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Declaration of Financial Interests

We have not had any relevant financial relationships during the past 12 months. . Declaration of Financial Interests. Video. How many of us treat chronic pain? What comes to mind when you think of patients with chronic pain? What are the common treatments for chronic pain?

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Declaration of Financial Interests

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  1. We have not had any relevant financial relationships during the past 12 months. Declaration of Financial Interests

  2. Video

  3. How many of us treat chronic pain? What comes to mind when you think of patients with chronic pain? What are the common treatments for chronic pain? Where are these treatments offered? And by whom? Do they work? Are they evidenced based? Audience Questions

  4. University of MassachusettsMedical School Joan B. Fleishman, PsyD Jeanna R. Spannring, PhD Christine N. Runyan, PhD Philip Bolduc, MD Implementing chronic pain groups in two diverse family medicine residency clinics

  5. Define group protocol for treatment of chronic pain Understand potential challenges and barriers to implementation in a primary care setting Describe patient and provider perspectives on efficacy of treatment modality Objectives

  6. Evidence and Rationale for Non-Pharmacological Treatment of Chronic Pain

  7. At least 116 million U.S. adults suffer from chronic pain conditions • more than heart disease, diabetes, and cancer combined • Annual economic cost including health care expenses and lost productivity: • $560 – 630 billion Scope & Nature of Chronic Pain Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: The National Academies Press.

  8. Pharmacotherapy Injections Procedures/Surgeries PT/OT CBT, mindfulness, psychotherapy Acupuncture Chiropractics Best Practices??? Current Treatments

  9. Core Content and Process Components Design of Groups

  10. Developed in CMHC in rural Colorado as a psychotherapy group • Intended to address this common co-morbidity of psychiatric illness • PTSD • Depression • Borderline Personality Disorder • Substance Abuse Background

  11. 8-sessions • 90 min/sessions • Dedicated nursing support • Population: • Pilot w/ specific PCP referral • All PCP referral • Part of pain contract Structure of session

  12. Stress & nervous system disorder Rules of Neuroplasticity: What is fired together is wired together What you don’t use you lose When you break old paths, you can use those nerves to make new paths

  13. Healthy Behaviors

  14. Healthy Behaviors

  15. Medication Options for Chronic Pain opioids NSAIDs Anti-convulsants SNRI/SSRI tricyclics

  16. CBT: Emotional Awareness Anger Sadness Fear Guilt

  17. CBT Triangle for Pain - stuck - Helpless/hopeless - No control/power -Take Control -Prove pain can’t stop me • Associated Emotions: • Depression • Associated Emotions: • Anger • Motivation • Stop • Prolonged rest • Associated Emotions: • Overwhelmed • Hopeless/helpless - Activity/overactivity

  18. CBT

  19. Mindfulness-based practice

  20. Development of and support through social network • Opportunity to ask questions • Graded skill building with individualized coaching • Assigned weekly practice • check-in and discussion • worksheets • Slide-shows with corresponding handouts • Cumulative patient handouts • Multi-disciplinary • Therapeutic intervention Fundamental Process elements

  21. Implementation

  22. Multi-disciplinary care/team approach • Bringing group psychotherapy to a primary care setting • Support from: • PCP • Medical Director support • Logistical support Essential Components

  23. Hahnemann Family Health Family Health of Worcester • 9,000; 50% Medicaid • CHC • Diverse patient population • Urban, academic, ambulatory primary care clinic • 9 physicians, 2 NPs, 12 residents, 3 BHCs, clinical pharmacists • 20,000; 90% Medicaid • CHC, FQHC • CMHC on site • Diverse patient population • 30% Spanish speaking • Chronic Pain Management Protocol • 20 physicians,12 NP/PAs, 12 residents, 1 BHC, 1 nurse midwife • 7advocates; 3 care managers Snapshot: clinic profiles

  24. Hahnemann Family Health Family health of worcester • Opioid contract • PCP-managed • High variability in implementation and prescribing practices • Practice-based registry • 3 providers with buprenorphine prescribing authority • Patients on opiates for 3+ months • Intake with program nurse • Monthly visits with nurse • Quarterly visits with PCP • Aberrant behaviors • Illicit substances • Misuse of prescription • Missing visits • Possible measures • More frequent visits • Urines and pill counts • Discharge from program Models Opiate Prescribing

  25. Outcome Data Results

  26. Attendance Age: mean = 50.95, sd = 10.54, range: 30 – 67 years Average group size = 5

  27. Each Session • Wong-Baker • Healthy Days Core Module (CDC HRQOL– 4) • Pre/Post • Brief Pain Inventory • Multi-dimensional Health Locus of Control • Patient Health Questionnaire (full version) • 12/20 complete sets for analysis Measures

  28. Wong-baker faces 8-17 respondents per session

  29. Brief Pain Inventory Pre N=16, post N=15

  30. Multi Dimensional Health Locus of Control

  31. Provider and Patient Perspectives

  32. Provider quotes

  33. Patient Voices

  34. Challenges

  35. Challenges and opportunities in your setting? • Take a moment to think about your setting. • Who would be on the team? • What challenges can you identify? • Talk with your neighbor. • What benefits might you expect? • Share with the group.

  36. Opportunities and Future Directions

  37. Link attendance to opiate contract • Multidisciplinary collaboration • Involve nutrition, PT, complementary alternatives etc. • Improved patient outcomes • Identifying what components contribute to change • Develop ongoing booster sessions • Provide further education and training to PCPs • Integration of feedback Opportunities

  38. Hahnemann family health Family health of Worcester • Continue program evaluations as quality improvement • Work towards sustainability • Continue to integrate modalities • PT/OT • Nutrition • Resident/Med student • Increased BH Role in Pain Management Program • Consulted at the time of referral • Follow patient through maintenance phase of treatment • Design maintenance programming • Workshop series for patients who have completed • Chiropractics, acupuncture, tai chi, yoga , self-hypnosis, nutrition Future directions

  39. What haven’t we thought of? How can we improve? Next steps? Questions and thoughts

  40. Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you! Session Evaluation

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