Integrated & Collaborative Care Practices for Teaching Pain

Management

Emilee J. Delbridge, PhD, LMFTDaniel S. Felix, PhD, LMFTDerrick L. Hasenour, MD

Ankush Goyal, MD

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # A1a, Proposal #5805078Friday, October 16, 2015

Faculty Disclosure

The presenters of this session• Have not had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able

to:

1. Identify specific educational approaches for addressing complex patients with chronic pain.

2. Discuss advantages & challenges of physicians and behavioral health clinicians collaboratively treating patients with chronic pain.

3. Practice developing integrated chronic pain management plans.

4. Improve skills in educating learners in complex patient encounters.

5. Identify benefits and challenges of educating using this clinical teaching approach.

Bibliography / References

1. Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ. 2010;340:c1035.

2. IOM (Institute of Medicine). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.

3. Stalmeijer, RE, Dolmans, HJM, Snellen-Balendong, HAM, van Santen-Hoeufft, M, Wolfhagen, IHAP, Scherpbier, AJJA. Clinical teaching based on principles of cognitive apprenticeship: Views of experienced clinical teachers. Acad Med. 2013;88:861-865.

4. Sveinsdottir, V, Eriksen, HR, Reme, SE. Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. Journal of Pain Research. 2012;5:371-380.

5. Wachtel, JK, Greenberg, MR, Smith, AB, Weaver, KR, Kane, BG. Residents as teachers: Residents’ perceptions before and after receiving instruction in clinical teaching. J Am Osteopath Assoc. 2013:113(1):23-33.

6. Pade, PA, Cardon, KE, Hoffman, RM, Geppert, CMA. Prescription opioid abuse, chronic pain, and primary care: A co-occurring disorders clinic in the chronic disease model. Journal of Substance Abuse Treatment. 2012;43:446-450.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Outline of Presentation

• 15 minutes: Chronic Pain Management Skills Intro & Inter-professional Teaching/Practice

• 15 minutes: Case Example Practice to apply CPM skills

• 5 minutes Review of Clinical teaching in CPM

• 5 minutes: Questions

What is Chronic Pain? “Physical or emotional suffering/discomfort caused

by illness, injury or stress, lasting longer than 3 months.”

• Nociceptive: Stimulation of peripheral nerve fibers

• Thermal• Mechanical• Chemical

Etiology of Pain

• Neuropathic: Damage affecting any part of the nervous system.

• Burning• Tingling• Electrical• Stabbing• Pins and Needles

Etiology of Pain

Etiology of Pain• Psychogenic pain: Caused prolonged mental,

emotional or behavioral factors. • Somatic• Conversion

Appropriate Pain Management

• Focus is on building relationshipso Learners & patients

• Full History of Pain & Thorough Examo Make an Accurate Diagnosis

• Multidisciplinary, Team-based Careo Mental health treatment, PT, Pharm, Imagingo Multiple learners

• Comprehensive Treatment Plan

Features of Pain Exam1. Pre-visit planning - Records - UDS/Inspect review

2. Assessment tools:- Initial pain assessment - PHQ-9 - GAD-7

3. Full HPI- Successes and failures

4. Review relevant histories

5. In-depth problem focused PE.

6. Labs/Imaging

7. Diagnosis w/ education

8. Plan of care and appropriate follow-up

Knowledge & Skills• Collaborative Treatment team/communication• Agenda-setting at beginning of clinic • No pain vs functional status goals• Skills related to exam, diagnoses, & plans

o UDS, Imaging, Physical Exam, Treatment Plan

• Use of medical therapies o Medications and interventions

• How to sell a plan with confidence to improve patient buy-in

Learner’s Case Narrative

A 20-yo WF with chronic low back pain after a therapeutic lumbar puncture for pseudo-tumor cerebrii in 2012.

• 2 Parts of this Practice Case

Pain Clinic Case Study

• Read through the case.

• Please get in groups of 3-5 o At least 1 medical provider per group

• In your group, discuss what an appropriate comprehensive treatment plan would be for this patient

Pain Clinic Case Study• Our approach

Pain Clinic Descriptive Data

• 165 patients seen since began in Feb 2014o 22% no show rate

• A sample of 77 patients:o Source of pain:

- Back (66%) - Knee (11%) - Hip (11%)- Neck (22%) - Shoulder (10%) - Fibromyalgia (7%)

Yes35%No 39%

Not known26%

Pain Im-provement

Yes22%

No 19%

Not known59%

Mood Im-provement

<60M36%

>60M12%

No 52%

Opiates Prescribed

Yes 48%

Resident Feedback/Data

• Sample of 23 residentso 12 had - 11 had not - participated in pain clinico Confidence means were higher (on a 1-5 scale)

3.02.6

2.22.6 2.4

3.4 3.3 3.23.7 3.6

Had NOT participated Had participated

Taking a full history

Diagnosing the cause

of pain

Comprehensive Treatment Planning

Collaborating with team

Referring out

Obtain a general medical history    

Obtain a history of medical treatments for pain    Obtain a history of non-medical treatments for pain (e.g. PT, OT, etc.)    

Obtain a past surgical history    

Obtain a history of physical trauma related to pain    

Obtain a history of opioid abuse    

Obtain a history of non-opioid substance abuse 36% 67%Obtain a history of psychosocial problems 27% 50%Obtain a history of mental health treatments 18% 42%Obtain a history of physical and/or sexual abuse    

Obtain a family history related to chronic pain    

Seek to understand what makes the pain better / worse    

Seek to understand how pain affects patient's functioning    

Seek to understand what patient's goals are for pain management    

Review past radiologic imaging 55% 92%Obtain a urine drug screen (UDS)    

Conduct a basic physical exam (i.e. heart, lungs, abdomen)    

Conduct a full shoulder exam 36% 83%Conduct a hip exam 36% 92%Conduct an SI joint exam 27% 92%Conduct a facet exam    

Conduct a neuroforaminal stenosis exam    

Conduct a spinal stenosis exam    

Conduct a degenerative disc exam 18% 42%Conduct a range of motion exam    

Conduct a knee exam 36% 83%Conduct an IT band exam 0% 42%Conduct a gait exam 36% 75%Conduct a podiatry (foot/ankle) exam    

Conduct a fibromyalgia exam    

Conduct a sensory exam    

Conduct a strength exam    

Conduct a reflexes exam    

Conduct a radicular symptoms exam    

Conduct a malingering exam    

Refer to physical therapy 64% 83%Refer to occupational therapy    

Refer to vocational rehab    

Refer to biofeedback    

Refer to a nutritionist    

Refer to bariatrics    

Refer to aquatics therapy    

Refer to massage therapy    

Refer for epidural injections    

Refer for spinal stimulation    

Refer for intrathecal pump    

Refer for acupuncture    

Refer for manipulation    

Refer to chiropractor    

Refer to mental health counselor 18%42%Refer to psychiatry    

Refer to yoga    

Refer to pharmacy    

Refer for cupping    

Utilize joint injections 18%42%Utilize trigger point injections    

Utilize TENS    

Recommend using heat    

Recommend using ice    

Recommend using topicals 45%75%Recommend using herbals (B-12, B-complex)    

Recommend using braces    

Prescribe Lyrica    

Prescribe Gabapentin (in the 1800-3000 mg range)    

Prescribe SNRI's 0% 50%Prescribe SSRI's 27%50%Prescribe TCA's    

Prescribe muscle relaxants 64%42%Prescribe Tramadol 27%58%Prescribe Kadian    

Prescribe Oxycontin    

Prescribe Methadone    

Prescribe Suboxone    

Prescribe Morphine    

Prescribe Oramorph    

Prescribe Percocet    

Prescribe Lortab    

Prescribe Norco 18%33%Prescribe Fentanyl Patch 18% 8%Prescribe NSAID's    

Prescribe Carbamazapine    

Prescribe Toradol    

Have not Have

Review of CPM Teaching

Skills Challenges• Relationship-building

o Learnerso Patients

• Team-based Care• Full History & Exam

-> Appropriate Diagnosis

• Comprehensive Treatment Plan

• Individual characteristics (of practitioners/pts)

• Lack of confidence (managing visit, prescribing medications)

• Time!• Developing shared

language• Pt’s readiness for change• Buy-in from various

providers

Questions?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor before

leaving this session.

Thank you!