1. The object of the physician is to find health. Anyone can find disease - A. T. Still, M.D., D.O. Christopher T Caldwell, D.O. Medical Director, Montana Spine and Pain Center Board-certified, Neuromusculoskeletal Medicine Boar-certified, Osteopathic Manipulative Medicine Fellowship-trained, Pain Medicine

2. Conflict of Interest Disclosure: Christopher T. Caldwell, D.O. Has NO real or apparent conflicts of interest to report.

4. Pain is hard-wired to fear Fear of Damage –Your back is Shot –What a Train Wreck –Worst I’ve ever seen Fear of the Future –Lucky to Not be Paralyzed –You’ll end up In a wheelchair Fear Sells –You’ll end up Needing Surgery

5. Need to Compensate for patients’ –Negative Attention Bias –Catastrophizing –Fear-avoidance –Low self-efficacy –False beliefs about pain

6. Stop Catastrophizing!!! Inflammatory Degenerative Arthritis Stenosis Annual tear Disc protrusion Facet arthropathy Bone spur “Out of place”

7. “Translate” for the patient Inflammatory Degenerative Arthritis Stenosis Annual tear Disc protrusion Facet arthropathy Bone spur “Out of place” Reassuring = No Danger Candles on your cake Wear and tear change Less breathing room Normal wear Gravity wins “Knuckle joints” Calcium inside a tendon Stuck

8. Finding Health is about Language Radiologists aren’t talking to patients –Don’t read reports to patients You are talking to their limbic system

10. Case 1 MD, 56 yo female, changing insurance – establishing with new pcp 9 years of low back pain 6 years of “total body” pain Methadone 90 mg three times daily hydrocodone/acetaminophen 5/325mg as needed – up to 6 tabs daily Pain Diagnosis : chronic pain syndrome, fibromyalgia Other Medical history: Type II diabetes, hyperlipidemia, fatty liver disease, obesity, remote tobacco history, depression, insomnia

11. Case 1 – More History Immigrated from Cuba in 1997 where she was a lawyer – Spanish speaking only In US worked at Goodwill sorting clothes Lived with alcoholic husband and 2 children Husband left soon after arriving and currently only one child living with her Injured back at Goodwill in 1998 and some time after that was declared disabled Brought Mother over in 2002

12. Case 2 BG 56 year old male Active problem list HIV+ Bacterial pneumonia, twice in last 5 years Neuropathy – HIV? lipodystrophy COPD > 40 pack years of tobacco History of poly-substance abuse, clean since age 42 Orthostatic hypotension Hypogonadism Depression with anxiety and insomnia Hepatitis C Chronic lumbar pain with radiculopathy Arrives by wheelchair, flat affect, on oxygen Doctor appointments are only time he leaves house

13. Challenging discussions Are you saying this is all in my head? It’s really not safe for a person with a condition like mine to do _____. But I have something real going on, so all of this doesn’t really apply to me. I need to get my pain under control before I can get back to_____. But what are you going to do for my pain?