The How and the What of Behavioral Health Intervention for Pain in a Medical Setting

6th Annual Montana Pain Initiative ConferenceUniversity of Montana

5/31/2014

Patrick Davis, PhDMontana Spine & Pain Center

Providence Health and Services St. Patrick Hospital

Missoula, MT

Conflict of Interest Disclosure

Has no real or apparent conflicts of interest to report.

Patrick Davis, Ph.D.

Why

Jenson & Turk (2014) Inadequacy of purely biomedical

treatments Demonstrated efficacy of behavioral

health interventions Behavioral health intervention for

chronic pain is a model for behavioral health intervention for other chronic health conditions

Stranger in a Strange Land

Role Clarity

Specialty Mental Health Professionalor

Primary Care Behavioral Health Consultant

Resources The Primary Care Consultant: The Next Frontier for Psychologists

in Hospitals and Clinics – James & Folen (Eds.) American Psychologist Special Issues

▪ Chronic Pain and Psychology (2014) ,Vol 69, No. 2▪ Primary Care and Psychology (2014), Vol 69, No. 4

When in Rome

Continuing Education A & P, etc.

Treatment Team Meetings Stay above the fray - Don’t form alliances

Documentation Rules: Abbreviations, Content consistent with procedure and diagnostic coding Timely, Legible, Brevity Action Oriented Balance of patient privacy and team need to know (minimum necessary rule)

Flexibility Schedule Practice habits

Ethical Differences Multiple relationships Patient autonomy v. Paternalism/non-maleficence

Laws in the House of God1. GOMERS DON'T DIE.2. GOMERS GO TO GROUND3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE

YOUR OWN PULSE.4. THE PATIENT IS THE ONE WITH THE DISEASE.5. PLACEMENT COMES FIRST.6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED

WITH A #14G NEEDLE AND A GOOD STRONG ARM.7. AGE + BUN = LASIX DOSE.8. THEY CAN ALWAYS HURT YOU MORE.9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.10.IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.11.SHOW ME A BMS (Best Medical Student, a student at the Best Medical

School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.12.IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE

A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.13.THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING

AS POSSIBLE.

But Seriously

1. Schedules are merely guidelines and aspirational.

2. Notes need to be completed on the same day that the service is provided whenever possible and no later than the following business day

3. You may have to provide referring providers with the language they need to ask you meaningful questions

4. If it takes more than one minute to read or explain your clinical impressions you will lose your audience

5. Be prepared for the warm handoff

6. Learn to translate medical jargon to street speak for patients

7. Ask the patient if they understand what the physical medicine provider told them

8. Clarify misconceptions

Primary Care CompetenciesReport of the Interorganizational Work Group

on Competencies forPrimary Care Psychology Practice

March 2013

6 broad core competency domains

Science Systems

Professionalism Relationships Application Education

Health & Behavior Codes

Who is eligible to use these codes? Psychologists, nurses, licensed clinical social workers, and

other non-physician health care clinicians whose scope of practice permits can bill the codes. Physicians performing similar services should use Evaluation and Management codes.

Focus of assessment not on mental health but rather on biopsychosocial factors important to physical health problems and treatment

Focus of intervention is to improve the patient’s health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems

Health & Behavior Codes

96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face with the patient; initial assessment.

96151 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face with the patient; re-assessment.

96152 Health and behavior intervention, each 15 minutes, face-to-face; individual.

96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients).

96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present).

96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present).

PAIN

Relevant Clinical Characteristics Childhood Sexual Abuse Adverse Childhood Experience (ACE) Study Suboptimal Attachment Dynamics Adverse Adult Experience Pain Behavior Attentional Bias/Somatic Focus Anxiety Depression Affective Distress in Response to Pain Catastrophizing Fear/Avoidance Low Self Efficacy Irrational Pain-Related Beliefs Characterological Negative Affectivity/Type D Personality Psychosocial Stress Deficient or Maladaptive Coping Strategies Tobacco Dependency Suboptimal Sleep Neuroplastic Change Posture Muscle Tension

Childhood Sexual Abuse

Norms in the general population 15-25% of females and 5-15% of males

▪ Finkelhor (1994)

Wurtele et al (1990) 39% of women & 7% of men seeking services for chronic pain

Finestone et al (2000) 69% of women in group therapy for survivors of childhood sexual

abuse v. 43% of combined control groups (psychiatric outpatients & nurses) reported chronic pain

Raphael & Widom (2011) Childhood abuse/neglect is associated with future chronic pain only

when PTSD is also present. Recommendation for assessment to “focus on PTSD rather than broad inquires into past history of childhood abuse or neglect”

Adverse Childhood Experience Schofferman et al (1992)

85% of patients reporting 3/5 types of childhood trauma had surgery failure v. 5% of those reporting 0/5 ▪ Sexual, physical, and/or emotional abuse, abandonment, and

parental substance abuse

ACE Study Emotional abuse, physical abuse, sexual abuse,

emotional neglect, physical neglect, parental separation, domestic violence, substance abuse, mental illness, prison

▪ http://acestudy.org/▪ http://www.cdc.gov/ace/index.htm

Attachment

Insecure Attachment Elevated prevalence of chronic widespread pain▪ Davies, Macfarlane, McBeth, Morriss, & Dickens, 2009)

Increased pain reporting and pain-related suffering among individuals with chronic pain ▪ McDonald & Kingsbury, 2006; McWilliams, Cox, & Enns, 2000;

Meredith, Strong, & Feeney, 2007

Higher health care utilization among chronic pain patients▪ Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003

Associated with a proclivity to catastrophize about pain▪ Kratz, Davis, & Zautra, 2011

Adverse Adult Experience

Trauma 66%-88% comorbid chronic pain in war veterans with PTSD ▪ Poundia et al (2006); Shipherd et al, (2007)

As much as 75% of torture victims develop chronic pain▪ Olsen et al (2007)

Trauma Onset FMS, RA▪ Hauser et al (2013): PTSD/FMS▪ Boscarino et al (2010): PTSD/RA

Stress▪ Khasar et al (2009): Cortisol and epinephrine cause intracellular

signal pathway changes in primary afferent nociceptor resulting in enhanced nociceptive signaling

Pain Behavior

Verbal: expressions of hurting; moaning, sighing, etc.

Non-verbal: limping, rubbing, grimacing, use of a cane, etc.

General activity level

Consumption of medications and use of other devices to control pain

Fordyce, W.E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby

Sanders, S.H. (2002). Operant conditioning with chronic pain: back to basics. In D.C. Turk & R.J. Gatchel (Eds.), Psychological approaches to pain management: a practitioner’s handbook. (pp. 128-137) New York: Guilford

Villemure & Bushnell (2009) Attentional Bias/Somatic Focus Anxiety Depression Affective Distress in Response to Pain

Provides a partial review of the literature demonstrating the impact of attention and mood on pain perception

MRI findings suggest that separate neuro-modulatory circuits underlie emotional and attentional modulation of pain

Catastrophizing

Seminowicz & Davis (2005)

Cites studies finding an impact of catastrophizing on pain intensity, disability, difficulty disengaging from pain, and predicting post-surgical pain levels

fMRI results demonstrated negative correlation between catastrophizing scores and activity of prefrontal cortical regions implicated in top down modulation of pain

Fear Avoidance

Vllaeyen & Linton (2012) Fear-avoidance model of chronic

musculoskeletal pain: 12 years on, PAIN, 153 (2012) 1144–1147

Low Self-Efficacy

Bandura (1977) Efficacy expectations determine how much effort people will expend

and how long they will persist in the face of obstacles and aversive experiences

A ‘‘resilient self belief system’’ whereby ‘‘people who believe they can exercise control over potential threats do not conjure up apprehensive cognitions and, hence, are not perturbed by them’’

Nicholas (2007) Brief summary of pain literature relevant to construct of self-efficacy▪ Treatment dropout▪ Pain behaviors▪ Work status▪ Medication use▪ Pain interference in daily behaviors

Author of the Pain Self-Efficacy Questionnaire (PSEQ)

Irrational Pain-Related Beliefs People are helpless to do anything about their pain People should not have to experience pain Pain is unacceptable The healthcare system can and should eliminate pain Pain makes it impossible to have a decent quality of life Life will just have to be on hold until pain goes away People who experience pain and physical limitations are worthless Pain always means the body is being damaged Pain means that it is not safe to exercise Increasing physical activity will cause increased pain Stress and emotions have nothing to do with pain Medication is the only effective treatment for pain Medication is the most effective treatment for pain

Cook & DeGood (2006): Cognitive Risk Profile for Pain (CRPP)

Characterological Negative Affectivity/Type D Personality

A tendency to experience negative emotions (e.g., anger, anxiety, sadness) across time and situations Barnett et al (2009) Type D personality and chronic

pain: construct and concurrent validity of the DS14

Melzack & Wall (1982). The Challenge of Pain

Janssen (2002) Negative affect and sensitization to pain

Negative Emotions

Negative emotions are associated with increased activation in the amygdala, anterior cingulate cortex, and anterior insula

These brain structures not only mediate the processing of emotions, but are also important nodes of the pain neuromatrix that tune attention toward pain, intensify pain unpleasantness, and amplify interoception (the sense of the physical condition of the body).

Thus, when individuals experience negative emotions like anger or fear as a result of pain or other emotionally salient stimuli, the heightened neural processing of threat in affective brain circuits primes the subsequent perception of pain

Psychosocial Stress

McFarlane (2007) Multiplicity of pathways between stress and

musculoskeletal pain▪ Posttraumatic body memory▪ Chronic HPA axis activation▪ Impact on CNS sensitization

Vachon-Presseau et al (2013) The overall portrait is that prolonged pain may

constitute an allostatic load in individuals showing more stress vulnerability, inducing long-lasting plastic changes that in turn instigate a spiraling down of the patient’s condition

Deficient/Maladaptive Coping Strategies

Riley & Robinson (1997) Revision of the Coping Strategies Questionnaire

(CSQ-R) Original CSQ conceived by Rosenstiel and Keefe 6 Scales▪ Distraction▪ Catastrophizing▪ Ignoring Pain▪ Distancing▪ Cognitive Coping▪ Praying

Tobacco Dependency

Behrend et al (2013) 5333 patients with spinal-related pain:▪ “As a group, those who had continued smoking during

treatment had no clinically important improvement in reported pain.”▪ “Compared with patients who had continued to smoke,

those who had quit smoking during the course of care reported significantly greater improvements in pain.”

Suboptimal Sleep

Cooperman et al (1934) Moldofsky et al (1975 & 1976) Roehrs et al (2006) Davies et al (2008) Okfuji & Hare (2011)

Sleep deprivation, and particularly lack of Stage 4 and REM sleep results in▪ Increased pain sensitivity▪ Increased musculoskeletal tenderness▪ Reduced pain tolerance▪ Reduced effectiveness of pain medication

Better sleep is associated with recovery from chronic widespread pain

Sleep Apnea – Epworth Sleepiness Scale

Neuroplastic Change

Seminowicz et al (2013) An 11-week CBT intervention for coping with chronic pain

resulted in increased GM volume in prefrontal and somatosensory brain regions, as well as increased dorsolateral prefrontal volume associated with reduced pain catastrophizing. These results add to mounting evidence that CBT can be a valuable treatment option for chronic pain

Zeidan, F., et al (2012) Reviews the growing literature documenting the benefits of

mindfulness meditation for reducing pain The data indicate that, like other cognitive factors that

modulate pain, prefrontal and cingulate cortices are intimately involved the modulation of pain by mindfulness meditation

Posture

Poor posture creates imbalances in the body in which some muscles are overworking and others are not doing their job

This creates stress on the joints, excessive tension in some muscles, deconditioning in other muscles and over time, leads to pain

Situational/Chronic Muscle Tension

Pretty much a no-brainer, but just for example:

Klinger et al (2010) Classical conditioning model of chronic muscle

tension Found that tension-type headache and low back

pain patients demonstrated a higher number of both conditioned and unconditioned muscle tension reactions in response to exposure to an aversive stimulus (electric shock)

Assessment

Pain

Numerical Analogue Scale (NAS) 0-10

McGill Pain Inventory –Short Form Sensory and Affective Dimensions

Multidimensional Pain Inventory Pain Severity Subscale

Psychosocial Factors Commercial Instruments

MMPI-2-RF Millon Behavioral Medicine

Diagnostic (MBMD) Pain Patient Profile (P3) Battery for Health Improvement -2

(BHI-2) Multidimensional Pain Inventory

(MPI)

Psychosocial Factors Non-Commercial Instruments

Hospital Anxiety and Depression Scale (HADS) Pain Catastrophizing Scale (PCS) Tampa Scale of Kinesiophobia (TSK) Chronic Pain Acceptance Questionnaire (CPAQ) Psychological Inflexibility in Pain Scale – 12 Item version

(PIPS-12) Pain Stages of Change Questionnaire (PSOCQ) Pain Self-Efficacy Questionnaire (PSEQ) Cognitive Risk Profile for Pain (CRPP) Screener for Opioid Addiction in Pain Patients – Revised

(SOAPP-R) Opioid Risk Tool (ORT) Epworth Sleepiness Scale and associated Snoring Scale

Treatment

Wall of Fame

Treatment Models

4 broad model of behavioral health intervention Jensen & Turk (2014)▪ Operant Models▪ Peripheral Physiological Models▪ Cognitive and Coping Models▪ Central Nervous System Neurophysiological Models

The Psychodynamic Perspective▪ Freud▪ Sarno

http://books.google.com/books?id=_8v-29HopocC&printsec=frontcover&source=gbs_ge_summary_r&cad=0