Transcript Using ACT to Improve Management of Chronic Pain in Primary Care

Patricia J. Robinson, PhD
Mountainview Consulting Group
behavioral-health-integration.com
[email protected]
(509)307-5333
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Workshop Overview
 Learn strategies for teaching ACT to medical
colleagues
 Based on an ACT conceptualization of experience of
chronic pain in the primary care setting
 Learn techniques for using ACT in monthly primary
care classes, and ways to integrate the class into a
primary care pathway approach to delivering services
 Learn strategies for preventing onset of chronic pain
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Abbreviations & Definitions
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PCP= primary care provider
PC= primary care
BHC= behavioral health consultant
“Addiction”= impaired control, compulsive use, cont’d use
despite harm, cravings
“Dependence”= state of adaptation manifested by a
withdrawal syndrome if the drug is decreased/stopped
“Chronic pain”= noncancer pain lasting > 3 months
“Misuse”=unintended use (recreation, give away, sell)
ACT=Acceptance and Commitment Therapy
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Chronic Pain in PC: Basic Info
 10-20% of PC pts report CP (Guereje et al., 1988)
 14% of PC pts with CP need tx for it (Smith et al., 2001)
 Most CP pts are treated in PC (Khouzam, 2000; Olsen
& Daumit, 2002) and the number is rising
 Mismatch between patient expectations and PC and
BH abilities, resulting in relationship problems
 HC Resources limited, specialty services often
inaccessible
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Chronic Pain in PC: Basic Info
 PCP training “sorely lacking” (Olsen & Daumit, 2004)
 Survey of residents: mean 2.2 and 2.3 for preparedness
and confidence, respectively, for treating CP (1-5 scale)
(Fagan, 2007)
 15% of PCPs feel comfortable with TX of CP (Potter et a,
2001)
 Lack of specialty help
 Application bio-medical model which works well with
acute problems and many problems with organic basis
 Time
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Chronic Pain in PC: Medication TX Info
 As pain medications become more powerful, pain
sensitivity increases
 Charges of under-treatment of pain
 Unclear effectiveness after 4 months (Marteil, et al)
 Studies often show decreased pain but not increased
function
 Studies lacking (use inactive placebos, unclear
methods, lack long-term)
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Chronic Pain in PC: Medication TX Info
 Addiction and Overuse (self-medicating)
 181% increase in opiod abuse in 90s (NIDA, 2005)
 25-30% of PC pts abuse meds (Chelminski, 2005, Reid,
2002)
 Diversion and Misuse (recreational) common
 Fear of DEA is a deterrent to RX’ing (Olsen & Daumit,
2004) (Criminal charges after Oxycontin deaths)
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Evidence for an ACT Approach to CP:
Evidence vs. Experience
 Attempt to suppress pain tends to increase it (Cioffi
& Holloway, 1993)
 ACT interventions improve tolerance of pain in
normal populations more so than CBT
interventions (Gutierrez, Luciano, Rodriguez, &
Fink, in press; Hayes, Bissett, Korn, Zettle,
Rosenfarb, Cooper, & Grundt, 1999)
 Acceptance accounts for more of variance in
outcome on pain, depression, anxiety, disability,
vocational functioning, and physical functioning
than existing measures of coping with pain
(McCracken & Eccleston, 2003)
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 Physical damage bears little relation to amount of
pain and relationship between functioning and
pain is weak; willingness to experience pain and
ability to act in a valued direction while
experiencing pain predicts functioning
(McCracken, Vowles, &Eccleston, 2004, later in
week at conference!)
 Supportive uncontrolled studies of ACT-based pain
programs (Robinson & Brockey, 1996)
 Controlled clinical trials supportive (Dahl, Wilson,
& Nilsson, 2007)
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Experiential Exercise
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Experiential Exercise
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Experiential Exercise
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ACT Perspective:
Challenges to PC Management of Chronic Pain
 Primary care providers struggle with problematic
relational frames
 Primary value is to help (most compassionate
sometimes most vulnerable)
 Lack of training and lack of positive impact promotes
avoidance (“Oh my gosh, Mr. X is here again, and I have
no idea . . .”)
 Limited time
 Limited resources for responding to demanding and/or
aggressive pt behavior (often no BH provider on team)
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ACT Perspective:
Challenges to PC Management of Chronic Pain
 Patients with (vulnerability to) chronic pain
 Have histories consistent with development of
problematic relational frames
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Lack of control and danger (trauma backgrounds)
Negative mood states and avoidant response strategies
(withdraw when “down”)
Use of alcohol / drugs to avoid suffering
Victim, aggressor perspective (right / wrong)
 Limited skills for mindfulness and acceptance
 Limited support for value-consistent actions
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ACT Perspective:
Challenges to PC Management of Chronic Pain
 Medications (oral and other) have problematic
relational frames
 “Magic” and often free
 “Happy” pills
 “Holding the wolf at the door”
 “More would be better”
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ACT Perspective:
Challenges to PC Management of Chronic Pain
 Pain detection and elimination are foci of primary care
services
 The Fifth Vital Sign
 Medical Model (search for organic basis)
 Often delays between transition from treating acute
pain to treating chronic pain (awaiting specialist care)
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Pt practices avoidance strategies
Pt’s behavior becomes less consistent with values
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ACT Perspective:
Challenges to PC Management of Chronic Pain
 Chronic pain is pain and unwillingness to have it
 Distress prominent in patient presentation
 Acute to chronic phase: More anxious
 Chronic: More depressed, angry, demanding, dull
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An ACT Perspective on
Challenges to PC Management of Chronic Pain
 Tendency for treatment of chronic pain to be some one
else’s job
 Referral to specialist (curative)
 Specialist return of pt to primary care
 Referral to pain clinic
 Pain clinic return of pt to primary care
 Tendency to see chronic pain treatment problems to be due
to care delivered by someone else
 Initial or previous prescriber of pain medications
 Failed back surgery
 Labor & Industry open claims
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The Inner Debate about the Pervasive
Problem of Pain in Primary Care
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Teaching ACT to PC Providers:
The Problem
 Fusion (attachment to scary and/or depressing
thoughts, pt and provider)
 Evaluation of pain/fear/discouragement/ depression
in good-bad terms (pt and provider)
 Avoidance of unwanted private experience (pt: victim
or aggressor behavior, provider: hand on the door)
 Reason giving to explain behavioral excesses or deficits
(pt: The pain/provider – is the reason --- for X; PC
provider: The pt is – difficult –a tx failure, a drug
seeker, etc.)
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Fusion: Patient and Provider
 Fusion is treating
our thoughts as if
they are what they
say they are.
 Fusion with
thoughts about the
unacceptability
(dangerousness,
shamefulness,
isolating qualities)
of pain
Patient: “This is what
happened to me . . .”
“This pain is killing me.
It’s a 10 and I can’t take it
any more! ”
“I’m damaged and no one
cares.”
PCP/BHC:
“Maybe, but I want to help
you . . . .”
“He looks like an abuser to
me!”
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Teaching ACT to PC Providers:
The Alternative
 Accept (what is present inside and outside the
skin)
 Pt: Pain and lack of control
 PC Provider: Unsatisfied patient and lack of
control
 Choose (a valued direction)
 Pt : QOL consistent with values
 PC Provider: Practice consistent with values
 Take action (valued, over and over again)
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The Message: Over and Over Again
 Chronic Pain Is
 Pain and Unwillingness to Have It
 Resulting in Overuse of Avoidance Strategies
(in regards to internal and
external stimuli) . . .
 This results in Psychologically Inflexible
Responding (which limits one’s ability to pursue
valued directions in life)
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3 ACT R Styles
(Imagine an aerial
view of a 3-legged
stool)
Aware:
Present in Moment
And Willing to
...
Open:
De-Fused and
Accepting
Psychological
Flexibility
Engaged:
Clear in Values and
Actively Pursuing
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Open: Defused and Accepting
 Hands to face and breathing them out
 Nose on computer and breathing self out 2 feet
 On-going 5 minute morning practice (pt at home, MD
and RN in clinic)
 Jotting down thoughts on paper (carrying in pocket of
pt coat, provider’s white coat)
 Physical rope in room (picking up when struggle
begins, changing use of space to allow pt and provider
to hold it together
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Aware: Present in Moment and
Accepting
 Breathing together
 Bowl of chronic pain soup
 Holding bowl
 Describing negative thoughts and feelings aloud, as
disliked and integral ingredients in soup
 Songs on a CD played in the clinic
 Eagle’s Eye view
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Engaged: Clear in Values and
Actively Pursuing
 Values vs. Goals (Plane Crash on a Dessert Island)
 Value Statement: Love, Work or Play
 (Alternatively, Relationships, Health, Work/Study,
Play/Spirituality)
 Bull’s Eye Prescription Pad
 Consistency pat 2 weeks, consistency score after
initiation of ACT strategies
 Exploration of barriers
 Teaching ACT skills that address the barriers
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MD, RNs, BHCs:
Intervention and Preventions
 RX Pad for Prevention, 1-page
handout used repeatedly at
class
 Keep values at the center of
patient and provider
interactions
 Strengthen PC and Pt, BHC
and Pt relationships
 Strengthen relationships
between pts
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Completes
pain
agreement
Refers to
BHC (sameday)
Monitor
outcomes,
change TX
Assessment
QOL
Orientation to
Class
Opiod Risk
Assessment
Monthly classes
(with PC
and/or RN)
Three Strikes
Coaching
Program
Evaluation
RN
Enrolls
patient
BHC
PCP
Intervention Pathway
Maintain
Pain & QOL
Registry
Work with
PC
prescriber
week prior to
class
Work with
BHC on day
of class
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Factors Associated with Increased
Risk of Misusing Opiods (ORT)
 Family History or
Personal History of
 Problems with alcohol
use
 Use of illegal drugs
 Misuse of RX drugs
 Age (18-45)
 History of childhood sexual
abuse (for women)
 DX of
 Depression
 ADHD
 OCD
 Schizophrenia
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Completes
pain
agreement
Refers to
BHC (sameday)
Monitor
outcomes,
change TX
Assessment
QOL
Orientation to
Class
Opiod Risk
Assessment
Monthly classes
(with PC
and/or RN)
Three Strikes
Coaching
Program
Evaluation
RN
Enrolls
patient
BHC
PCP
Intervention Pathway
Maintain
Pain & QOL
Registry
Work with
PC
prescriber
week prior to
class
Work with
BHC on day
of class
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Factors Associated with Increased
Risk of Misusing Opiods (ORT)
 Family History or
Personal History of
 Problems with alcohol
use
 Use of illegal drugs
 Misuse of RX drugs
 Age (18-45)
 History of childhood sexual
abuse (for women)
 DX of
 Depression
 ADHD
 OCD
 Schizophrenia
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Class Organization
 Introduction(s):
 Of class members (new and on-going), includes topic
suggestions (specific to barriers to valued actions since
previous monthly meeting)
 Of ACT model
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Workability of pain elimination, avoidance, control
Value consistent action (Bull’s Eye Handout)
 Assessments:
 Healthy Days Questionnaire
 Pain Acceptance Questionnaire (quarterly)
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Class Organization
 Medication Sign Up List
 Pt sign in
 Delivered to pharmacy for RX fills
 1:1 Check-ins
 BHC goes round table
 Looks at assessment results, compares with previous
findings, notes pt need for 1:1 with PC if such exists
 Work individually or in pairs discussing values and
value directed behavior change results
 Acknowledgement of birthdays, efforts
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Class Organization
 Acknowledgement of birthdays (Pain, pain, pain)
 Acknowledgement of value consistent action,
commitment statements, exercises
 Skill work, experiential exercises
 End (BHC charts / includes description of exercise /
skill and individual pt outcomes)
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Class Interventions:
Goals and Workability
 What is your goal with pain? (stop, eliminate vs. live
with / manage)
 What have you done to try to achieve that goal?
 How has that strategy worked in the short-term? In
the long-term?
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Class Interventions: DeFusion
 Courage Breath
 Pain, pain, pain (tune of Happy Birthday)
 Passengers on a Bus
 Silent together and holding our thoughts and feelings
lightly, like we might hold a crying baby
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Class Interventions:
Observer Self and Mindfulness
 Observer Self vs. Self as Content (story)
 Life Circle
 Time Line
 Mindfulness
 Wise Self
 Eagle River video, Eagle perspective
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Uses Bull’s
Eye RX Pad
to shift
focus
Values
Clarification
Committed
Action Plan
Family
Support
PCP
Risk
assessment
4-8 weeks
post-injury
BHC
PCP
Prevention Pathway
Refers to
QOL
Program if
indicated at
3 months
post-injury
Refers to
BHC as
indicated
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Patient Interventions:
Actions Consistent with Values
 Clarifying values
 Committed Action
 Making and implementing behavior change plans that
are consistent with values
 Bull’s Eye
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Patient Satisfaction
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PCP Satisfaction
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PCP Top Ratings
 Year 1: Able to access effective programs, Have skills
to work effectively, Look forward to seeing CP
patients
 Year 4: Able to access effective programs, Pain meds
are very helpful, Have skills to work effectively
 Year 5: Pain meds are very helpful, Able to access
effective programs, Have skills to work effectively, I
usually have a new idea about how to help my most
difficult CP patients
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Dr. Sauerwein
 Prevention of chronic pain
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