Session #A3a
Friday, October 17, 2014
A Six-Session Evidence-Based Protocol for the
Treatment of Individuals with Chronic Pain in a
Primary Care Setting
Abigail Lockhart, PsyD, Postdoctoral Psychology Fellow
Laurie Ivey, PsyD, Clinical Psychologist
Samantha Monson, PsyD, Clinical Psychologist
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships during the
past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Describe a brief six-session individual treatment intervention that
can be implemented by Behavioral Health Providers in integrated
care settings.
• Describe how to facilitate improved communication with the
patient’s PCP and other PCMH treatment providers in order to
promote collaborative models of care.
• Identify strategies for recruiting patients in primary care.
• Describe how to support patients develop sustainable life changes
after the six sessions are complete.
Bibliography / References
Carlson, M. (2014). CBT for Chronic Pain and Psychological WellBeing: A Skills Training Manual Integrating DBT, ACT,
Behavioral Activation and Motivational Interviewing. John
Wiley & Sons.
McCracken, L. M., Sato, A., & Taylor, G. J. (2013). A trial of a brief
group-based form of acceptance and commitment therapy
(ACT) for chronic pain in general practice: pilot outcome
and process results. The Journal of Pain, 14(11), 13981406.
McCracken, L.M., & Vellman, S.C. (2010). Psychological flexibility in
adults with chronic pain: A study of acceptance,
mindfulness, and values-based action in primary care.
Pain, 148: 141-147.
Vowles, K.E., & Thompson, M. (2011). Acceptance and Commitment
Therapy for chronic pain. In L.M. McCracken (Ed.)
Mindfulness and acceptance in behavioral medicine:
Current theory and practice (pp. 31-60). Oakland: New
Harbinger Press.
Wetherell, J.L. et al. (2011). A randomized, controlled trial of
acceptance and commitment therapy and cognitivebehavioral therapy for chronic pain. Pain, 152: 2098-2107.
Learning Assessment
• A learning assessment is required for CE
credit.
• Question and answer opportunities will be
incorporated throughout this presentation.
Prevalence of Chronic Pain
Condition
Number of Sufferers
Source
Chronic Pain
100 million Americans
Institute of Medicine of The National Academies (2)
Diabetes
25.8 million Americans
American Diabetes Association (3)
(diagnosed and estimated
undiagnosed)
Coronary Heart
Disease
(heart attack and
chest pain)
Stroke
16.3 million Americans
Cancer
11.9 million Americans
American Heart Association (4)
7.0 million Americans
American Cancer Society (5)
American Academy of Pain Medicine, Get the Facts on Pain - http://www.painmed.org/patientcenter/facts_on_pain.aspx
Stats
 Pain is a significant public health problem that costs
society at least $560-$635 billion annually
Institute of Medicine Report: Relieving Pain in America: A Blueprint for Transforming
Prevention, Care, Education, and Research, 2011
 Worldwide, up to 22% of primary care patients suffer
from chronic debilitating pain*
 53% of chronic pain patients treated on an ongoing
basis are treated by primary care physicians*
* By the Numbers: Pain Management and Primary Care Published Online: Wednesday,
June 27th, 2012. www.painlive.com
Colorado Medicaid Study
 Nearly 15,000 Medicaid patients in Colorado had one or
more of those traits in the year analyzed, which put them
at a risk of overdose from 9- 14 times higher, depending on
the trait exhibited
 At least 1 of those traits showed up in 174 Medicaid
patients who overdosed in the year studied
 556 beneficiaries, 15 of whom overdosed, had all 3 traits
Evidence Base
•
“When added to usual care, both ACT and CBT can improve pain
interference, depression, and pain-related anxiety in individuals with chronic
pain.”
Wetherell, J.L. et al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral
therapy for chronic pain. PAIN, 152: 20982107.

3.
Standardized instruments
Brief Pain Inventory (Short Form)
PHQ-9
GAD-7

Intra-patient data collection
1.
2.
Collaborative Model of Pain
Management
PATIENT CULTURE
PAIN
PARTNERS
PROVIDER
PATIENT
PATIENT
PARTNERSHIP
 Perspective of letting the patient be the guide to ensure
productive outcome
 Facilitation of communication amongst the team
PROVIDER PARTNERSHIP
PROVIDER






Helpful when providers partner (decreases dread)
Co-consult with patient beginning, middle, end
Intervention most effective if physician partners
Reinforcing skills AMAP
Checking in with patient on what is most helpful
Supportive partnership/stance in decreasing/maintaining
medications or eliminating opiates—holding the Rx line!
CULTURE
1.
2.
3.
4.
CULTURAL
PARTNERSHIP
What do you think caused(s) the pain (problem)?
Has anyone else helped you with this pain (problem)? How so?
Are there things that help you that our doctors don’t know about?
What kind of treatment do you think you should receive?
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical
lessons from anthropologic and cross-cultural research. Annals of Internal
Medicine, 88(2)
CULTURE
CULTURAL
PARTNERSHIP
Through attuned questioning, you may find…
…pain = distress (e.g., trauma response).
Session 1


Introduce 6 session outline
Partnership Goals, including goals of the intervention: To develop
a curiosity for engaging with pain in an alternative way
 Screening Tools
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
4. Culture Questions
5. Assess physician/team relationships & lay framework for team



Review BPI with patient, focus on how pain is interfering with the
patient’s functioning
Discuss difference between acute pain and chronic pain
Homework – Complete Valued Living Questionnaire
Session 1


Introduce 6 session outline
Partnership Goals, including goals of the intervention: To develop
a curiosity for engaging with pain in an alternative way
 Screening Tools
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
4. Culture Questions
5. Assess physician/team relationships & lay framework for team



Review BPI with patient, focus on how pain is interfering with the
patient’s functioning
Discuss difference between acute pain and chronic pain
Homework – Complete Valued Living Questionnaire
Shared Pain Management
Plan: Session 1
1.
Relay culture
question answers
2. Medication goals
(maintenance,
decrease, other)
Session
2
 Review Valued Living Questionnaire
 Develop functional goals based on individual responses on Valued
Living Questionnaire
MIND/BODY CONNECTION
 Negative emotions and pain – pathways intersect in the brain
 A-B-C Model
 How you think about pain, it is the way you are going to feel
 What are your beliefs about pain?
 What can you do to help?
 Keep your mind busy, Self-talk
 Explore thoughts and emotional reactions to sensations in the body
– Introduce body scan
 Homework – Body scan
Session
2
 Review Valued Living Questionnaire
 Develop functional goals based on individual responses on Valued
Living Questionnaire
MIND/BODY CONNECTION
 Negative emotions and pain – pathways intersect in the brain
 A-B-C Model
 How you think about pain, it is the way you are going to feel
 What are your beliefs about pain?
 What can you do to help?
 Keep your mind busy, Self-talk
 Explore thoughts and emotional reactions to sensations in the body
– Introduce body scan
 Homework – Body scan
Shared Pain Management
Plan: Session 2
1.
Values
2. Functional goals

Screening Tools
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
Session 3
Gate Control Theory of Pain


Current stressors that may exacerbate pain
Role of sleep in the management of chronic pain


Adaptive vs. Maladaptive Coping Skills




Discuss Sleep Hygiene and provide handout
Evaluate beliefs about medications, opiate use, illicit drug use
What adaptive coping skills are you already using?
Review “A-B-C’s” (Adding Pleasure, Building Mastery, Coming Back to
the Present Moment)
Homework - Pleasant and unpleasant events calendar
Session 3

Screening Tools
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
Gate Control Theory of Pain


Current stressors that may exacerbate pain
Role of sleep in the management of chronic pain


Adaptive vs. Maladaptive Coping Skills




Discuss Sleep Hygiene and provide handout
Evaluate beliefs about medications, opiate use, illicit drug use
What adaptive coping skills are you already using?
Review “A-B-C’s” (Adding Pleasure, Building Mastery, Coming Back to
the Present Moment)
Homework - Pleasant and unpleasant events calendar
Shared Pain Management
Plan: Session 3
1.
Barriers Identified
2. Plan to address
Session 4
 Review pleasant events scheduling homework
 Discuss barriers
 Increasing Positive Experiences
 Nutrition
 What foods should be avoided
 Drink recommended amount of water
 Avoid alcohol and nicotine
 Exercise
 Discuss current activity level and explore barriers
 Why exercise helps
 Alternative ways to be active
 Homework – Build in at least one new activity to pleasant
events calendar
Session 4
 Review pleasant events scheduling homework
 Discuss barriers
 Increasing Positive Experiences
 Nutrition
 What foods should be avoided
 Drink recommended amount of water
 Avoid alcohol and nicotine
 Exercise
 Discuss current activity level and explore barriers
 Why exercise helps
 Alternative ways to be active
 Homework – Build in at least one new activity to pleasant
events calendar
Shared Pain Management
Plan: Session 4
1.
Gains/Positive
experiences to date
Session 5
 Review new activity homework, address barriers
RELAXATION
 Why relaxation helps
 Review and practice relaxation strategies
 Diaphragmatic breathing
 Guided imagery
 CALM exercise
BUILDING NETWORK OF SUPPORT
 Tree of support exercise
 Homework – Schedule time to practice relaxation strategies
Session 5
 Review new activity homework, address barriers
RELAXATION
 Why relaxation helps
 Review and practice relaxation strategies
 Diaphragmatic breathing
 Guided imagery
 CALM exercise
BUILDING NETWORK OF SUPPORT
 Tree of support exercise
 Homework – Schedule time to practice relaxation strategies
Shared Pain Management
Plan: Session 5
1.
Additional gains
2. Ongoing support
team & plan for
future


Session 6
Review homework
Final session screenings
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
SUSTAINING CHANGE
 Create plan for addressing barriers to sustaining change (e.g.,
flare-ups and bad days)
 How to involve your network of support
 How to utilize your PCP

Homework – Talk to at least one person in your support
network about how they can help you stay on track


Session 6
Review homework
Final session screenings
1. Brief Pain Inventory (Short Form)
2. PHQ-9
3. GAD-7
SUSTAINING CHANGE
 Create plan for addressing barriers to sustaining change (e.g.,
flare-ups and bad days)
 How to involve your network of support
 How to utilize your PCP

Homework – Talk to at least one person in your support
network about how they can help you stay on track
Shared Pain Management
Plan: Session 6
1.
Additional gains
2. Ongoing support
team continued….
Patient Pearls
 I have worked with a number of different mental health
providers and no one has ever asked me about my pain.*
 By asking me to participate in this intervention, you really
validated my pain and how much it impacts my health.*
•
Paraphrased from patient interactions
Pearls combat Dread
Resources for Patients
 Managing Pain Before It Manages You, 3rd Edition by
Margaret Caudill, MD, PhD, MPH
 Get Out of Your Mind and into Your Life: The New
Acceptance and Commitment Therapy by Steven
Hayes, PhD
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!