# Presentation: 293991

## John D. Otis, Ph.D.
VA Boston Healthcare System

- John D. Otis, Ph.D.
- VA Boston Healthcare System

## A Historical look at Pain Management

- The Problem of Pain
- Cognitive Behavioral Therapy for Chronic Pain

## Slide 3

## Most pain relievers were made from plants and could be deadly when taken in overdose. One of the most commonly used substances was opium derived from the poppy flower. Other substances used included alcohol or wine, mandrake, belladonna, and marijuana. 

- Most pain relievers were made from plants and could be deadly when taken in overdose. One of the most commonly used substances was _opium_ derived from the poppy flower. Other substances used included _alcohol or wine_, _mandrake_, _belladonna_, and _marijuana_.

## Potions that included these substances were commonly available around the turn of the century and promised to cure a variety of afflictions.

## Slide 6

## Pain is one of the most common complaints made by patients to primary care providers in the VAHCS (approximately 50% of patients).

- Pain is typically an adaptive reaction to an injury and gradually decreases over time.
- However, for some people pain persists past the point where it is considered adaptive and contributes to negative mood, disability, and increased use of healthcare system resources.

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

- Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
- Chronic pain = Pain with a duration of 3 months or greater that is often associated with functional, psychological and social problems that can negatively impact a persons life.

## Current estimates are that the medical costs of back pain in the USA exceed $90 billion dollars per year (Spine, 2004).  

- Current estimates are that the medical costs of back pain in the USA exceed $90 billion dollars per year (Spine, 2004).
- Chronic pain costs $61.2 billion per year in lost productivity (JAMA, 2004).
- One quarter of the people with back pain account for 75% of the costs, and 10% account for more than half the costs.

## Henry Knowles Beecher: WWII Soldiers & Pain

Observed that soldiers with serious wounds complained of less pain than did his postoperative patients at Massachusetts General Hospital. 

Hypothesis:  => The soldier's pain was alleviated by his survival of combat and the knowledge that he could now spend weeks or months in safety and relative comfort while he recovered. The hospital patient, however, had been removed from his home environment and now faced an extended period of illness and the fear of possible complications. 

- Henry Knowles Beecher: WWII Soldiers & Pain
- Observed that soldiers with serious wounds complained of less pain than did his postoperative patients at Massachusetts General Hospital.
- Hypothesis:  => The soldier's pain was alleviated by his survival of combat and the knowledge that he could now spend weeks or months in safety and relative comfort while he recovered. The hospital patient, however, had been removed from his home environment and now faced an extended period of illness and the fear of possible complications.

## Slide 11

## Disability

- Negative self-talk
- Poor sleep
- Missing work

- Muscle atrophy &
- weakness
- Weight loss/gain

- Less active
- Decreased motivation
- Increased isolation

_**Disability**_

_**Pain**_

_**Distress**_

## Over time, negative thoughts and beliefs about pain, and behaviors related to pain can become very resistant to change. 

- Over time, negative thoughts and beliefs about pain, and behaviors related to pain can become very resistant to change.

**Thoughts**
-   My pain is going to kill me
-   This is never going to end
-   I'm worthless to my family
-   I’m disabled
-   There is nothing I can do
-    for myself
-   I'm a bad father, husband,
-    and provider

**Behaviors**
-   Staying in bed all day
-   Sleeping all day
-   Staying away from friends
-   Decreasing activities that
-    have the potential to
-    increase pain
-   Taking more medication
-    than prescribed

## Research supports the efficacy of CBT for the treatment of chronic pain (Morley et al., 1999)

- Components of CBT for pain include:
- Identifying inaccurate beliefs about pain
- Reconceptualizing pain as subject to personal control through the influence of thoughts, feelings, and behaviors
- Teaching cognitive and behavioral coping skills (e.g., cognitive restructuring, activity pacing, etc.)
- Practice and consolidation of coping skills through practice, and reinforcement of their appropriate use

## A number of studies have identified CBT as an effective treatment approach for chronic pain conditions, including headache, rheumatic diseases, chronic pain syndrome, chronic low-back pain, and irritable bowl syndrome (Compas, et al.,  1998). 

- A number of studies have identified CBT as an effective treatment approach for chronic pain conditions, including headache, rheumatic diseases, chronic pain syndrome, chronic low-back pain, and irritable bowl syndrome (Compas, et al.,  1998).
**Meta-analyses:**
- Morley, Eccleston, and Williams (1999) = CBT for chronic pain is effective, as it resulted in significantly greater improvements in pain experience, cognitive coping and appraisal, and reductions in behavioral expressions of pain when compared with alternative active treatments.
- Hoffman, Papas, Chatkoff, & Kerns, (2007) = cognitive-behavioral and self-regulatory treatments specifically were found to be efficacious  for the treatment of low back pain

## Involves the integration and collaboration of multiple healthcare disciplines with specialized training in the assessment and treatment of pain, with the goals of addressing the physical, social and psychological components of pain and creating an individualized treatment plan for each patient.

- This approach for pain management has been shown to be highly effective in promoting positive cognitive and behavioral changes in individuals with chronic pain (Flor, Fydrich & Turk, 1992).

## “I’m not crazy”

- “I’m not crazy”
- “I've done this before”
- “The pain is in my back, not in my head”
- “Does this mean that you are taking away my medication?”
- _The bad handoff _– Prescriber: “You must see psychology before I prescribe your pain medications”

## Describe Pain
Surgery pending?
Current medications & where prescribed
Is she taking his medications appropriately?
Seeking to increase %SC or litigation pending?
What are his goals for the future?
What is her mood like? Psych history?
Substance abuse - now or in past?
What kinds of coping skills does he have?
How does her spouse react when she is in pain?
What are his beliefs about his pain?
Did she like her job?
What are his hobbies?
Observe pain behaviors

- Describe Pain
- Surgery pending?
- Current medications & where prescribed
- Is she taking his medications appropriately?
- Seeking to increase %SC or litigation pending?
- What are his goals for the future?
- What is her mood like? Psych history?
- Substance abuse - now or in past?
- What kinds of coping skills does he have?
- How does her spouse react when she is in pain?
- What are his beliefs about his pain?
- Did she like her job?
- What are his hobbies?
- Observe pain behaviors

## Develop a timeline of events.
Integrate interview and assessment data in order to determine events that have led the patient to where he/she is today.
What factors, both external and internal, are contributing to the patient’s pain problem.
Antecedents and consequences of pain behavior

- Develop a timeline of events.
- Integrate interview and assessment data in order to determine events that have led the patient to where he/she is today.
- What factors, both external and internal, are contributing to the patient’s pain problem.
- Antecedents and consequences of pain behavior

## Session 1 	 	Rationale for Treatment

- _Session 1_ 	 	Rationale for Treatment
- _Session 2_	 	Theories of Pain, Breathing
- _Session 3_	 	PMR & Visual Imagery
- _Session 4_	 	Cognitive Errors
- _Session 5_	 	Cognitive Restructuring
- _Session 6_	 	Stress Management
- _Session 7_	 	Time-Based Activity Pacing
- _Session 8_	 	Pleasant Activity Scheduling
- _Session 9_	 	Anger Management
- _Session 10_ 		Sleep Hygiene
- _Session 11_      	Relapse prevention

## Session 1:  The “Sell”:
If patients are not convinced that the investment of their time will pay off they will be less likely to follow through with the treatment plan = more dropouts.
Set Achievable Therapy Goals:
Goals should be measurable
Monitor Homework Completion
Tailor the treatment to your patient
Don’t focus on “pain”

- Session 1:  The “Sell”:
- If patients are not convinced that the investment of their time will pay off they will be less likely to follow through with the treatment plan = more dropouts.
- Set Achievable Therapy Goals:
- Goals should be measurable
- Monitor Homework Completion
- Tailor the treatment to your patient
- Don’t focus on “pain”

## Slide 22

## Managing Chronic Pain

- _[Managing Chronic Pain](http://www.amazon.com/Managing-Chronic-Pain-Cognitive-Behavioral-Treatments/dp/0195329163/ref=pd_sxp_grid_i_0_0/102-9280640-7289729)_
- _[Therapist Manual](http://www.amazon.com/Managing-Chronic-Pain-Cognitive-Behavioral-Treatments/dp/0195329163/ref=pd_sxp_grid_i_0_0/102-9280640-7289729)_

**Managing Chronic Pain**
**Workbook**

## Slide 24