Chronic Pain: Skills not PillsCare Transformation Collaborative of R.I.NELLY BURDET TE, PSY.D.

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Objectives•Define chronic pain and understand how adults and children are statistically impacted, as well as overlap between depression, anxiety and substance use

•Identify how screening tools in primary care can assist in understanding behavioral health comorbidity

•Learn to apply cognitive behavioral interventions in a busy primary care practice and incorporating into the care plan’s with five major elements

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Definitions◦ Pain without a biological value that has persisted

beyond the normal time (6 weeks) and despite the usual customary efforts to diagnose and treat the original condition and injury. 6

◦ Pain that continues when it should not 1

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Most common reason to visit PCP

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But I’m not a pain specialist◦ 5-33% prevalence in primary care settings 1

◦ 20% to 40% of children and adolescent impacted with ability to express pain at about 2 years of age, but reliable use of self-report numeric rating > 8 years of age 1, 5

◦ Most common chronic pain conditions ◦ Children and Adolescence: musculoskeletal pain, headaches, and abdominal pain 1

Adults: back pain, severe headache or migraine pain, neck pain and facial pain. 7

◦ Childhood chronic pain predisposes continuation of pain later in life and development of new forms of chronic pain 1

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“The presence of psychological difficulties should in no way invalidate a patient’s

complaint of pain, not should it eliminate the possibility that a general medical condition may also be present that is causing the pain.” 6

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IBH Pain Assessment◦ Current and/or history of: 6

◦ Depressive symptoms ◦ Physical/sexual abuse ◦ Chemical dependency

◦Role of stress and connection to pain, how patient thinks about their pain 3

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Depression & Chronic Pain2

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Depression & Chronic Pain: Causal or Casual?

◦ Depression is a biological relative of chronic pain 3

◦ Norepinephrine & Serotonin

◦ Depression precedes development of chronic pain 3

◦ Depression is a consequence and follows after chronic pain 3

◦ Patients with chronic pain are 4 times more likely to have comorbid depression than pain-free primary care patients 6

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Anxiety and Chronic Pain◦ 16.5% to 28.8% overall prevalence anxiety disorders 3

◦ Anxiety disorders more commonly occur before onset of chronic pain 3

◦ Risk factor for development of chronic pain 6

◦ Associated with fear of pain and fear of movement/reinjury 3,6

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Substance use and Chronic Pain◦ Increased prevalence (lifetime rates of 23%-41%) of

substance use in chronic pain 1,3

◦ Most commonly abused: Alcohol and Narcotics 3

◦ Most individuals have onset of substance use before onset chronic pain 3

◦ Chronic pain is NOT a unique risk factor for substance 3

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© Reproduced with permission Copyright with 2013 by Ronald D. Siegel, Michael H. Urdang, and Douglas R. Johnson

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© Reproduced with permission Copyright 2013 by Ronald D. Siegel, Michael H. Urdang, and Douglas R. Johnson

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Screening Tools◦ No diagnostic test for chronic pain 6

◦ Patient self-report is most reliable indicator of the existence and intensity of pain after age 8 6

◦ Many evidence-based screening chronic pain tools exist for non-verbal patients 5

◦ Dementia◦ Children◦ End of life

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Why skills not pills?◦ Pain is real, not in your head 6

◦ Psychological distress about pain actually amplifies one’s experience of pain. 1

◦ Pain catastrophizing◦ Magnification of threat, rumination, perceived inability to cope with pain◦ Consistently associated with greater physical and psychosocial dysfunction,

even after controlling for pain and depression levels4

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Cognitive Behavioral Therapy◦ Gold standard psychological treatment for individuals

with wide range of pain problems 4

◦ Three decades of application to chronic pain 4

◦ Randomized control trials show effectiveness in children, adults and older adults 4

◦ Compared to usual care for pain, small to medium effects on pain intensity, catastrophizing and mood

◦ Small effects on pain-related disability and activity interference

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How does CBT work?Goals of CBT: 4

◦ Reduce perception of pain and psychological distress◦ Improve physical and role functioning by helping decrease maladaptive

behaviors and increases adaptive behaviors, identify and correct maladaptive thoughts and beliefs, and increase self-efficacy for pain management.

◦ No standard protocol for CBT 4; techniques include:Relaxation Training Guidance in Activity PacingGoal-setting Behavioral ActivationProblem Solving Training Cognitive Restructuring

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Who can provide CBT?◦ Anyone that is trained and has 10 minuteshttp://www.10minutecbt.co.uk/

◦ Massachusetts General Hospital Psychiatry Academyhttp://mghcme.org/page/cognitive_behavioral_therapy

◦ Beck Training Institute for CBThttp://mghcme.org/page/cognitive_behavioral_therapy

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ACPA 1 chronic pain care plan

◦ Set personal goals◦ Improve sleep◦ Increase physical activity◦ Manage stress◦ Decrease pain

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Set personal goals◦ Realistic and reasonable 1

◦ Goal pain reduction and control rather than complete elimination. 1

◦ Schedule return visits on regular schedule rather than letting pain levels control frequency 6

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Improve sleep◦ Common for people with persistent pain to believe

that they sleep poorly because of pain, which may be true 1

◦ Studies demonstrate that it often happens the other way – poor sleep increases pain. 1

◦ Guidelines for better sleep handout

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Increase physical activity◦ Increased weight and obesity are often associated

with chronic pain, likely because of decreased activity, the use of certain medications and even depression that can lead to poor dietary habits. 1

◦ Obesity can cause or worsen sleep apnea, and people with chronic pain have a tendency to gain weight due to decreased activity. 1

◦ Pacing Handout

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Manage stress and decrease pain◦ Unhelpful thinking styles handout

◦ Relaxed Breathing handout

◦ Progressive Muscle Relaxation handout

◦ Decatastrophizing handout

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Treatment Recommendations◦ If mild to moderate depressive symptoms, treat both

behavioral health and physical health manifestations of pain 6

◦ If comorbid SEVERE major depressive disorder is diagnoses concurrently with chronic pain, depressive symptoms should be the primary focus of treatment 6

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Handouts◦ http://

media.psychology.tools/worksheets/english_us/guidelines_for_better_sleep_en-us.pdf

◦ http://media.psychology.tools/worksheets/english_us/pacing_for_pain_and_fatigue_en-us.pdf

◦ http://media.psychology.tools/worksheets/english_us/unhelpful_thinking_styles_en-us.pdf

◦ http://media.psychology.tools/worksheets/english_us/relaxed_breathing_en-us.pdf

◦ http://media.psychology.tools/worksheets/english_us/progressive_muscle_relaxation_en-us.pdf

◦ http://media.psychology.tools/worksheets/english_us/decatastrophizing_en-us.pdf

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References1. ACPA Resource Guide to Chronic Pain Medication and Treatment (2015). American Chronic Pain Association Inc.

Rockland, CA. http://www.theacpa.org/uploads/documents/ACPA_Resource_Guide_2015_Final%20edited%20(3).pdf

2. Arnow BA, Hunkeler EM, Blasey CM, et al. (2006). Comorbid depression, chronic pain, and disability in primary care. Psychosomatic Medicine, 68(2):262-268

3. Dersh, J., Polatin, P. B., & Gatchel, R. J. (2002). Chronic pain and psychopathology: research findings and theoretical considerations. Psychosomatic medicine, 64(5), 773-786.

4. Ehde, D.M., Dilworth, T.M. and Turner, J.A. (2014). Cognitive-behavioral therapy for individuals with chronic pain Efficacy, innovations and directions for research. American Psychologist, 69 (2), 153-166.

5. Herr K., Coyne, P.J., McCaffery, M., Manworren, R., and Merkel, S. (2011). Pain assessemtn in the patient unable to self-report: position statement with clinical practice recommendations. Pain Management Nursing, (12) 4, 230-250.

6. Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Institute for Clinical Systems Improvement. Assessment and Manage ment of Chronic Pain. Updated November 2013

7. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.http://www.cdc.gov/nchs/data/hus/hus06.pdf.