Integrated Models of Care: Pain Management Robert D. Kerns, PhD National Program Director for Pain Management, VACO Chief, Psychology Service, VA Connecticut Professor of Psychiatry, Neurology and Psychology, Yale University

Integrative care

Psychology, psychologists, and pain management  Primary models of pain perception emphasize the central role of psychological factors  Role of psychological factors in the development and perpetuation of persistent pain is universally accepted  Psychological interventions for pain management are accepted as efficacious and cost-effective  Approximately 20% of members of IASP and APS are psychologists  Current president of APS is Dennis Turk, a psychologist  Goal of VHA National Pain Management Strategy is to incorporate an interdisciplinary, multimodal approach to pain management

Efficacy of psychological interventions for chronic pain  Meta-analysis of RCTs of psychological treatments for clbp  Effect sizes were calculated from 22 RCTs  Positive effects of psychological interventions, relative to numerous control conditions, were noted for pain intensity, interference, quality of life, and depression  Cognitive-behavioral and self-regulatory treatments were found to be efficacious  Multidisciplinary treatments that included psychological interventions had positive long-term effects on return to work

Integrative model of pain care  Stepped care approach to pain management –Level one: Primary responsibility rests with primary care providers –Level two: “Living with Pain Class”  Patient education and rehabilitation model –Review of common pain conditions –Personal review of medications –Discussion of self-management model –Personalized exercise plan –Practice of self-regulatory pain strategies, e.g., breathing, relaxation, activity pacing –Level three: Comprehensive Pain Management Center

Comprehensive Pain Management Center at VA Connecticut  Integrative clinical, research, and training program  Interdisciplinary staff  “Virtual Clinic”  Primary Care Clinic integration  Primary roles of psychologists –Conduct comprehensive pain assessments –Development and enactment of integrative treatment plan –Care coordination –Primary clinician in delivery of psychological treatment –Assessment of outcomes –Education and training –Research

Targets for improvement Improved access Improved access Successful engagement Successful engagement Reduced drop-out Reduced drop-out Enhanced adherence to treatment recommendations Enhanced adherence to treatment recommendations Maintenance of treatment gains Maintenance of treatment gains Relapse prevention Relapse prevention

Ongoing research  Targeting these areas for improvement –Refine CBT to promote engagement, adherence, and outcomes –Refine CBT for special populations  Elderly  Women with vulvodynia  Painful diabetic neuropathy  MS-related pain –Investigate treatment process variables  Readiness for self-management of pain

Refining processes of referral and engagement Education/Training of primary care providers Education/Training of primary care providers  Knowledge and attitudes about self-management treatments  Patient-centered counseling/Use of motivational interviewing techniques  Respond to patient concerns and beliefs that are incongruent with adoption of a self-management approach  Endorse self-management treatment and goals  Assure follow-up and continued coordination of care

Training primary care providers Brief educational session Brief educational session  Relevance of self-management and rehabilitation approaches  Overview of multidisciplinary pain center  Review of pathway for referral Group training followed by individual consultation Group training followed by individual consultation Use of modeling (video) VIDEO_TS.IFO Use of modeling (video) VIDEO_TS.IFOVIDEO_TS.IFO

PRIME-CBT Based in a primary care setting Based in a primary care setting Collaboration with primary care practitioner (PCP) Collaboration with primary care practitioner (PCP) Explication of referral process Explication of referral process PCP education and training PCP education and training Modifications to CBT Modifications to CBT

Refining self-management treatment Collaborative sessions involving primary care provider Collaborative sessions involving primary care provider Explicit attention to readiness to adopt a self-management approach Explicit attention to readiness to adopt a self-management approach Use of stage-matched tasks and processes of change (e.g., consciousness raising with “precontemplators”, increasing support for “strivers”) Use of stage-matched tasks and processes of change (e.g., consciousness raising with “precontemplators”, increasing support for “strivers”) Use of motivational interviewing strategies (expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy) Use of motivational interviewing strategies (expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy)

Results of PRIME CBT study Both CBT (n=33) and PRIME CBT (n=33), relative to TAU (n=23), demonstrated significantly greater improvements on measures of pain, disability, and emotional distress Both CBT (n=33) and PRIME CBT (n=33), relative to TAU (n=23), demonstrated significantly greater improvements on measures of pain, disability, and emotional distress PRIME CBT, relative to CBT, resulted in: PRIME CBT, relative to CBT, resulted in:  significantly increased adherence to weekly homework and goals  significantly greater goal accomplishment  significantly greater patient satisfaction Mean percent intersession adherence for PRIME CBT was approximately 70% Mean percent intersession adherence for PRIME CBT was approximately 70%

Tailored CBT CBT as inherently flexible approach that accommodates to “prescriptive treatment planning” CBT as inherently flexible approach that accommodates to “prescriptive treatment planning” Assess patient preferences for learning specific pain coping skills Assess patient preferences for learning specific pain coping skills “Tailor” CBT on the basis of patient preferences “Tailor” CBT on the basis of patient preferences Employ motivational interviewing techniques to encourage “forward stage movement” or enhanced readiness to adopt specific pain coping skills Employ motivational interviewing techniques to encourage “forward stage movement” or enhanced readiness to adopt specific pain coping skills