Treating Patients with Chronic Pain

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Treating Patients with Chronic Pain

• OPA Convention February 22, 2009
• Rhonda Nemeth, Ph.D., C.Psych.

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Chronic pain vs. Pain Disorder

• Impact on life
• Emotional status
• Secondary gain

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Pain Disorder vs. Motivational Issues

• Pain not significant.
• Secondary gain of greater importance.
• Marked discrepancy between report of function and
  assessment findings.

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Pain Disorder combined with other factors

• Depression
• PTSD
• Anger/Resentment
• Lack of interest to change

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Traditional Psychotherapy vs. Rehabilitation

• Psychoeducation
• Self-management
• Client variables
• Motivation to change
• Third party payment
• Cognitive sophistication
• Time frame
• Role of supportive therapy
• Relapse prevention

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Psycho-Social Factors Affecting Rehabilitation

• Attitudes and Beliefs
• Behaviors
• Compensation Issues
• Diagnosis / Treatment
• Emotions
• Family/Friends
• Work

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New Zealand Guidelines Group

• www.nzgg.org.nz
• Focused on the delivery of high quality health
  care and disability services through a change in
  culture based on evidence and effectiveness.
• 13 points for early behavioral management of low
  back pain.

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Attitudes and Beliefs about Pain (Yellow Flags)

• Pain is harmful/disabling?gaurding
• Pain must be eliminated
• Expectation of more pain with activity
• Catastrophizing
• Pain is uncontrollable
• Passive approach toward rehabilitation

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Behaviors (Yellow Flags)

• Excessive rest or downtime
• Avoidance of usual activity and lifestyle
• Irregular physical exercise poor pacing
• Extremely high pain ratings
• Excessive reliance on aids
• Poor sleep quality
• Self medicating

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Compensation Issues (Yellow Flags)

• No financial incentive to return to work
• Delay in receiving income support
• History of prior claims due to other injuries or
  pain problems
• History of extended time off work due to injury
  or pain
• History of same pain problem
• Prior ineffective case management

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Diagnosis and Treatment (Yellow Flags)

• Provider sanctioning disability, not providing
  intervention to improve function
• Conflicting diagnoses or explanations for pain
• Diagnostic language leading to catastrophizing

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Diagnosis/Tx continued (Yellow Flags)

• Multiple visits to provider in past year
• Expects a cure due to belief that everything can
  be fixed
• Dissatisfaction with previous treatment
• Advice to quit job

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Emotions (Yellow Flags)

• Fear increased pain with activity/work
• Low mood, loss of enjoyment
• Irritability
• Hypervigilant of body sensations
• Feeling stressed loss of control
• Social anxiety or disinterest
• Feeling useless and unneeded

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Family (Yellow Flags)

• Overly protective
• Overly solicitous
• Punitive
• Non-supportive of return to work
• Lack of support to discuss problems

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Work (Yellow Flags)

• Shift work
• No opportunity for graduated return to work
• Negative experience of management dealing with
  pain problems
• No interest from employer

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Identifying Those at Risk

• Gather information pertaining to potential yellow
  flags.
• Will justify treatment.

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Questions to Ask

• What do you understand to be the cause of your
  pain?
• What are you expecting will help?
• How is your employer responding to your pain?
  Your co-workers? Family?

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Questions continued

• What are you doing to cope with pain?
• Do you think that you will return to work? When?
• What stops you from returning to work?
• How has your mood been lately?
• What are you doing everyday?
• Any problems with the insurer?

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Psychological Reports

• Should reflect the yellow flags.
• Should include tests of effort/motivation. and/or
  have one test with strong validity scales.
• History
• Family
• Education, work
• Personality

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Treatment Components

• Cognitive
• Emotional
• Interpersonal
• Physical

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Work with others to give patient the green
light.
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Treatment Modalities

• CBT techniques
• Relaxation mindfulness meditation
• Interpersonal therapy
• Assertiveness training
• Exercise and diet monitoring pacing
• Sleep hygiene
• Motivational interviewing

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Treatment Plan (OCF-18)

• Number of sessions
• Complexity
• Motivation
• Describe components
• Coordination with other providers
• Psychoeducation material
• Homework
• Educate Insurer prior to submitting

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Case Examples