Patient Chronic Pain Educati

Taking self‐management from 

classroom classroom to the clinic

Anthony Anthony J. Mariano, Mariano, PhD

VA Puget Sound Health Care Syste

Seattle, WA
National National Pain Education Education Workg

Workg

• Samantha Boris‐ West Haven

• Stephen Eraker – Seattle

• David Cosio, Chicago

• Colin Fernandes‐ Martinez

• Layne Goble‐ Charleston

• Jill Klayman – Milwaukee

• Tony Mariano‐ Seattle• Erica Hugo‐ Chicago

• John Melendez‐Benabe‐ West Palm Beach

• Candon Norton‐ Tampa

• Karen Spencer ‐ Washington, DC

• John Otis‐ Boston

• Rochelle Rubin – Brooklyn

• Anne Toothaker‐Boise
VISN 20

• Significant inv

in provider provider an

education sinc

• Cynthia Cynthia Joe, M

– Chair, VISN 20 

Committee

• Provider educ

module 2008; 

• Patient Educat

mod l u e 2012
Overview

• Assumptions and definitions• Why is patient patient education education important? important?• Where do patients learn about chroni

What are they learning?

• What do patients NEED to learn about 

How can we teach them?

• N ti a onal st t ra egies in patient educatio

• VISN 20 educational “intervention”
Educational Problem

• Our most “difficult pain patients” resp

poorly to educational efforts

– The overwhelmed and the overwhelmin

to engage in self‐management management

– Unmotivated: don’t want to help themse– Secondary gain: compensation, drugs, et
Educational Solution

• “Education” is an ongoing clinical proc

• Every prescription, prescription, referral, referral, or treatme

treatme

attempt ... or refuse... teaches the me

goals, outcomes outcomes, and responsibilities responsibilities

• Recognizing the conflict between wha

teach the patient in the classroom and 

they learn from us in the clinic
Key Assumptions

• Chronic pain is a l fi elong condition wh 

not "curable“

• Treatment goals are functional; self‐

management is essential

• Patient beliefs and expectations regar

pain and its treatment treatment are major dete

dete

of treatment outcomes

• Clinical d i ec sion‐making is the result o

interaction of patient and provider be
Chronic Chronic Pain Experience Experience

• Chronic pain is b t es understood as a proces

evolves over time

• The chronic pain experience results from th

progression progression of the patient patient’s illness, illness, the soci

soci

context in which it occurs, and the interacti

between health care professionals and pati

– Osterweis, M, Kleinman, A, Mechanic, D. Pain and disabi

behavioral and public policy perspectives. Washington, 

Academy Press, 1987
Key Distinction

• “Simple” chronic pain responds to st d an ard

treatments

– Pt. is generally generally functional functional– Interactions are mutually satisfying

• “Complex” chronic pain does not respond t

standard treatments...including education

– Syndrome across all painful conditions

– Declining function over time in spite of progres

aggressive aggressive, expensive expensive, and risky medical medical treatm

treatm

– Hx “enigmatic” presentations to multiple provid

– Mutually unpleasant interactions
–

Why is education education importa

importa

• Bodenheimer and colleagues (2002) JA

series: “chronic care model”

– Proposed radical changes to the pt‐prov

relationship relationship in primary primary care managemen

managemen

chronic illness“informed informed, activated activated patients patients interact interact wi

prepared, proactive practice teams”
Why is education education importa

importa

• Bodenheimer and colleagues (2002) JA

series: “chronic care model”

– Traditional care: providers as experts, pa

passive passive recipients recipients of care

– Chronic care model: provider as consulta

offering offering guidance guidance and support support to patient patient 

functions as his/her own principal careg

regard to chronic chronic condition condition
Why is education education importa

importa

• Self‐management is the core of the ch

care model

• Inevitable in all chronic illness• Day‐to‐day d ii ec s ons about medi i cat o

lifestyle, exercise, managing stress,compliance, etc., that have significant

influence influence on health and functioning functioning
Why is education education importa

importa

• Responsible for creating and maintain

life roles and cop g in with their emotio

reactions to their conditions

• Patients share responsibilities for outc
aae et etc.

Why is education education importa

importa

• Structural initiatives: Medical home, PACT• “Patient‐centered care”, “collaborative care

decision‐making”

• Assume well‐educated educ t a ed pa tstien will make m

rational decisions about their treatment, se

management, etc.
Why is education education importa

importa

• Particularly important with chronic pa

misinformed patients

– May expose themselves to undue risks

• Surgeries Surgeries, invasive invasive procedures procedures, high‐dose op

op

– Drive up health care costs with unreason

unreason

demands

• Unnecessary t t es s and referrals
Why is education education importa

importa

• Chronic pain and patient education

– Cop g, in self‐management, and pain man

skills training has been recognized as a kcomponent of multidisciplinary care for 
–

Why is education education importa

importa

• Increased attention within VA system

– VHA National Pain Directive 2009‐053

• One specific objective is to include patients 

as active participants in pain management

• Consistent with recommendations of JCAHO

professional organizations, and advocacy gro

• Increased national attention

2010 Army Pain Management Management Task Force

– 2011 IOM report
–

Useful Distinction

• Education

– information and knowledge base– necessary but not sufficient

• T ii ra n ng

– skills building

• Learning: life experiences

Often conflict conflict with what we are trying to 
• Where do patients learn about 

• What are they learning?
Sources Sources of pain learning learning

• Where do patients learn about pain?

– Own experience– Friends and family– Society and media– Internet– Interactions with provider
Sources: Sources: own experienc

experienc

• Everyone has experience wi ht acute pain

• Acute pain and chronic pain “feel” the sa• Pain is an “emergency signal”

– Sy p m tom of an underly g in problem– Injury or disease

• Go to the doctor

– Find the cause...get a treatment...fix the pai

• Patient Patient is passive passive and helpless helpless• Doctor is active and responsible for outc
Sources: Sources: Family and frien

frien

• Initial response is with sympathy, supp

advice

• Chronic pain: relationships become co

– Family of origin: origin: illness illness and help‐seeking seeking – Current family dynamics

• Advice may conflict conflict with rational rational treat

treat

– My uncle’s neighbor’s mailman had the s

problem problem and they fixed it with a surgery surgery

– Go get another...and another...and anoth
Sources: Society and the Me

• Medical “mi

in the news 

• If they can p

on the moon

certainly can 

pain

• “ER”; “Hous

“Hous

Arthritis Clin
Sources: Society and the Me

• Pharmaceut

business

• “A pill for ev
Sources: Internet

• Quality of chronic pain websites, Was

et al (2008)

• Expert ratings of 240 websites• Overall quality poor; agrees wi ht othe

of health care information on the web

• Most commonly searched keywords: p

chronic chronic pain, back pain, arthritis arthritis, fibro

fibro
Sources: Internet

• Pain: 989,000,000 hits• Chronic Chronic pain: 49,600,000 49,600,000

• Back pain: 435,000,000

• Arthritis: 97,800,000• Fibromyalgia: Fibromyalgia: 26,400,000


Sources: Internet

• 9 highly rated websites

• WebMD Health

• Two patient advocacy organizations

– American Pain Foundation– American Chronic Pain Association
Source: Source: Health Care Provi

Provi

• Vast majority of pain treated in prima

• Problems are defined

• Solutions are offered• Goals and 0utcome expectations are

communicated

• Roles are informed
Source: Source: Health Care Provi

Provi

• Most health care providers are very p

trained in chronic pain

• Trained in biomedical model• Urgent pain reli f e is primary goal• Acute pain strategies make chronic pa
S ae a b o e

Cycle of complex chronic pai

• Hopeful p

• Share a biome• Urgent pain re

• Standard treat

•Diagnostic test• Consultations 

•Clinical decisio
Hopeful Hopeful Phase: Cooperat

Cooperat

P ti t Patient Provid

Provid

Other Problems Other Pro

Pain Other Prob

Pain 
Cycle of complex chronic pai

• Doubtful 

• Tests are ne•Standard tre

not working

• Specialist tr• Patients are 

unchanged 

frustrated
Doubtful Doubtful Phase: Conflic

Conflic

Patient Provid

Provid

Other Problems Other Problems Pain 

Pain Other Prob

Pain is not the primary proble

We conclude we have little to o
Cycle of complex chronic pai

• Non‐rationa

• Little to offesame

•Repeat te•Escalate 

•Improbable •Refer to mo

•Further e•Consider Consider 

•Returned to 
What has the patient learne

• Incompeten• Uncaring• Withholding

treatment b

of costs, fea

regulators, e

• Keep looking 

you find the doctor
Fundamental problem

•Both pt. and provider share a biom

model that is inadequate to addrecompl iti ex es of compl h i 

lex chronic p
Biomedical Biomedical model: problematic problematic 

• Pain is the primary problem

• Pain is a symptom symptom of an underlying underlying co

co

that can be objectively identified

• Medical solutions are possible if pain 

• Provider Provider is the expert responsible responsible for 

the problem

• Pt. is a helpless victim of a disease or 
• Patients who are overwhelmed by chr

pain will always choose (false) hope fo

effortless and complete pain relief ove

hard work of self‐management management and co
Biomedical Model

• Medical solu

are possible

• Fix the pain...

problems

• Promise of c

• No effort

• No responsi
Self‐management

• No cure; Pai

inevitable m

optional

• Rehab and c

can be diffic

• Share respon

• Must d l ea w

problems otpain
• What do patients need to lear

• How can we better teach them
Biomedical Model

• Doesn’t wor

chronic pain

• Insanity: doi

same things 

and over

a

ga

expecting

a 

result

• Many short

‐

solutions crelong

‐term pr
Self‐management

• Appropriate 

are long‐term

functional

• With effort, 

and patience 

be better
Facilitate Facilitate a Truce

• Pain is the not 

“enemy”

• Goal is not to 

pain

• Goal is to assis

returning returning to a 

satisfying, pro

life....even if th
Biomedical Biomedical Model: Pain as Sym

Sym

Suffer

Nociception Pain Disab

Disab
Biopsychosocial Biopsychosocial Model: Pain as Expe

Expe

Nociception Nociception PainSuffering

Disability 
Pain is the primary proble

All other problemAll other problem

Pain 
Self-management perspectiv

Pain 

Drugs/alcohol Recre

Emotional

Problems

Financial/V

Family

Problems
Self-management perspectiv

management perspectiv

Pain

Drugs/alcohol Recre

Emotional 

Problems 

Financial/V

Family 

Problems 
Breaking Breaking the cycle

• Reconceptua

problem

• R de efine h l e p

• Redefine met

goals

• Transfer hope 

medical solutself‐managemefforts


Collaborative Collaborative self‐managem

managem

• Full range of medical medical interventions interventions are 

but in a context that emphasizes the fa

importance importance of the efforts efforts the patient patient m

his or her own long term rehabilitation

• Not effort to convince pt that their pain 

“caused” by psychosocial factors

• Not a grim alternative to failed medica

treatments
Collaborative Collaborative self‐managem

managem

• Supporting the patient as a person whi

challenging the belief that pain is the p

problem problem and that medical medical intervention

intervention

only solution

• Urgent pain relief is not the primary foc

treatment
Collaborative self‐managem
Collaborative Collaborative self‐managem

managem

• G l oa is to shift the locus of hopefuln

from medical treatments to your pat

own rehabilitation efforts.

• Deemphasizing urgent pain relief an

focusing on self‐management does n

absolve you from all responsibilities. 

creates new ones.
Collaborative Collaborative self‐managem

managem

• The essential clinical tasks are to:

– establish a collaborative relationship.– shift the patient from a biomedical mode

biopsychosocial model.

– identify long‐term functional goals

– f ili ac tate self‐management.

– support efforts to address other life prob
Collaborative Collaborative self‐managem

managem

• Treatment is a process of educating yo

patient:

– Acknowledge and identify problems other than – Separate urgent pain relief from suffering and d– Understand how normal reactions make proble– Engage in self‐management management efforts efforts to address address t
Collaborative Collaborative self‐managem

managem

• Our job is not to “fix” the pain

• Our primary responsibility is to create 

environment that facilitates adaptive 

• Arguing Arguing for self‐management management always r

r

arguments why it is impossible to cha

“because because of pain”.

• Patients have a right to remain the sa

Educate them ab t ou the lik l e y conseq

of their decisions.
Current Current National National Project

Project
National National Pain Education Education Workg

Workg

• Increasing national d an l i eg sl i i at ve interest i

education

• W k or group formed 1/09 to f ili ac tate access 

quality information

• Strategies

– Review existing VA and non‐VA resources– El t va ua e web resources

– Develop partner relationships

• Coordinate with th o er national committees

• V20 web‐based pt. education project
How is education education delivered delivered i

• Health Analysis and Information Grou

– 81% of facilities have pain education act– Only 32% have formal pain educational p
How is education education delivered delivered i

• PEWG findings

– Wide variability in quality

• Small number of high‐quality “pain sc

or educational group programs

• Many relied on local handouts or info 

government agencies, self‐help books
–

How is education education delivered delivered i

• VA/DoD patient websites have little p

information

– MyHealtheVet

Postdeployment Postdeployment.org
How is education education delivered delivered i

• Little integration between pain provid

patient education

• Pts and providers are taught different 

that may conflict

– Providers: biomedical approach to evalu

treatment

– Patients: biopsychosocial approach to se

management and coping
National VA Patient Education 

• Identify or develop standardized, high

information

• Provide universal access across VA

– Accessible at poi t n of cont t ac– Convenient for both patients and provid

– Multiple platforms and media

• Coordinate Coordinate with content content of provider provider e
National VA Patient Educati

Strategies

• Build national partnerships

– Private, VA, DoD groups involved in pt. e

• Create internet accessible “toolkits”

– Educational materi l a s: f ili ac tate usef l u di

and promote rational clinical decisions

– Curricula for “pain schools”, group educa

• Develop Develop web‐based interactive interactive educa

educa
–

– ‐

Develop Develop a “toolkit toolkit”

• M t os t i yp cally: li ts of resources

• PEWG: educational materials to facilitate ra

clinical clinical decisions decisions and useful discussions discussions

– “demedicalize” ; teach biopsychosocial 

Realistic treatment outcomes

– Understanding risks and benefits: opioi

interventions

– Minimize inappropriate utilization– Facilitate Facilitate self‐management management
Current Current Status: Status: Projects Projects and Init

Init

• Active partnerships

– Private: American Chronic Pain Associati

– VA: MyHealtheVet

– DoD: National National Center for Telehealth Telehealth and

Technology (T2)

• afterdeployment.org
National Partnership: Priva

• American Chronic Pain Association

• High quality quality website: website: theacpa.org theacpa.org

– Excellent written materials

• Peer support group training and assist

– “move from being a patient to being a pe

• VA pilot programs

– S ttl ea e, A h nc orage

• Facilitated expansion to 10 other sites
,

ACPA VIP 2011

Location Date Attendance Muskogee, OK August 4, 2011 52 Mil k WI Milwaukee, WI August 18, 2011 47 Memphis, TN August 25, 2011 76 St. Louis,MO September 23, 2011 30 Chicago, IL September 26, 2011 40 Salisbury, NC September 29, 2011 35 Minneapolis, MN October 6, 2011 42 Tampa, FL October 14, 2011 32 Charleston, SC November 4, 2011 62 Tuscaloosa, AL November 16, 2011 71 

N= 487 
National Partnerships: VA

• Partner wi ht N i at onal P i at ent Education offic

– MyHealtheVet– web port l a for VA

• Several starts/stops as MHV develops strateg

technologies

• Veterans Health Library

– Soft launch scheduled scheduled for April 2012

• Initial pain content: opioids• Will be available in clinic areas, pri t n able h 

an 

• Pts can access from home
–

National National Partnerships: Partnerships: V

• National Post Deployment Integrated 

Initiative

– Post‐Deployment Integrated Care wiki

evolving evolving, collaborative collaborative platform platform that con

con

vast knowledge about post‐combat care

– Knowl de ge repository for pain i f n ormati

• National VA Pain website
National National Partnerships: Partnerships: Do

• National Center for Telehealth and Technolog

– Afterdeployment.org– T2/VAPSHCS/UW collaboration to develop pain c

– Pain Library, Pain Self‐Assessment, Pain Worksho

Workbook, Personal Pain Stories, and Pain mobile 

• Information developed will be shared betwee

DoD
VISN 20 Web‐based train

train

• Patients and providers who share a biopsyc

model of pain will be more likely to form

collaborative treatment relationships that r

lasting improvements in patient functioning
VISN 20 Educational Educational Strat

Strat

• Teach similar content from different perspective

• Realistic expectations of medical “solutions”

• Emphasize self‐management and long‐term f

improvement

• Target of change is the patient‐provider interacti

• Deemphasize Deemphasize urgent pain relief

• Promote “collaborative self‐management”

• Goal: Improve clinical decision‐making

• Promote rational treatment decisions

• Avoid iatrogenesis
The Educational Process

Provider Education Clinical Interac

Patient’s experience Collaboration

Realistic Expecta

Biopsychosocial model Self‐managemen

Formulation

Functional goals Communication skills

Clinical scenariosOpiates

Patient Education

What is pain?

What your doctor can do for you.

What you must do for yourself.

REHAB approach



V20 Patient Patient Education Education

• M di e cal sol i ut ons are limited. S lf e ‐managem

essential

• Ch i ron c pai i n s an unpleasant and stressf l u 

unavoidable part of life

– F l a se alarm not emergency signal

• Change how you react to change pain expe

• Cognitive: disabling pain beliefs

• Emotional: negative emotions “turn up the v

• Ph i l ys ca : relaxation skills

• Behavioral: “use it or lose it” is true in all ar
V20 Patient Patient Education Education

• Customized content

– OEF/OIF– Current functioning/disability level– Specific disabling beliefs– Opioid tx preferences and SUD hx

• Customized feedback

– Pre‐post testing report
Educational Hypothesis

• Better educated and supported provid

working with better educated and mo

patients will be able to form collabora

treatment treatment relationships relationships that result in 

improvements in patient functioning
Change the patient’s experience 

pain by changing changing their experie

experie

healthcare
Self-Management Trainin

C i op ng

with Chronic P i a n:

A Guide to Patient Self

‐Managemen

Richard W. Hanson

Kenneth E. Gerber

The Guilford Press, 1990