We have not had any relevant financial relationships during the past 12 months.
DECLARATION OF FINANCIAL INTERESTS
AUDIENCE QUESTIONS
How many of us treat chronic pain? What comes to mind when you think of
patients with chronic pain? What are the common treatments for
chronic pain? Where are these treatments offered?
And by whom? Do they work? Are they evidenced
based?
IMPLEMENTING CHRONIC PAIN GROUPS
IN TWO DIVERSE FAMILY MEDICINE RESIDENCY CLINICS
Joan B. Fleishman, PsyDJeanna R. Spannring, PhDChristine N. Runyan, PhDPhilip Bolduc, MD
University of MassachusettsMedical School
OBJECTIVES
Define group protocol for treatment of chronic pain
Understand potential challenges and barriers to implementation in a primary care setting
Describe patient and provider perspectives on efficacy of treatment modality
SCOPE & NATURE OF CHRONIC PAIN
At least 116 million U.S. adults suffer from chronic pain conditions more than heart disease, diabetes, and
cancer combined Annual economic cost including health
care expenses and lost productivity: $560 – 630 billion
Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: The National Academies Press.
CURRENT TREATMENTS
Pharmacotherapy Injections Procedures/Surgeries PT/OT CBT, mindfulness,
psychotherapy Acupuncture Chiropractics
BEST PRACTICES???
BACKGROUND
Developed in CMHC in rural Colorado as a psychotherapy group
Intended to address this common co-morbidity of psychiatric illness PTSD Depression Borderline Personality Disorder Substance Abuse
STRUCTURE OF SESSION
8-sessions 90 min/sessions Dedicated nursing support Population:
Pilot w/ specific PCP referral All PCP referral Part of pain contract
STRESS & NERVOUS SYSTEM DISORDER
Rules of Neuroplasticity:1.What is fired together is wired together
2.What you don’t use you lose
3.When you break old paths, you can use those nerves to make new paths
MEDICATION OPTIONS FOR CHRONIC PAIN
opioids
tricyclics
NSAIDs
SNRI/SSRI
Anti-convulsants
CBT: EMOTIONAL AWARENESS
FearSadness
Guilt
Anger
PET Card(Emotional Awareness)
Physical Sensations
Clenched jaw/hands, heart pounding, rush of blood to the head
Emotions Angry, frustrated, overwhelmed
Thoughts I’m over this.When is it going to stop?!?
CBT TRIANGLE FOR PAIN
Thoughts
BehaviorsPain
- stuck- Helpless/hopeless- No control/power
Associated Emotions:-Depression - Stop
- Prolonged rest
- Activity/overactivity
Associated Emotions:-Overwhelmed-Hopeless/helpless
Associated Emotions:-Anger-Motivation
-Take Control-Prove pain can’t stop me
CBTThought Record
Situation Emotions 0-10 Automatic Thoughts Unhelpful Thoughts
Alternative Thoughts Emotions 0-10
Wake up in pain…again
PAIN 9/10
AngrySadOverwhelmedHopeless
109
1010
“not again”This’ll never end!I can’t take it anymore…
LabelingFortune tellingOvergeneralizing
I’ve gotten through it before, and I have strategies to help me…I can do this, even though it sucks
AngrySadFrustratedHopeful
5646
FUNDAMENTAL PROCESS ELEMENTS Development of and support through social
network Opportunity to ask questions Graded skill building with individualized
coaching Assigned weekly practice
check-in and discussion worksheets
Slide-shows with corresponding handouts Cumulative patient handouts Multi-disciplinary Therapeutic intervention
ESSENTIAL COMPONENTS
Multi-disciplinary care/team approach Bringing group psychotherapy to a
primary care setting Support from:
PCP Medical Director support Logistical support
SNAPSHOT: CLINIC PROFILESHAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER
9,000; 50% Medicaid CHC
Diverse patient population
Urban, academic, ambulatory primary care clinic
9 physicians, 2 NPs, 12 residents, 3 BHCs, clinical pharmacists
20,000; 90% Medicaid CHC, FQHC CMHC on site Diverse patient population 30% Spanish speaking Chronic Pain Management
Protocol 20 physicians,12 NP/PAs,
12 residents, 1 BHC, 1 nurse midwife
7 advocates; 3 care managers
MODELS OPIATE PRESCRIBING
HAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER
Opioid contract PCP-managed High variability in
implementation and prescribing practices
Practice-based registry 3 providers with
buprenorphine prescribing authority
Patients on opiates for 3+ months
Intake with program nurse Monthly visits with nurse Quarterly visits with PCP Aberrant behaviors
Illicit substances Misuse of prescription Missing visits
Possible measures More frequent visits Urines and pill counts Discharge from program
ATTENDANCE
Age: mean = 50.95, sd = 10.54, range: 30 – 67 years
Average group size = 5
68.03%
31.97%
referred attended 1st
48.72%51.28%<6 ses-sionscompleted
MEASURES
Each Session Wong-Baker Healthy Days Core Module (CDC HRQOL–
4) Pre/Post
Brief Pain Inventory Multi-dimensional Health Locus of Control Patient Health Questionnaire (full version) 12/20 complete sets for analysis
BRIEF PAIN INVENTORY
pain severity functional impairment0
1
2
3
4
5
6
7
8
9
10
Mean Scaled Score for BPI
prepost
scale
score
Pre N=16, post N=15
MULTI DIMENSIONAL HEALTH LOCUS OF CONTROL
internal chance powerful others-15
-10
-5
0
5
10
15
20
25
30
Pre-/Post-score differences
diff
ere
nce
internal chance powerful others
-1.00
-0.50
0.00
0.50
1.00
1.50
2.00
mean
mean
CHALLENGES AND OPPORTUNITIES IN YOUR SETTING?
Take a moment to think about your setting.
Talk with your neighbor.
Share with the group.
Who would be on the team?
What benefits might you expect?
What challenges can you identify?
OPPORTUNITIES
Link attendance to opiate contract Multidisciplinary collaboration
Involve nutrition, PT, complementary alternatives etc.
Improved patient outcomes Identifying what components contribute to
change Develop ongoing booster sessions Provide further education and training to
PCPs Integration of feedback
FUTURE DIRECTIONS
HAHNEMANN FAMILY HEALTH FAMILY HEALTH OF WORCESTER
Continue program evaluations as quality improvement
Work towards sustainability
Continue to integrate modalities PT/OT Nutrition Resident/Med student
Increased BH Role in Pain Management Program Consulted at the time of
referral Follow patient through
maintenance phase of treatment
Design maintenance programming Workshop series for
patients who have completed
Chiropractics, acupuncture, tai chi, yoga , self-hypnosis, nutrition