The 5 Domains of Best Pain Care - OHSU€¦ · • PHQ-4 (depression and anxiety) • Pain Anxiety Symptom Scale (PASS) • Pain Catastrophizing Scale (PCS) • PTSD screen for primary

The5DomainsofBestPainCare

CatrionaBuist,Psy.D.OregonHealthandScienceUniversity

OHSUAssistantProfessorinAnethesiology andPerioperativeMedicine&PsychiatryChair,OregonPainManagementCommission

OregonInstituteofOccupationalHealthSciences,OHSUPainatWork:HowtoPrevent,RecognizeandTreat

Wilsonville,ORMay31,2018

Disclosures

• Theauthorhasnothingtodisclose.

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Objectives

• Identify5keydomainsofbestpracticepaincare

• Understandtheroleofshareddecisionmakinginimprovingtreatmentplanning

• Recognizefeaturesofcomplexpaininapatientpresentation

• IdentifyOregonresourcesforyouandyourpatientsandcolleagues

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4ProvidenceHealthandServices copyright

Painalwaysresultsfrombodilydamage?

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Biopsychosocial ModelBecausePainisComplex!

•Anxiety•Depression•PTSD•Catatrophizing•FearofMovement•Traumahistory

WhatAreWeOftenReallyMedicatingWithOpiates???

ToolsWeCouldUseMoreOftenforScreening

• BodyMap• BriefPainInventory(BPI)• PHQ-9(depression)• PHQ-4(depressionandanxiety)• PainAnxietySymptomScale(PASS)• PainCatastrophizingScale(PCS)• PTSDscreenforprimarycare(PC-PTSD-5)• AdverseChildhoodExperiences(traumahistory)• STOP-BANG(sleepapnea)• STarT BackTool(screenforbiopsychosocialissues)• PEG(pain,enjoymentinlife,generalactivity)

Centralsensitization=Awindupofthenervoussystemwhichbecomesregulatedinapersistentstateofhighreactivityandisassociatedwiththedevelopmentandmaintenanceofchronicpain

Our goal is to help people get their life back…

TheirShrinking World…

Redirectconversationsawayfromeliminatingpainandmovetowardsmanagingpainwithafocuson:

- Function- Qualityoflife- Livingameaningfullife

• Physicians• PhysicianAssistants• Nursing• Acupuncture• Psychologists• Physicaltherapists• Occupationaltherapists• Chiropracticphysicians• Naturopathicphysicians• Pharmacists• Dentists

RequiredPainManagementEducation

www.oregonpainmodule.org

PrioritizingCare:KeyDomains

Knowledgeofpain

Nutrition

Activity

Sleep

Mood

• KeyConcepts• Strategies• Resources• Connecting with

yourpatient

Wheretostartwithacomplexpresentation:shareddecisionmakinghelpspatientsengageandenhancesmotivationalinterviewingtowardspositivebehaviorchange.

AvailablebylinkhereandinResourcesectionandOPMCwebsite. Providence Toolkitisavailable

PainToolKit

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MotivationalInterviewing

Skills

ExpressEmpathy

RollwithResistance

Developdiscrepancy

Supportself-efficacy

Avoidargumentation

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TraumaInformedCare

Culturalcompetence

Familyempowerment

TraumaCompetenceSafety

Trustworthiness

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PainEducationAsATreatmentInterventionDecreaseinpainrating(VanOosterwijcketal2011,Meeusetal,2010,Ryanetal,2010,Moseley,2002,2003,2004)

Decreaseinfearofre-injury(VanOosterwijcketal2011,Moseley,2002,2003)

Decreaseinpaincatastrophizing(Meeus etal,Moseley2004,Louw etal2011,ArchPhys MedReh Systematicreview)

Decreaseinutilizationofservicespostoperatively(Adriaan Louw,PhD,PT,etSPINEVolume39,#18)

Increaseinfunction(VanOosterwijcketal2011,Moseley,2002,2003,,Louw etal2011ArchPhys MedReh Systematicreview)

Increaseinmobility(MoseleyandHodges, Clin JPain. 2004 Louw etalPhysiotherapyJ,2011)

NoraStern,MSPTProvidenceHealthandServices copyright

OregonPainGuidanceMay17,2018 24

OregonPainGuidanceMay17,2018 25

https://www.youtube.com/watch?v=MqoS7RUrUqg

OregonPainGuidanceMay17,2018 26

OregonPainGuidanceMay17,2018 27

OregonPainGuidanceMay17,2018 28

OregonPainGuidanceMay17,2018 29NEVESTHATFIRETOGETHERWIRETOGETHER

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ThreatValue

MorePain LessPain

Painresponsechangesbasedonthreatvalue

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Clicktoaddtext

ProvidenceHealthandServicescopyright

Negativethoughtsaboutpaincanleadtomaladaptivecopingandincreasedsufferinganddisability

Thought:“IhaveDDD.”“Mybackiscrumbling”

Emotion:fear

Behavior:seekadditionalmedicaltreatment

Idea:changewordingfrom“DDD”to“normalagerelatedchanges.”

KnowledgeofPain:Strategies

Changelanguagetodecreaseunintentionalthreat

- "Sorebutsafe"- "Paindoesnotequalharm"- "Thereisalotthatyoucandotochangeyourpain"

Teachaboutpainincludingpainprocessingandneuroplasticity/reversibilityUsingwrittenmaterialandvideosPainknowledgeassessmenttools: click

here,orseeaddendumorOPMCwebsite

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Translations:English,Spanish,Russian,Cantonese,Arabic,Somali,Vietnamese

KeyDomains:Sleep

Knowledgeofpain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

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FromCBT-i:- Getoutofbedifcan’tsleep- Bedforsleepandpartnertime- Sleeprestrictiontobuildupsleeppressure- Scheduleworrytime- Createtimetounwindbeforesleep

Connectingwithpatient

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AdaptedfromWenzel,Brown,Karlin 2011Ex.Ifbackpainisexperiencedstandingupfromachairapersonmayfeeldiscouragedandfrustrated(emotion)Andthink,“ifItrytodoanythingtodayI’mgoingtohurtmore(thought)whichmayleadtostayingintheirreclinerandavoidingmovingfortherestoftheday(behavior)

CBTforChronicPainTherapistManualfromVA

Anxiety&PTSD Thought:“Ifeeloverwhelmed.”“Ifeeloutofcontrol”“nobodyunderstandsorbelievesme.”

Emotion:fear,anxiety

Behavior:shutdown

Catastrophizing =magnifyingthenegativeandanticipatingtheworsecasescenarioThought:“mypainwillneverstop”or“nothingcanbedonetoimprovemypain.”“IfthispaincontinuesIwillendupinawheelchairlikemymother”

Emotion:feelhelplessandoverwhelmed,anxiety

Behavior:stopallactivity

Depressionornegativeaffect

Thought:“Ican’tdoanythingthatIenjoy”“LasttimeIwenttotheparkwithmykidsIhadaflareup”“IfeelguiltyIcan’ttakecareofmykids,spouse,contributetothefamilylikeIwantto.”

Emotion:depression,sadness

Behavior:withdrawalfromactivity

Lossofselfandidentity Thought:“I’vealwaysworkedsohardtobethebest______.WhoamInow?”“Ihavelostmyindependence.”

Emotion:shame,sadness,grief

Behavior:stopactivity,socializing,gettingdressed,doingthingsenjoydoing

Blackandwhitethinking

Thought:“IfIcan’t_____likeIdidbefore,Iamnotgoingtodoanythingatall.”

Emotion:anger,sadness

Behavior:stopallfunactivity

ShouldThought:“Ishould beabletodanceallnightlong,gotothemallalldaywithmyfriends,mowthelawn,fishwithmybuddiesprovideformyfamilylikeIuseto.”

Emotion:shame,guilt,sadness

Behavior:retreatintoself.Stopsocializingandgoingout

WhatHappensWhenStressContinuesPainbecomesthelionfollowingyouaround…

- Increasedpain- Depression- Moodswings- Celldeathinthe

hippocampus- Memorychanges- Poortissuehealing- Weightgain- Alteredimmunity

(FromExplainPain,2003)

Quietingstressresponsequietspain

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PainStress

Response

QuietingStressResponse

Pain

Sleep

Anti-InflammatoryChemicals

ReleaseInflammatoryChemicals

Copyright(C)2016ProvidenceHealth&Services

Relatedproblems:• Poorsleep• Poordigestion• Healingdifficulties• Painandachinessallover

PhysiologicalQuietingVideo

Copyright(C)2016ProvidenceHealth&Services 55

Roleofthefamily&others?

Mayrequirehelpingthemunderstandpain

Settingboundaries

Gettingridoftoxicrelationships

Improvingcommunicationskills

“People don’t hurt if they

have something better to do.”

W. Fordyce, Ph.D

“Lowering yourstressresponsetopainwillreduceyourpain.Hereishow:

Thesamepartsofoursystemthatworkhardwhenwefeelstressalsoworkhardwhenwefeelpain.

That’sbecausebothfeelingsareparofourEmergencyResponseSystem.Whenourbrainsensedanger,itactivatesthissystem.Stressdoesn’tdirectlycarepain.Butstresscanmakepainworseanditcanmakepainlastlonger.”

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Relaxationvideos:Bodyscan,progressivemusclerelaxationandbreathingEnglish,SpanishandRussian

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HurtvsHarm&FearofMovement(kinesiophobia)

Thought:“painmeansIamhurtingmyself.”Emotion:fear(ofpain)Behavior:stopallactivity,guard,protect,holdbreath

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OregonPainGuidanceMay17,2018 63

OregonPainGuidanceMay17,2018 64https://www.youtube.com/watch?v=hjenuiXDUZg

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)

ExpectFlareUpsandteachflareupmanagementstrategiestobuildself-efficacyandincreasesenseofcontrol

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KnowledgeofPainandActivity:Resources

Activityvideosegmenttobeembeddedsoon

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PainCareisEveryone’sJob

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AddChristinahistoryhereandsolicitconversation• Identifyareasoffocus

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• Firstslide:herfirstpresentation

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CatrionaBuist,[email protected]

ResourcesFollow

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Legislation established a Pain Task Force in 1997; followed by The Pain Management Program and Coordinator position in 1999; And, in 2001 the Pain Management Commission.

• 17 voting members, 2 legislative members

Oregon Pain Management Commission:

• MDs• PhysicianAssistant• Nurses• NursePractitioner• NaturopathicPhysician• ChiropracticPhysician• Acupuncturist• Pharmacist• Psychologist• Dentist

• AddictionCounseling• PhysicalTherapist• OccupationalTherapist• HealthCareConsumers• PatientAdvocates• PublicRepresentative• LegislativeMembers

-Senate-House

90Providenceoregon.org/paintoolkit

Newresourcesforclinicians

#PainMed2018 AAPM34thAnnualMeeting|April26-29,2018 91

LorimerMosely– ChronicPainTametheBeast5’utube

https://www.youtube.com/watch?v=XwBYkw-iZdQ

Understandingpainandwhattodoaboutitinlessthan5minutes- JointPainEducationProjectvideofromtheDepartmentofDefenseandVeteransHealthAdministrationtolearnmoreaboutchronicpainmanagement.

https://www.youtube.com/watch?v=cLWntMDgFcs

“UnderstandingPainandWhattodoAboutItinlessthan5Minutes”utube

ClassesonLivingWellwithChronicPainwww.healthoregon.org/livingwell

This2015bookisdesignedtohelpmanagepainsopeoplewithchronicpaincangetonwithlivingasatisfying,fulfillinglife,andincludestheMovingEasyProgram CD.ThisbookandCDarethecompanionresourcestotheChronicPainSelf-Managementworkshop.

SleepResources

1. Maintainaregularbedandwaketimeschedule,includingweekends2. Establisharegular,relaxingbedtimeroutine3. Workoutregularly(stopexercise3hoursbeforebed)4. Noelectronicsinbedroom- TV,phones5. NoexposuretoTVorcomputers2hourspriortobedtime6. Usebedroomonlyforsleepandpartnertime7. Finisheatingatleast2-3hoursbeforebed8. Refrainfromtakingnaps(notmorethan20’)9. Avoidcaffeineafternoon10. Avoidalcoholclosetobedtime

Resource:CBT-i Coach

HealthySleepResourcesfromKimberlyHutchison,MD,FAASMBooks

1. TheInsomniaAnswer:APersonalizedProgramforIdentifyingandOvercomingtheThreeTypesofInsomnia,byPaulGovinksyandArtSpielman.2. SayGoodnighttoInsomnia,byGreggJacobs.

Apps,Podcasts,orOnlineResources

1. InsightTimer(free)2. Noisli.com(varioussounds)3. SmilingMinds4. SimpleHabit5. RelaxandSleepWellbyGlennHarrold(free)6. Calm7. Headspace8. Sleep withMePodcast9. JeffBridgesSleepingTapes

CBTI

1. ClevelandClinicMindfulnessBasedInsomniaTherapy($40for6weekonlineprogram) http://www.clevelandclinicwellness.com/Programs/Pages/Sleep.aspx#pop2. OHSUIndividualCBTI(AmyKobus,PhD)or OHSUGroupCBTI(TeniDavoudian,PhD)3.SHUTi($149),CBTI-coach(free),NightOwl($10)

AlternativeTherapiesforAdults

1. EssentialOilSprays(lavenderisapopularscent)2. WorryStone(alsoknownaspalmstonesorthumbstones)aresmooth,polishedstoneswithathumb-sizedindentationinthecenter.Theyareusedbyholdingbetweentheindexfingerandthumbandrubbinggentlyforrelaxationoranxietyrelief.3. Acupuncture4. MassageTherapy

• CBTManualforChronicPainhttps://www.va.gov/PAINMANAGEMENT/docs/CBT-CP_Therapist_Manual.pdf

• BeverlyThornhasalowliteracymanualforchronicpain

CognitiveBehavioralTherapy(CBT)Resources

Acceptance & Commitment Therapy (ACT) resourcesSteven Hayes, 1994

https://contextualscience.org/act

https://www.actmindfully.com.au/

PortlandPsychotherapyClinichttp://portlandpsychotherapyclinic.com/resources/acceptance_and_commitment_therapy_exercises_and_audiofiles/

KevinVowelsACTmanualhttps://contextualscience.org/files/CP_Acceptance_Manual_09.2008.pdf

NeuroplasticityResources

MindfulnessandRelaxationResources

MotivationalInterviewingforHealthcareProfessionals-OnlineEducationCollegeofNursingattheUniversityofColoradohttp://www.ucdenver.edu/academics/colleges/nursing/programs-admissions/CE-PD/Pages/Motivational-Interviewing-for-Healthcare-Professionals.aspx

TheEfficacyofMotivationalInterviewinginAdultswithChronicPain:AMeta-AnalysisandSystematicReviewDionAlperstein&LouiseSharpeTheJournalofPain,Vol17,No4(April),2016:pp393-403.“MIsignificantlyincreasedadherencetochronicpaintreatmentintheshortterm…”

MotivationalInterviewingresources(MillerandRollnick,2009)

FreeVideoTrainingonDifficultConversationshttps://www.scopeofpain.com/

• SCOPEofPainisaseriesofcontinuingmedicaleducation/continuingnursingeducationactivitiesdesignedtohelpyousafelyandeffectivelymanagepatientswithchronicpain,whenappropriate,withopioidanalgesics.

• Trainer’stoolkit- 7videos:• Initiatingopioidtherapy,discussingsafetyandbenefit• Assessingandmanagingaberrantopioidtakingbehavior• Discussingdiscontinuationofopioidsduetolackofbenefitandexcessiverisk• Modifyingtreatmentplanofinheritedpatientonhighdoses• Assessingandmanagingillicitdruguseinpatientwithchronicopioidtherapy• AssessingandmanagingPDMPquestionableactivityinestablishedpatientandinanewpatient

ResourcesforUnderstandingtheIssuesRelatedtotheOpioidEpidemic&toHelpPatients

ChasingHeroin(Frontline&PBS)

http://www.pbs.org/wgbh/frontline/film/chasing-heroin/

FreePainCME

www.coperems.org

www.scopeofpain.com

www.pcsso.org www.pcssmat.org

March2016NationalPainStrategy- outlinesactionsforimprovingpaincareinAmerica toreducetheburdenandprevalenceofpainandtoimprovethetreatmentofpain(CourtesyofDr.SeanMacKey)

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InitiativetoAddressOpioidsandDrugswithAddictive/AbusePotential

IMPROVEPATIENTCAREREDUCERISKSTOPATIENTSBY

MAKINGPHYSICALANDBEHAVIORALHEALTH

TREATMENTS SAFER,addressinghistoryoftrauma,and

providingnon-pharmacologicaltreatmentoptions

REDUCE PATIENTHARMSREDUCEHARMSANDSUPPORTRECOVERYFROMSUBSTANCEUSEDISORDERSbymakingSubstanceUseDisorder

treatmentmoreaccessibleandaffordable,andaddressingrecoveryasachronicdisease

IMPLEMENT POPULATION-BASED STRATEGIES

ProtectthecommunitybyREDUCINGTHENUMBEROF

PILLSINCIRCULATIONthroughimplementationofsafeprescribing,storage,and

disposalpractices

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Aim:Reducedeaths,overdoses,andharmstoOregoniansfromopioidsandotherdrugswithaddictive/abusepotentialthroughpublichealthandhealthsystemsinterventions

EDUCATIONANDOUTREACH

DATATOINFORM,MONITOR,ANDEVALUATE

EvidenceBasedReportsSupportingMultidisciplinaryTreatmentforChronicPain

3/16CDC urgedhealthcareproviderstoturntonon-drugandnon-opioidpainkillersbeforeconsideringopioids

11/16AgencyforHealthcareResearchandQuality- 800pagereviewonchronicLBP-nonpharmacologicaltherapiesappeartobeeffectiveforimprovingpainorfunctionincludingexercise,yoga,taichi,psychologicaltherapies,multidisciplinaryrehabilitation,acupuncture,spinalmanipulation…

2/17AmericanCollegeofPhysicians adviseddoctorsandpatientstotrynon-drugtherapiessuchasexercise,acupuncture,taichi,yoga,chiropractorandavoidprescriptiondrugsorsurgicaloptionswhenpossible.Ifnon-drugtherapiesfail,recommendnonsteroidalanti-inflammatorydrugsasfirstlinetherapy,ortramadolorduloxetineassecondlinetherapy.

11/17InstituteforClinicalandEconomicReviewFinalReport– recommendsenhancedcoverageofcertainnon-drugmanagementoptionsforlowbackpainincludingacupuncture,CBT,MBSR,andyoga