Understanding the Chronic Pain MedsCheck trial...(PHQ‐4) Brief and accurate detection of anxiety and depressive disorders Generalized Anxiety Disorder‐7 scale (GAD‐7) Patient

Understanding the Chronic Pain MedsCheck trialDebbie Rigby

Advanced Practice Pharmacist

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Chronic pain

Ongoing chronic pain is an

epidemic in Australia

Learning objectives

Understand the objectives of a Chronic Pain MedsCheck

Identify concepts of patient activation, validation and catastrophising in patient conversations

Interpret responses to common pain assessment tools

Apply patient‐centred approach to pain management during medication reviews

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Declarations

PSA Project Advisory Group

PSA Project Working Group

Author, Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018

Chronic Pain MedsCheck trial Expert Panel

Chronic Pain MedsCheck Trial Objectives

The Chronic Pain MedsCheck Trial objective is to evaluate the efficacy of the Chronic Pain MedsCheck service in:

preventing incorrect use and/or overuse of pain medication

increasing patients’ pain medication health literacy

improving their ability to self‐manage their chronic pain

improving their overall quality of life

The Chronic Pain MedsCheck Trial is funded by the Australian Government Department of Health as part of the Sixth Community Pharmacy Agreement (6CPA) Pharmacy Trial Program (PTP)

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Trial interventions

The trial intervention from pharmacy will include:

Supported self ‐management of patients taking medication

who are dealing with chronic pain for more than three

months through pharmacist advice

Pharmacy‐based evaluation of patient’s medicine

Provision of an action plan

action plans will incorporate education, self‐management and

referral to other health professionals where additional support

is required

Six week and/or three month follow up after the initial service


Key steps

Registration and on‐line training

Trial software access

Patient recruitment (40 patients)

Completion of surveys

Relationship building with GPs and allied health professionals

Provision of information about accessing additional support, or where appropriate a referral to the patients’ GP or allied health professional

Collection of minimum set of data for evaluation


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PSA Guidelines

Trial service overview

Identification of patient need and informed consent

Medication reconciliation

Assess pain experience

Patient education and/or referral

Develop written action plan

Assess progress against action plan (and update if required) at each follow‐up review

Determine if additional services are required by the patient eg. staged supply or DAA

** MedsCheck program cannot be used for a Chronic Pain MedsCheck service

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Source: Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018.


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Multimodal therapy

Goal of treatment of chronic pain is to provide lasting and meaningful reduction in pain with concomitant improvement in overall functioning and health‐related quality of life

Multimodal treatment strategies encompass behavioural, physical and integrated medical approaches

Primary goal of this holistic approach is to reduce pain‐related distress, disability and suffering

Patient‐centred conversation

Belief about the causes of pain

Knowledge, expectations and preferences for pain management

Expectations of outcome of pain treatment

Reduction in pain required for patient satisfaction or to resume reasonable activities

Typical coping response for stress or pain

Presence of anxiety or psychiatric disorders already diagnosed

Family expectations and beliefs about pain and stress

Acute Pain Management: Scientific Evidence (3rd edition), ANZCA & FPM

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Patient activation levels

Individuals tend to be passive and feel overwhelmed by managing their own health. They may not understand their role in the care process.

01Individuals may lack the knowledge and confidence to manage their health.

02Individuals appear to be taking action but may still lack the confidence and skill to support their behaviours.

03Individuals have adopted many of the behaviours needed to support their health but may not be able to maintain them in the face of life stressors.

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BMC Health Serv Res 2016;16:582.

Validation

Validation has been defined as a process in which a listener

communicates that a person’s thoughts and feelings are

understandable and legitimate

Pain 2015;156(2):215‐9.

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Six levels of validating behaviours

Level Description

Listening and observing Listening and paying attention to the patient,

may involve eye contact, nodding

Accurate reflection Restating what has been heard to convey

understanding of message

Articulating the unverbalised Inferring thoughts or feelings that may be

implied in the disclosure

Validating in terms of

sufficient (but not necessarily

valid) causes

Validating what the patient said is

understandable given their past experience

with pain

Validating as reasonable in

the moment

Validating what the patient said is justified in

terms of their current situation

Radical genuineness Treating the patient as a valid and capable

individual

Pain 2015;156(2):215‐9.

Share pain‐related thoughts

and feelingsValidation

Reduction in emotional arousal and negative affect

Reduction in pain

Catastrophising and acceptance are strongly related to outcomes of emotional distress such as depression and anxiety and functional status

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Pain Catastrophizing

Source: https://www.survivestrivethrive.com/pain‐catastrophizing/

Pain catastrophizing is the tendency to have unhelpful, dominating thoughts

Are you scared your pain won’t get better?

Are you afraid your pain will get worse?

Does your pain make you feel anxious – a lot?

If you are dominated by thoughts of your pain – it might be making your pain worse.

When you live with constant pain, unpredictable symptoms & low levels of energy – it is only natural that you don’t have a sunny outlook on life.

However, if your mind is occupied with negative thoughts & feelings – it can increase your levels of pain.


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3 common thought patterns

Rumination

Magnification

Helplessness

Clin J Pain 2001;17:52–64.

Pain Catastrophising Scale

Sub‐scale Statements

Helplessness I worry all the time about whether the pain will end

I feel I can’t go on

It’s terrible and I think it’s never going to get any better

It’s awful and I feel that it overwhelms me

I feel I can’t stand it anymore

There’s nothing I can do to reduce the intensity of the pain

Rumination I anxiously want the pain to go away

I can’t seem to keep it out of my mind

I keep thinking about how much it hurts

I keep thinking about how badly I want the pain to stop

Magnification I become afraid that the pain will get worse

I keep thinking of other painful events

I wonder whether something serious may happen

Psychol Assess. 1995;7(4):524‐532.

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Focus on the positive

Focus on what you can do rather than what you can’t

Recognise unhelpful thoughts and feelings when they occur

Learn the science of pain

Learn psychological strategies (CBT, ACT)

Holistic approach

Plan ahead for pain flare‐ups


Mindfulness

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Achieving pain relief may be less important than improving physical functioning

Patients are encouraged to use mindfulness in order to participate fully in the present moment, which may involve mindful participation in physical activities

Mindfulness skills training helps patients to observe negative pain thoughts (I can’t move because it hurts) without acting on them

Pain assessment tools

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PEG3‐item scale

Source: Rigby DA. Language of pain. AJP February 2019.

5 As ‐Opioid therapy monitoring tool

The 5 As are primarily a tool for the monitoring of opioid therapy. They are designed to determine if the therapy is still valid, by determining if the benefits continue to outweigh the risks of treatment.

Activity

Analgesia

Adverse effects

Aberrant behaviour

Affect

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/.../5_As_of_Analgesia.pdf

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Mini‐ePPOC

Brief Pain Inventory (BPI)

Patient Health Questionnaire‐4 (PHQ‐4)

Pain Self‐efficacy Questionnaire (PSEQ)

https://ahsri.uow.edu.au/eppoc/forms/index.html

Brief pain inventory (BPI)

Assesses severity of pain and its impact on functioning

Location of pain

Severity of pain (worst, least, average, right now)

Impact of pain on daily function

Pain medications

Amount of pain relief in the past 24 hours or past week

Interference (general activity, mood, walking ability, normal work, relation with other people, sleep, enjoyment in life)

BPI gives two main scores: a pain severity score and a pain interference score

www.aci.health.nsw.gov. au/__data/assets/pdf_file/0015/212910/Brief_Pain_Inventory_ Final.pdf

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Patient Health Questionnaire (PHQ‐4)

Brief and accurate detection of anxiety and depressive disorders

Generalized Anxiety Disorder‐7 scale (GAD‐7)

Patient Health Questionnaire‐8 (PHQ‐8)

Psychosomatics 2009;50:613–21.


Pain self‐efficacy is a belief in one’s ability to carry out

activities even when in pain, and is important in coping

effectively with pain.

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10‐item questionnaire that assesses the confidence people with chronic pain have in performing activities while in pain

PSEQ‐2: 2 items assess confidence in one’s ability to work and lead a normal life despite pain

www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/212909/PSEQ_Final.pdf

Pain assessment tools incorporated in the mini‐ePPOC


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Additional assessment tools in evaluation arm

AQoL‐4D quality of life tool

Self‐management tool

Health literacy tool

Key messages

Supporting patients with chronic pain – be kind and careful

Exploring a patient’s beliefs and attitudes may identify the need for multimodal treatment approach

Assessment tools will aid in providing appropriate care and referrals

Be mindful of language used by the patient and yourself

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Documents

Understanding the Chronic Pain MedsCheck trial...(PHQ‐4) Brief and accurate detection of anxiety and depressive disorders Generalized Anxiety Disorder‐7 scale (GAD‐7) Patient