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

1. 6th Annual Montana Pain Initiative Conference University of Montana 5/31/2014 The How and the What of Behavioral Health Intervention for Pain in a Medical Setting Patrick Davis, PhD Montana Spine & Pain Center Providence Health and Services St. Patrick Hospital Missoula, MT

2. Conflict of Interest Disclosure Has no real or apparent conflicts of interest to report. Patrick Davis, Ph.D.

3. 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

4. Stranger in a Strange Land

5. Role Clarity Specialty Mental Health Professional or 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

6. 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

7. Laws in the House of God GOMERS DON'T DIE. GOMERS GO TO GROUND AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE. THE PATIENT IS THE ONE WITH THE DISEASE. PLACEMENT COMES FIRST. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM. AGE + BUN = LASIX DOSE. THEY CAN ALWAYS HURT YOU MORE. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER. 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. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

8. But Seriously • Schedules are merely guidelines and aspirational. • Notes need to be completed on the same day that the service is provided whenever possible and no later than the following business day • You may have to provide referring providers with the language they need to ask you meaningful questions • If it takes more than one minute to read or explain your clinical impressions you will lose your audience • Be prepared for the warm handoff • Learn to translate medical jargon to street speak for patients • Ask the patient if they understand what the physical medicine provider told them • Clarify misconceptions

9. Primary Care Competencies Report of the Interorganizational Work Group on Competencies for Primary Care Psychology Practice March 2013 6 broad core competency domains Science Systems Professionalism Relationships Application Education

10. 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

11. 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).

12. PAIN

13. 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

14. 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”

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Fear Avoidance • Vllaeyen & Linton (2012) • Fear-avoidance model of chronic musculoskeletal pain: 12 years on, PAIN, 153 (2012) 1144–1147

22. 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)

23. 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)

24. 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

25. 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

26. 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

27. 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

28. Tobacco Dependency • Behrend et al (2013) • 5333patients 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.”

29. 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

30. 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

31. 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

32. 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)

33. Assessment

34. Pain • Numerical Analogue Scale (NAS) • 0-10 • McGill Pain Inventory –Short Form • Sensory and Affective Dimensions • Multidimensional Pain Inventory • Pain Severity Subscale

35. 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)

36. 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

38. Treatment

39. Wall of Fame

40. 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