Spotlight on Pain Management- 21 -Department of Veterans Affairs

# Department of Veterans Affairs

**Spotlight on Pain Management Cyberseminar**

**Patient Pain Education: Taking self-management from the class room to the clinic**

**Presenter:  Anthony J. Mariano, PhDVA Puget Sound Health Care System**

Bob Kerns:  Good morning, everybody. Welcome to this month’s spotlight on pain management. I’m Bob Kerns. I’m the National Program Director on Pain Management, and it’s my privilege to welcome you to this month’s teleconference webinar. Today, we’re privileged to have Dr. Tony – Anthony Tony Mariano, who will be presenting on Patient Chronic Pain Education: Taking self-management from classrooms to the clinic. 

Dr. Mariano received his Doctoral Degree in Clinical Psychology in 1986 at the University of New Mexico and since 1987; he’s worked as a staff psychologist at the VA Puget Sound Health Care System in Seattle. His duties include fifteen years working on the spinal cord injury service and he’s been the clinical director of the pain clinic there since 1987 and is currently Acting Chief of Pain Services. 

Dr. Mariano is a member of the VA’s National Pain Management Strategy Coordinating Committee where he is the chair of a national workgroup on patient education. He’s the primary author of a web-based provider education program that has been completed by more than 8,000 VA medical staff members. He’s currently authoring a web-based patient education program that compliments this provider training. 

His leadership on the patient education is particularly important to VA as we work to empower Veterans and their care partners, family members in pain management and particularly pain self-management. It is my great privilege to welcome Dr. Mariano to us today. Tony? Take it away.

Dr. Mariano:  Okay, thanks Bob. I had to use my screen, okay? 

Moderator:  Your screen looks great, yes. 

Dr. Mariano:  I’ve got this thing up there that’s screen sharing. Should I click on that to get rid of it?

Bob Kerns:  We actually are not able to see that.

Dr. Mariano:  Oh, well. Whoa.

Bob Kerns:  We can only see your slides.Dr. Mariano:  Well, okay. I can only see part of my slides.

Bob Kerns:  Well, if you click on the orange arrow, it will collapse it.

Dr. Mariano:  There we go. Okay. Thank you. Thanks, Bob. I would like to thank the organizers who invited me this morning. Before I get started, I would also want to give a nod of thanks to the members of the National Pain Education Workgroup. This is a very hard working group in multi-disciplines from VA’s across the country. Okay. I’m having a little problem with my screen, Heidi. Okay I’m fine. I also want to really give my thanks to the administration of VISN 20. They’ve made a significant investment in both provider and patient education since 2006 and I really want to thank Dr. Cynthia Joe, the Chief of Staff up in Anchorage who chairs our VISN 20 Pain Committee. She is pretty much single-handedly gotten us funding to write both the provider education module that was released in 2008 and we’re revising this year. And the patient education module that I will be talking about later that will virtually be completed within the next couple of weeks.

Today, I will be talking about a wide variety of topics, but I really want to start off explaining some of the assumptions that I make and providing you some of the definitions and distinctions. I will spend some time talking about why patient education is important and really point out that patient education is the foundation of many of the current healthcare models that we’re using today.

It’s interesting to think about what actually patients learn about pain and where they’re learning because there are many sources of barriers to the self-management we’re trying to teach. I’ll spend some time thinking about what patients actually need to learn and how can we teach them and argue for the point of view that the primary place of learning is not in the classroom or groups, but in the interactions we have daily with patients in the clinic. I’ll then talk some about national strategies for pursuing in-patient education and then briefly introduce the product that we’re working up here in VISN 20.

The basic problem that we find with education is that our most quote difficult patients really respond poorly to educational efforts. So folks that are overwhelmed by pain and overwhelming us in the healthcare system very often refuse to engage in self-management. Unfortunately, we then perceive them to be unmotivated and conclude they obviously don’t want to do what’s best for themselves. They just don’t want to help themselves. Or we invoke concepts like secondary gain that folks are looking for drugs or compensation or attention.

The real solution is to recognize that education is not something that we do to patients but it’s something we share with patients. The education that’s truly important that’s part of the ongoing clinical process. It’s literally – every prescription, referral or treatments we attempt are those we refuse, teaches the patients important things about the methods of pain care. What are the goals and outcomes? What are our mutual responsibilities? The large part of the problem is that what we try to teach the patient in the classroom in terms of self-management, we often contradict with our own behaviors in our own behaviors as we pursue urgent pain relief within a biomedical model. 

So my assumption really, is that chronic pain is a lifelong condition. It’s not curable. So therefore, the appropriate treatment goals are functional and self-management that really is key. I also further assume that its patient beliefs and expectations regarding pain and its treatment are major determinants of how that treatment works. The further assumption is not just the beliefs of the patient, but our beliefs that determine the kinds of clinical decisions that are a result of our interactions.

From my point of view, I think it’s most useful not to think of chronic pain as a symptom, but to understand that it’s a very complex human experience and one of the best perspectives that I’ve seen and point out that it’s twenty-five years old. Chronic pain is a process that evolves over time from the entire progression through the patient’s illness, the social and cultural context from which it occurs, and I’ve underlined to emphasize the patients interactions with us.

A distinction I find very useful is between simple and complex chronic pain. Thank goodness probably ninety percent of the patients we encounter have quote simple chronic pain, which is defined as responding to standard treatments. People are generally functional through interactions with us and are happy. We perceive them to be compliant and they generally do well. So pain is just one problem in their life.

What we usually think of as pain patients, I refer to as complex patients –Complex chronic pain patients because literally by definition, their pain does not respond to what works for the ninety percent of others. And this includes education. I’ll point out that this is a syndrome that occurs in almost every painful condition. The key characteristic is that people are declining over time despite the more we do for them. So they’re getting worse the more we do. They have a history of what I refer to as enigmatic presentations and they seem any doctors. The enigma is the conflict between how disabled they say they are and the lack of objective findings. It’s also important to recognize that as much as we find them difficult, they also find their interactions with us to be unpleasant.

So why is education important? I think you have to look back to these ten years, to a series of articles written by Bodenheimer, Wagner, Von Cour and others who were published in the Journal of the Medical Association describing a chronic care model. This was really important because it proposed radical changes in the patient / provider relationship in primary care when it comes to managing chronic illness. The vision or goal is quote informed in activated patients interacting with prepared and proactive practice teams.

What this translates to is the difference between traditional care where providers act as experts and patients are seen as passive receivers of care. In the chronic care model, we function more as consultants that function more as consultants that offer guidance and support and the patient is really seen as functioning as their own principle caregiver with regard to their chronic problems.

As a result, self-management is at the core of the chronic care model. Self-management is recognized as literally inevitable in every chronic illness. As people need to make day to day decisions about their care including medications, exercise, how they manage stress, their generally lifestyle and it is explicitly recognized that all of these factors influence their health and function.

Furthermore, the patient is seen as being responsible for creating and maintaining new life roles in coping with the understandable emotional reactions to their conditions. In particular, as a result, patients are seen as sharing some responsibility for their outcomes. When you look at what’s happened over the last ten years, you’ll see that these ideas have been incorporated into large structural initiatives like the Medical home or here within the VA – the PACT. When you look at the literature, ideas like patient centered and collaborative care, shared decision-making – all share the assumption that a well-educated patient will make more rational decisions about their treatment and will be more likely to participate in self-care. 

In pain, this is seen as particularly important because misinformed patients may demand unreasonable tests, unreasonable referrals and they drive up healthcare costs. They may demand urgent pain relief and therefore expose themselves to undue risk from surgeries or invasive procedures or unsafe doses of medications – particularly the opiates. 

We actually know the idea the chronic pain and patient education are intricately related goes back decades. So concepts like coping and self-management, pain-management and skills training have always been recognized as an important component of multi-disciplinary care for pain.

More recently within the last several years, the VA has explicitly – in the VA, the Veteran’s National Pain Directive of 2009 recognized that the specific objective to include both patients and their families as active participants in pain management is very consistent with nearly every professional pain organization advocacy group, JCAHO, etc. In the last couple of years, a couple major reports – 2010 Army Pain Management Taskforce initiated last years institute of medicine report also underscored the importance of patient education.

I think it’s very helpful to make a distinction, however, between education, training and learning. People usually think of education as the provision of information and the building of a knowledge base. It is noted that this is a necessary but not a sufficient condition for behavior change. Training, on the other hand usually pertains to skill building. Learning usually refers to more general life experiences. I think that is very important when we deal with chronic pain folks, is to understand that much of what they are learning in life conflicts with what we are trying to teach.

Exactly where do patients learn and what are they learning? I think several sources of learning include their own experience. Experience of their friends and family. Certainly they learn about pain through the media and society. The internet- people are out there all the time looking for information and again, they learn about pain from what we do in the clinic.

Just briefly, if you look at their own experience, virtually everybody has experience with acute pain. One of the difficulties is that both acute and chronic pain feels the same to the individual. Acute pain is an emergency signal. It is a symptom that there’s some sort of underlying problem and that care is needed. What people have learned is that when you hurt, you go to the doctor and the doctor’s job is to find the cause. You then get an appropriate treatment and the pain is resolved. Within this relationship, the patient’s job is to do what the doctor says. You are perceived to be passive and helpless and the doctor is the one who is responsible for the outcomes of the treatment.

Family and friends also provide information and learning. Initially, families respond with sympathy and support and advice, but in chronic pain, things get much more complicated. When you look, people learn about pain from their family of origin where people are exposed to illness and the help-seeking model. What’s going on currently in the family has profound effects on what people are learning about pain. And very often they service as advice givers and some of this advice, as I know here, conflicts with rational treatment. So people are often looking at their uncle’s neighbor’s mailman and trying to make leaps between what someone else has done and what the person’s particular condition. Ultimately the patient’s family that is also suffering with this pain problem provided to go get another opinion when we cannot make the pain go away.

It’s important to understand that we live literally in a society that is a culture of cures so that – like US News. People believe there is no excuse for pain and that somehow we have these answers. If they can put a man on the moon, we certainly should be able to fix someone’s back pain. Miracles – excuse me, are what make the news. Miracles and instant solutions are what make shows like ER and even a show like House where even a doctor has a percoset problem.

I think, as I like to say to patients, this is the world of TV and you’re never going to see a show about the arthritis clinic or the primary care clinic where people are trying to deal with chronic problems. It’s also important to realize that pharmaceuticals are big business. Literally on TV and in ads, we’re inundated with the concept that with every pill – there is certainly a solution in pill form for every problem that human’s experience.

The Internet – Washington a couple of years ago, actually did an expert rating. They went through 240 rep’s websites and concluded that generally the quality is poor. This agrees with generally what other people find in regards to healthcare information. When you look at the most commonly searched keywords, which I just did last week, you find that if you search pain, there’s almost a billion hits on Google. At least when you get to fibromialgia, you only have to wade through twenty-six million sources. 

What’s very important to realize is that some of the more glitzy, well-funded sites like, for example, Partners Against Pain, you really have to drill down. And what you’ll find at this particular site is that the partner behind this is Perdue. And Perdue is the maker of Oxyconton. So people have different agendas very often. They did conclude there were nine highly rated websites. They liked WebMD. Also there were two website advocacy groups, the American Pain Foundation and I’ve highlighted the American Chronic Pain Association. As I describe later, we have close working relations with this group and I would highly recommend their site as a source of well-written, highly reliable information.

What I will talk more about is that we, ourselves, are important sources of learning. When you look at primary care, the vast majority of pain is treated in primary care. It’s here were primary problems are defined. It’s where we offer solutions. Importantly, it is where we communicate what a realistic goal and expected outcome is. And we communicate information about responsibility in roles.

The problem becomes that most healthcare providers are very poorly trained in chronic pain. They are highly trained in an acute model and a biomedical model where the urge in pain relief is the primary goal in treatment. But when we look at it more closely, what we recognize is that acute pain strategies actually make chronic pain worse. We’ve described this in our provider module, as some of you may have gone through. I’ll go through this briefly, where we envision what we refer to as an Iatrogenic Cycle, where someone with complex chronic pain enters into the healthcare system. Things are initially hopeful as both the patient and the provider share a common model: biomedical. They both think pain relief is the appropriate goal. They try what works with other people. They offer diagnostic tests and consultations. And really things proceed quite rationally.

If you look at it this way, both the patient and the provider perceive pain as the primary problem and if you fix pain, the other problems will be resolved. What happens is as these tests come back negative, and I’m talking about complex patients primarily. What works for other people do not work for this individual? When the specialists are scratching their head, ultimately what happens is the patient is sent back to primary care. Doubt creeps into the relationship and basically conflicts develop. 

We then essentially change our model so that what has worked for others hasn’t worked for this patient. We begin to conclude that obviously pain is not the primary problem. We don’t have much to offer; yet they are still under our care. When we have nothing else to offer, we have little choice but to keep doing more of the same. So we usually repeat taste, escalate medicines. We may get creative in our diagnostic considerations. We then refer to specialists who further escalate medicines or expose people to really risky treatments but ultimately, this patient is returned to primary care where the situation degenerates into hopelessness and ultimately rejection.

So really, what has the patient learned? What I suggest the patient has learned is that their disabling chronic illnesses are much more real than our imaginary medical expertise. People conclude, after this experience, that you must be incompetent or uncaring – that the reason you are not giving them the tests or the drugs they need is because of costs or fear of regulators. But mostly what people learn is to keep looking and looking until you come across the right doctor.

So the basic problem here is that both the providers and the patient share a biomedical model that is inadequate to address the complexities of chronic pain. Among the more problematic belief among this point of view – excuse me- is that pain is the primary problem. And that it is the symptom of an underlying condition that has to be identified if it is real. If the person has a real problem, then a medical solution must be available. And you, as the highly trained medical expert, are responsible for fixing it. The patient is the helpless victim who can really do nothing about this injury or disease.

What I suggest to you, though, is that patients who are overwhelmed by chronic pain, will always choose hope for an effortless pain relief over the hard work of self-management and coping, even if that hope is mistakenly placed on biomedical treatments. I like to think of the biomedical model as a fancy car that everybody wants. 

The idea that medical solutions are possible, that cure is possible, that all you have to do is fix the person’s pain and all of their multiple life problems go away. There will be no effort and ultimately no responsibility. When you compare that to self-management, trying to convince patients to use self-management is like trying to sell this Volkswagen. It is beat up and tough. We’re trying to teach people that there’s no cure. At best, pain is inevitable and maybe they can do something about the misery, but this requires effort and coping can be difficult.

We’re asking patients to share responsibility and ultimately we’re asking patients to be addressing life problems other than pain. So what actually do we need to teach them? What do they need to learn? Essentially we need to teach them that there’s no engine in that car. The biomedical model doesn’t work. It’s crazy for us to be doing the same things over and over again and expecting a different result. We need to help patients understand that many short-term solutions that provide urgent pain relief ultimately create long-term problems in terms of more disability and dysfunction.

We need to convince them that even the hard work of self-management that it’s worth it and that with some effort and some practice and some patience, life really will be better. It won’t be better next week and it won’t be better with a pill. But six months from now or a year from now, while working together with them, their life can be better even if they hurt. And I think that’s the idea. We need to help patients understand that pain is not the enemy. Our goal is not to kill the pain, but the purpose of working with complex pain is to help them return to a full and satisfying and productive life even if they still hurt. 

We need to teach them that the biomedical model, this linear and unidirectional model that we’re all suffering and disability is related to pain that can ultimately be fix if only we find the source of the injury – that this is much too simplistic. That really pain is a much more complex human experience and we can influence pain by directly influencing and treating people’s suffering and disability. We need to help people to move from thinking of pain as their only problem to really pain as one of many problems. Ultimately, what we want to do is help people separate pain from these problems as we work with them to address family problems and emotional problems, et cetera.

If we’re going to break the cycle, we really need to think about the problem differently. We need to redefine what it means to help and how we work as providers. We need to be more comfortable with ambiguous physical findings. And ultimately, we need to recognize that there are no simple medical solutions to complex pain problems. We need to then help work with the patient to transfer hope from what we can do to what they must do. As this chart shows, we need to learn to be more comfortable in the teaching/coaching role of the chronic care model than in the expert role of the biomedical model. 

I also, even though it’s easy to draw comparisons between a bio-cycle social and a biomedical model, I want to point out a bio-cycle social model subsumes a biomedical model. So everything rational and appropriate we do for patients, but it’s in a context that recognizes the complexity of the pain experience. What I call this is collaborative self-management. So again, a full range of medical interventions or treatments are offered, but while we are doing this, we are teaching people that what they do is much more important than what we do. We’re not trying to convince people that pain is caused by psychosocial factors and certainly if you look at the literature, it’s not a grim alternative. It is the self-management and coping as the treatment of choice for these folks.

It consists of supporting the patient as a person as we challenge the belief that pain is the major problem and that the only acceptable solutions are medical. You need to help change the focus from urgent pain relief to long-term function. We’ve described this in the provider module as the VMA model, which basically says that the first task, really, is to validate the person’s experience. To let them know that we believe them that they have real pain regardless of what the object tests findings are. We need to help educate not only about self-management, but we need to educate them about the limits of what we can do. We need to acquire motivational skills and really keep the focus on reactivation.

So the goal, then, becomes shifting the goal from what we do to what they do, but yet deemphasizing urgent pain relief doesn’t absolve us from responsibilities. It really creates new ones so that the task becomes working on establishing this collaborative relationship and teaching the person to shift from a biomedical to a more complex bio-psychosocial model. And helping them identify goals and facilitating and supporting their efforts to address problems other than pain.

So it’s a process of education – helping people identify and acknowledge that they have other problems. Help in separating urgent pain relief from suffer and disability and it’s very important to communicate patients that they’ve gotten where they are by reacting normally. Normal reactions to chronic pain, if you react to chronic pain as if it’s an acute problem, again, the problems become worse. It’s trying to help them move forward in these efforts. But that this way, our job is not really to fix the pain. Our primary responsibility is to create and environment that facilitates the patients making adaptive choices. It’s important to understand that it’s not a matter of arguing or cajoling. The more we argue for self-management, the more the patient will argue back why it is impossible to change because of pain.

And I encourage people to read some of Mark Jenson’s work on motivation interview and pain. There’s a number of practical suggestions for dealing with those difficult situations. I think it’s very important to recognize that patients have a right to remain the same. If we come up with a rational and reasonable treatment plan and the patient rejects it, it’s not really a reason to change the plan. Our responsibility is to then educate them about the likely consequences of their decisions to not comply with medications and not exercise and not deal with other problems, et cetera.

So nationally, I would just talk about what we’re trying to do. We’ve been working for a couple of years and have a couple of strategies. The first thing we did was review what’s out there in the VA and outside the VA; we spent a lot of time at web resources. I spent a lot of effort developing partner relationships, coordinating with other committees and some of the work we’ve been doing here at VISN 20. When you look at – excuse me- the HAIG survey, they found almost eighty-one percent of the facilities have pain education activities of some sort, but only about a third had formal education programs. When we actually went and tried to survey, we found very wide variability in quality.

There were literally a handful of very high quality group education programs in the VA and most programs heavily rely on handouts from government agencies, self-help books, et cetera. When we looked at what was available on the VA and DoD websites, my healthy bit was the VA web portal that posted afterdeployment.org is the website for the Department of Defense. What you found was neither of these organizations had information on pain. 

Most concerning, what you find is that there’s no integration between what we teach providers and what we try to teach patients. So literally, provider education is what we teach providers of biomedical approach to how to evaluate and treat pain. Yet, we’re trying to teach patients a bio-psychosocial approach and this is a concern. 

So our goal, then, becomes to identify and develop more standardized, high-quality information. What we are committed to is that this information has to be universally accessible and had to be convenient and we wanted to cross multiple platforms. We also thought it was important to coordinate this with what we teach ourselves. So what we were going to do was build national partnerships with both VA and DoD groups. Our goal was to create toolkits, which really were – we perceived them to be most useful to facilitate discussions at the site of contact. The goal – and they could also be used for pain schools, et cetera and work we’re doing on interactive stuff.

Most typically, when you think of a toolkit, it’s a simple list of resources. Some of our ambitions are a little larger where we view these as materials that a busy primary care provider could actually use to help teach patients some concepts that are normally done inside groups. The goal is to teach a biomedical model and to really teach that this is not a medical problem – to let people know that this is a realistic outcome, risks, benefits. The long-term goal really being to minimize inappropriate utilizations and risks.

So, what we’ve done is we’ve developed active partnerships with the American Chronic Pain Association and the Department of Defense for the National Center for Health and Technology. They are the people who see afterdeployment.org. Privately, we work very closely with Tammy Cowlin who is the founder and CEO of the American Chronic Pain Association. Again, I encourage everyone to go check out the site. One of the things that they do is, they’re very involved in setting up peer support groups with the goal of helping patients move from being a patient to being a person. What we did was we had a couple of pilot programs here in Anchorage. These were working out, we then last year facilitated their access to VA resources in ten other sites. What this chart shows is that these are the sites where they’ve gone out and helped set up fifty-eight peer support groups across the VA. They’ve trained almost five hundred people in this and we’re hoping they are going to get funding to do more of that this year.

With the VA, we’ve partnered with the national patient education office that oversees myhealthevet, which improved over the last couple of years. We’ve had a couple of starts and stops. As myhealthevet is developing their own strategies and changing technologies. The good news is that I think we are settled on a very encouraging, viable strategy where they’re developing a Veteran’s health library. It’s supposed to be launched any day. Our initial pain content that will be on myhealthevet will be around opiates. When this is up and running, people should be able to access this. In the clinic areas, people will be able to access this from home.

We’re also just starting work with the National Post-Deployment Integrated Care folks. What they’re developing is a wiki. It’s quite impressive.  The goal is to have a knowledge repository for pain information and some of the members on my committee will be working with them. Then, of course, we’re working to do posting material on the VA pain website. The work we’re doing is very exciting with T2 and the DoD. Again, I encourage you to look at this and envision the kinds of programs and the information that they have, for example, on PTSD to be translating information on pain.

So we’re working with their subject matter experts to develop a pain library and self-assessment workshops, mobile applications – this is an ongoing relationship. What I think is very exciting is that any information that we develop with them, the DoD, will be sharing back to the VA and ultimately we can post some of this information on myhealthevet. From our point of view at VISN 20, our hypothesis really has been that patients and providers that share a bio-psychosocial model of pain – we hope they will be more likely to form a collaborative treatment relationship that will result in lasting improvements in function.

Our strategy has been a little different because our goal is to teach content from different perspectives. What we’re trying to do is teach both providers and patients that realistic expectations of medical solutions and to deemphasize long-term improvements. The target of change in our point of view is the patient provider interaction. We want to change the conversation and clinical decision making about what appropriate treatments and safe treatments are and to avoid the Iatrogenic Cycle that I described earlier.

If you look at the actual content, first we’ve developed provider education where we teach providers to really understand that patients who are overwhelmed by pain aren’t just asking to have back pain fixed. They really bring into the clinic a multitude of life problems that are best conceptualized within the bio-psychosocial model. We teach people that the goal, when you have a complex patient, is not necessarily to diagnose in the traditional medical sense, but to formulate and understand where pain has fit into the entire path of this person’s life.

There’s some information there on communication skills. There’s nine clinical scenarios that people have found difficult with some kind of what do you say when a patient refuse to do a urine test or when they ask for an early refill. And then there’s a lot of information on the opiate medications. What we’re doing now in patient education is basically broken down into four sections. The first section is basic pain information. What is pain? We’re trying to help people understand the complexity. We use gate control, as a metaphor to help them understand the difference between acute and chronic pain would be one section. 

The second section is what your doctor can do for you. This is particular organized around evaluations so that teaching people that you can’t measure pain with machines. We organize something around surgeries and interventions, giving people the idea that there is no quick fix. And that for many patients, these kind of procedures are not appropriate and then encouraging them to speak with their primary care provider. Most of the module really focuses on what you have to do for yourself. We use it under this kind of organization I’ll describe briefly later. We have the rehab approach.

Again, the goal is to promote collaboration of realistic expectations and to really shift the conversation. It’s like a screenshot of one of the introductory pages. It will give you a sense of what we’re trying to do. The working title of this is Take Charge, Live Well, Even If You Hurt. Essentially, the perspective is that chronic pain is no different than diabetes or any other chronic illness. What you have to do is really change the way you perceive it and change your behavior. The idea is that people really need to become their own experts in pain management. We draw the distinction between a patient with pain and a person with pain and the difference is that if a person is stuck in the role of patient, really life is on hold until pain is fixed. They wait for a medical solution while life problems are getting bigger and then from the patient’s point of view, this Iatrogenic Cycle that I described is really experienced more as a merry-go-round where you’re stuck on a ride wishing for a golden ring that really doesn’t exist.

In contrast, the goal then is to be shifting people to a point of view where life is no longer on hold. They’re not waiting to be pain free. They become more active in their own care and they have a more clear understanding of what we can and cannot do for them. So this is organized under what we call the rehab approach, which is really – starts off with redefining the problems and the solutions. People need to learn to expect some pain, but they don’t have to be disabled and suffer. People need to have plans for those days when they really hurt badly so the emphasis is not on activation, not only physically but in every area of their life as they build a life that’s more hopeful and healthy.

So, these are some of the key ideas. The idea that just because there’s no medical solution really doesn’t mean that there is no solution to their problem. The chronic pain itself is very unpleasant and stressful, but it’s unavoidable. The key really is to recognize that the pain – chronic pain is a false alarm, not an emergency signal. The core skills that we’re trying to teach is to change how to react to pain. If you change how you react, you change the pain experience itself. And then along cognitive – the cognitive level, we’re specifically focusing on common pain beliefs like hurt equals harm; pain is my primary problem, et cetera.

Emotionally, people – we deal with the fact in negative emotions, really they turn up the volume on pain. There’s some sections on relaxation skills. The focus on behavior is not just on physical exercise, but really on reengaging in virtually every aspect of life. One of the things we’re very happy about is because this is an interactive program; we can customize the content so that if a person who has recently been deployed, they will get different information. They will get an additional screen on coming home and post-war adjustment and how that influences pain as opposed to someone who has not recently deployed. 

We also realized that people we’re hoping will use this will vary from the completely disabled person that we see sometimes who is completely in bed ninety percent of the day to the person who’s out there working part time or is a student full time. So, what we’re able to do is based on pre-testing. We can give people different advice and different information based on their level of disability. We also give them based on some of the disabling beliefs I was mentioning. And interestingly, based around the opiates. If people are on opiates or if they want increases or if they have – whether or not they have a substance abuse disorder. You get different kinds of presentation and content. 

And then there’s a system where we do pre-post testing and based on these scores, people get different advice. So the hypothesis that we’re generally working on in all of these efforts is that better educated and supportive providers who work with better educated and motivated patients ultimately will be able to collaborate in a way that results in a lasting improvement in functioning. Because I firmly believe that we can change the patient’s experience of pain by changing their experience of healthcare. And here’s a flash from the past. This is a book that was written, I point out, in 1990. I put it on there to say that in the last twenty plus years, I’ve never seen a better book written on self-management. So those of you who have some interest, I suggest you try to see if your library has a copy. And that’s it. I’m done.

Q:  Fantastic. Thanks so much.

Dr. Mariano:  What do I do now?

Q:  Well, we’re going to get started on questions now. I just want to let the audience know that if you have any questions to submit, please use the Q and A screen on your webinar dashboard, which is on the right hand side of your screen. Just use the orange arrow to collapse that against the side of your screen. Type your questions into us there. We do have one question received so far. With a new push to obtain BMI relative to pain issues, you promote ruling out medical issues prior to mental health issues, or in conjunction with mental health and or addiction assistance coupled with perhaps gastric banding or bypass.

Dr. Mariano:  That was one question?

Q:  That was all, yes.

Dr. Mariano:  Well, let me take the general point first. I think it’s very important to understand that we have to be absolutely sure that every rational medical test and treatment has been done when people come in. The point is that it’s not do you do it, do you emphasize mental health treatments or medical treatments. I mean, people are coming with pain and we need to rule out the potentially fixable. The challenge becomes do you need to repeat once? Maybe. Do you need to repeat two, three, five times? I make the argument that we’re ultimately doing more harm than good. I’m not real clear about what all was the – obviously there was some concern about weight or something? I didn’t really follow that to be honest with you? With the banding? What was that? Could you repeat that Heidi?

Q:  It was the push to obtain BMI related to pain issues. Just wondering if there is addiction coupled with gastric banding or bypass?

Dr. Mariano:  Here’s what I would say. I’m not aware of a push to obtain BMI, other than certainly there’s a more general recognition that physical conditioning that people get disuse syndromes overlaid whatever their initial problem is. What I suggest, and again, I’m a psychologist not a physician, but gastric banding and solutions like that – if you take a person who’s overwhelmed by chronic pain, who’s a hundred pounds overweight and they have long standing issues that are related to complex family issues, magically making a hundred pounds disappear doesn’t fix their pain.

Q:  Okay. Thank you. We have got a couple requests for you to put the slide back up with the book title and the author?

Dr. Mariano:  Oh. Let me see if I can do that. They don’t like my guy?

Q:  You know, I think it’s a really cute picture. But, to go back, if you go to the lower left hand corner of your screen, you can see the watermark. Yep. Click right on that to go back.

Dr. Mariano:  This guy had a gastric procedure.

Q:  He looks like he had it.

Dr. Mariano:  He feels better.

Q:  Okay, great. We’ve got a couple questions, also, on how people can access the patient education materials that you used?

Dr. Mariano:  Well, I did the – I’ll do it in two steps. One, what’s freely available that I highly recommend is the information at the American Chronic Pain Association. The information I’m referring to in the VISN 20 module is not quite done. I’m hoping that this would be several months. We actually are trying to decide how we make this available. There are certain things we have to go through. I’d say to people, we would probably make this announcement over the VA listserv as we figure out how we’re going to do this. The other information that I was referring to should be available on myhealthevet, once they move into active enrollment, so to speak or access is more appropriate. I suspect that will be in a month or so. So it’s kind of in the works and it shouldn’t be that long.

Q:  Okay, that’s good. And that’s going to be on the Pain Listserv?

Dr. Mariano:  No, I’m saying the Pain Listserv – I would imagine that we would use the Pain Listserv as a way of announcing to people when information and where it’s available.

Q:  Perfect. I just wanted to make sure people would know where to get that. 

Dr. Mariano:  The VA Pain Listserv.

Q:  Perfect, perfect. Okay, the next question here. Please describe further how you customize the patient education.

Dr. Mariano:  Well, I thought I – I guess I would say this. What’s very important is that people – as people go through – that’s one of the advantages of doing things on the interactive program is that you can customize. And so a very important part is around functional levels. So that someone who is bed all day – some of the goals that you would ask that person to do would be to get up and get dressed. This is not an appropriate goal for someone who is out going to school everyday, so a more appropriate goal for that person would be maybe to learn to monitor their communications and learn what people are hovering over them and how to deflect that in a kind way.

And then also, I think that another very important area is around the opiate issue so that you’ll find some people have substance use histories and they don’t want opiates. They should be given different information that someone who has a substance use history who is on a stable dose or someone who wants to decrease. That’s the partial answer, anyway.

Q:  Okay, great. Thank you. The next question: which VA facilities have the top notch pain schools to learn from them?

Dr. Mariano:  I think if somebody sends me an email, I’d be happy to do that. And then I can put you in touch. I mean, I could just mention briefly, and this isn’t in any kind of order or to leave anybody out, but I know that certainly the people down in Tampa – Jill Claim, Nancy Wietemer has shared a lot of information out in Philadelphia. I wouldn’t want to leave anybody out. If somebody asks me, I could put them in touch with some folks. People have been very generous in sharing their materials. It’s nice.

Q:  Fantastic, thank you. The next question is what are the pathways to creating and integrating such a model of pain management in my VA, where there is no official pain clinic?

Dr. Mariano:  Here’s where I would say – having a pain clinic can be a huge advantage or not. And when you actually look at most pain programs, most pain programs and most pain specialists consist of people who are highly trained in interventions and biomedical skills. I think that the – if you have someone who can work with you, there’s a really real place for those skills but for the kinds of patients that are the most troublesome that I’m describing, they need something different. So, whether or not you have a pain clinic, what’s important is to try to identify people in primary care who are willing to kind of collaborate. I think the collabertion really needs to be between mental health, primary care and then addictions as needed and other specialists like rehab, et cetera.

Q:  Okay, great. Thank you. The next question: I use motivational interviewing techniques to help motivate individuals to help change behavior. What else would you consider to help people in changing behavior?

Dr. Mariano:  To be – what I would say is this. When you’re in a clinical interaction, the most powerful way of changing the patient’s behavior is to change your own behavior. I think that what often happens is that we follow the patient’s lead and I think that sometimes that’s appropriate but if a person starts saying I can’t do this because of pain. Or the only medication that works is whatever. Something inappropriate. 

I think that one of the things that everyone of us can do is to really make more firm and clear decisions about what’s our policies, what are our goals and what do we expect? Here up in Seattle, one of the things that we’ve been doing for many years is that we do our patient education before we engage patients in treatment. It’s really an orientation so that when we get new patients referred to us, we bring them in a group of forty. We then offer them four classes and the first class is really an orientation to our policies. 

It’s really an effort to validate their experience and their sense of frustration of being caught in a medical system that blames them and doesn’t trust them. So what we tell them is – and actually, I will tell you that most of the provider modules that I’m writing is really based on what we teach people in these classes. So literally, we follow the same structure, which is an orientation to policies, and not just this is what our doses are, but an orientation of – it doesn’t make sense to anybody that we can fix you when you’ve had fifteen other doctors that can’t fix you. But what we can offer is to work with you. That kind of a thing, and then we follow very much the here’s the basics of pain. Here’s what doctors can do and here’s what you have to do.

Q:  Thank you. The next question we received: what would you recommend as the best resource for mental health clinicians to refer to a crafting education and why to use self-management for patients? Would that be in the book or are there any others that you would recommend.

Dr. Mariano:  I think that the Hanson book is just classic and they do it very well. I think the question of why to use self-management is not a mental health issue. I think that the key education needs to come from the medical people. You need to collaborate with your medical people, where the first thing they have to do is stand in front of patients and say we don’t have a solution. That doesn’t mean that you don’t have a real problem. So self-management should not be something that’s put off into the mental health. The self-management really needs to be something that medical providers need to be engaged in.

Q:  The next question: Is anyone developing a chronic pain tele-health protocol? We have many for other chronic issues like substance abuse, DHS, obesity et cetera.

Dr. Mariano:  There are a lot of people that are working. I know there’s a program at VISN 1 who has a very active program where they’re doing individual cognitive behavior therapy over the web with people. Also, just more generally, one of the things that’s going on that is that people like Matt Gallagher and a bunch of other people are actively working on a project that’s called SCAN. It’s basically – it’s teleconsultation where the model is one in which people present cases. Where they usually have a didactive twenty minutes or something content area and then people can present cases to a panel that has some expertise. But then people can watch. This is something that’s based on something out of University of New Mexico. It’s been widely used in other conditions. We’re using it up here at the University of Washington with pain. SCAN is really just the VA version of ECHO. I know that people right now are actively developing that curriculum. 

Q:  And I just want to mentioned that Dr. Sullenger will actually be presenting on Pain Management in December of this year. I know that is many months off, but I don’t have a topic yet. I am assuming he will most likely be speaking on telehealth and we will be sending the registration information to everyone on that when we get closer to that time. Okay. The next question: With the new tax model, we are lucky to see our patient once a year. How do you coordinate this by phone when it is something that should be observed and touched on a more frequent basis?

Dr. Mariano:  I guess there’s no easy answer. People – to me, the biggest impediment to quality pain care is structural. I think that it’s easy to provide treatments in fifteen minutes. It’s not easy to provide care in fifteen minutes. And these are issues that – I mean, my own personal feeling is that – I guess the good news is that at least at high conceptual levels, these kind of models will recognize the importance of the relationship and recognize the importance of education. I think the way that they have been translated still needs some work. I guess the answer is you cannot take care of a person with complex pain by seeing them once a year. As a matter of fact, they won’t tolerate that because what they’ll do is show up in the emergency room or start having crises. I think that’s one of the problems because the only way folks get care that they need is by having a crisis. The more they have crisis, the more standoffish we get. I wish I had a better answer.

Q:  Thank you. Tony, both for you and our audience, I just want to mention that we are past the top of the hour. We have about fifteen pending questions still. I know I spoke with you yesterday about going over time, but I want to make sure our audience knows. Are you still able to stay late and cover some of these questions or would you prefer to do that offline?

Dr. Mariano:  I can stay for a little while.

Q:  Okay, yeah. I know that sometimes we could have gone forty-five minutes over.

Dr. Mariano:  Yeah.

Q:  When we get to a point where you have to leave, just let me know.

Dr. Mariano:  Okay.

Q:  But for our audience, we are recording this session. I apologize if you do need to leave and if we haven’t gotten to your question. It will be available in the archive.

Dr. Mariano:  Can I ask you a question? Is my screen still being shared?

Q:  It is.

Dr. Mariano:  Can I undo that?

Q:  I can take it off.

Dr. Mariano:  Thank you. Okay. That works. 

Q:  Okay, there we go. Okay, the next question: How well do you think VA clinicians are doing in managing pain patients in the aspects of self-management techniques?

Dr. Mariano:  I guess I would say this, and I wouldn’t – I wouldn’t related this to VA. I’d say in general, in our healthcare system, where we’re just like the previous question where productivity is being measured by through-put as opposed to quality – I think that as a system we do pretty poorly. And I think it’s because of all of the reasons that I tried to outline. We don’t understand the complexity of the problem. We don’t train people and give people skills. And it’s – we’ve asked primary care to take on an impossible task, sometimes. So no blame, it’s just an honest description of at least my opinion.

Q:  Okay. Thank you. The next one here. I have a comment, not sure if I should read it over the phone but I’m going to anyway. I am going to get a lot of responses on that. Dr. Hans did a patient handbook for coping with chronic pain when he was a VA at Long Beach. He retired last year. I have it as a PDF if you would like to have it. It is a large file updated in 2007. It is not written for public health literacy folk, however. So I’m not – I don’t want to give the person’s name out. I guess if people are looking for it, they can send us an email at cyberseminar@VA.com. Tony, I’m not sure if you have this or if you would like a copy of it. Dr. Mariano:  I guess I would say this. I would like a copy of it, so whoever has it, I don’t know how – I mean, I would be glad to look at it and then if it’s something that might be more broadly useful, we can contact him and ask if we can use it in the VA. Whoever it is, I appreciate it. Send it to me.

Q:  I’m messaging your email address over to them right now. So. Perfect. Okay, the next question – we all know that education is important. However, to achieve behavioral change requires time and commitment and it is time that primary care does not have. Do you have any suggestions on what to do?

Dr. Mariano:  I think that, and this I think is part of the – at least my hope for the concept of a team. I think that primary care – it can’t do this alone. Period. The End. It just can’t. So I think that the idea is that we have to partner. We have to be clear and careful in that we’re all giving the patient the same message and I think that’s one of the major points that I tried to express today. Very often you may have a psychologist or a mental health person or an educator trying to communicate self-management as the goal, where you have a primary care provider who is in a difficult situation and doesn’t know what to do. So they repeat an X-Ray or escalate a medication. Patients get caught in the middle, so I think that what primary care’s responsibility is towards what I said at the end, which is really to redefine their job when it comes to complex chronic pain. And then to develop some of the skills. People cannot do this without education support, policy support, administration support. That’s just – I believe those are the facts. It really is to develop a team around this. What doesn’t work is this. The patient comes into primary care and you send them off to a pain specialist or a mental health person or whatever and they just keep coming back. There needs to be a core perspective.

Q:  Alright. Thank you. The next question. Are you aware of many VA’s who are using mindfulness-based stress reduction and are they happy with the result?

Dr. Mariano:  I think that – here’s what I would say. I would be surprised if there is any VA that is not using mindfulness-based concepts for something. I mean, we have mindfulness for everything now a days, I think it’s a very useful construct or concept. I think that the idea of mindfulness in pain is probably imbedded in anyone who is doing a pain school. And again, how useful is it? I think one of the challenges is that it’s very useful for patients who are prepared. So that people who are open to these concepts certainly can benefit from these kinds of skills that the challenge we have is, again like I mentioned earlier, that our most difficult patients will not respond to this because mindfulness makes no sense to them. Not when they think that all they need is another surgery like their neighbor’s doctor got or something. So for the right person, the right group of people, I think these kinds of things are wonderful. The challenge is who are those and people and what do you do with the people who are not ready for that?

Q:  Okay, thank you. The next question – how do we figure into the patient education process that the patients complain that if you don’t give me my narcotics, I’m going to call my congressmen?

Dr. Mariano:  Here’s what I would say – I think that when patients say that to me, I give them my business card so that they spell my name correctly. I think the key, really, is that if you are confident in your approach that you have policies that are sensible and defendable, this is not something to be concerned about. If your policies are chaotic or if your policies have been just a continued escalating until you become uncomfortable, then I think you have a problem. I think that, for example here, we have very firm policies about maximum doses of opiates that we use. We’ve done this for the twenty-five years that we’ve been here. We’re very comfortable with that because we don’t think that escalating opiates is safe or effective. That was even through the nineties when certainly the medical area was going to opposite direction. So, what am I trying to say? I think get together a team and decide in advance what your policies are. Give those policies to everyone and you should have no problem because that’s what you do.

Q:  Alright, thank you. Next question – how does the VA policy of the patient’s pain is what the patient says it is figure into the patient education process

Dr. Mariano:  I think that if the patients pain is what they say it is, really relates to the fact that we cannot objectively measure pain. It’s – pain is fundamentally a subjective objective. The best we are going to do is zero to ten. You can ask people about function and I encourage people to be asking less about pain severity and more about function. And I think that makes perfect sense. What we say to patients is we believe you. The question when – if you’ve gone into being a complex patient is less what’s causing the pain than what are we going to do about the pain. So I think that’s a perfectly reasonable thing. I think that it’s important not to think that patient’s pain is whatever it says it is means that the patient’s treatment is whatever it wants. That’s not the same statement.

Q:  Okay. Thank you. The next question is do you have patients that fill out a pre-assessment form to individualize education?

Dr. Mariano:  The answer is no. I would say we used to back when – we had a very elaborate pre-evaluation but frankly it just got ponderous and it got to the point where if we weren’t using it, these were for clinical or programmatic work, we just stopped asking patients. I think what we’re excited about is – I mean, like many pain clinics, we’re overwhelmed. We can’t meet the demand at our pain center. We get people from multiple sites. One of the things that we’ve built into this web-based program that I’ve been talking about is a pre-assessment and a post-assessment. One of the ways that we’re basically considering using this is that asking people, for example, who live a couple hundred miles away who want to be treated to do the pre-post and bring this information in with them. So, we will be using this once we have the module done as part of our plan. Right now, we’re not.

Q:  Okay. Thank you. The next question – please give us a little more detail about your comment about pain patients. They got where they are by acting normally.

Dr. Mariano:  I think one of the things –and this is a metaphor that I talk about in the provider module and I use virtually at every orientation session. I think that it’s very important to communicate to patients that they are not responsible for the situation that they’re in. Now whether or not that’s true, everybody shares responsibility, but you don’t want this to be blame. So I use a metaphor for example, of erosion and that the idea that no matter how strong you are, you can be like a piece of granite and water dripping, et cetera et cetera, you will break down. Which communicates to patients that you are not weak because you are overwhelmed by pain. What we then do as part of the education is to say, look you think pain is an emergency signal and you think that has been functional. When you hurt you should stop and when you hurt, you should go to the doctor. When you hurt, you should rest. When you hurt, you should give up responsibilities. All of this is fine if you have an acute problem that gets resolved in a week or two, but when you have pain that lasts years, those responses, even though they are normal, are no longer functional. 

Q:  Okay. Thank you. The next question – as a psychologist, how do you determine when it makes sense to encourage a patient to be assertive in requesting further tests or treatment versus when to realize they’re just chasing and need to focus on acceptance and self-management?

Dr. Mariano:  I think that at least for myself, one of the other things that’s the – unique about our program is we do what we call a co-disciplinary approach. There’s literally – whenever a patient comes in to the clinic, they see a medical provider and a psychologist at the same time. This is something we came up with in the late ‘80s as an enhancer to the problem that people would come to see our person and say that they are doing terribly. And then they come to see me, we were seen parallel, and they would say they are doing great because they don’t want to see a mental health person. We started to see people together and it works fantastically for us in terms of it being more efficient. You get a lot more out of a half hour joint appointment than you do out of two half hour individual appointments. It also communicates to patients that psychosocial information is appropriate. And we also let people know in the orientation. So, back to the question about the evaluations, I have the advantage of medical provider there with me, but our assessment if people want a further evaluation. Here’s the caveat. I’m going to assume the person has had at least two workups that come back negative. What we would spend more time –as a psychologist, I would say what is it that they think is wrong with them? What do they think they’re going to find. What you often find is what people are looking for is validation that they have a legitimate medical problem. And they are struggling for more because people are rejecting. If, however, the person hasn’t had an adequate work up, we without hesitation refer them or order the tests ourselves.

Q:  Okay. Thank you. The next question – are there any particular resources that address the psychogenic pain in people with APPSD diagnosis?

Dr. Mariano:  here’s what I would say. One, I would encourage people not to conceptualize things as psychogenic, at least in the way that I hear that term. Psychogenic is an old style term that is based on a biomedical dual – is the pain physical or is it psychogenic? That’s really not a useful concept because all pain is influenced by psychological and physical factors simultaneously. I think that John Otis’ work on PPSD pain is a good place to start if you are interested in that particular problem.

Q:  Okay. Great. Thank you. The next question – do pain diaries figure into appropriate patient education? 

Dr. Mariano:  I’ll give you my own experience. I don’t use pain diaries and I’ll tell you why I don’t use pain diaries. People already spend way too much time focusing on pain and so I’m not really that interesting in I hurt more, I hurt here. The only time I might use that is I might ask people if when you’re hurting, take a look at what’s going on around you and to try to identify some sort of stress pain relationship. If I’m going to ask people to do a diary, I ask people to keep track of their functional time. So it’s a different shift. Our goal is not to reduce pain so much as it is to build health. And I think we do not want to encourage, again, a complex pain patient more time thinking about how much they hurt. I’ve had many patients come in with very detailed diaries. I say this is really impressive that you can generate this kind of organization and that you can put this effort but now I want you to tell me how much you’re walking and how many times you are going to the park, et cetera, et cetera.

Q:  Okay, thank you. And Tony, just to let you know, we have five questions that are still pending.

Dr. Mariano:  We can do them quick.

Q:  Okay, sounds good.

Dr. Mariano:  We probably have five people online.

Q:  No, you’ve got one hundred and twenty people still here.

Dr. Mariano:  Still? Hardcore. Alright.

Q:  Yeah. Can you give us a resource for motivation interviewing with chronic pain?

Dr. Mariano:  Mark Jensons from the UW, the University of Washington, I’m sorry. He’s done a lot of writing on motivational interviewing and pain. I’m sure there are other people but he has a couple of book chapters that are very useful. I suggest starting with his work.

Q:  Okay, thank you. Next question – are you aware of any information regarding a long term use of larica. Specifically, is long term use of larica ultimately detrimental to chronic pain?

Dr. Mariano:  I don’t know anything about the long-term use of larica. I’m assuming they are talking about physical complications, et cetera.

Q:  It’s tough because I’m just getting a question written in and I don’t have a lot of background information on it. Next question – any idea on how to change staff perspectives on treatment of pain, especially in nurses et cetera?

Dr. Mariano:  I have – I would say this. It’s something that needs to be continually worked on. And, you know, that’s one of the reasons, here, why we started with provider education. People are highly trained and highly successful in a biomedical approach and it’s very – it’s a very difficult challenge to get people to switch. My experience is this, and I tell this to patients. I think that there is no bad guys, so to speak, in this. I think people, and I say this to patients, too. I say in many ways you are victims of people trying to help you and they don’t know how. The problem isn’t the provider. The provider is the provider’s skill set in education, which is very successful in other circumstances and not here. The way we’re doing it here, I mean, and again is why I gave the nod to VISN 20 is that back in 2008, we literally made going through this education course a requirement for everybody. So, that was a bit of an overshoot as we’re revising it, what are going to do is require – and again, you need some administrative support. All of our primary care providers and mental health providers go through both the patient and the provider training. I think that working with people, you need to find a core group of likeminded people. But it is a tough sell, frankly, to get people enthusiastic about working with complex pain patients.

Q:  Okay. Thank you. The next question – what is the role of biofeedback at your facility and are you aware of VA personnel who are leaders in biofeedback?

Dr. Mariano:  We don’t have or use biofeedback. It’s not because we – we don’t have the staff or the equipment. I think it has – again; I’m not an expert in biofeedback. I haven’t used it in many years. I think it has a very meaningful role with some group of patients and – I don’t know who the VA person to refer you to in biofeedback. Dr. Bob Kerns might know, or somebody like Michael Clark down in Tampa. They have big networks and they might be able to answer that question through the VA listserv. 

Q:  We’ll be forwarding these questions so he may have additional to add. Okay, and our last question. Regarding your pain orientation group, what are your show rates? My experience with these types of groups is that they have poor attendance. Do you have any recommendations to improve attendance to such groups?

Dr. Mariano:  We will clarify first with us, what we do is we take everyone, so we have no screening criteria’s. About, probably forty percent of the patients who are referred to us initially don’t come. So, of the patients who come – that are completion rate through the classes is probably around eighty five percent. So, the challenge really becomes the people who – and again, we send people information so they are aware what we are doing. We’ve also been around here a long time so that a particular group is people who have problems misusing opiate medication do everything they can do avoid coming to see us because they know about our policy. What we’re trying to do now which is an easy solution for us, but it puts people right back in primary care. And we are actually trying to work out some more systemic solutions to this. We’re working with addictions, for example. I’m developing an opiate misuse high risk collaborative program. I think if your program is like mine, you are very busy and overwhelmed with just the people who do show up, but that’s not fair to primary care because they are stuck with the ones who don’t. I guess I’ll stop there.

Q:  That’s nice. That’s fair. And that actually wraps up our questions. Did you have any last remarks you wanted to make before we close out today?

Dr. Mariano:  Nope. Thank you very much.

Q:  Okay. Tony, thank you so much for taking the time to put this together and really for staying late. We got through all the questions and we very much appreciate it. To our audience, thank you for joining us today. Our next section is a series where Sara Crine will be presenting web-based interventions for exercise. We will be sending out registration information in a couple of weeks on that. Thank you, everyone for joining us and we hope to see you at a future session.

Dr. Mariano:  Thanks.

Q:  Thank you, bye.

**[End of Recording]**