Transcript Medical-Model-vs-Psychosocial-Model-of-Pain-May-2016

MEDICAL MODEL vs
BIOPYSCHOSOCIAL MODEL
Or, Everything You Always Wanted to Know But Were
Afraid to Ask!
A Thoughtful Approach to Pain Management
Dr. Peter Rothfels
Chief Medical Officer, Director of Clinical Services
WorkSafeBC
May 21, 2016
DISCLOSURE
•
My salary is paid by WorkSafeBC
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No conflict of interest
•
I have lots of opinions
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OBJECTIVES
By the end of this presentation, the attendees will
1. Understand what is meant by “the Medical Model”
2. Understand the basic concepts of the “Biopsychosocial
Model”
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OBJECTIVE #1
MEDICAL MODEL
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CASE STUDY
Typical:
48 year-old male, 5’10”, 210 lbs.
injures dominant right shoulder
while lifting 15 lb. block.
No prior right shoulder history, a
few STI’s (work related) in past
15 years. Smokes ½ ppd,
single,2 teenage children.
Diagnosis:
Right shoulder strain.
Plan:
Conservative. NSAIDS.
F/U:
2 weeks.
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2 WEEKS…
•
Increased pain,
decreased ROM,
complaining of loss of
strength
PLAN: X-ray, PT, Tylenol #3 added.
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4 WEEKS…
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X-rays show early
degenerative AC joint
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Patient has increasing
pain, decreased ROM,
now pain radiating to
neck
PLAN: X-ray c-spine, continue PT, Tylenol #3 refilled
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6 WEEKS…
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X-rays show mild
degenerative cervical
disc disease
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Patient presents with
right shoulder and neck
pain “can’t do anything
at home”, angry, not
sleeping, stress
PLAN: Oxycodone prescribed for pain, Lorazepam for stress, refer Ortho
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8-10 WEEKS…
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MRI arranged, shows
rotator cuff
tendonopathy, no tear,
labrum normal
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Oxycodone and
Lorazepam refilled, “Z
drug” to help him sleep
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12 WEEKS…
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Ortho assessment,
subacromial
impingement, early
degenerative changes
PLAN: Steroid Injection
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14 WEEKS…
F/U with GP:
PAIN! PAIN! PAIN!
Injection not helpful,
DEPRESSED!
Increased neck pain,
stiffness, paresthesias
to fingers
Assessment:
Thoracic Outlet
Syndrome
PLAN: Refer neurology and MRI of thoracic outlets.
SSRI antidepressant added.
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16 WEEKS…
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PAIN! PAIN! PAIN!
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Waiting for Neuro
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Oxycodone no longer
helping, MS Contin
20mgs bid prescribed
PLAN: 2nd Steroid Injection
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18 WEEKS…
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MRI Thoracic Outlets
normal
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Neurology normal,
aside from mild bilateral
median nerve
neuropathy
PLAN: Refill all medications
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20 WEEKS…
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PAIN! PAIN! PAIN!
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Can’t do anything at home
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Depressed
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Angry
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MS-Contin 20 mgs not
strong enough
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Wants 2nd Ortho opinion
PLAN: MS-Contin 40 mgs bid prescribed with
MSIR for breakthrough
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22 WEEKS…
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Second orthopedic
assessment
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Agrees with first opinion, no
rotator cuff pathology,
surgery unlikely to help
including a subacromial
decompression
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24 WEEKS…
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PAIN! PAIN! PAIN!
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Depression
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GP now recommends
physiatrist consult and
prescribes
Hydromorphone, as
well as Lorazepam,
SSRI, and Z
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26 WEEKS…
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Specialist Diagnosis:
»
Cervico-ScapularThoracic Myofascial Pain
Syndrome
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Recommends:
Botox, Gabapentin,
Amitriptyline
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28-52 WEEKS…
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PAIN! PAIN! PAIN!
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Depressed
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Angry
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Diagnoses including CRPS,
Fibromyalgia, etc.
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Chronic Pain Program: not
helpful
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Patient has not returned to
work, very depressed,
socially isolated, etc.
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Medical Model
• Injury
• Pain
• Pathology of bone, muscle or peripheral nerve
• Pills (opioid) deficiency
• Treatment
• A little, more, a lot more, way way more…
• Resolution
• Discharge
• Send to Psychiatry
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Medical Model
• “P” Paradigm:
• Prescribe Pills
• Palliate Pain
• Perform Procedures
• Please Patient
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“The first duty of the physician is
to educate the masses to not
take medicine.”
Sir William Osler (1849-1919)
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OBJECTIVE #2
BIOPSYCHOSOCIAL MODEL
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Reduced activity
Central Sensitization
Unhelpful beliefs and
thoughts
CHRONIC
INJURY
Tissue
damage
(nociceptive)
PAIN
Repeated treatments,
medications and
failures
Long term use of
analgesics/sedatives
PHYSICAL
DETERIORATION
Depression
Helplessness
Frustration
Anger
Poor Sleep
Side Effects
Lethargy
Fatigue
Constipation
Loss of job, financial, family
and stress
Excessive suffering
and disability
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Biopsychosocial Model
• Focus on Individual
• Focus on Function (Activity/Movement)
A.
Health related factors
B.
Personal factors
C.
Environmental factors
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Biopsychosocial Model ~ Pain & Disability
A. Health Related Factors
• Health care providers attitude, knowledge and expectations
• Severity of anxiety or depressive symptoms
• Duration of disability
• Co-morbidities (other physical and psychological conditions)
• Substance abuse disorder
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Biopsychosocial Model ~ Pain & Disability
B. Personal Factors
• Socioeconomic status
• Patient’s understanding of condition and expectations
• Catastrophization – heightened pain expression
• Coping style – avoidant, passive, dependent
• Disability belief – fear of re-injury
• Pain belief – pain means something is seriously wrong
• Perceived injustice – work, home, “life”
• ACE (adverse childhood event)
• Job dissatisfaction, negative feelings toward work, supervisor, co-workers
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Biopsychosocial Model ~ Pain & Disability
C. Environmental Factors
• Personal relationships, social network
• Unmarried, poor relationship situation
• Lack of family, friends, and/or community support
• Social isolation at home
• Stressful life events
• Secondary gain – insurance, WCB, family, etc.
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Biopsychosocial Model
• Pain score… how helpful is this?
• Ask:
• “How much does your pain bother you?”
• “Pain bothersomeness?”
• “In what way?”
• “How is your pain affecting your life?”
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Pain vs Suffering
Listen to their words
Many patients have been told by several past providers…
“You have to learn to live with it”
But How??
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Discussion Points
• Explain pain
• Including central sensitization (in lay terms)
• Hurt vs Harm
• Ask about their expectations
• What are their functional goals?
• Talk about other modalities, activation
• Set very achievable and realistic short term goals
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Modalities/Techniques
Ways to Decrease Pain Intensity
1. CBT – Cognitive Behavioural Therapy
2. DBT – Dialectical Behaviour Therapy
3. ACT – Acceptance and Commitment Therapy
4. Attention/Distraction
5. Mindfulness
6. Yoga
7. Activity (don’t call it exercise)
8. Contingency Management – using incentives to motivate change
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It’s Not Magic or “Fluffy”
• Specific or non-specific pain – central sensitization
• Rational evidence based treatments
• Opioids are rarely beneficial – benefit vs risk
• Listen
• Be empathetic
• Schedule another appointment – more time
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Therapeutic Alliance
Patient
Doctor
fear
anger
anxiety
guilt
Shame
loss
fear of abandonment
frustration
resentment
hopelessness
food, housing, transportation
criminal justice system
honesty
compassion
understanding
tact
thick skin
sense of humour
knowledgeable
empathy
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What can we give our patients?
Particularly those with long term chronic pain conditions…
• months to years of medicalization
• months to years of specialists, multiple investigations, surgeries
• months to years of cocktails of medications, usually including
(high dose) opioids
We can also
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Give our patients…
Therapeutic Optimism
HOPE
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“In theory, there is no difference
between theory and practice;
in practice, there is.”
Dean Fixsen
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THANK YOU!
QUESTIONS?
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