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Understanding the Five Key Domains of Best Practice Pain Care and

Making your Job easier: New Pain Education Tools for Oregon Providers and Patients

Nora Stern, PT, MSPT, Clinical Program Manager, Comprehensive Pain Service, Providence Health and Services

Catriona Buist, PsyD, Assistant Professor, Department of Anesthesiology and Perioperative Medicine and Psychiatry

Sara Love, ND, Sr. Project Manager/Sr. Improvement Facilitator, Comagine-Oregon

Kevin Novak, MS, Research Assistant, Comagine-Oregon

Oregon Conference on Opioids and Other Drugs, Pain and Addiction Treatment

Bend, Oregon

May 29, 2019

Learning Objectives:

Learn communication strategies to better navigate difficult conversations about pain and to redirect a treatment plan that addresses the 5 key domains of best-practice pain care

Learn about state-wide resources for pain education and treatment and apply tools to more effectively screen, educate and provide care for patients with persistent pain

63 y/o female with fibromyalgia 20 years

Medical Hx: Complex history

Pain Presentation: Pain in multiple sites, including knees and low back, pain all over, moves around, worse with stress and cold weather

Medication: Methadone and benzodiazepine

Sleep: Poor sleep, untreated sleep apnea

Physical/function: Generally deconditioned, afraid to move because of pain

Mental health hx: Multiple issues & cognitive decline

Social/work: Supportive family and church, retired shopkeeper

Nutrition: Gained 40 lbs in last year

Substances: Personal and family hx of alcohol and substance abuseFictional patient, stock photo 2019

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Key Points

• Pain is a multi-dimensional experience

• All pain is real pain

• Nociception is neither necessary nor sufficient for pain

•PAIN ≠ HARM

Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010

Redirect conversations:

Away from eliminating pain

Towards:

Understanding Pain

Function

Quality of life

Living a meaningful life

Self-management

Goal of Treatment is to Help the Patient Increase Life

PainPain

Life

LifeTreatment and increased self-efficacy

Pain

Life

PEG Tool (Krebs, 2009)

https://www.oregonpainguidance.org/resources/difficult-conversations/

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Prioritizing Care: Key Domains

Knowledge of pain

Nutrition

Activity

Sleep

Mood

• Key Concepts• Strategies• Resources• Connecting with

your patient

Videos, written material and trackers

English, Spanish, Simplified Chinese, Vietnamese, Russian

Clinician Guide

https://www.oregonpainguidance.org/resources/patient-education-toolkit/

Shared Decision Making Tool starts the conversation

https://www.oregonpainguidance.org/resources/patient-education-toolkit/

Key domains: Knowledge of pain

Knowledge of pain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

Understanding Pain

Videos

Written material/shared decision makingTools for explaining pain

Key Domains: Activity and Pacing

Knowledge of pain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

Key domain: Activity

• Gradual return to activity to improve conditioning

• Pacing – WORKING SMARTER NOT HARDER

• Activity improves sleep

• REMEMBER: YOU ARE SORE BUT SAFE

• Doing more is more important than exercising

• Expect flare ups and learn to manage them with pacing

• Gentle movement, tai chi, therapeutic yoga, aquatic exercise, PT, OT

• Remember: MOTION IS LOTION

Oregon Pain Guidance May 17, 2018 22

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

Activity tools:

Key Domains: Sleep

Knowledge of pain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

Key Domain- Sleep

Sleep – wake cycle often disruptedFatigue makes pain worseRest is essential to rejuvenate and repair tissuesLearning to calm the nervous system can promote restTeach sleep hygieneAddress sleep apneaSleep log could be helpful to see patternsRefer for Cognitive Behavioral Therapy for Insomnia CBT-I (CBT-i coach)

Sleep: Tools

Video:

Focus treatment on these key domains

Knowledge of pain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

Common Co-morbid Psychological Conditions w Chronic Pain

Thought Emotion Behavior

Anxiety & PTSD “I feel overwhelmed”“I feel out of control”“Nobody understands me”“Nobody believes me”

Fear Withdraw from activity

Depression “Last time I went to the park I had a flare up, I can’t do anything I enjoy”“I feel guilty I can’t contribute to my family”“I feel worthless”

Grief Guilt

Withdraw from activity

Grief & Loss of Identity

“I’ve always hard to be the best ___”“Who am I now?”“My daughter has to help me wash my hair and shave my legs”“I use to be the provider for the family”“I’ve lost my sense of independence”

ShameGrief

Withdraw from activity

Our goal is to help people get their life back…

Their Shrinking World…

Mood – Key Domain

• Depression, anxiety, PTSD, history of trauma,

complex grief, isolation and stress can impact pain

• The brain interprets chronic pain as a chronic stressor and actives the body’s stress response

• The release of cortisol and pro-inflammatory cytokines can affect tissue regeneration, immune function and metabolic controls which can increase pain

• Decreasing pleasurable activities increases the focus on pain

YOUR WORDS MATTER! Negative thoughts about pain can lead to maladaptive coping and increased suffering and disability

Thought: “I have DDD.” “My back is crumbling”

Emotion: fear

Behavior: seek additional medical treatment

Idea: change wording from “DDD” to “normal age related changes.”

NeuroplasticityThe ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury.

Remember:

THE NERVES THAT FIRE TOGETHER WIRE TOGETHER

Calming the Nervous System

•Diaphragmatic breathing•Mindfulness training•Progressive muscle relaxation•Visualization• Self-hypnosis•Biofeedback• Sleep •Movement (tai chi, yoga)•Apps: Calm.com, Headspace.com, Insighttimer.com

Mood: Tools

Video

Key domains: Nutrition

Knowledge of pain

Nutrition

Activity

Sleep

Mood

KEYDOMAINS

Nutrition – Key Domain

• What we eat can throw fuel on the pain, affect energy level & make us feel worse

• Explore knowledge of healthy eating and cooking

• Understand barriers to eating healthier

• Dietary log can be helpful

Nutrition: Tools

Video

Medication: Tools

Video

RELIEF+: Preventing Opioid Harms in Older AdultsSara Love, ND, Senior Project Manager, Comagine Health

Kevin Novak, MS, Research Assistant, Comagine Health

May 28, 2019

Funding for the Opioid Safety Special Innovation Project, titled RELIEF+,was provided by the Centers for Medicare & Medicaid Services (CMS HHSM-500-T0008).

Special Thanks

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Who is Comagine Health?

• Comagine Health, formerly Qualis Health and HealthInsight, is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.

• Our Mission: Together, with our partners, we work to improve health and to create a better health care system so that people and communities will flourish.

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Disclosures

• Sara Love, ND: No actual or potential conflict of interest in relation to this program or presentation.

• Kevin Novak, MS: No actual or potential conflict of interest in relation to this program or presentation.

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Learning Objectives

• This presentation is intended to enable participants to…

• Recognize important caveats for treating pain in older adults

• Locate the RELIEF+ Toolkit and be able to describe its components.

• Understand how to use the RELIEF+ toolkit, and how it can address barriers to treatment.

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Quick Overview of Topics Already Covered

Biopsychosocial Model of Pain

The Five Domains of Best Practice Pain Care

How to treat pain in older adults

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Older Adults and Pain

1 in 4 Community-Dwelling Older Adults experiences agonizing pain DAILY.

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What are your barriers to effective and safe pain management for older adults?

Bio

Psycho

Social

Logistics

Clinic Specific

Patient Specific

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Biological barriers to pain management in older adults

• Reduced mobility and physical activity

• Changes in metabolism (pharmacokinetics)

• Genetic predispositions

• Changes in nervous system response (nociception)

• Comorbidities, many times leading to potentially dangerous drug–drug interactions

• Opioid Use Disorder

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Psychological barriers to pain management in older adults

• Cognitive decline

• Depression and anxiety

• Fluctuations in mood

• Unaddressed psychological problems (e.g., PTSD)

• Beliefs around pain and when opioids are appropriate

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Social barriers to pain management in older adults

• Loneliness and social isolation

• Lack of proper social support systems

• Disintegrating social networks

• Change of living settings

• Transportation challenges

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Clinic barriers to pain management in older adults

• Technological challenges• Electronic health records

• PDMP

• MED calculators

• Workflow considerations

• Patient/family-centered goal setting

• Care coordination between settings

• Access to a variety of nonpharmacological care modalities

• Insurance considerations

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Introducing “Resources Encouraging Lifestyle Interventions and Enhanced pain treatment for 55+” (RELIEF+)

https://healthinsight.org/relief-plus/

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RELIEF+

Improving pain management and opioid safety for older adults (55+)

• Target: primary care providers, clinic staff, pain specialists, and behavioral health specialists

• Program: web-based / printable resources and online training

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Objectives of the RELIEF+ Toolkit

• Empower primary care clinics to use an evidence-based, patient-centered approach to persistent pain management tailored for older patients (55+)

Purpose

• Reduce risky prescribing practices

• Reduce opioid-related hospitalizationsPrimary goals

• Assess the cost-effectiveness and overall impact of two levels of clinic intervention

Secondary goal

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Training Videos

Eight online modules

Each video focuses on one of four topics:

• Communicating for opioid safety and pain management

• Nonpharmacological approaches for pain management

• Opioid prescribing and monitoring best practices

• Screening for and addressing opioid use disorder

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RELIEF+ Website

Access to the RELIEF+ Video Training Series

Practice resources and printable materials

Links to publicly available data and clinical resources

6 AMA PRA Category 1 CreditsTM available

https://healthinsight.org/relief-plus

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Expert Advisory Committee

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How RELIEF+ can address barriers to pain treatment for older adults

Barrier How RELIEF+ Addresses

Biological Barriers • Help clinicians understand biological changes in older adults, and adjust treatment plans to be more focused on gradual change.

Psychological Barriers • Use motivational interviewing and communication techniques to dispel maladaptive beliefs about pain, and to help address underlying psycho-emotional problems.

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How RELIEF+ can address barriers to pain treatment for older adults

Barrier How RELIEF+ Addresses

Social Barriers • Being supportive as a clinician and staff. Encourage patients to engage in social activities and spend more time with friends and family.

Logistic Barriers • Modify workflows as needed to streamline care, create patient-centered goals and continue to build relationships with community partners.

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Questions?

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Contact information

• Sara Love, NDslove@comagine.org

• Kevin Novak, MS knovak@comagine.org

This material was prepared by Comagine Health (formerly HealthInsight), the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-OSSIP-19-04-OR 5/6/19

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63 y/o female with fibromyalgia 20 years

Medical Hx: Complex history

Pain Presentation: Pain in multiple sites, including knees and low back, pain all over, moves around, worse with stress and cold weather

Medication: methadone and benzodiazepine

Sleep: Poor sleep, untreated sleep apnea

Physical/function: Generally deconditioned, afraid to move because of pain

Mental health hx: multiple issues & cognitive decline

Social/work: supportive family and church, retired shopkeeper

Nutrition: gained 40 lbs in last year

Substances: personal and family hx of alcohol and substance abuseFictional patient, stock photo 2019

Shared Decision Making Tool starts the conversation

Questions

References: OPMC/OPG Pain Education ToolkitActivity

• 1. Ambrose KR, Golightly YM. Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Practice & Research Clinical Rheumatology. 2015;29(1):120-30.

• 2. Andersen LN, Juul-Kristensen B, Sørensen TL, Herborg LG, Roessler KK, Søgaard K. Efficacy of tailored physical activity or chronic pain self-management programme on return to work for sick-listed citizens: A 3-month randomised controlled trial. Scandinavian Journal of Public Health. 2015;43(7):694-703.

• 3. Boutevillain L, Dupeyron A, Rouch C, Richard E, Coudeyre E. Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PloS One. 2017;12(7):e0179826.

• 4. Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. The Clinical Journal of Pain. 2015;31(2):108-14.

• 5. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;1:CD011279.

• 6. Law LF, Sluka KA. How does physical activity modulate pain? Pain. 2017;158(3):369.

• 7. Marshall PW, Schabrun S, Knox MF. Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain. PloS One. 2017;12(7):e0180788.

• 8. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa C. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094.

• 9. Spine-health. Pain Treatments Health Center [Internet]. VERITAS Health. 2018 [cited 27 September 2018]. Available from: https://www.spine-health.com/treatment.

• 10. Suorsa K, Lynch-Jordan A, Tran S, Edwards N, Kashikar-Zuck S. (504) Rates of physical activity and perceived social support among young adult women with juvenile-onset fibromyalgia. The Journal of Pain. 2016;17(4):S100-1.

References: OPMC/OPG Pain Education ToolkitMindset• 1. Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research.

2016;9:457.

• 2. Finlay KA, Peacock S, Elander J. Developing successful social support: An interpretative phenomenological analysis of mechanisms and processes in a chronic pain support group. Psychology & Health. 2018;33(7):846-71.

• 3. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Practical Pain Management. 2015;15(6):70-5.

• 4. Hazeldine-Baker CE, Salkovskis PM, Osborn M, Gauntlett-Gilbert J. Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain. British Journal of Pain. 2018;12(2):87-94.

• 5. Hood A, Pulvers K, Carrillo J, Merchant G, Thomas M. Positive traits linked to less pain through lower pain catastrophizing. Personality and Individual Differences. 2012;52(3):401-5.

• 6. Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The impact of social isolation on pain interference: A longitudinal study. Annals of Behavioral Medicine. 2018. DOI: 10.1093/abm/kay017.

• 7. Koechlin H, Coakley R, Schechter N, Werner C, Kossowsky J. The role of emotion regulation in chronic pain: A systematic literature review. Journal of Psychosomatic Research. 2018;107:38-45.

• 8. Lerman SF, Rudich Z, Brill S, Shalev H, Shahar G. Longitudinal associations between depression, anxiety, pain, and pain-related disability in chronic pain patients. Psychosomatic Medicine. 2015;77(3):333-41.

• 9. Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubiner H, Keefe FJ. Pain and emotion: a biopsychosocial review of recent research. Journal of clinical psychology. 2011;67(9):942-68.

• 10. Ramírez-Maestre C, Esteve R, López-Martínez AE, Serrano-Ibáñez ER, Ruiz-Párraga GT, Peters M. Goal adjustment and well-being: The role of optimism in patients with chronic pain. Annals of Behavioral Medicine. 2018. DOI: 10.1093/abm/kay070

• 11. Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English longitudinal study of ageing. British Journal of Pain. 2018:2049463718802868.

References: OPMC/OPG Pain Education ToolkitSleep

• 1. American Sleep Association. About sleep [Internet]. American Sleep Association. 2018 [cited 27 September 2018]. Available from https://www.sleepassociation.org/about-sleep/.

• 2. Cheatle MD, Foster S, Pinkett A, Lesneski M, Qu D, Dhingra L. Assessing and managing sleep disturbance in patients with chronic pain. Anesthesiology Clinics. 2016;34(2):379-93.

• 3. Cho S, Kim GS, Lee JH. Psychometric evaluation of the sleep hygiene index: A sample of patients with chronic pain. Health and Quality of Life Outcomes. 2013;11(1):1.

• 4. Choy EH. The role of sleep in pain and fibromyalgia. Nature Reviews Rheumatology. 2015;11(9):513.

• 5. Deardorff WW. Practicing good sleep hygiene [Internet]. VERITAS Health. 2018 [cited 27 September 2018]. Available from https://www.spine-health.com/wellness/sleep/practicing-good-sleep-hygiene.

• 6. Harrison L, Wilson S, Heron J, Stannard C, Munafò MR. Exploring the associations shared by mood, pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample. Psychology & Health. 2016;31(5):565-77.

• 7. Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Medicine Reviews, 22, 23-36.

• 8. Koffel E, Kroenke K, Bair MJ, Leverty D, Polusny MA, Krebs EE. The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial. Health Psychology. 2016;35(1):41.

• 9. Lerman SF, Finan PH, Smith MT, Haythornthwaite JA. Psychological interventions that target sleep reduce pain catastrophizing in knee osteoarthritis. Pain. 2017;158(11):2189-95.

• 10. National Sleep Foundation. Pain and sleep [Internet]. National Sleep Foundation. 2018 [cited 27 September 2018]. Available from https://www.sleepfoundation.org/sleep-disorders-problems/pain-and-sleep.

• 11. Nijs J, Loggia ML, Polli A, Moens M, Huysmans E, Goudman L, Meeus M, Vanderweeën L, Ickmans K, Clauw D. Sleep disturbances and severe stress as glial activators: key targets for treating central sensitization in chronic pain patients? Expert Opinion on Therapeutic Targets. 2017;21(8):817-26.

• 12. Tang NK, Lereya ST, Boulton H, Miller MA, Wolke D, Cappuccio FP. Nonpharmacological treatments of insomnia for long-term painful conditions: a systematic review and meta-analysis of patient-reported outcomes in randomized controlled trials. Sleep. 2015;38(11):1751-64.

• CLINICIAN GUIDE: APPENDIX

References: OPMC/OPG Pain Education ToolkitNutrition

• 1. Cooper L, Ryan CG, Ells LJ, Hamilton S, Atkinson G, Cooper K, Johnson MI, Kirwan JP, Martin D. Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review. Obesity Reviews. 2018:19:989-1007.

• 2. De Gregori M, Muscoli C, Schatman ME, Stallone T, Intelligente F, Rondanelli M, Franceschi F, Arranz LI, Lorente-Cebrián S, Salamone M, Ilari S. Combining pain therapy with lifestyle: the role of personalized nutrition and nutritional supplements according to the SIMPAR Feed Your Destiny approach. Journal of Pain Research. 2016;9:1179.

• 3. Eatright.org. Food [Internet]. Academy of Nutrition and Dietetics. 2018 [cited 27 September 2018]. Available from: https://www.eatright.org/food.

• 4. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007;129(1-2):210-23.

• 5. Okifuji A, Hare BD. The association between chronic pain and obesity. Journal of Pain Research. 2015;8:399.

• 6. Ray L, Lipton RB, Zimmerman ME, Katz MJ, Derby CA. Mechanisms of association between obesity and chronic pain in the elderly. Pain. 2011;152(1):53-9.

• 7. Rondanelli M, Faliva MA, Miccono A, Naso M, Nichetti M, Riva A, Guerriero F, De Gregori M, Peroni G, Perna S. Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents. Nutrition Research Reviews. 2018;31(1):131-51.

• 8. Ruskin DN, Kawamura Jr M, Masino SA. Reduced pain and inflammation in juvenile and adult rats fed a ketogenic diet. PloS One. 2009;4(12):e8349.

• 9. Silişteanu SC, Covaşă M. Reduction of body weight through nutrition intervention reduces chronic low back pain. In E-Health and Bioengineering Conference (EHB), 2015 Nov 19 (pp. 1-

References: OPMC/OPG Pain Education ToolkitTapering/Multi-domain• Tapering

• 1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45.

• 2. Murphy L, Babaei-Rad R, Buna D, Isaac P, Murphy A, Ng K, Regier L, Steenhof N, Zhang M, Sproule B. Guidance on opioid tapering in the context of chronic pain: Evidence, practical advice and frequently asked questions. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada. 2018;151(2):114-20.

• 3. Sullivan MD, Turner JA, DiLodovico C, D’Appollonio A, Stephens K, Chan YF. Prescription opioid taper support for outpatients with chronic pain: A randomized controlled trial. The Journal of Pain. 2017;18(3):308-18.

• 4. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Internal Medicine. 2018;178(5):707-8.

• 5. Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid therapy for chronic pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense clinical practice guideline. Pain Medicine. 2017;19(5):928-41.

• 6. McPherson S, Smith CL, Dobscha SK, Morasco BJ, Demidenko MI, Meath TH, Lovejoy TI. Changes in pain intensity following discontinuation of long-term opioid therapy for chronic non-cancer pain. Pain. 2018:159(10):2097-2104

• 7. Matthias MS, Johnson NL, Shields CG, Bair MJ, MacKie P, Huffman M, Alexander SC. “I’m not gonna pull the rug out from under you”: Patient-provider communication about opioid tapering. The Journal of Pain. 2017;18(11):1365-73.

• 8. Friedman Z, Arzola C, Postonogova T, Malavade A, Siddiqui NT. Physician and patient survey of taper schedule and family physician letters following discharged from the acutepain service. Pain Practice. 2017;17(3):366-70.

• 9. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. May Clin Proc. 2015; 90(6):828-842.

• Multi-Domain Sources

• 1. Butler DS, Moseley GL. Explain Pain. 2nd Edition. NOIgroup Publications; 2013.

• 2. Turk DC, Winter F. The pain survival guide: How to reclaim your life. American Psychological Association; 2006.

References

• Barbour KE, Helmick CG, Boring MA, Brady TJ. Vital signs: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2013–2015. Morb Mortal Wkly Rep. 2017 March 7.

• Brennan N and Mattick K. A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers. Br J Clin Pharmacol. 2013 Feb 1;75(2):359-72.

• Coon JT, Abbott R, Rogers M, et al. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. J Am Med Dir Assoc. 2014 Oct 31;15(10):706-18.

• Duncan DF, Nicholson T, White JB, et al. The baby boomer effect: changing patterns of substance abuse among adults ages 55 and older. Journal of Aging & Social Policy. 2010 Jun 30;22(3):237-48.

• Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016:65(1):1-49.

• Elliott RA. Problems with medication use in the elderly: an Australian perspective. Journal of Pharmacy Practice and Research. 2006 Mar 1;36(1):58-66.

• Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409-414.

• Guerriero, F and Reid, CM. New opioid prescribing guidelines released in the US: What impact will they have in the care of older patients with persistent pain? Current Medical Research and Opinion. 2017:33(2):275-278.

• https://www.cdc.gov/nchs/data/hus/hus06.pdf

• https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57

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References• Johannes CB, Le TK, Zhou X, et al. The prevalence of chronic pain in United States adults: results of an Internet-based survey. The Journal of Pain.

2010 Nov 30;11(11):1230-9.

• Johnson MJ, May CR. Promoting professional behavior change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open. 2015;5:e008592. doi: 10.1136/bmjopen-2015-008592

• Kantar Health. The global health and wellness report 2018. Kantar Health; 2019, p. 325. Available from: https://info.kantarhealth.com/global-health-wellness-report.

• Kress HG, Ahlbeck K, Aldington D, et al. Managing chronic pain in elderly patients requires a CHANGE of approach. Current Medical Research and Opinion. 2014 Jun 1;30(6):1153-64.

• Marra EM, Mazer-Amirshahi M, Mullins P, Pines JM. Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015). West J Emerg Med. 2018;19(4):678–688. doi:10.5811/westjem.2018.5.37853

• Salzman C. Medication compliance in the elderly. J Clin Psychiatry. 1995;56 Suppl 1:18-22; discussion 23

• Saunders KW, Dunn KM, Merrill JO, et al. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010:25:310-5.

• Sawyer P, Bodner EV, Ritchie CS, et al. Pain and pain medication use in community-dwelling older adults. Am J Geriatr Pharmacother. 2006;4(4):316-24.

• Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170:1968-76.

• Weiss A, Bailey M, O’Malley L, et al. Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014. HCUP Statistical Brief #224, June 2017.

• Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002 Nov 11;162(20):2269-76.

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• Physicians

• Physician Assistants

• Nursing

• Acupuncture

• Psychologists

• Physical therapists

• Occupational therapists

• Chiropractic physicians

• Naturopathic physicians

• Pharmacists

• Dentists

Required Pain Management Education

www.oregonpainmodule.org

The Oregon Pain Website: https://www.oregonpainguidance.org/

Pain and Opioids & Addiction ECHO https://www.oregonechonetwork.org/

Lorimer Moseley—Tame The Beast—It's time to rethink persistent pain

https://youtu.be/ikUzvSph7Z4

Motivational Interviewing for Healthcare Professionals -Online EducationCollege of Nursing at the

University of Coloradohttp://www.ucdenver.edu/academics/colleges/nursing/programs-admissions/CE-PD/Pages/Motivational-Interviewing-for-Healthcare-Professionals.aspx

The Efficacy of Motivational Interviewing in Adults with Chronic Pain: A Meta-Analysis and Systematic ReviewDion Alperstein & Louise Sharpe The Journal of Pain, Vol 17, No 4 (April), 2016: pp 393-403.“MI significantly increased adherence to chronic pain treatment in the short term…”

Motivational Interviewing resources (Miller and Rollnick, 2009)

Motivational Interviewing Network:

https://motivationalinterviewing.org/

Understanding Pain and Whatto Do About Itin Less than5 Minutes

Joint Pain Education Project video from the Department of Defense and Veterans Health Administration to learn more about chronic pain management.

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