a brief overview of pain coping deprescribing · august 24, 2016 deprescribing jessica visco,...

DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD,

CGP

SeniorPharmAssist

Webinar #1Webinar #20

A Brief Overview of Pain Coping Skills Training Rationale and Strategies

Laura Porter, Ph.D.

Department of Psychiatry & Behavioral Sciences

Duke University School of Medicine

Disclosures No commercial support has influenced the planning of the

educational objectives and content of the activity. Any

commercial support will be used for events that are not CE

related.

There is no endorsement of any product by DUHS

associated with the session.

No influential financial relationships have been disclosed by

planners or presenters which would influence the planning of

the activity. If any arise, an announcement will be made at

the beginning of the session.

This program is supported by a Geriatric Workforce

Enhancement Program (GWEP) grant (U1QHP28708) from

the U.S. Bureau of Health Professions Health Resources

and Services Administration (HRSA).

Objectives

Describe the evolution in our understanding of pain

Summarize research on psychological processes in pain

Identify common, effective pain coping skills

Identify key components in training patients to use pain

coping skills

Describe the role of family caregivers in pain coping

Identify methods of assessing pain and applying pain

coping skills in patients with dementia

Traditional Model of Pain

• Pain is often viewed

as a sensory event

• Due to tissue

damage

• Treat injury/disease,

pain will be relieved

OUCH!

R. Descartes (17th Century)

Pain

Evolution of Pain Models

• Newer theories and

research about pain

indicate pain is a

multidimensional

experience

Sensory

Affective

Cognitive

Motivational

Brain Imaging

Studies

Evolution of Pain Models

The Pain Neuromatrix

Neuromatrix Theory

Sensory inputs

Visual and other inputs that influence cognitive interpretation

Phasic and tonic cognitive-emotional inputs from brain

Activity of body’s stress regulation systems

• Produce pattern that evokes pain

Key Point: A patient’s thoughts, emotions and behaviors (appraisals and coping efforts) shape and influence the pain experience

Pain as a Stressful Event

Outcome 1

Persistent Outcome 2

Pain

Outcome 3

Stress and Coping Theory (Lazarus and Cohen, 1977)

Persistent

Pain Appraisal Outcome

Conscious judgments:

• Judgment of painful event as

benign/irrelevant vs. threat/harm/loss

• Judgment of what can be done

Threat/Loss Appraisal

A B C

Event Appraisal Feelings/Behavior

“I can’t cope.

Pain flare There is nothing ???

I can do. I will end

up in a wheelchair”

Threat/Loss Appraisal

A B C

Event Appraisal Feelings/Behavior

“I can’t cope. Fear

Pain flare There is nothing Depression

I can do. I will end Avoidance

up in a wheelchair” Irritability

A Different Type of AppraisalA B C

Event Appraisal Feelings/

Behavior

Pain flare “ I know this will ???

be tough but I

know some things

I can do to manage

it.”

Effects of a Challenge

AppraisalA B C

Event Appraisal Feelings/

Behavior

Pain flare “ I know this will Concerned, but

be tough but I confident;

know some things pacing

I can do to manage activites

it.”

Findings from cross-sectional and

longitudinal studies

Pain coping

&

Appraisal

Outcomes

-Reports of pain – intensity, interferene, reports

of lab pain stimuli (QST)

-Directly observed pain behaviors

-Measures of psychological distress--depression,

anxiety, fear anger

-Assessments of physical disability—self reports,

performance based measures (speed of

walking, movement, grip strength)

-Behavioral outcomes-medication intake, return

to work, recovery from injury or surgery.

Key findings:

1. Passive or escapist coping relates to poor

outcomes

2. Active coping relates to good outcomes

3. Appraisals are very important

Psychosocial Treatment Protocols

Alter Pain Coping and Appraisal

Appraisal

+

CopingOutcome

• Cognitive behavioral

therapy (CBT)

• Mindfulness-based stress

reduction (MBSR)

• Acceptance & Commitment

Therapy (ACT)

And improve outcomes …….Arthritis pain

Cancer pain

Musculoskeletal pain (low back pain)

Migraine headache

Tension headache

Cognitive-Behavioral Pain

Coping Skills

Relaxation

Imagery

Pleasant activity scheduling

Activity-rest cycle

Cognitive restructuring

Mechanisms: decrease muscle tension, reduce

catastrophizing, increase positive emotion, promote

activity and engagement, increase self-efficacy

Delivering pain coping skills

interventions• Buy in from patient is critical

• Provider strong recommendation is invaluable

• Rationale for learning new pain management strategies

• Important components of skills teaching• Modeling of skill

• Practice the skill

• Reinforcement of skills practice and problem solving

• Rehearsal – plans for daily use

Rationale: Connections between pain,

thoughts, feelings, and behaviors

This will

never get

better. I can’t

do anything

to cope with

this pain.

This pain

has

ruined

my life.

Negative Thought

Negative

Feelings &

Physical

Reactions

Negative Actions

More

Negative

Thoughts

Gate Control Theory of Pain

Sensation Center

GATE

FEELINGS

CENTER

THOUGHTS

CENTER

Example: Relaxation

Provide rationale

Lead patient through exercise

Elicit feedback: “what did you notice?”

Address challenges

Encourage regular practice

Anticipate challenges/barriers

Example: Activity Rest Cycle Goal: pace activities and gradually increase them

without increasing pain

Social Context• Family caregivers are often integrally involved in pain

management• monitoring symptoms• administering medications• dealing with side effects• communicating with health professionals

• They often feel overwhelmed, frustrated, and helpless • Seeing a loved one in pain activates the same brain areas involved

when one experiences pain oneself (mirror neurons) (Simon & Lamm, 2009)

• They often overestimate patient pain

• Their response can make things better or worse

Benefits of including family caregivers

in pain coping skills training

• Increases caregiver understanding of the patient’s pain

and the role that pain coping skills can play

• Enhances caregivers’ self-efficacy (confidence) for

helping the patient manage pain

• Learn coping skills to manage their own stress and

symptoms

• Provides opportunities for positive interactions

Dementia and Pain Assessment• Ask patients simple questions about pain

• Ask about “aches” and “discomfort” and what activities

makes it worse

• Use a verbal descriptor scale (no pain--worst possible

pain)

• Observe behaviors and nonverbal indicators pain and

distress (PAINAD Scale): • Breathing

• Negative vocalization

• Facial expression

• Body language

• Consolability

• Ask family caregivers about behavior changes that may

signal pain (e.g., aggression, restlessness)

Dementia and Pain Coping• Modify delivery of pain coping skills based on patient’s

level of cognitive function

• Consider additional strategies such as music therapy,

gentle movement

• Involve a family caregiver

• Educate about the role of pain coping skills

• Provide skills for assessing pain and patient’s response to

intervention

Continuing Education Credits 1 hour of CE credit is being offered for this webinar.

For the live webinar, to obtain the credit you must:

Add your name to the chat box (to verify attendance)

Complete the survey. The survey will open automatically at the end of the webinar and the link will be sent in a follow-up email.

If you did not register for this webinar and would like CE credit, contact gero@duke.edu