We have not had any relevant financial relationships during the past 12 months.

We have not had any relevant financial relationships during the past 12 months.

DECLARATION OF FINANCIAL INTERESTS

VIDEO

AUDIENCE QUESTIONS

How many of us treat chronic pain? What comes to mind when you think of

patients with chronic pain? What are the common treatments for

chronic pain? Where are these treatments offered?

And by whom? Do they work? Are they evidenced

based?

IMPLEMENTING CHRONIC PAIN GROUPS

IN TWO DIVERSE FAMILY MEDICINE RESIDENCY CLINICS

Joan B. Fleishman, PsyDJeanna R. Spannring, PhDChristine N. Runyan, PhDPhilip Bolduc, MD

University of MassachusettsMedical School

OBJECTIVES

Define group protocol for treatment of chronic pain

Understand potential challenges and barriers to implementation in a primary care setting

Describe patient and provider perspectives on efficacy of treatment modality

EVIDENCE AND RATIONALE FOR NON-PHARMACOLOGICAL TREATMENT

OF CHRONIC PAIN

SCOPE & NATURE OF CHRONIC PAIN

At least 116 million U.S. adults suffer from chronic pain conditions more than heart disease, diabetes, and

cancer combined Annual economic cost including health

care expenses and lost productivity: $560 – 630 billion

Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: The National Academies Press.

CURRENT TREATMENTS

Pharmacotherapy Injections Procedures/Surgeries PT/OT CBT, mindfulness,

psychotherapy Acupuncture Chiropractics

BEST PRACTICES???

Core Content and Process Components

DESIGN OF GROUPS

BACKGROUND

Developed in CMHC in rural Colorado as a psychotherapy group

Intended to address this common co-morbidity of psychiatric illness PTSD Depression Borderline Personality Disorder Substance Abuse

STRUCTURE OF SESSION

8-sessions 90 min/sessions Dedicated nursing support Population:

Pilot w/ specific PCP referral All PCP referral Part of pain contract

STRESS & NERVOUS SYSTEM DISORDER

Rules of Neuroplasticity:1.What is fired together is wired together

2.What you don’t use you lose

3.When you break old paths, you can use those nerves to make new paths

HEALTHY BEHAVIORS

HEALTHY BEHAVIORS

Overactivity

Increased Pain & Fatigue

Prolonged Rest

Diminished Productivit

y

MEDICATION OPTIONS FOR CHRONIC PAIN

opioids

tricyclics

NSAIDs

SNRI/SSRI

Anti-convulsants

CBT: EMOTIONAL AWARENESS

FearSadness

Guilt

Anger

PET Card(Emotional Awareness)

Physical Sensations

Clenched jaw/hands, heart pounding, rush of blood to the head

Emotions Angry, frustrated, overwhelmed

Thoughts I’m over this.When is it going to stop?!?

CBT TRIANGLE FOR PAIN

Thoughts

BehaviorsPain

- stuck- Helpless/hopeless- No control/power

Associated Emotions:-Depression - Stop

- Prolonged rest

- Activity/overactivity

Associated Emotions:-Overwhelmed-Hopeless/helpless

Associated Emotions:-Anger-Motivation

-Take Control-Prove pain can’t stop me

CBTThought Record

Situation Emotions 0-10 Automatic Thoughts Unhelpful Thoughts

Alternative Thoughts Emotions 0-10

Wake up in pain…again

PAIN 9/10

AngrySadOverwhelmedHopeless

109

1010

“not again”This’ll never end!I can’t take it anymore…

LabelingFortune tellingOvergeneralizing

I’ve gotten through it before, and I have strategies to help me…I can do this, even though it sucks

AngrySadFrustratedHopeful

5646

MINDFULNESS-BASED PRACTICE

FUNDAMENTAL PROCESS ELEMENTS Development of and support through social

network Opportunity to ask questions Graded skill building with individualized

coaching Assigned weekly practice

check-in and discussion worksheets

Slide-shows with corresponding handouts Cumulative patient handouts Multi-disciplinary Therapeutic intervention

IMPLEMENTATION

ESSENTIAL COMPONENTS

Multi-disciplinary care/team approach Bringing group psychotherapy to a

primary care setting Support from:

PCP Medical Director support Logistical support

SNAPSHOT: CLINIC PROFILESHAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER

9,000; 50% Medicaid CHC

Diverse patient population

Urban, academic, ambulatory primary care clinic

9 physicians, 2 NPs, 12 residents, 3 BHCs, clinical pharmacists

20,000; 90% Medicaid CHC, FQHC CMHC on site Diverse patient population 30% Spanish speaking Chronic Pain Management

Protocol 20 physicians,12 NP/PAs,

12 residents, 1 BHC, 1 nurse midwife

7 advocates; 3 care managers

MODELS OPIATE PRESCRIBING

HAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER

Opioid contract PCP-managed High variability in

implementation and prescribing practices

Practice-based registry 3 providers with

buprenorphine prescribing authority

Patients on opiates for 3+ months

Intake with program nurse Monthly visits with nurse Quarterly visits with PCP Aberrant behaviors

Illicit substances Misuse of prescription Missing visits

Possible measures More frequent visits Urines and pill counts Discharge from program

Outcome Data

RESULTS

ATTENDANCE

Age: mean = 50.95, sd = 10.54, range: 30 – 67 years

Average group size = 5

68.03%

31.97%

referred attended 1st

48.72%51.28%<6 ses-sionscompleted

MEASURES

Each Session Wong-Baker Healthy Days Core Module (CDC HRQOL–

4) Pre/Post

Brief Pain Inventory Multi-dimensional Health Locus of Control Patient Health Questionnaire (full version) 12/20 complete sets for analysis

WONG-BAKER FACES

1 2 3 4 5 6 7 80123456789

10

mean score

Session

Score

8-17 respondents per session

BRIEF PAIN INVENTORY

pain severity functional impairment0

1

2

3

4

5

6

7

8

9

10

Mean Scaled Score for BPI

prepost

scale

score

Pre N=16, post N=15

MULTI DIMENSIONAL HEALTH LOCUS OF CONTROL

internal chance powerful others-15

-10

-5

0

5

10

15

20

25

30

Pre-/Post-score differences

diff

ere

nce

internal chance powerful others

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

mean

mean

PROVIDER AND PATIENT PERSPECTIVES

PROVIDER QUOTES

PATIENT VOICES

CHALLENGES

CHALLENGES AND OPPORTUNITIES IN YOUR SETTING?

Take a moment to think about your setting.

Talk with your neighbor.

Share with the group.

Who would be on the team?

What benefits might you expect?

What challenges can you identify?

OPPORTUNITIES AND FUTURE DIRECTIONS

OPPORTUNITIES

Link attendance to opiate contract Multidisciplinary collaboration

Involve nutrition, PT, complementary alternatives etc.

Improved patient outcomes Identifying what components contribute to

change Develop ongoing booster sessions Provide further education and training to

PCPs Integration of feedback

FUTURE DIRECTIONS

HAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER

Continue program evaluations as quality improvement

Work towards sustainability

Continue to integrate modalities PT/OT Nutrition Resident/Med student

Increased BH Role in Pain Management Program Consulted at the time of

referral Follow patient through

maintenance phase of treatment

Design maintenance programming Workshop series for

patients who have completed

Chiropractics, acupuncture, tai chi, yoga , self-hypnosis, nutrition

What haven’t we thought of?How can we improve?

Next steps?

QUESTIONS AND THOUGHTS

SESSION EVALUATION

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!