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Pain Self-Care Tools for Veterans
Beth L. Dinoff, Ph.D.Director VIPS
Veterans Integrative Pain ServicesFayetteville VA Medical Center
Grand RoundsAugust 7, 2015
I have no financial disclosures to share. I have had chronic pain since 2001. I was a pain psychologist in training for
almost a decade before developing chronic pain.
Disclosures
Review common types of chronic pain responsive to patient self-care.
Describe self-care tools for recovery from chronic pain used in the primary care setting.
Demonstrate applications of self-care and recovery in clinic practice.
Learning Objectives
Definitions
Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
International Association for the Study of Pain
Chronic Pain
Chronic pain is without apparent biological value that has persisted beyond the normal tissue healing time (usually taken to be 3 months)
Responsive to Self-Care Skills International Association for
the Study of Pain
More Definitions
Self-Management (Self-Care)
Patients having a responsibility for managing some aspects of the condition independently or in conjunction with health care provider
Built upon a patient-centered approach, planned over time, enhances patient autonomy
“…Patient attitudes, behaviors and skills directed toward managing the impact of the condition(s) on all aspects of living.”
Flinders Human Behaviour and Health Research Unit, 2007
Medications = Functional improvementMedications ≠ Reduction in pain scores
Brief Education About Pain Medications
Whenever long-term pain meds of any kind are being considered for veteran’s chronic pain treatment plan… Always implement self-care strategies.
Pain medications can actually INCREASE pain sensations (opioid induced hyperalgesia).
Who and What Responds to Self-Care?
Who (i.e., which patients)?
Veterans Older adults Males Females Children Adolescents People with MH conditions
What (Pain Conditions)?
Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic
Percentage of veterans with chronic pain: 50% – 80%
VA PACTs see veterans 1 – 2 times annually Follow-up appointments last 30 minutes maximum Female veterans are at high risk for chronic pain Veterans with chronic pain commonly have multiple
co-morbidities, e.g., mental illness, substance use issues, and/or polytrauma
Chronic pain is complex, difficult, and often frustrating for VA providers (Dinoff et al., 2009)
Why Self-Care for Vets in Pain?Provider Perspective
16/90 clinical providers responded to Survey Monkey questionnaire (i.e., physicians, clinical pharmacists, nurse practioners, psychologists)
56% of providers were male Number of pain patients seen weekly
Fewer than 15: 63% 15 – 30: 25% 31 – 45: 13%
Treatments most commonly used: NSAIDS, antidepressants
Is Discomfort with Pain Management Linked to Provider Job Stress? A Pilot Study of VA Clinical
providers(Dinoff, Pilkinton, Dutton, Ustinov, & Jacobs, 2009)
Is Discomfort with Pain Management Linked to Provider Job Stress? A Pilot Study of VA Clinical
Providers(Dinoff, Pilkinton, Dutton, Ustinov, & Jacobs, 2009)
Positive Correlation ↑↑
r = .59 (p = .04) As challenging problems
increased (↑) Vets with addictions Documentation requirements
The more stress providers experienced (↑) Difficult relations with coworkers Having too much work to
complete
Negative Correlation ↓↑
r = -.58 (p = .02) Health care providers who
were more willing to work with chronic pain patients (↑) Became less distressed about
prescribing opioids (↓) Felt less fear of potential legal
actions (↓) Felt less coerced into
prescribing opioids (↓)
“Okay, so that study was about providers at a different VA. What makes you think that it applies to the FNCVA?”
Are We Really
Stressed About Pain
Management?
Question: The work that I do at the VA with Veterans in chronic pain is:
Satis
fyin
g
Challe
ngin
g
Frus
tratin
g
Wor
st P
art
0
6
Perceptions of Working with Vet-erans in Chronic Pain at the FNCVA
(July, 2015)PrescribersPsychologists/SWNurses RN/LPNOthers
Clinician Ratings
Why Self-Care for Vets in Pain?Because Pain Hurts Veterans
Pain on the battlefield lets you know that you’re alive. When pain continues, it takes away your willingness to stay that way.
An Unknown Military Veteran of the Iraqi Campaign
The acute care model of pain treatment just doesn’t work. Standard diagnostic testing commonly provides very little
useful information. Veterans become frustrated. The Veteran thinks nobody believes him/her. Veteran gets referred to mental health. The Veteran knows that s/he’s not “crazy.” Medications are stopped, nothing new is offered to them,
and Veterans they don’t know why when they are hurting. Veterans are hurting and don’t know what to do in order
start feeling better.
Why Self-Care for Vets in Pain?Veteran Perspective
Doleys and Dinoff highlight the potential contribution of psychosocial factors to interventional procedures whenever the desired outcome involves a reduction in subjective pain and patient adaptation to the experience of pain.
Doleys DM, & Dinoff BL. Psychological aspects of interventional therapy. Anesthesiol Clin North America 2003 Dec;21(4):767-83.
Damush et al. showed enhancing patient self-management skills decreased pain severity and improved functional status
Damush TM,Weinberger M, Perkins SM, et al. The long-term effects of a self-management program for inner-city primary care patients with acute low back pain. Arch Intern Med 2003;163:2632–8.
Proposes a model for pain self-management that involves activities and coping strategies; also recognizes the role of social connectedness of Veterans is vital to pain self-management.
Matthias MS, Miech EJ, Myers LJ, Sargent C, & Bair MJ. An expanded view of self-management: Patients’ perceptions of education and support in an intervention for chronic musculoskeletal pain. Pain Med 2012; 13: 1018-1028.
Pain education must be included with self-management skills training to be most effective as prevention of chronic pain.
Cosio D, Hugo E, Roberts S, & Schaefer D. A pain education school for Veterans: Putting prevention into VA practice. Federal Practioner 2012; March; 23-29.
Pain Self-Management: Does it Really Work?
Who and What Responds to Self-Care?
Who (i.e., which patients)?
Veterans Older adults Males Females Children Adolescents People with MH conditions
What (Pain Conditions)?
Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic
How to Help Engage a Patient in Pain Self- Care or Management
• Listen to the patient’s ideas and feelings about the illness or disease.
• Take time during consultation and recognize that chronic conditions change very slowly.
• Realize that you don’t complete the process in one consultation. Change is a process that occurs over time.
• Start somewhere with one goal.
Borrowed from SCAN-ECHO presentation by Drs. Chris Spevak and Ilene Robeck (August 4, 2015)
Trans-Theoretical Stages of Change
Model
Stages DefinedPre-contemplation: Not thinking about changeContemplation: Thinking about changePreparation: Getting ready to changeAction: Actually changing behaviorsMaintenance: Change is now routine or a habitRelapse: Returned to former behaviors
What Patients Say
I may.
I won’t.
I am.
I can’t. I still
am.
I will.
I’ve tried that before. It won’t work for me. You don’t understand my pain.
I want my pain meds. My pain is different than the others. I can barely walk.
Pain Self-Care Tools and Skills
Pain Education Gate Control Theory, Neuroplasticity
Improve Functioning Sleep, Movement, Employment
Emotion Regulation Fear, Anger, Anxiety
CBT and ACT Catastrophizing, Acceptance, Engage
Socialization Family, Friends, Pain Support Groups
Understanding pain What are the pain pathways in
my body? Why am I hurting? How do pain treatments work? Theories of pain
Gate Control Theory Medical model vs.
Biopsychosocial Model Neuroplasticity (!)
Self – Care: Pain Education
The Brave New World of Neuroplasticity and Pain
No pain
Acute pain
Chronic pain
Movement – Engaging the body – Yoga – Activities Sleep – Reduce napping – Enhance restorative sleep Reduce Substance Use – Tobacco, Marijuana, ETOH,
Food….. Pleasurable events – Hobbies – Valued living Work – Employment – Household Pacing – Stress management – Triggers
Self Care: Improve Functioning
Pain vs. SufferingFear of pain
Fear of injury from activityAnger management
Anxiety and depressionPost-traumatic stress
ForgivenessGrief and loss
Catastrophizing
Self-Care: Emotion Regulation
Self-Care: CBT and ACT
Thoughts Feelings Behaviors Goal
setting Relaxation
training Pleasant
events
Cognitive Behavioral TherapyAcceptance and Commitment
Therapy
Psychological flexibility
Experiential avoidance
Committed action Cognitive fusion Personal Values Acceptance Willingness
Family members – Decrease enabling behaviors
Increase compassionate supportPartner – Sex – Intimacy
Churches/Mosques/SynagoguesSupport groups
FriendsCo-workers
Pets
Self-Care: Socialization
↓ ↓ ↑
Clinical Practice ApplicationsBegin Where the Veteran Wants to Begin
Pain Education Improve Functioning Emotion Regulation CBT and ACT Socialization
Non-jargon conversations
PT, OT, walking Show compassion Catastrophizing/
Accept Family, intimacy
Start with one approach. Set goals with the Veteran. Give praise for successes.
Case Presentation: Ms. Trice
Vital Signs
Temp: 97.6 F [36.4 C] Pulse: 78 Resp: 16 BP: 121/80 Pain: 9 Height:70 in [177.8 cm] Weight:222.5 lb [101.1 kg] BMI: 32.0
Active Problems
Dizziness Deep venous thrombosis of LE Urinary incontinence GERD Migraine, unspecified, Paresthesia Neuropathy Chronic Low Back Pain Allergies Hyperlipidemia
57yo, divorced, Caucasian female, post-Vietnam
50% SC Intervertebral disc syndrome (40%) Neuralgia of external popliteal nerve (20%), Varicose veins
(0%)
Started having back pain while in the military 30+ years ago
Progressively worsened with pregnancies (x3) Honorable discharge, tried PT (-), TENS (+) 5/2009 had microdiscectomy or microdecompression, L5-S1, reduced pain 2-3 months When pain worsened, she was placed on methadone Pain begins LB, radiates thru right buttock, calf, foot Sharp, burning pain, numbness, right side weakness Evaluated for spinal cord stimulator in 2014,
recommended psychotherapy
Case Presentation: Ms. Trice57yo, divorced, Caucasian female, post-
Vietnam50% SC Intervertebral disc syndrome (40%)
Neuralgia of external popliteal nerve (20%), Varicose veins (0%)
Veteran was seen by clinical psychologist for 4 one-hour psychotherapy sessions over the span of 2 months.
Veteran described as: “motivated and engaged in therapy. She understood concepts rapidly and had relevant questions….approach made sense to her…could help her to manage her chronic pain.”
Focus of psychotherapy: “reducing suffering while accepting that the physical sensation of pain, diffusion from thoughts, emotions, and bodily sensations, and fostering a relationship with the pain which is present-focused, non-judgmental, and mindful.”
Skills taught or used: deep breathing, body scan, values identification, present focus, welcoming of pain sensations
7 months later requested booster sessions - veteran was experiencing family stressors and noticed an increase in pain symptoms
Case Presentation: Ms. TriceBehavioral Health
Summary and ConclusionsWho and What Responds to Self-Care?
When Do We Initiate Self-Care Conversations?
Who (i.e., which patients)?
Veterans Older adults Males Females Children Adolescents People with MH conditions
What (Pain Conditions)?
Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic
Every time you discuss pain.
Bounty wants to know
Do you have any questions?