naadac - nonopioid pain therapy 12-16-2020
TRANSCRIPT
NAADAC
Nonopiate Therapy
Dec. 16, 2020
>> JESSICA O'BRIEN: Welcome today's webinar. I am the trainer and content manager at NAADAC and I will be the organizer for the training springtime ledger all here today. Closed captioning is provided by Captionaccess and click on the link to use closed captioning. Every NAADAC webinar has its own webpage that houses everything you need to know about that particular event. Immediately following the live event today you will find the online CE quiz link on the same website you use to register for the webinar. So everything you need to know will be permanently [email protected]/non-‐opiate therapy, and you can see the website link at the top of the slide.
We are using Goto Webinar for the event and you will notice the panel on the side of your screen. You can see the orange arrow and it will minimize the menu and get out of your way or expanded by pressing the arrow again.
If you have questions for the presenter please type them in the questions box address your questions. under the questions tab there are the handouts and user friendly instructional guide. You can see the online CE quiz and immediately earn your CE certificate so please use the instructions in the handout tab when you're ready to take the quiz but now let me introduce you to today's presenter. Dr. Tammy Fleming has been working in pain management for almost 20 years including inpatient rounds of facilities with large volumes of patients with a history of substance use disorder. She is involved in multiple committees and serves on the University of Pittsburgh physicians pain steering committee. With others who treat those with substance use disorders.
50% of her patients have substance use disorder or substance use disorder issues, either active or in their history with the new pain related issues so NAADAC is delighted to have this presenter here with us today. And for you to get all this wonderful information so Tammy, if you are ready I will hand it to you.
>> TAMMY FLEMMING: Thank you so much for the introduction. Good afternoon everyone and if you are on the East Coast I hope you are enjoying our snowstorm. I am glad to be at home. I have to admit. We have about 6 inches of snow outside. I live in Pittsburgh so hopefully everybody is staying warm and safe. Today we are going to talk about pain management and some other options for treating pain management that do not include opiates. Sometimes opiates are something we must use in every patient but trying to give some other options as well.
So learning objective one. We will be able to identify the members of an interdisciplinary team. Be able to identify five medications or procedures for pain management and acquire basic skills and methods for pain management. So when we talk about non-‐opiate treatment of pain and the rationale behind it, pain is more than a sensory experience. It has cognitive behavioral social cultural and spiritual dimensions to it. And these are ways that we can treat the patient in a different way working on the cognitive and cultural dimensions that surround pain management as a whole. And it is mostly treated best with a combination of pharmacologic and nonpharmacological therapies. Comprehensive pain management has been shown to improve pain and increase function, improve outcomes and decrease depression and anxiety with patients.
So we go after and interdisciplinary approach. And where I work, we strongly focus on this interdisciplinary approach. We have occupational therapy, physical therapy, pain psychology, pain psychiatry, physicians who specialize in different areas of affordable we have a neurologist in our group, that is not typically a pain management certification as a neurologist, but she handles most of our migraines and fibromyalgia patients. We have another physician who specializes in facial pain. As well as chronic abdominal pain so we've felt this interdisciplinary approach to dealing with patients with pain and how can we add everything store practice.
We do medical marijuana, we also have an acupuncturist within our group. And so we really work on trying to put all these things together. I forgot also, we have a social work of worth in our group.
The trademarks of an interdisciplinary approach is assured philosophy, mission and objectives. We all have complementary roles and we have an open communication, our system is set up with EPIC charting where we are able to communicate with each other simply. Integration of knowledge in skills, shared problem-‐solving, consensus-‐based decisions and shared accountability. Our goals are clear focus, realistic and measurable.
We have a program that is based on each patient so we can discuss different goals for the patient did with COVID we've gotten more inventive about that but we still have the program set.
The accepted gold standard for the G Bid of high impact chronic pain is an interdisciplinary model. So pain medicine physicians, neurosurgery, rheumatology psychiatry, neurology, sleep medicine and PM&R psychologists that specialize in pain, rehab and neuropsychology, and also PTs motives, RNs, SWs, and I find this helpful because it helps take comfort in that we are not alone in treating pain we are all working together and we all have the same goal. And it makes, since pain management can be such a difficult field, it allows us to feel we are all working together towards the greater good.
why use and interpret disciplinary approach? The presence of pain affects all aspects of a patient's functioning, there's holistic treatment were readdressed bio, psychosocial factors. Any opportunities develop the team approach are included so we typically interview the patient, we meet together and discuss -‐-‐ and make a plan with the patient as to how we feel our physical therapist or occupational therapist, our pain psychologist could fit into their care. Do they need all three pieces of the program are just a pain psychologist?
Having them participate with us in the self-‐management guarantees participation, accountability, independence and gives them skill building.
So who is included in a multidisciplinary team? Right now we are dealing-‐-‐ at multiple hospitals are dealing with the new requirements for multidisciplinary pain team. We have come up with what we figure is the gold standard, which is a lot of these groups within this section. And we've come up with maybe your hospital does not have all the scripture you group does not have all of these people. But as many pieces of this puzzle that you can put into place, the better off the patient care will be.
We have the patient in the center with the physician, the nurse and psychologist, the social worker,, sponsor and addiction-‐ologist so I'm also reaching out to the patient that's often in recovery that's not on any medication assisted treatment and they are in the hospital with a broken leg. So how do we help them with their pain? We may reach out with her sponsor or
bring the social worker on board to connect that patient to the proper avenues so that we treat that patient with everybody on board and everybody is on the same page.
Please share your primary role, whether it be nurse, doctor, counselor, social worker, peer recovery support or other?
>> JESSICA O'BRIEN: Let me grab the poll question here. Please share your -‐-‐ now you should see the poll on your screen to go ahead and select your answer. People are on top of it here.
[Poll]
>> JESSICA O'BRIEN: Let me give you five more seconds. Do not forget to put your questions and the questions box we can answer them at the end in the Q&A and I am going to close the poll now and share the results, so you should see them pop up on your screen.
>> TAMMY FLEMMING: Okay. Awesome. So, we've got a lot of counselors on here. That is great but some of this that I will speak to, you guys will know very well and just maybe not how to put it together with pain management. And so I look forward to any questions you might have at the end.
So what do we put in our chronic pain management toolkit? First we have discovered if we acknowledge the patient is expressing pain, that sounds a little silly but a lot of our patients, particularly those with substance use and abuse history feel like they need to explain their pain. They need to get us to believe they are having pain and once we acknowledge they are experiencing pain, that allows us to get on the same page with the patient because these patients feel like you just think I'm trying to get more medicine or I'm trying to do something I should not be doing. My first response typically is, no, I know you are having pain. Totally on the same pages you. We just need to work together on a good plan.
Avoid making them feel like they do not have physical problems. Even if medically we do not know what the physical condition is. Sometimes chronic abdominal pain we may not be able to find the source but it does not mean we make the patient feel like it is in their head. Can we still treat the patient as they are experiencing pain of some sort.
Avoid heavy anatomy or research-‐based explanations. That is the last thing the patient wants to hear. They want you to talk to them One on one and not try to hide behind a lot of anatomy or research-‐based explanations.
Once you acknowledge the pain I find that you can focus, you can shift the focus to function. For example, I see you are suffering, I can imagine everyday things are hard for you with this pain. Let's talk about what you're having a hard time at home. We can acknowledge the pain but refocus them onto how can we help you? What can we do to make things better for you?
Empower your patient and make them feel like they can be smarter than the pain. The p to their success, which I am sure you are all familiar with on the road to recovery with substance use disorders. Chronic pain fits in that category for the patient has to be in control of that recovery not the therapist.
Pain is a difficulty you have in your life however whether it controls your life or future is up to you. I have had clinicians that you can be up chronic pain patient or patient with chronic pain and I would rather be the latter because it means chronic pain is a part of me and does not define me. And when you explain that the patient's, a lot of times it is in eye opener to them and they don't have to be defined by this disease, they can be defined by what they do in life and how they move forward.
We want to promote independence as much as possible. We want to provide structure and strategies but it's important that we do not make the goals for the patient. We may guide them in their goals and assist them in making those goals but we do not make the goals for the patient.
We want to use motivational interviewing techniques which I am speaking to the choir on that one. Open ended questions and inquiring why they feel a certain way or how confident they can be to change.
So, the pain cycle starts with physical changes so they may have muscle spasms which decreases their flexibility and strength and it starts to change their posture and that leads to a functional change where they do not do as much because it hurts so they will stay in bed or in
their chair, they decrease challenge to activity because they're not doing anything. Now they have decreased social contact, and that leads to emotional changes of frustration, anxiety, depression, low-‐self-‐esteem and fear. When we have all those together they start to feed off of one another's , less functional.
They do not want to get out of bed, all my knee hurts when I walk so I stopped walking. Now they're not going out and meeting their friends. I have a patient who is older and suffers from depression to begin with and one of the biggest things we talk about is how many times did she go swimming each week. I require that, I want her to go two times a week, not because the swimming is not good for her and activities good for, but she tends to on Fridays when she goes over they all go out to lunch afterward which is good for her.
So those are the kind of things I am talking about to break t
So how do you break the cycle? You teach the patient to accept the pain and there is not a cure or easy fix. And accepting it can move past it. I often talk about a patient who had neuropathic pain. Unfortunately, his with idiopathic meaning we don't know why he had this pain. So we went there medication after medication. And then we had him in therapy and we were using creams and medications and I think at one point we had even gone to opiates because we just didn't know what else to do for him.
He had been seeing our doctor about six months. And just that particular time, I was the one doing his intake. And we are talking and chatting and I said, something he has said to me and I said, you do realize that the nerve damage is done. There is no going back from this point as far as the neuropathy. So even if we found out tomorrow why, it wouldn't change her current outcome. Now, can we move forward? Absolutely.
But what has happened has happened, it is nerves. From that day on, he was able to wean off all his opiates, was on minimal adjuvant and got his life back and stopped seeing us because he understood at that moment that there was no cure. This was not going to be an easy fix, he was not going to be pain-‐free and just learning to accept that changed his whole outcome. Getting involved we want patients to take an active role in their recovery and set priorities. Look beyond the pain to the important things in life.
I have a patient who has trigeminal neuralgia and she struggles to look past the pain. She struggles to look at what is important in her life. She has allowed it to shelter her, in her home
probably 85-‐95% of the time and she is only in her 30s. It is just because she cannot look past the pain issue.
We want to set realistic goals that are within your power to accomplish. We want small victories. Like you are doing anything, like weight loss, celebrate the small victories with a new shirt or extra walk, whatever it might be. You want short-‐term and long-‐term goals. You want smart goals specific and measurable, attainable, relevant and time-‐based.
I spell that out because I'm one of the people that I have to always look that up every time I read it. I know what it means in general but I'm going to be honest it is one of those things for me.
Reach out. You want to share what you've learned with friends and family and coworkers and teach others about pain management and your management in the process. We have a part of our thing where we do group therapy where one might say oh my gosh, a roomful of chronic pain patients, wow, but it is worked out really well. They really do feed off each other in a positive way. Saying, hey, when I tried X and really work for me, maybe you should try it. I use my tenens unit at this point and this point in the day and it gets me through. Things have worked well for our patient population.
Types of pain were going to talk about the two different types to give you some background. Nonsusceptible pain is from trauma to the tissue paid transmitted from periphery to spinal cord. It is described as dull, aching, throbbing and sharp and it is opioid responsive. So it nonsusceptible is the easy pain to treat. Somebody fell and broke their legs and life goes on. When it becomes a chronic issue is when it becomes an issue for us, because those can no longer be opiate responsive.
Neuropathic pain is the bane of my existence. It results from damage to the peripheral or central nervous system. So this could be diabetic neuropathy to central stroke syndrome. Damage can come from trauma or disease. It is usually described as burning, shooting, electrical, tingling, and it always requires multimodal treatment. There are multiple medications we typically use, I will go through those, but it really does take pretty much all of them put together to help with pain.
What are some medications and other things that we do use. NSAIDs, opioids, adjuvant medications, invasive techniques and then we will look at the non-‐pharmacological.
A little brief overview of the non-‐opiates like acetaminophen and NSAIDs, they're both effective against nociceptive pain. People have an analgesic ceiling in patients particularly those with a history of substance use disorder, sometimes they think that the idea of taking more makes things better applies even to acetaminophen and NSAIDs. I have a young gentleman in the hospital who just was admitted for a GI bleeding because he was taking 5-‐6 ibuprofen every 3-‐4 hours.
We really want to instruct that they do have an analgesic ceiling. Like ibuprofen is 2400 mg a day. And it can cause bleeding or kidney damage if that is exceeded.
We restricted Tylenol 24 g and 24 hours to prevent liver damage. That has now become 2 g in 24 hours.
NSAIDs, these have a black box warning because of cardiac effects. All of the anti-‐inflammatories with the exception of Celebrex are COX one and COX two. COX one is what we do not want within and said, it upsets your stomach and creates a block of histamine release as well as decrease platelet aggregation. So those two things are things that you'd not take an anti-‐inflammatory for. But they do come with the program, so when you're taking it, for the COX two, Celebrex is the only COX to only medication. Those who have been unable to take an anti-‐inflammatory because of reflux or a blood thinner that they are on Celebrex is a good option for that.
Adjuvants. So antidepressants play a large part in what we do. Not just because of the aspects that help pain, but because we often tell people, they will come in and are crying and are upset and they will see you just need to treat my pain. And we tried to explain to them that if we do not improve your mood, the pain onto better. So we need to do our part to make your mood better so that we can help your pain.
Cymbalta is used most frequently, it was created specifically with chronic pain in mind. It has an NMDA receptor that helps neuropathic pain. And in in addition it helps the mood so the patient suffering from psychosocial issues with their pain, they are depressed and do not want
to get out of the house, the pain cycle we were talking about, Cymbalta can help with the pain and help with their mood and get them moving forward. Anticonvulsants such as gabapentin and pregabalin, they suppress neural firing so they are useful to neuropathic pain. So there is abuse potential that we are currently facing which is why it has become scheduled in many states, Pennsylvania is not. But Ohio and West Virginia has been so I do not use that lightly. We are more careful than we used to be but it's one of the better medications to use for neuropathic pain, simple because it is cheap. We come across a lot of patients that don't have insurance or Medicaid and we need to be mindful of medications that are not expensive. One of the best things that ever happened to us recently in the past year is this became generic. Being generic now has improved costs and improved what we’re trying to do with patients so that is been a godsend for us.
These are hardly used anymore but we do use muscle relaxers. I will say with all of them with the exception of soma, that has addictive qualities to it so we do not use it. But Robaxin, Baclofen, Flexeril, those help with a lot of times, the side effects can be making patients tired so that can improve their sleep as well. We use steroids through injection form to decrease pain by decreasing edema. Often injections will just break the cycle of the pain and give the patient a bit of a breather of pain so they can move forward and reset themselves. Topical's, we are gaining ground with compounds which I will go over in a moment.
Topical anti-‐inflammatory-‐-‐Voltearen Gel, this is reasonably affordable, it is not super inexpensive, particularly the patients only paying two dollars when it was covered by insurance. But once the insurance is over-‐the-‐counter the insured stops covering them usually but it's available and often helpful with osteoarthritic type pain, knees, joints and things like that. The Flexor patch really never took off because it's never been approved by insurance, Aspercreme has come out with aromatherapy and with Lidocaine. We will talk about aromatherapy at the end of it so that it plays into using that for pain management as well.
Topical lidocaine, we can get patches. They have little systemic absorption for the do need to be given an adequate trial of about two weeks. The biggest adverse reaction is redness or rash at the site. They are now in generics of the not covered by insurance with the exception of postherpetic neuralgia, but over the counter is 4% and this brand is 5% so that's not that big of a difference.
Other topical jobs like capsaicin and things, bio freeze which is helpful for patients.
There are specialty compounding creams Being used more and more. They are typically created with special pharmacy. They are compounded but they have less than 1% systemic absorption. For example, I had a patient who had diabetic neuropathy. In his feet. We gave him gabapentin. 100 mg had him walking into walls every time he got out of bed pretty just really could not tolerate it. Tried Cymbalta and there were side effects. Add Lyrica and had problems with that. We went to a compound cream with local anesthetic next with gabapentin in the agreement itself. He applies three times a day, it works in he has no issues and he has no pain with no side effects.
So little bit about injection certain nerve blocks, these can be up to diagnose pain. A variety of them can be used. They are not a cure but can provide a break in the cycle of the pain.
So, we have a cervical or lumbar epidural steroid injection for those can also break off into selective were we target specific nerves for specific pain. Medial branch block treats basically chronic low back pain grid we are doing a lot with joint injections. Such as there is a new procedure called Coleef which is an option for patients who cannot have a total knee due to health concerns and are too young or old or not a candidate. Had a total knee and it didn't work, we can block the nerves and then we can proceed to burning the nurse and having that patient one to two years relief. I don't think anyone realized how prevalent this issue was until there was a commercial here in Pittsburgh on one of our local news channels on this new procedure about two years ago when it started.
And the website crashed the next day at greater than 80,000 people trying to access it at one time. So knee pain is a big issue. We are working on trying to use the same technique for sacroiliac pain as well as hip pain rated
Trigger point injections can be helpful for muscle spasms, and then very specific nerve blocks based on different pain conditions.
We are going to talk about non-‐pharmacology. So, the biggest thing is that people ask me, how does this reduce pain? There's about five different things. It can reduce pain by interrupting the transmission of the signal before they produce awareness in the brain. It may work by competing for attention and limiting one's capacity to feel the pain.
A lot of them produce a relaxing effect such as massage or sometimes exercise or heat and can release the physical or emotional tension which decreases pain. They can possibly stimulate the release of your body's natural endorphins and the natural opiate that we produce. They can work by changing pain related thoughts. So all of those things are very important when trying to treat pain.
So, like I said, potential mechanisms, the interrupt pain transmission, release tension, release the peptides and change pain related thoughts.
Regardless of the effect on the intensity of pain, there are additional benefits to nonpharmacologic interventions. Reducing anxiety, improving one's mood and you give someone control over the pain. If you teach them about cognitive behavioral therapy were buyout therapy for distraction, it gives some control over their pain instead of letting the pain Have control over them. Improving sleep. If your sleep is not good, you have fatigue you will not perceive your pain well. Improving function, which improves the pain. And hopefully affect most importantly, improving your quality of life.
What are some barriers? We have a lot of barriers. Lack of knowledge. Belief that nonpharmacologic interventions are not effective. That is both on both ends of it, patients believe that we have staff that believe that. There's a big thing work nursing does not document these types of interventions because they do not feel they are effective.
I can tell you when I talk about it in nurse residency or in orientation, I get a lot of eye roles from nursing staff like oh essential oils will fix everything? No, they are not. But can they help a patient with pain maybe take away 5%? Okay, well if I add six things that take away 5%, I've decreased their pain by 30%. That is a large number two somebody who is chronic pain.
Perceptions that the patient will not be receptive. I can tell you, most of the time patients are receptive to anything that will try to help. Lack of time and equipment. A lot of things I will show you later do not require a lot of equipment but they do require some time, and that is something that we try to encourage nursing to carve out when they can.
And lack of support from colleagues and administrators. I will tell you, in light of the opiate crisis, none opiate, non-‐pharmacology pain management has taken off in such a way and gotten
so much support from administration because they are looking now for ways to improve pain without dipping into the opiate epidemic.
So it's really been an open window for nursing staff. And my colleagues, to work with administration because there now focused on improving these things.
So let's talk about basic comfort measures. Positioning. One of my patients was struggling because he was so tilted in the bed, it was a simple maneuver just to straighten him out. It sounds silly, but Elinor just a little tilted it's no big deal. No, positioning is important. Environmental conditions such as lighting, noise, temperature.
My dad is 86 and likes to mow the entire lawn and I tried to explain If you took breaks and if you paced your time you would not be down for 48 hours doing that and trust me, do not say that I've already tried doing it instead, he just will not let me. He wants to have it just so, and instead of taking breaks and pacing his activities and resting, he does the whole thing and then he is down and out for the count for 48 hours but then looking at supportive devices, how can we make sure, is or something that we can be doing for the patient supportively to help them maneuver better?
Physical exercise. Aerobic exercise and resistance training. Passive exercise and those already debilitated pretty useful for low back pain, osteoarthritis, we develop a plan for daily exercise. An hour of physical therapy. Or 30 minutes of physical therapy is not going to correct 16 hours of poor posture. So we work with the patients on developing something that the lifestyle change for them to better help them move and function.
That being said, I want to ask everyone here, how many nets of physical activity do you personally get every day?
>> JESSICA O'BRIEN: Let me launch this second poll. Stay tuned and it should pop up on your screen. They go. How many minutes of physical activity personally that per day. And don't forget to put your questions in the questions box today.
I am going to close the poll now and share the results.
>> TAMMY FLEMMING: Okay. We got some very active people. Yay you! I am not that good, I will admit it. This is great. That is the kind of encouragement we need for our patients because when you tell somebody who has been doing no physical activity, a lot of times they are noncompliant. Now you're telling somebody does zero physical activity that we want you to work up to doing 30-‐45 minute per day. You know? So working with the patient in developing ways to make that happen is part of what we do as well.
So we don't just say to the patient, okay, I want you to do exercise About 30-‐40 minutes a day. Like I was saying with my patient with a swimming pool, I say to her, I want you to go to the pool 2-‐3 times a week and I will call you on Friday before I leave work for the day and see how many times you did that this week. Sue give the patient what they should do, how they can accomplish it, and hold them accountable to accomplishing that task.
Occupational therapy, we facilitate through the therapeutic use of everyday activities, they work with the patient's to see how they are doing things and could they provide better ways of doing things? Could we give them other devices to help them with their activities? And we want to maximize the patient's function.
We evaluate for baseline level of participation in activities of daily living. Leisure and work greatly focus on function, education and compliance rather than pain reduction because if patients are focus on their pain it makes it difficult to help them and we want them to focus on getting better and feeling better.
Establish an understanding of the occupational therapists role. Again, making sure they understand this is about independence and control and self-‐management.
How does occupational therapy help? They break the pain cycle of getting the patient moving, thereby managing pain. They teach them pacing as we talked about great analysis of their physical life and what they are doing pretty help them establish a walking program. Maybe an upper extremity exercise program if they have knee pain so let's not focus on where the pain is let's focus on extremities that are working well.
We work on body mechanics. We work on simple vacation and planning so that plan out the day so they don't expend all the energy they do have pretty work on flare management and I can tell you flare management, as a whole, does not include increasing patients medications. We work with heat, ice, rest, exercise, things like that.
Making sure they have leisure time and using it well. Because that is important in helping with pain. And making sure they are setting goals. I use this to talk to nursing staff, if patient had survey and their pain is a five what was post to b_0, while we as nurses think five is fine, the patient that thought it was zero does not think five is fine. So goalsetting is important for patients. Whether it establishes the pain goal, a goal for function, whether like I said it is establishing a goal of, I'm going to go swim two or three times this week.
Pacing. We want to find a patient's baseline. Then we want to report progress and increase their accountability and allow them to do a self-‐reward when they do things well and pace. They may have some pain, so they will take a little rest, but it eases up but then they go overboard. So we need to teach them to break the cycle of the overactivity piece.
We try to teach them the three day rule. So if you have a bad day three days in a row, now we need to talk, now we need to adjust something. But if it is just one bad day, and everybody's allowed to have that. Even two. When it stretches into three now we need to talk about your goals and what you are doing with her pain management again.
Ergonomics breed ensuring the environment is conducive to success. We all have that crease where we are doing this these days. Seating, sleeping options, lighting, sound and distractions are considered important. Finding out what position is the human body comfortable and that depends on the individual paired while we follow ergonomics but also making sure we reach the patient's goals.
Leisure. Analyze the activity and body parts involved, the physical demand required and do we need to make an adaptation so you continue to do the things you likely a lot of the males that come in, this is golfing, they like to golf. And the doctor work for is a huge golfer. And if something impacts his golf game, he takes it very seriously. If it is an ache or pain, it suddenly becomes very focused because it impacts his leisure so patients are no different. We need to make sure we are helping them do the things that they like to do in addition to what we are asking them to do to improve their function.
So let's talk about heat, that is one that is easy. We need to be careful using it. I can't tell you how many times patients come in for injections and I raise their shirt and see the outlines of the heating pad. We need to instruct that that is why they all come now without 20 minutes shut off. But it is good for muscle tension and spasms. Arthritic type pain and postoperative pain. Just to be careful with bleeding, topical menthol are medicated ointments particularly Lidocaine because they can't feel how hot whatever they are applying is they can earn their skin but otherwise he can be very effective way to deal with pain.
Patients often ask what is better, hot or cold? I say that is up to you. This needs to work for you.
Is cold makes you feel better even if 100 other people say heat, then cold is your thing. It can decrease sensitivity to pain, it can also provide a competing sensory explains because that cold is shocking. We prefer not to use it in the patients with poor circulation such as ruffled vascular disease or radiated skin.
Massage. Sadly, this used to be taught in nursing school but it no longer is. It is a very effective way to help with pain. I had a patient one time where we had, she was having cancer pain and on multiple opiates and medications, all these different therapies, I came in the next morning and she was lying in bed comfortably and I said what happened? She said the nurse came in around 1 AM with some hot oil, hot lotion, massage, Techne and with warm blankets and really had a good night sleep. So I try to encourage nursing staff to not lose this skill because it can be helpful for patients.
Patients with fibromyalgia Our pre-‐COVID, we encourage them if they can afford it to get may be monthly or every other monthly massages. It can be very helpful for pain.
Duration can be five minutes if in one hour but we have to be careful with thrombocytopenia, fragile skin, DVDs, acute inflammation or skin infections or superficial tumor sites.
TENS UNIT, this works well for patients, again the biggest thing is I was guilty of this -‐-‐ I put one on my husband after applying Lidocaine to his skin come he couldn't feel it so I kept turning it
up, that was dumb I admit it -‐-‐ and I realized my mistake thankfully quickly and took it all off. But something to be careful about.
We cannot use it on patients that have pacemakers or other implanted electrical devices, these were a little easier to use because they were covered by insurance but they are no longer covered. But I can tell you I ordered one online for about $22 from Amazon.
Cognitive behavioral strategies. We want to change the way pain is interpreted and experience. Modify the thoughts and turn attention away from pain so it gives the patient control over the pain.
So that is where pain psychology comes in. There is now a lot of evidence that the treatment of chronic pain cannot be done effectively while ignoring psychological factors. There are numerous psychological approaches and techniques for the treatment of chronic pain. Patient resistance to the referral is suggestive of a lack of understanding. I can tell you we have a pain psychologist on board and typically patients, we struggle to get them to see her. Because they will say that you think I'm crazy and you think it's in my head but no, I want her to give you different ways to cope with the pain so that you do better. I can tell you hands down, every patient that has seen her once to return to her. Because she really does give them good coping skills and other aspects.
We've hired other pain psychologists and they all have the same response pre-‐ patient's left talking to them because they empower them to handle the pain a different way.
So what are some psychological therapies, cognitive-‐behavioral therapy, contingency management, hypnosis, biofeedback, psychotherapy and we will break down a few of these.
Cognitive-‐behavioral therapy. Again, I'm preaching to the choir here. First-‐line psychological treatment for chronic pain involves education, relaxation training, time-‐based activity pacing. Behavioral activation and problem-‐solving skills.
Fear avoidance, this is the biggest problem that we have. The belief that pain means harm. And activity that causes pain might cause -‐-‐ it might cause pain to be avoided. Let's say if the
patient hurts their back. We tell them to sit on the couch, no I will lift and move that bridge so patients start to get comfortable in not moving and they say I'm hurt I better not do that, instead of realizing that pain is not-‐-‐ or hurt is not always harmful. Sometimes moving those muscles for the first time will be painful but that is okay. Are not necessarily going to hurt yourself.
Fear of pain or anticipating the pain and not actually the expense of being produces such a strong negative reinforcement of those behaviors breed the fear of reinjury are better predictors of functional limitations than any biomedical parameter. That just amazes me, that somebody's fear of moving or the fear of being reinjured is actually a better predictor of their functional limitation.
You want to provide corrective feedback to learn that hurt and harm are not the same. You want to give them some exposure to those things that are intended to challenge those catastrophic interpretations of the consequences of the activity. I read something at persuading someone that hurt does not mean harm is to convince somebody or persuade somebody of something so fundamentally countercultural that it will hardly ever change without intervention so if you do not help that patient do that or bring it up or talk about it, the patient's will not move out of that fear of hurt and harm on their own. Yukon CBT, again treatment goals focus on helping patients realize they can self-‐manage. There is a wealth of evidence that CBT can restore function and reduce pain.
Acceptance and commitment therapy. Also it has strong research support as a treatment for chronic pain these are two books I have referenced. Living beyond Pain and happiness trap.
Mindfulness meditation. Observation without judgment, of thoughts and emotions as they arise moment by moment. Intentional self-‐regulation of attention on particular aspects of the inner and outer experience. And mindfulness-‐based stress reduction program, we have one at the UPMC Center for integrative medicine. Our pain psychologist actually led our group through one of this to show us how mindful meditation can be helpful even our stressed environments.
Biofeedback. Use of electrical sensors to look at the physiological process and bring them under voluntary control. Generally this is done through relaxation. It can help with the stress response and patients can learn to exert control over these processes and assist in regulating their autonomic nervous system.
Mechanisms of involved in biofeedback Is unknown but is generally a sense of relaxation that’s an important feature. This is more of a feature of autotherapies that we do.
Self-‐management. It is important the patient is on board and wants to have some self-‐control and management of the symptoms. Self-‐management is an important complement the biopsychosocial approaches.
Motivational interviewing. The state of acceptance is important. If they don't want to go to PT and OT, motivational interview is a clinical tool we can use to foster motivation for chronic pain self-‐management.
Distraction. These are simple things I like to teach more so for nursing. I know there are a few nurses in physicians on the line for distraction directs attention from the pain. It requires mental capacity to concentrate. There is awareness of pain when distraction ends. A physician that use this to do extensive nerve blocks presurgery because the patient's physician was in the OR and could not sign consent for the surgical procedure so we could not give them sedation to do the block. He did a great mixture of distraction and imagery and the patient is to get through very extensive nerve blocks with zero sedation.
Choose something that patient is interested in consistent with their ability to concentrate and energy level. He's an activity that stimulates hearing, sight, touch/movement.
Relaxation. Pain caused by muscle tension, this is great for, you want to release stress and tension associated with the pain read arthritic or procedural postoperative pain at our backs off and spasm resulting from injury so this is a way to help relax through it.
You want to do rhythmic breathing, heart deep breathing, cp progressive muscle relaxation, stretch based relaxation.
Imagery, use one's imagination. It is a good distraction, like I said, relaxation imagery, pleasant scene, some people find imaging of the pain itself can break the cycle, it is used for back pain, post-‐operative pain or arthritic pain.
You might want to use a script or live guide, use multiple senses and be careful with patients with obvious psychiatric illness.
Supportive therapy. We've all found that this is been successful both sides in chronic pain and in your world. Expression of feelings of pain encouragement and discussion of other problems and referral.
Some of the other things we have looked at is acupuncture/acupressure and weave a physician in our group who does acupuncture. Chiropractic and osteopathic medicine. Art therapy, music therapy. And again, like with music therapy and these other things it is really patient specific. Perk some patients like to relax to Led Zeppelin and some like to relax to classical music, really keeping the patient in mind with this.
Other complement readings or Therapeutic Touch, Reiki dietary supplements,, magnet therapy, homeopathic. Pain is the most frequent reason to use the complementary alternative medicines.
What are future options? We are talking briefly about aromatherapy. There was a study done in Philadelphia in a Children's Hospital where they used a stress survey to staff only, the used aromatherapy and staffing areas so they didn't interfere with patient care and then three months later they repeated the stress survey. There was a 50% reduction in staff stress and the only thing that was done was aromatherapy.
So we need to give this more credit than we do. I know at the hospital we worked out we are using this more and more and there is a new thing we are using cold Queasy, that's aromatherapy for nausea for patients with chemotherapy -‐induced nausea. This is up-‐and-‐coming for us to look at.
CBD has been showing some promise. In Pennsylvania it's medically legal but not recreational and they can sell over-‐the-‐counter CBD that has 3.2% of THC actually in it, even though it is legally recreationally here. Some patients have failed urine toxicology screens using CBD oil tincture over the tongue when it was bought over-‐the-‐counter and it was only .3% THC. But it has strong some success.
Barriers to pain relief related to substance use disorder. We have a lot of healthcare professional problems with opiate phobia leads to under prescribing and under administration of patients. Matter what the patient's history, if they break their leg we need to treat that pain. Fear of scrutiny and lack of knowledge about addiction tolerance and physical dependence. We want to work with patients and their families. We have patients who fear addiction and will not take adequate doses of medication. And this decreases their function and to do well. And families can withhold analgesics from patients. In healthcare systems. Healthcare systems, are now a little more onboard than they have ever been due to the other issues with the opioid crisis.
Pain management is inadequate knowledge and fear of addiction, diagnosis requires ongoing assessment of aberrant behaviors. Our goals include improving analgesia and activities of daily living while controlling adverse events and aberrant behaviors. Pain management requires effective communication and of multimodal approach. In patients with an addictive disease present unique challenges, but obviously deserve appropriate pain management.
And that is it.
>> JESSICA O'BRIEN: All right. So let's get to some questions. The first question is from Emily. Thoughts on use of Neurontin for chronic pain.
>> TAMMY FLEMMING: So we use Neurontin for chronic pain a lot. We actually have even started using it for chronic abdominal pain, which we never did before. We feel that the nerves are stretching in the abdomen just like they do, going down your leg, and it is a different type of radiating pain so we been using gabapentin. We are just being a little more careful with it and cautious, due to its addictive qualities.
>> JESSICA O'BRIEN: Great. The second question is from Jake from Denver. I work in a clinic with the primary population of individuals expensing homelessness, and that comes along with stigma and we have an MD that specializes in chronic pain but otherwise the rest of the team are generalists, counselors, case managers. If you could add one more specialist next who would you recommend?
>> TAMMY FLEMMING: Geez [Laughter]. You have an MD that is pain? Then to be honest, I would probably recommend adding an APP. We collectively at least in our group, we tend to treat those types of patients where the physicians are more focused on the injection patients in different therapies like that where we focus more on the adjuvants ... occupational therapy. The other thing to add would be like our pain group where we have a pain psychologist, that would be another great addition to your staff if you don't have one of those. They are hard to find but they are fabulous when you can get one.
>> JESSICA O'BRIEN: Keenan asks, what about the side effects of tiredness/sleepiness come with Cymbalta, how do you deal with this or what are other options?
>> TAMMY FLEMMING: Similar to if a patient has that side effect with gabapentin, we start out low and we only give them 20 mg which is the baby list dose allowed and available so we give them 20 and have them take it at bedtime and do that for maybe two-‐three weeks. Helping them to understand that while it may not help their pain or move just yet, we may need to just build the tolerance to the medication and then we will increase them to 40 and 60 and may just hang out at 60. Sometimes we go to 90. If they can't tolerate Cymbalta we go to and a trip to lien-‐ and one of those instead.
>> JESSICA O'BRIEN: They follow up with what about lotos naltrexone?
>> TAMMY FLEMMING: That is one of the questions that I may have to put back into my Q&A I am researching that currently myself. We've just started as a group providing that the patients. Initially it was just the physicians doing it and now we are seeing this patient says follow-‐ups. So am on a physician who is prescribing it and we are as well as APP so I'm working on that a little bit so on a Q&A follow-‐up, I will add to that for you.
>> JESSICA O'BRIEN: Great. Thank you. Juliet from Washington, how do you motivate someone whose chronic pain is one of the primary crutches for the substance use disorder?
>> TAMMY FLEMMING: That's where we work with trying to treat them in the other ways as much as we possibly can. Because those are the patients the produce the biggest challenges and were seeing what we can do with their pain and specifically in opiate format. Those are the patients that I really try to get into our program or get in with an occupational therapist, to
work with their function versus working at they feel like I went to physical therapy. While you may have gone through back but not for a full functional plan for yourself to get better. I will also say that is again were pain psychologist and psychiatrist, to play a lot because they help with the other aspects of pain care.
>> JESSICA O'BRIEN: Great. What about people who do not qualify for insurance? We have some self-‐pay patients this may be cost prohibitive for.
>> TAMMY FLEMMING: What we’re trying to work on and this is our biggest issue, what I encourage patients to try to do is maybe come up with one visit -‐-‐we work with our departments as well. In okay this patient is never insurance. So, they will not see all three views so can we have them come to you once and set up a program, a good exercise, good routine for them-‐-‐, granted it is not the perfect scenario but it gives them some background at least. And then make arrangements and say in six weeks, so the patient can have some time in between costs, to go back and see them and make sure they are doing the things correctly that they were taught. In the maybe again one more time in six weeks, just as a refresher again. So they can try to work through it that way. It is not ideal. But it's the only option we have currently.
>> JESSICA O'BRIEN: Okay. This is a question from Joe. Any tips on tapering opioids?
>> TAMMY FLEMMING: Sure. So it all depends on which one. Usually, the accepted, as long as the patient -‐-‐ so ... let me step back a second. If the patient is being tapered because we are tapering due to the opioid crisis and they are on a high dose and that kind of thing, those at a little tricky because patients are used to taking a certain dose and it gets a little more difficult as we carry through. With those patients, because there is no pressing issue in mind, I may only decrease them by 10-‐15% over the course of two months. And then another 10%. And then another 10%.
The other thing we found success with his he put them on a certain regimen for two months and then the third month-‐-‐ because typically they see us every three, on that third month is when we decrease the opiates. So they are only on it a month before the-‐-‐, oh my gosh I have to do this for two whole months before I'm going to see them again or three months before all be seen again, they do the regular regimen and then decrease the third month and then come and see us. So they don't feel like they've been left out in the cold as much.
If it is because of a reason, particularly some aberrant behavior or a Toxicology screen or something like that, we do it more rapidly, unfortunately we do it within 4-‐6 weeks and we just -‐-‐ if they are on 30 ms Oxycontin three times a day, I'm sorry we take them down to 15 bid daily and off. And it is a rapid ween. But if you are doing it gently just for the sake that they are on opiates. We take them down by 10%.
>> JESSICA O'BRIEN: If someone wants to learn about occupational or aromatherapy, who were they asking where would they start?
>> TAMMY FLEMMING: Aromatherapy, those are more with like at Living young-‐-‐ , there are information on their website as far as occupational therapy, that's where you have to touch base as to who is local to you and reach out to people in the area. There are people that are specialized in chronic pain occupational therapy throughout the US, they just may be harder to find.
>> JESSICA O'BRIEN: Okay. There are a lot of questions.
>> TAMMY FLEMMING: My boss is Duetera.
>> JESSICA O'BRIEN: What are the best ways to help a client with opiate phobia?
>> TAMMY FLEMMING: That's my crazy thing. I try to point out -‐-‐ the downsides of not taking them. If a patient hurts themselves and are not doing their PT, they will not get better. So that same focus of, you've got to get moving to get better, you have to improve your function to get better. And sometimes in order to do that you may need assistive devices to make that better in a short period of time. I also find if it is a patient with a history of substance use disorder, reassuring them that I am on top of that. I don't plan on giving it to them month after month. And we will set up a very detailed winning plan with them while I am talking to them.
And then I typically bring a family member on board if I can. So that I may have a spouse or a parent or somebody in the house who can ensure that weaning occurs.
>> JESSICA O'BRIEN: All right. This question is from Tiffany from LA, in keeping with them being self-‐sustaining and accountable, would it be more helpful to have them call or text you as opposed to having the provider call and check in with them, as in the example used you want them to swim three times a week and will call them on Friday to find out how many times a week it was done?
>> TAMMY FLEMMING: In theory, yes. And we are working on that. We are working on an interactive program currently that patients will be allowed to text in. With this particular patient, she is 82 and a bit persnickety and a problem child. I love her to death. But her depression gets the best of her which really kills her pain issues.
So she is better -‐-‐ is more knowing your patient, she is somebody that I need to be accountable to call her, she will not call me. But you are correct, and that is something we're working towards right now.
>> JESSICA O'BRIEN: Great. Good news. This question is from Laura. How do you approach clients who are a little stubborn in admitting that pain may give them limitations like a client that may believe they can out with their pain but cause themselves more harm?
>> TAMMY FLEMMING: That would be my dad. My favorite story was I handed him, I think a couple Tylenol and he said, are you sure? This is what I do for a living, Dad. It's hard to help those patients. The important part is showing them where they're causing themselves harm. And what I have learned with him is that I can't just tell him to pace. I need to show him how. I need to set the guidelines with him so he understands what I'm saying. Like, it is all most like if you say just do this and they don't understand what that really means, sometimes you just have to spell it out. It may not work but that's what I've done so far and it's worked well.
>> JESSICA O'BRIEN: Good advice on that one. Jennifer asks, would you talk about bergamot being helpful for addiction patients and how it works and what is it about it in Alcohol versus other addictions.
>> TAMMY FLEMMING: Any people with addictions feel hopeless and helpless but this is what some people struggle with their aromatherapy because there's a whole side of it where
lavender is felt to help you relax, bergamot is supposed to make you relax but there's a side of aromatherapy where they feel a certain scents can make you feel less hopeless, and bergamot is felt to be one that inspires that feeling. That when you are feeling that there is a treatment center, I think it's in Las Vegas and they actually have their clients put bergamot on a cotton ball and carry it in their pocket and when they're feeling hopeless or feel very down, they encourage their clients to pull it out, smell it and maybe put it on the rest and it's thought the help of feelings like that. I don't know there's an exact science behind it I feel like it's one of those things that it's a small thing and if it would help the patient, then all the better.
>> JESSICA O'BRIEN: I don't think I'm familiar with bergamot.
>> TAMMY FLEMMING: Is very citrusy I like it. Because I don't like lavender.
>> JESSICA O'BRIEN: Question from Linda. Any thoughts on chronic pain protocols for dystonia?
>> TAMMY FLEMMING: Gosh, that is a tough one. We do a lot with trigger point injections with those patients. And we try to set up physical therapy or occupational therapy like immediately after the trigger points so when they are at their most relaxed state, sending them overdue stretching, and we also do a lot with TENS with those patients particularly. And works very well for them because it's an area we can target Britt
>> JESSICA O'BRIEN: This person I do not have a name but says, working to foster care system but judges in foster care do not allow for THC or CBD, how can we change this?
>> TAMMY FLEMMING: That is a super tough one but CBD is the thing I was stressing, if you look at them and now that I have said it everyone will pay closer attention but there are sheets selling it -‐-‐ I was looking at their dummies and it says on their specifically, "sans THC". So that is what I encourage my clients to look for because I had an administrator on duty, nursing staff using gummi's, came in and we were talking about it and she was like oh my gosh, let me take a look and hers did not quantify that there was no THC. And in this state of Pennsylvania you can sell .3% so that is the biggest encouragement to make sure people are being very careful, that is one if they want to use CBD.
Two, I don't know, we take three steps forward and two steps back every time we do something with medical marijuana. We show that patients are doing better and people are feeling better, they used opiate -‐-‐ opiate use disorder as one of the certifiable diagnoses now. It is a very hit and miss -‐-‐ some areas do better than others, in Pennsylvania we had a struggle and only had it legalized for three years now read and we are having huge problem with supply and demand. I have patients that use it and what they use that was helping, they were able to reduce opiates is not available the second third time they go back and I don't think people really pushing for it so all metal loss for that one and I really wish -‐-‐ I am with you that I wish people would understand that it's a really good treatment plan.
>> JESSICA O'BRIEN: Kurt asks, is there a good place to reference any studies or evidence regarding different not opiate treatments?
>> TAMMY FLEMMING: Yes honestly, a lot of the newer stuff I have added, I just searched "non-‐pharmacology pain management" and a wealth of info comes up because people are looking for that and they want that. Even when I was talking to friends other nonmedical in a hospital like a friend that's an EMT said, oh my gosh can I see that lecture because people are looking for better ways to handle this. So there are a lot of resources out there now.
>> JESSICA O'BRIEN: Here is one from Amanda. How do you handle a patient who is Doctor shopping. Unfortunately this is still possible, what documentation is important to have in your medical notes when Doctor shopping is occurring?
>> TAMMY FLEMMING: There are two parts to this. I'm having the same album in my hospital and I say gosh, if there were only a button we could push and see all the info that we needed.
I document thoroughly a lot of our fellows have actually taken to doing screenshot of the PDMP itself and flighting it into our notes so that they can show that, being clear in your documentation, the only caveat I would say to make sure that you pay attention to it and this is PDMP, on the other side of the patients that go to a skilled facility for example, the physician who wrote the order for the patients leave the hospital will only write four of 15 pills for them to leave but they have to have a valid prescription to come into the facility. It cannot be electronic it needs to be written prescription. Patients go to the skilled facility and there may be two or three different PCPs or two or three different APP's seeing that patient during that
time. Nobody rides for more than 3-‐5 days of opiates when patient is in a skilled facility because they don't want to have them with excess medication sitting there.
So physician once reference to the patient "failed" PDM P but it was because the patient had just been seen by different providers in the skilled facility, they had all written prescriptions and then when the patient came out and went back to her pain Doctor the entrance, he said well we are not covering anything, if at all these prescriptions and meanwhile while she was in the facility she paid cash which just really threw everybody for a loop on the PDMP. So they haven't figured out a way, for exam I work in the North Hills in Pittsburgh, my cohort works in Shadyside and my physician is based in Oakland and we have three different addresses for the PDMP so it appeared to someone else that we were from a different practice when we are clearly not. So unfortunately the PDMP is not the fullest proof way to prove Doctor shopping just throwing that out there because it's just a caveat to think about. Otherwise I would -‐-‐ I think our fellows do a good job they do a screenshot of the PDM P when they put it in the note.
>> JESSICA O'BRIEN: A lot of good suggestions for that.
All right we have one more question. I will try and -‐-‐ I will try to put this in -‐-‐ Natalie asks, what is the thought with biofeedback or ADS for pain?
>> TAMMY FLEMMING: Biofeedback, the problem is it just tends to be so complicated, and it's a little more detail for patients to learn. It is not something we use frequently so I'm not as well versed in it. I know our pain psychologist is more of the cognitive behavioral techniques as well as distraction and imagery and those things, versus biofeedback because it requires somebody to really concentrate and learn how to do that written some of her patients just do not have the mental capacity to do that.
>> JESSICA O'BRIEN: Okay. Well, we are about out of time and we got to the questions. So thank you so much, Dr. Fleming. And this is recorded so you can go back and see it and the slides are also available. A reminder that the information that you need for the webinar is a valve on the same website that you registered so you can find the online CE quiz link on that same page as well. NAADAC.org.
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