tools for changing the conversation about pain: resources for...

Tools for Changing the Conversation about Pain:

Resources for Clinicians and Patients

Nora Stern, MS PTProvidence Comprehensive Pain Service

Portland, Oregon

nora.stern@providence.org https://www.oregon.gov/oha/HPA/dsi-pmc/Pages/pain-care-

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Disclosures

• The speaker has no disclosures

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• Content in this presentation is based on the pain education module of the Oregon State Pain Commission, “Changing the Conversation about Pain,” and the patient education content from Oregon State Pain Commission, “Pain Care Toolbox.”

nora.stern@providence.org https://www.oregon.gov/oha/HPA/dsi-pmc/Pages/pain-care-toolbox.aspx

Learning Objectives:

• Address contemporary pain science • Learn communication strategies to better navigate difficult

conversations about pain and to redirect a treatment plan that addresses the 5 key domains of best-practice pain care

• Understand the role of pain science in opioid prescribing, deprescribing and pain care treatment

• Learn about Oregon state’s free resources for pain education and treatment and apply tools to more effectively screen, educate and provide care for patients with persistent pain

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How cool is treating pain?

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What messages might she have inadvertently gotten from this course of care?

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Mary’s thoughts“My life is unmanageable.”

“Medication is the only thing that helps me.”

“I have degeneration in my knee. I need to take it easy because of my pain, it’s not safe for me to do very much.”

“My pain is terrible and it will never get better.”

Fictional patient, stock photo 2019

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As you start to think about a taper plan, what are your options in the conversation about pain?

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8/22/2019 Creamer et al , British Journal of Rheumatology 0886 Vol 36 No 7, 1997 p 726-7 16

10% with no arthritis on xray have severe pain!!

Half of people with severe arthritis in the knee have no symptoms

• PT First: $4793 less per episode of care than radiology first (Fritz 2011 n=406)

PAIN AND THREAT DETECTION

Mobilizing the Emergency Response System

• EMERGENCY VEHICLE IMAGE

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Key Domains:Understanding painKey concepts

• Pain is a multi-dimensional experience• This means the care plan must look at the entire person• All chosen treatments are equally important.

• All pain is real pain

• Nociception is neither necessary nor sufficient for pain

• PAIN ≠ HARMAdapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010

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Pain Education as a Treatment InterventionEvidence through systematic review

Pain Neuroscience education can:Ability to cope with their condition*

Kinesiophobia*

Catastrophizing*

Disability and pain **

Utilization of services ***

*Watson, J et al, Pain Neuroscience Education for Adults with Chroinic MSK PainL A Mixed Methods Systematic review and meta-analusis, J of Pain, 2019

**L Wood and P Hendrick, Eur J Pain 2019 Feb 23 (2) 234-49

*** Louw, A. , PhD, PT, et al, “Preoperative Pain Neuroscience Education for Lumbar Radiculopathy, A Multicenter Randomized Controlled Trial With 1-Year Follow-up,” SPINE 2014 Volume 39 , Number 18 , pp 1449 – 1457

PEG Tool (Krebs, 2009)

https://www.oregonpainguidance.org/resources/difficult-conversations/

Key Domains:Understanding painKey strategies

• Pain Care Toolbox• Use of different phrasing and language• Consider implications of ordering radiological studies• Videos, written material, possible referral to a Pain PT

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Key Domains:Understanding painMessages

“Your pain is very real.”“Your pain can change.”“Understanding pain helps make sense out of it and gives you a better sense of how you can take action to change.” • PAIN ≠ HARM

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Key Domains:Understanding painMore Messages

• “Sore but safe.”• “Motion is lotion.”• “This is a process, be patient with yourself”• “Your pain can change, there are many things that we

can explore together. I am here to be your support and be your coach. You are the one who can make the changes.”

• “Neuroplasticity got you into this, and neuroplasticity can get you out of it.”

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Key Domains: Activity

Knowledge of pain

Nutrition

Activity

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Key Domains:ActivityKey concepts

• Activity improves sleep• Activity reorganizes the sensory cortex to decrease

pain• Conditioning, mobility and strength will make daily

tasks easier and less threatening

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Key Domains:ActivityKey strategies

• Pain Care Toolbox• “Doing more” is more important than exercise• Gentle global movement, tai chi, therapeutic yoga,

aquatic exercise, mindful movement, PT, OT• Encourage all gains no matter how small • Think Neuroplasticity

• Increase sensory input• Increase pleasurable activities

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Key domain: ActivityMessages

• Gradual return to activity “Start low, go slow, keep going.”

• Pacing – “Work smarter, not harder.”• Doing more is more important than “exercising”• Expect flare ups and learn to manage them with

pacing• “You are sore but safe”• “Motion is lotion”

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https://www.youtube.com/watch?v=hjenuiXDUZg

Key Domains: Sleep

Knowledge of pain

Nutrition

Activity

KEYDOMAINS

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Key Domain:SleepKey Concepts

• Sleep – wake cycle often disrupted• Rest is essential to rejuvenate and repair tissues• Fatigue makes pain worse

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Key Domain:SleepKey strategies

• Pain Care Toolbox • Promote relaxation skills (mindfulness, meditation, breathing)• Teach sleep hygiene• Address sleep apnea• Refer for Cognitive Behavioral Therapy for Insomnia CBT-I (CBT-i coach)

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Key Domain:SleepMessages

“Rest is essential to rejuvenate and repair tissues.”

“Improving your sleep is one of the most important things for helping pain.”

“Learning to calm the nervous system can promote rest.”nora.stern@providence.org

https://www.oregon.gov/oha/HPA/dsi-pmc/Pages/pain-care-toolbox.aspx

Focus treatment on these key domains

Knowledge of pain

Nutrition

Activity

KEYDOMAINS

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Key Domain:MoodKey concepts

• Pain response and stress response linked • Cortisol and pro-inflammatory cytokines release:

• Decrease in tissue regeneration, immune function and metabolic controlswhich can increase pain

• Mood and pain inter-relate:• Depression and isolation • Anxiety• PTSD and history of trauma• Complex grief

• Pleasurable activities decrease pain by redirecting attention and through elevation in mood the focus on pain

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Goal of Treatment is to Help the Patient Increase Life

Pain Pain

LifeTreatment and increased self-efficacy

Courtesy of Catriona Buist, Psy D

Key Domain:MoodKey strategies

• Pain Care Toolbox • Validate relationship between mood and pain• Encourage activity, especially social activity• Consider BH referral• Support relaxation/ mindfulness training:

• Diaphragmatic breathing• Mindfulness training• Progressive muscle relaxation• Visualization• Self-hypnosis• Biofeedback

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Key Domain:MoodMessages

“It’s really normal to feel down when you live with pain• ANDDepression, anxiety, PTSD, history of trauma, complex grief, isolation and stress can impact pain”“Finding ways to lift your mood is an important part of our pain care plan for you.”

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Key domains: Nutrition

Knowledge of pain

Nutrition

Activity

KEYDOMAINS

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Nutrition – Key DomainKey points

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Nutrition:Key message

• It might be more helpful to think about adding in foods that are high in important nutrition, than to worry as much about stopping other foods.

“What we eat can throw fuel on the pain, affect energy level & make us feel worse. Foods that are rich in nutrients like fruits and vegetables are like water on the fire.”

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Nutrition – Key DomainStrategies

• Pain Care Toolbox

• Explore knowledge of healthy eating and cooking

• Encourage positive changes rather than focusing on negative aspects

• Avoid the term “diet”

• Dietary log can be helpfulnora.stern@providence.org

Oregon State Pain CommissionPain Care Toolbox

Tools for you and your patient

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Videos, written material and trackers

English, Spanish, Simplified Chinese, Vietnamese,Russian

Oregon State Pain CommissionPain Care Toolbox

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SLEEP DIARY WORKSHEET

STRESS DIARY WORKSHEET

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Clinician Guide

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Shared Decision Making Tool starts the conversation

https://www.oregon.gov/oha/HPA/dsi-pmc/Pages/pain-care-toolbox.aspx nora.stern@providence.org

Videos Written material/shared decision making

Tools for explaining pain

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Activity tools:Videos Written material/shared decision making

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Sleep: ToolsVideos Written material/shared decision making

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Mood: ToolsVideos Written material/shared decision making

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Nutrition: Tools

Videos Written material/shared decision making

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Medication: Tools Videos Written material/shared decision making

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• Let’s revisit Mary

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So… where do you start?

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Questions

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Pain education references

1. Butler, David, (2000) The Sensitive Nervous System, Noigroup Publications, Australia, p. 75, 78, 88, 35.

2. Butler, David; Moseley, Lorimer, (2003) Explain Pain, Noigroup Publications, Australia, Breakthrough with Multiple Clinical Implications. Pain Res. Manage, 2002: 7(2): 81-92.

3. Doidge, Thomas, “The Brain that Changes Itself”, Penguin Press.

4. Edwards, Robert et al, “Association of catastrophizing with interleukin-6 responses to acute pain, “Pain 140, 2008

5. George, Steven, et al, “Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting”, Eur Spine J (2009) 18:1050–1058 from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting,” Eur Spine J (2009) 18:1050–1058

6. Grimmer-Somers, Karen et al, “A review and critique of assessment instruments for patients with persistent pain.” J Pain Res. 2009; 2: 21–47.

7. Institute of Medicine, National Academies, “Relieving Pain in America,” National Academies Press, Washington, DC 2011

8. Lidbeck J. Central, “Hyperexcitability in Chronic Musculoskeletal Pain: A Conceptual Breakthrough with Multiple Clinical Implications”, Pain Res. Manage, 2002: 7(2): 81-92.

9. Louw A, Diener I, Butler DS, Puentedura EJ. “The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.” Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.

10. Louw, A. , PhD, PT, et al, “Preoperative Pain Neuroscience Education for Lumbar Radiculopathy, A Multicenter Randomized Controlled Trial With 1-Year Follow-up,” SPINE 2014 Volume 39 , Number 18 , pp 1449 - 1457

11. Luciano, Juan V, PhD, et al, “Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients, a randomized controlled trial,” Clin J Pain, Vol 27, 5, June 2011

12. Maebori, Donna, et al: Neurophysiological Changes with Chronic Pain: Implications for Treatment, Providence Rehabilitation Services, Portland Oregon.

13. Meeus, M., PhD, et al, “Pain Physiology Education Improves Pain Beliefs in Patients With Chronic Fatigue Syndrome Compared With Pacing and Self-Management Education: A Double-Blind Randomized Controlled Trial,” Arch Phys Med Rehabil Vol 91, August 2010

14. Moseley GL., “Widespread brain activity during an abdominal task markedly reduced after pain physiology education: MRI evaluation of a single patient with chronic low back pain. “Australian Journal of Physiotherapy 51: 49-52]

15. Moseley GL., A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy, 2003:8(3): 130-140.

16. Moseley, GL, and David Butler, The Explain Pain Handbook Protectometer, NOI Group Publications, 2015

17. Moseley, G. Lorimer, PhD, Nicholas, Michael K, Ph D, and Hodges Paul W., PhD. “A randomized controlled trial of intensive neurophysiology education in chronic low back pain,” Clinical Journal on Pain, Vol. 20, p 324-330 200418. Stern, Nora, et al, Pain education in primary care and rehab services improves patient outcomes, Journal of Pain, April 2017;Volume 18, Issue 4, Supplement, Page S50

19. Watson JA1,et al, Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019 Mar 120 Wood L Hendrick PA A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability

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References: OPMC/OPG Pain Education ToolkitActivity

1. Ambrose KR, Golightly YM. Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Practice & Research Clinical Rheumatology. 2015;29(1):120-30.

2. Andersen LN, Juul-Kristensen B, Sørensen TL, Herborg LG, Roessler KK, Søgaard K. Efficacy of tailored physical activity or chronic pain self-management programme on return to work for sick-listed citizens: A 3-month randomised controlled trial. Scandinavian Journal of Public Health. 2015;43(7):694-703.

3. Boutevillain L, Dupeyron A, Rouch C, Richard E, Coudeyre E. Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PloS One. 2017;12(7):e0179826.

4. Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. The Clinical Journal of Pain. 2015;31(2):108-14.

5. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;1:CD011279.

6. Law LF, Sluka KA. How does physical activity modulate pain? Pain. 2017;158(3):369.

7. Marshall PW, Schabrun S, Knox MF. Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain. PloS One. 2017;12(7):e0180788.

8. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa C. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094.

9. Spine-health. Pain Treatments Health Center [Internet]. VERITAS Health. 2018 [cited 27 September 2018]. Available from: https://www.spine-health.com/treatment.

10. Suorsa K, Lynch-Jordan A, Tran S, Edwards N, Kashikar-Zuck S. (504) Rates of physical activity and perceived social support among young adult women with juvenile-onset fibromyalgia. The Journal of Pain. 2016;17(4):S100-1

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References: OPMC/OPG Pain Education ToolkitMindset1. Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research. 2016;9:457.

2. Finlay KA, Peacock S, Elander J. Developing successful social support: An interpretative phenomenological analysis of mechanisms and processes in a chronic pain support group. Psychology & Health. 2018;33(7):846-71.

3. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Practical Pain Management. 2015;15(6):70-5.

4. Hazeldine-Baker CE, Salkovskis PM, Osborn M, Gauntlett-Gilbert J. Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain. British Journal of Pain. 2018;12(2):87-94.

5. Hood A, Pulvers K, Carrillo J, Merchant G, Thomas M. Positive traits linked to less pain through lower pain catastrophizing. Personality and Individual Differences. 2012;52(3):401-5.

6. Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The impact of social isolation on pain interference: A longitudinal study. Annals of Behavioral Medicine. 2018. DOI: 10.1093/abm/kay017.

7. Koechlin H, Coakley R, Schechter N, Werner C, Kossowsky J. The role of emotion regulation in chronic pain: A systematic literature review. Journal of Psychosomatic Research. 2018;107:38-45.

8. Lerman SF, Rudich Z, Brill S, Shalev H, Shahar G. Longitudinal associations between depression, anxiety, pain, and pain-related disability in chronic pain patients. Psychosomatic Medicine. 2015;77(3):333-41.

9. Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubiner H, Keefe FJ. Pain and emotion: a biopsychosocial review of recent research. Journal of clinical psychology. 2011;67(9):942-68.

10. Ramírez-Maestre C, Esteve R, López-Martínez AE, Serrano-Ibáñez ER, Ruiz-Párraga GT, Peters M. Goal adjustment and well-being: The role of optimism in patients with chronic pain. Annals of Behavioral Medicine. 2018. DOI: 10.1093/abm/kay070

11. Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English longitudinal study of ageing. British Journal of Pain. 2018:2049463718802868.

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References: OPMC/OPG Pain Education Toolkit: Sleep

1. American Sleep Association. About sleep [Internet]. American Sleep Association. 2018 [cited 27 September 2018]. Available from https://www.sleepassociation.org/about-sleep/.

2. Cheatle MD, Foster S, Pinkett A, Lesneski M, Qu D, Dhingra L. Assessing and managing sleep disturbance in patients with chronic pain. Anesthesiology Clinics. 2016;34(2):379-93.

3. Cho S, Kim GS, Lee JH. Psychometric evaluation of the sleep hygiene index: A sample of patients with chronic pain. Health and Quality of Life Outcomes. 2013;11(1):1.

4. Choy EH. The role of sleep in pain and fibromyalgia. Nature Reviews Rheumatology. 2015;11(9):513.

5. Deardorff WW. Practicing good sleep hygiene [Internet]. VERITAS Health. 2018 [cited 27 September 2018]. Available from https://www.spine-health.com/wellness/sleep/practicing-good-sleep-hygiene.

6. Harrison L, Wilson S, Heron J, Stannard C, Munafò MR. Exploring the associations shared by mood, pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample. Psychology & Health. 2016;31(5):565-77.

7. Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Medicine Reviews, 22, 23-36.

8. Koffel E, Kroenke K, Bair MJ, Leverty D, Polusny MA, Krebs EE. The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial. Health Psychology. 2016;35(1):41.

9. Lerman SF, Finan PH, Smith MT, Haythornthwaite JA. Psychological interventions that target sleep reduce pain catastrophizing in knee osteoarthritis. Pain. 2017;158(11):2189-95.

10. National Sleep Foundation. Pain and sleep [Internet]. National Sleep Foundation. 2018 [cited 27 September 2018]. Available from https://www.sleepfoundation.org/sleep-disorders-problems/pain-and-sleep.

11. Nijs J, Loggia ML, Polli A, Moens M, Huysmans E, Goudman L, Meeus M, Vanderweeën L, Ickmans K, Clauw D. Sleep disturbances and severe stress as glial activators: key targets for treating central sensitization in chronic pain patients? Expert Opinion on Therapeutic Targets. 2017;21(8):817-26.

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References: OPMC/OPG Pain Education ToolkitNutrition

1. Cooper L, Ryan CG, Ells LJ, Hamilton S, Atkinson G, Cooper K, Johnson MI, Kirwan JP, Martin D. Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review. Obesity Reviews. 2018:19:989-1007.

2. De Gregori M, Muscoli C, Schatman ME, Stallone T, Intelligente F, Rondanelli M, Franceschi F, Arranz LI, Lorente-Cebrián S, Salamone M, Ilari S. Combining pain therapy with lifestyle: the role of personalized nutrition and nutritional supplements according to the SIMPAR Feed Your Destiny approach. Journal of Pain Research. 2016;9:1179.

3. Eatright.org. Food [Internet]. Academy of Nutrition and Dietetics. 2018 [cited 27 September 2018]. Available from: https://www.eatright.org/food.

4. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007;129(1-2):210-23.

5. Okifuji A, Hare BD. The association between chronic pain and obesity. Journal of Pain Research. 2015;8:399.

6. Ray L, Lipton RB, Zimmerman ME, Katz MJ, Derby CA. Mechanisms of association between obesity and chronic pain in the elderly. Pain. 2011;152(1):53-9.

7. Rondanelli M, Faliva MA, Miccono A, Naso M, Nichetti M, Riva A, Guerriero F, De Gregori M, Peroni G, PernaS. Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents. Nutrition Research Reviews. 2018;31(1):131-51.

8. Ruskin DN, Kawamura Jr M, Masino SA. Reduced pain and inflammation in juvenile and adult rats fed a ketogenic diet. PloS One. 2009;4(12):e8349.

9. Silişteanu SC, Covaşă M. Reduction of body weight through nutrition intervention reduces chronic low back pain. In E-Health and Bioengineering Conference (EHB), 2015 Nov 19

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References: OPMC/OPG Pain Education ToolkitTapering/Multi-domain

Tapering

1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45.

2. Murphy L, Babaei-Rad R, Buna D, Isaac P, Murphy A, Ng K, Regier L, Steenhof N, Zhang M, Sproule B. Guidance on opioid tapering in the context of chronic pain: Evidence, practical advice and frequently asked questions. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada. 2018;151(2):114-20.

3. Sullivan MD, Turner JA, DiLodovico C, D’Appollonio A, Stephens K, Chan YF. Prescription opioid taper support for outpatients with chronic pain: A randomized controlled trial. The Journal of Pain. 2017;18(3):308-18.

4. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Internal Medicine. 2018;178(5):707-8.

5. Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid therapy for chronic pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense clinical practice guideline. Pain Medicine. 2017;19(5):928-41.

6. McPherson S, Smith CL, Dobscha SK, Morasco BJ, Demidenko MI, Meath TH, Lovejoy TI. Changes in pain intensity following discontinuation of long-term opioid therapy for chronic non-cancer pain. Pain. 2018:159(10):2097-2104

7. Matthias MS, Johnson NL, Shields CG, Bair MJ, MacKie P, Huffman M, Alexander SC. “I’m not gonna pull the rug out from under you”: Patient-provider communication about opioid tapering. The Journal of Pain. 2017;18(11):1365-73.

8. Friedman Z, Arzola C, Postonogova T, Malavade A, Siddiqui NT. Physician and patient survey of taper schedule and family physician letters following discharged from the acute pain service. Pain Practice. 2017;17(3):366-70.

9. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. May Clin Proc. 2015; 90(6):828-842.

Multi Domain Sources

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• Physicians• Physician

Assistants• Nursing• Acupuncture• Psychologists• Physical therapists• Occupational

therapists• Chiropractic

physicians• Naturopathic

physicians• Pharmacists• Dentists

Required Pain Management Education

www.oregonpainmodule.orgnora.stern@providence.org https://www.oregon.gov/oha/HPA/dsi-pmc/Pages/pain-care-

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RELIEF+Improving pain management and opioid safety for older adults (55+)• Target: primary care providers, clinic staff, pain

specialists, and behavioral health specialists• Program: web-based / printable resources and online

training

https://healthinsight.org/relief-plusnora.stern@providence.org

Pain and Opioids & Addiction ECHO https://www.oregonechonetwork.org/

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Lorimer Moseley—Tame The Beast—It's time to rethink persistent pain

https://youtu.be/ikUzvSph7Z4

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Motivational Interviewing for Healthcare Professionals - Online EducationCollege of Nursing at the University of Coloradohttp://www.ucdenver.edu/academics/colleges/nursing/programs-admissions/CE-PD/Pages/Motivational-Interviewing-for-Healthcare-Professionals.aspx

The Efficacy of Motivational Interviewing in Adults with Chronic Pain: A Meta-Analysis and Systematic ReviewDion Alperstein & Louise Sharpe The Journal of Pain, Vol 17, No 4 (April), 2016: pp 393-403.“MI significantly increased adherence to chronic pain treatment in the short term…”

Motivational Interviewing resources (Miller and Rollnick, 2009)

Motivational Interviewing Network:

https://motivationalinterviewing.org/

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Understanding Pain and Whatto Do About Itin Less than5 Minutes

Joint Pain Education Project video from the Department of Defense and Veterans Health Administration to learn more about chronic pain management.

https://www.youtube.com/watch?v=cLWntMDgFcs

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tools for changing the conversation about pain: resources for...

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