cognitive-behavioral and self-regulatory treatments were found to be efficaciousfound to be efficacious
Multidisciplinary treatments that included psychological Multidisciplinary treatments that included psychological interventions had positive long-term effects on return to interventions had positive long-term effects on return to workwork
Integrative model of pain careIntegrative model of pain care
Stepped care approach to pain managementStepped care approach to pain management– Level one: Primary responsibility rests with primary care Level one: Primary responsibility rests with primary care
providersproviders– Level two: “Living with Pain Class”Level two: “Living with Pain Class”
Patient education and rehabilitation modelPatient education and rehabilitation model– Review of common pain conditionsReview of common pain conditions– Personal review of medicationsPersonal review of medications– Discussion of self-management modelDiscussion of self-management model– Personalized exercise planPersonalized exercise plan– Practice of self-regulatory pain strategies, e.g., breathing, relaxation, Practice of self-regulatory pain strategies, e.g., breathing, relaxation,
Comprehensive Pain Management Comprehensive Pain Management Center at VA ConnecticutCenter at VA Connecticut
Integrative clinical, research, and training programIntegrative clinical, research, and training program Interdisciplinary staffInterdisciplinary staff ““Virtual Clinic”Virtual Clinic” Primary Care Clinic integration Primary Care Clinic integration Primary roles of psychologistsPrimary roles of psychologists
– Conduct comprehensive pain assessmentsConduct comprehensive pain assessments– Development and enactment of integrative treatment plan Development and enactment of integrative treatment plan – Care coordinationCare coordination– Primary clinician in delivery of psychological treatmentPrimary clinician in delivery of psychological treatment– Assessment of outcomesAssessment of outcomes– Education and trainingEducation and training– ResearchResearch
Targets for improvement
Improved accessImproved access Successful engagementSuccessful engagement Reduced drop-outReduced drop-out Enhanced adherence to treatment Enhanced adherence to treatment
recommendations recommendations Maintenance of treatment gainsMaintenance of treatment gains Relapse preventionRelapse prevention
Ongoing research Ongoing research
Targeting these areas for improvementTargeting these areas for improvement– Refine CBT to promote engagement, adherence, and Refine CBT to promote engagement, adherence, and
outcomesoutcomes– Refine CBT for special populationsRefine CBT for special populations
ElderlyElderly Women with vulvodyniaWomen with vulvodynia Painful diabetic neuropathyPainful diabetic neuropathy MS-related painMS-related pain
– Investigate treatment process variablesInvestigate treatment process variables Readiness for self-management of painReadiness for self-management of pain
Refining processes of referral and engagement
Education/Training of primary care providers Education/Training of primary care providers Knowledge and attitudes about self-management Knowledge and attitudes about self-management
treatmentstreatments Patient-centered counseling/Use of motivational Patient-centered counseling/Use of motivational
interviewing techniquesinterviewing techniques Respond to patient concerns and beliefs that are Respond to patient concerns and beliefs that are
incongruent with adoption of a self-management incongruent with adoption of a self-management approachapproach
Endorse self-management treatment and goalsEndorse self-management treatment and goals Assure follow-up and continued coordination of Assure follow-up and continued coordination of
carecare
Training primary care providers
Brief educational sessionBrief educational session Relevance of self-management and Relevance of self-management and
rehabilitation approachesrehabilitation approaches Overview of multidisciplinary pain centerOverview of multidisciplinary pain center Review of pathway for referralReview of pathway for referral
Group training followed by individual Group training followed by individual consultationconsultation
Use of modeling (video) Use of modeling (video) VIDEO_TS.IFO
PRIME-CBT
Based in a primary care settingBased in a primary care setting Collaboration with primary care Collaboration with primary care
practitioner (PCP)practitioner (PCP) Explication of referral processExplication of referral process PCP education and trainingPCP education and training Modifications to CBTModifications to CBT
Refining self-management treatment
Collaborative sessions involving primary care providerCollaborative sessions involving primary care provider Explicit attention to readiness to adopt a self-management Explicit attention to readiness to adopt a self-management
approachapproach Use of stage-matched tasks and processes of change (e.g., Use of stage-matched tasks and processes of change (e.g.,
consciousness raising with “precontemplators”, increasing consciousness raising with “precontemplators”, increasing support for “strivers”) support for “strivers”)
Use of motivational interviewing strategies (Use of motivational interviewing strategies (expressing expressing empathy, developing discrepancy, rolling with resistance, empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy)and supporting self-efficacy)
Results of PRIME CBT study
Both CBT (n=33) and PRIME CBT (n=33), relative to TAU Both CBT (n=33) and PRIME CBT (n=33), relative to TAU (n=23), demonstrated significantly greater improvements on (n=23), demonstrated significantly greater improvements on measures of pain, disability, and emotional distressmeasures of pain, disability, and emotional distress
PRIME CBT, relative to CBT, resulted in:PRIME CBT, relative to CBT, resulted in: significantly increased adherence to weekly homework significantly increased adherence to weekly homework
Mean percent intersession adherence for PRIME CBT was Mean percent intersession adherence for PRIME CBT was approximately 70%approximately 70%
Tailored CBT
CBT as inherently flexible approach that accommodates CBT as inherently flexible approach that accommodates to “prescriptive treatment planning”to “prescriptive treatment planning”
Assess patient preferences for learning specific pain Assess patient preferences for learning specific pain coping skillscoping skills
““Tailor” CBT on the basis of patient preferencesTailor” CBT on the basis of patient preferences Employ motivational interviewing techniques to Employ motivational interviewing techniques to
encourage “forward stage movement” or enhanced encourage “forward stage movement” or enhanced readiness to adopt specific pain coping skillsreadiness to adopt specific pain coping skills