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August 2009

Leveraging Cognitive-Behavioral Approaches to Pain Management. August 2009. Andrew Bertagnolli , PhD Senior Consultant – Behavioral Medicine & Pain Management.

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August 2009

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  1. Leveraging Cognitive-Behavioral Approaches to Pain Management August 2009 Andrew Bertagnolli, PhD Senior Consultant – Behavioral Medicine & Pain Management

  2. Andrew Bertagnolli, PhD has no financial interest or other relationship with the manufacturers of any commercial product and /or providers of commercial services discussed in this educational presentation nor with any commercial supporters of this course. Disclosure

  3. Tasks for Patients with Chronic Conditions • Self-Managing the Illness • Taking medications • Monitoring the illness • Carry on Normal Roles and Activities • Manage the Emotional Impact of the Illness

  4. Self-Management: What is it? Self-managementis defined as the tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions

  5. Current State: Biomedical Model • Predominant Focus on Physical Processes: • Pathology of the Illness • Biochemistry of the Illness • Physiology of the Illness

  6. Biopsychosocial Model • Predominant Focus on Complex Interaction Between: • Biology (physiology, pathology, biochemistry) • Psychology (thoughts, feelings, behaviors) • Society (socioeconomics, culture, technology)

  7. Model for Chronic Pain ManagementCMI Clinical Practice Guidelines (2003) Cognitive Behavioral Therapy Pharmacological Management and Other Rx Patient Self Care Physical Therapy Complementary & Alternative Medicine

  8. Kaiser Permanente Pain ManagementComplete Care • Evidence-Based • Patient-Centered • Multi-Disciplinary • Complete Continuum • Emphasis on Self-Management

  9. Overall Treatment Approach • In deciding the best treatment approach, the following should be considered: • Maximizing functional status • Reducing pain • Addressing associated symptoms (eg: sleep, fatigue and mood) • Designing a treatment plan should involve an individualized assessment and be multifactorial including: • Self-management • Physical activity/movement • Medications • Interventional approaches • Psychological approaches • Complementary-alternative (CAM) approaches

  10. Assumptions of Comprehensive Pain Programs • Pain impacts multiple areas • No cure – must learn to manage • Hurt ≠ Harm • Improved function is goal • not pain relief per se • Self-management is key • Multiple approaches are best

  11. Ripple Effect of Chronic Pain Relationships Sleep Mood Activities Physical

  12. Comprehensive Pain Programs • Less intensive than FRPs • Grounded in biopsychosocial model • Integrate psychology, physical therapy, medicine with self-management • High degree of case/care coordination

  13. What is CBT? Psychological interventions designed change behavior, thoughts or feelings, to help patients experience less distress and satisfying and productive lives

  14. Cognitive-Behavioral Treatment • Standard psychosocial intervention for pain • Short-term, structured, focused, goal-oriented approach • Flexible and able to be tailored to individual patient needs • Compatible with a range of other treatments • Extensively evaluated in rigorous clinical trials • has solid empirical support for use in pain management

  15. Predominant Themes • Promotion of a self-management perspective • Relaxation skills training • Cognitive therapy • Cognitive restructuring or self-statement analysis • Behavioral activation and management • Goal-setting and pacing strategies • Combat activity avoidance • Problem-solving skills training • Interventions modifying perception or emotional response to pain, • Guided imagery, desensitization, hypnosis, or attention control exercises • Communication skills training or family interventions • Habit reversal • Maintenance and relapse prevention

  16. Cognitive-Behavioral Model Thoughts Behaviors Feelings Symptoms

  17. More than a set of techniques • Use as organizing strategy for rehabilitation • Example: Difficulties that arise during physical therapy • Only due to physical limitations? • Also due to anticipatory fear regarding increased pain or injury • Need to address both performance of physical therapy exercises and body mechanics, but also patient’s expectancies and fears

  18. Cognitive-Behavioral Model “Why am I having this pain?” “This pain means I have injured myself!” Increased Isolation, Decreased Activity Depression, Anxiety, Fear, Anger Increased Pain, Insomnia

  19. What is Progress? • Emphasize small steps • Use changes in functional improvement • Focus on small changes revised gli 10/02/2003

  20. Pros Relatively-low cost Compatible with other interventions Physical Therapy, Pharmacotherapy Promotes self-management of a chronic condition Strong empirical support Cons Not suitable for patients with moderate to severe cognitive impairment Requires sustained and active patient participation Requires psychologists with specialized training Pros & Cons to CBT

  21. Criteria for Success?Depends From Who’s Vantage Point Society Workers Compensation Return to Work Healthcare Utilization Managed Care Organizations Functional, Emotional Improvements Healthcare Provider Satisfaction Low Adverse Events Individual Pain Relief Gatchel & Okifuji (2006) Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain. Journal of Pain. 779-793.

  22. Data: Comprehensive Pain Programs • Pain Reduction: • 20-30% on average • 30% on average with opioids alone • Increased Activity: • 65% increase • 35% conventional care • Return to Work: • 66% RTW • 27% conventional therapies • Healthcare Utilization • 33% reduction overall • 15% subsequent surgery • Approximately 50% in TAU • Medication: • 22% use medications at 1 year • 75% use medications at 1 year Mayer, et al (1987) Prospective two-year study of functional restoration in industrial low back pain . JAMA Patrick, et al (2004) Long-term outcomes in multidiscplinary treatment of chronic low back pain. Spine Hazard, et al (1989) Functional restoration with behavioral suppot: A one-year prospective study of patients with chronic low-back pain. Spine

  23. Meta-AnalysisMorely, Eccleston& Williams (1999) • 25 trials included • Across a variety of common, non-headache, conditions • CBT vs. wait-list control • Dependent variable domains • Pain experience • Mood • Cognitive-coping & appraisal • Pain behavior • Physical Activity • Social role functioning • Results • CBT were superior across all domains • Grand mean effect size of 0.46 Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.

  24. What’s the Evidence for Other Treatments? • Epidural Steroids • No strong evidence for or against any type of injection therapy for subacute or chronic low-back pain (Cochrane Review 2008) • Spinal Fusion • Moderate evidence that instrumentation can increase the fusion rate, but any improvement in clinical outcomes is marginal (Cochrane Review 2005) • Opioids • Despite concerns about addiction and diversion there are no studies that identify those for whom benefit will exceed risk versus those for whom risk will exceed benefit (Cochrane Review 2008)

  25. Spinal Fusion vs CPP • N=349 • Chronic low back pain > 1 year • Randomized • Spinal fusion • Chronic pain program • 24 month follow-up • Measures • Oswestry • Short Form 36 (SF-36) • Both groups improved • No evidence that surgery had greater outcome Fairbank, et al (2005) Randomized controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehavilitationprogramme for patients with chronic low back pain: The MRC spine stabilisation trial. British Medical Journal

  26. Model for Chronic Pain ManagementCMI Clinical Practice Guidelines (2003) Cognitive Behavioral Therapy Pharmacological Management and Other Rx Patient Self Care Physical Therapy Complementary & Alternative Medicine

  27. Partnership with American Chronic Pain Association • Began in August 2007 • Currently have 6 groups running • Southern California (4 English & 1 Spanish) • Mid Atlantic (4 English) • Hosted at KP facilities • KP members trained to be group facilitators • KP members encouraged to attend after discharge from intensive pain management programs • Beginning to explore promotion to community at large • KP staff comments: • Overall, both internally and with our members, this has been a very successful and beneficial partnership. • Remain enthusiastic about the concept and potential.

  28. www.kp.org/pain Self Management Programs

  29. Care for Pain Care Pathway Including CFP Level 3 Services (Chronic Pain Case Mgmt Programs) Incorporate into Discharge Plan Level 2 Services (Chronic Pain Care Programs) Incorporate into Discharge Plan Direct Referral from PCP Level 1 Services (Primary Care)

  30. Keys for Success Educate patient about their condition provide consistent information provide a diagnosis where possible educate regarding difference between acute and chronic pain partner with patient to help improve their function goal is pain MANAGEMENT not total pain relief acknowledge that this can be a difficult task Develop a treatment plan Assess chronic pain from a biopsychosocial perspective Identify objective markers of function as treatment goals Emphasize that treatment needs to be multidisciplinary and multimodal May need to frequently remind patient of the goal of improved function rather than being pain free

  31. Keys for Success Encourage maximum levels of function • determined by objective physical limitations, rather than perceived pain Restore physical conditioning • gradually • systematically with specific exercise prescriptions Do not treat chronic pain as a medical emergency • remain calm and dispassionate, yet supportive • dispel errant beliefs and fears Seek multidisciplinary consultation from specialists

  32. Is It Worth It All?

  33. Questions & Comments?

  34. Andrew Bertagnolli, PhD Kaiser Permanente – Care Management Institute 1 Kaiser Plaza, 16th Floor Oakland, CA 94612 510-271-5771 andrew.bertagnolli@kp.org

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