“It Still Hurts” - ASPMN

9/21/2012

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“It Still Hurts”

Promoting Self Management for Chronic Pain

Christine Stamatos, DNP-CLong Island Regional Arthritis & Osteoporosis Care

Pat Bruckenthal, PhD, APRN-BC, ANPAssociate Professor, Stony Brook School of Nursing

Objectives

• Describe KEY components of SM for chronic pain

• Recognize BARRIERS to providing SM for chronic pain• Utilize BRIEF ACTION PLANNING to promote SM• Identify at least 3 TOOLS available for promoting SM

Why Self Management?

• Prevalence of …• IOM Report: in America (2011)

Chronic pain affects 116 million US adults More than DM, CAD & Cancer combined! Annual costs $560-635 billion Direct HC costs and loss productivity 14% of all Federal health care dollars attributable to pain Amounts to $2,000 for everyone living in the U.S.

• Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education and research• Toblin et al. (2012). A population based survey of chronic pain. Pain; 152(6): 1249-1255.

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Personal Costs

• 30-40% chronic pain is not well controlled• Nearly 20% describe Mod- SEVERE pain

• 50% of these adults describe persistent pain• > 50% have chronic fatigue/ sleep problems• 40-44%

“Can’t think clearly, feel helpless, can’t remember life without pain”

• > 20-30% experience depression

• Breivik et al. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain; 10: 287-233. • Toblin et al. (2012). A population based survey of chronic pain. Pain; 152(6): 1249-1255.• Mainer et al. (2012). Treatment profiles and costs of patients with chronic pain. ClinicoEconomics and Outcomes Research; 4: 39-47.

Why Self Management?

Efficacy of Medications in FM:• Decade of little effect • Evidence of harm• - Persistent GI irritation• - Concerns about CV effects• - Fear of opiate use• $$ 3,800/yr new meds vs. $65

for traditional TCAs

Wolfe et al. (2011). Longitudinal study of pharmacologic therapy in FM. Abstract Hauser, W., Jung, E., Wolfe, F. (2011). The German Fibromyalgia Consumer Reports.

Self Management

• #1 Recommendation by…• IOM report “Relieving Pain in America”

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Meta-analysis SM1970-2010 RCT only

• Key Meta Analysis Identify Improvements in…• Pain• Self Efficacy• Fatigue• Anxiety• Depression • Quality of Life• Function• Health care utilization

• Best of the Best• Brady et al. (2011). CDC. Primarily ASMP• Carnes et al. (2012). Clin J Pain; 28(4): 344-354. • Iverson et al. (2010). Ann Rheum Dis; 69: 955-963.• Du et al. (2011). Pt Ed & Coun; 85: e299-e310.

*No Adverse Events*

Summary of 40 years Research…

• Group programs• Strengthens confidence, social interaction• Individual programs also beneficial• Variety formats effective including online, mail

• Led by health professionals• Duration approximately 8 wks• COMPONETS:

• Pain Education • Clear use of Cognitive Behavioral principles

• Cognitive restructuring• Relaxation/ Distraction• Problem Solving

• Action Planning• Exercise/ Pacing• Manualized approach• Opportunity for “booster” sessions

Effectiveness of SM• Evidence is STRONG• Physiologic:

• Pain threshold: • Ang et al. (2010). A, C & R; 62(5): 618-23.• Emery et al. (2006). J Pain Symp Management; 31(3): 262-269

• f MRI findings • DeRubeis et al. (2008). Nat Rev Neuroscience; 9(10): 788-796.• DeCharms et al. (2005). PNAS; 102(51): 18626-18631.• Peyron et al. (2000). Neurophysiologie Clinique; 30(5): 263-288.

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What is Self Management?

• Research says…• Remember: EXPRESS

• EX EXercise• P Psychiatric issues addressed• R Regaining strength• E Education• S Sleep hygiene• S Stress

Hassett & Gevirtz (2009). Rheum Dis Clin N Am; 35: 393-407Hassett & Williams (2011). Best Practice & Research Clin Rheum; 25: 299-309

Barriers to Access:

• Interest• McCurry et al. (2011). J PsychosomaticRes; 71: 296-299• Austrian et al. (2005). J Am Geriatric Soc; 53(5): 856-861

• Actual participation• Bruce et al. (2007). A & R; 57(5): 1009-1017

• Issues: Accessibility• Program specific• Participant related issues: Stigma

• What now??

Here’s what’s happening…State of Evidence •Large prospective RCTs

• BeST “Back Skills Training Trial”• Lamb et al. (2010). Lancet; 375: 916-923.

• SCAMP “Stepped Care for Affective Disorders and MSK Pain”• Kroenke et al. (2009). JAMA; 301(20): 2099-2110.• Matthias et al. (2012). Pain Med; DOI: 10.1111/j.1526-

4637.2012.01433.x

• IMPACT “Improved Mood Promoting Access to Collaborative Treatment”

• Lin et al. (2006). Gen Hosp Psych; 28: 482-486.

• Treatment for Medically Unexplained Symptoms• Smith et al. (2006). J Gen Intern Med; 21: 671-677.

• ESCAPE “Enabling Self Management and Coping with Arthritis Knee Pain through Exercise”

• Hurley et al. (2012). A, C & R; 64(2): 238-247.

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Motivating Patients with Persistent Pain:Nursing Strategies

Objectives

• Describe client-centered approaches tomotivation

• Incorporate Brief Action Planning techniques into client centered care for pain management

The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you would rather not.

-Mark Twain

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Client Centered Approaches to Motivation

• Motivational Interviewing (MI)• Miller, W., Rollnick, S.

• Brief Action Planning (B.A.P.)• Cole, S., Cole, M.

Motivational Interviewing

“ Motivational Interviewing is a collaborative conversation to strengthen a person’s own motivation for a commitment to change” (Miller, W. 2002)

• Spirit of MI• Collaboration• Evocation• Respect for Autonomy

Brief Action Planning (B.A.P.)“ a pragmatic motivational and self-

management support tool useful in virtually all clinical contexts …..which utilizes B.A.P. in a stepped-care application of Motivational Interviewing that can be flexibly delivered to all patients/clients at all levels of readiness for change” (Cole, S.)

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Motivational Model of Pain Self Management

(Jensen, Nielson, Kerns, 2003)

Perceived Importance-Beliefs regarding cost/benefit ratio-Learning history-Current contingencies

Self Efficacy-Personal experience-Modeling-Verbal persuasion-Perceived barriers

Readiness to change-(or maintain) self management behaviors

Self-Management Behaviors (coping)ExercisePacingRelaxationAssertivenessTask persistenceBody mechanicsPositive self talkIgnoring painAvoid asking

for assistanceAvoid guardingAvoid

catastrophizingAvoid pain

contingent restAvoid pain

contingent analgesics

B.A.P.

• Nine core principles •structured around

• Three foundation questions

B.A.P. Core Principles and Questions1. Action planning should be individual centered, ie. What the patient wants to do, not what he/she is told to do. (spirit of MI: Evocation)

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Core Principles and Questions

2. Action Planning is collaborative

-Spirit of MI: Collaboration 3. Action planning respects the

right of the individual to change or not to change

-Spirit of MI: Autonomy


4. Action planning should be ‘SMART’ (Specific, Measurable, Achievable, Relevant, and Timed)

What?Where?When?How often?


5. After the plan has been formulated, the clinician/coach elicits a final commitment statement.

“ Just to make sure we understand each other, would you please tell me back what you’ve decided to do?”

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6. Offer a behavioral menu when needed or requested.

“Is it OK if I make some suggestions? Many patients in your situation choose to work on….”

Core Principles and Questions7. Confidence levels are elicited

and problem solving utilized for confidence levels less than 7.

Problem solving confidence levels < 7

“ 5 is great, a lot higher than 0. I wonder if there is any way we might modify the plan to get you to a level of 7 or more? Maybe we could make the goal a little easier, or you could ask for help from a friend or family member, or even think of something else that might make you feel more confident ?”

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8. Action planning includes arranging follow-up or other accountability.


9. Question one is routinely integrated into chronic care, preventive, coaching, and therapeutic visits.

What happens when the answer to Question One is not a simple “YES” ?

• Category one response: “yes”• Category two response: “I need

more information or ideas for help”

• Category three response: Complex, persistent unhealthy behaviors (PUB)

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Responding to emotions of PUB

• Reflection: “ I can see this is difficult for you”

• Validation: “ I understand why you would feel this way”

• Support: “ I am here to help you in any way I can ”

• Partnership: “Let’s work on this together”

• Respect: “ I’m impressed with how you are coping under the circumstances”

Motivating Patients with Persistent Pain to Action: Nursing Strategies

• Increase perceived importance of pain SM• Encourage Positive Outcome Expectancies• Identify and incorporate contingencies • Reinforce self management coping behaviors

• Increase self-efficacy for pain SM• Coach the patient to practice self management

strategies• Gently challenge distorted cognitions and

provide directed active listening to support self efficacy beliefs

• Problem solve regarding perceived barriers

Resources• http://www.comprehensivemi

.com - brief-action-planning

• Miller, W., Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change (2nd ed.) Guilford Publications: New York

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Additional Resources:

• The “Pain Psychologist”• Where to find them…

• http://www.goodtherapy.org/therapy-foundation.html

• What they can do?• Individual and/or Group

• Access may be limited…• What now?

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Online Resources:

• Industry Sponsored Sites• http://www.painaction.com (Endo)• http://www.knowfibro.com (Lilly)

• Caution: industry, .com scams• webutationhttp://www.webutation.net/go/about• Ihealthbeat.orhttp://www.ihealthbeat.org

Online Resources:

• Patient Centered Organizations• American Chronic Pain Association

• http://www.theacpa.org/default.aspx

• Arthritis Foundation• http://www.arthritis.org/understanding-pain.php• Walk with Ease Program• http://www.arthritis.org/walk-with-ease.php

• Self Management: Stanford• Better Choices, Better Health• http://restartliving.org

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Mobile Access:

• “Apps”• My Pain Diary: Chronic Pain Mngmt

http://itunes.apple.com/us/app/my-pain-diary-chronic-pain/id338627856?mt=8

• Tract and React: from Arthritis Foundation• http://www.arthritistoday.org/tools/track-and-

react/index.php• Many Relaxation Apps

• Serenity: The relaxation apphttp://taptaptap.com/serenity/

• Silent Island Relaxation http://www.silentisland.org/Silent_Island_Relaxation/Home.html

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Mobile Access:Cognitive• eCBT apphttp://itunes.apple.com/us/app/ecbt-mood/id324060472?mt=8

Print Options:

• Pain Survival Guide Dennis Turk & Fritz Winter

• Managing Pain before Pain Manages YouMargaret Caudill

• Walk with Ease• Decreased disability, improved function, SE and strength• Callahan et al. (2011). A,C & R; 63(8): 1098-1107.

• Online PDF sources:• painonline.org http://www.painonline.org• American Pain Society

http://www.ampainsoc.org/resources/people.htm

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Innovative Strategies:

• TIVR: Therapeutic Interactive Voice Response• Naylor et al. (2010). J Pain; 11(12): 1410-1419.

• Group Sessions• BeST: Groups led by OT, PT, Nurses

• Lamb et al. (2010). Lancet; 375: 916-923.

• ESCAPE: Groups led by PT• Hurley et al. (2011). A, C & R; DOI 10.1002/acr.20642

• Pre treatment Groups: Led by OT, PT, MD, Psych• Davies et al. (2011). Pain Med; 12(1): 59-71.

• Coordinated Care: Chronic Disease Management• SCAMP & IMPACT trials & Smith et al. • MOVE “Managing Osteoarthritis Very Effectively”

• Broderick, Bruckenthal, Keefe, et al. In progress

• Goal: Intensive behavioral tx for Chronic Pain

References:• Ang, D. C., Chakr, R., Mazzuga, S., France, C. R., Steiner, J., & Stump, T. (2010). Cognitive-behavioral therapy attenuates

nocioceptive responding in patients with fibromyalgia: A pilot study. Arthritis Care and Research, 62(5), 618-623.

• Austrian, J. S., Kerns, R. D., & Reid, M. C. (2005). Perceived barriers to trying self-management approaches for chronic pain inolder adults. Journal of American Geriatric Society, 53(5), 856-861.

• Brady, T. J., Murphy, L., Beauchesne, D., Bhalakia, A., Chervin, D., Daniels, B., et al. (2011). Sorting through the evidence for the Arthritis Self-Management Program and the Chronic Disease Self-Management Program: Executive summary of ASMP/CDSMP Meta-Analyses.

• Bruce, B., Lorig, K., & Laurent, D. (2007). Participation in patient self-management programs. Arthritis Rheum, 57(5), 851-854.

• Callahan, L.F., Shreffler, J.H., Altpeter, M., Schoster, B., Hootman, J., Houenou, J., Martin, K.R., & Schwartz, T.A. (2011). Evaluation of group and self-directed formats of arthritis foundation’s Walk With Ease program. A, C & R; 63(8): 1098-1107.

• Carnes, D., Homer, K. E., Miles, C. L., Pincus, T., Underwood, M., Rahman, A., et al. (2011). Effective delivery styles and content for self management interventions for chronic musculoskeletal pain: A systematic literature review. Clin J Pain. Oct 13, 2011.

• Committee on Advancing Pain Research, C., and Education; Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education and research.: Institute of Medicine of the National Academies.

• Davies, S., Quintner, J., Parsons, R., Parkitny, L., Knight, P., Forrester, E., et al. (2012). Preclinic group education sessions reduce waiting times and costs at public pain medicine units. [Research Support, Non-U.S. Gov't]. Pain medicine, 12(1), 59-71.

• Hassett, A. & Gevirtz, R. N. (2009). Nonpharmacologic treatment for fibromyalgia: Patient edcucation, cognitive behavioraltherapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin N Am; 35: 393-407.

• Hassett, A. L., & Williams, D. A. (2011). Non-pharmacological treatment of chronic widespread musculoskeletal pain. Best practice & research. Clinical rheumatology, 25(2), 299-309.

References: • Hochberg, M. C., Altman, R. D., April, K. T., Benkhalti, M., Guyatt, G. H., McGowan, J., et al. (2012). American College of

Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care and Research, 64(4), 465-474.

• Hurley, M. V., Walsh, N. E., Mitchell, H., Nichols, J., & Patel, P. A. (2012). Long term outcomes and costs of ESCAPE-knee pain: An integrated rehab programme for chronic knee pain. Arthritis Care and Research, 64(2), 238-247.

• Iverson, M. D., Hammond, A., & Betteridge, N. (2010). Self-management of rheumatic diseases: state of the art and future perspectives. Ann Rheum Dis, 69, 955-963.

• Kroenke, K., Bair, M. J., Damush, T. M., Wu, J., Hoke, S., Sutherland, J., …Tu, W. (2009). Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA, 301(20), 2099-2110.

• Lamb, S. E., Hansen, Z., Lall, R., Castelnuova, E., WIthers, E. J., Nichols, V., …Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness. Lancet, 375, 916-923.

• Lin, E. H., Tang, L., Katon, W., Hegel, M. T., Sullivan, M. D., & Unutzer, J. (2006). Arthritis pain and disability: response tocollaborative depression care. Gen Hosp Psychiatry, 28(6), 482-486.

• Naylor, M. R., Naud, S., Keefe, F. J., & Helzer, J. E. (2010). Therapeutic Interactive Voice Response (TIVR) to Reduce AnalgesicMedication Use for Chronic Pain Management. J Pain.

• Mainer et al. (2012). Treatment profiles and costs of patients with chronic pain. ClinicoEconomics and Outcomes Research; 4: 39-47.

• Smith, R. C., Lyles, J. S., Gardiner, J. C., Sirbu, C., Hodges, A., Collins, C., et al. (2006). Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. [Comparative Study Randomized Controlled Trial Research Support, N.I.H., Extramural]. Journal of general internal medicine, 21(7), 671-677.

• Toblin et al. (2012). A population based survey of chronic pain. Pain; 152(6): 1249-1255.

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“It Still Hurts” - ASPMN