467 – Case Management for Chronic Pain
Dr. Dawn-Elise Snipes PhD, LPC, LMHC


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Executive Director, AllCEUs
• Define the problem
• Examine the similarities between CNCP, mental health issues and addiction
• Identify the impact of CNCP on patients
• Explore biopsychosocial resource needs for secondary and tertiary prevention.
• Historically, pain without an apparent anatomical or neurophysiological origin was labeled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust. It is 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.
• Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.
• CNCP patients with addictive disorders 32%
• People >20 with pain lasting >3 months 56%
• People with disabling pain in the previous year 36%
• Children with chronic pain 11%-38%
• Pain may have a long course with multiple episodes
• Chronic pain can be highly stressful for patients and families
• Care for people with chronic pain is increasingly done in outpatient
• 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
• Across CP conditions there is generally a shift away from brain regions engaged in processing the sensory component of pain toward regions that encode emotional and motivational subjective states
• Experiences of physical and social pain (ie, social rejection, exclusion, bullying, negative social evaluation, loss of a close relationship), share neurochemical and neural substrates
• Young people with comorbid depression and CP are at an increased risk of suicide

Pain and Mental Health
• CNCP and addiction or mood disorders frequently co-occur and fluctuate in intensity over time and under different circumstances
• They share neurophysiological patterns including
• Increased inflammatory cytokines
• Altered levels of dopamine, serotonin and norepinephrine
• Hyperactive HPA-Axis
Effective pain management in patients with comorbid issues must address all conditions simultaneously.

Similarities– Pain, MH and SUD
• Treatment of one condition can support or conflict with treatment for the other.
• A medication appropriately prescribed for a particular chronic pain condition may be inappropriate, given the patient’s SUD or mental health history.
• Are mediated by genetics and environment.

Biopsychosocial Impact of Pain
• Sleep
• Pain
• Medication side effects
• Fatigue
• Circadian rhythm disruption
• Physical changes (weight changes, ports, pumps, hair loss)
• Loss of mobility
• Depression
• Anxiety
• Anger/Irritability
• Grief/Adjustment
• Jealousy or resentment
• Withdrawal
• Self Esteem changes
• Loss of social support or paternalism
• Inability to engage in prior important activities
• Loss of independence
• Vocational problems
• Financial hardships (Medical expenses, job loss, environmental modifications)
• Access to nutritious food
• Physical, sexual and emotional relationship problems

Common Chronic Pain Conditions
• Low Back Pain
• Neck Pain
• Upper Back Pain
• Arthritis
• Fibromyalgia
• Chron’s Disease
• Migraines

Assessing for Chronic Pain
• Assessment instruments include the McGill Pain Questionnaire For a list of additional assessment tools, see TIP 54
• Assessment of CNCP should document:
• Pain onset, quality, and severity
• Results of investigations into etiology
• Pain-related functional impairment
• Emotional changes (e.g., anxiety, depression, anger)
• Pre-existing mental health, trauma or addiction issues
• Cognitive changes (e.g., attentional capacity, memory)

Assessing for Chronic Pain
• Assessment cont…
• Beliefs about the pain that they experience such as what causes it, how long it will last, whether it is curable, what effects it will have in their lives, what treatments might be relevant, and whether it is understood and believed as “real” by clinicians
• Family response to pain (i.e., supportive, enabling, rejecting)
• Parental cognitive responses to pain, such as parental pain catastrophizing or exaggerated negative pain appraisals, have been found to influence both parents’ emotional reactions to pain and child functional disability

Assessing for Chronic Pain
• Assessment cont…
• Environmental consequences (e.g., disability income, loss of desired activities, absence from desirable or feared work)
• Daily pain assessment
• Descriptive language
• Numerical Scales
• Verbal Scales
• Visual Scales

Assessing for Chronic Pain

• Exacerbating factors—Makes it worse
• Emotional
• Mental
• Physical
• Environmental
• Social
• Mitigating factors – Helps Pt Feel Better
• Emotional
• Mental
• Physical
• Environmental
• Social

Goals of Chronic Care Models
• Shift from acute & episodic to ongoing proactive care
• Emphasizes
• Prevention (getting worse, developing other conditions)
• Patient’s role in managing health with mutual goal setting and action planning (self-management)
• The goal of self-management interventions are to:
• Improve knowledge about the condition and intervention options
• Increase confidence in the ability to change
• Leverage what he or she can do to promote personal health (prevention)

Goals of Chronic Care Models
• The goal of self-management interventions are:
• Improve motivation and problem solving rather than simple compliance with a caregiver’s advice
• Help the participants’ master six fundamental self-management tasks:
• Solving problems including preventing problems and relapse
• Making decisions
• Using resources
• Forming a patient -provider partnership
• Making action plans for health behavior change
• Self-tailoring
Chronic Pain Management
• Discuss treatment goals that include:
• Reducing pain.
• Maximizing function.
• Improving quality of life.
• Addressing co-occurring mental disorders.
• Incorporating suitable nonpharmacologic and complementary therapies for symptom management.

Developing Acceptance
• Deciding that pain “is” and choosing not to focus/dwell on it leads to:
• Lower pain intensity.
• Less pain-related anxiety and avoidance.
• Less depression.
• Less physical and psychosocial disability.
• More daily uptime.
• Better work status.
For a list of tools to assess coping, see TIP 54, Chapter 2, Exhibit 2-12.

• There are many similarities between Pain, mood and addictive disorders
• Integrated, concurrent, biopsychosocial treatment is vital
• Mood impacts pain which impacts life satisfaction
• Recovery supports realistic beliefs and identifies controllable factors enhanced outcomes
• Patients with current addictions or mental health issues need concurrent treatment