Managing Chronic Pain Patients When The Magic Cure Has Ended

1. 1 Managing Chronic Pain Patients When The Magic Cure Has Ended Julie Rickard, PhD Columbia Valley Community Health Behavioral Medicine jrickard@cvch.org

2. 2 Overview Primary Care BH Integrated Model of Care CVCH Pain Program Barriers to pain control Pain management Pain & substance abuse evaluations Pain group topics PCP prescribing Coping

3. 3 Integrated BMed Consultation Service was started to support PCPs ~80% of psychotropic meds are rx by PCPs High incidence of unfounded somatic complaints Psychosocial issues of pts Avg. 14-18 pts per day Brief solution focused Function driven with health focus

4. 4 Integrated BMed Consultation Meet pt at time of crisis Works on compliance with PCP recs Establishes pt goals for dep, anx, PTSD, function, health, etc. Educates pt on variety of issues Checks in on med compliance, benefit, & SE Assesses barriers to function/compliance Assist with pain management program

5. 5 CVCH Pain Program Narcotic contract includes: Medication expectations Pain group Random UDS Compliance with BMed recommendations Pain & Substance Use Evaluation Opioid Oversight Committee Disruptive Patient Pathway

6. 6 Pain Patients Take up enormous staff & provider time Frequent calls, appts, ER visits, noncompliance We want them to have good QOL & function We want them to be happy & satisfied with their care We work harder at them getting better

7. 7 Pain Patients We often feel frustrated / hopeless to help them get better They complain often they aren�t getting their needs met or don�t have the right meds They don�t comply with recommendations

8. 8 Pain Patients Many pain pt issues, providers weren�t trained to deal with or make better�they are behavioral / psychosocial issues Don�t own their issues�provide them with tools. Their crisis is not yours! Meds only manage 10-30% of pain mgmt Many other factors are involved with good pain mgmt

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10. 10 Pt Barriers to Pain Mgmt Sexual Abuse hx PTSD Reason for the pain Dep. / anxiety Disability or L&I claim pending Sleep dysfunction Substance abuse Poor insight Secondary gain Family support Financial issues Culture / ethnicity Medication mis-mgmt Stress Homeless

11. 11 Physician Barriers to Pain Mgmt Lack of desire to treat pain pts Lack of training in pain mgmt Neg beliefs about pts with pain Fear of drug seeking Lack of boundaries with pts Ethnic/racial/gender biases Lack of time to assess issues Lack of support from other providers Reliance on behavioral cues Lack of BMed support

12. 12 Chronic Pain Management Requires a team of people (PCP, specialist, BMed, therapist, psychologist, staff, pharmacy) Good boundaries/limits established early (contract) Consistent messages between providers �I know someone who is getting ___ from�� Pts won�t like it, but they will comply with it (They only know what you tell them)

13. 13 Chronic Pain Management Don�t color the picture�be black & white Make sure that if you are uncomfortable having confrontational conversations that someone on the team can do it. Joint / collaborative visits with pts Share the difference b/t pain management & pain cure�pts want a cure. Ask what their expectations are for pain mgmt

14. 14 Chronic Pain Management Most of the work is around the pts perceptions of their pain & how they interpret pain signals Utilize staff to help with gathering info (questionnaires, goals, etc.) Policies & procedures should guide your practice

15. 15 Pain & Substance Abuse Eval Refer when possible to BMed Consultant Make sure the referral states your needs/concerns They need to know how you manage your practice (nuances: THC, early refills, 3 strikes, etc.) Assesses risk of narcotic rx & pts ability to be compliant with meds Don�t rx narcotics on initial contacts No walk-in rx of narcotics

16. 16 Pain & Substance Abuse Eval Educate pt on narcotic contract & what constitutes failure Go over all points on the contract & pts role Inform that you are info gathering on 1st visit Have medical records from other PCPs Use DIRE Scale � to determine appropriateness of meds

17. 17 Pain & Substance Abuse Eval Assess barriers to pain control & make recs accordingly Depression scale (PHQ, etc.) Chronic pain scale � preferably assesses function Numerical pain rating scale (0 � 10) Assess pts level of insight Compliance with other tx

18. 18 Pain & Substance Abuse Eval Where are the pts at in their grieving/adjustment process? Denial (Not me) Pain/Guilt � feeling fully (I should have) Anger (Why me, it�s not fair) Bargaining (I�ll do anything) Depression (I�m sad, why bother) Reconstruction � rebuilding their life Acceptance (Life will be ok)

19. 19 Pain & Substance Abuse Eval Losses associated with pain Function / independence Job / security Identity Family, friends, connections Housing Car Self esteem Financial / provider status

20. 20 Pain & Substance Abuse Eval How do they deal with change? Flexible, pos, neg, pessimistic, etc. Make recommendations: Drug/alc assessment, inpatient Not good candidate for narcotic meds vs good SSRI, sleep hygiene, etc. Make sure they understand the expectations on them to participate in their care

21. 21 Pain Group Goal is to decrease provider/staff time when dealing with chronic pain pts Goal is improved insight into ways of coping that are not meds & improved function Some pts may not be appropriate (high functioning pts, disturbed or beh issues) 1 � hours, 1 time a month New topic each month

22. 22 Pain Group - Topics 1. How to be a good pt / pain mgmt program Communicating with providers Appropriate behaviors Expectations Red flags 2. Pain pathways & neuronal connections

23. 23 Pain Group - Topics 3. Role of depression & anxiety in depression 4. Grief & loss stages Creating chronic pain goals Motivation to change & Cognitive Behavioral Model of change Changing their perception of pain

24. 24 Pain Group - Topics 8. Expectations of current vs. old self Pacing 100 % vs. 60% energy resources 9. Nutrition & benefits of exercise 10. Addiction, dependence, & pseudoaddiction 11. Sleep hygiene

25. 25 Pseudoaddiction Caused by undertreated pain Pt exhibits aberrant behaviors similar to drug seekers / addicts Not what is expected given known pain issues Staff frequently label the pt Pain issues diminish with adjustment of meds to therapeutic dose

26. 26 Pain Group - Topics 12. Medication Management 1. Use of benzos (risk of OD) 2. Short acting vs. long acting narcotics 3. Accidental OD (when sick, extras) 4. Taking as rx 5. Use of alcohol or other substances 6. Doctor shopping

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28. 28 Patient Fears I have no say in what happens Doctors will take away my meds or change them I can�t be honest I have no power I never know what to ask

29. 29 PCP Prescribing Be honest about what you will or won�t do Straight talk with handouts Have them repeat back what your expectations are Consider a 28 day prescribing cycle Reduces pt withdrawal & phone calls Keeps refills on same day

30. 30 PCP Prescribing Medications are tied to pt function Lowest dose for highest amount fxn Set goals Random urine drug screens Make this a habit THC? How many second chances? Document need/fxn when over state limit

31. 31 PCP Prescribing Train staff in how to respond to requests No PRN meds Utilize alternative meds first before narcotics SSRIs NSAIDS Anti-convulsants Vitamin D Set up Opioid Oversight Committee to manage problem pts / other clinic policies

32. 32 PCP Prescribing Dx with possible strong psych components (after thorough eval) Chronic Fatigue & Fibromyalgia Low Back Pain d/t trauma Injured at work Headaches / Migraines IBS, GI issues TMJ Arthritis usually has minimal psych involvement

33. 33 The Magic Is Gone Coping Strategies Progressive muscle relaxation Breathing Vibration Distraction Imagination Perception (when you change the way you look at things, the things you look at change)

34. 34 The Magic Is Gone Hypnosis Biofeedback Acupuncture Massage Laugh Socialize Hobbies, interests, work

35. 35 The Magic Is Gone Change the way you talk/think about pain Relax Exercise Walk Nutrition Stay active Medication

36. 36 Questions?

37. 37 Contact Information Julie Rickard, PhD BMed Program Manager Columbia Valley Community Health Wenatchee, WA jrickard@cvch.org 509-664-3531 (office)

38. 38 Contact Information Julie Rickard, PhD Mariposa Behavioral Consulting Training, seminars, consulting on PCBH model 8 hr DVD available to train consultants mariposaconsulting@earthlink.net www.mariposabehavioralconsulting.com 509-881-8193