1. www.pspbc.ca Brief Action Planning Adapted from the work of Dr. Rahul Gupta, Margie Wiebe (RN) & CCMI

2. 2 Agenda 1.Peer Sharing/Learning (30 mins) 2.Advanced Pain Tool Use (45 mins) Comprehensive BAP Patient Self-Manangement Mindfulness/Relaxation Techniques Practicing using techniques 3.Return to Function (30 mins) Break (15 mins) 4.Pharmacotherapy (45 mins) Non-opioid pharmacotherapy Opioid Management  Comorbidity between addiction and pain 5.Case Study Application (30 mins) Assessing Pain and creating a management strategy 6.Wrap up (15 mins) Action period planning

3. 3  Use appropriate tools to assess pain and plan a a management strategy for 6 patients with chronic pain  Reflect on his/her delivery of pain tools and develop a process improvement plan Learning Objectives – LS 2

4. 4 Faculty/Presenter Disclosure Faculty’s Name: Speaker’s Name Relationship with commercial interest: -Grants/Research Support: PharmaCorp ABC -Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd -Consulting Fees: MedX Group Inc. -Other: Employee of XYZ Hospital Group

5. 5 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [desribe support here – e.g. educational grant] This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support] Potential for conflicts(s) of interest: -[Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose products are being discussed in this program]. -[Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program. [Enter generic and brand name here].

6. 6 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document

7. 7  Define Brief Action Planning (B.A.P.) and describe the process  Explore a case study illustrating how B.A.P. supports patient self-management  Practice B.A.P. to develop comfort and skill Learning Objectives - BAP

8. 8 “ Everyone has a doctor in him or her, we just have to help that doctor in its work. The natural healing force within each of us is the greatest force in getting well.” -Hippocrates (460-377 B.C.) (c) Gupta 2013

9. 9 What is Brief Action Planning?  a highly structured  patient-centered  stepped-care  evidence-informed self-management support technique based on the principles and practice of Motivational Interviewing. Gutnick et al, 2014, Jrnl Clin Outcomes Mgmt Reims et al, Brief Action Planning White Paper, 2014 both available at www.centreCMI.cawww.centreCMI.ca

10. 10 Spirit of Motivational Interviewing  Compassion  Acceptance  Partnership  Evocation Miller W, Rollnick S. Motivational Interviewing: Helping People Change, 3ed, 2013

11. 11 “Is there anything you would like to do for your health in the next week or two?” “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” “Would it be helpful to set up a check on how things are going with your plan?” Behavioral Menu If Confidence <7, Problem Solve Barriers Check on progress Elicit a Commitment Statement SMART Behavioral Plan

12. 12 Three Questions of B.A.P. “Is there anything you would like to do for your health in the next week or two?” “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” “Would it be helpful to set up a check on how things are going with your plan?”

13. 13 Five Skills of B.A.P. Behavioral Menu If Confidence <7, Problem Solve Barriers Check on progress Elicit a Commitment Statement SMART Behavioral Plan

14. 14 “Is there anything you would like to do for your health in the next week or two?” “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” “Would it be helpful to set up a check on how things are going with your plan?” Behavioral Menu If Confidence <7, Problem Solve Barriers Check on progress Elicit a Commitment Statement SMART Behavioral Plan

15. 15 Example Case

16. 16 62 year old female cashier with long history of severe migraines, still debilitating 1x weekly (in bed 2 days). On long-acting opioid, sumatriptan and codeine for BTP.  Continues to miss many afternoons at work due to migraines  Low self-esteem, timid++, anxious, perfectionist  Frustrated, feels “at the mercy” of migraines, lots of incompletions  Is there anything you would like to do for your health in the next week or two? Example Case

17. 17  “I want to make my mornings less stressful” Example Case

18. 18  We are trained to focus on what’s wrong with ourselves  Preoccupation with “what’s wrong” means less focus on what allows us to flourish  The brain cannot visualize “negatives”  The brain is continually responding to pictures  Research suggests shifting focus to positive visuals enhances cognitive abilities and inspires action  Example: “I want to stop being in so much pain”.  Physician: What would you prefer to experience?  “I want to feel more comfort in my body”.  “I want to feel energetic”. Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332. Stating Action Plans in the Positive

19. 19 “I want to make my mornings less stressful”.  What would you prefer?  To feel more at ease in the mornings.  How will you start?  Don’t know. Example Case

20. 20 Skill #1 Offer a behavioral menu when needed or requested. Behavioral Menu

21. 21 1.“Is it okay if I share some ideas from other people who are working on something similar?” 2.If yes, share two or three varied ideas briefly all together in a list. Then say… 3.“Maybe one of these would be of interest to you or maybe you have thought of something else while we have been talking? ” Healthier eating Physical Activity Better Sleep Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010 Behavioral Menu

22. 22  Is it ok to share some ideas?  You might consider working on becoming more assertive, or getting better at completing things.  Does one of these ideas interest you, or maybe you have thought of something else?  “I want to make my mornings less stressful” Example Case- Behavioural Menu

23. 23 Skill #2 Action Planning is “ SMART ” : Specific, Measurable, Achievable, Relevant and Timed. SMART Behavioral Plan With permission: What? When? Where? How often/long/much? Start date? Based on the work of Locke (1968) and Locke & Latham (1990, 2002); Bodenheimer, 2009

24. 24 “I want to make my mornings less stressful”.  Would it be okay to get more specific?  Sure  What would you like to do?  To feel more at ease in the mornings.  How will you start?  Don’t know. Example Case: SMART goal-setting

25. 25 “I want to feel more at ease in the mornings”.  Can I share some ideas that have worked for others?  You might pace yourself differently, or reduce your expectations. Does that trigger any thoughts?  I will not answer my phone til noon, I will say NO to unreasonable requests for my time, I will break tasks into 30 minute chunks.  What’s enough for the first 2 weeks?  5 mornings “of ease” per week. Example Case: SMART goal-setting

26. 26 Is her plan “SMART”?  Specific, stated in positive  Measurable  Achievable  Relevant  Timed Locke & Latham. Building a Practically Useful Theory of Goal Setting & Task Motivation. American Psych, 2002;57, 705-717 Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332. Bodenheimer. Goal-Setting for Behavior Change in Primary Care. Pt Educ Couns 2009;76(2):174-80 Skill #2 SMART Behavioral Plan

27. 27  After the plan has been formulated, the clinician elicits a final “commitment statement.” The strength of the commitment statement predicts success on action plan. Skill #3 Elicit a Commitment Statement Aharonovich, E. Cognition, commitment language, and behavioral change…Psychology of Addictive Behaviors, 2008;22:556-562 Amhrein PC. Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 2003;71:862-878

28. 28  Just to make sure we both understand the details of your plan, would you mind putting it together and saying it out loud?  “Over the next 2 weeks, I will make my mornings feel more at ease. I will not answer the phone til noon, I will say NO to unreasonable requests, and I will break tasks into 30 minute segments. I will do this 5x per week.” Example Case: Eliciting a Commitment Statement

29. 29 Three Questions of B.A.P. “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?”

30. 30 Skill #4 Problem-solving is used for confidence levels less than 7. Note: If the patient indicates his/her level is <7, the likelihood of a successful behavioural change is low. Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009. Problem Solving

31. 31 People’s beliefs about their capabilities to perform specific behaviors and their ability to exercise influence over events that affect their lives. Self- efficacy beliefs determine how people feel, think, motivate themselves and behave. - Albert Bandura Self-efficacy Mt Frosty, BC by C. Davis

32. 32 Confidence <7 “A __ is higher than a zero, that’s good! We know people are more likely to complete a plan if it’s higher than 7.” Confidence <7 “A __ is higher than a zero, that’s good! We know people are more likely to complete a plan if it’s higher than 7.” “Any ideas about what might raise your confidence?” Assure improved confidence. Restate plan and rating as needed. Assure improved confidence. Restate plan and rating as needed. Behavioral Menu Yes No Problem solving

33. 33  Considering a scale of 0-10, how sure are you about completing your plan?  “4/10.”  OK, 4 is better than 3! When confidence is greater than 7, people are more likely to succeed. Do you have any ideas about how you might raise your confidence to a 7 or greater?  “If I expect myself to do it even 2x per week, that feels more possible.”  How sure are you now?  “8/10.” Example Case: Problem Solving “I want to feel more at ease in the mornings”.

34. 34 “Would it be helpful to set up a check on how things are going with your plan?”

35. 35 Skill #5 Checking on the plan builds confidence. Check often with new action plans and decrease frequency as behavior is more secure. When working with a clinician Regular contact over time is better than 1x intervention. Follow-up builds a trusting relationship. Resnicow, 2002; Artinian et al, Circulation, 2010 Check on progress

36. 36 Checking On Plan with Clinician “How did it go with your plan?” Completion Partial completion Did not carry out plan Recognize partial completion “What would you like to do next?” Reassure that this is common occurrence Recognize success

37. 37 “Is there anything you would like to do for your health in the next week or two?” “How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)?” Have an idea? Not sure? Behavioral Menu Not sure? Behavioral Menu Not at this time SMART Behavioral Plan With permission: What? When? Where? How often/long/much ? Start date? With permission: What? When? Where? How often/long/much ? Start date? Permission to check next time 1) Ask permission to share ideas. 2) Share 2-3 ideas. 3) Ask if any of these ideas or one of their own ideas might work. 1) Ask permission to share ideas. 2) Share 2-3 ideas. 3) Ask if any of these ideas or one of their own ideas might work. Elicit a Commitment Statement Confidence ≥7 Confidence <7, Problem Solving Confidence <7, Problem Solving “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” Check on Progress “Would it be helpful to set up a check on how things are going with your plan?” How? When? How? When?

38. 38 The client does the most talking in Brief Action Planning

39. 39  Use “Worksheet” as your guide  Divide into groups of 2 (patient & provider)  Spend 5 minutes in each role, then switch  PATIENT: Choose something real you want to do in the next week or two  PROVIDER: Use 5 minutes to practice approach EXERCISE –Practicing B.A.P.

40. 40 EXERCISE –Practicing B.A.P. De-Brief

41. 41 1.Practice and get feedback. 2.Set SMART goals for yourself. 3.Choose easy patients to start with. 4.Work over multiple appointments. 5.Focus on the spirit of the interview. Tips For Using These Tools

42. 42  Program started in 1979 at U Mass Medical School by Dr. Jon Kabat-Zinn  8 week group program, usually 2.5 hour class with all-day retreat  Trainings include breath/body awareness, developing acceptance of present moment, and understanding stress physiology  Over 30 years of research, documenting its value in improving patient self-management and the capacity to more effectively deal with stress & illness Mindfulness Based Stress Reduction (MBSR)

43. 43  Chronic Pain Vowles & McCracken 2005, 2008  108 & 171 patients respectively, intensive programs  demonstrated improvements pre- to post- treatment on measures of pain, depression, pain-related anxiety, disability, medical visits, work status and physical performance  Chronic Pain: Simpson & Mapel 2011  RCT with 32 people: mix of FM, arthritis, IBS, migraines etc  Significant positive changes around rumination, magnification and helplessness (better able to manage pain) MBSR & Chronic Pain

44. 44  Low Back Pain: Morone, Greco & Weiner 2008  RCT with 37 people: greater acceptance, engagement in activities and overall physical functioning  Failed Back Surgery Syndrome: Esmer et al 2010  Single-center, prospective, randomized trial with 25 people: clinically significant increase in pain acceptance, sleep & QoL measure, decrease in pain, functional limitation & frequency of use/potency of analgesics MBSR-Chronic Back Pain

45. 45  Fibromyalgia: Kaplan, Goldenberg & Galvin-Nadeau 1993  Pre-post assessments with 59 people: improved sleep, pain, fatigue, well-being, coping and FM symptomatology (SCL-90- R)  51% responders (moderate to marked improvement)  Fibromyalgia: Weissbecker et al. 2002  RCT with 91 women: improved sense of coherence*, lower perceived stress and less depression *Sense of Coherence: disposition to experience life as meaningful and manageable MBSR & Fibromyalgia

46. 46  Mindful Listening (to self and patient)  Use CBIS handouts on body scan and mindfulness  Give mindfulness options for behavioural menu options (do one thing at a time, slow down, “nothing” time, breath awareness)  Suggest books  Be aware of local mindfulness programs How might you bring Mindfulness to the Clinical Encounter?

47. Suggested Books

48. 48  CBIS handouts (body scan, mindfulness meditation, relaxation)  Mindfulness-Based Chronic Pain Management www.neuronovacentre.ca www.neuronovacentre.ca  The Mindfulness Solution to Pain (Dr. Jackie Gardner- Nix)  MBSR courses being held around BC www.mbsrbc.cawww.mbsrbc.ca  Pain BC www.painbc.cawww.painbc.ca  Center for Mindfulnesswww.umassmed.edu/cfm/stress/index.asp xwww.umassmed.edu/cfm/stress/index.asp x Mindfulness Resources

49. 49  It is common for those dealing with chronic pain to focus on past issues (good or bad), future concerns or judgments about the present  Mindfulness is the capacity to BE WITH and IN the constant flow of present moment  It allows for a clearer understanding of how thoughts and emotions can impact health and quality of life  This capacity is inherent with each person, and can be cultivated through practice  Would you like to hear some options for exploring mindfulness, or do you have some ideas of your own? Introducing Mindfulness to Patients

50. 50 Questions?

51. 51  Center for Comprehensive Motivational Interventions www.centreCMI.cawww.centreCMI.ca  Patient Self-Management Module (VCH) of PSP Resources