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Tackling Persistent Pain in Primary Care: Pilot Study Using ACT

This pilot study explores the use of Acceptance and Commitment Therapy (ACT) in primary care settings to address persistent pain. Learn practical techniques for implementing ACT in integrated healthcare settings.

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Tackling Persistent Pain in Primary Care: Pilot Study Using ACT

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  1. Tackling Persistent Pain in Primary Care: Early Stages of a Pilot Study using Acceptance & Commitment Therapy (ACT) Kathryn (“katie”) Kanzler, PsyD, ABPP Patti Robinson, PhD Kanzler@uthscsa.eduPatti@mtnviewconsulting.com

  2. disclosures • This study is supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2 TR001118. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  3. outline • The problem of persistent pain • Possible solutions • Our study • Population health methodology • Key elements of protocol • Practical techniques for PCBH settings

  4. Objectives • By the end of our webinar, you will be able to: • Discuss why persistent pain is a challenge in primary care settings • Explain how to use population health approaches to target specific research and clinical populations • Understand methods of getting “buy in” to conduct research in PCBH clinics • Use one or more ACT techniques to help patients with persistent pain in primary care

  5. introduction The problem of persistent pain

  6. What is the problem? • Persistent (“chronic”) pain is more prevalent than diabetes, heart disease and cancer – combined1 • Most patients with persistent pain get care from their Primary Care Clinicians (PCCs) 2 • PCCs find these patients to be stressful!3 • They’re complex and have more pain than those in tertiary settings4, are at risk for addiction5, have co-morbid psychological problems3 1 CDC. Relieving Pain in America: Blueprint for Transforming Prevention, Care, Education, and Research. 2011. 2 Fortney L. Prim Care Rep. 2012;18(11):137-151. 3 Jamison RN, Kerry Anne Sheehan B, Elizabeth Scanlan N, Ross EL. J Opioid Manag. 2014;10(6):375-382. 4 Fink-Miller EL, Long DM, Gross RT. J Am Board Fam Med. 2014;27(5):594-601. 5 Potter M, et al. J Fam Practice. 2001;50(2):145-145.

  7. The Problem, cont’d • Opioids are among the most commonly used pain management tools1 • Linked with abuse, dependence, and death • Compared to other specialties, in primary care, opioid prescriptions increased more than 7% from 2007-20122 • Opioids don’t necessarily “work” • Benefits over time are dubious3 • Don’t always lead to better pain control or improved functioning4 • Opioid-induced hyperalgesia is a risk5 • Need for multidisciplinary “whole person” treatment1 Feelings Thoughts Body PAIN Dowell D, Haegerich TM, Chou R. JAMA. 2016;315(15):1624-1645. Levy B, Paulozzi L, Mack KA, Jones CM. Am J Prev Med. 2015;49(3):409-413. Noble M et al. Cochrane Database Syst Rev. 2010;1(1). Von Korff M, Kolodny A, Deyo RA, Chou R. Ann Intern Med. 2011;155(5):325-328. Lee M, Silverman S, Hansen H, Patel V. Pain physician. 2011;14:145-161. Behavior Environment

  8. What can be done? • Evidence-based psychological treatments reduce disability, CDC recommends1 • Acceptance & Commitment Therapy (ACT)2,3 is a CBT-type treatment with strong evidence for people with persistent pain4-5 • ACT improves physical functioning and decreases distress through4-6 • Increased acceptance • Reconnection with values • Reduction of unhelpful control strategies • Most patients with pain don’t access ACT, usually provided in specialty settings … Most patients come to primary care! • Dowell D, Haegerich TM, Chou R. JAMA. 2016;315(15):1624-1645. 4. Hann KE, McCracken LM. J Contextual Behav Sci. 2014;3(4):217-27. • Hayes SC, Strosahl KD, Wilson KG. Guilford Press; 1999. 5. Vowles KE, McCracken LM, O'Brien JZ. Behav Res Ther. 2011;49:748-55. • Hayes SC, Strosahl KD, Wilson KG. Guilford Press; 2011 6. Robinson P, Gould D, Strosahl K. New Harbinger Publications; 2011.

  9. Psychological Flexibility ACT model Be here now Know what matters Open Up Be present, open up, do what matters Watch your thinking Do what it takes Pure Awareness (Hayes, 2011; Harris, 2009)

  10. FACT Open Aware Engaged Strosahl KD, Robinson PJ, Gustavsson T. Brief interventions for radical change: Principles and practice of focused acceptance and commitment therapy. New Harbinger Publications; 2012.

  11. Who can help?? • Integrated Behavioral Health Consultants (BHCs)1may be the key! • BHCs enhance whole-person treatment2,3 • BHCs can deliver brief, effective, evidence-based non-pharmacologic interventions2-4+ • Persistent pain hasn’t been studied specifically • ACT (or focused ACT; fACT)5is easily delivered in the PCBH model6 • One study found ACT to be effective in primary care (16 hours, group format)7 • No studies on ACT delivered in an integrated setting • Clinics with BHCs may be a great place to access ACT, but…is it effective? • Robinson PJ, Reiter JT. Springer; 2007 & 2016. • Bryan CJ, Corso ML, Corso KA, Morrow CE, Kanzler KE, Ray-Sannerud B. J Consult Clin Psychol. 2012;80:396-403. • Ray-Sannerud BN, Dolan DC, Morrow CE, Corso KA, Kanzler KE, Corso ML, Bryan CJ. Fam Syst Health. 2012;30:60-71. • Vogel M, Kanzler KE, Goodie J, Aikens J. J Behav Med. 2017; 40: 69-84. • StrosahlKD, Robinson PJ, Gustavsson T. New Harbinger Publications; 2012. • Robinson P, Gould D, Strosahl K. New Harbinger Publications; 2011. • McCracken McCracken LM, Sato A, Taylor GJ. J Pain. 2013;14(11):1398-406.

  12. Next steps Study!

  13. Aims & Hypotheses* Aim 1: To determine feasibility and effectiveness Hypothesis A: Brief ACT treatment reduces physical disability and medication misuse in persistent pain patients when delivered by an integrated behavioral health consultant in primary care. Aim 2: To examine mechanisms of change Hypothesis B: Improvements in patient functioning will be mediated by changes in pain acceptance and value-based activities. Acceptance & Values-Based Activity ACT via BHC Decreased Disability, Medication Misuse * All this in the context of team-based primary care

  14. methodology Borrowing from population health

  15. Population Health in PCBH • Population health: “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”1 • Population health care is happening in primary care • This is the vertical integration in PCBH • Clinical pathways can target specific populations2,3 • This study targets the population of patients with persistent pain • Kandig D, Stoddart G. Am J Public Health. 2003 March; 93(3): 380–383. • 2. Robinson PJ, Reiter JT. Springer; 2016. • 3. Hunter CL, Goodie JL. Families, Systems, & Health. 2010;28(4):308.

  16. Setting: San Antonio, TX • Family Medicine Clinic, Patient Centered Medical Home (NCQA-II) • Team includes: MDs, DO, FNPs, PharmD, BHCs, Psychiatrist, RN, LVNs, MAs • Over 6,000 patients; 65% Female; 30% Hispanic/Latino

  17. S T E P S Identification: Build EHR Registry Patients seen in last 30 days: Persistent Pain = 705 On opioids = 108 (26%) Recruitment: Ads, Secure msgs, Calls Screening / Enrollment Baseline Assessment Stratified Randomization ACT + Standard of Care (N=30) Control (Enhanced Primary Care) (N=30)

  18. Active Control Week One BHC Visit Assessment #1: Week Two Intervention: Class #1 Education: Pacing Assessment #2: Week Three Intervention: Class #2 Education: Sleep Assessment #3: Week Four Intervention: Class #3 Education: Relaxation Assessment #4: Week Twelve Intervention: Booster Education: Goals Assessment #5: Week Twenty-Four

  19. assessments Clinical practice CDC Healthy Days Core Measure (CDC HRQOL-4) PHQ-9 Study measures • Current Opioid Misuse Measure (COMM) • Chronic Pain Acceptance Questionnaire (CPAQ) • Chronic Pain Values Inventory (CPVI) • Oswestry Disability Index (ODI) • Numeric Rating Scale for pain (NRS) • Self-Compassion Scale-Short Form (SCS-SF)

  20. Tips for Getting buy-in for new PCBH programs/projects • Lots of communication, including rationale, ”costs,” and expected outcomes • Get medical director on board ASAP • Keep impact on workflow minimal • Keep effort low for clinicians & staff • Find your champions • Be creative • And most importantly… feed them! My team loves pizza, tacos, brownies, and avocado-laden salads! Yum! Yours?? See also Goodie JL, Kanzler KE, Hunter CL, Glotfelter MA, Bodart JJ. Ethical and effectiveness considerations with primary care behavioral health research in the medical home. Families, Systems, & Health. 2013 Mar;31(1):86.

  21. Clinical take-aways Practical stuff

  22. key elements of the act intervention Quality of Life & Pain Treatment Manual BHC visit: Assessment and Program orientation Class A: Values and Action, Caring and Toward Moves Class B: Noticing unhelpful STEM and DOTS, Using Toward Move Cues Class C: SMARTER Goals, Persistent Action Booster: Start Again…And Again

  23. Clinical take-away: The matrix The matrix… Adapted from Polk KL, Schoendorff B, Webster M, Olaz FO. The essential guide to the ACT Matrix: A step-by-step approach to using the ACT Matrix model in clinical practice. New Harbinger Publications; 2016.

  24. Clinical take-away The Bull’s Eye… Adapted from Tobias Lundgren’s and Russ Harris’ "Bull’s Eye” worksheets

  25. Feelings summary Thoughts Body PAIN • Persistent pain is highly prevalent • Most persistent pain care is provided in primary care • ACT is an evidence-based treatment for pain • BHCs can deliver ACT or fACT in primary care • Our pilot study is underway to examine feasibility & effectiveness of this approach • Design of investigations using of fACT-based interventions in primary care maximize their value by using a population-based care framework • Be thoughtful in methods to get clinic buy-in for new projects/programs • The Bulls Eye and the Matrix are transparent fACT interventions that promote team-based care Behavior Environment

  26. Acknowledgements Many thanks to the whole team: Alex F. Bokov, PhD, Epidemiology & Biostatistics, Psychiatry, UT Health San Antonio Alex Carrizales, BS, Psychiatry, UT Health San Antonio (Research Assistant) Eliot Lopez, PhD, Psychiatry, UT Health San Antonio Donald D. McGeary, PhD, ABPP, Psychiatry, UT Health San Antonio Jim Mintz, PhD, Psychiatry, UT Health San Antonio (Co-Mentor) Mariana Munante, MD, Family & Community Medicine, UT Health San Antonio Jennifer Potter, PhD, Psychiatry, UT Health San Antonio Dawn I. Velligan, PhD,Psychiatry, UT Health San Antonio (Mentor)

  27. Questions & discussion

  28. Thank you! Pain is inevitable. Suffering is optional. Haruki Murakami Kathryn E. Kanzler, PsyD, ABPP Director of Integrated Behavioral Health, Primary Care Center Assistant Professor – Psychiatry & Family and Community Medicine UT Health San Antonio kanzler@uthscsa.edu Patti Robinson, PhD Director of Training & Program Evaluation Mountainview Consulting Patti@mtnviewconsulting.com

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