Transcript Understanding Chronic Pain And A Pathway Approach To

Developing Integrated Care Clinical
Pathways: The Example of Chronic
Pain
Kirk Strosahl Ph.D.
Central Washington Family Medicine
[email protected]
www.behavioral-health-integration.com
Clinical Pathway Targets: What Are
the Priorities in Your Clinic?
• High prevalence (depression) or high
impact (chronic pain) conditions
• Variability among providers
• Evidence available for preferred treatment
• Patient preference
• Provider preference
• Resources (opinion leaders, grants)
• Cost savings or practice leveraging
Five Steps To Developing
Population-Based Pathways
1. Choose a common condition that is amenable to a
systems approach to care.
2. Identify a method for identifying patients in the primary
care practice who have the selected condition.
3. Choose measurable outcomes that reflect best
evidence-based medical or behavioral health practice for
that condition.
4. Form a high performance team to implement a system of
care that improves outcomes.
5. Measure outcomes regularly and make changes as
needed to improve outcomes
Examples of Clinical Pathway
Targets
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Depression
Alcohol-Drug Abuse
Diabetes
Chronic Pain Syndrome
Anxiety
Smoking
Obesity
Qualities of an Integrated Pathway
• Stepped care approach to accommodate
varying levels of severity and motivation
• Shortened sessions
• Condensed treatment packages
• Multiple delivery formats
• Patient education philosophy
• Designed for use by all PC team members
• Culturally competent
What Makes Chronic Pain So
Difficult For Physicians?
• There is no cure for it (even successful treatment
involves residual pain)
• The help seeking, help rejecting stance of CP patients
(My pain is at a 10, but don’t try to get me to do those
morning stretches) pushes a lot of hot buttons
• Negative feedback loop (nothing you are doing is helping
me) makes it very unrewarding for the provider
• Fear of substance abuse, addiction and diversion and
possible legal sanctions
• Many PCPs use acute care strategies for a problem
which is a chronic condition (PRN medications for pain
presentations) and thus develop a revolving door
What Makes Chronic Pain So
Difficult For The Patient?
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Pervasive sense of isolation
Loss of contact with a “normal day”
Perception that others do not believe the pain is real
Perception of being promised one thing (a cure), but
delivered another (a curse) by the medical establishment
Perception of being viewed as an “addict” by others
because of dependency on narcotics
Criticism from family members and friends for variable
day to day performance
Self criticism for not being able to “rise above the pain”
Common co-morbid states like depression, anxiety
amplify pain experience
Which Treatments Are Effective for
Chronic Pain and Which Aren’t?
• Evidence for long term usefulness of narcotics is
very limited (particularly end state functioning)
• NSAIDS are more likely to reduce or eliminate
pain and should be first line treatments
• Cognitive and behavioral interventions have
been repeatedly shown to be effective at
improving functional status, less so with pain
• Regimens of exercise aimed at stretching and
limbering have been repeatedly shown to reduce
pain and improve functional status
A Contextual Behavioral Model of
Chronic Pain (McCracken, 2006)
• Pain plus the unwillingness to have pain leads to
a refusal to accept the reality of pain
• Pain is perceived as the main obstacle to vital
living; thus, the goal is first to eliminate pain and
then vital living can happen
• Since pain cannot be controlled or eliminated,
the paradoxical result is an increasing focus on
pain experience and its elimination
• This leads to an ever widening pattern of
behavior designed to control pain, at the
expense of living a vital life
Components of Contextual
Cognitive Behavioral Treatment
• Pacing—Adapting daily activity pattern to match pain
tolerance, so as to optimize “up time”
• Attention Diversion—Mental strategies for focusing
attention away from pain, or re-associating pain
sensations in a way that reduces pain experience
• Cognitive Restructuring—Strategies designed to defeat
“pain catastrophizing” and pain related avoidance
• Acceptance/Mindfulness—Strategies that promote pain
acceptance and the ability to stay detached in the
presence of pain
• Value Based, Motivation Enhancement—Strategies
designed to clarify and help patient pursue valued life
directions in spite of pain
Clinical Philosophies of the Pain
and Comfort Program
• Pain must be assessed and treated within a
biopsychosocial framework
• The goal of treatment is not the elimination of pain, but
the restoration of functioning
• Any treatment that is not improving functional status will
not be continued
• Long term narcotics treatment always comes with
“strings attached”
• Evidence based care is the strongest platform from
which to engage the patient
• All chronic pain patients started as acute pain patients
and thus there must be a place for prevention
Pain & Comfort Program Goals
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Promote functional improvement
Increase pain acceptance & engagement in life
Decrease reliance on long term narcotics use
Identify and manage patients at risk for
substance abuse or addictive behaviors
• Prevent the onset of chronic pain by working
aggressively with acute pain patients
• Seamlessly integrate behavioral and medical
interventions within a single care plan
Primary Care Behavioral Health Model: The
Platform For An Integrated Pain Pathway
• Behavioral Health Consultation
– BHC works within medical exam room area as a core
team member
– Schedule is open and designed for fast, easy access
at the time of medical visits (Lucy is in)
– Visits are short (15-25 minutes) and consultatively
oriented
– The MD remains “in charge” of the patient’s
healthcare plan
– Intervention model is a temporary co-management
approach
– Most patient encounters are warm handoffs from a
immediately preceding medical visit
Components Of The CWFM Pain &
Comfort Program
• Standardized format for initial MD assessment
– Establish the diagnosis (acute vs. chronic pain)
– Assess level of pain related disability
– Establish the treatment plan (includes medication and
behavioral management)
– Assess potential for opiod abuse and make a decision
about medication (Opioid Risk Tool)
– Establish pain contract and set functional goals
– Refer to BHC in every case for evaluation of
psychosocial factors and preparation for class
Components of the CWFM Pain
and Comfort Program
• Treatment Phase
– Generally, long acting narcotics are substituted for
short acting narcotics as the base pain treatment
– Monthly Pain and Comfort Class is center piece of
the treatment and is required for continuation of
narcotics
– Class uses CCBT model of pain treatment with
different modules offered repeatedly over time
– Pain disability assessments are taken on every
patient at every class meeting
– Scores entered into EMR note, along with narrative
comments about patient progress
Components of the CWFM Pain
and Comfort Program
• Progress Monitoring
– Outcomes are measured monthly in terms of pain
disability index and pain acceptance scale
– PADT (Pain Assessment Documentation Template)
used by MD’s at every pain management visit
– Failure to improve in functional status over time
triggers a review of the entire treatment plan
• MD and BHC consult to identify barriers to improvement and
develop new interventions
• MD may choose to taper off narcotics because of lack of
functional improvement
Components of the CWFM Pain
and Comfort Program
• Risk Monitoring
– “Three Strikes Program” establishes three levels of
aberrant drug use behavior
• Misuse/abuse/addiction
– Misuse  re-educate patient
– Abuse  Caution
• Express concern and set limits
• Consider tapering/stopping addictive medicines
• Consider specialty consultation or referral to BHC for 1:1
evaluation
– Addiction/Diversion  STOP
Components of the CWFM Pain
and Comfort Program
• Prevention
– Chronic pain syndrome is an iatrogenic phenomenon
– By changing the initial “message” to acute pain
patients, MD’s and the BHC can avoid the control and
eliminate pain trap
• Protocol
– When an acute pain patient requests the first refill of a
prescribed narcotic, an automatic referral to the BHC
is generated
– A chronic pain risk assessment is performed
– A high risk patient is managed differently than a low
risk patient
Components of the CWFM Pain
and Comfort Program
• High Risk Patient Prevention Protocol
– A definite, short range date is set for the termination
of narcotic medicine
– Patient is told that some pain complaints turn out to
be chronic and the goal is to learn to live a vital life
even if the pain persists
– BHC is involved with patient to teach pain
management skills, to identify the patient’s values and
to address any reversible risk factors (i.e., patient
hates job or is seeking workman's’ compensation for
an injury)
Summary
• Chronic pain syndrome is a complicated biopsychosocial
disorder that nevertheless is very manageable using an
integrated primary care team model
• The new contextual behavioral treatments are extremely
potent and are easily adapted to a classroom format
• Physicians readily respond to a structured, evidence
based approach that is easily learned and easy to apply
• Clinic wide, the program is actually popular with patients
and has improved MD self perceived efficacy in working
with chronic pain patients
• A fully integrated biopsychosocial program for chronic
can be implemented in a relatively short period of time