Case Management for Chronic Pain | Comprehensive Case Management Certification

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I'd like to welcome everybody today's presentation on case management for chronic pain.

I am your host, Dr. Donnelly Snipes.

We're going to define the problem of.

Chronic pain and you know why we.

Should care about it. Examine the similarities between chronic non cancer.

Pain so you will see that acronym cncp that's chronic non cancer pain, Mental Health issues and Addiction will identify the impact of chronic non cancer pain on patients and explore the biopsychosocial resource needs for secondary and tertiary prevention.

So I'm going to read to you.

A little bit of an abstract of one study that I looked at that I just couldn't paraphrase any better and it is the one that's hyperlinked on this page.

Historically, pain without an apparent cause was.

Labeled as psychopathological or all in your head.

This approach is damaging to the patient.

And provider alike because it pollutes the therapeutic relationship by introducing an element of mutual distrust. It's demoralizing to the patient who feels at fault, disbelieved and alone.

Moreover, many medically unexplained pains are now.

Understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry so long time ago. Few years ago even they didn't believe that fibromyalgia actually existed. They thought it was all in people's heads. Now they recognize oh it actually exists. Adjustment disorder, according to this article, remains the most appropriate, accurate and acceptable diagnosis for people who are overly concerned about their pain. Instead of doing finding a disorder that has, you know, somatization in it, the adjustment disorder is the recommended diagnosis of choice, if you will.

So that's just kind of something to think about.

If we don't take our patients reports of pain seriously, we may be unintentionally disrupting the therapeutic relationship. And I know working in addictions for, you know, almost 20 years, a lot of patients with addictions also have chronic pain. And we're going to talk a lot about that. This is actually partially based on the treatment improvement protocol from SAMHSA on treating chronic pain in patients who are in recovery from substance abuse. But I digress. It is really important to pay attention to their pain and not automatically think that they are drug seeking.

Pain.

Patients have addictive disorders about 32% of the time. So about 32% of pain patients have addictive disorders.

That's important to remember because that means one third of people that are going.

To the pain clinics actually do have some underlying addiction.

About 56% of people that are older than 20 years old report having pain.

Lasting greater than three months at some point in their lives.

36% of people report having disabling pain.

In the previous year. Now, that wasn't for a significant duration, but it was disabling, such as migraines, that may put somebody flat out in bed for a day or two or three at a time. One statistic that I found that was particularly disturbing to me was that 11 to 38% of children in the general population report living with chronic pain. Now, there's chronic pain because of stress that causes GI upset and other things. You know, that's actual pain. That's real pain there. Chronic pain because of tension, just like adults have.

But there's also in children as they grow.

If you remember where the phrase growing pains came from, it's important to recognize that children may have some growing pains and there may be more aches and pains during, episodically, during the growth and development process. That doesn't mean we should ignore their chronic pain because it is going to impact them.

We need to remember that chronic pain may have a long course with multiple.

Episodes where it gets better for a little while and then it starts hurting again. And we don't want to ignore that. We also don't want to tell people, okay, once your pain goes away, it's never coming back, which is what we get a lot from. People go to physical therapy to get fixed or cured. And it's important for them to recognize that that pain may come back and now they have more tools to deal with it. But it doesn't mean that just because it's gone right now that it's gone forever.

Chronic pain can be highly stressful for patients and families.

And this is where a lot of that biopsychosocial case management comes in. Care for people with chronic pain is increasingly done in outpatient services, which means the family is helping the person, you know, the other 23 hours of the day and six days a week, where when they're not in clinic, when they're not receiving treatment, and that's assuming they're going in, you know, even once a day for treatment.

But that is a lot of time.

That family is spending with someone with chronic pain. And if they don't understand the impact of chronic pain or they don't understand. Their loved one with chronic Pain, it can start causing a variety of relationship issues.

Untreated mood and addictive disorders in individuals with chronic pain increases morbidity and mortality.

Rates and reduces the capacity for self management.

Chronic pain due to one condition can cause increases in systemic inflammation and widespread.

Pain for people, which may result in overlapping pain conditions. That's important for us to remember.

If somebody has a shoulder injury that.

Is causing chronic pain, the brain sends out or triggers the excretion of inflammatory substances that are supposed to increase the blood flow to that area to help in healing.

Unfortunately, just like we know when we.

Take aspirin, it doesn't go directly to that spot. When the brain excretes those inflammatory substances.

They circulate throughout the body, which can.

Cause inflammation in other areas.

Across chronic pain conditions, there's generally a shift away from brain regions engaged in.

Processing the sensory component of pain toward regions that encode emotional and motivational subjective states. I thought that was really interesting when I read that study, that when they did brain scans on people that had chronic pain, there was less activity in those areas where the brain processes pain itself, the touch and the tactile sensations, and there was more activity in the areas that correspond to emotion and thinking. So the takeaway from that study was that a large part of pain may be able to be mitigated, not eliminated, but mitigated, by examining emotions and thoughts surrounding the pain in order to reduce the activity in that area of the brain as well. So we really want to quiet and calm the brain so that HPA axis isn't all excited all the time.

Another interesting thing that came from a different study was that experiences of physical.

And social pain, and they defined social pain as rejection, exclusion, bullying, negative social evaluation, or loss of a close relationship.

So social problems, experiences of both physical.

And social pain share neurochemical and neural substrates. When we experience physical pain, our body responds in a very similar way to when we experience social pain. So that was another link between our perception of pain and our feeling of pain and our cognitions and emotions, not just our tactile sensations.

Young people with comorbid depression and chronic.

Pain are at an increased risk of suicide. We need to remember this. A lot of the cognition that we're talking about and the emotions that are involved in the perception of pain take.

Place in the prefrontal cortex.

And we know that in young people, the prefrontal cortex doesn't completely develop until about age 24.

So when you're working with a 6.

Year old that has chronic pain or a 16 year old that has Chronic pain. They may not have the same cognitive abilities. They may not actually have the brain development that would enable them to deal with pain in the same way that a 24 or 44 year old may. Which we do need to recognize that, but going along with that. Since a lot of our pain perception, according to these studies, may be intertwined with our higher order thinking and emotions, we do need to remember that young people who tend to have less developed prefrontal cortex, less impulse control and problem solving skills, may be at a higher risk of suicide because they perceive this pain as intractable.

Chronic pain and addiction or mood disorders frequently co occur and fluctuate in intensity.

Over time and under different circumstances.

It is important to remember that, you know, even thinking like today, this week.

A cold front is coming in. And no matter how much you know, the research says that it doesn't exist. I can tell you when a cold.

Front is coming in.

My joints hurt a little bit more. You know, the places where I've torn a meniscus or something, I tend to feel a little bit more achy during those periods when the barometric pressure changes.

So it's important to.

Recognize the things that may cause fluctuations in intensity over.

Time and under different circumstances. When we look at circumstances when stress.

Goes up, the likelihood that there's going.

To be an increase in pain may exist.

So we want to help people recognize that if they can help control their stress, it may help control their pain a little bit. Let's think about why that exists. Remember, when the HPA axis is activated, that's our threat response system.

One of the things that happens when.

Cortisol is secreted is that serotonin levels change.

Typically they get a little bit lower.

Because it's not the time. Certain types of serotonin level, certain types of serotonin gets lower because it's not the time to relax. And serotonin is one of our modulating neurochemicals, if you will.

The effect of that or side effect.

Of that is the fact that another function of serotonin is pain perception. So when we have low levels of certain types of serotonin, then we often have lower levels of a pain threshold. We want to help people recognize that. So if they manage their stress, they can raise their levels of serotonin to what's adequate for them. And that will also help increase their pain threshold and may reduce some of their pain. It's important to recognize the physiological underpinnings of emotions.

Mood, addiction and pain share neurophysiological patterns, including increased inflammation we know that there is a huge correlation between increased systemic inflammation and depression. Whether it causes it or is correlated with it, they're not really sure, but.

They know that there's a strong correlation between the two. We know that when people are under a lot of stress, which happens when they are using addictive substances and subjecting their bodies to regular stress, that HPA axis is activated, which again causes increased circulation of those inflammatory chemicals in our body. And then pain we've already talked about increases inflammation. So that's one pathway that they share.

And if we can help people control.

Their stress and learn coping skills to deal with their pain, which we're going to talk about later in the presentation.

Then we can also help them reduce.

Some of those inflammatory substances in their body, which can reduce their overall, potentially overall pain.

Altered levels of dopamine, serotonin, and norepinephrine.

Are common in all three mood, addictive and pain situations. And a hyperactive HPA axis, as I just explained, is another commonality between those three things. So if we can get that HPA axis under control, that threat response system under control, if we can reduce cortisol.

Levels, then we can theoretically help the.

Person allow their body to, to rebalance the dopamine, norepinephrine and serotonin and improve their pain threshold.

Effective pain management in patients with comorbid.

Issues must address all conditions simultaneously. Now, I say multiple issues and all conditions.

When we're talking about patients with trauma.

It'S important to remember that patients with a history of trauma often have a dysregulated HPA axis or which may mean that they are going to have more difficulty with pain perception because that regulatory system is out of whack, so to speak. Their serotonin levels tend to be lower. Their cortisol levels tend to go from very low to very high. All of a sudden, treatment of one.

Condition, pain, mental health, or addiction, can support or conflict with the treatment of the others. A medication appropriately prescribed for a particular.

Chronic pain condition, for example, may be.

Inappropriate given the patient's substance use or mental health history.

And Barrett brought this question up, and I'm going to address it a few more times throughout the presentation. But let's talk about CBD oil right now.

CBD oil has been touted for, for.

Its benefits in the treatment of symptoms of depression, of pain, of a variety of other things. And while I'm not arguing with that, I also want to increase your awareness that CBD oil can interact with other things like medications, SSRIs. Somebody may be taking, which can cause serotonin syndrome. It can also has been found to potentiate other herbs like St. John's wort, and could potentially cause a manic episode in somebody who's bipolar. We do want to recognize the dangers there. Now, CBD oil doesn't have the psychoactive component of thc. So theoretically it is not going to. Would not be something that would trigger a relapse in somebody with addiction. But, you know, CBD oil is also not regulated. So there is a trace amount of THC in most CBD oil products on the market. It's a matter of considering what's in the best interest of the client and making sure, especially if they're taking herbs or medications that, that are addressing their neurotransmitters, that they need to be medically supervised when they're starting the CBD oil. CBD oil is also, since it's not regulated, the amount of the active constituent in any preparation that you get may not be uniform across a single bottle or set of pills or, you know, between different makers. So it's important for people to understand that too. So if they get it from one one maker one time and another maker another time, they may not be the same exact dosage of the active constituents.

But there are a lot of people.

Who want to explore CBD oil.

And, you know, that's important for them.

To educate themselves and make decisions about what they want to do. But we do need to educate them, especially if they are taking anything that alters their serotonin levels or which includes opioids, that we need to educate them about serotonin syndrome. So that is my serotonin syndrome soapbox for the day. Okay.

Biopsychosocial impact of pain. When we are in pain, we don't sleep as well. Number one, when we're in pain, our.

Body, the primitive areas of our body, say we are the weak link and the pride, and we're the one that may get eaten by the hungry lion.

But more practically than that, when we're in pain, we can't get comfortable.

When we can't get comfortable, we don't get good sleep.

When we don't get good sleep, it.

Contributes to elevated HPA axis, higher levels of cortisol. The adenosine in our brain doesn't get clear, cleared out at the end of the day, so we don't feel rested the next morning. We may have more difficulty concentrating, yada, yada.

So it's a problem. Pain also causes pain.

And we already talked about that.

If you have pain in one area.

Because of, you know, splinting that area or babying that area, whatever you want to call it, you may cause pain in other areas. I know I did that with my hip. I had a hip injury and I was evidently walking a little bit differently. And I ended up causing a whole cascade of muscular imbalances which caused a whole bunch of other pain, which wasn't a good thing.

We want to make sure people are.

Aware that when they're in pain, it's going to affect them because we naturally want to protect that area.

Medication side effects can also impact people.

Who are experiencing chronic pain to the extent that they may not want to take them or they may get addicted to them. You have two ends of the spectrum.

Medication side effects can be drowsiness from.

Opioids or euphoria from opioids that we need to take a look at. That may make them difficult, may make it difficult for people to drive.

And this is not necessarily just opioids.

There is some evidence for the prescription of things like benzodiazepines or anti anxiety medications or muscle relaxers for pain, which can also make it difficult for a person to drive, make them more sleepy, make it harder for them to sleep at night. But they're drowsy during the day and they're ODing on caffeine. You know how it goes.

Fatigue, circadian rhythm disruption. When people are not sleeping well, their.

Circadian rhythms get out of whack. So their cortisol peaks and valleys aren't.

In line with when they're sleeping, which further disrupts their sleep and further contributes.

To the likelihood of the development of mood disorders.

Physical changes as a result of pain can be aesthetic, which can be hard for a lot of people, especially if.

It'S something that is obvious to anybody on the street, something that is happening to your face or if you lose a limb or something like that is a little more obvious than say if you have a insulin pump implanted.

Either way, if there is pain and.

Whatever is causing the pain causes physical changes, including weight changes, because they can't get up. You know, they have chronic back pain or chronic knee pain and they can't exercise the way they used to anymore, they may put on weight. And if they used to exercise a lot because they prided themselves in staying fit and maintaining a certain body fat percentage or whatever, this can take a huge ding on their self esteem and we need to work with them on how they're going to grieve that loss and accept it basically is the short.

Version Loss of mobility can contribute to problems with pain.

And this is where case management comes in. Some we aren't as clinicians going to be able to help them learn to walk again or whatever.

But we need to recognize what does.

Loss of mobility mean to them. What does it mean in terms of their self concept? What does it mean in terms of them being able to get nutritious food? You know, can they get to the kitchen to make their food? Can they get to the store to get the food so they have something to cook? And those are all things that we need to consider. And if they can't, we either need to reach out to a case manager or help them figure out how to access those resources ourselves. A lot of the bigger cities now have grocery stores that will actually develop.

Deliver food to people's door.

I know you can get the non perishables from a variety of different places, but a lot of grocery stores are actually starting to also deliver fresh food so they can order their meat, their dairy, their produce and have it delivered the same day, which is huge for people. For example, people who are older, who can't drive anymore, or who are afraid to drive. That's the case of my grandparents in law.

I guess it's important to recognize what things are there. Or Ubers, you know, teaching people how.

To use ubers if they can afford it to go to the grocery store and get what they need.

But mobility is a big issue and it also can impact people's ability to.

Do their activities of daily living. If you have a shoulder injury, for example, and you are somebody who does.

A lot of stuff to your hair.

In the morning, and men or women, doesn't matter if you are somebody who has to be raising your hands over your head, you may find that loss of mobility because of that shoulder injury is causing you problems in other areas. So you're not able to get yourself fixed up the way you want to. And so you may not feel as attractive, as presentable as whatever. Again, that can be a huge thing on people's self esteem.

Depression is a sense of hopelessness and hopelessness.

And people often develop depression when they experience experience some sort of injury or something that causes chronic pain. Lack of quality sleep contributes to depression because it, number one, you know, causes us to feel fatigued and difficulty concentrating and all that kind of stuff. But it also contributes to our.

We can also develop depression as a.

Result of the losses that we experience.

We can develop anxiety.

Is this pain ever going to stop? Is this pain going to get worse? Is this pain Going to stop me from doing other things. People can start worrying about the pain. Is this pain something else that's more nefarious, like cancer? A lot of people when they have chronic pain, start worrying that there may be something, you know, bigger and more devastating underneath can contribute to anger and irritability.

I don't know about you, but when.

I'm in pain, I'm not a pleasant person to be around. I don't do pain very well.

And it can make people more irritable.

Think about if you've had a kink in your neck even, and how much more frustrating it was if somebody came up in your peripheral vision that day and you couldn't turn your head to see them.

You're like, just come around in front.

Of me so I can see you. Normally, you may not be that irritable. But our limitations or feeling our limitations as a result of that. Most of us want to be the masters of our own body. And sometimes pain can challenge us.

Grief and adjustment issues, looking at what people lost.

And it can be functionality, but it also can be things that are more vague like their sense of hope or their sense of fairness in the world. You know, it's not fair that I have this pain all the time. Or there are a lot of other things that people may need to grieve. It is definitely if they've got chronic pain, like maybe they have chronic rheumatoid arthritis, they may need to grieve the fact that they don't have control over that aspect of their body and they are always now going to experience some level of pain and they'll have to move towards acceptance of that.

They may feel jealous or resentful of.

People who don't have pain. They may withdraw from others because they are irritable, they are tired, they feel hopeless, or their self esteem has taken a nosedive.

They may experience loss of social support.

Because people are like, you know, you're always in pain. You have migraines like every third day. I can't be there for you all the time. And so they lose their social support.

Or the other end of the spectrum.

Is people become paternalistic. This is especially true of parents who have children with chronic pain. The caregivers become so controlling to try to prevent that pain from happening, or so overdoing, I don't know the word I want to use, paternalistic, that the person feels somewhat suffocated by all of the attention and they feel like they can't do anything. They feel like they're being watched, like A hawk all the time.

Inability to engage in prior important activities.

Is another thing that needs to be grieved.

And we want to help people figure out if there are modifications.

For example, right now I am blessed that I can still bend down to the ground and do my gardening in the garden. But when the day comes that I can't do that, if the day comes that I can't do that, gardening is very important. Growing my own food organically is very important to me. What can I do? Raised boxes and raised hydroponic boxes are the next steps that I would consider taking. So I could still engage in that without having to bend down and get all the way down to the ground.

For people who, you know, like to paint, it's important to think about that.

When my grandfather was got Parkinson's disease.

He had the shakes.

Now that's not pain, but he did have the tremors that kept him from being able to paint as well. And what could he do differently or what could he do that still allowed him to paint? Well, he couldn't cut in anymore, if you're familiar with painting. He couldn't do the edges anymore, but he was able to use a roller and do big walls and things like that so he could at least participate in what was going on.

But working with people to brainstorm ways.

They can modify their beloved activities to things that they can do. My stepfather, when at a certain point he was having back pain, and the man lives to play golf, he played golf every single day of his retired life. To the best of my knowledge, they lived on a golf course, so it was easy for him to get out there. But his back pain got to the point where it was impairing his golf swing, which was hurting his golf score, which was hurting his self esteem. And he was getting frustrated and angry and feeling hopeless and helpless and useless and old. And, you know, there was a lot of stuff that came with it.

And it was important for him to.

Go to physical therapy. And then, you know, before he could go back out playing again, you know, he started with things like putting, because putting didn't require the same muscle engagement and torsion on his back that was causing the pain.

So he was still able to get.

Out and play some. And then he worked up to the point he never got back to playing eight holes, but he did work up to the point where he could go out and play nine holes. And he was tired after that and he was a little bit sore, but it was better than nothing. And he was grateful that he was able to get Back out and do nine holes.

Working to find compromises. Loss of independence we've really talked about.

In terms of loss of mobility.

But people also, if they are in chronic pain, they may not be able to work anymore. There are, if you go to the.

JAN Network, JAN Job Accommodation Network, they give you suggestions for reasonable accommodations for just about any disability out there. It's important to help people realize what sort of accommodations are out there so they can stay employed as long as they want to.

But at a certain point, if they.

Are not able to maintain gainful employment and then their income may go down, which also may contribute to additional losses of independence and things that they wanted to do.

Financial hardships can also occur because of medical expenses.

If you've got chronic pain and you're going to a pain medicine physician, you have doctor's visits that are going to be repeated. And until you pay your deductible, a lot of times you are paying 100% out of pocket. And a lot of people have higher deductibles now. So medical expenses can be quite costly.

Job loss and environmental modifications. If somebody, for example, has to have.

A knee replaced or has chronic knee pain so they can't go up and down the stairs anymore, and they have to have one of those, you know, pseudo elevators installed, that's an environmental modification to help them maintain their independence and or despite having their pain. But it can be a bit costly.

And physical, sexual and emotional relationship problems. We don't talk about this a lot, but when people are in pain, it's.

Hard to have a high libido. A lot of times when people are in pain, they feel drained and exhausted a lot of times so they're not thinking about sex, which can negatively impact their connection with their partner if their partner is not supporting in the way they want their partner to be supportive of their pain and their recovery process, or whatever you want to call it, then that might also cause relationship issues. We need to make sure there is open communication between family members, not just intimate partners, about what's causing the pain, what's going on, and what they can do to best address it.

Common chronic pain, low back pain, neck.

Pain, upper back pain, arthritis, fibromyalgia, tmj, Crohn's disease, and migraines. Those aren't all of them by any means, but, you know, arthritis covers a whole big scope of things. Fibromyalgia, what we're looking at is, you know, the most common types of pain. It doesn't mean people won't have some other pain out there. But you know, these are the things that we want to screen for when.

We assess for chronic pain, the McGill.

Pain Questionnaire, and it's hyperlinked here in your PDF in the classroom. You can, you know, pull that up and you can see the PDFs that are online that you can use for the McGill Payne questionnaire.

Basically, it's a little diagram of a.

Person and it has them describe the type of pain, the duration, etc.

The assessment of pain should document.

Now, this isn't a full assessment of the person, this is just a pain assessment.

Here we want to look at the pain onset.

When did it start? What is the quality of the pain? Is it shooting, stabbing, aching, burning? And what's the severity on a scale of 1 to 5, 1 being no pain at all, 5 being the most excruciating pain you've experienced, you know, where are you at?

We should ask for results of investigations.

Into the cause of pain. We aren't medical doctors, we're not going to be investigating the cause of the pain, but we want to know what the cause of the pain is so we can educate ourselves if necessary and we can help the patients educate themselves about what's causing it, what the prognosis is, etc.

We want to look at pain related functional impairment for the person. What does this pain keep you from.

Doing that you used to do, that you want to do, that you miss doing?

Let's start making a list of those.

Things and again figuring out ways to compromise or try to help them make it work or find substitutes or find people that can help them do those sorts of things. Emotional changes related to the pain, this isn't just their mood disorders, this is how have your emotions changed, how have your feelings changed, your mood changed since this pain started? When you are having a high pain day, what are your moods like? When you are having a low pain day, what is your mood like pre.

Existing mental health, trauma or addiction issues?

So we know if there may be.

Something in there that is contributing to.

A reduced pain threshold. And that's one of the things that I keep trying to point out with clients, when I'm working with clients who have chronic pain. I'm not saying it's all in your head. What I'm saying is that depression and stress and other things cause chemical reactions in your body that, that reduce your pain threshold that actually cause you to feel pain more acutely. And if I know or if we know when we do this assessment that the person has a history of depressive issues Then we know that if they start having a depressive episode, their pain is probably going to increase. Likewise, if they start having a pain episode, their depression may increase and we need to be aware of that to modulate both of them.

Cognitive changes since the pain started Remember.

When you don't sleep or don't sleep well, your brain cannot clear out the adenosine, which is what causes you to feel sleepy and foggy headed towards the end of the day. When that doesn't happen with regularity, you start having more difficulty with concentrating and memory.

But also when that HPA axis is.

Activated and people are experiencing pain, it alters the other neurochemicals like dopamine and norepinephrine, which are important for attention, memory and learning. When those are altered because of pain, people are going to have difficulty paying attention to things besides their pain.

We also want to assess their beliefs and part of this is a making.

Our assessment more culturally sensitive. We want to understand their beliefs about the pain that they're experiencing, such as what causes it? Where do you think this pain came from?

Do you think it's cancer?

Do you think it is a curse? Do you think it is from your depression? Do you think it's from stress because.

Of your bad relationship?

What is it that you think is causing this pain? How long do you think it will last? Do you think it is curable? What effects is this pain going to have in your life and what effects is it having now?

What treatments are you interested in exploring? And that is a really important question to ask people.

You know, many people may not know what treatments are out there. Which brings us back to the CBD oil discussion that we had earlier. Some people may want to explore that. Some people may want to explore medical marijuana. Some people may want to explore nerve blocks or things. You know. There are a lot of alternatives besides opioid based medications, but we need to ask them what treatments might be relevant. Physical therapy, hot and cold massage therapy, There's a lot of stuff out there.

And we want to assess whether they.

Feel like their pain is understood and believed to be real by clinicians. If they don't feel like they're being taken seriously, that often increases their perception of pain because it increases their sense of feelings of anxiety and sense of hopelessness and helplessness.

We want to examine people's families response to pain. And I use the family to refer basically to the people that live with them.

But it can be extended family as they define it. It doesn't have to be blood relatives, but those people that are important in the person's life.

Interestingly, when we're talking about children with.

Chronic pain, parental cognitive responses to pain, such as catastrophizing or exaggerated negative pain.

Appraisals, influence both the parent's emotional reaction.

And and the functional ability levels of the child.

So if parents are feeling like it's.

A catastrophe and thinking this pain is excruciating and making it into a catastrophe, then that often wears off on the child. And this child starts using emotional reasoning to think, oh, well, mom or dad says this is like really dangerous and really awful, so it must be. We really want to help them use fact based reasoning and get away from that emotion. Focused reasoning and fact based reasoning. I use that kind of loosely when we're talking about pain, let's use the facts. Let's ask Junior, you know, on this likert scale of 1 to 4 or 1 to 5, how bad's your pain today? You know, I want Junior to tell me instead of assuming that because he grimaced when he got up from the sofa, that his pain must be a 5 today. Let's ask Junior. Let's, you know, get the facts from the person who's experiencing the pain instead of trying to mind read, instead of trying to hover and helicopter.

That's really difficult for a lot of.

Parents who really want to caretake. And it's hard to see your kid in pain.

It really is.

It doesn't matter if it's an earache that you know is going to go away in a week or if it's something more chronic than that. You want to make it better. But children with chronic pain, we may not be able to make it completely better. Instead of focusing on the pain the child has, helping parents focus on on the pain the child doesn't have. So if the child says, okay, my pain is a two today, well, that's awesome that it's not a four. Let's, you know, revel in the fact.

That today's a two. That's a pretty good day.

Instead of getting depressed and frustrated and saying, well, you know, I want it to be a zero, we need to.

Assess the environmental consequences of the pain. Disability income can be one of them.

With children who have chronic pain, most.

Of the time, they don't have to.

Be homeschooled, they don't have to have special educational interventions.

But if they do for some reason and the parent has to quit their.

Job, we need to be aware of that.

The person may have a loss of.

Desired activities because of their pain.

And this can be.

Episodic, you know, when my knee flares up, I can't run. And that, you know, really irritates me because I love running.

When my knee flares up, what can.

I do that I similarly enjoy? That's not going to make the pain worse.

And there may be absence from desirable or feared activities.

If you want to do something, the person may not be able to do things that they want to do. Likewise, they may focus on the pain in order to avoid doing things that they don't want to do. You know, with kids, they may not want to clean their room, so suddenly they may be in a lot of pain. For adults, you know, you may not want to go to work, so maybe you're suddenly in a lot of pain. We do want to look at some of those underlying motivations and see if there are any patterns for when it flares up, because then we want to also address, you know, the pain may flare up because the person's anxiety went up. Okay, so let's talk about that anxiety about work that is causing your pain to increase. That is causing your HPA axis to get wonky and reduce your pain threshold.

Encourage people to do a daily pain assessment using some sort of descriptive language.

And for kids, it's going to be different than for adults. You can use numerical scales. And I encourage you, please, when you use Likert scales, to use a verbal or pictorial anchor for every single point. And ideally, make it an even number, because if you make it an odd number, more often than not, people are going to choose the middle number, which is usually 3. So on a scale of 1 to 4, what's your pain like today? Zero pain, excruciating pain, a little bit of pain, or moderate pain. Those are pretty easy to differentiate.

When you start getting too many increments.

It'S hard to know, like, on a scale of 1 to 10, what really is the difference between a 7 and an 8? You know, I have a hard time with that. With four points, it's easier to differentiate.

They can use verbal scales.

They can tell you it is no pain. It is minimal, moderate, or excruciating. Or they can use visual scales with happy faces, you know, for children.

Or they can even actually use a.

Scale and you can say, okay, move the little marker up to where your pain level is.

Whatever works for that person.

But we want to get a daily pain assessment from them to figure out, you know, other things that might be.

Contributing to it other than mood.

You know, it can be the way they sleep. It could be what they did, the Day before, it could be, you know.

Pressure systems coming in.

It could be a variety of different things. If you wear different types of shoes, like if you wear heels one day and flats the next, you may notice a difference in your pain.

We want to ask people to keep track, and they may not know at the initial assessment, but keep track over the first couple of sessions. What makes their pain worse?

Emotionally? When they have certain feelings, does it make their pain worse? When they have certain thoughts, does it make their pain worse? When they have certain physical conditions, like when they're more tired, their pain is worse?

Environmental issues like we just talked about.

And socially, are there things that make them feel more pain, like when they're around certain people that probably raise their stress levels?

Mitigating factors what helps the patient feel better?

What helps them feel happy even with the pain? In acceptance and commitment therapy, we call this living in the and I can have a rich and meaningful life and experience pain. They don't preclude one another. Just because I have some pain doesn't mean that I am completely unable to have a rich and meaningful life. So even when you're having pain, what can you do to help you feel better emotionally? What can you do to help you get in a more optimistic frame of mind? What can you do to help yourself feel better physically? Have more energy, feel less stiff and achy, or whatever the person reports they.

Have environmentally, what can you do to help your pain? When my back is hurting some days.

I I have one of those big bouncy ball chairs and I will sit on that instead of sitting in this because that helps me sit with better posture, which reduces my back pain. So I know that's something I can do if my back is hurting?

And socially, what things can you do?

What friends can you surround yourself with? Where can you get social support that can help you feel better?

Chronic pain support groups are great.

I encourage people with chronic pain to.

Explore those in addition to social support.

Not related to their pain. Sometimes getting out and doing something or even having a friend come over for tea or coffee or something can help distract them from some of the low grade pain that they can't completely eliminate.

Goals of chronic care models is to shift from acute episodic treatment to ongoing proactive care mindfulness.

Instead of waiting until the pain starts to flare up again every single day, we're asking the person or the person's asking themselves, how am I feeling? What can I do to best prevent my pain today or minimize my pain today?

It emphasizes prevention. We want to make sure that well, help the person do everything they can.

To make sure the pain doesn't get worse.

And we don't want them to develop.

Other conditions like depression or anxiety or addiction or other pain conditions as a result of this particular pain issue.

We also emphasize the patient's role in.

Managing their health with mutual goal setting and action planning. We don't make the plan for them. They need to take the reins and figure out what goals do I want to achieve, what do I want my life to look like with this new situation? You can use narrative therapy. You know, I'm a fan.

When they close that last chapter, they.

Close out was the pain free chapter and they're opening up this new chapter or this new season in the miniseries of their life. And this is a new characteristic that their character has. How is that person going to play it out and have a rich and meaningful life and live with experience, accept the pain.

The goals of self management interventions are to improve knowledge about the condition and intervention options.

There are a ton of things out there, tens units, massage, physical therapy. I have a video on the all CEU's education channel on non pharmacological pain interventions. An entire hour of different types of activities that have been found to help people reduce non cancer chronic pain.

We want people to increase their confidence in their ability to change, increase their confidence in their ability to.

Manage this condition.

Even, you know, recognizing that there are.

Good days and bad days.

And we want to help the person leverage what he or she can do to promote personal health.

What can they do to make their body operate, make their body machine as functional as it possibly can be? You know, there may be some misfiring, if you will, of some of the pain neurons and that's, you know, not exactly clinically accurate, but you know what.

I'm saying, they may have pain.

What can they do to help their body function as well as possible, despite the fact that that one system is slightly offline.

The goals of self management interventions are to improve motivation and problem solving rather than simple compliance with a caregiver's advice. I want them to, when they have.

Pain, maybe reach out, ask for suggestions.

But then figure out what's going to.

Work best for them and what they believe will help. There's a huge factor in their confidence in the intervention.

Help participants master six fundamental self management tasks. Solving problems, including preventing other problems and relapse. Making sure that they're aware if they.

Have a history of depression, what triggers their depression. Well, we need to be aware of that in addition to being aware of what triggers their pain issues and what things can they do on a daily basis to prevent both of those things from recurring?

We want to increase their confidence in their ability to make decisions and use resources, Help them learn how to, you.

Know, reach out and connect with resources for social support, for social services, for transportation, for counseling, for medicine.

If the person can't get their medicine because they can't afford it, there are.

Those programs like GoodRx, and there's a new one out there that people can download that can help reduce the cost of medications. There's also patient assistance program programs. If you go to the website of the pharmaceutical company that makes the medication and look for their page on patient assistance programs, most of the time you can find a patient assistance program for clients who are financially unable to afford their medication, to get it for like $4 a month or for free. And also look at different formularies like at Walmart or grocery stores or drugstores in your area to see if that particular medication happens to be on their list of drugs that's approved for, you know, $4 a month or whatever. But a lot of people aren't aware that those resources even exist out there.

We also want to help them figure.

Out how to find and use resources on the Internet, at the library, wherever, to learn about their condition, help them figure out how to vet resources to make sure that they are legit and learn everything that they need to.

We want to help them master the task of forming a patient provider relationship.

Instead of expecting us to do it for them or to fix them or whatever, we want to help them form this relationship where they feel like they're an equal part and they're empowered to, to make suggestions, to say no, to present the goals that they want.

We want to help them learn how.

To make action plans for health behavior change. Learn how to set those smart goals. Remember, specific, measurable, achievable, sma, relevant and time limited.

And self tailoring. Help them figure out how to tailor.

Different approaches to meet their needs. You know, maybe they can't go to massage therapy every single day, so what can they do on the days they can't go to massage therapy? What can they get one of those shiatsu back massage pads that helps or something? What can they do to tailor their treatment in a way that does not.

Overtake their life and in a way.

That makes their life rich and meaningful?

EMDR is another intervention that can also.

Be used as well as guided imagery hypnosis, you know, cued progressive muscular relaxation. Like I said, there's Tons of different suggestions on the non pharmacological pain intervention video.

We want to discuss treatment goals with patients that include reducing pain.

Obviously they come to us, they are frustrated, they're upset. We're not their medical doctor, so we're not going to be doing a lot of reduction. But we want to help them feel empowered. We want to help them feel courageous and determined and dedicated and all those positive words that they can reduce their pain to a tolerable level. We want to also help them recognize.

And accept the reality that pain free.

May not be an option for them anymore. So they need to revel in the pain less pain days.

We want to help them maximize function, improve their quality of life, address co occurring mental disorders.

This can include trauma. Sometimes what caused the pain may have been a trauma.

Sometimes pain can exist as a result of trauma.

We do want to pay attention to trauma. Remember, there are people, for example, who have limbs amputated that have phantom pain.

And that pain is very real.

Even though the limb is not there anymore, their brain still kind of thinks it's there for some reason. That pain is very real. We want to make sure that they feel heard, they feel believed, they feel understood, and that we are addressing all parts of their issue and we want.

To help them incorporate suitable non pharmacologic.

And complementary therapies for symptom management. They've also found recently that bergamot is great for helping reduce anxiety and pain, especially in patients with dementia. But that's a whole side note.

We want to help clients decide that.

The pain is and choose not to focus or dwell on it. This will help them lower their pain intensity, have less pain related anxiety and avoidance, less depression, less physical and psychosocial disability, more uptime and better work status. When my knee hurts, and it does periodically, instead of avoiding everything that could.

Make it hurt, I just accept that.

Okay, I'm going to be doing this and some days my knee is going to say that I'm done, but I am going to do it up until that point, until the point where I'm feeling pain and then I'm going to back off.

It's important to pace yourself as well.

And not overdo getting back into it where you exacerbate the pain.

There are many similarities between pain, mood and addictive disorders. It's important that we provide integrated concurrent biopsychosocial treatment. If we have somebody who's in a lot of pain and they're depressed, we can try to help them treat their.

Pain until the cows come home. But as Long as the neurochemicals that are involved in their depression are out of balance, their pain is not probably going to experience the resolution that they want. We need to make sure that we're addressing the causes of the pain. Anything that is keeping that HPA axis overly activated and keeping the pain moderating neurochemicals like GABA from flowing through the body as effectively.

Mood impacts pain, which impacts life satisfaction, recovery from chronic pain, supports realistic beliefs.

About how much pain resolution can exist.

And identifies controllable factors so the person recognizes, well, you know, I can't control.

The weather, so my arthritis may act up when a cold, cold front comes in. Can't control that, but what can I control? Well, if I've got arthritis in my hands, maybe I can wear warming gloves when that happens to help keep my joints a little looser. So thinking about what is it that I can control in this situation to enhance outcomes.

And finally, remember, patients with concurrent addictions.

Or mental health issues need that concurrent treatment.

So going back to what Barrett had asked earlier, part of it is semantics.

When we are working with clients who have chronic pain, we don't want to tell them it's all in their head. We want to help them understand that pain is real and it alters their brain chemicals, which can affect their mood. And when their mood is lower, that also affects their brain chemicals, that affects their pain perception. So what we want to help them do is optimize their mind, body functioning and help them get that HPA axis and those brain neurochemicals kind of back in alignment for what's helpful for them, which means addressing stress and depression and anxiety so their brain and body can relax, which will help reduce their pain. It's not going to eliminate it, but it will help reduce their pain. So then we need to ask, what is it that's contributing to your depression, anxiety, guilt, grief, etc.

And it is important to make sure that everybody's aware about the addictive potential.

Of a lot of things out there, including Kratom, CBD oil and opioids. Not saying that those are the only ones, but all of those do have addictive potential. It doesn't mean they're going to cause somebody to become addicted. And we also want to make sure they understand that. Bless her heart. My grandmother thought that Xanax was addictive and if she took it once, she was going to become an addict and it took us forever to help her understand that. There's lots of people that take Xanax on an as needed basis that don't ever develop addictions. So you know, being aware of what addiction is but also being aware if a person does have a history of addiction, the types of things that they need to be cognizant and aware not.

To take, and the interventions that they.

Can use that are not based in addictive type medications.

I actually found a great 60 page.

Article on psychosocial interventions and it's it's in the additional resources section of your class. Not something you need to read for the CEUs, but I will be doing an on demand class on that on Psychosocial impacts of chronic pain and interventions. Kind of newer research that they've done recently.

But anyway, everybody have a fabulous weekend. Stay warm, stay safe. If you're in a place that got.

Snow, have a lot of fun going out, snowboarding. I wish we could do that. I just want one day of really good snow and then it can all melt away. But you know, if I don't get it, it is what it is. Have a great weekend. Between writing notes, filing insurance claims and.

Scheduling with clients, it can be hard to stay organized. That's why I recommend Therapy Notes.

Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months.

Of TherapyNotes by just using the promo code CEU when you sign up for a free trial at therapynotes.com.

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