The document discusses an integrative approach to pain management that includes both medications and non-medication strategies. It emphasizes that pain is a biopsychosocial phenomenon influenced by biological, psychological, and social factors. An effective treatment plan requires a collaborative, multidisciplinary approach that addresses the underlying causes of pain and develops skills to help patients better manage their pain and take back control of their lives from pain. Non-medication strategies like learning, exercise, stress management, and building a support system can help improve pain and function when used as part of a comprehensive treatment plan.

1. B E Y O N D T H E O P I O I D E P I D E M I C
PAT I E N T C E N T E R E D C O L L A B O R AT I V E C A R E F O R PA I N
M A N A G E M E N T

2. Managing pain requires more then medications it requires an integrative approach.
Medications are one tool in the tool kit. Learning skills, understanding pain and
building a plan can help you take your power and life back from pain.
One in 10 Americans
Experience Chronic Pain.
Effective pain management
of pain can improve quality
of life and reduce pain.

4. GOAL OF THIS TALK
TO MAKE PAIN TREATMENT LESS PAINFUL…
• In this presentation we will…
– Move from a hammer to tool kit:
“If it can’t be fixed with a hammer it’s soon to be
beyond repair.” – Proverb from Maintenance Crew
– Move beyond the cartesian model of pain to
understanding the brain and the role of neuroplasticity
in pain. The brain is a learning machine it wants to learn
about threats. Pain is a threat. The brain learns pain.
– DevelopTreatment Plan andTeam:
Pain is complex treatment is complex too. Address
underlying cause,Y Model, PainTeam, and Skills to
Engage patient.

5. YPain Neuroscience
Education (PNE)
1
Functional Goals
IntegratedTreatment,
Pain Catastrophising
2a
HurtVs. Harm,
Pain Movement
ExposureTherapy
2b
Pain is in the brain and it can change…
1. Hyperactive threat signal
2. Hyperalgesia from medications
3. Allodynia and Central Sensitization
While we can’t stop all pain we can
help our brain rewire away from pain.
Three BasicTools…
1.Accept some pain,
2. Strengthen your body,
3. Manage your pain (not control pain).
★ You are not making up your pain.
★ All sensations are created in the brain.
★ When pain is chronic it is an illness to
itself.
★ Neuroplasticity is how the brain
re-wires & pain rewires the brain.
The brain can become wired for pain

6. Pain is complex
treatment needs to
be as complex.

7. SECTION 2
PA I N I S B I O P S Y C H O S O C I A L

8. •Concentration
•Depression
•Anxiety
•Fear about future
•Beliefs about self
•Emotional overwhelm
•Fear of movement
•Thinking & attitude
PsychologicalBiological
•Fight/Flight/Stress
•Pain with movement
•Change is diet
•Sexual health
•Medication impacts e.g.
constipation
•Immune response
•Insomnia
Social
•Family relationships
•Difficulty keeping
appointments
•People not understanding
•Social isolation
•Loneliness
•Challenges working
Pain is a biopsychosocial phenomena…

10. 1. Neuron are learning machines
2. Cross wiring happens through
synaptic plasticity, poor inhibition
of pain, increased pain sensation
to the brain.
3. These changes function like an
amplifier on pain.

11. Zaki, J., Wager, T. D., Singer, T., Keysers, C., & Gazzola, V. (2016). The anatomy of suffering: understanding the relationship between
nociceptive and empathic pain. Trends in cognitive sciences, 20(4), 249-259.

12. Behavioral
Therapies
• Individual Therapy
• Health Pain Group
• PTSD, Stress, Depression
Group
• Social Engagement Plan
• Chronic Pain CBT
• Acceptance and
Commitment Therapy
Procedures
Devices
• Injections: Joint,
Trigger Point, Epidurals
• TENS Machine
• Specialty Treatment:
Orthopedics, Neurosurgery,
Pain Clinics
• RICE: Rest, Ice,
Compression, Elevation
Medication
• NSAID/Acetaminophen
• Anticonvulsants
• Antidepressants
• Topical: Lidocaine/Capsaicin
• Immune modulators
• Muscle relaxants
• Buprenorphine
• Lowest Possible
Opioid Dose
Movement
Therapies
• Physical/Occupational
Therapy
• Graded activity exposure
• Exercise/Endurance
• Warm Pool/Pool Exercise
Integrative
Therapies
• Massage, Counterstrain
• Chiropractic, Acupuncture
• Supplements,
Anti-inflammatory diet
• Yoga, Tai Chi, Qigong
• Mindfulness
If Opioids Are Part of
Treatment Plan
★ Set a goal to improve function
★ Understand overdose risk and
have a Naloxone Rescue Kit
★ Risk of dependence
★ Opioid Hyperalgesia
★ Digestion Challenges
Tip: Managing Pain
We can not cure pain but
we can manage it. Managing
pain is like having four flat
tires you have to fill all the
tires to make a full life.

13. Physical Health and Function Neuroplastic/Brain Change
Spiritual and Meaning Emotional Wellbeing
1. Undress physical issues
2. Develop strength &
endurance
3. Develop a functional goal
(Victor Frankel What if Why)
4. Pain Management Plan
1. Unlearn pain avoidance
2. Condition emotionally and
physically
3. Pain exposure therapy
4. Decreased pain perception
5. Change brain chemestry
1. Reconnect with family,
meaning and community.
2. Survive any what if you
have a why.
3. Life direction and purpose.
4. Peace/Serenity Pain not
Suffering
1. Reduce trauma, depression
and anxiety
2. Self-compassion and
motivation
3. Reduce pain suffering
4. Internal locus of control
Recovery&ChronicPain

14. PAIN
Your Life
PAIN
Your Life
Goal of Treatment…
GrowYour Life Bigger than Pain

15. Discussion: Patient Education Pain
• What are some points you wish your patients knew about
pain?
• What are some insights you have seen changed patients
motivation? Pain suffering? Internal locus of control?

16. Clinical Skill: Practice pain education

17. SECTION 3
Y MODEL – PAIN NEUROSCIENCE, PAIN
EXPOSURE, REDUCE PAIN SUFFERING

18. Phase 1 Global Activation
Amygdala and Emotion Structures. Pain
is not localized.
Phase II Pain is Localized
The brain locates the pain in a specific
part of the body and attempts to
identify the source
Phase III Pain Inhibition
Endogenous analgesics produce
inhibition turns off pain after signal is
not useful

19. Peripheral
Sensitization
Prostaglandins
Injury
Arachidonic
Acid
COX Enzyme
Allodynia

20. CentralandPeripheral
Sensitization
Allodynia
Pain experienced from normal stimuli
Cross wiring between pain
and normal sensation
Hyperalgesia
When painful stimuli is perceived as
more painful then it should be.

21. kinesiophobia
Pain Sensation Tissue Harm

22. Improving function
improves pain and builds a
life that we enjoy
As you learn to manage
your pain your functioning
improves
Living Our Best Life with Chronic Pain…
Functional Goals Pain Management

23. YPain Neuroscience
Education (PNE)
1
Functional Goals, Mood,
PTSD,Anxiety
Pain Catastrophizing
2a
HurtVs. Harm,
Pain Movement
ExposureTherapy
2b

24. Discussion: Building Pain Acceptance
• Reducing suffering is relational…
• How do you help patients understand the difference
between hurt and harm?
• How do you help patients develop functional goals?
• How do you discuss acceptance vs. giving up?

25. Clinical Skill: Building Pain Acceptance

26. SECTION 4
COLLABORATIVE PLANNING FOR PAIN

27. BACKGROUND
CLINICAL
GUIDELINES
From 2016 CDC Guidelines
“Multimodal and multidisciplinary
therapies helped reduce pain and
improve function more effectively than
single modalities.”
(Dowell, Haegerich, & Chou, 2016)
CDC Guidelines
According to CDC guidelines
Non-Opiate and Non-Pharmacological
management of pain are the first line of
treatment.
(Dowell, Haegerich, & Chou, 2016)
Multi-DisciplinaryTx is a
Standard of Care
(CDC and ICSI Guidelines)
Multi-Disciplinary Integrated treatment is
considered an optimal standard of care for all
patients with chronic pain and particularly for
patients who have failed other treatments
(Hooten et. al., 2017; Dowell, Haegerich, & Chou, 2016).
TheseTreatments Include
1. NSAIDs, SSRIs/SNRIs,
2.Anti-Convulsant; Physical
therapy/Occupational Therapy;
3. Behavioral Treatments (CBT,ACT, Pain
Neuroscience Education);
4. Nerve blockers, trigger point injections
etc. (Dowell, Haegerich, & Chou, 2016)

28. Pain Management System of Care
Level 3 Multidisciplinary High RiskTeam
Integrated pain management using share the care model for highest risk PTs
Level I - Coordinated Pain Care
Increased support and effective care for pain patients
Acute PainTrack
Early treatment planning, education and focus on function not just pain reduces the
number of patients on risky doses
1
2
4
Level 2 Collaborative Care
Collaborative care approach that reduces provider burden and increases care
3

30. Pain Perception
1. Anticonvulsants
2. TCA’s
3. Alpha 2 Agonists
4. SSRIs/SNRIs
5. Opiates
PainTransmission
1. Nerve Blocks
2. SSRIs/SNRIs
3. Oxytocin
Pain Peripheral Signal
1. Anticonvulsants
2. NSAIDs
3. Capsaicin
4. Local Anesthetic

31. Discussion: Building Pain Acceptance
• How do you have discussion about pain when people have
a fixed medicalized belief about pain?
• What has worked to help a patient who has tried
everything try something new?

32. Clinical Skill: Collaborative Pain Discussion