Tackling Issues in Pre-Surgical Psychological Assessments

1. Tackling Issues in Pre-Surgical Psychological Assessments Brent Van Dorsten, Ph.D. President: Colorado Center for Behavioral Medicine President: Colorado Pain Society (2014- Present) 4600 South Syracuse Street – 9th Floor Denver CO 80237 303-256-6625 (O); vandorsten@ccbm.com

2. It is more important to know which person has a disease than to know which disease the person has. - Sir William Osler (1849-1919)

3. The Epidemiology of Pain 80% of all MD visits include the complaintof pain Turk & Gatchel 1996 Over 1/3 of Primary Care visits are for the primary complaint of painUpshur et al. 2010 Up to 50% of US adults have pain at any time Gatchel et al. 2007; Elliott et al 1999; Walker 2000 Psychosocial factors strongly contribute to pain onset, severity, chronicity and disability Van Dorsten & Weisberg (2011), Van Dorsten 2010 Most expensive 20% of patients account for 88% of all healthcare costs Ashe et al. 2001

4. The Chronic Nature of Patients With Pain: Why? • 379 neuropathic pain patients referred for first evaluation at a German pain clinic. • 8 MDs for 10 years prior to referralStrumpf et al. 1993 • 134 CRPS patients – initial evaluation: US Pain Clinic • 5 MDs for 30 months prior to referralAllen et al. 1999 • 77 pain patients – first referral to NZ Pain Clinic • 6 yrs, intensity 7.9 at referral time Petrie et al. 2005 • TMD/face pain patients referred to US face pain clinic • 3.2 MDs for 34 mo. prior to referral Glaros et al. 1995

5. Why Pursue Behavioral Evaluations Prior to Implantation Surgery? • Historically reported that ~50% of patients receive ~ 50% pain relief 1-2 years after implantation • Psychological and behavioral/lifestyle factors widely shown to influence the outcome of medical treatment for pain • Proclivity of many physicians to attribute failed surgeries solely to psychological factors Tait et al., 2005 • Most common reasons? Insurance mandate and/or because the physician has already conducted a “subjective psychological assessment” and is concerned about the patient’s psychosocial status

6. Behavioral Evaluations Prior to Implantation Surgery: New Idea? • Long et al. (1981) reported a 33% success rate in unscreened patients compared with 70% success rate in patients completing psychological evaluationDoleys 2006 • Norman Shealy implanted first SCS (1968) and stressed the importance of the patient’s psychological condition/patient selection (1975) • Doleys (1997)…Need evaluation of specific psychological factors NOT a general psychological or psychiatric assessment • Daniel et al. (1985) used psychological assessment factors to predict outcome of surgery with 76.5% accuracy • North et al. (1996) reported that at least 20% of patients “misrepresent” trial success in order to get a permanent implant

7. Behavioral Assessment and Treatment Goals The ultimate goal of a pre-surgical behavioral evaluation is to increase the probability in YOUR favor of implanting the appropriate patients, NOT implanting an inappropriate patient, and to allow you to improve your post-surgical outcomes with a modicum of personal and clinic resources.

8. Behavioral Assessment and Treatment Goals Far too often, referrals for pre-surgical psychological assessments are made for the sole purpose of obtaining insurance authorization to conduct a trial and implant If behavioral care is not to be a component of ongoing treatment for the patient, a pre-surgical assessment is largely meaningless

9. Behavioral Assessment and Treatment Goals In Neuromodulation • Identify threats to treatment success • Increase insights into maladaptive coping • Develop short (1-3 month) and long-term (9-12 month) treatment goals • Shape patient expectations towards management not cure • Devise structured, measurable behavioral strategies to improve lifestyle patterns

10. Behavioral Pain Management What it IS… • Short term problem-focused cognitive and behavioral strategies intended to decrease suffering and increase adaptive daily activities • A means of identifying and minimizing the effect of behavioral or affective risk factors on outcome

11. Behavioral Pain Management What it is NOT… • An “alternative” to medical care • Long-term psychotherapy to find the “real reason” a patient is reporting pain • Intended to “cure” pain complaints by resolving the “underlying” emotional issues

12. Referral Criteria for Pre-Surgical Behavioral Evaluations • Subjective symptoms inconsistent with identifiable medical pathology • High levels of mood or psychiatric distress • History of psychiatric/psychological treatment • Sleep disturbance (insomnia or hypersomnia) • Excessively high or low treatment expectations • Marital distress or lack of social support • Negative work attitudes/dissatisfaction Block et al. 2003

13. Behavioral Referral Criteria • Excessive disability from pain > 3 months • Prolonged “activity intolerance” after injury • Excessive reclining (>15+ hours) • “Catastrophizing” regarding recovery • Negative outcomes with all other treatments • High dose opioids and/or anxiolytics/benzos • Litigation or continuing benefits s/p injury • History of non-adherence with treatment • Persistent maladaptive coping efforts Block et al. 2003

14. Depression and Medical Treatment Outcome Depression • Prevalence among Medical Patients • 5-40% in primary care Coyne 2002; Niles 2005, Gaynes 2007 • 30-40+% among patients with pain Turner 1984 • ~50% Gatchel & Young (2005) preliminary data of patients with pain disorders • A common condition that merits at least initial evaluation in patients with pain

15. Anxiety and MedicalTreatment Outcome Anxiety • Prevalence Among Medical Patients • 49% Primary Care, 52% Specialty Clinics • Social phobia, GAD, PTSD Gaynes et al. 2007 • 40-50% preliminary data of pain patients • Gatchel & Young 2005, Reid et al. 2002 • A common condition that merits at least initial evaluation in patients with pain

16. Influence of Mood on Medical Treatment Outcome Depression and Anxiety Disorders INCREASED: • Health care utilization, MD/ER visits • Medication use (3-6 fold increase in opioid prescriptions) Reid et al. 2002; Sullivan et al. 2005 • Premature treatment drop-out, relapse after treatment • Sedentary activity, alcohol/drug use • Number of health and pain complaints • Pain severity • Post-operative pain • Duration of pain • Functional limitation and disability Adapted from Van Dorsten & Weisberg 2011

17. Influence of Mood on Medical Treatment Outcome Depression and Anxiety Disorders DECREASED: • Return to work • Adherence with treatment recommendations • 1.79-3.0 odds ratio of poor adherence Grenard et al. 2011, DeMatteo et al. 2002, Gonzales et al. 2008 • Overall rehabilitative outcome • ~50% retention of information provided Adapted from Van Dorsten & Weisberg 2011

18. Methods of Summarizing Psychological Assessment Data 3-4 Pre-Surgical “Systems” previously published • Each considers several “weighted” medical and psychological risk factors • Typically offers “red-yellow-green” or “good-fair-poor” classifications • Predictive accuracy of “scorecards” 75-85% • Good candidates have consistently shown superior pain relief, improved functional ability, less pain medication, and fewer complications and re-surgeries • Offers tangible treatment recommendations

19. REFERRING OFFICE RESPONSIBILITIES -AVOID CONTAMINATING EVALUATION • Present Solid Rationale for Behavioral Assessment • DO NOT TELL PATIENTS “You’re a good candidate unless the psych eval rules you out” • DO NOT TELL PATIENTS what to say in order to get approved for implant (e.g., “you must tell me that you got at least 50% relief during trial”) • Discuss need for ongoing care to improve functional outcomes – will not “just happen” • Devise plan for repeated measure of FUNCTION

20. REFERRING OFFICE RESPONSIBILITIES -AVOID CONTAMINATING EVALUATION • Emphasize that a “Behavioral Health” or “Behavioral Pain” evaluation is conducted as a standard part of the assessment • The PURPOSE of a Behavioral Pain assessment is to better elucidate the impact of a patient’s pain condition on their daily function. This allows us to identify specific targets for behavior change. • The PURPOSE of a “psych eval” is to determine the patient’s psychiatric functioning to better elucidate signs of mental illness.

21. Pre-Surgical Psychological Screening (PPS) Block et al. (2001) empirically tested predictive accuracy of various factors • Evaluated 204 patients prior to lumbar fusion or laminectomy (by definition…our patients have failed these procedures as well…) • Considered multiple medical and psychological risk factors • Evaluated predictions against outcomes • VAS/NRS, medication use, Oswestry

22. Risk Factor Pending Litigation Worker’s Compensation - current Job Dissatisfaction Heavy Job Demands Substance Abuse Family Reinforcement of Pain Marital Dissatisfaction Physical/Sexual Abuse History Pre-Injury Psychological Treatment Risk Score 2 2 1 = Mod, 2 = Severe 2 = >50 lbs lifting 1 = Pre-Injury, 2= Current 1 = Mod, 2 = Extreme 1 = Mod 2 = Extreme 1 = Past, 2 = Current 1 = Outpt, 2 =Inpatient PPS Psychological Risk Factors

23. Risk Factor MMPI-2 Elevations > 70 (max = 4) HS – Hypochondriasis HY – Hysteria D – Depression PD – Resistant to Authority/Anger PT – Psychasthenia Coping Strategies Quest. (max = 2) Low Self-Reliance Poor Ability to Control Pain Psychological Total Risk Score Risk Score 2 2 2 = Pre-Existing 1 = Reactive to Pain 2 1 2 2 ≥10 = high risk PPS Psychological Testing Risk Factors

24. Risk Factor Chronicity of Health Complaints Previous Spine Procedures Destructiveness of Procedures Non-Organic Signs Non-Spine Related Medical Treatments Smoking Obesity (Class II) Medical Total Risk Score Risk Score 0-2 (duration) 0-2 (number) 1 = Laminectomy 2 = Fusion 2 = If Present 1-2 (amount) 1-2 (amount) 1 if ≥50 % of Ideal Wt ≥8 = high risk PPS Medical Risk Factors

25. PPS Determination of Surgical Prognosis GOOD – Low Medical and Psych Risk 15.2% of Block (2001) Sample FAIR – One HIGH and One LOW Risk 58.8% of Block (2001) Sample POOR – High Medical and Psych Risks 26% of Block (2001) Sample

26. PPS Accuracy of Prediction GOOD Prognosis Group 9.7 False Positive Rate (3/31) FAIR Prognosis Group 19.2 False Positive Rate (23/120) POOR Prognosis Group 11.3 False Negative Rate (6/53)

27. PPS Factor Contributions to Overall Prediction of Surgical Outcome Psychological Testing Data Correctly Classified 78.4% of Cases PLUS Psychological Interview Data Correctly Classified 83.3% of Cases (4.9%) PLUS Medical Risk Factors Correctly Classified 84.3% of Cases (1%) **Only Obesity > 50% of ideal body weight contributed to prediction of outcome !!

28. Fear Avoidance of Activity“Kinesiophobia” Avoidance of adaptive activity stemming from the maladaptive belief that activity will produce actual tissue damage, physical re-injury, or uncontrollable pain levels Fear Avoidance/Kinesiophobia: SO WHAT? Fear avoidance strongly predicts functional disability in both adults and children! Pain-related fear shown to be more disabling than pain severity! Can this phenomenon be treated? CBT/In vivo exposure to feared activities more effective than education, PT, graded activity increases Vlaeyen et al. 2002, Linton et al. 2002, Lohnberg 2007

29. Maladaptive CopingPain “Catastrophizing” Tendency to resort to dramatic or catastrophic thinking when one is in pain, including hopelessness about ability to control pain Pain “Catastrophizing”: SO WHAT? • Tendency to catastrophize shown to correlate with: • Pain intensity, perceived disability, medication use, hopelessness, referrals to specialists, depression, anxiety, and activity interference Bishop & Warr 2003, Severeijns et al. 2004, Turner et al. 2001

30. Patient Goals for Treatment Outcome What do patients identify as clinically important treatment endpoints? • Robinson et al. Pain Medicine, 2005. Patient Centered Outcome Questionnaire (PCOQ) Assesses patient expectations/goals for treatment in four domains: Pain, fatigue, emotional distress, interference with daily activities Requests patients to rate levels of severity 0 “none” – 10 “worst imaginable”

31. Patient Goals for Treatment Outcome Robinson et al. Pain Medicine, 2005. Patient Centered Outcome Questionnaire(PCOQ) Usual “Successful” “Expected”Importance Pain 6.1 2.7 (56%) 2.7 9.2 Fatigue 5.9 2.6 (65%) 2.5 8.4 Emotion/Distress 5.5 1.8 (67%) 2.2 7.7 Interference 6.4 2.0 (68%) 2.6 8.2

32. Patient Goals for Treatment Outcome Robinson et al. Pain Medicine, 2005. Patients expect much greater reductions in pain than has previously been reported to consider pain treatment as “successful.” They also expect sizable changes in non-pain measures for treatment success.

33. How Much of a Pain Decrease is “Meaningful”? • On the Numerical Rating Scale (0-10), research has consistently shown a “clinically meaningful” decrease in pain intensity equates to 2.5 units or ~33% of the initial score Cepeda et al. 2003; Ferrar et al. 2000; 2001; 2010; ; Fisher et al. 2008; Salaffi et al. 2004; Williamson & Hoggart 2004 • CBT Pain Rehabilitation programs shown to decrease pain report an average of 30-35% - equal to pain decreases with opioid or other adjuvant (anti-depressant, anti-convulsant) medications, and better than “conservative medical care” Turk & Burwinkle 2005 • What is the most common “success criteria” for evaluation of neuromodulation treatment? At least 50% pain reduction? Where was it derived from? Is it reasonable or a threat to failure in every case? Can it be sustained over long periods of time?

34. Pre- and Post-Treatment Decisions • Significant differences may exist between determining whether a patient “qualifies” for neuromodulation treatment and whether we are confident that they will demonstrate long-term improvements in pain and function • How to involve behavioral specialists in decision whether to pursue treatment, preparing the patient for the treatment, objectively evaluating the efficacy of a trial, and maximizing the probability of behavior change after implantation.

35. What to Do With “Poor” Prognosis Candidates? • Considering Spine Surgery Data, It is Reasonable To Assume That As Many As 33% of SCS Candidates Are Probably LOUSY Candidates At First Glance • Consider the Concept of a “Bull-Pen” To Which Poor Candidates Are Referred to Address Candidacy Issues for Several Sessions (e.g., 30-60 days) • Perhaps as Many as Half Can Become Reasonable Candidates for Surgery With Behavioral Interventions • This Might Improve “Borderline” Candidates OR Increase Confidence in NOT TO IMPLANT Others

36. Cognitive-Behavioral Pain Treatment Cognitive-Behavioral Pain Management • Evidence of Efficacy • CBT constitutes the cornerstone upon which “functional restoration” programs are established • Strong evidence that CBT reduces pain related disability • Strong evidence of benefit in adults, adolescents and children Allen & Woolfork 2010; Brox et al. 2003; Eccleston et al. 2003; Morley et al. 1999; Palermo et al. 2010; Turner & Jensen 1993 • Meta-Analysis of RCT’s of CBT and BT for chronic pain demonstrate the effectiveness of active behavioral therapies for pain with an average significant effect size of 0.5 Morley et al. 1999 ; Ostelo et al. 2005So What? What does this effect size compare to?

37. Examples of Effect Size for Generally Accepted Medical “Associations” • 0.02 Aspirin reduces risk of death by heart attack • 0.03 Chemotherapy increases survival in breast cancer • 0.08 Calcium improves bone mass in pre-menopausal women • 0.11 Antihistamines reduce runny nose and sneezing • 0.23 Alcohol influences aggressive behavior • 0.30 Sleeping pills show short-term improvement in insomnia • 0.38 Viagra improves male sexual functioning • 0.50 CBT therapies are effective for management of pain • 0.55 Gender and arm strength (men are typically stronger) Meyer et al. 2001

38. Cognitive-Behavioral Pain Treatment • Common components: • Pain education, establishing measurable treatment goals, self-monitoring of pain and pain-related cognitions, graded activity increases; relaxation training, sleep hygiene instruction (CBTi); treatment adherence and home practice (PT); fear-avoidance of activity; active > passive coping; pain catastrophizing, mood management (~40% prevalence of mood disorder) • Individual or Group Treatments • 8-16 week intervention with education, skill training, problem solving, home practice, relapse prevention

39. Reminders • Multidisciplinary assessment and treatment offers multiple advantages relative to single provider approaches Van Dorsten 2006 • MANY psychosocial threats to treatment outcome exist and pose MUCH STRONGER PREDICTORS OF TREATMENT OUTCOME THAN ARE MEDICAL RISK FACTORS • Behavioral health care is now routinely billed and collected via MEDICAL and not MENTAL HEALTH insurance sources (H&B Codes)

40. Reminders • If pain or function improves with behavioral treatment, it does NOT “prove” that the pain was “psychogenic” in nature • Getting a standard “psych eval” is unlikely to offer any more accurate prediction of outcome than no evaluation at all • Focusing on functional change is the best assessment of success in pain treatment – and behavior change typically requires ongoing behavioral care