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We have not had any relevant financial relationships during the past 12 months. . Declaration of Financial Interests. Video. How many of us treat chronic pain? What comes to mind when you think of patients with chronic pain? What are the common treatments for chronic pain?

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audience questions

How many of us treat chronic pain?

What comes to mind when you think of patients with chronic pain?

What are the common treatments for chronic pain?

Where are these treatments offered? And by whom?

Do they work? Are they evidenced based?

Audience Questions
joan b fleishman psyd jeanna r spannring phd christine n runyan phd philip bolduc md

University of MassachusettsMedical School

Joan B. Fleishman, PsyD

Jeanna R. Spannring, PhD

Christine N. Runyan, PhD

Philip Bolduc, MD

Implementing chronic pain groups in two diverse family medicine residency clinics


Define group protocol for treatment of chronic pain

Understand potential challenges and barriers to implementation in a primary care setting

Describe patient and provider perspectives on efficacy of treatment modality

scope nature of chronic pain

At least 116 million U.S. adults suffer from chronic pain conditions

    • more than heart disease, diabetes, and cancer combined
  • Annual economic cost including health care expenses and lost productivity:
    • $560 – 630 billion
Scope & Nature of Chronic Pain

Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: The National Academies Press.

current treatments





CBT, mindfulness, psychotherapy



Best Practices???

Current Treatments

Developed in CMHC in rural Colorado as a psychotherapy group

  • Intended to address this common co-morbidity of psychiatric illness
    • PTSD
    • Depression
    • Borderline Personality Disorder
    • Substance Abuse
structure of session


  • 90 min/sessions
  • Dedicated nursing support
  • Population:
    • Pilot w/ specific PCP referral
    • All PCP referral
    • Part of pain contract
Structure of session
stress nervous system disorder
Stress & nervous system disorder

Rules of Neuroplasticity:

What is fired together is wired together

What you don’t use you lose

When you break old paths, you can use those nerves to make new paths

medication options for chronic pain
Medication Options for Chronic Pain






cbt emotional awareness
CBT: Emotional Awareness





cbt triangle for pain
CBT Triangle for Pain

- stuck

- Helpless/hopeless

- No control/power

-Take Control

-Prove pain can’t stop me

  • Associated Emotions:
  • Depression
  • Associated Emotions:
  • Anger
  • Motivation
  • Stop
  • Prolonged rest
  • Associated Emotions:
  • Overwhelmed
  • Hopeless/helpless

- Activity/overactivity

fundamental process elements

Development of and support through social network

  • Opportunity to ask questions
  • Graded skill building with individualized coaching
  • Assigned weekly practice
    • check-in and discussion
    • worksheets
  • Slide-shows with corresponding handouts
  • Cumulative patient handouts
  • Multi-disciplinary
  • Therapeutic intervention
Fundamental Process elements
essential components

Multi-disciplinary care/team approach

  • Bringing group psychotherapy to a primary care setting
  • Support from:
    • PCP
    • Medical Director support
    • Logistical support
Essential Components
snapshot clinic profiles
Hahnemann Family Health

Family Health of Worcester

  • 9,000; 50% Medicaid
  • CHC
  • Diverse patient population
  • Urban, academic, ambulatory primary care clinic
  • 9 physicians, 2 NPs, 12 residents, 3 BHCs, clinical pharmacists
  • 20,000; 90% Medicaid
  • CMHC on site
  • Diverse patient population
  • 30% Spanish speaking
  • Chronic Pain Management Protocol
  • 20 physicians,12 NP/PAs, 12 residents, 1 BHC, 1 nurse midwife
  • 7advocates; 3 care managers
Snapshot: clinic profiles
models opiate prescribing
Hahnemann Family Health

Family health of worcester

  • Opioid contract
    • PCP-managed
    • High variability in implementation and prescribing practices
    • Practice-based registry
  • 3 providers with buprenorphine prescribing authority
  • Patients on opiates for 3+ months
  • Intake with program nurse
  • Monthly visits with nurse
  • Quarterly visits with PCP
  • Aberrant behaviors
    • Illicit substances
    • Misuse of prescription
    • Missing visits
  • Possible measures
    • More frequent visits
    • Urines and pill counts
    • Discharge from program
Models Opiate Prescribing


mean = 50.95, sd = 10.54, range: 30 – 67 years

Average group size = 5


Each Session

    • Wong-Baker
    • Healthy Days Core Module (CDC HRQOL– 4)
  • Pre/Post
    • Brief Pain Inventory
    • Multi-dimensional Health Locus of Control
    • Patient Health Questionnaire (full version)
    • 12/20 complete sets for analysis
wong baker faces
Wong-baker faces

8-17 respondents per session

brief pain inventory
Brief Pain Inventory

Pre N=16, post N=15

challenges and opportunities in your setting
Challenges and opportunities in your setting?
  • Take a moment to think about your setting.
  • Who would be on the team?
  • What challenges can you identify?
  • Talk with your neighbor.
  • What benefits might you expect?
  • Share with the group.
o pportunities

Link attendance to opiate contract

  • Multidisciplinary collaboration
    • Involve nutrition, PT, complementary alternatives etc.
  • Improved patient outcomes
    • Identifying what components contribute to change
  • Develop ongoing booster sessions
  • Provide further education and training to PCPs
    • Integration of feedback
future directions
Hahnemann family health

Family health of Worcester

  • Continue program evaluations as quality improvement
  • Work towards sustainability
  • Continue to integrate modalities
    • PT/OT
    • Nutrition
    • Resident/Med student
  • Increased BH Role in Pain Management Program
    • Consulted at the time of referral
    • Follow patient through maintenance phase of treatment
  • Design maintenance programming
    • Workshop series for patients who have completed
    • Chiropractics, acupuncture, tai chi, yoga , self-hypnosis, nutrition
Future directions
session evaluation

Please complete and return theevaluation form to the classroom monitor before leaving this session.

Thank you!

Session Evaluation