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A Shifting Paradigm: From Biomedical to

Biopsychosocial Interactions

Jeannie A. Sperry, PhD, LP, ABPPCo-chair, Division of Addictions, Transplant, and Pain, Department of Psychiatry and Psychology, Mayo Clinic Assistant Professor, Mayo Clinic School of Medicine, Rochester, Minnesota

August 22, 2017

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Acknowledgement

• The following individual contributed to the content: Jennifer L. Murphy, PhD

Master Trainer,VA CBT for Chronic PainSupervisory Psychologist,Pain SectionJames A. Haley Veterans HospitalTampa, Florida

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Accreditation and Credit Designation

• Accreditation:

The American Academy of Pain Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

• Credit Designation:

The American Academy of Pain Medicine designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Speaker and Planning Committee Disclosures

Speaker: Content Contributor:

Jeannie A. Sperry, PhD, LP, ABPPCo-chair, Division of Addictions, Transplant, and Pain, Department of Psychiatry and Psychology, Mayo Clinic Assistant Professor, Mayo Clinic School of Medicine No relevant financial relationships

Jennifer L. Murphy, PhD Master Trainer,VA CBT for Chronic PainSupervisory Psychologist,Pain SectionJames A. Haley Veterans HospitalNo relevant financial relationships

Planners:Larry C. Driver, MDUniversity of Texas Distinguished Teaching Professor,Professor, Department of Pain Medicine,Professor, Section of Integrated Ethics,The University of Texas M.D. Anderson Cancer CenterNo relevant financial relationships

Jennifer Westlund, MSWDirector of Education, AAPMNo relevant financial relationships

Angela CaseyVP, Medical Director, PharmaCom GroupNo relevant financial relationships

Stephanie LeeMeetings Manager, PharmaCom GroupNo relevant financial relationships

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Target Audience

• The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction

• Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators

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Educational Objectives

• At the conclusion of this activity, participants should be able to:1. Describe the critical interaction between biopsychosocial

factors in the manifestation, maintenance, and treatment of chronic pain

2. Identify at least two ways to discuss the biopsychosocial approach with patients so that they appreciate the complex interplay of psychosocial variables in the pain experience

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Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue

damage or described in terms of such damage.

International Association for the Study of Pain. Pain 1979;6:249-52.

Illustration of the pain pathway in René Descartes’ Traite de l’homme (Treatise of Man) 1664.

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MotivationalAffectiveMotivationalAffective

Pain Experience

Sensory Discriminative

Sensory Discriminative

CognitiveEvaluativeCognitiveEvaluative

PAIN EXPERIENCE

PAIN EXPERIENCE

Gatchel RJ, et al. Psychol Bull 2007;133:581-624.

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Pain Experience

Pain & suffering

Medical intervention

Perceived threats

Injury or illness

Self-management

strategiesEconomic situation

Overall health

History & experience

Situation

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Biomedical or Biopsychosocial

• Biomedical Focus on purely biological

factors in illness/disease Predominant model used

in medical education/by medical providers

Health = freedom from:o Diseaseo Paino Defect

• Biopsychosocial Focuses on 3 factors which

all play a role in illness/ disease process/functioning:o Biological/physiologicalo Psychologicalo Social

Acknowledges the interaction between the physical body and the mind and social context

Gatchel RJ, et al. Psychol Bull 2007;133:581-624.

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Effective Pain Management

• Requires an integrated bio-behavioral approach and understanding of relevant psychosocial factors and the peripheral and central systems

• The importance of psychosocial variables is often underestimated and misunderstood by patients and providers, despite the evidence supporting their relationship to the pain experience

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Why Does the Gap Between Standard and Practice Exist?

• Biopsychosocial model is the recognized gold standard

• However, clinical practice is largely based on biomedical perspective

• How does this gap impact patients?

• How does the gap impact provider satisfaction?

• What can we do to change the culture and shift the paradigm?

IOM Committee on Advancing Pain Research, Education and Care. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine; 2011.Interagency Pain Research Coordinating Committee. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. U.S. Department of Health and Human Services; 2016.

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Unified Front?

• Medical providers acknowledge psychosocial factors in pain experience and treatment outcomes

• Recognition of limitations of a purely biomedical focus

• Accept chronic pain as a chronic condition

• A clear consistent message about realistic options and outcomes, focused on living a quality life with pain

• Biopsychosocial care is the best foundation for care, not the last resort

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Early and Often

• Introduce the biopsychosocial model to patients as early as possible, especially by medical providers

• Educate on complexity of chronic pain

• Positively impact ‘buy in’• Need for comprehensive,

multimodal approach• Encourage self-managed

techniques• Factors should be discussed

and integrated every visit

Biologicalfactors

Biologicalfactors

Social factorsSocial factors

Psychological factors

Engel GL. Science 1977;196:129-36.Engel GL. Am J Psychiatry 1980;137:535-544.Gatchel RJ, et al. Psychol Bull 2007;133:581-624.

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Pain Train

• Biopsychosocial aspects are the engine, not the caboose • Using analogies can help explain complex concepts: e.g. you don’t get to pick all the cars on the train, but you

can help steer the train in your chosen life journey

© Joe Mabel/Wikimedia Commons/CC-BY-SA-3.0/GFDL © JohnInDC (Own work)/Wikimedia Commons/CC BY-SA 3.0

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CASE: 45-Year-Old Married Teacher

• Presents seeking medication for pain and feeling “on edge”

• Chief complaint: fibromyalgia and “fiber fog”

• Consumes a few drinks 2-3 times/week

• Hydrocodone/acetaminophen reduces pain from 7 to 4 on a 1-10 scale for about 2 hours

• She is smoking, missing work, and “moody”

• She wants you to prescribe hydrocodone/acetaminophen, lorazepam, and methylphenidate

• What will you prescribe?

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What Would You Prescribe?

Opioids?Benzodiazepines?

Stimulants?Antidepressants?

Antabuse?Other?

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What May Your Prescription Imply?

• Medication: Medication is the answer.

• Surgery referral Surgery is the answer.

• Etc.

• Etc.

• Eventual result: Passive approach to a chronic problem that requires a proactive engaged patient

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Never Only Opioids…

• In 2012, National Institutes of Health’s working group on integrative pain strategies for the military declared that “opioids alone cannot be the answer.”

Briggs JP. NCCIH Research Blog. July 14, 2014. https://nccih.nih.gov/research/blog/opioid-military

Stepped Care:

NIH Pain Consortium

Topical treatments

Non pharmacological treatments:Yoga, heat and cold, exercise, manual therapies, weight loss, CBT, meditation, massage, acupuncture, self-management, TENS , assistive devices

STEP1

Systemic analgesics: a.Level 1: acetaminophen 3000 mg/d or

short-term NSAIDs b.Level 2: non acetylated salicylatesc. Level 3: low-dose, short-acting opioids d.Duloxetine (likely addresses central sensitization)

STEP5

SurgerySTEP6

STEP2

Local injections STEP

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Spine injections:(epidural steroid injection, trigger point injection) as a means to get patient to physical therapy

STEP4

Morone N, et al. An Older Adult with Chronic Low Back Pain. NIH Pain Consortium, Centers of Excellence in Pain Education. 2013.

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Prescribe Evidence-Based Therapy For Chronic Pain

1. Soothe the central nervous system

2. Change pain thoughts3. Change pain behaviors4. Ask family to change

reaction to pain

5. Daily physical activity6. Change relationship to pain7. Focus on life8. Help body and brain heal: Sleep hygiene Don’t smoke

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Biopsychosocial Multimodal Menu: Reduce Distress and Symptoms

BIO PSYCHO SOCIAL

Rational polypharmacy NSAIDs Anticonvulsants Tricyclics/SNRIs

Cognitive behavioral therapy

Productive activities

Physical conditioning Physical therapy Occupational therapy Exercise

Physiological soothing Relaxation techniques Progressive muscle

relaxation Biofeedback

Plan fun activities with adults outside of the home

Physical therapies Counterstimulation

• TENS Heat/cold

Yoga/tai chi Engage with family

Activity pacing Stay active

Increase positive self-talkReduce time off feet

Reduce catastrophizing

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Change Patient’s Relationship to Pain

• Acceptance: Letting go of struggle against the way things are now Peaceful coexistence with pain

Promote acceptance of pain in life, so can focus energy on having quality of life

IOM Committee on Advancing Pain Research, Education and Care. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine; 2011. McCracken LM. Pain 1998;74:21-7. McCracken LM, Vowles KE. Am Psychol 2014;69:178-87.

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Change Focus from Pain to Quality of Life

• What gives your meaning?

• What are your most important values? eg, loving partner, fun parent

• What goals do you have to honor these values?

• What actions are you taking to live your life consistent with your values?

Goal is to enlarge life not reduce pain

1. Being kind even when in pain2. Shared activities despite pain3. Etc…

Your Goals

McCracken LM, Vowles KE. Am Psychol 2014;69:178-87.

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Discuss Dialing Down the Danger Signal to Reduce Catastrophizing and Anxiety

Pain Amplifying

“I can’t stand this.” “I don’t like it, but I’ve dealt with worse.”

“It’s killing me.”“It’s bothering me,

so I'll need to adjust my day.”

“I should be pain free.”

“I choose to make the most of each day.”

“I can’t live like this.”

“This will pass. My life matters.”

Pain Dampening

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Be Mindful of Our Own Catastrophizing

• If I (stop opioids, suggest CBT, etc), the patient will get mad at me.

• They will stop coming in and buy heroin on the streets.• If my Press Ganey scores drop, my director will be upset

with me, I’ll lose my job, my children will go hungry…• I should please all of my patients.

Self-CBT: Is this accurate? Is it helpful?

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Change the Scale

• NOT “What’s your pain rating on a 1 to 10 scale?”

• How many steps are you averaging each day?

• How many minutes of relaxation breathing are you doing on most days?

• How many tai chi or yoga classes have you attended (or videos watched) since our last visit?

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Change the Conversation at Each Visit

• NOT “How’s your pain?”

• How was your meeting with the pain psychologist?

• What is the most interesting thing you learned from the pain care book you are reading?

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How to Shift Locus of Control at Each Visit

• What are you most proud of regarding your progress since our last visit?

• How are you managing difficult days?

• What “movement medicine” are you doing now?

• What “relaxation medicine” are you practicing?

• What “pleasure medicine” will you do before our next visit?

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How to Shift Perspective at Each Visit

• How has your family responded to your progress?

• How have your friends supported your changes?

• Since they are so concerned about you, how can you reassure them and have them support your progress?

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Discuss Changing Pain Behaviors

• Focusing on pain: Makes the pain worse Is time-consuming Can lead to isolation from friends

and family Affects relationships

• So I’ve noticed that you tend to hold your neck, tilt, etc. What else have you noticed that

you do that shows pain? How can you change that?

Diers M, et al. Exp Brain Res 2012;218:619-28.

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Have Patient Ask Family Members to Ask About Plans/Distractions, Not About Pain

• When spouse/significant other is solicitous, person with chronic pain: Has increased pain Has increased pain behaviors Has decreased functioning Has increased opioid use

Cunningham JL, et al. Pain Med 2012;13:1034-39. Campbell P et al. Pain Med 2012;13:204-14.Band R et al. Clin Psychol (New York ) 2015;22:29-46.Prenevost MH, Reme SE. Scand J Pain 2017;16:150-7.Newton-John TR. Pain Manag 2013;3:485-93.

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Move Patient From Passive Role to Active Role

• How can I support you in your progress?

• What area of functioning are you working on now?

• What have you found to be the most helpful so far in achieving that goal?

• What will be the next step that you will take in your pain care plan?

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Pain Care Plan

What are you willing

to do? How

confident are you?

Good nutrition

Get enough sleep

Daily exercise

Ask for help when

needed

Schedule breaks

Steady pace

Active relaxation

Watch your

(pain) language

Daily stretch, tai chi, yoga

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CASE: 45-Year-Old Married Teacher

• Presents seeking medication for pain and feeling “on edge”

• Chief complaint: fibromyalgia and “fiber fog”• Consumes a few drinks 2-3 times/week• Hydrocodone/acetaminophen reduces

pain from 7 to 4 on a 1-10 scale for about 2 hours• She is smoking, missing work, and “moody”• She wants you to prescribe hydrocodone/acetaminophen,

lorazepam, and methylphenidate • What will you prescribe?

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Biopsychosocial Script

1. Physical activity medicine: Walk 5 minutes daily

2. Relaxation medicine: Listen to relaxation CD 2X/day

3. Movement medicine: Stretch 10 minutes AM and PM

4. Pleasure medicine: Pleasant activity 20 minutes/day

5. Desensitization medicine: Begin SNRI

6. Social medicine: Attend Yoga class 2 x week

7. Anti-hyperalgesia medicine: Reduce opioid by 10%/week

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Summary

• Biopsychosocial care for chronic pain should begin at first visit and be reinforced at each visit

• Promote self-efficacy and self-care

• Use language to change locus of control

• Encourage the patient’s active role in their care

• Imply momentum in their movement

• Help find healing community for wellness

References

•Band R, et al. Patient outcomes in association with significant other responses to chronic fatigue syndrome: a systematic review of the literature. Clin Psychol (New York ) 2015;22:29-46.

•Briggs JP. Pain and opioid use in U.S. soldiers: the imperative for researching effective pain management options in the military. NCCIH Research Blog. 7.14. 2014. https://nccih.nih.gov/research/blog/opioid-military

•Campbell P, et al. The role of relationship quality and perceived partner responses with pain and disability in those with back pain. Pain Med 2012;13:204-14.

•Cunningham JL, et al. Associations between spousal or significant other solicitous responses and opioid dose in patients with chronic pain. Pain Med 2012;13:1034-9.

•Diers M, et al. Treatment-related changes in brain activation in patients with fibromyalgia syndrome. Exp Brain Res 2012;218:619-28.

•Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.

•Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535-544.

•Gatchel RJ, et al. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull 2007;133:581-624.

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References

• Interagency Pain Research Coordinating Committee. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. U.S. Department of Health and Human Services; 2016.

• International Association for the Study of Pain. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain 1979;6:249-52.

• IOM Committee on Advancing Pain Research, Education and Care. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine; 2011.

•McCracken LM. Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain 1998;74:21-7.

•McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol2014;69:178-87.

•Morone N, et al. An Older Adult with Chronic Low Back Pain. NIH Pain Consortium, Centers of Excellence in Pain Education; 2013.

•Newton-John TR. How significant is the significant other in patient coping in chronic pain? Pain Manag 2013;3:485-93.

•Prenevost MH, Reme SE. Couples coping with chronic pain: How do intercouple interactions relate to pain coping? Scand J Pain 2017;16:150-7.

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PCSS-O Colleague Support Program and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will answer questions about educational content that has been presented through PCSS-O project. To join email: pcss-o@aaap.org.

For more information on requesting or becoming a mentor visit:

www.pcss-o.org/colleague-support

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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology

(AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American

Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance

Abuse Training (SECSAT).

For more information visit: www.pcss-o.orgFor questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and

moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

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