Integrated Models of Care:Integrated Models of Care:Pain ManagementPain Management

Robert D. Kerns, PhDRobert D. Kerns, PhDNational Program Director for Pain Management, VACONational Program Director for Pain Management, VACO

Chief, Psychology Service, VA ConnecticutChief, Psychology Service, VA ConnecticutProfessor of Psychiatry, Neurology and Psychology, Yale Professor of Psychiatry, Neurology and Psychology, Yale

UniversityUniversity

Integrative care Integrative care

Psychology, psychologists, and pain Psychology, psychologists, and pain managementmanagement

Primary models of pain perception emphasize the central Primary models of pain perception emphasize the central role of psychological factorsrole of psychological factors

Role of psychological factors in the development and Role of psychological factors in the development and perpetuation of persistent pain is universally acceptedperpetuation of persistent pain is universally accepted

Psychological interventions for pain management are Psychological interventions for pain management are accepted as efficacious and cost-effective accepted as efficacious and cost-effective

Approximately 20% of members of IASP and APS are Approximately 20% of members of IASP and APS are psychologistspsychologists

Current president of APS is Dennis Turk, a psychologist Current president of APS is Dennis Turk, a psychologist

Goal of VHA National Pain Management Strategy is to Goal of VHA National Pain Management Strategy is to incorporate an interdisciplinary, multimodal approach to incorporate an interdisciplinary, multimodal approach to pain managementpain management

Efficacy of psychological Efficacy of psychological interventions for chronic paininterventions for chronic pain

Meta-analysis of RCTs of psychological treatments for clbpMeta-analysis of RCTs of psychological treatments for clbp

Effect sizes were calculated from 22 RCTsEffect sizes were calculated from 22 RCTs

Positive effects of psychological interventions, relative to Positive effects of psychological interventions, relative to numerous control conditions, were noted for pain intensity, numerous control conditions, were noted for pain intensity, interference, quality of life, and depressioninterference, quality of life, and depression

Cognitive-behavioral and self-regulatory treatments were Cognitive-behavioral and self-regulatory treatments were found to be efficaciousfound to be efficacious

Multidisciplinary treatments that included psychological Multidisciplinary treatments that included psychological interventions had positive long-term effects on return to interventions had positive long-term effects on return to workwork

Integrative model of pain careIntegrative model of pain care

Stepped care approach to pain managementStepped care approach to pain management– Level one: Primary responsibility rests with primary care Level one: Primary responsibility rests with primary care

providersproviders– Level two: “Living with Pain Class”Level two: “Living with Pain Class”

Patient education and rehabilitation modelPatient education and rehabilitation model– Review of common pain conditionsReview of common pain conditions– Personal review of medicationsPersonal review of medications– Discussion of self-management modelDiscussion of self-management model– Personalized exercise planPersonalized exercise plan– Practice of self-regulatory pain strategies, e.g., breathing, relaxation, Practice of self-regulatory pain strategies, e.g., breathing, relaxation,

activity pacingactivity pacing

– Level three: Comprehensive Pain Management CenterLevel three: Comprehensive Pain Management Center

Comprehensive Pain Management Comprehensive Pain Management Center at VA ConnecticutCenter at VA Connecticut

Integrative clinical, research, and training programIntegrative clinical, research, and training program Interdisciplinary staffInterdisciplinary staff ““Virtual Clinic”Virtual Clinic” Primary Care Clinic integration Primary Care Clinic integration Primary roles of psychologistsPrimary roles of psychologists

– Conduct comprehensive pain assessmentsConduct comprehensive pain assessments– Development and enactment of integrative treatment plan Development and enactment of integrative treatment plan – Care coordinationCare coordination– Primary clinician in delivery of psychological treatmentPrimary clinician in delivery of psychological treatment– Assessment of outcomesAssessment of outcomes– Education and trainingEducation and training– ResearchResearch

Targets for improvement

Improved accessImproved access Successful engagementSuccessful engagement Reduced drop-outReduced drop-out Enhanced adherence to treatment Enhanced adherence to treatment

recommendations recommendations Maintenance of treatment gainsMaintenance of treatment gains Relapse preventionRelapse prevention

Ongoing research Ongoing research

Targeting these areas for improvementTargeting these areas for improvement– Refine CBT to promote engagement, adherence, and Refine CBT to promote engagement, adherence, and

outcomesoutcomes– Refine CBT for special populationsRefine CBT for special populations

ElderlyElderly Women with vulvodyniaWomen with vulvodynia Painful diabetic neuropathyPainful diabetic neuropathy MS-related painMS-related pain

– Investigate treatment process variablesInvestigate treatment process variables Readiness for self-management of painReadiness for self-management of pain

Refining processes of referral and engagement

Education/Training of primary care providers Education/Training of primary care providers Knowledge and attitudes about self-management Knowledge and attitudes about self-management

treatmentstreatments Patient-centered counseling/Use of motivational Patient-centered counseling/Use of motivational

interviewing techniquesinterviewing techniques Respond to patient concerns and beliefs that are Respond to patient concerns and beliefs that are

incongruent with adoption of a self-management incongruent with adoption of a self-management approachapproach

Endorse self-management treatment and goalsEndorse self-management treatment and goals Assure follow-up and continued coordination of Assure follow-up and continued coordination of

carecare

Training primary care providers

Brief educational sessionBrief educational session Relevance of self-management and Relevance of self-management and

rehabilitation approachesrehabilitation approaches Overview of multidisciplinary pain centerOverview of multidisciplinary pain center Review of pathway for referralReview of pathway for referral

Group training followed by individual Group training followed by individual consultationconsultation

Use of modeling (video) Use of modeling (video) VIDEO_TS.IFO

PRIME-CBT

Based in a primary care settingBased in a primary care setting Collaboration with primary care Collaboration with primary care

practitioner (PCP)practitioner (PCP) Explication of referral processExplication of referral process PCP education and trainingPCP education and training Modifications to CBTModifications to CBT

Refining self-management treatment

Collaborative sessions involving primary care providerCollaborative sessions involving primary care provider Explicit attention to readiness to adopt a self-management Explicit attention to readiness to adopt a self-management

approachapproach Use of stage-matched tasks and processes of change (e.g., Use of stage-matched tasks and processes of change (e.g.,

consciousness raising with “precontemplators”, increasing consciousness raising with “precontemplators”, increasing support for “strivers”) support for “strivers”)

Use of motivational interviewing strategies (Use of motivational interviewing strategies (expressing expressing empathy, developing discrepancy, rolling with resistance, empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy)and supporting self-efficacy)

Results of PRIME CBT study

Both CBT (n=33) and PRIME CBT (n=33), relative to TAU Both CBT (n=33) and PRIME CBT (n=33), relative to TAU (n=23), demonstrated significantly greater improvements on (n=23), demonstrated significantly greater improvements on measures of pain, disability, and emotional distressmeasures of pain, disability, and emotional distress

PRIME CBT, relative to CBT, resulted in:PRIME CBT, relative to CBT, resulted in: significantly increased adherence to weekly homework significantly increased adherence to weekly homework

and goalsand goals significantly greater goal accomplishmentsignificantly greater goal accomplishment significantly greater patient satisfactionsignificantly greater patient satisfaction

Mean percent intersession adherence for PRIME CBT was Mean percent intersession adherence for PRIME CBT was approximately 70%approximately 70%

Tailored CBT

CBT as inherently flexible approach that accommodates CBT as inherently flexible approach that accommodates to “prescriptive treatment planning”to “prescriptive treatment planning”

Assess patient preferences for learning specific pain Assess patient preferences for learning specific pain coping skillscoping skills

““Tailor” CBT on the basis of patient preferencesTailor” CBT on the basis of patient preferences Employ motivational interviewing techniques to Employ motivational interviewing techniques to

encourage “forward stage movement” or enhanced encourage “forward stage movement” or enhanced readiness to adopt specific pain coping skillsreadiness to adopt specific pain coping skills