psychological/behavioral strategies for pain management ......strategies for pain management: tools...
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Psychological/BehavioralStrategiesforPainManagement:
ToolsforPCPstoUseina20MinuteVisit
J.AlexisOrtiz,Ph.D.AttendingPsychologist/ClinicalInstructor
StanfordUniversityAddictionMedicineProgramortiza@stanford.eduCSAMTAPCWebinar
FridayFebruary24,2017OrtizCSAMWebinarPsychPainMgmtTools2-24-17
Disclosures/ConflictsofInterest
Thespeakersandplannersofthiswebinarhavenorelevantfinancialrelationshipstodisclose.
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Overview• Caseexample• Tipsandtechniquesfromthefollowingmodalities:• MotivationalInterviewing(MI)• CognitiveBehavioralTherapy(CBT)• DialecticalBehavioralTherapy(DBT)• AcceptanceandCommitmentTherapy(ACT)
•Managingproviderburnout• Takehomepoints• Handouts:Resourcelist
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CaseExample• Serena,46yearoldmarriedCaucasianfemale,presentingwithchronicpain,depressivesymptoms,insomnia,traumahx,passiveSI• Statessheis“sickandtiredofbeinginpainallthetime"• SocHx: Workedasanurseuntillastyear,has3children,limitedfinances• Dx:FibromyalgiaDepressionOpioidusedisorder(hx ofhydrocodonedependence)InsomniaPTSD
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ToolsfromMotivationalInterviewing
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MITools:FoundationalSkills
Open-endedquestions – ”Whatcanyoudothisweektohelpyou,insteadofyourpain,beinthedriver’sseat?”
Affirmations – “You’redoingagreatjobstickingwithyouropioidtaper.”
Reflections – Repeat/Paraphraseesp.pt’schangelanguage- “It’sreallyimportanttoyoutofindotherlong-termsolutionstodealwithpain.”
Summaries – Repeat/Paraphrasekeytakehomepts –”Soyourtopreasonsforwantingtostayoffopioidsare…”
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MITools:Rulers- Importance,Confidence,Readiness
:
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MITools:Rulers• “Onascalefrom0to10,howimportant isitforyouto…”• Findwaystolivethelifeyouwantevenifyouhavepain?• Quitopioids?• Adheretoapainmanagementprogram?
• “Onascalefrom0to10,howconfident areyouinyourabilityto...”• “Onascalefrom0to10,howready areyouto…”
• AfterEACHQUESTIONaskfollow-up:“Whya[number]andnot[alowernumber]?”• Canalsoask:Whatwouldhelpgetyoufroma[number]toa[highernumber]?”/“Whatwouldhavetohappen?”
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MITools:Additionaltechniques• Emphasizeautonomy• Askpermissionbeforeprovidingadvice• “DoyoumindifIsharesomethoughts/tools/concernsaboutthat?”
• Endofsessionquestion:• “Whatareyougoingtotakeawayfromtoday’ssession?”• “What’sthenextstepforyou?”• “Whatwillhelpyou,insteadofyourpain,bemoreincontrolthisweek?
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Question1:WhichofthefollowingisNOTanMI-consistent(OARS)strategy?
A.“Whywoulditbeimportantforyoutofindotherwaysbesidesmedicationtomanageyourpain?”B.“Ihavetotellyou,youneedtostoptakingopioidsnow.”C.“You’rereallydeterminedtonotletpaintakeawaythejoyinyourlife.”D.”Itsoundslikeyourhealth,wantingtobeagoodparent,andnotwantingtobedependentonmedicationareyourprimaryreasonsforstayingoffofopioids.”
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Answer=B
“Ihavetotellyou,youneedtostoptakingopioidsnow.”
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ToolsfromCognitiveBehaviorTherapy
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Persistent Painwork,
CBTTool:PainCycle - Thenaskaboutfitwithownexperience
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CBTTools:CBTforChronicPainSkillstoaddressinterrelationshipsamongthoughts,emotions,behaviors
• ActivityPacing– “Sometimeswecangetintoacycleofoverdoingonedayandthenunderdoing(beingwipedout)thenextday,whichdoesn’thelplong-term.Wouldyoubewillingtotrydoingsomeconsistentactivity/walkingtohelpmakemoresteadyprogress?Whatmightbethebenefitsofthat?Howmanydayswouldyoubewillingtodothat?”
• RelaxationTraining– “Extratensioninthebodycanworsenthepain,let’spracticetaking3slowbreathstogether,infor4seconds,hold,thenoutfor6seconds.Good.”
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CBTTools:CBTforChronicPain• SMARTGoals– Helpptsmakegoals:Specific,Measureable,Attainable,Realistic,Time-bound
• CognitiveRestructuring– “Whenyoutellyourselfyou’realwaysgoingtobemiserable,howdoesthatimpactyourmoodandbehavior?Whatwouldyoutellafriendinthesamesituation?”
• BehavioralActivation– ”Itseemslikeyou’vetakenalotofenjoyableactivitiesoutofyourlifebecauseofpain,that’sunderstandable,butlikelynotmakingyoufeelbetterlong-term.Whatwouldyoubewillingtoaddbackinthisweekthatyouenjoy?WhatdoyoumissaboutXactivity?”
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Question2:Serena states”Iworkbetterhavingonereallyproductiveday,eventhoughIenduppayingforitlater”,
whichCBTtechniquewouldbemostindicated?A.BehaviorActivationB.ActivityPacingC.ThoughtStoppingD.RelaxationTraining
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Answer=B
ActivityPacing
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ToolsfromDialecticalBehaviorTherapy
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DBTTool:Validation• “Findingthekerneloftruthinanotherperson’sperspectiveorsituation;verifyingthefactsofasituation.”(Linehan,1997)• “Acknowledgingthataperson’semotions,thoughts,andbehaviorshavecausesandarethereforeunderstandable.”(Linehan,1997)
• Whatcanwevalidate? (Linehan,1997)•Thefactsofasituation•Aperson’sexperiences,feelings,beliefs,opinions,suffering,difficulties
• VALIDATIONDOESNOTMEANAGREEMENTORREINFORCEMENT• Don’tvalidatetheinvalid
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Whyvalidate?Whenptsdon’tfeelvalidated…
• Anger,agitation• Opposition• Defensiveness• Notunderstood• Overwhelmed• Ashamed• Trapped• Uncomfortable• Donotadheretotreatment• DonotreturntotreatmentOrtizCSAMWebinarPsychPainMgmtTools2-24-17
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Whyvalidate?Whenptsfeelvalidated/feelinvalidated…
• Understood• Respected• Engaged• Collaborative• Safe• Empowered• Hopeful• Interested• Wantingtocomebacktotreatment• WillingtotryoutrecommendationsOrtizCSAMWebinarPsychPainMgmtTools2-24-17
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ValidationStems(+)1.)Pt:“Ijustneedpainmeds,that’stheonlythingthathelps.”Pr:“Iknowyouwanthelpmanagingthispain,andIwanttosupportyouinthat.Wedon’tofferopioids,hereiswhatweoffer… haveyoutriedXbefore?…”
2.)Pt:“Youdon’tgetit,I’vebeenthroughallthisstuffbefore,I’mjustexhausted.”Pr:”Itmakessensethatyoufeelexhaustedgivenbeinginpainforsolong,andyetyou’reheretoday,Iseethatthere’sapartofyouthatwantstofindanotherwaytomanagethispain.”
3.)Pt:“Doctorskeeptellingmetojustmeditate,that’snotgoingtomakemypaingoaway.”Pr:“You’refeelinglikethosethingswon’tmakeanydifference.Iunderstandthat,atthesametime,Icantellyoumanypatientsfindthemhelpful.Icanrecommendsomeapps,books,orprogramssoyoucancheckitoutforyourself,whichwouldyouprefer?”
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DBTTool:STOP(mindfulness)• STOP• Takeastepback• Observe:use5senses,acknowledgethepain,noticewhatelseispresentbesidespain• Proceedmindfully:Primarygoal?Top3reasonswhyIwanttostayoffopioids?Whatwouldmakethingsbetter/worse(thatisinmycontrol)rightnow?
• Practicewithpt:• “Ok,let’strythistogether,let’sstop,take3breaths,whatdoyounoticeinandoutsideofyourbodyrightnow,whatcanyoudoforyourselfinthismoment?”
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DBTTool:RadicalAcceptance
”Sometimeswecan’tkeeppainfuleventsandexperiencesfromcomingourway.Wecan’talwayscontrolwhathappenstous,butwecanchoosehowwerespond.Wecanfightagainstrealityandthenthat’swhereourtimeandenergywillgo,ORwecandecidetotryandworkwithwhatishappeningrightnow.”
ACCEPTANCEVS.CHANGE
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DBTTool:RadicalAcceptance
• “Radicalacceptancemeanscompletelyacceptingtherealitythatweareinpainatthismoment.Itdoesnotmeanwantingorlikingthepain.Itisacknowledgingthatlifecanbeworthlivingevenwithpainfuleventsinit.”• “Whatiswithinyourcontroltochange?”(e.g.,behavior,narrative,meaning-making)• “Whatwouldbehelpfultobringacceptancetoinyourlife?”(e.g.,presenceofatleastsomepainatsomepoint)
ACCEPTANCEVS.CHANGE
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ToolsfromAcceptanceandCommitmentTherapy
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#TheStruggleIsReallyReal
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ACTforChronicPain• ACTislessaboutmakingpaingoawayandmoreaboutgettingdisentangledfromthoughts/feelingsandgettingptsmovinginadirectionthatisimportanttothem.• Whereistheirfocus/effort?- Isthept’slifeabouttryingtonotfeelpainoraboutbuildingarich,full,meaningfullife?• Whatthoughts/storiesaretheyfusedwith?• ACTisaboutlivinglifefromthefeetup,nottheheaddown
• “Whathaspainbeenkeepingyoufromdoingthatisimportanttoyou?”• “Howwouldyourlifelookdifferentifyouweremorefocusedonwhatmatteredtoyouinsteadoftryingtofeellesspain?”
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Question3:WhatwouldNOTbeanACT-consistentmessagetocommunicatetoSerena?
A.“Let’sconcentrateongettingridofthispain.”B.”Ihearthatyouwantthepaintogoaway,ifyoudidn’thavepainwhatwouldlookdifferentforyou?”C.“Whatdoyoucareabout?”D.“Wouldyoubewillingtohavesomepainintheserviceofpursuingthethingsthatareimportanttoyou?”
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Answer=A
“Let’sconcentrateongettingridofthispain.”
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Whataboutus?ManagingProviderBurnout
• Radicalself-care– Whohealsthehealer?• Consultroutinely– Stateyourneeds:problem-solving,validationforyourself,orempathyforthepatient• Mindfulness – STOPbefore/afterseeingthept,takeabreathwhenyouwalkthroughthedoorway,digitaldetox/technologyhiatus• Celebratesmallvictories– Whatare3thingsthatwentwellwithptcarerecently?• (Re)connectingwithvaluesandpurpose– Howisdoingthisworkconsistentwithwhatyouvalueinlife/whatisimportanttoyou?
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ReconnectingwithEmpathy
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TakeHomePoints• Useyourresources– Refertobehavioralhealthifavailable• Validatept’s(andourown)suffering/struggle• Empowerthept - whyisthisimportanttoyoutomakechanges?,whatdoyouwanttolookdifferentinyourlife,whatwouldhelpwiththat?• Shiftproblem-solvingonusbacktoptsinconnectionwiththeirownvalues
• Rememberthepowerof(andevidencebasefor)positivereinforcement• CMEs – ConsideradditionaltraininginMotivationalInterviewing,CBTforChronicPain,ACTforChronicPain,DBT
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Thankyou!
Questions?
Feedback?
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February 24, 2017
Psychological/Behavior Strategies for Pain Management: Tools for PCPs to Use in a 20 Minute Visit 1
Friday,04/28/2017:TaperingOpioids
Friday,05/19/2017Friday,06/23/2017Friday,07/28/2017Friday,08/18/2017*Friday,09/22/2017
NEXTWEBINAR:Friday,03/24/2017:Managing Acute and Perioperative Pain in Patients on
Medication-Assisted Treatments (MAT)
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February 24, 2017
Psychological/Behavior Strategies for Pain Management: Tools for PCPs to Use in a 20 Minute Visit 2
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