a brief overview of pain coping deprescribing · august 24, 2016 deprescribing jessica visco,...
TRANSCRIPT
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DeprescribingJessica Visco, PharmD, CGP
SeniorPharmAssist
August 24, 2016
Deprescribing
Jessica Visco, PharmD,
CGP
SeniorPharmAssist
Webinar #1Webinar #20
A Brief Overview of Pain Coping Skills Training Rationale and Strategies
Laura Porter, Ph.D.
Department of Psychiatry & Behavioral Sciences
Duke University School of Medicine
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Disclosures No commercial support has influenced the planning of the
educational objectives and content of the activity. Any
commercial support will be used for events that are not CE
related.
There is no endorsement of any product by DUHS
associated with the session.
No influential financial relationships have been disclosed by
planners or presenters which would influence the planning of
the activity. If any arise, an announcement will be made at
the beginning of the session.
This program is supported by a Geriatric Workforce
Enhancement Program (GWEP) grant (U1QHP28708) from
the U.S. Bureau of Health Professions Health Resources
and Services Administration (HRSA).
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Objectives
Describe the evolution in our understanding of pain
Summarize research on psychological processes in pain
Identify common, effective pain coping skills
Identify key components in training patients to use pain
coping skills
Describe the role of family caregivers in pain coping
Identify methods of assessing pain and applying pain
coping skills in patients with dementia
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Traditional Model of Pain
• Pain is often viewed
as a sensory event
• Due to tissue
damage
• Treat injury/disease,
pain will be relieved
OUCH!
R. Descartes (17th Century)
Pain
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Evolution of Pain Models
• Newer theories and
research about pain
indicate pain is a
multidimensional
experience
Sensory
Affective
Cognitive
Motivational
Brain Imaging
Studies
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Evolution of Pain Models
The Pain Neuromatrix
Neuromatrix Theory
Sensory inputs
Visual and other inputs that influence cognitive interpretation
Phasic and tonic cognitive-emotional inputs from brain
Activity of body’s stress regulation systems
• Produce pattern that evokes pain
Key Point: A patient’s thoughts, emotions and behaviors (appraisals and coping efforts) shape and influence the pain experience
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Pain as a Stressful Event
Outcome 1
Persistent Outcome 2
Pain
Outcome 3
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Stress and Coping Theory (Lazarus and Cohen, 1977)
Persistent
Pain Appraisal Outcome
Conscious judgments:
• Judgment of painful event as
benign/irrelevant vs. threat/harm/loss
• Judgment of what can be done
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Threat/Loss Appraisal
A B C
Event Appraisal Feelings/Behavior
“I can’t cope.
Pain flare There is nothing ???
I can do. I will end
up in a wheelchair”
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Threat/Loss Appraisal
A B C
Event Appraisal Feelings/Behavior
“I can’t cope. Fear
Pain flare There is nothing Depression
I can do. I will end Avoidance
up in a wheelchair” Irritability
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A Different Type of AppraisalA B C
Event Appraisal Feelings/
Behavior
Pain flare “ I know this will ???
be tough but I
know some things
I can do to manage
it.”
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Effects of a Challenge
AppraisalA B C
Event Appraisal Feelings/
Behavior
Pain flare “ I know this will Concerned, but
be tough but I confident;
know some things pacing
I can do to manage activites
it.”
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Findings from cross-sectional and
longitudinal studies
Pain coping
&
Appraisal
Outcomes
-Reports of pain – intensity, interferene, reports
of lab pain stimuli (QST)
-Directly observed pain behaviors
-Measures of psychological distress--depression,
anxiety, fear anger
-Assessments of physical disability—self reports,
performance based measures (speed of
walking, movement, grip strength)
-Behavioral outcomes-medication intake, return
to work, recovery from injury or surgery.
Key findings:
1. Passive or escapist coping relates to poor
outcomes
2. Active coping relates to good outcomes
3. Appraisals are very important
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Psychosocial Treatment Protocols
Alter Pain Coping and Appraisal
Appraisal
+
CopingOutcome
• Cognitive behavioral
therapy (CBT)
• Mindfulness-based stress
reduction (MBSR)
• Acceptance & Commitment
Therapy (ACT)
And improve outcomes …….Arthritis pain
Cancer pain
Musculoskeletal pain (low back pain)
Migraine headache
Tension headache
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Cognitive-Behavioral Pain
Coping Skills
Relaxation
Imagery
Pleasant activity scheduling
Activity-rest cycle
Cognitive restructuring
Mechanisms: decrease muscle tension, reduce
catastrophizing, increase positive emotion, promote
activity and engagement, increase self-efficacy
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Delivering pain coping skills
interventions• Buy in from patient is critical
• Provider strong recommendation is invaluable
• Rationale for learning new pain management strategies
• Important components of skills teaching• Modeling of skill
• Practice the skill
• Reinforcement of skills practice and problem solving
• Rehearsal – plans for daily use
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Rationale: Connections between pain,
thoughts, feelings, and behaviors
This will
never get
better. I can’t
do anything
to cope with
this pain.
This pain
has
ruined
my life.
Negative Thought
Negative
Feelings &
Physical
Reactions
Negative Actions
More
Negative
Thoughts
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Gate Control Theory of Pain
Sensation Center
GATE
FEELINGS
CENTER
THOUGHTS
CENTER
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Example: Relaxation
Provide rationale
Lead patient through exercise
Elicit feedback: “what did you notice?”
Address challenges
Encourage regular practice
Anticipate challenges/barriers
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Example: Activity Rest Cycle Goal: pace activities and gradually increase them
without increasing pain
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Social Context• Family caregivers are often integrally involved in pain
management• monitoring symptoms• administering medications• dealing with side effects• communicating with health professionals
• They often feel overwhelmed, frustrated, and helpless • Seeing a loved one in pain activates the same brain areas involved
when one experiences pain oneself (mirror neurons) (Simon & Lamm, 2009)
• They often overestimate patient pain
• Their response can make things better or worse
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Benefits of including family caregivers
in pain coping skills training
• Increases caregiver understanding of the patient’s pain
and the role that pain coping skills can play
• Enhances caregivers’ self-efficacy (confidence) for
helping the patient manage pain
• Learn coping skills to manage their own stress and
symptoms
• Provides opportunities for positive interactions
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Dementia and Pain Assessment• Ask patients simple questions about pain
• Ask about “aches” and “discomfort” and what activities
makes it worse
• Use a verbal descriptor scale (no pain--worst possible
pain)
• Observe behaviors and nonverbal indicators pain and
distress (PAINAD Scale): • Breathing
• Negative vocalization
• Facial expression
• Body language
• Consolability
• Ask family caregivers about behavior changes that may
signal pain (e.g., aggression, restlessness)
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Dementia and Pain Coping• Modify delivery of pain coping skills based on patient’s
level of cognitive function
• Consider additional strategies such as music therapy,
gentle movement
• Involve a family caregiver
• Educate about the role of pain coping skills
• Provide skills for assessing pain and patient’s response to
intervention
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