Leveraging Cognitive-Behavioral
Approaches to Pain Management
August 2009
April 2009
Andrew Bertagnolli, PhD
Netta Conyers-Haynes,
Senior Consultant – Behavioral Medicine
Principal Consultant, Communications
& Pain Management
Disclosure
Andrew Bertagnolli, PhD has no financial
interest or other relationship with the
manufacturers of any commercial
product and /or providers of commercial
services discussed in this educational
presentation nor with any commercial
supporters of this course.
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Tasks for Patients with Chronic
Conditions
•Self-Managing the Illness
•Taking medications
•Monitoring the illness
•Carry on Normal Roles and Activities
•Manage the Emotional Impact of the Illness
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Self-Management: What is it?
Self-management is defined as the tasks that
individuals must undertake to live with one or more
chronic conditions.
These tasks include having the confidence to deal
with medical management, role management and
emotional management of their conditions
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Current State: Biomedical Model
Predominant Focus on Physical Processes:
•Pathology of the Illness
•Biochemistry of the Illness
•Physiology of the Illness
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Biopsychosocial Model
Predominant Focus on Complex Interaction Between:
•Biology (physiology, pathology, biochemistry)
•Psychology (thoughts, feelings, behaviors)
•Society (socioeconomics, culture, technology)
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Model for Chronic Pain Management
CMI Clinical Practice Guidelines (2003)
Cognitive
Behavioral
Therapy
Pharmacological
Management
and Other Rx
Patient
Self
Care
Physical
Therapy
Complementary
& Alternative
Medicine
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Kaiser Permanente Pain Management
Complete Care
•Evidence-Based
•Patient-Centered
•Multi-Disciplinary
•Complete Continuum
•Emphasis on Self-Management
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Overall Treatment Approach
 In deciding the best treatment approach, the following should be
considered:
 Maximizing functional status
 Reducing pain
 Addressing associated symptoms (eg: sleep, fatigue and mood)
 Designing a treatment plan should involve an individualized
assessment and be multifactorial including:






Self-management
Physical activity/movement
Medications
Interventional approaches
Psychological approaches
Complementary-alternative (CAM) approaches
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Assumptions of Comprehensive Pain
Programs
•
•
•
•
Pain impacts multiple areas
No cure – must learn to manage
Hurt ≠ Harm
Improved function is goal
 not pain relief per se
• Self-management is key
• Multiple approaches are best
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Ripple Effect of Chronic Pain
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Comprehensive Pain Programs
Less intensive than FRPs
Grounded in biopsychosocial model
Integrate psychology, physical therapy,
medicine with self-management
High degree of case/care coordination
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What is CBT?
Psychological interventions designed change
behavior, thoughts or feelings, to help patients
experience less distress and satisfying and
productive lives
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Cognitive-Behavioral Treatment
 Standard psychosocial intervention for pain
 Short-term, structured, focused, goal-oriented
approach
 Flexible and able to be tailored to individual
patient needs
 Compatible with a range of other treatments
 Extensively evaluated in rigorous clinical trials
 has solid empirical support for use in pain management
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Predominant Themes
 Promotion of a self-management perspective
 Relaxation skills training
 Cognitive therapy

Cognitive restructuring or self-statement analysis
 Behavioral activation and management


Goal-setting and pacing strategies
Combat activity avoidance
 Problem-solving skills training
 Interventions modifying perception or emotional
response to pain,

Guided imagery, desensitization, hypnosis, or attention control exercises
 Communication skills training or family interventions
 Habit reversal
 Maintenance and relapse prevention
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Cognitive-Behavioral Model
Thoughts
Behaviors
Feelings
Symptoms
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More than a set of techniques
 Use as organizing strategy for rehabilitation
 Example: Difficulties that arise during physical
therapy
 Only due to physical limitations?
 Also due to anticipatory fear regarding increased pain
or injury
 Need to address both performance of physical
therapy exercises and body mechanics, but also
patient’s expectancies and fears
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Cognitive-Behavioral Model
“Why am I having this pain?”
“This pain means I have injured
myself!”
Increased Isolation,
Decreased Activity
Depression, Anxiety,
Fear, Anger
Increased Pain, Insomnia
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What is Progress?
Emphasize small steps
Use changes in functional improvement
Focus on small changes
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revised gli 10/02/2003
Pros & Cons to CBT
Pros
 Relatively-low cost
 Compatible with other
interventions
• Physical Therapy,
• Pharmacotherapy
 Promotes self-management of
a chronic condition
 Strong empirical support
Cons
 Not suitable for patients with
moderate to severe cognitive
impairment
 Requires sustained and active
patient participation
 Requires psychologists with
specialized training
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Criteria for Success?
Depends From Who’s Vantage Point
Society
Workers
Compensation
Return to Work
Healthcare Utilization
Managed Care
Organizations
Functional, Emotional
Improvements
Healthcare
Provider
Satisfaction
Low Adverse
Events
Individual
Pain
Relief
Gatchel & Okifuji (2006) Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of
Comprehensive Pain Programs for Chronic Nonmalignant Pain. Journal of Pain. 779-793.
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Data: Comprehensive Pain Programs
 Pain Reduction:
 20-30% on average
 30% on average with opioids alone
 Increased Activity:
 65% increase
 35% conventional care
 Return to Work:
 66% RTW
 27% conventional therapies
 Healthcare Utilization
 33% reduction overall
 15% subsequent surgery
 Approximately 50% in TAU
 Medication:
 22% use medications at 1 year
 75% use medications at 1 year
Mayer, et al (1987) Prospective two-year study of functional restoration in industrial low back pain . JAMA
Patrick, et al (2004) Long-term outcomes in multidiscplinary treatment of chronic low back pain. Spine
Hazard, et al (1989) Functional restoration with behavioral suppot: A one-year prospective study of patients with chronic low-back pain. Spine
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Meta-Analysis
Morely, Eccleston& Williams (1999)
 25 trials included
 Across a variety of common, non-headache, conditions
 CBT vs. wait-list control
 Dependent variable domains






Pain experience
Mood
Cognitive-coping & appraisal
Pain behavior
Physical Activity
Social role functioning
 Results
 CBT were superior across all domains
 Grand mean effect size of 0.46
Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of
cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.
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What’s the Evidence for Other Treatments?
• Epidural Steroids
 No strong evidence for or against any type of injection therapy
for subacute or chronic low-back pain (Cochrane Review 2008)
• Spinal Fusion
 Moderate evidence that instrumentation can increase the fusion
rate, but any improvement in clinical outcomes is marginal
(Cochrane Review 2005)
• Opioids
 Despite concerns about addiction and diversion there are no
studies that identify those for whom benefit will exceed risk
versus those for whom risk will exceed benefit (Cochrane
Review 2008)
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Spinal Fusion vs CPP
•
•
•
•
•
•
•
N=349
Chronic low back pain > 1 year
Randomized
Spinal fusion
Chronic pain program
24 month follow-up
Measures
 Oswestry
 Short Form 36 (SF-36)
• Both groups improved
• No evidence that surgery had greater outcome
Fairbank, et al (2005) Randomized controlled trial to compare surgical stabilisation of the lumbar
spine with an intensive rehavilitation programme for patients with chronic low back pain: The
MRC spine stabilisation trial. British Medical Journal
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Model for Chronic Pain Management
CMI Clinical Practice Guidelines (2003)
Cognitive
Behavioral
Therapy
Pharmacological
Management
and Other Rx
Patient
Self
Care
Physical
Therapy
Complementary
& Alternative
Medicine
26
Partnership with American Chronic Pain
Association
Began in August 2007
Currently have 6 groups running


Southern California (4 English & 1
Spanish)
Mid Atlantic (4 English)
Hosted at KP facilities
KP members trained to be group
facilitators
KP members encouraged to attend
after discharge from intensive pain
management programs
Beginning to explore promotion to
community at large
KP staff comments:


Overall, both internally and with our
members, this has been a very
successful and beneficial
partnership.
Remain enthusiastic about the
concept and potential.
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www.kp.org/pain
Self Management
Programs
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Care Pathway Including CFP
Level 3 Services
(Chronic Pain Case
Mgmt Programs)
Level 2 Services
(Chronic Pain Care
Programs)
Incorporate into Discharge Plan
Care for Pain
Level 1 Services (Primary
Care)
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Keys for Success
Educate patient about their condition
provide consistent information
provide a diagnosis where possible
educate regarding difference between acute and chronic pain
partner with patient to help improve their function
goal is pain MANAGEMENT not total pain relief
acknowledge that this can be a difficult task
Develop a treatment plan
Assess chronic pain from a biopsychosocial perspective
Identify objective markers of function as treatment goals
Emphasize that treatment needs to be multidisciplinary and multimodal
May need to frequently remind patient of the goal of improved function
rather than being pain free
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Keys for Success
Encourage maximum levels of function
determined by objective physical limitations, rather than perceived
pain

Restore physical conditioning


gradually
systematically with specific exercise prescriptions
Do not treat chronic pain as a medical emergency


remain calm and dispassionate, yet supportive
dispel errant beliefs and fears
Seek multidisciplinary consultation from specialists
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Is It Worth It All?
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Questions & Comments?
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Andrew Bertagnolli, PhD
Kaiser Permanente – Care Management Institute
1 Kaiser Plaza, 16th Floor
Oakland, CA 94612
510-271-5771
andrew.bertagnolli@kp.org
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