1

Carolyn Buesgens MA RN-BC ANP-BC Minneapolis VAHCS

Objectives 1 Define factors contributing to increased

complexity and risk in patients with chronic pain 2 Explain the limitation of opioids as unimodal

therapy for chronic pain 3 Describe a multimodal rehabilitation approach in

addressing factors of high risk or complex chronic pain

2

3

Biological components Psychological components Social components

4

5

bull 41year-old man with chronic low back pain bull sp lumbar epidural spinal injections and lumbar fusion bull 2011 EMG No evidence of peripheral neuropathy of the LE bull Past history of Valium overdose and suicide attempts bull Positive family hx substance abuse bull Mental health diagnoses depression anxiety disorder opioid and alcohol

dependence mood disorder rt medical condition bull Poor activity tolerance on Methadone 90 mg daily (limited standing and

sitting) bull Left his job two years ago bull Adjuvant medications gabapentin cyclobenzaprine venlafaxine bull Patient expressed desire to come off Methadone bull Non-pharmaceutical approaches stress management classes pain coping

skills class depression management skills ACT classes bull Physical therapy ldquodidnrsquot workrdquo

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Objectives 1 Define factors contributing to increased

complexity and risk in patients with chronic pain 2 Explain the limitation of opioids as unimodal

therapy for chronic pain 3 Describe a multimodal rehabilitation approach in

addressing factors of high risk or complex chronic pain

2

3

Biological components Psychological components Social components

4

5

bull 41year-old man with chronic low back pain bull sp lumbar epidural spinal injections and lumbar fusion bull 2011 EMG No evidence of peripheral neuropathy of the LE bull Past history of Valium overdose and suicide attempts bull Positive family hx substance abuse bull Mental health diagnoses depression anxiety disorder opioid and alcohol

dependence mood disorder rt medical condition bull Poor activity tolerance on Methadone 90 mg daily (limited standing and

sitting) bull Left his job two years ago bull Adjuvant medications gabapentin cyclobenzaprine venlafaxine bull Patient expressed desire to come off Methadone bull Non-pharmaceutical approaches stress management classes pain coping

skills class depression management skills ACT classes bull Physical therapy ldquodidnrsquot workrdquo

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

3

Biological components Psychological components Social components

4

5

bull 41year-old man with chronic low back pain bull sp lumbar epidural spinal injections and lumbar fusion bull 2011 EMG No evidence of peripheral neuropathy of the LE bull Past history of Valium overdose and suicide attempts bull Positive family hx substance abuse bull Mental health diagnoses depression anxiety disorder opioid and alcohol

dependence mood disorder rt medical condition bull Poor activity tolerance on Methadone 90 mg daily (limited standing and

sitting) bull Left his job two years ago bull Adjuvant medications gabapentin cyclobenzaprine venlafaxine bull Patient expressed desire to come off Methadone bull Non-pharmaceutical approaches stress management classes pain coping

skills class depression management skills ACT classes bull Physical therapy ldquodidnrsquot workrdquo

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Biological components Psychological components Social components

4

5

bull 41year-old man with chronic low back pain bull sp lumbar epidural spinal injections and lumbar fusion bull 2011 EMG No evidence of peripheral neuropathy of the LE bull Past history of Valium overdose and suicide attempts bull Positive family hx substance abuse bull Mental health diagnoses depression anxiety disorder opioid and alcohol

dependence mood disorder rt medical condition bull Poor activity tolerance on Methadone 90 mg daily (limited standing and

sitting) bull Left his job two years ago bull Adjuvant medications gabapentin cyclobenzaprine venlafaxine bull Patient expressed desire to come off Methadone bull Non-pharmaceutical approaches stress management classes pain coping

skills class depression management skills ACT classes bull Physical therapy ldquodidnrsquot workrdquo

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

5

bull 41year-old man with chronic low back pain bull sp lumbar epidural spinal injections and lumbar fusion bull 2011 EMG No evidence of peripheral neuropathy of the LE bull Past history of Valium overdose and suicide attempts bull Positive family hx substance abuse bull Mental health diagnoses depression anxiety disorder opioid and alcohol

dependence mood disorder rt medical condition bull Poor activity tolerance on Methadone 90 mg daily (limited standing and

sitting) bull Left his job two years ago bull Adjuvant medications gabapentin cyclobenzaprine venlafaxine bull Patient expressed desire to come off Methadone bull Non-pharmaceutical approaches stress management classes pain coping

skills class depression management skills ACT classes bull Physical therapy ldquodidnrsquot workrdquo

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics andor

high dose opioid

6

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Recent estimates suggest that pain and depressive disorder co-occur 30-60 of the time

Anxiety disorders may be present 35 of the time among person with chronic pain

Pain and PTSD co-occur 20-34 of persons with chronic pain meet criteria for PTSD chronic pain is present in 45-87 of persons with PTSD

Pain is present in 37-61 of patients seeking substance use disorders treatment

Pain undermines effective treatment for depression anxiety disorders PTSD and substance use disorders

7

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

When disability greatly exceeds what would be expected on the basis of physical findings alone

When patients make excessive demands on the health care system

When patients persist in seeking medical tests and treatments that are not indicated

When patients display significant emotional distress (eg depression or anxiety)

When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen

Adapted from Turk et al 2010

8

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Complex-chronic pain does not respond to our usual treatments (the ldquopain patientsrdquo) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more

aggressive expensive and risky medical treatments Unpleasant interactions Dissatisfied customers Medication adherence issues Overwhelmed and overwhelming

Iatrogenesis is a significant problem for this population A Mariano Seattle VA

9

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

KirshKL Passik S Exp Clin Psychopharm 2008 16(5) 10

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Not all patients are good candidates for opioid therapy

Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk

11

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients

with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARSSISAP Current Opioid Misuse Measure (COMM)

12

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Opioids are such a big part of the problem principally because they are such a small part of the solutionrdquo

Anthony Mariano PhD Seattle VAMC

13

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

High dose opioid use occurred in 24 of all chronic pain patients and in 82 of all chronic pain patients prescribed opioids long-term

The average dose in high-dose group was 3249 (SD=2851) The only significant demographic difference among groups was race w

black veterans less likely to receive high doses High-dose patients were more likely to have four or more pain diagnoses

and the highest rates of medical psychiatric and substance use disorders After controlling for demographic factors and VA facility neuropathy

low back pain and nicotine dependence diagnoses were associated w increased likelihood of high-dose prescriptions

High dose patients frequently did not receive care consistent w treatment guidelines There was frequent use of short-acting opioids urine drug screens were administered to only 257 of patients in the prior year and 32 received concurrent benzodiazepine rx which may increase risk for OD and death Morasco et al 2010

14

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Veterans with mental health diagnoses prescribed opioids especially those with PTSDlt were more likely to have comorbid drug and alcohol use disorders receive higher-dose opioid regimens continue taking opioids longer receive concurrent prescriptions for opioids sedative hypnotics or both and obtain early opioid refills

Seal et al 2012

15

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

16

2012 A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to lt 200 MED

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths 2011 JAMA 305 1315-1321

Dunn et al Opioid prescriptions for chronic pain and overdose 2010 Annals of Internal Medicine 152 85-92

Gomes et al Opioid dose and drug-related mortality in patients with nonmalignant pain 2010 Arch Int Med 171686-693

17

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

18

2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely

aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting

available behavioral pain programs o Trackingperformance measures

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

-8

-19

-27

-44

-50

-60

-50

-40

-30

-20

-10

0

10

Percent Reduction in Number of Patients at 50+ 100+ 200+ 500+ and 1000+ MEQday

Minneapolis VA May 2011 - September 2012

gt50 MEQ

gt100 MEQ

gt200 MEQ

gt500 MEQ

gt1000 MEQ

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Your patient does not have a right to opioids They have a right to good care and appropriate treatment and in some cases withdrawing or withholding opioids is ethically mandated

A Mariano PhD Seattle VAMC

20

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

21

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

22

Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-upmonitoring

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

23

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Validation ndash much of the struggle with patients relates to our communication of doubt

Education ndash the basis of effective long term care is a shared understanding of chronic pain

Motivation ndash patients vary in their willingness to engage in self management

Activation ndash primary clinical focus is on changing the way patients relate to pain Mariano PhD Seattle VA

24

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Shared by patients who are overwhelmed by pain and providers who find these people overwhelming Belief that objective evidence of diseaseinjury is

required for pain to be ldquorealrdquo View of pain as the only problem and which needs to

be avoided at all costs Expectation that urgent pain relief is the major goal of

treatment Overconfidence in medical solutions Provider is the ldquoexpertrdquo responsible for outcomes Patient is helpless ldquovictimrdquo of underlying diseaseinjury A Mariano Seattle VA 25

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Optimal treatment paradigm Comprehensive assessment and individualized

treatment plan Offer hope and help patient connect with their

valued life End uncertainty

26

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

ldquoTreating a pain patient can be like fixing a car with four flat tires You cannot just inflate one tire and expect a good result You must work on all fourrdquo Penny Cowan Executive Director American Chronic Pain Association

27

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Supportive therapies Cognitive-behavioral therapy

Re-conceptualizing of pain as problem to be solved Coping skills training

Behavioral Interventions Altering pain-related communication Behavioral activation

Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation

autogenic training) Hypnosis

28

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Mindfulness based programs ACT Acceptance and Commitment Therapy Books - Dahl JA amp Lundgren T (2006) Living beyond your pain Using acceptance and commitment therapy to ease chronic pain Oakland CA New Harbinger -Dahl JA Wilson KG Luciano C and Hayes SC (2005) Acceptance and commitment therapy for chronic pain Reno NV Context

Mind-Body Skills -cmbmorg Mindfulness Based Stress Reduction

Kabat-Sinn J Full Catastrophe Living Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness

29

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Urgent and absolute pain relief while it is an appropriate goal in acute and cancer pain is an inappropriate goal in the treatment of chronic pain It should not be the major focus of treatment A Mariano PhD

Seattle VAMC

30

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Redefine the problem and the solutions

Expect some pain ndash but reject disability and suffering

Have a plan for bad days

Activate Activate Activate

Build a health and hopeful lifestyle

31

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Missed opportunities to improve health and prevent further morbidity and disability

Address co-morbidities

Sleep apnea Insomnia Obesity DM Smoking

32

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

33

ldquohellipthe inappropriate treatment of pain includes nontreatment undertreatment overtreatment and the continued use of ineffective treatmentsrdquo The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States Inc Medical Boards 2004

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Arnstein P St Marie B Managing Chronic Pain with Opioids A call for change Nurse Practitioner healthcare foundation 2010 wwwnphealthcarefoundationorg 2010 accessed 100112

Breckenridge J Clark JD Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain J Pain 2003 Aug4(6)344-50

Bodenheimer T Lorig K Holman H Grumbach K Patient Self-management of Chronic Disease in Primary Care 2002 JAMA 288(19) 2469-2475

Bohnert et al Association between opioid prescribing patterns and opioid overdose-related deaths JAMA 2011 305 1315-21)

Bruera E Moyano J Seifert L et al 1995 The frequency of alcoholism among patients with pai due to terminal cancer Journal of Pain and Symptom Management 10 599

Chabal C Jacobson L Edmund F Mariano A Narcotics for Chronic Pain Yes or No A Useless Dichotomy APS Journal 1992 l(4) 276-281

Chelminski P Ives T Felix K Prakken S Miller T Perhac J Malone R Bryant M DeWalt D Pignone M A primary care multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden or psychiatric comorbidity BMC Health Services Research 2005 53

bull Dersh J Gatchel RJ Polatin P Mayer T Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability J Occup Environ Med 2002 May44(5)459-68

Dobscha SK Corson K Flores JA et al Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates Pain Med 2008 9(5) 564-71

Dunn KM et al Opioid prescriptions for chronic pain and overdose A cohort study Ann Intern Med 2012 15285-92

Dworkin R Richlin D Handelin D Brandt L Predicting treatment response in depressed and non-depressed chronic pain patients Pain198624 343-353

Fillingim R Doleys D Edwards R Lowery D Clinical Characteristics of Chronic Back Pain as a Function of Gender and Oral Opioid Use Spine 2003 January 28 (2) 143-150

Fishbain DA Cole B Lewis J et al What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuseaddiction andor aberrant drug-related behaviors A structured evidence-based review Pain Med 20089444-459

Guideline on Chronic Pain Assessment and Management Institute for Clinical Systems Improvement (ICSI) Copyright 2009 34

Jamison RN Kauffman J Katz NP Characteristics of methadone maintenance patients with chronic pain J Pain Symptom Manage 2000 19 53-62

Linton S A review of psychological risk factors in back and neck pain Spine 200025 1148-1156

Mariano A ldquoPatient Chronic Pain Education Taking self‐management from the classroom to the clinicrdquo

httpsvawwvisn23portalvagovminSiteDirectory np nd Menefee LA Cohen M Anderson WR Doghramji K

Frank EA Lee H Sleep disturbance and nonmalignant pain a comprehensive review of the literature Pain Med 20001156-172

McCracken L Vowles K Eccleston C Acceptance-based treatment for persons with complex long standing chronic pain A preliminary analysis of treatemt outcome in comparison to a waiting phase Behavior Research and Therapy 43(10) 1335-1346

Michna E Ross EL Hynes WL Nedeljkovic SS Soumekh S Janfaza D Palombi D Jamison RN Predicting aberrant drug behavior in patients treated for chronic pain Importance of abuse history J Pain Symptom Manage 2004 Sep28(3)250-8

Morasco BJ Duckart JP Carr TP et al Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain Pain 2010151625-632

Osterweis M Kleinman A Mechanic D Pain and disability clinical behavioral and public policy perspectives Washington DC National Academy Press 1987

Passik SD Issues in long-term opioid therapy unmet needs risks and solutions Mayo Clin Proc 200984593-601)

Passik SD Kirsh KL Whitcomb L et al A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy Clin Ther 200426552-561

Pizzo P Clark N Alleviating Suffering 101- Pain Relief in the United States 2012 N ENGL J MED 3663 197-9

Relieving Pain in America A Blueprint for Transforming Prevention Care Education and Research Washington DC The National Academies Press 2011Brennan

Robeck I Opioids The good the bad the ugly SCAN Echo presentation

Savage SR Assessment for addiction in pain-treatment settings Clin J Pain 200218S28-S38

Stuart and Lieberman (2002) The 15-minute hour Practical therapeutic intervention in primary care (3d ed)

Seal K Shi Y Cohen B Maguen S Krebs E Neylan T Association of Mental Health Disorders with Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan JAMA March 307(9)940-947

SAMHSA TIP 54 Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders 2012 US Department of Health and Human ServicesSAMS

TurkD Audette J Levy R Mackey S and Stanos S Assessment and Treatment of Psychosocial Comorbidities in Patients With Neuropathic Pain Mayo Clin Proc 201085(3)(suppl)S42-S50

Vlaeyena J amp Linton S Fear-avoidance and its consequences in chronic musculoskeletal pain

a state of the art Pain 85 (2000) 317-332 Wasan A Davar G Jamison RThe association between

negative affect and opioid analgesia in patients with discogenic low back pain Pain 2005 117(3) 450ndash61

Weingarten TN Shi Y Mantilla SB Hooten WM Warner DO Minnesota Medicine 2011 Mar Vol 94(3) Pp 35-7

35