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- 1. Materials Created By: Durham Interdisciplinary Pain Clinic (DIPC) of the Durham VA Health Care System Funding Provided By: VISN 6 Mid-Atlantic Research, Education and Clinic Center (MIRECC) Veteran's Guide to Effective Chronic Pain Management
- 2. 2 Goals for Today 2 Basic ways to manage pain and improve function 3 Understand pain and its impact on your life 4 Tips to help you communicate with medical provider(s) 1 Define pain (acute and chronic)
- 4. 4 DEFINING PAIN Definition and Prevalence Experience Unpleasant Damage Subjective http://www.iasp-pain.org/ International Association for the Study of Pain (IASP): “An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
- 5. 5 DEFINE PAIN Acute Pain vs. Chronic Pain Acute Pain Chronic Pain Lasts less than 6 months Lasts more than 6 months Symptom (of tissue damage) Becomes the illness vs. symptom of something else Expected to go away No known cure / Focus on function Useful signal something’s wrong Signal is no longer helpful as a warning sign Rest often recommended Rest (too much) can make things worse Less (short-term, limited) life disruption More (long-term, ongoing) life disruption
- 6. 6 THE IMPACT OF PAIN: Biopsychosocial Model The Pain Cycle Time off work, money worries, relationship concerns Persistent pain Being less active Loss of fitness, weak muscles and joint tissues Lack of energy, tiredness Stress, anxiety, fear, anger, frustration Depression, mood swings Negative thoughts, fears about pain and the future
- 7. 7 DEFINE PAIN The Pain Experience Pain messages received Signal is connected to many parts of the brain – centers for sleep, appetite, memory, learned behavior, anxiety, and mood Nerves send pain messages Pain messages can be modified Messages can be “wound up” or “wound down” by signals from the brain Pain sources Adapted from The British Pain Society (2010)
- 8. 8 DEFINE PAIN The Pain Experience Gate Control Theory Information from the brain (thoughts) can open or close the gate Gate Open: More Pain Gate Closed: Less Pain Brain Spinal Cord Pain Signal (Melzack & Wall, 1965)
- 9. 9 Social • Family / friends to help? • Do others do things for you that you could do? Activity • Too much / too little? • Unhealthy coping tools? Emotional • Fear pain flares or avoid things because of pain? • Anger, sadness, loneliness Mental • Attention: Is pain always the focus? • Beliefs: Do you feel pain is uncontrollable? Physical • Body Change • Muscle Tension GATE CONTROL THEORY Opening the “Gate” (More Pain)
- 10. 10 Social • Family / friends help when needed • Others encourage you to stay active and healthy Activity • Pacing strategies • Healthy coping tools and work / life balance Emotional • Calm and hopeful • Able to relax and prevent major mood swings due to pain Mental • Attention: Helpful distraction tools? • Beliefs: Do you believe you can control (and predict) pain? Physical • PT, stretching, exercise, massage • Heat/Cold, TENS unit, medication GATE CONTROL THEORY Closing the “Gate” (Less Pain)
- 11. 11 Manage Pain
- 12. 12 MANAGE PAIN The Chronic Pain Experience Everyone’s Pain is Different increase from “usual” pain level and may vary in how long it lasts Flare-up present about ½ the day or more Continuous Location Initial cause Perceived severity, etc. Chronic Pain Pattern
- 13. 13 MANAGE PAIN Veteran-Centered Treatment FOUNDATION Health Behaviors & Self-Care INDIVIDUALIZED PLAN Medications Surgical Physical Medicine Psychological / Behavioral Stimulation Specialty Pain Clinic
- 14. 14 MANAGE PAIN Health Risks of Long-Term Opioid Use Health Risks CDC Guideline for Prescribing Opioids for Chronic Pain (3/16/16) Risk of Increasing Dosage Risks / Benefits of Continued Use Death Accidental overdose Tolerance / Dependence Hyperalgesia (more sensitive to pain) Weaker immune system Sexual dysfunction Constipation
- 15. 15 MANAGE PAIN Change Your Thinking: Self-Care and Management What can I do today to help manage my pain? How can I still do things important to me even if pain is there? What has helped me get through a bad pain day in the past?
- 16. 16 MANAGE PAIN Our Response to Pain Matters Increase Pain Unhealthy Responses Thoughts • My life is controlled by my pain. • No one understands what I’m going through. Behaviors • Inactivity • Isolating from others • Not taking care of oneself Decrease Pain Healthy Responses Thoughts • I am having a bad pain day, but I can still get things done. • When I have felt pain like this in the past, it was helpful to apply a hot compress. Behaviors • Doing things you enjoy • Being physically active • Taking care of yourself (physically & mentally)
- 17. 17 MANAGE PAIN Self-Care Strategies Stress (Manage Stress) • Relaxation: meditation, prayer, reading a book • Staying active: walking, social activities, volunteering Sleep (Improve Sleep) • Consistent wake time and rise time • Bed only for sleeping • No alcohol / caffeine close to bedtime • Use CPAP if prescribed Healthy Weight (Eat Healthier) • Limit sugary drinks and alcohol • Add more fruits / vegetables / water • Eat at restaurants less often
- 19. 19 UNDERSTAND PAIN How We Move Matters: Introduction to Time-Based Pacing Alternate Between Active and Rest Time (Cycle) After I walk for 10 minutes and rest for 15 minutes, I walk again for another 10 minutes. Over time, the more cycles of walking and resting I do the more overall walking I can accomplish. Find Your Rest Time If I rest for 15 minutes, I can start walking again without experiencing a pain-flare up. Find Your Active Time I can walk for 10 minutes before a pain flare-up.
- 21. 21 COMMUNICATE EFFECTIVELY 10 Tips to Get the Most Out of Your Doctor’s Visit 1 Prepare for the visit 2 Be clear and to the point 3 Know your healthcare team 4 Take medicines as prescribed 5 Be honest and open 6 Listen carefully and take notes 7 Ask about timing of expected results 8 Phone Calls: Plan your message ahead 9 Ask About Follow-Up: when, triggers 1 0 Arrive early (parking, check-in, etc.) In using these tips, we hope that you and your provider are able to communicate more effectively to reach pain-related goals. Used with permission from Dr. MJ Mariano, Puget Sound VA
- 22. 22 Today's Summary 1 Understand our pain better 2 Be an active part of our own pain management 3 Team up with providers and communicate well We can live better with pain if we do a few things:
Editor's Notes
- Welcome and speaker introductions. General group guidelines: -Please turn off (silence) cell phones -We encourage you to participate as much as you feel comfortable. However, we will be covering a lot of information so at times will need to move the conversation along to make best use of time. -Please be respectful of other’s opinions and allow everyone the opportunity to speak/participate. -You can share what you learn (information), but keep information about other group members private. Specific Introduction about the class: This class was developed by several pain specialists from different disciplines including anesthesiology, nursing, pharmacy, physiatry, primary care, psychiatry, and psychology. We have heard many patients say, “I wish my doctors would talk to each other”. So, we did. And we found that by combining efforts of people with different areas of expertise, we were able to develop approaches that no one specialty could do on its own. The result is this educational program that addresses pain management with an emphasis on a biopsychosocial approach to pain care. Perhaps most importantly, this approach includes the one expert on your pain that is most often excluded: YOU!
- There are a few things that we hope you learn today. We want to help you understand the cultural shift in chronic pain treatment from a biomedical to biopsychosocial approach. This means that your care for chronic pain will focus on the biology of the problem in addition to some psychological and social factors (bio-psycho-social). We’ll talk more about that in detail, and will discuss some additional supportive concepts, such as the chronic pain cycle that will hopefully make this model more clear. To begin; however, we’ll discuss the differences between acute and chronic pain. Conceptually, this is something that you are likely aware of; however, we will make this distinction today to demonstrate how acute and chronic pain are different and why they should be treated or managed differently. This is a key piece to understanding the shift from a biomedical to biopsychosocial approach to pain care. Then, we’ll talk about how chronic pain impacts our lives. Chronic pain does not occur in isolation, but rather is a result of multiple influences. We will briefly discuss some strategies to help manage chronic pain conditions and focus on the concept of managing pain and improving function, rather than curing the pain or expecting it to go away. Setting reasonable expectations for pain intensity and function is a very important fist step in effective chronic pain care management. Finally, we will discuss a few ways that you can improve communication with your pain care provider.
- Before we talk about the formal definition of pain, let’s discuss how common it is. How many people know someone else in your lives (whether a family member, friend, coworker) that also deals with chronic pain? What percentage of people in the US do you think struggle with chronic pain? (Take guesses from participants) Chronic pain is unfortunately a common experience for many people in this country The CDC has estimated that 1 in 4 individuals (25%) in the US experience chronic pain (NCHS, 2006). Estimates as high as 50% male Veterans seen in the VA have chronic pain conditions (Kerns et al., 2003). How would you define pain? Elicit responses.
- The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage. One of the most important components of this definition is the “sensory OR emotional experience.” This definition clearly captures the complex nature of the pain experience. It says that there doesn’t have to be a somatic/sensory/bodily injury or tissue damage for someone to feel intense chronic pain. There’s no definition of what is “real” or “not real” pain. Pain is an experience, and the pain experience should be validated. There are a couple of other ways to conceptualize or define pain: Pain is unpleasant, that’s obvious. Pain is an experience We feel pain both physically and emotionally It is impossible to say pain is just a physical or just an a emotional experience. It’s both! Pain impacts mood and mood (stress) impacts pain. Pain does not happen in isolation. We’ll talk more about this connection later in the presentation. Pain is subjective No technology (lab tests/imaging study) can measure pain; there is no pain thermometer Our perception of pain is critical, and everyone’s experience is different. Pain is typically associated with actual or potential tissue damage (like when you burn your hand). Sometimes we know the source of our pain (for example arthritis, diabetic neuropathy, injury), but sometimes you may not know the direct cause. When we can’t find the underlying “cause” of pain, it can be stressful and lead to responses that make our pain worse.
- Pain can be classified in 2 ways: acute vs. chronic Briefly solicit some thoughts from the audience on the difference between acute and chronic pain Acute pain example: hand on hot stove, spraining your ankle, etc. Chronic pain example: long-term pain in a body part that doesn’t go away (can persist when there is no clear evidence of the initial tissue damage). Examples could include degenerative conditions, long-term back pain. Layering of acute and chronic – acute pain flare-ups that occur simultaneously with “routine” chronic pain. Ask why it is important to make the distinction between acute and chronic pain. Then, explain that acute and chronic pain are distinctly different conditions that require different interventions. So, even though we understand the definitions, sometimes, this can be confusing to both patients and to providers and we use acute pain interventions for chronic pain conditions. Go through each bullet comparing and contrasting acute and chronic pain; taking care to remind patients regularly we make these distinctions to effectively guide treatment and recovery expectations. Today we are going to discuss ways to focus on MANAGING pain (vs. curing) with a goal of giving you more control of your pain so you have more control of your life. The first step is to better understand your pain experience.
- How does pain impact your life? Elicit brief responses. We use the term biopsychosocial model to explain the impact of pain Tie in participant’s responses to the following: Bio: how it impacts our biology (or physical body) Psych: how it impacts our psychology (or emotional health) Social: how it impacts our social life (family/friends/work) The Chronic Pain Cycle demonstrates the interplay between chronic pain and all domains of your life (physical, emotional health, social/family, work, etc.) Proceed through each graphic on the image, it doesn’t matter where you begin, as all are a part of the pain cycle. If you start with pain, then the following is a logical progression: Chronic pain can lead to people becoming less active. Sometimes this is due to the pain associated with certain movements (e.g. walking), but other times it is related to fears of harming oneself more (increasing pain or injury). When we become less active, our bodies lose fitness and our muscles become weaker and our joints stiffer. Think of an athlete during spring training. How do you think they feel physically when they start being active after months of being less active on their off-season? Elicit responses As a result, we lose our stamina and we feel more tired and experience low energy. What is your mood typically like when you feel very tired or fatigued? It’s natural for us to experience negative emotions (such as irritability, stress, worry) when we feel fatigued and in pain. Negative thoughts often accompany our negative moods, such as “I can’t do anything when I have pain like this.” We often worry about our pain and how it will affect us in the future. We often start avoiding our friends/family and any activities that involves movement because it hurts to move. The combination of experiencing a negative mood, being less active, and not spending time with friends/families or engaging in meaningful activities leads to distress (such as mood swings and/or depression) and to increased disability (not being able to complete chores, go to work), which further increases distress and increases our pain experience. Thus, chronic pain affects all areas of your life, including how you feel physically, emotionally, and how you interact with others. Today, we are going to discuss ways to break this pain cycle. But first, let’s talk a little bit about the underlying mechanisms of pain; the biology.
- Historically, explanations of how humans feel pain have been too simple and did not accurately capture the full pain experience. For example, it was originally believed that if you had an injury on a specific part of your body (e.g., hand) then a pain signal would only travel in one direction (from your hand to your brain) to signal your pain. This signal meant stop doing what you’re doing that is causing the pain. We now have a more complete explanation of how we feel pain in our body. If we look at this image, we see that the pain signals travel from the pain source along nerve fibers (like wires) though the spinal cord, to the brain. Our pain signals are received in the brain, where we also have areas that process sleep, emotions, and memory. Our pain messages can be modified in the brain and as a result, we can feel more or less pain. For people with chronic pain: Cells at the nerve endings, in the spinal cord, and in the brain can become over sensitized as a result of constant pain input This is called “wind-up” and is one of the reasons why persistent pain does not go away easily, even if the initial cause of pain is discovered and treated. In simple terms, the body’s warning system become more sensitive, producing an increased feeling of pain even though there may no longer be any continuing damage to the body Take away: Chronic pain leads our body to become more sensitive to pain. Pain is a complicated mixture of signals from the body and how the brain interprets them. But how does this work?
- NOTE: This is an animated slide. It demonstrates that when more closed, the “gate” still allows some pain signals to travel to the brain, but that those signals can be reduced. Have you ever noticed some times you are less aware of your pain than at other times? What’s going on at those times? (Elicit brief responses) Gate Control theory focuses on how different factors can increase or decrease our pain experience. In the last slide, you learned how nerves from all over the body run to the spinal cord, “which is the first main meeting point for the nervous system.” In the spinal cord, you “might imagine a series of “gates” into which messages about pain arrive from all over the body. The “gates” control what messages pass through from your body to your brain. If the gates are more open, then a lot of pain messages pass through to the brain and you are likely to experience a high level of pain. If the gates are more closed, then fewer messages get through and you are likely to experience less pain. Why is this important? If we know which factors increase or decrease our pain experience, we can exert some control over our own pain experience. You can be your own gatekeeper. How do we do this?
- Here is a list of factors that open the gate (i.e., increase our pain experience). Elicit responses as appropriate for categories. Physical: What do you notice about your pain when your muscles are tensed? Mental: What we pay attention to matters; is your mind always focused on your pain? Do you believe that your pain is uncontrollable? Emotional: Negative emotions (e.g., anger, sadness) can open the “gate,” and also may create muscle tension to further worsen pain. Fear of pain, or anticipating a pain flare-up can also cause us to avoid activities we really want to do. This can lead to reduced activity and stiffness, and also can lead to some of the negative emotions that open the pain “gate” and make pain worse. Activity: What happens when you push yourself too far? How about if you are inactive for several consecutive days? Are you using unhealthy coping tools? Are you using food or substances (like alcohol, illicit drugs, cigarettes) to cope with your pain? Social: Do you have people in your life who can help when you need it? On the opposite end, do you have people in your life who do things for you that you could do yourself? How might having people help you too much open the gate?
- The good news is that we also know factors that can close the gate (decrease our pain experience.) Physical: Trying a variety of pain management strategies can help with pain. Mental: What do you notice about your pain when you are watching your favorite television program or listening to favorite music? Do you believe you have some control (or can predict) your pain experience? Emotional: Positive emotions, such as feeling calm or hopeful, or being able to relax can improve pain. Also feeling a sense of control can help improve pain. Activity: Having a healthy mix of both rest and activity is helpful. Social: Having people in your life who can help when needed, but also encourage you to stay active and be healthy. It is important to surround ourselves with people who we feel connected to, who provide support when we need it, and who we feel good about being around.
- Next, we are going to discuss ways to manage pain which are all aimed to help improve your ability to live well despite pain. As we discuss these options (some of which may be new to you), we encourage you to think of how you can apply them to your pain.
- We can experience different types of pain, and each person’s pain is unique. For example, you may all have different pain locations, or you may all have the same pain location, but your injuries may be different. Some of you may report less pain than others, and some may be able to function better than others. What is common for chronic pain conditions is a pattern of continuous pain and flare-ups. We will discuss treatment strategies to help manage both continuous pain and flare ups, and how to address acute on chronic pain.
- Earlier we discussed how multiple factors influence our pain experience Biopsychosocial Model- notes how our pain is influenced by our physical health, emotional health, and social life Gate Control Theory- how different factors “open” or the “close” the gate (i.e., increase/decrease our pain) Pain is impacted by multiple factors (e.g., stress, body changes), so your treatment plan will need to include treatments targeting each of these factors. Everyone here today has their own unique pain experience and thus, it is essential that your treatment plan be tailored specifically for you. Not a one size fits all approach. Go through each bubble in this order: Healthy Behaviors & Self-Care You play the most important role in your treatment. Taking care of yourself is a critical aspect of dealing with chronic pain. As discussed earlier, there are things you can do to improve or worsen your pain experience. You are in the driver’s seat and can influence your pain experience. Later in this presentation, we will discuss specific strategies you can use to improve your pain. Remainder of treatments. These treatments are available in the medical facilities like VA and you may benefit from a combination of these treatments to most effectively deal with your pain. Note, that medications are listed last, as they are often thought of first.
- This slide is an opportunity to briefly discuss with patients why their providers may be pursuing opioid tapers and/or are hesitant to start long term opioid therapy. Patients may wish to share their own experiences with providers and medication changes (positive and negative). Do your best to empathically reflect concerns, but redirect them to the content of the presentation. Be familiar with the resources available at your institution and in the community for referral recommendations (i.e., pharmacy, interdisciplinary pain clinics, opioid assessment clinics, etc.). Long term opioid treatment is often an area of confusion and stress for many individuals with chronic pain. For acute pain or cancer pain, opioids can be an effective way to manage pain. For long-term pain, benefit is unclear, however it is clear that there is substantial risk of harm with long term use, including: (descriptions listed below, elaborate as appropriate). All-cause mortality Individuals using long-acting opioids for chronic pain (versus other types of medications: anticonvulsants or cyclic antidepressants) were at a significant increased risk of death from all causes investigated (respiratory, cardiovascular, and non-overdose causes such as accidents or medication interactions) Unintentional overdose The risk for accidental overdose can increase with higher doses of prescribed opioids, and can include concerns such as respiratory depression (i.e., stop breathing), cardiac (heart) risks, and fatal drug interactions Opioid-induced tolerance / Dependence Over time, our bodies become less sensitive to opioids, which lead to increase in dosage over time and higher risk for side-effects or complications. This can lead to physical and psychological dependence on a medication that was prescribed originally to help pain, resulting in a new health concerns that will likely require formal treatment to return to better health. Opioid-induced hyperalgesia (OIH) OIH is a state of nociceptive sensitization caused by exposure to opioids. It is characterized by a paradoxical response that occurs when a patient’s pain is treated with opioids and he/she becomes MORE sensitive to painful stimuli. So, over time, they may feel more pain and/or be more sensitive to pain despite no change in medical condition. Immune system changes Opioids cause immune system to weaken making it harder to fight infections Sexual dysfunction Opioids are known to cause sexual side-effects (i.e., erectile dysfunction) Constipation Opioids are well-known to cause gastrointestinal side-effects such as chronic constipation. This link is so well known that we now have new medications on the market targeting the treatment of “opioid induced constipation” Due to our increasing understanding of opioid risks, the Centers for Disease Control and Prevention (CDC) in March 2016 developed guidelines to help protect patients from long-term opioid use. Medical providers are advised to follow these guidelines and these guidelines have influenced how they have approached prescribing opioids. Your providers will evaluate the risk and benefits of continued use of these medications and also are aware of the risks that come with increasing dosage of these meds. **Do not make any changes own your own in regards to these medications, but consult with your medical providers.
- Shifting perspective or changing how you think about your pain can be challenging; however, this is important in helping you live well with/despite the pain. Read through questions on the slides. Shifting the perspective or changing how one thinks about their pain can be challenging; however, this is important in helping individuals be able to live well with/despite the pain. These statements represent examples of ways of thinking that can lead to a more active and healthy response to your pain. This is the foundation for Cognitive Behavioral Therapy for Chronic Pain (CBT-CP). It’s essential to validate how challenging it can be to shift one’s perspective. It’s more than just thinking good thoughts. Negative, self-defeating, or pessimistic thoughts about pain are common and often automatic, and simply trying to avoid negative thoughts altogether is unrealistic. The process of shifting one’s perspective is about identifying automatic thoughts when they arise (because they will!), recognizing that they are often inaccurate and lead to unproductive behaviors and outcomes, and then trying to replace the thought by attending to more balanced, helpful thoughts. This process takes time and practice, and it won’t happen immediately for most patients. Because this process can be challenging, it is a key skill discussed in CBT-CP. Most VA systems offer CBT-CP either in a group or individual format. Remember, because of the way pain is experienced in the brain, this is not just about learning to live with the pain. Making changes that allow patients to live well despite pain can reduce the pain. Just as some responses such as inactivity and isolation can lead to a cycle of worsening pain, positive changes can lead to a cycle of improving pain!
- How we respond to pain directly impacts our pain experience in negative (open pain “gate”) or positive ways (closing pain “gate”) Unhealthy responses to pain include unhelpful thoughts about our pain, particularly that it is uncontrollable and unpredictable. Review example thoughts. Unhealthy responses also include unhealthy behaviors that increase pain, including being inactive, isolating ourselves from others, and overall not taking care of ourselves. Also note the interaction of these unhealthy thoughts and behaviors: these unhealthy thoughts can lead to these unhealthy behaviors, which perpetuate the unhealthy thoughts (reference the chronic pain cycle here). The good news is that we know what type of thinking and behaviors can help us decrease our pain. Healthier ways to responding to pain, include: helpful thoughts (review examples) and healthy behaviors, including: doing things you enjoy, being physically active, and taking care of yourself. A healthier interaction between thoughts and behaviors exists here too. Healthier thoughts can lead to healthier behaviors, which perpetuate the health thoughts.
- Taking time to take care of yourself is one way to help gain more control over your pain experience. Stress can take a toll on your overall health, and may increase pain. When you feel stressed what do you notice about how you feel? Can lead to muscle tension, negative emotions, posture changes. Some ways to manage stress include: engaging in relaxing or calming activities (such as meditation, prayer, reading a book, etc.) and staying active (exercise, volunteering, yoga) Getting better quality of sleep can also help improve pain experience. Listed are some strategies to help you improve sleep without medication. We also recognize that pain can negatively impact your sleep as well. Implementing these other strategies can help. Our bodies may feel less painful with more restorative sleep, and if we wake up refreshed we have a better opportunity to do productive things during the day that lower our stress level and help us feel more in control of our lives despite pain. Maintaining a healthy weight through healthy nutrition and exercise can also improve pain experiences. Making small changes can add up over time. Think about setting concrete goals like increasing daily servings of vegetables (e.g., to 3 if you eat 2 usually) and making small changes in your physical activity level (e.g., walk to the mailbox 1-2 times per day, stand and stretch or walk around for 5 minutes every hour if you’re sitting most of the time at work or home) If you are feeling like you could use some help learning more and working on these strategies, encourage you to let us or your medical providers know because there are services in the VA (MOVE! program, Wellness groups with Primary Care Psychology) that can help support you on those goals.
- Now, we will talk a bit more about how to understand pain so that you can live more effectively with (or despite) pain.
- Today, we have discussed the importance of being active, but some of you may be thinking “I’d like to be more active, but where do I start?” Time-Based Pacing is a strategy to help you engage in activities that may be more difficult due to chronic pain Involves taking breaks at regular times, not “pushing through” until the task is done Professional athletes take regular water breaks on the sidelines in order to perform at their peak efficiency. Their coaches know that if they keep their players in the game until they are worn out or dehydrated then they will not be performing at their best. The same can be applied to chronic pain. In order to be your most efficient, it is helpful to take breaks in order to perform at your best. Active Time: How long you can do a task safely without causing a pain flare-up Rest time: Estimate how long you need to rest before doing activity again. Go though example. People who use time-based pacing actually get MORE accomplished. Can be used for physical activities such as example (mowing lawn) because they are not sidelined for hours or days after pushing themselves too hard. If you have a group who could benefit from some additional explanation of time-based pacing, the companion Presenter’s Guide contains graphs that you can re-create on a white board showing time based pacing activity. But also could be used for other activities that may have been more difficult, such as sitting down and reading a book
- Another strategy to help manage your pain is to communicate well with your providers. Providers can support you on your goals, and help you to better understand your condition and treatment plan.
- Here is a list of top ten tips to making the most of your health care visits. In using these tips, we hope that you and your provider are able to communicate more effectively to reach pain-related goals. Review each tip with additional information provided below: 1. Be prepared for the visit. Write down concerns and questions and prioritize them as there may not be enough time during the visit to discuss everything. Consider writing an agenda and sharing it with the provider at the beginning of the visit. The provider may share his/her agenda as well. Patients should expect that providers will ask about routine health issues such as high blood pressure, diabetes, and health screening. A new agenda can be established based on the priorities of each party. 2. Provide complete but succinct information. Although it would be helpful to be able to expand on their pain experience, time is limited during appointments, so it is important to include relevant and appropriately detailed information. Encourage patients to include information about expectations of pain care interventions and of their provider and to be prepared to describe pain location, severity, duration and current function. They should also mention if function has changed as a result of treatment. 3. Know who’s who on the health care team. Ask if it’s not known. Patients in VA have PACT teams that include primary care providers, nurses, and mental/behavioral health staff. Patients should be aware that a separate mental health appointment is often not required, so patients can meet with mental health staff during their primary care appointments. In addition, some pain-related groups are run out of primary care and are readily accessible to those receiving primary care services at VA. Encourage patients to ask about these opportunities. 4. Take medicines as prescribed. Encourage the patient to keep the team informed about changes in medication regimens s/he would like to make. Patients can reach out to providers at appointments, via phone calls, or through My HealtheVet. Reiterate that patients should not take medications that are prescribed to others and are not use illicit substances to treat pain or any other condition. 5. Be honest and as open as possible. Encourage patients to let their provider know if there is anxiety about the visit or any problems. Providers are not able to read minds, so patients need to be honest about their experiences, symptoms and care. Encourage patients to talk with providers about function and what they are able to do or not do. In this way, providers can work collaboratively with patients to set functional goals that are easy to evaluate. 6. Listen carefully & take notes. Listening to information one may not 100% agree with can be challenging. Listen to what you provider has to say and consider the options presented. Encourage patients to remain open to new or even old approaches to pain care that have been effective in the past. Suggest patients write things down so that they can remember all of the information provided during the appointment. 7. Ask for information about time frames to expect test results, change in symptoms, etc. and when to report back if not received. If patients have had pain for many months, it probably won’t get better overnight. Have realistic expectations about time frames for improvement. 8. Plan phone message before you call. Be concise and succinct. Busy providers will appreciate a short message with a specific and well-organized question. For example, the patient might say, “Hi, this is John Smith 1234, date of birth 1/1/1974. My primary care provider is Dr. Smith. My ibuprofen prescription was changed, and I would like to speak with someone to tell me if I am taking it the right way. My number is 123-4567.” 9. Ask for clarification about when to follow up and under what circumstances. Patients may not understand how to take medications when they have a pain flare or an acute pain condition. Being prepared for these circumstances can provide the patient with a sense of control and predictability, which is very important for positive pain outcomes. For example, if a patient has 2 different pain medicines, a heating pad, and a TENS unit to use as for pain flares, they should have a plan for how and when to use them. 10. Plan to arrive at appointments early enough to deal with possible delays due to traffic, parking issues, etc. That way, the provider will have the maximal amount of time to be able to spend working with the patient. Sometimes clinics get behind for all kinds of reasons (emergencies do happen!), and patients can do their part to try to keep the clinic on track instead of running late.
- We covered a lot of information today. We hope that we provided you with a framework to understand the transition in chronic pain treatment from a biomedical to biopsychosocial approach. In support of this, we discussed how acute and chronic pain differ and emphasized how this guided different treatment approaches. In addition, we talked about how chronic pain interacts with different areas of our lives. Pain has a reciprocal relationship with our mood, our interactions with others, and our physical function. Fortunately, we have some control over how much we allow pain to impact our lives. We discussed some strategies to do this, all while developing a better understanding of how our pain is experienced from a biological perspective. Finally, we discussed a few ways that you can improve communication with your pain care provider. Presenters should be prepared to provide patients with resources available to them at their local facilities and within the community. Consider inclusion of behavioral health interventions, complementary care, Whole Health classes and any other opportunities for patients to become engaged in their own pain care.