By: Shannon Perkins, PhD; Brooke Babyak, MD; and Tessa Wilson, MSW
Reprinted from the fall 2019 issue of The Ohio Family Physician.
Patients with non-malignant chronic pain frequently present in the primary care setting. One survey of primary care physicians reported over a third of outpatient encounters involved a complaint of chronic pain.1 The estimated prevalence of chronic pain in adults in the United States is between 11% and 40% and has an estimated cost between $560-635 billion in 2010.2,3 Because of the complexity of the disease, multiple treatment modalities exist and have been studied. Many of the non-pharmacological treatments for chronic pain involve behavioral health interventions. These have been found to reduce pain, disability, psychological distress, and catastrophizing thoughts.4 Additionally, group therapy has demonstrated the strongest benefits.5
Summa Health Family Medicine Center (FMC) has developed “All the Care You Need is Here,” a comprehensive program for integrated behavioral health (IBH) for chronic medical and behavioral health conditions. We have recently developed and launched “Living with Pain (LWP)”, an IBH pain management program which focuses on tracking and monitoring our patients receiving long-term opioid therapy (LTOT), and incorporating psychoeducation and cognitive-behavioral coping skills into their care. Summa FMC is requiring all patients on LTOT to participate in this program. This program is optional and encouraged for patients with chronic pain who are not on LTOT.
The LWP program involves attending one behavioral health (BH) interview annually, three group therapy sessions annually, and IBH services during their physician appointments. Nursing and BH staff keep a registry of all patients on LTOT. Policies and patient contracts were updated to reflect required participation in LWP. Patients deemed not appropriate for group participation are able to attend individual sessions instead.
The LWP initial or annual interview is a comprehensive psychodiagnostic interview conducted by the behavioral health counselor (BHC). We ask detailed questions about the patient’s pain, including the intensity of pain on a 0-10 scale, location of pain, duration of symptoms, qualities of pain (e.g., dull, sharp, stabbing, etc.), how pain impacts everyday life, factors that make pain better or worse, and past treatments for pain. We also assess for comorbid mental health and/or substance use disorders, as well as history of traumatic events.
Patients attending the initial or annual LTOT visits complete several self-report measures, in addition to the LWP interview. The Quality of Life Scale6 is a quick 0-10 rating of the patient’s overall quality of life and functioning. The pain, enjoyment, general activity (PEG) scale7 asks patients to rate their average pain in the past week, and the degree to which pain has interfered with their activities and enjoyment of life. The Pain Catastrophizing Scale8 assesses thoughts and feelings related to pain. The Pain Outcomes Profile9 evaluates the impact of pain on daily functioning. The Patient Health Questionnaire10 screens for depression. The Primary Care PTSD Screen for DMS-511 screens for post-traumatic stress disorder. The Alcohol Use Disorders Identification Test12 is a commonly used screener for alcohol use disorders and we supplement this with two brief questions about drug use. The BHC scores these measures and keeps track of them in a database.
In creating our group curriculum, we consulted the therapist manual for the “Cognitive Behavioral Therapy for Chronic Pain Among Veterans”13 and revised the content to create curriculum for three group sessions. We anticipate expanding our materials to create content for additional group sessions over time.
Each group session begins with a discussion of expectations for group members. The first session educates patients about the biopsychosocial model of pain. It also orients participants to the Cognitive Behavioral Therapy for chronic pain model, which involves helping patients to understand the relationships between their thoughts, feelings, and behaviors. Patients are helped to adopt a problem-solving, action-oriented approach to coping with their chronic pain. Activity pacing is a fundamental concept introduced in the first session, which involves learning to balance exercise and rest to optimally manage pain.
In the second session, patients learn relaxation skills, such as deep breathing, progressive muscle relaxation, and guided imagery. Patients are also educated on sleep hygiene. The third session covers additional cognitive-behavioral coping skills, such as increasing awareness of negative thoughts related to pain and learning techniques to modify these thoughts. This session also encourages scheduling of leisure and recreational activities and explores how to overcome barriers to engaging in these activities.
BHCs then follow up with patients during their LTOT visits with their physicians to reinforce coping skills learned during group sessions. They also collaborate with the patient to help them set specific, measurable, attainable, relevant, and time bound (SMART) goals related to coping with pain and improving quality of life.
We have received positive feedback from our patients who have participated in the program. One patient, a 50-year-old woman who has struggled with chronic pain for much of her adult life, reports significant improvement in her everyday functioning. The sessions helped her to set small behavioral goals to improve her quality of life, such as caring for her appearance by putting on makeup daily, taking walks around the lake, and joining a gym. She is going to attend extra group sessions voluntarily with the goal of learning additional coping skills. She has been a valuable group member by engaging others in discussion and encouraging them to set their own goals.
In an ongoing effort to continue providing the best evidence-based care for our patients with chronic pain, we are participating in the Six Building Blocks of Safer Opioid Management program.12 Our participation in this program thus far has identified the need for provider and staff education in using patient-centered communication skills during potentially challenging discussions related to opioid safety, risks, and tapering, as well as engaging patients in discussions related to goal-setting and self-management of chronic pain. We will be working over the course of the next year to develop and implement this education.
Our longer term goals for continuing to develop our LWP program include the integration of osteopathic manipulation into LTOT and other chronic pain visits, as well as the integration of pharmacy, physical therapy, and occupational therapy into visits.
References available on the OAFP website.