1. Michael J. Lewandowski, Ph.D.
Non-Pharmacological Approaches to Chronic Pain
Michael J. Lewandowski, Ph.D.
History:
Who am I?
A good place to start today is with Pharmacological approaches
ACUTE PAIN You BET - shoulder surgery days I was glad to have opioids AND for my tension headaches Im glad to use IBUPROPHEN
BUT CHRONIC PAIN
Effectiveness = 50% and then 30%
Make this interactive – so ask questions
Clinical Associate Professor
Department of Psychiatry
School of Medicine
Adjunct Faculty Psychology Department
University of Nevada

2. Goal of Presentation: “Psychologically Informed Medical Practice”
MY GOAL TODAY IS TO CONVINCE YOU TO DEVELOP A
I THOUGHT OF AN EASY WAY To remember this but the acroymn DIDN’T Capture the message VERY WELL
KEY ISSUE IS INTEGRATION OF BEHAVIORAL HEALTH AND PRIMARY MEDICAL CARE
People who live with chronic illness and pain need to tell their story to their doctor. They need to be heard.
AND your need to know what YOUR patient is THINKING.
A term used in the Physical Therapist in 2011
Here are the reasons WHY TO DO THIS

3. Western Pain Society Meeting 2014 – Stanford University
Rewriting the Pain Equation: from Biopsychosocial to Sociopsychobiological
BACKGROUND: I was at Standford for the WESTERN PAIN SOCIETY meeting AND I HEARD DANIEL CARR speak
HE SAID WE NEED TO FLIP THE EQUATION
He made a valid point in this lecture: IT IS NOT FROM A MOLECULAR perspective (THE BIOLOGY) that we understand someone’s pain
Its from a contextual, social, environmental, cognitive and personal perspective.
I am here today to help you with NON_PHARMACOLOGICAL TOOLS TO HELP YOUR PATIENT WITH CHRONIC PAIN
Daniel Carr, MD Director Program on Pain Research, Education and Police Professor of Public Health and Community Medicine, Tufts University School of Medicine
Western Pain Society Meeting 2014 – Stanford University

4. Psychosocial factors appear to play a larger prognostic role than physical factors in low back pain.
changes in behavioral variables may be more important than physical performance factors for successful treatment of chronic low back pain.
Wessels T, van Tulder M, Sigl T, Ewert T, Limm H, Stucki G. What predicts outcome in non-operative treatments of chronic low back pain? A systematic review. European Spine Journal. 2006;15:1633–1644.

5. There is evidence to suggest that fear plays a significant role when pain has become persistent
ANXIETY AND FEAR (EMOTIONAL VARIABLES)
George SZ, Fritz JM, Childs JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38:50–58.

6. Psychological factors are predictors of chronicity and disability in people with low back pain.
Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976). 2002;27:E109–120

7. Identification of elevated psychosocial distress has been strongly linked to poor clinical outcomes in a variety of health care settings.
distress/depression plays an important role at early stages of low back pain

8. Physical distress, depression, and fear avoidance are well-defined psychosocial entities that are best assessed with specific screening tools.
With affordable care act, the integration of behavioral psychological services with primary health care is critical and expected.
In a direct access environment, YOU ARE the patient's first contact regarding their current condition.
Collaboration and integration of services is what is going to be required in health care future.

9. Screening Tools MSQS STarT ORT WHODAS 2.0
HERE IS THE PROBLEM: YOU DON’T HAVE TIME PEOPLE WANT AN EXPLANATION OF THEIR PAIN . . .THEY NEED TO TELL YOU THEIR STORY . . .
BE HEARD BY YOU
HERE IS HOW YOU LISTEN…….. IN A VERY EFFICIENT MANNER . . .
SHARE 3 such screening tools and show you how you can SQUEEZE out information about your patient and get a MUCH better understanding of what they are experiencing
I have developed a tool to help you as physicians HEAR your patients PAIN STORY
They need to be heard and you need to listen to what they are thinking to BEST help them.
SCREENING TOOLS ADMINISTERED ON AN IPAD FOR INSTANT RESULTS AND INTEGRATION INTO EMR

10. Screening for Psychosocial Risk Factors
Identification of elevated psychosocial distress has been strongly linked to poor clinical outcomes in a variety of health care settings.
RISK STRATIFICATION
MSQS STarT ORT

11. Risk Factors MY PATIENT 55 year old single female
Worked at physically demanding job
Low SES
10th grade education
2 spinal surgeries (lumbar fusion and cervical fusion)
Chronic pain for 3 years

12. I am wondering what made your score a 10 instead of say a 3 or 4?”
The “Ruler” Question
“I see you gave yourself a 10 or 100% agreement that you need more medical treatment.
I am wondering what made your score a 10 instead of say a 3 or 4?”
GETS AT CORE BELIEFS
WELL YOU KNOW THAT IF I STILL HAVE PAIN I HAVENT HEALED.
THIS BURNING PAIN I HAD PRIOR TO MY FIRST AND SECOND SURGERY AND ITS BACK AGAIN IM WORRIED I NEED ANOTHER SURGERY!
HELPS YOU GET AT WHAT THIS PERSON IS REALLY THINKING AND WORRIED ABOUT

13. The SUBTITLE SAYS IT ALL
Book
THIS BOOK WILL CHANGE YOUR MEDICAL PRACTICE. ROLLNICK AND MILLER HIT THE BALL OUT OF THE PARK
The SUBTITLE SAYS IT ALL
HELPING PATIENTS CHANGE BEHAVIOR.
FOR YOUR LIBRARY
I WILL BE SHOWING YOU MY FAVORITE MOTIVATIONAL INTERVIEWING QUESTION OF ALL TIME

14. Opioid Risk Tool (ORT)
The ORT is a self-report that is designed to predict the probability of a patient’s displaying aberrant behavior when prescribed opioids for chronic pain.
Scores of 0-3 are associated with low risk, 4-7 with moderate risk, and 8 and over with high risk.
Webster LR. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine ;6(6):
IF YOU PRESCRIBE OPIOIDS TO YOUR PATIENTS YOU BETTER BE ABLE TO SAY TO THE GOVERNMENT THAT YOU ASSESSED THEIR RISK
Opioid Risk Tool (ORT)
The ORT is a self-report that is designed to predict the probability of a patient’s displaying aberrant behavior when prescribed opioids for chronic pain. It consists of items on family history of substance abuse, personal history of substance abuse, age, history of preadolescent sexual abuse, and psychological disease. The OTR shows excellent discriminatory ability in both men and women. The most common aberrant behaviors were solicitation of opioids from other providers, unauthorized acceleration of opioid dose, abnormal urine and blood screening, and use of more opioids than those prescribed. Scores of 0-3 are associated with low risk, 4-7 with moderate risk, and 8 and over with high risk.
Score: 14
High Risk
Areas of Concern:
Family History of Alcohol Abuse
Family History of Illegal Drug Abuse
Family History of Prescription Drug Abuse
Personal History of Alcohol Abuse
History of Preadolescent Sexual Abuse
Psychological Disease (Depression)
Webster LR. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine ;6(6): Used With Permission.

15. STarT Back Screening Tool (SBST)
Brief 10 questions - validated tool, designed to screen pain patients with low back pain for prognostic indicators that are relevant to initial decision making.
Keele University, Arthritis Research UK
STarT Back Screening Tool (SBST)
The Keele STarT Back Screening Tool (SBST) is a brief validated tool, designed to screen pain patients with low back pain for prognostic indicators that are relevant to initial decision making. The STarT Back Screening Tool allocates patients to different treatment pathways based on their prognosis (low, medium, or high risk of poor outcome). The tool helps to group patients into 3 categories of risk of poor outcome (persistent disabling symptoms) - low, medium, and high-risk. By being able to categorize patients into these 3 groups, we are then able to target interventions to each sub-group of patients to help improve outcome.
LOW RISK of developing long term problems.
No significant barriers to recovery. Short-term treatment may speed recovery – recommended.
Analgesia and advice - single session with a physiotherapist - package of advice to support self-management of back pain.
No significant barriers to recovery. Short-term treatment may speed recovery - recommended: good package of advice about how to manage back pain in a single session with a physical therapist/physiotherapist.
MODERATE RISK of developing longer term problems
Potential physical and psychological barriers to recovery. Thorough assessment is required by a practitioner/behavioural medicine specialist skilled in the assessment and management of physical pain disorders.
Analgesia and advice, recommend a standardised package of exercise and manual physical therapy/physiotherapy as well as addressing potential psychological barriers to recovery.
HIGH RISK of developing longer term problems
Potential significant psychological and physical barriers to recovery. Thorough assessment is required by a practitioner/behavioural medicine specialist skilled in the assessment and management of complex pain disorders.
Adopt a bio-psychosocial approach to care. Analgesia and advice, manual therapy and exercise. Address patient’s concerns and beliefs about managing back pain such as an explanation of the effects of depression, fear avoidance and catastrophising on the maintenance of back pain.
Keele University, Arthritis Research UK and their affiliates designed the STarT Back Screening Tool for use by health care providers. The Tool was designed to be used by clinicians to aid the clinical reasoning processes of a health care practitioner, including consideration of Red Flags. Whilst any development of the STarT Back Tool can be used by the general public, the Tool was not designed for use by the general public and the results should be interpreted in consultation with a health care practitioner. Validity of the Tool has been established for paper versions of the questionnaire, not for the electronic versions in the App. Users are referred to the Tool bibliography for scientific papers relating to validity and utility of the Tool. Keele University and Arthritis Research UK do not endorse or recommend any of the service providers or third parties who may support or develop the Tool in any way.
Bibliography:
Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. May ;59(5):
Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening Questionnaire. Eur J Pain. Jan 2010;14(1):83-89.
Hill JC, Vohora K, Dunn KM, Main CJ, Hay EM. Comparing the STarT back screening tool's subgroup allocation of individual patients with that of independent clinical experts. Clin J Pain. Nov-Dec 2010;26(9):
Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. Oct ;378(9802):
Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Physical therapy. May 2011;91(5):
STarT - Copyright Keele University1/8/07. Funded by Arthritis Research UK

16. YOU SHOULD HAVE 20 COPIES OF THIS IN YOUR OFFICE
Book
PUBLISHED IN THIS REMAINS THE ABSOLUTE BEST EMPIRICALLY SUPPORTED BOOK ON LOW BACK PAIN
YOU SHOULD HAVE 20 COPIES OF THIS IN YOUR OFFICE
21-PAGES
“DESPITE WHAT YOU MIGHTH HAVE HEARD” SECTION

17. AUSTRIALIAN SPIRAL SOFT-COVER GREAT FOR YOUR OFFICE WAITING ROOM
Book
AUSTRIALIAN SPIRAL SOFT-COVER
GREAT FOR YOUR OFFICE WAITING ROOM
GREAT PICTURES PEOPLE LIKE IT

18. PEOPLE NEED AN EXPLANATION/LABEL/DIAGNOSIS FOR THEIR CHRONIC PAIN
Book
MY BIBLE AND GO TO TEXT JANET TRAVELL JFK’S DOCTOR A STORY ABOUT HIS ROCKING CHAIR SHE DID PRESCRIBE IT FOR HIS MYOFASCIAL PAIN
PEOPLE NEED AN EXPLANATION/LABEL/DIAGNOSIS FOR THEIR CHRONIC PAIN
AS A NON-PHYSICIAN THE MOST ACCURATE DIAGNOSIS I CAN GIVE IS YOU HAVE MUSCLE PAIN FANCY WORDS OFTEN HELP MYOFASCIAL PAIN
I SHOW THEM THEIR PICTURE IN THIS BOOK AND THEY ARE AMAZED

19. Free Relaxation Response Resource MY FAVORITE IS BREATHING ZONE
Website
Free Relaxation Response Resource
MY FAVORITE IS BREATHING ZONE

20. App

21. Behavioral Activation Strategies
Activity Pacing
Graded Increases in Activity
Movement is life
Breaking the paired association
PAIN TEACHS US TO BE STILL
MOVEMENT IS LIFE
The more I do the more I hurt

22. Non-Pharmacological Treatment Options
Cognitive Behavioral Therapy
2012 Cochrane Review (Williams, Eccleston, Morely)
35 studies reviewed with 4788 subjects
Evaluation timepoints: post-tx and 6 mo f/u
CBT has small effect for disability and pain
CBT had moderate effects for mood and catastrophizing

23. Book

24. I CALL THIS MY PAIN ROAD MAP
Questionaire
I CALL THIS MY PAIN ROAD MAP
IT ATTEMPTS TO COVER THE TOP TEN THINGS YOU NEED TO KNOW
GET YOUR PATIENT TO FILL THIS OUT - ACTIVE ROLE

25. Contact info