chronic pain non-pharmacological approaches for healthier ......able to list 4 techniques to manage...

Cynthia Baker, LCSW,

LSCSW, CSW-

Gerontology

Regional Clinical Director

Deer Oaks – A Behavioral

Health Solution

Leading Age Missouri

Annual Conference

Chronic Pain Non-Pharmacological Approaches for

Healthier Outcomes for Seniors

OBJECTIVES

1. By the conclusion of this training, participants will be

able to list 4 techniques to manage chronic pain.

2. At the end of the presentation, participants will be

able to distinguish at least 2 differences between

acute pain and chronic pain.

3. Participants will be able to develop a non

pharmacological comprehensive treatment plan for

chronic pain.

4. After attending this session, participants will be able to

list 3 pain-gate factors.

5. After this session, attendees will be able to list 3

unhelpful thinking styles that contribute to increasing

pain awareness.

Heroin?

• When opioid addicts need higher doses of

prescription opioids (or when supplies

become too difficult to obtain), many turn

to heroin.

• It is four times more potent and costs less.

• Three of every four new heroin users report

previous abuse of prescription opioids.

9

Primary care providers account for approximately 50% of prescription opioids dispensed.

How’d we get into this mess? The Perfect Storm:

• Regulators focused on pain control, “5th Vital Sign”

• Pharmaceutical companies marketing “safe” pain meds

• Traditional and current medical school education woefully

inadequate in regard to treatment of pain (and diagnosing

addiction)

• US culture → “anything can be cured with a pill”

To CDC/Probe

Need to teach providers:

• Identify and treat/refer - Addiction

• Evidence-Based Treatment of chronic pain

• Every guideline, including CDC, shows best evidence is for multimodal, multidisciplinary treatment

• This should reduce use of opiates, as long-term prescribing of opiates for CP is NOT recommended

14

CTX – PCPs Providers who prescribed =/>30 day supply of opioids over a 3-month period

Per CDC to Patients

Know your options:

Talk to your doctor about ways to manage your pain that don’t involve

prescription opioids. Some of these options may actually work better and have

fewer risks and side effects. Options may include:

• Acetaminophen (Tylenol®) or ibuprofen (Advil®)

• Cognitive behavioral therapy

• Physical therapy and exercise

• Medications for depression or for seizures

• Interventional therapies (injections)

Pain education

• Pain education is one element

of treatment that is unique and

precedes all pain-specific

psychological approaches.

• Pain education is an effective

psychological intervention that

can challenge maladaptive

pain beliefs about the meaning

of pain. Pain-CBT, pain-ACT,

and chronic pain self-

management include pain

education.

Activating Relaxation Response

•

• All evidence-based psychological

treatment for pain involves activating

the relaxation response and use of skills

that directly or indirectly promote

regulation of cognition, emotion, and

physiological arousal.

• Relaxation response is an element that

is common to all psychological

treatment approaches.

This Photo by Unknown Author is licensed under CC BY

CBT for Chronic Pain

• Time-Limited

• Goal-Oriented

• Empowerment of individuals by teaching:

• Challenging and/or altering of beliefs or thoughts

• Changing behaviors (MI)

• Relaxation skills/strategies

• In the literature, “CBT” can include:

• Cognitive restructuring

• ACT and DBT

• All relaxation techniques (including mindfulness, BFB, guided

imagery, etc.)

• Stress management

• Practical coping skills/strategies/behaviors

• Identify and treat: depression, anxiety, post-trauma

Why opioids May not be recommended for CP

• Function tends to worsen with long-term use, and effectiveness decreases.

• Other medications and treatments work as well or better for CP.

• Go over accidental overdose rates, addiction, etc.

• Are not first-line or even recommended unless pain is mod-severe pain (usually

acute) and there have been adequate trials of all non-opiate, non-pharm

treatments, or care is palliative.

• Name the medications and non-meds that are in this class:

• Codeine, hydrocodone, Demerol, morphine, oxycodone, fentanyl,

tramadol

• Discuss symptoms other than addiction:

• Tolerance, dependence, increased sensitivity to pain (OIH), constipation,

nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, depression,

lower sex drive, impotence, low energy/strength, itching and sweating,

negative effects on respiration, death

https://www.youtube.com/watch?v=MI1myFQPdCE “Brainman stops his opioids”

Step 1 for Chronic Pain

• Complete pre-testing (BPI?)

• Explain the process and ground rules

• Explain differences between Acute and Chronic Pain (CP)

• Explain biopsychosocial nature of pain

• Discuss impact of chronic pain on the individual

Acute Chronic

• Examples: broken bone,

toothache, childbirth

• Serves as a warning

• Is time-limited

• 3-6 months

• Examples: chronic headaches,

fibromyalgia, neuropathies, LBP,

nonspecific neck pain

• Warning system gone awry

• Serves no useful purpose

• Not life threatening (but

miserable)

Note: You can have acute over chronic, or chronic over acute pain.

Impact of Chronic Pain

• Looking for a cure

• There are few cures in medicine

• Sleep disruption

• Deconditioning (Lack of movement)

• Emotions

• Bidirectional nature of depression, anxiety

• History of abuse/neglect/trauma

• Social interactions

• Activities

• Getting things done

• Overdoing it

https://www.youtube.com/watch?v=5KrUL8tOaQs

https://www.youtube.com/watch?v=MI1myFQPdCE

“Brainman stops his opioids”

Opiates

Medications

• Meds are only one “tool” in the toolkit; opiates are only one med class that’s

effective for pain.

• Only change pain by a few points on the 10-point scale.

Movement

• Discuss how deconditioning worsens pain and/or can cause new pain

• In CP, “hurt does not mean harm”

• Frequent “little bits” better than one long session – to avoid Flare-ups

• Discuss options for movement/exercise

• Stretching, strengthening, aerobic

• Walking

• Pool, recumbent stationary bikes, pumping arms - options for those with LE limitations

• If needed, ask PCP to refer to PT for “Home exercise program for chronic pain”

• Support PT recommendations; coordinate care

• Use motivational interviewing to come up with a small movement-related goal

Pacing

Planning

Prioritizing• Encourage incorporation of leisure/pleasant activities

• Brainstorm on these

• Encourage activities that are Important vs. Not Important

Relaxation• Mini-relaxation techniques

• Breathing to a count

• Cleansing breaths

• Body scan

• Relaxing music

• Other techniques

• Mindfulness

• Guided Imagery/Visualization

• Yoga breathing

• Progressive Muscle Relaxation

• Biofeedback (Google “Journey of the Wild Devine” Ornish/Chopra)

• Autogenic Training

• Meditation

• *Qigong

• *Yoga

• *Tai Chi

Http://kp.org/listen (free)

Choose “podcasts” on the left

At list, choose either “Listen” or “Download”

http://www.healthjourneys.com/ (reasonably priced)

“Stress” • Stress is not what’s “out there,” but rather how it affects you;

we aren’t helpless victims of “stressors.”

• Change can result in a stress reaction, even if it’s positive

change.

• Not all negative situations are worth the effort it would take

to reduce their effects.

• Changing how we think about things can change the

reaction.

• Setting up for cognitive restructuring

• Note: Past or present trauma could come out here and may

need to be dealt with in future/additional sessions.

• Good place to talk about anger and forgiveness – which

isn’t about the other person.

Sleep • Go over Sleep Hygiene

• Give handout

• Discuss sleep meds

• Antidepressants and antihistamines are preferable to

true sleep meds, which are essentially benzodiazepines

and have significant side effects (and are not to be

taken concurrently with opiates)

• Discuss caffeine

• Effects on Sympathetic nervous system and resulting

effects on pain and sleep.

• Recommend slow taper – 10-20% every 4-5 days

• Give handout

• Discuss negative sleep cycle and use of relaxation

techniques.

Social Support System

Discuss who is in patient’s system.

Friends

Acceptance

Guidance/Advice

Encouragement

Practical Assistance

Companionship

Support when I’m down

Excitement or new ideas

Fun

Company in new situations

Known me a long time.If there are few names,

means patient needs to extend the system.

Discuss options for extending the system.

Assertiveness

• Contrast assertiveness with aggressiveness

and passiveness

• Bill of Rights

• “I” statements – Develop a from to be used

for these.

• Are there situations or persons in which or with

whom it’s easier or harder to be assertive?

Typical Unhelpful Thinking Styles

Use examples related to pain:

• Catastrophizing – best predictor of ongoing pain

• All or nothing, black/white

• Overgeneralization

• Personalization

• Emotional reasoning

• Should-y thinking

• Blaming

• Jumping to conclusions

• Minimization/maximization

• Entitlement fallacy – In the US, we tend to think we’re entitled to

a pain-free existence

• Etc.

Recommendations for Re-Structuring

• Use a simple ABCD form for homework, where

A – Activating event

B – Belief or thought about event

C – Consequences of B (resulting feelings/behaviors)

mad/sad/glad/afraid

pain

behaviors

D – Disputing thoughts (how else might I think about this)

• Teach that A does not lead to C; B leads to C

• Have patient complete the ABCD form after he/she negative reactions; completing it after positive reactions can be revealing also.

• Focus on gradual move to earlier in the process – before the negative reaction.

Maintenance Plan

Recommend development of a Form for this, which can be scanned and put in chart.

• Patient to develop a Maintenance Plan – ongoing activities to manage pain.

• This must be a lifestyle.

• Point out that this lifestyle is just a healthy one – for anyone, not just those with CP.

• Patient should complete the form, addressing:

• Activity planning using the 3 P’s

• Daily relaxation

• Daily movement/exercise

• Positive/helpful thinking

• Social support activities

• Pleasant activities

• Appropriate medications

• Ongoing assertiveness

• Ongoing sleep hygiene

• Ongoing stress management

Flare Management

Recommend development of a Form for this, to be scanned into chart:

Patient to complete a Flare Management Plan

•“Don’t panic” reminder

•Relaxation (website, recording, etc.)

•Do Not Disturb Sign

•Heat/cold packs

•Topicals

•RICE – rest, ice, compression, elevation

•Warm bath

•Reduce activity by 50%, but don’t stop

•Focus on stretching more than aerobics

•Contact information for a support person - ask for encouragement.

•Keep the Toolkit in a convenient place

Cynthia Baker, LCSW,

LSCSW, CSW-Gerontology

Regional Clinical Director

573-489-0868

Deer Oaks – A Behavioral

Health Solution

Www.deeroaks.com

210-615-3484

Leading Age Missouri

Annual Conference

Chronic Pain Non-Pharmacological Approaches for

Healthier Outcomes for Seniors