Pain Self-Care Tools for Veterans

Beth L. Dinoff, Ph.D.Director VIPS

Veterans Integrative Pain ServicesFayetteville VA Medical Center

Grand RoundsAugust 7, 2015

I have no financial disclosures to share. I have had chronic pain since 2001. I was a pain psychologist in training for

almost a decade before developing chronic pain.

Disclosures

Review common types of chronic pain responsive to patient self-care.

Describe self-care tools for recovery from chronic pain used in the primary care setting.

Demonstrate applications of self-care and recovery in clinic practice.

Learning Objectives

Definitions

Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

International Association for the Study of Pain

Chronic Pain

Chronic pain is without apparent biological value that has persisted beyond the normal tissue healing time (usually taken to be 3 months)

Responsive to Self-Care Skills International Association for

the Study of Pain

More Definitions

Self-Management (Self-Care)

Patients having a responsibility for managing some aspects of the condition independently or in conjunction with health care provider

Built upon a patient-centered approach, planned over time, enhances patient autonomy

“…Patient attitudes, behaviors and skills directed toward managing the impact of the condition(s) on all aspects of living.”

Flinders Human Behaviour and Health Research Unit, 2007

Medications = Functional improvementMedications ≠ Reduction in pain scores

Brief Education About Pain Medications

Whenever long-term pain meds of any kind are being considered for veteran’s chronic pain treatment plan… Always implement self-care strategies.

Pain medications can actually INCREASE pain sensations (opioid induced hyperalgesia).

Who and What Responds to Self-Care?

Who (i.e., which patients)?

Veterans Older adults Males Females Children Adolescents People with MH conditions

What (Pain Conditions)?

Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic

Percentage of veterans with chronic pain: 50% – 80%

VA PACTs see veterans 1 – 2 times annually Follow-up appointments last 30 minutes maximum Female veterans are at high risk for chronic pain Veterans with chronic pain commonly have multiple

co-morbidities, e.g., mental illness, substance use issues, and/or polytrauma

Chronic pain is complex, difficult, and often frustrating for VA providers (Dinoff et al., 2009)

Why Self-Care for Vets in Pain?Provider Perspective

16/90 clinical providers responded to Survey Monkey questionnaire (i.e., physicians, clinical pharmacists, nurse practioners, psychologists)

56% of providers were male Number of pain patients seen weekly

Fewer than 15: 63% 15 – 30: 25% 31 – 45: 13%

Treatments most commonly used: NSAIDS, antidepressants

Is Discomfort with Pain Management Linked to Provider Job Stress? A Pilot Study of VA Clinical

providers(Dinoff, Pilkinton, Dutton, Ustinov, & Jacobs, 2009)

Is Discomfort with Pain Management Linked to Provider Job Stress? A Pilot Study of VA Clinical

Providers(Dinoff, Pilkinton, Dutton, Ustinov, & Jacobs, 2009)

Positive Correlation ↑↑

r = .59 (p = .04) As challenging problems

increased (↑) Vets with addictions Documentation requirements

The more stress providers experienced (↑) Difficult relations with coworkers Having too much work to

complete

Negative Correlation ↓↑

r = -.58 (p = .02) Health care providers who

were more willing to work with chronic pain patients (↑) Became less distressed about

prescribing opioids (↓) Felt less fear of potential legal

actions (↓) Felt less coerced into

prescribing opioids (↓)

“Okay, so that study was about providers at a different VA. What makes you think that it applies to the FNCVA?”

Are We Really

Stressed About Pain

Management?

Question: The work that I do at the VA with Veterans in chronic pain is:

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Perceptions of Working with Vet-erans in Chronic Pain at the FNCVA

(July, 2015)PrescribersPsychologists/SWNurses RN/LPNOthers

Clinician Ratings

Why Self-Care for Vets in Pain?Because Pain Hurts Veterans

Pain on the battlefield lets you know that you’re alive. When pain continues, it takes away your willingness to stay that way.

An Unknown Military Veteran of the Iraqi Campaign

The acute care model of pain treatment just doesn’t work. Standard diagnostic testing commonly provides very little

useful information. Veterans become frustrated. The Veteran thinks nobody believes him/her. Veteran gets referred to mental health. The Veteran knows that s/he’s not “crazy.” Medications are stopped, nothing new is offered to them,

and Veterans they don’t know why when they are hurting. Veterans are hurting and don’t know what to do in order

start feeling better.

Why Self-Care for Vets in Pain?Veteran Perspective

Doleys and Dinoff highlight the potential contribution of psychosocial factors to interventional procedures whenever the desired outcome involves a reduction in subjective pain and patient adaptation to the experience of pain.

Doleys DM, & Dinoff BL. Psychological aspects of interventional therapy. Anesthesiol Clin North America 2003 Dec;21(4):767-83.

Damush et al. showed enhancing patient self-management skills decreased pain severity and improved functional status

Damush TM,Weinberger M, Perkins SM, et al. The long-term effects of a self-management program for inner-city primary care patients with acute low back pain. Arch Intern Med 2003;163:2632–8.

Proposes a model for pain self-management that involves activities and coping strategies; also recognizes the role of social connectedness of Veterans is vital to pain self-management.

Matthias MS, Miech EJ, Myers LJ, Sargent C, & Bair MJ. An expanded view of self-management: Patients’ perceptions of education and support in an intervention for chronic musculoskeletal pain. Pain Med 2012; 13: 1018-1028.

Pain education must be included with self-management skills training to be most effective as prevention of chronic pain.

Cosio D, Hugo E, Roberts S, & Schaefer D. A pain education school for Veterans: Putting prevention into VA practice. Federal Practioner 2012; March; 23-29.

Pain Self-Management: Does it Really Work?

Who and What Responds to Self-Care?

Who (i.e., which patients)?

Veterans Older adults Males Females Children Adolescents People with MH conditions

What (Pain Conditions)?

Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic

How to Help Engage a Patient in Pain Self- Care or Management

• Listen to the patient’s ideas and feelings about the illness or disease.

• Take time during consultation and recognize that chronic conditions change very slowly.

• Realize that you don’t complete the process in one consultation. Change is a process that occurs over time.

• Start somewhere with one goal.

Borrowed from SCAN-ECHO presentation by Drs. Chris Spevak and Ilene Robeck (August 4, 2015)

Trans-Theoretical Stages of Change

Model

Stages DefinedPre-contemplation: Not thinking about changeContemplation: Thinking about changePreparation: Getting ready to changeAction: Actually changing behaviorsMaintenance: Change is now routine or a habitRelapse: Returned to former behaviors

What Patients Say

I may.

I won’t.

I am.

I can’t. I still

am.

I will.

I’ve tried that before. It won’t work for me. You don’t understand my pain.

I want my pain meds. My pain is different than the others. I can barely walk.

Pain Self-Care Tools and Skills

Pain Education Gate Control Theory, Neuroplasticity

Improve Functioning Sleep, Movement, Employment

Emotion Regulation Fear, Anger, Anxiety

CBT and ACT Catastrophizing, Acceptance, Engage

Socialization Family, Friends, Pain Support Groups

Understanding pain What are the pain pathways in

my body? Why am I hurting? How do pain treatments work? Theories of pain

Gate Control Theory Medical model vs.

Biopsychosocial Model Neuroplasticity (!)

Self – Care: Pain Education

The Brave New World of Neuroplasticity and Pain

No pain

Acute pain

Chronic pain

Movement – Engaging the body – Yoga – Activities Sleep – Reduce napping – Enhance restorative sleep Reduce Substance Use – Tobacco, Marijuana, ETOH,

Food….. Pleasurable events – Hobbies – Valued living Work – Employment – Household Pacing – Stress management – Triggers

Self Care: Improve Functioning

Pain vs. SufferingFear of pain

Fear of injury from activityAnger management

Anxiety and depressionPost-traumatic stress

ForgivenessGrief and loss

Catastrophizing

Self-Care: Emotion Regulation

Self-Care: CBT and ACT

Thoughts Feelings Behaviors Goal

setting Relaxation

training Pleasant

events

Cognitive Behavioral TherapyAcceptance and Commitment

Therapy

Psychological flexibility

Experiential avoidance

Committed action Cognitive fusion Personal Values Acceptance Willingness

Family members – Decrease enabling behaviors

Increase compassionate supportPartner – Sex – Intimacy

Churches/Mosques/SynagoguesSupport groups

FriendsCo-workers

Pets

Self-Care: Socialization

↓ ↓ ↑

Clinical Practice ApplicationsBegin Where the Veteran Wants to Begin

Pain Education Improve Functioning Emotion Regulation CBT and ACT Socialization

Non-jargon conversations

PT, OT, walking Show compassion Catastrophizing/

Accept Family, intimacy

Start with one approach. Set goals with the Veteran. Give praise for successes.

Case Presentation: Ms. Trice

Vital Signs

Temp: 97.6 F [36.4 C] Pulse: 78 Resp: 16 BP: 121/80 Pain: 9 Height:70 in [177.8 cm] Weight:222.5 lb [101.1 kg] BMI: 32.0

Active Problems

Dizziness Deep venous thrombosis of LE Urinary incontinence GERD Migraine, unspecified, Paresthesia Neuropathy Chronic Low Back Pain Allergies Hyperlipidemia

57yo, divorced, Caucasian female, post-Vietnam

50% SC Intervertebral disc syndrome (40%) Neuralgia of external popliteal nerve (20%), Varicose veins

(0%)

Started having back pain while in the military 30+ years ago

Progressively worsened with pregnancies (x3) Honorable discharge, tried PT (-), TENS (+) 5/2009 had microdiscectomy or microdecompression, L5-S1, reduced pain 2-3 months When pain worsened, she was placed on methadone Pain begins LB, radiates thru right buttock, calf, foot Sharp, burning pain, numbness, right side weakness Evaluated for spinal cord stimulator in 2014,

recommended psychotherapy

Case Presentation: Ms. Trice57yo, divorced, Caucasian female, post-

Vietnam50% SC Intervertebral disc syndrome (40%)

Neuralgia of external popliteal nerve (20%), Varicose veins (0%)

Veteran was seen by clinical psychologist for 4 one-hour psychotherapy sessions over the span of 2 months.

Veteran described as: “motivated and engaged in therapy. She understood concepts rapidly and had relevant questions….approach made sense to her…could help her to manage her chronic pain.”

Focus of psychotherapy: “reducing suffering while accepting that the physical sensation of pain, diffusion from thoughts, emotions, and bodily sensations, and fostering a relationship with the pain which is present-focused, non-judgmental, and mindful.”

Skills taught or used: deep breathing, body scan, values identification, present focus, welcoming of pain sensations

7 months later requested booster sessions - veteran was experiencing family stressors and noticed an increase in pain symptoms

Case Presentation: Ms. TriceBehavioral Health

Summary and ConclusionsWho and What Responds to Self-Care?

When Do We Initiate Self-Care Conversations?

Who (i.e., which patients)?

Veterans Older adults Males Females Children Adolescents People with MH conditions

What (Pain Conditions)?

Headaches Low back pain Osteoarthritis Fibromyalgia Neck, shoulders, arms Legs, knee, and foot Visceral Neuropathic

Every time you discuss pain.

Bounty wants to know

Do you have any questions?