Motivational Interviewing for Chronic Pain Management Jill Schneiderhan

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Motivational Interviewing for Chronic Pain Management Jill Schneiderhan, MD Clinical Instructor, Department of Family

Motivational Interviewing for Chronic Pain Management Jill Schneiderhan, MD Clinical Instructor, Department of Family Medicine University of Michigan Darren Jones, Ph. D Director of Behavioral Medicine Providence Hospital Family Medicine Residency Program

 Audience includes anyone working with patients with chronic pain The authors of this

Audience includes anyone working with patients with chronic pain The authors of this presentation have nothing to disclose

Objectives • Participants will be able to identify common self management strategies that have

Objectives • Participants will be able to identify common self management strategies that have evidence based research regarding their role in the reduction of chronic pain. • Participants will be able to understand the basic concept of Motivational Interviewing as it applies to chronic pain management. • Participants will be able to perform a brief motivational interviewing intervention for a patient with chronic pain.

Epidemiology • Approximately 76. 2 million Americans suffer chronic pain • Roughly 63% of

Epidemiology • Approximately 76. 2 million Americans suffer chronic pain • Roughly 63% of patients seek help from their PCP • Accounts for 20% of outpatient visits and 12% of all prescriptions • Most common cause of long-term disability • Lost work days in the United States estimated at more than 50 million days per year • The annual cost of untreated or undertreated pain to taxpayers and employers has been calculated at over $100 billion per year, in direct and indirect expenses -National Center for Health Statistics 2006 report

Definitions Chronic pain has been defined as pain which lasts beyond the ordinary duration

Definitions Chronic pain has been defined as pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal. International Association for the Study of Pain & American College of Rheumatology define as pain > 3 months DSM – IV defines as pain > 6 months

Treatment of Chronic Pain Pharmacological Non-opioid: NSAID’s, acetaminophen, opioids Adjuncts: SNRI, TCA’s, gabapentin/pregabilin Non-pharmacological

Treatment of Chronic Pain Pharmacological Non-opioid: NSAID’s, acetaminophen, opioids Adjuncts: SNRI, TCA’s, gabapentin/pregabilin Non-pharmacological Prescribed by physician (acupuncture, massage, psychotherapy, physical therapy) Self-directed (tobacco cessation, increased activity, improved sleep, weight loss, glycemic control)

Self-Directed Tobacco Cessation Exercise, Activity, & Pacing Sleep Quality Weight Loss Blood Sugar Control

Self-Directed Tobacco Cessation Exercise, Activity, & Pacing Sleep Quality Weight Loss Blood Sugar Control Mood Regulation Stress Reduction

Tobacco Cessation Smoking and pain have a complex relationship The relationship appears to be

Tobacco Cessation Smoking and pain have a complex relationship The relationship appears to be both causal and reciprocal Nicotine Implicated in the development of low back, knee pain and headaches possibly through vascular vs degenerative processes Consistently associated with increased pain intensity and functional interference Paradoxically can produce a temporary analgesic effect Activates nicotinic acetylcholine receptors leading to increased dopamine secretion Thought to induce a sense of relaxation and well being that counteracts the aversive pain state Tobacco cessation decreased amount of opioid use 1. Parkerson, H, et al. Understanding the relationship between smoking and pain. Expert Rev. Neurother. 13(12), 1407– 1414 (2013) 2. Patterson, A, et al. Smoking Cigarettes as a Coping Strategy for Chronic Pain is Associated with Greater Pain Intensity and Poorer Pain-Related Function. J Pain. 2012 March ; 13(3): 285– 292.

Activity/Exercise - formal plans Decrease in overall pain Increased activity – less formal Some

Activity/Exercise - formal plans Decrease in overall pain Increased activity – less formal Some studies show suggesting increased activity is more effective than a formal exercise program Group Exercise Decrease in pain, increase in function Group exercise produced decreased pain for 1 year vs. 6 months with PT Pain specific PT with ongoing exercise Decrease in chronic low back pain with core muscle strengthening 1. Hwi-Young, et al. Effects of the CORE Exercise Program on Pain and Active Range of Motion in Patients with Chronic Low Back Pain. J. Phys. Ther. Sci. 26: 1237– 1240, 2014. 2. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005; (3): CD 000335. 3. Mior S. Exercise in the treatment of chronic pain. Clin J Pain. 2001; 17(4 suppl): S 77– 85. 4. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach. Spine. 1992: 17: 641 -652.

Sleep Quality Pain and sleep – causation vs. reciprocity Many studies initially looked at

Sleep Quality Pain and sleep – causation vs. reciprocity Many studies initially looked at poor sleep as a function of more pain More recent studies shifting toward poor sleep causing increased pain Trouble sleeping led to increase diagnosis of fibromyalgia within the next 10 years Lack of sleep leads to increased sensitivity to painful stimuli Dysregulation of endogenous opioid systems Attenuation of the analgesic efficacy of μ-opioid receptor agonists 1. Finan, P, et al. The Association of Sleep and Pain: An Update and a Path Forward. The Journal of Pain, Vol 14, No 12 (December), 2013: pp 1539 -1552

Obesity negatively impacts chronic pain Stress on entire musculoskeletal system especially joints Systemic pro-inflammatory

Obesity negatively impacts chronic pain Stress on entire musculoskeletal system especially joints Systemic pro-inflammatory state worsening widespread and local pain Higher BMI is associated with increased intensity and disability with low back pain In a study of 372 patients seeking care at university based pain clinic higher BMI correlated to decreased function, increased depression, and decreased quality of life 1. Arranz, L, et al. Effects of Obesity on Function and Quality of Life in Chronic Pain Conditions. Curr Rheumatol Rep (2014) 16: 390. 2. Urquhart, D, et al. 2011 Young Investigator Award Winner: Increased Fat Mass Is Associated With High Levels of Low Back Pain Intensity and Disability. Spine Volume 36, Number 16, pp 1320– 1325 3. Marcus, D. Obesity and the Impact of Chronic Pain Clin J Pain • Volume 20, Number 3, May/June 2004

Diabetes & Chronic pain A recent study of black patients of low socioeconomic status

Diabetes & Chronic pain A recent study of black patients of low socioeconomic status showed Moderate to severe pain correlated to high glycemic index Those with pain – ate more high fat foods, exercised less and had more symptoms of depression When controlled for self management behaviors and symptoms of depression there was still an increase in A 1 C in those with pain vs. those without 1. Herbert, M, et al. Association of pain with Hb. A 1 c in a predominantly black population of community-dwelling adults with diabetes: a cross-sectional analysis. Diabetic Medicine. 30, 1466– 1471 (2013)

Summary Data is rich on findings of how patients can improve their pain with

Summary Data is rich on findings of how patients can improve their pain with improved self management So…how do we help them get there?

Overview of Motivational Interviewing First published in 1983 Originally designed as brief intervention for

Overview of Motivational Interviewing First published in 1983 Originally designed as brief intervention for alcohol abuse Expanded use in 1990’s It is not a panacea It is not a new idea It is not that different from what you may already do

Overview of Motivational Interviewing Works by activating patients own motivation for change and adherence

Overview of Motivational Interviewing Works by activating patients own motivation for change and adherence The WAY you talk with patients can influence their personal motivation Evidence-based Can be brief Can be targeted

The Myth of the Unmotivated Patient: Assumptions of MI No patient is completely unmotivated

The Myth of the Unmotivated Patient: Assumptions of MI No patient is completely unmotivated Motivation for change is malleable Motivation is shaped within the context of the patient -doctor relationship Treatment is often too focused on giving patient what they lack (medication, knowledge, insight, skills)

The Spirit of Motivational Interviewing Collaborative: a partnership Evocative: focused on evoking what patient

The Spirit of Motivational Interviewing Collaborative: a partnership Evocative: focused on evoking what patient already has Honoring patient autonomy: an acceptance that people can and do make choices about their lives

The Spirit of Motivational Interviewing People generally resist being coerced Ironically, this is partly

The Spirit of Motivational Interviewing People generally resist being coerced Ironically, this is partly why MI works Acknowledging the freedom not to change can make the change possible The focus is always on what the patient is ready, willing, and able to do during today’s visit

MI Guiding Principles: RULE Resist the righting reflex: we want to fix, right? stop

MI Guiding Principles: RULE Resist the righting reflex: we want to fix, right? stop that! Understand your patients motivations: it is their reasons for change that are vital, not yours Listen to your patient: not easy to do Empower your patient: better outcomes when patient participates

How to Facilitate a Motivational Interviewing Session: Step one Set the agenda: find the

How to Facilitate a Motivational Interviewing Session: Step one Set the agenda: find the target behavior Make the connection between the behavior and their chronic pain Gather relevant details about behavior

How to Facilitate a Motivational Interviewing Session: Step Two Determine the current stage of

How to Facilitate a Motivational Interviewing Session: Step Two Determine the current stage of change The intervention should match the current stage of change The goal for the visit should be to help move patient one stage forward

How to Facilitate a Motivational Interviewing Session: Step Three Ask about the positive (good

How to Facilitate a Motivational Interviewing Session: Step Three Ask about the positive (good things) aspects about the target behavior Builds rapport and identifies the losses associated with behavior change Summarize the positives

How to Facilitate a Motivational Interviewing Session: Step Four Ask about the negative (not

How to Facilitate a Motivational Interviewing Session: Step Four Ask about the negative (not so good things) aspects of the target behavior Can you tell me about the down side? What are some aspects you would not miss? Summarize the negatives

How to Facilitate a Motivational Interviewing Session: Step Five Explore how the target behavior

How to Facilitate a Motivational Interviewing Session: Step Five Explore how the target behavior impacts goals for chronic pain treatment

How to Facilitate a Motivational Interviewing Session: Step Six Assess patient’s decision about behavior

How to Facilitate a Motivational Interviewing Session: Step Six Assess patient’s decision about behavior change Restate their identified dilemma After this discussion, are you more clear about what you would like to do? So where are you at on this issue now?

How to Facilitate a Motivational Interviewing Session: Step Seven Goal setting What will you

How to Facilitate a Motivational Interviewing Session: Step Seven Goal setting What will you do in the next one or two days? What will you be your next step? Have you ever done any of these things before to achieve this? Who will be helping and supporting you?

How to Facilitate a Motivational Interviewing Session: Step Seven On a scale of 1

How to Facilitate a Motivational Interviewing Session: Step Seven On a scale of 1 to 10 how confident are you that you can achieve this goal? If under 7 the goal may need to be modified Address barriers and identify support

How to Facilitate a Motivational Interviewing Session: Step Seven SMART goals Specific Meaningful Assessable

How to Facilitate a Motivational Interviewing Session: Step Seven SMART goals Specific Meaningful Assessable Realistic Timed

How to Facilitate a Motivational Interviewing Session: Step Seven If no decision (or decision

How to Facilitate a Motivational Interviewing Session: Step Seven If no decision (or decision is to continue the behavior) If no decision, express empathy for difficulty of ambivalence Ask if there is something else which would help them make a decision? Ask if it would be ok to revisit the issue at a future visit (and then do so!). If decision is to continue the behavior, go back to explore the ambivalence.

Application of MI to Chronic Pain

Application of MI to Chronic Pain

MI Assess what behaviors need changes in regards to chronic pain Assess what stage

MI Assess what behaviors need changes in regards to chronic pain Assess what stage of change a patient is at in regards to making behavior changes Use MI to move them forward on the Stages of Change wheel

Practice Exercise What behavior would you like to target? Pair up One person is

Practice Exercise What behavior would you like to target? Pair up One person is a patient One person is the clinician

Patient 51 yo female with 20 years of chronic widespread pain Does not exercise

Patient 51 yo female with 20 years of chronic widespread pain Does not exercise nor is she working due to pain Currently smokes – started 5 years ago to cope with pain Pick any behavior you wish to target

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Summary There are many self-directed behaviors that can be targeted for the improvement of

Summary There are many self-directed behaviors that can be targeted for the improvement of chronic pain symptoms Smoking, activity level, sleep hygiene, weight loss These behaviors should be routinely discussed at every visit Motivational Interviewing is a method for targeting those behaviors