understanding the chronic pain medscheck trial...(phq‐4) brief and accurate detection of anxiety...
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Understanding the Chronic Pain MedsCheck trialDebbie Rigby
Advanced Practice Pharmacist
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Chronic pain
Ongoing chronic pain is an
epidemic in Australia
Learning objectives
Understand the objectives of a Chronic Pain MedsCheck
Identify concepts of patient activation, validation and catastrophising in patient conversations
Interpret responses to common pain assessment tools
Apply patient‐centred approach to pain management during medication reviews
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Declarations
PSA Project Advisory Group
PSA Project Working Group
Author, Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018
Chronic Pain MedsCheck trial Expert Panel
Chronic Pain MedsCheck Trial Objectives
The Chronic Pain MedsCheck Trial objective is to evaluate the efficacy of the Chronic Pain MedsCheck service in:
preventing incorrect use and/or overuse of pain medication
increasing patients’ pain medication health literacy
improving their ability to self‐manage their chronic pain
improving their overall quality of life
The Chronic Pain MedsCheck Trial is funded by the Australian Government Department of Health as part of the Sixth Community Pharmacy Agreement (6CPA) Pharmacy Trial Program (PTP)
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Trial interventions
The trial intervention from pharmacy will include:
Supported self ‐management of patients taking medication
who are dealing with chronic pain for more than three
months through pharmacist advice
Pharmacy‐based evaluation of patient’s medicine
Provision of an action plan
action plans will incorporate education, self‐management and
referral to other health professionals where additional support
is required
Six week and/or three month follow up after the initial service
The Chronic Pain MedsCheck Trial is funded by the Australian Government Department of Health as part of the Sixth Community Pharmacy Agreement (6CPA) Pharmacy Trial Program (PTP)
Key steps
Registration and on‐line training
Trial software access
Patient recruitment (40 patients)
Completion of surveys
Relationship building with GPs and allied health professionals
Provision of information about accessing additional support, or where appropriate a referral to the patients’ GP or allied health professional
Collection of minimum set of data for evaluation
The Chronic Pain MedsCheck Trial is funded by the Australian Government Department of Health as part of the Sixth Community Pharmacy Agreement (6CPA) Pharmacy Trial Program (PTP)
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PSA Guidelines
Trial service overview
Identification of patient need and informed consent
Medication reconciliation
Assess pain experience
Patient education and/or referral
Develop written action plan
Assess progress against action plan (and update if required) at each follow‐up review
Determine if additional services are required by the patient eg. staged supply or DAA
** MedsCheck program cannot be used for a Chronic Pain MedsCheck service
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Source: Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018.
Source: Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018.
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Multimodal therapy
Goal of treatment of chronic pain is to provide lasting and meaningful reduction in pain with concomitant improvement in overall functioning and health‐related quality of life
Multimodal treatment strategies encompass behavioural, physical and integrated medical approaches
Primary goal of this holistic approach is to reduce pain‐related distress, disability and suffering
Patient‐centred conversation
Belief about the causes of pain
Knowledge, expectations and preferences for pain management
Expectations of outcome of pain treatment
Reduction in pain required for patient satisfaction or to resume reasonable activities
Typical coping response for stress or pain
Presence of anxiety or psychiatric disorders already diagnosed
Family expectations and beliefs about pain and stress
Acute Pain Management: Scientific Evidence (3rd edition), ANZCA & FPM
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Patient activation levels
Individuals tend to be passive and feel overwhelmed by managing their own health. They may not understand their role in the care process.
01Individuals may lack the knowledge and confidence to manage their health.
02Individuals appear to be taking action but may still lack the confidence and skill to support their behaviours.
03Individuals have adopted many of the behaviours needed to support their health but may not be able to maintain them in the face of life stressors.
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BMC Health Serv Res 2016;16:582.
Validation
Validation has been defined as a process in which a listener
communicates that a person’s thoughts and feelings are
understandable and legitimate
Pain 2015;156(2):215‐9.
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Six levels of validating behaviours
Level Description
Listening and observing Listening and paying attention to the patient,
may involve eye contact, nodding
Accurate reflection Restating what has been heard to convey
understanding of message
Articulating the unverbalised Inferring thoughts or feelings that may be
implied in the disclosure
Validating in terms of
sufficient (but not necessarily
valid) causes
Validating what the patient said is
understandable given their past experience
with pain
Validating as reasonable in
the moment
Validating what the patient said is justified in
terms of their current situation
Radical genuineness Treating the patient as a valid and capable
individual
Pain 2015;156(2):215‐9.
Share pain‐related thoughts
and feelingsValidation
Reduction in emotional arousal and negative affect
Reduction in pain
Catastrophising and acceptance are strongly related to outcomes of emotional distress such as depression and anxiety and functional status
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Pain Catastrophizing
Source: https://www.survivestrivethrive.com/pain‐catastrophizing/
Pain catastrophizing is the tendency to have unhelpful, dominating thoughts
Are you scared your pain won’t get better?
Are you afraid your pain will get worse?
Does your pain make you feel anxious – a lot?
If you are dominated by thoughts of your pain – it might be making your pain worse.
When you live with constant pain, unpredictable symptoms & low levels of energy – it is only natural that you don’t have a sunny outlook on life.
However, if your mind is occupied with negative thoughts & feelings – it can increase your levels of pain.
Source: https://www.survivestrivethrive.com/pain‐catastrophizing/
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3 common thought patterns
Rumination
Magnification
Helplessness
Clin J Pain 2001;17:52–64.
Pain Catastrophising Scale
Sub‐scale Statements
Helplessness I worry all the time about whether the pain will end
I feel I can’t go on
It’s terrible and I think it’s never going to get any better
It’s awful and I feel that it overwhelms me
I feel I can’t stand it anymore
There’s nothing I can do to reduce the intensity of the pain
Rumination I anxiously want the pain to go away
I can’t seem to keep it out of my mind
I keep thinking about how much it hurts
I keep thinking about how badly I want the pain to stop
Magnification I become afraid that the pain will get worse
I keep thinking of other painful events
I wonder whether something serious may happen
Psychol Assess. 1995;7(4):524‐532.
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Focus on the positive
Focus on what you can do rather than what you can’t
Recognise unhelpful thoughts and feelings when they occur
Learn the science of pain
Learn psychological strategies (CBT, ACT)
Holistic approach
Plan ahead for pain flare‐ups
Source: https://www.survivestrivethrive.com/pain‐catastrophizing/
Mindfulness
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Achieving pain relief may be less important than improving physical functioning
Patients are encouraged to use mindfulness in order to participate fully in the present moment, which may involve mindful participation in physical activities
Mindfulness skills training helps patients to observe negative pain thoughts (I can’t move because it hurts) without acting on them
Pain assessment tools
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PEG3‐item scale
Source: Rigby DA. Language of pain. AJP February 2019.
5 As ‐Opioid therapy monitoring tool
The 5 As are primarily a tool for the monitoring of opioid therapy. They are designed to determine if the therapy is still valid, by determining if the benefits continue to outweigh the risks of treatment.
Activity
Analgesia
Adverse effects
Aberrant behaviour
Affect
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/.../5_As_of_Analgesia.pdf
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Mini‐ePPOC
Brief Pain Inventory (BPI)
Patient Health Questionnaire‐4 (PHQ‐4)
Pain Self‐efficacy Questionnaire (PSEQ)
https://ahsri.uow.edu.au/eppoc/forms/index.html
Brief pain inventory (BPI)
Assesses severity of pain and its impact on functioning
Location of pain
Severity of pain (worst, least, average, right now)
Impact of pain on daily function
Pain medications
Amount of pain relief in the past 24 hours or past week
Interference (general activity, mood, walking ability, normal work, relation with other people, sleep, enjoyment in life)
BPI gives two main scores: a pain severity score and a pain interference score
www.aci.health.nsw.gov. au/__data/assets/pdf_file/0015/212910/Brief_Pain_Inventory_ Final.pdf
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Patient Health Questionnaire (PHQ‐4)
Brief and accurate detection of anxiety and depressive disorders
Generalized Anxiety Disorder‐7 scale (GAD‐7)
Patient Health Questionnaire‐8 (PHQ‐8)
Psychosomatics 2009;50:613–21.
Pain Self‐efficacy Questionnaire (PSEQ)
Pain self‐efficacy is a belief in one’s ability to carry out
activities even when in pain, and is important in coping
effectively with pain.
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Pain Self‐efficacy Questionnaire (PSEQ)
10‐item questionnaire that assesses the confidence people with chronic pain have in performing activities while in pain
PSEQ‐2: 2 items assess confidence in one’s ability to work and lead a normal life despite pain
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/212909/PSEQ_Final.pdf
Pain assessment tools incorporated in the mini‐ePPOC
Source: Guidelines for pharmacists providing services for the Chronic Pain MedsCheck trial. PSA, 2018.
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Additional assessment tools in evaluation arm
AQoL‐4D quality of life tool
Self‐management tool
Health literacy tool
Key messages
Supporting patients with chronic pain – be kind and careful
Exploring a patient’s beliefs and attitudes may identify the need for multimodal treatment approach
Assessment tools will aid in providing appropriate care and referrals
Be mindful of language used by the patient and yourself
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