C1-D1. Taming the Beast: Use of Cognitive Behavioral Therapy (CBT)

Taming the Beast: Use of CognitiveBehavior Therapy in Treatmentof Co-existing Disorders of Chronic Pain,Depression and AddictionJoan Cronin MS, RN, PMHCNS-BC, CARN, LADC;Virginia Nash, DNP, RN, PMHCNS-BC;Connie Luedtke, MA, RN-BC and Susan King, RNSeptember 8 th , 2011ObjectivesDefine one way the CBT approach can be used inchronic pain rehabilitation.Identify outcome measures used in this three-weekrehabilitation program.Describe nursing strategies used when addressing thesynergistic effect of these co-existing conditionsDescribe interventions used to address substance usein the context of chronic pain and depression.Complexity of Co-Existing ConditionsChronic Pain, Depression & AddictionChronic Non-Cancer Pain (CNCP) is a common,complex, disabling condition (Chen, Wong & Chu, 2004)Depression is often part of the symptom picture ofchronic pain (Chen et al.; Thorn, 2004).Addiction and substance use problems may complicatethe symptom picture of persons with chronic painfurther (Ballantyne & LaForge, 2007)1

Complexity of Co-Existing ConditionsChronic Pain & Addiction“Patients who experience either addiction or painhave historically shared being misunderstood,underdiagnosed, and undertreated. Whenindividuals experience coexisting chemicaldependency and pain, this experience isamplified.” (Trafton, Oliva, Horst, Minkel, & Humphreys, 2004as quoted from St. Marie, 2010 page 623)Assessment Tools forChronic Pain & Addiction“Addictions and pain literature have inspired tooldevelopment to identify patients who are atrisk for abusing prescription pain medicationsused to treat their pain…specialists havecriticized DSM-IV as inappropriate foridentifying opioid misuse in pain patients”(Savage, 1999; Sees & Clark, 1993 as quoted in St. Marie, 2010,p. 621)What is Chronic Pain?An unpleasant sensory and emotionalexperience associated with actual or potentialtissue damage, or described in terms of suchdamage....Pain is always subjective....It isunquestionably a sensation in apart or parts ofthe body, but it is also always unpleasant andtherefore also an emotional experience.(IASP, 1994)2

What is Chronic Pain?The IASP and many pain experts deemthat in many cases, chronic pain is adisease in its own right (EFIC, 2001), aposition supported by the Institute ofMedicine Report June 29, 2011Chronic PainPain is a universal experience. Commonchronic pain conditions affect at least116 million U.S. adultsCosting $560–635 billion annually indirect medical treatment costs and lostproductivityRelieving Pain in America: A Blueprint for Transforming Prevention, Care, Education,and Research. Institute of Medicine Report June 29, 2011DepressionDepression rates among persons with chronicpain is 3-4 times higher than the generalpopulation. (Sullivan, Reesor, & Fisher, 1992)Overlapping symptoms of pain and depressionCBT-evidence based treatment formanagement of depression3

What is AddictionPrimary, chronic, neurobiologic disease, with genetic,psychosocial, and environmental factors influencingits development and manifestations. It ischaracterized by behaviors that include one or moreof the following: impaired control over drug use,compulsive use, continued use despite harm andcraving.American Academy of Pain Medicine, American Pain Society, American Society of PainManagement Nurses, and American Society of Addiction MedicinePhysical DependencePhysical dependence is a state of adaptationmanifested by withdrawal syndrome,produced by abrupt cessation, rapid dosereduction, or decreasing blood levels of thedrug.American Academy of Pain Medicine, American Pain Society, American Society of PainManagement Nurses, and American Society of Addiction Medicine“The Elephant in the Living Room”Addiction4

“The Elephant in the Living Room”Chronic pain“The Elephant in the Living Room”Depression‘The Elephant in the Living Room”Chronic pain+ Depression+ Addiction“The Beast”5

Establishing the Efficacy of CBT forTreatment of Chronic PainInternational Association for the Study Pain in the10 th World Congress (2005)Cognitive Behavioral Therapy is as effective for aheterogeneous group of chronic pain sufferers as anypublished therapy for any specific type of painEfficacy of CBT for Chronic PainTurk (2002) Review of comprehensive pain rehabilitation programsMore cost effective than implantation of spinal cordstimulators, intraspinal drug delivery systems/surgery.Significantly greater reduction in medication use, and healthcare utilizationSignificantly greater increases in functional activities, returnto work, closure of disability claimsSubstantially fewer iatrogenic consequences/adverse events.Multidisciplinary Pain RehabilitationCognitive-behavioral approachImprovement of physical functioningImproved general functional status (ADLs, social,household, recreational)Improved vocational/school functioningReduction in health care utilizationReduction/discontinuation of opioids, sedativehypnoticand over the counter medicationsReduction in pain level (not always attainable)6

APS Task Force Review (2006) - Compared to differenttreatment modalities including the standard medical approachor medication management, MPRP is the only therapeuticapproach that has demonstrated treatment efficacy and costeffectivenessfor functional restoration and major outcomevariables (pain severity, healthcare utilization, medication use,disability claims).Overview of Mayo Clinic ComprehensivePain Rehabilitation Center (PRC)Three week program developed in 1974 in Rochester, MN~450 patients annuallyPatients average length with chronic pain~ 9+ yearsBack pain, fibromyalgia & headache most commonParticipants range in age from 13 to 90Focus on functional restoration and quality of lifeDiscontinuation of opioids for pain while learning othercognitive-behavioral strategies for coping7

Overview of Pain Rehabilitation Center3 week program with rolling admission20-30 patients at any given time, divided in 2 teamsMonday – Friday 8 a.m. to 5 p.m.2 day family education programAftercare programPREP - 2 day pain rehabilitation executive program3 week Adolescent program with extensive parent programmingComprehensive Multidisciplinary TeamPatientPhysiciansPsychologistsClinical nurse specialistsRN case managersPhysical therapyOccupational therapyPharmacistDietitianChaplainsVocational counselorTobacco treatmentspecialistsClinical assistantsSecretaryPain Control Methods Commonly UsedPrior to PRCMedicationsSurgeriesInjectionsStimulatorsImplanted pumpsComplementary &alternative medicineVarious proceduresPhysical therapyRestYou name it!8

Just Say No to Drugs???Can this REALLY be an alternative treatmentto opioid therapy??Opioid Therapy for Chronic PainEarly 1990s national pain organizations challenged thenation to provide better pain management to all patientsIt was determined that there need not be an “upper limit”for opioid prescriptions for those in painIn 1997, APS and AAPM issued consensus statement thatopioid therapy for Chronic Non-Cancer Pain is a legitimatemedical practiceMinimized concerns of addiction, respiratorydepression and other side effects, and tolerance1997 to 2006 - 90% increase in opioid prescriptionsBut, is it Effective?Six meta-analyses and reviews of randomized, double-blind,placebo-controlled trials of opioids for CNCPFlawed Empirical EfficacySignificant drop out rates/exclusion criteriaVery short-term outcomes (avg. 5 weeks!)Lack of clinically significant reduction in painNo documented improvement in functioningPossible publication bias9

But, is it Effective?Additional Reasons for ConcernTolerance/Dependence, AddictionPossible Opioid-induced HyperalgesiaOpioids maintained despite decline infunctioning and no improvement in pain (fearmotivated?)Pain behaviors predict physicians’prescriptionsWhat did the Consensus statement REALLY say??“periodic reexamination is warranted toassess the nature of the pain complaint andto ensure that opioid therapy is still indicated.Attention should be given to the possibility ofa decrease in global function or quality of lifeas a result of opioid use” [1997, p. 3].What did the Consensus statement REALLY say??“Consideration should be given to differenttreatment modalities, such as a formal painrehabilitation program, the use of behavioralstrategies, the use of noninvasive techniques,or the use of medications, depending uponthe physical and psychosocial impairmentrelated to the pain” [1997, p. 3].10

What has Really Happened?Interactive map show state by state annual change inprescription narcotic consumption (1997-2006)AZ had a 640% increase in oxycodone consumption (#6 incountry DE was #1)Money spent on Marketing for opioids increased from $11to $30 billionSpending on outpatient prescriptions tripled in 10 years(4.2 in 1996 to 13.2 billion in 2006; AHRQ, 2009)1999-2006, fatal poisonings involving opioids more thantripled from 4,000 to 13,8000 (NCHS, 2009)http://www.lasvegassun.com/multimedia/rx_interactive/Evidence-based practice guidelines forCNCP and opioidsConclusionICSI, 2008; Sanders et al., 2005Controlled opioid trials have limited applicability tothe long-term use of opioids in clinical practiceClinicians should consider other forms oftreatment including rehabilitation approach thatemphasizes self-management and functionalrestorationPain 140 (2008) 177-18911

CBT Goals of the Mayo PRCLearn healthy ways of responding to flares of chronicpainPractice lifestyle self-management approachNot from one prescription or procedure to the nextFocus on functional goalsSkills trainingIncrease the controllability of own pain and quality oflifeDeveloping ResiliencyReplace pain contingent lifestyleCBT TriangleCBT Focused GroupsIdentifying relationships between thoughts, moods, andbehaviorsIdentifying, challenging & changing maladaptive thoughtpatternsThoughtsMoodsBehaviorsCognitive-Behavioral TechniquesNo single coping technique has proven to beuniversally effective –It is the combination of multiple personalizedtechniques incorporated into one’s lifestyle thatleads to success in restoring functioning and qualityof lifeCBT can be used at any time during course of pain– not solely after failure of other treatments12

Cognitive-Behavioral TechniquesPatient education –• Acute vs. Chronic pain• Central SensitizationReinforce wellness behaviors• responses to pain, generates consequences– Behavior rewarded is behavior repeated– Behavior not rewarded is “extinguished”• avoidance• verbal/nonverbal pain behaviorsCognitive-Behavioral TechniquesRegular exercise – reverse deconditioning• hurt ≠ harm;• gradual and progressiveAppropriate Pacing of activities• “push-crash-burn” cycle• Appropriate ergonomics (PT/OT)Sleep hygiene, sleep restriction• sleep efficiency• Treat as primary insomnia using CBTCognitive-Behavioral TechniquesDistraction• humor, leisure and pleasant activities, hobbiesStress managementRelaxation Training• biofeedback, diaphragmatic breathing imagery,progressive muscle relaxation, yoga13

Cognitive-Behavioral TechniquesGrief and Loss –New Identity beyond pain and being a patientCommunication/Assertiveness trainingFamily education and trainingRelapse prevention/problem solving• “difficult day plan for managing flares”Cognitive-Behavioral TechniquesCognitive restructuring• pain catastrophizing;• controllability,• positive coping• Challenge rigid thinkingThought Record: One Technique(ABCDE format by Aaron Beck)Activating EventTriggers, context (i.e. losing a job and having chronic pain)BeliefNegative, inaccurate, automatic thoughts (i.e. “I’m a loser!”)ConsequencesFeelings (i.e. angry, sad)Behaviors (i.e. isolate, don’t take care of self)14

Thought Record(ABCDE format by Aaron Beck)DebateEvidence supporting belief• (i.e. lost job; feel like a loser)Evidence not supporting belief• (i.e. look at other successes; chronic pain is not synonymous withbeing a “loser”; focus on what is possible)Exciting New Conclusions(i.e." Losing a job and having chronic pain does not mean Iam a loser! I can focus on taking care of myself and what ispossible.”)Managing Co-Existing ConditionsChronic pain, depression & addictionCognitive behavioral strategies have been shown to improvedepression and help persons effectively manage chronic pain(Bennett & Nelson, 2006; Chen et al, 2004; Turk, 2003; Wells-Federman, Arnstein, Caudill,2002; Wells-Federman, Arnstein, Caudill-Slosberg 2003)Cognitive behavioral strategies including pain managementcombined with relapse prevention has been shown to helppersons with substance use disorders and chronic pain todecrease pain, manage emotions, and reduce medicationreliance (Currie, S., Hodgins, D., Crabtree, A., Jacobi, J. & Armstrong, S., 2003)Bewildered by the BeastPrograms not equipped to deal with these coexistingdisordersIncreased number of patients on opioidsIncreased polypharmacyHigher daily morphine equivalentsDissatisfaction of medication use by patients,providers, and familiesMultitude of risks associated with use of opioids15

Percentage of Patients UsingOpioids at Admission70Percent6050402002 2003 2004 2005 2006 2007 2008 2009 2010YearMean Daily Morphine EquivalenceDosage (MED) on AdmissionMED (mg)14013012011010090802002 2003 2004 2005 2006 2007 2008 2009 2010YearPercentage of Patients UsingBenzodiazepines at Admission5040Percent30201002002 2003 2004 2005 2006 2007 2008 2009 2010Year16

Percentage of Patients Using Trifectaat AdmissionPercent16141210864202002 2003 2004 2005 2006 2007 2008 2009 2010YearPercentage of Patients UsingStimulants at AdmissionPercent1210864202002 2003 2004 2005 2006 2007 2008 2009 2010YearAcknowledging the Beast in the RoomTalking about our preconceptions and biasesImprove knowledge and skill of taperingopioids- Clinical Opiate Withdrawal ScaleOngoing discussions with staff,patients/familiesCreating and using neutral languageAllowing the process of change to occur17

Taming the BeastBuilding rapport – developing trustNonjudgmental approachHybridized-skilled assessmentValidating patient’s personal experiencePatient AdvocateEstablishment of safe medication tapersKnowledge and understanding of substanceuse disorders & painC.O.R.E. versus M.O.S.T.Continued Opportunity for RehabilitativeExperienceMore Opportunity for Successful TomorrowsWhich option?Criteria for recommendationM.O.S.TStronger focus on risks of mood alteringsubstances misuse/abuse based on:Past /present use of mood altering substancesUse of pain medications in ways other thanprescribed, (i.e. anxiety, stress)Concerns expressed by family or healthcare providersAberrant behaviorsGenetic predispositionHealth risks18

M.O.S.T.Goal: Increase awareness of substanceuse risks and provide ongoing education,recommendations and resources asneeded.Preparing the Patient for MOSTMotivational interviewing and Stages of ChangeGathering informationPatient-history of substance use, current use,misuse/abuse of substances including medications,alcohol, illicit drugs, and patient concernsFamily and home provider inputPRC treatment team makes recommendationbased on information gatheredPatient can ultimately make the choiceWhat happens in MOSTTherapist style-nonjudgmentalConfidential-trust within group (no labels,judgment, criticism, blame)Focus on how substance use affects life (notpain stories)Provide an environment for self reflectionEducation regarding substance use19

Group Topics in MOSTPhysical/medical aspects of substance abuseincluding disease modelCycle of pain and substance usePersonal use patterns-sharing time lineFamily aspects, history, effects onrelationship, family concernsManaging high risk situations, triggers foruse, avoiding cross-addiction and other risksPossible Next Steps for MOST PatientsWhen the patient is readyUsing SAMSHA, provide information about treatment programsProvide support and encouragement during transitionWhen the patient is not readyProvide a clear message to patient, his/her support persons, andhome providers about PRC recommendation for treatmentUsing SAMSHA, provide information about treatment programsKeeping the doors openOutcome MeasuresMultidimensional Pain Inventory (MPI)• Pain Severity and Suffering• Life InterferencePain Catastrophizing ScalePain Self-Efficacy ScaleCES-D• Depression20

DemographicsCORE (n=230) MOST (n=246)Age 47 47Education (years) 14.8 14.6Duration of pain(years)Years takingnarcotic12.1 11.35.2 5.2% Married 48% 51%Admit BMI 29.5 29.5Type the footnote/source in this space61OPIOIDS, BENZOS, AND SEDATIVES/HYPNOTICS…A LETHAL TRIFECTAN=476 CORE MOSTOpioid 36% 64%Benzodiazepine 38% 62%Sedative/hypnotic 43% 57%LETHAL TRIFECTA 7% 18%p < 0.001p < 0.001P=0.08p

Other DrugsCORE MOSTTobacco use 20% 80%Past CD Tx 17% 83%% Current 50% 50%alcohol use% Past heavy 6% 27%Alcohol Use& Daily alcohol 8% 19%useMarijuana use 0.4% 13%P < 0.001P < 0.001nsP < 0.001Pain Severity (MPI)Mean T-Score(SD=10)6040200nsPREnsPOSTMOSTCOREWithin Subjectsp < .001(both groups)General Activity (MPI)Mean T-Score(SD=10)6050403020100nsPREnsPOSTMOSTCOREWithin Subjectsp < .001(both groups)22

Mean T-Score(SD=10)50403020100Pain Self-Efficacyp

Revelations: The Beast Can be Tamed!The way we approach patients mattersLanguage mattersTiming mattersThe relationship mattersRevelations: The Beast Can be Tamed!Awareness of their cycle of pain,substance use or depression is important,more so focusing on ways these can bebrokenGaining knowledge specific to addiction,depression, chronic pain is beneficialAcceptance and application of conceptslead to positive outcomesReferencesASPMN Position Statement Pain Management in Patients with AddictiveDisease http://www.aspmn.org/Organization/documents/addictions_9pt.pdfBallantyne, J. & LaForge, S. (2007). Opioid dependence and addictionduring opioid treatment of chronic pain. Pain, 129, 235-255.Bennett, R., & Nelson, D. (2006). Cognitive behavioral therapy forfibromyalgia. Nature Clinical Practice Rheumatology, 2 (8), 416-424.Chen, P.P., Wong, T.C., & Chu, M.C. (2004). Chronic pain management:A paradigm change. The Hong Kong Practitioner, 26,(6) 277-284.Retrieved on November 7, 2008 from British Libraryhttp://www.hkcfp.org.hk/article/2004/06/page277_283dp.html24

ReferencesCommittee on Advancing Pain Research, Care, and Education; & Board onHealth Sciences Policy. (June 29, 2011). Relieving pain in America: Ablueprint for transforming prevention, care, education, and research.Institute of Medicine of the National Academies; The NationalAcademies Press, Washington, D.C.Currie, S., Hodgins, D., Crabtee, A., Jacobi, J. & Armstrong, S. (2003).Outcome from integrated pain management treatment for recoveringsubstance abusers. The Journal of Pain, 4, (2), 91-100.Gatchell, R. J. & Okifuji, A. (2006). Evidence-based scientific datadocumenting the treatment and cost-effectiveness of comprehensivepain programs for chronic nonmalignant pain. The Journal of Pain, 7,11), 779-793.ReferencesInternational Association for the Prevention of Pain: Working together forpain relief. http://www.iasppain.org/Content/NavigationMenu/WorldCongressonPain2/History/default.htmInstitute for Clinical Systems Improvement (2008, 3 rd edition). Health CareGuideline: Assessment and management of chronic pain.Sanders, S. H., Harden, R. N. and Vicente, P. J. (2005), Evidence-BasedClinical Practice Guidelines for Interdisciplinary Rehabilitation of ChronicNonmalignant Pain Syndrome Patients. Pain Practice, 5: 303–315.Savage, S. R. (1999). Opioid therapy of chronic pain: Assessment ofconsequences. Acta Anasethesiologica of Scandinavica, 43, 909-917.ReferencesSees, K. L., & Clark, H.W. (1993). Opioid use in the treatment of chronicpain: Assessment of addiction. Journal of the Pain and SymptomsManagement, 8, 257-264.Soligo, T. & Richards, A. (June 6, 2008). Prescription Narcotic Consumption;Perscription Narcotic Interactive Website. Las Vegas Sun.http://www.lasvegassun.com/multimedia/rx_interactive/Sullivan, M., Reesor, K., Mikail, S. & Fisher, R. (1992). The treatment ofdepression in chronic low back pain: Review and recommendations. Pain50, 5-13.25

ReferencesSt. Marie, B.J. (2010). Coexisting Addiction and Pain. In B.J. St. Marie(Ed.) Core Curriculum for Pain Management Nursing, 2 nd Edition.Dubuque, IA: Kendall-Hunt Publishers, pp. 617-629.Thorn, B. E. (2004). Cognitive therapy for chronic pain. New York: TheGuilford Press.Townsend, C.O., Kerkvliet, J.L., Bruce, B.K., Rome, J.Dl, Hooten, W.Ml,Luedtke, C.A., & Hodgson, J.E. (2008). A longitudinal study of theefficacy of a comprehensive pain rehabilitation program with opioidwithdrawal: Comparison of treatment outcomes based on opioid usestatus at admission. Pain, 140, 177-189.ReferencesTrafton, J., Oliva, E.M., Horst, D.A., Minkel, J.D., & Humphreys, K.(2004). Treatment needs associated with pain in substance usedisorder patients: Implications for concurrent treatment. Drug andAlcohol Dependence, 73, 23-31.Turk, D,C. (2002). Clinical effectiveness and cost-effectiveness oftreatments for patients with chronic pain. Clin J Pain, 18(6), 355-365.Turk, D. C., (2003). Cognitive-behavioral approach to the treatment ofchronic pain patients. Regional Anesthesia and Pain Medicine, 28(6),573-579.ReferencesWells-Federman, C., Arnstein, P., & Caudill, M. (2002). Nurse-ledmanagement program: Effect on self-efficacy, pain intensity, painrelateddisability, and depressive symptoms in chronic pain patients.Pain Management Nursing, 3 (4), 131-140.Wells-Federman, C., Arnstein, P., & Caudill-Slosberg, M. (2003).Comparing patients with fibromyalgia and chronic low back painparticipating in an outpatient cognitive-behavioral treatmentprogram. Journal of Musculoskeletal Pain, 11(3), 5-12.26