D E PA R T M E N T T I T L E
Welcome!
- Housekeeping
- Bathrooms
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Disclosure
All Faculty and Planning Committee Members have reviewed the presentation slides and
ensure content is evidence-based and free of commercial bias. There are no relevant
financial interests or relationships to disclose.
Fiona Donald, MD
Phillip O. Coffin, MD MIA
Blue Walcer, MPH
Judith Martin, MD
Matt Tierney, NP, CNS
Richard McKinney, MD
Barbara Wismer, MD, MPH
Scott Steiger, MD
Marsha Haller, MD
Kate Schopmeyer, PT, DPT, CSCS,
CPE
James Gasper, PharmD, BCPP
Tina Farales, DOJA
Diana Coffa, MD
Serenity Banden, RN, MSN, NP-C
Simone Heron-Carmignani,
PhD
Mimi Zou
Kris Leonoudakis Watts
The following two faculty members will be discussing unapproved/investigational use of a
commercial product:
Name
Off-label discussion?
Phillip O. Coffin, MD, MIA
Yes – the intra-nasal administration of naloxone is not yet
approved as a route of administration by FDA
Matt Tierney, NP
Yes – will discuss analgesic benefits of sublingual
buprenorphine, a drug approved only for the treatment
of opioid use disorder
Resources
http://www.sfhp.org/providers/pain-management/
Email: [email protected]
The value of explaining the neurophysiology of pain and how to
provide effective education to your patients in pain
Kate Schopmeyer, PT, DPT, CPE,CSCS
PT Program Coordinator ▪ Pain Management
San Francisco VA Healthcare System
2015
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
 I have no conflicts of
interest to disclose.
 The views expressed in
this presentation are my
own and do not
necessarily reflect the
official position of the U.S.
Department of Veterans’
Affairs.
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Practicing for 10 years
Manual PT
Orthopedic and sports medicine
Post-op outpatient rehabilitation
Acute rehabilitation, Long-Term
Care, Worker’s Compensation
 Pain Management since 2008





Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
 I may challenge your
understanding of pain.
 I encourage you to
challenge my
understanding of this
material.
 I may change my future
views based on evidence.
 I encourage you to change
your current and future
views based on evidence.
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Learning Objectives
1. Explain why understanding the role of the nervous system is
a valuable and important aspect of a comprehensive plan to
improve function in people living with persistent pain.
2. Review current research highlighting the benefit of
explaining pain from a nervous system perspective.
3. Help providers feel confident when explaining the complex
nature of chronic pain in patient-friendly language to help
patients better understand their condition.
4. Provide practical teaching tools to facilitate effective
teaching that is also consistent with the biopsychosocial
model of care.
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Pain in society and in medicine
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Patients want to know:
What is wrong with me?
How long will it take?
What can I do for it?
What can other healthcare professionals do for it?
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Moseley, GL, Butler, DS, Beames, TB, Giles, TJ. (2012) The Graded Motor Imagery Handbook. Adelaide: Noigroup Publications.
Biomedical model
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
16th Century
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
pain
behavior
suffering
pain
nociception
Adapted from Loeser Model of pain
(1983)
Loeser JD, Ford WE. Chronic Pain. In: Carr JE, Dengerink HA, (eds). Behavioral Science in
the Practice of Medicine. New York: Elsevier Biomedical:1983:331-345.
2013--Daniel B. Carr, MD,
FABPM, FFPMANZCA (Hon.)
Co-Founder and Director of
the Pain Research,
Education and Policy
Program (PREP) at the Tufts
University School of
Medicine
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Tissue-focused
Interventions targeting
peripheral tissues
Nociception=pain
Patient management
often passive
Primarily curative monotherapies
Among the bricks…
Butler, Neuro Orthopedic Institute WCPT 2011
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Beyond the bricks…
• Focus on disease AND illness
• Includes precursors to
injury/disease (psychological and
social factors)
• Strong focus on connection
between brain and body
• Patient involvement very active
• Emphasizes interdisciplinary and
rehabilitative therapies
• Includes neurophysiology
education
Butler, Neuro Orthopedic Institute WCPT 2011
“… research on neuroplasticity and psychosocial genomics
lends compelling support to this perspective by elucidating
mechanisms through which psychosocial forces shape
neurobiology”. 1
The Biopsychosocial (BPS) model of pain is the personal
construction of attitudes and beliefs related to injury and
nociception, and how these interact with social, cultural,
linguistic and workplace influences.
The BPS approach to the understanding and treatment of
pain is the dynamic and reciprocal interaction between
biologic, psychological and sociocultural variables that shape
the person’s responses to painful experiences.2
1) Garland, E. L., & Howard, M. O. (2009). Neuroplasticity, psychosocial genomics, and the biopsychosocial paradigm in the 21st century. Health & Social Work, 34(3), 191-199.
2) Turk D, Flor H. Chronic pain: a biobehavioral perspective. In: Gatchel R, Turk D,editors. Psychosocial factors in pain. Critical perspectives. New York: The Guilford Press; 1999. p.
18–34.
•
•
•
•
•
•
•
•
•
•
genetics
•
hpa axis
•
physiological
response
medication
response
learning
memory
beliefs psychological
attitudes
experience
perceptions
fight/flight
immunity
biological
•
•
•
•
family
• economics
dynamics
• culture
housing
relationships
social
social
support
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Arthritis and pain are not
predictive.
Increased sensitivity happens
all over the body with
symptomatic OA.
Finan et al 2013
King et al 2013
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Brinjikji W et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
Asymptomatic Adults with Degenerative Scan Findings
80
70
Spondylolisthesis
60
Facet degeneration
Annular fissure
Age 50
Disk protrusion
Disk bulge
40
Disk height loss
Disk signal loss
Disk degeneration
30
20
0
100
200
300
400
500
600
700
Number of Individuals
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Asymptomatic Adults with Degenerative Scan Findings
3110 asymptomatic individuals
80
96% of 80
year olds
have DDD
70
60
50% of 50
year olds
have disc
bulges
Age50
Spondylolisthesis
Facet degeneration
Annular fissure
Disk protrusion
22% of 40
year olds
have
facet DJD
40
Disk buldge
Disk height loss
Disk signal loss
Disk degeneration
33% of 30
year olds
have DDD
30
20
0
37% of 20
year olds
100 DDD
have
200
300
400
500
600
700
Number of Individuals
Brinjikji W et al, 2015
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Does it matter for
diagnosing pain?
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Poor posture doesn’t predict pain
 (Christensen et al 2008)
 (Widhe 2001)
Hip position or pelvic alignment
doesn’t predict pain
 (Grundy et al 1984)
 (Hides et al 2010)
No good evidence that poor
posture causes pain.
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Form follows function.
Pain Science for Rehabilitation Specialists
Kate Schopmeyer, DPT, CPE | SFVAMC |
2015
What the patient may hear
What the clinician may say
“You pain because of your…”:
 Poor posture
 Weak core
 Leg length discrepancy
 Bulging disc
 Tight hamstrings
 Impinged shoulder joint
 Arthritis
 “I need my pelvis fixed”
 “My back is vulnerable because
my core is weak”
 “I’m always going to be messed
up because one leg is longer
than the other”
 “Painful movement means I
might burst my disc that’s
already bulging”
 “I’ve always had tight
hamstrings; I guess now I’ll
always have back pain”
Tissue damage without pain?
Pain without tissue damage?
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Fisher et al. Minerva. British Medical Journal. 1995
Meaning
Context
Expectations
Experience
Moseley & Arntz (2007), Pain 133; 64-71
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Preoperative Neuroscience Education: Single
fMRI case
Submitted for Publication Louw, Diener,
Peoples and Puentedura 2014
48hours pre-op 31 year-old lady
MRI: marked herniated L5/S1 disc; central and left towards the
nerve root
Preoperative Neuroscience Education for Lumbar
Radiculopathy: A Multicenter RCT
64 Patients scheduled for L-Surgery
Randomized
32
Surgeon
Education
Louw A, Diener I, Landers MR, Puentedura EJ.
Preoperative Pain Neuroscience Education for
Lumbar Radiculopathy: A Multi-Center
Randomized Controlled Trial With One-Year
Follow-Up. Spine. May 28 2014.
32
Surgeon
Education +
Neuroscience Ed
Low Back Pain Leg Pain
Oswestry
Fear Avoidance
Pain Catastrophization
Pain Knowledge
Surgery Experiences Cost Analyses
Preoperatively 1, 3, 6 and 12 months postop
Preoperative Neuroscience Education for Lumbar
Radiculopathy: A Multicenter RCT
 One year follow-up
 Superior results (no
statistical significance):
 Back Pain
 Leg Pain
 Catastrophization
 Fear Avoidance
 Pain Knowledge
Louw A, Diener I,
Landers MR,
Puentedura EJ.
Preoperative Pain
Neuroscience
Education for
Lumbar
Radiculopathy: A
Multi-Center
Randomized
Controlled Trial With
One-Year Follow-Up.
Spine. May 28 2014.
Satisfaction with LS
Louw A, Diener I, Landers MR, Puentedura EJ.
Preoperative Pain Neuroscience Education for Lumbar
Radiculopathy: A Multi-Center Randomized Controlled
Trial With One-Year Follow-Up. Spine. May 28 2014.
Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative Pain Neuroscience
Education for Lumbar Radiculopathy: A Multi-Center Randomized Controlled
Trial With One-Year Follow-Up. Spine. May 28 2014.
Healthcare Cost 1 year out…
45% less on medical tests and treatments…
Therapeutic Neuroscience Education (TNE) or
Explaining Pain (EP) is increasingly shown to
improve outcomes for people with persistent pain.
Using biomedical models to explain a pain
condition may increase fear and subsequently
increase pain.
1.
2.
Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability,
anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine & Rehabilitation, 92(12), 20412056.
Zimney, K., Louw, A., & Puentedura, E. J. (2014). Use of Therapeutic Neuroscience Education to address
psychosocial factors associated with acute low back pain: A case report. Physiotherapy: Theory and Practice, 30(3),
202-209.
Pain and the brain
Nervous system adaptation
Tissue problem vs pain problem
“Thoughts are nerve impulses,
too”
Explaining pain (BPS model)
improves outcomes
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
“All these things
influence, and are
influenced by,
pain.”
PAIN
Explain Pain
2003
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
 Nociception and nociceptive pathways (neurons, synapses, action
potentials)
 Spinal inhibition and facilitation
 Peripheral and central sensitization
 Plasticity of the brain and nervous system
Moseley, Hodges, et al., 2004;
Van Oosterwijck, Nijs et al., 2011
 No reference to anatomical models
 No discussion of emotional or behavioral aspects of pain
 Use prepared examples and metaphors
 Include illustrations (hand drawings or other visual aides)
1. Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease
catastrophizing in people with chronic pain. Clin J Pain. 2013 Jan;29(1):20-5.
2. Adriaan Louw, Emilio Puentedura. Therapeutic Neuroscience Education: Teaching Patients About Pain; A guide for clinicians. USA: International
Spine and Pain Institute; 2013.
“Thought viruses”, fear-avoidance, neurocortical
changes, stress consequences, lifestyle choices
SENSITIZING FACTORS
Diabetes
Depression
PTSD
Decreased blood flow
Medications
Smoking/Tobacco
Alcohol
Stress
Inactivity
Poor sleep
Poor diet
DE-SENSITIZING FACTORS
Exercise routine
Medications
Active lifestyle
Stress reduction
Awareness/Pacing Improved sleep
Mindfulness
Whole foods diet
TENS
Understanding pain
 Persistent pain is not just about the “tissue issues”
 The central nervous system plays a big role
 Pain is an output of the brain, which influences inputs
 Pain production is dependent on meaning, context,
expectations and experience
 Consistent language across professions is ideal
 Explaining Pain (EP) or Therapeutic Neuroscience Education
(TNE) should be part of a comprehensive pain treatment
plan
“From the brain alone arise our pleasures,
laughter, and jests, as well as our sorrows,
pain, and griefs.”
—Hippocrates
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Simple tools to use in the office.
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
“Our skin shows signs of age with
wrinkles and spots. Our spine show
signs of age in other ways.
Osteophytes and degenerative
changes are like wrinkles on the
inside.”
--Protectometer (Moseley, Butler 2015
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Input informs output.
Output becomes new
input.
Louis Gifford Mature Organism Model
(2002)
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
Based on Gifford’s
Mature Organism
Model
Threat?
Beliefs
Experience
Context
Meaning
Expectations
Culture
Memory
Scrutinize
ACTION
Behaviors
Posture
Guarding
Seek help
Limit activities
Ignore
Move slowly
Brain
Environment
(5 senses)
Body
(ANS)
Physiology
Stress hormones
Immune molecules
Inflammation
Pain
Muscle tension
Sensitization
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
How
dangerous is
this?
“Pain is a call to action, not a
damage meter.”
~Todd Hargrove
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
1. “Pain Explained” by the Central London Healthcare System
2. “Brainman Chooses”
3. Short videos by Neil Pearson, PT
 Explaining Pain with Details (3:23)
 3 Exercise Guidelines (6:41)
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
1. Adrianne Louw’s Tools
• TNE: “Teaching Patients About Pain” guide for
clinicians
• “Why You Hurt” TNE System (flash cards)
• “Why Do I Hurt?” educational booklet
2. Free e-Book: “Pain Science
Education Workbook for Patients
and Therapists”
www.physiofundamentals.com
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain
Conference
 noigroup.com
 physiofundamentals.com
 lifeisnow.ca
 bettermovement.org
 gradedmotorimagery.com
 painscience.com
 bodyinmind.org
 healthskills.wordpress.com
Kate Schopmeyer, DPT, CPE | SF Health Network | Pain Conference
Thank you!
Kate Schopmeyer, DPT, CPE | SF Health
Network | Pain Conference
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PLEASE RETURN BY 10:30AM
Integrative Medicine for Pain
What works and how to access care
What is Integrative Medicine?
• Combines of
conventional medicine
with complementary
modalities
What is Integrative Medicine?
• NIH defines 5
categories:
– Mind-body medicine
– Biologically based
therapies
– Manual medicine
– Whole medical systems
– Energy medicine
Energy Healing
Tai Chi/Qi gong
TCM Ayurveda
Homeopathy
Naturopathy
Yoga
Hypnosis
Non-vitamin
natural products
Deep breathing
Progressive
relaxation
Guided
imagery
NCCAM Survey of US adults 2010
Nutritional
therapies
Megavitamin
Meditation
Biofeedback
Movement
therapy
Traditional
Healers
Chiropractic
Massage
Do Our Patients Use These Therapies?
50
45
40
35
30
25
20
15
10
5
0
Which modalities will we discuss?
Whole system:
• Acupuncture (TCM)
Mind-Body
• Meditation
• Yoga
• Tai Chi
Biological remedies
• Brief overview
– Cat’s Claw
– Glucosamine
Chondroitin
– SAM-e
– Anti-inflammatory Diet
– Turmeric
– Omega-3 FA
Traditional Chinese Medicine
• Flow of Qi
• Balance Yin and Yang,
Hot and Cold, Wet and
Dry
Traditional Chinese Medicine
•
•
•
•
•
•
•
Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
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•
Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
•
Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
•
•
•
•
•
Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
•
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Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
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•
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Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
Traditional Chinese Medicine
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•
•
•
•
•
•
Acupuncture
Acupressure
Moxabustion
Cupping Therapy
Exercise
Nutrition
Herbs
VA Evidence Map for Acupuncture
Hempel S, Taylor SL, Solloway MR, et al. Washington (DC):
Department of Veterans Affairs; 2014 Jan.
10-30% Pain
reduction
Resources for Low Cost Acupuncture
• American College of Traditional Chinese
Medicine
• Glide Memorial Church Health Center
• San Francisco Community Acupuncture
• Health and Environmental Resource Center
• Osher Center for Integrative Medicine
community care fund
How to look these up
• San Francisco Health Plan has an online guide
to low cost integrative medicine services
• Google “SFHP low cost integrative medicine”
• http://www.sfhp.org/files/providers/communit
y_resources/SFIntegrativeMed_Resources.pdf
Mind-body Medicine
Meditation
A family of self-regulation practices that focus
on training attention and awareness in order to
bring mental processes under greater voluntary
control and thereby foster general mental wellbeing and development and/or specific
capacities such as calm, clarity, and
concentration.
Concentration
Mindfulness
• Sound
• Physical Sensation
• Image
• Physical Sensations
• Sounds
• Emotions/Thoughts
Compassion/
Loving Kindness
• Words or phrases
• Images
•Emotive
Primary impact
on:
• Quality of Life
• Wellbeing
• Control
• Acceptance
Hempel S, Shekelle P et al. Washington (DC): Department of Veterans Affairs; 2014 Oct.
Resources
• No free MBSR classes in SF currently
• Many religiously based free mindfulness and
meditation classes
– San Francisco Zen Center
– San Francisco Insight
– Integral Yoga Institute
– San Francisco Buddhist Center
VA Evidence Analysis for Yoga
Coeytaux, R et. al. Washington (DC): Department of Veterans Affairs; 2014 Aug
• Studies show consistent short term benefit in
pain score with SMD of -0.48, CI -0.65 to -0.31
• Also show long term benefit with SMD of -0.33;
95% CI, -0.59 to -0.07
Styles of yoga in RCTs
• Iyengar
• Hatha
• Viniyoga
Local Resources
• SFGH Wellness Center Yoga Classes
• Donation classes at
– Grace Cathedral
– Laughing Lotus Yoga Center
– Yoga to the People
• Free classes
– Sports Basement
VA Evidence Map for
Tai Chi
Hempel S, Taylor SL, Solloway MR, et al.
Washington (DC): Department of
Veterans Affairs; 2014 Sep.
Typically 20-30%
pain reduction
Resources
• San Francisco General Hospital Wellness
Center
Herbs and Supplements
• Osteoarthritis
– Glucosamine Chondroitin
– Cat’s Claw (Uña de gato)
– SAM-e
• Inflammatory causes
– Turmeric
– Basil, hot peppers, ginger
– Omega-3 fatty acids
– Anti-inflammatory diet
Helping Patients Engage with a
Multimodal Approach
Tools you can use in your practice
Tools we will review today
• The Acute vs. Chronic Pain Grid
– How is chronic pain unique and why are
medications not enough
• The Multimodal Approach
– What are the other options?
• Loeser’s Onion
– Understanding the role of thoughts and feelings
• Closing Your Pain Gates
– Learning about your personal experience of pain
The Acute vs. Chronic Pain Grid
Acute Pain
Time course
Quality of
Pain
Location
Cause
Treatment
Chronic Pain
The Acute vs. Chronic Pain Grid
Time course
Quality of
Pain
Location
Cause
Treatment
Acute Pain
Chronic Pain
Short term
Long term
The Acute vs. Chronic Pain Grid
Acute Pain
Chronic Pain
Time course
Short term
Long term
Quality of
Pain
Often sharp, some ache
Often aching, burning,
tingling, shooting
Location
Cause
Treatment
The Acute vs. Chronic Pain Grid
Acute Pain
Chronic Pain
Time course
Short term
Long term
Quality of
Pain
Often sharp, some ache
Often aching, burning,
tingling, shooting
Location
Often focal, easy to
point to
Often vague, moving
Cause
Treatment
The Acute vs. Chronic Pain Grid
Acute Pain
Chronic Pain
Time course
Short term
Long term
Quality of
Pain
Often sharp, some ache
Often aching, burning,
tingling, shooting
Location
Often focal, easy to
point to
Often vague, moving
Cause
Usually known cause
Often unknown or multiple
causes
Treatment
The Acute vs. Chronic Pain Grid
Acute Pain
Chronic Pain
Time course
Short term
Long term
Quality of
Pain
Often sharp, some ache
Often aching, burning,
tingling, shooting
Location
Often focal, easy to
point to
Often vague, moving
Cause
Usually known cause
Often unknown or multiple
causes
Treatment
Medication works great
Medication is not enough.
Need a multi-modal
approach
Pharmacologic
Physical
Complementary and
Alternative Medicine
Cognitive and
Behavioral
Pharmacologic
Physical
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•Procedural pain clinic:
• baclofen pumps, etc.
•Buprenorphine
•Naloxone
Complementary and
Alternative Medicine
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•Procedural pain clinic:
• baclofen pumps, etc.
•Buprenorphine
•Naloxone
Complementary and
Alternative Medicine
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Exercise
•Stretching
•Paceing
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•Procedural pain clinic:
• baclofen pumps, etc.
•Buprenorphine
•Naloxone
Complementary and
Alternative Medicine
•Acupuncture
•Mindfulness Based Stress Reduction
and meditation
•Yoga Classes
•Tai-chi classes
•Massage
•Manual Medicine
•Anti-inflammatory diets and herbs
•Supplements
•Guided imagery
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Exercise
•Stretching
•Paceing
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•Procedural pain clinic:
• baclofen pumps, etc.
•Buprenorphine
•Naloxone
Complementary and
Alternative Medicine
•Acupuncture
•Mindfulness Based Stress Reduction
and meditation
•Yoga Classes
•Tai-chi classes
•Massage
•Manual Medicine
•Anti-inflammatory diets and herbs
•Supplements
•Guided imagery
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Exercise
•Stretching
•Paceing
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
•Pain Group
•Individual therapy
•Brief cognitive and behavioral
interventions in clinic
•Visualization, deep breathing, meditation
•Sleep hygiene
•Gardening, being outdoors, going to
church, spending time with friends and
family, etc.
Three Dimensional Theory of Pain
Cognitive
Evaluative
Affective
Emotional
Sensory
Discriminatory
•Psychotherapy
Suffering
•Group Therapy
•Hypnotherapy
Cognitive
•Meditation
•Guided Imagery
•Relaxation Exercises
Emotional
•Pills •Patches
Sensory
•Injections •Surgery
•Physical Therapy Discriminatory
•Chiropractic • Herbs
•Acupuncture
Closing your Pain Gates
Ouch!
Ouch!
Ouch!
C
L
O
S
E
D
G
A
T
E
S
O
P
E
N
G
A
T
E
S
Bang!
Bang!
Bang!
Things that Open the Pain Gates
Things that Close the Pain Gates
• Emotions/Feelings
• Emotions/Feelings
– Sadness, Anger, Anxiety
• Physical Events
– Not enough sleep
– New injury
• Thoughts
– Too much focus on pain
– Self-criticism
• People/Surroundings
– Isolation/loneliness
– Stress from family, friends,
money, housing, etc.
– Happiness, Gratitude,
Relaxation
• Physical Events
– Taking medications
– Staying active
• Thoughts
– Hopeful thoughts
• People/Surroundings
– Healthy relationships/support
– Enjoyable activities, work,
hobbies
Practice one of these with a partner
• Find a partner
• Choose one exercise and use the handout to
guide you through practicing it
• Change roles in 3 minutes
• Each partner can choose a different exercise
so that you can experience both
Lunch Break 11:30 - Noon
- Different box lunch options will be delivered
to your tables
- Feel free to swap with others to get the lunch
you prefer
- If you are vegan, please come to the back to
retrieve limited supply of vegan lunches
Please return by Noon for CURES presentation
Pearls from
Mind Body
Medicine
Rick McKinney, MD
September
2015
The Gratitude Journal
• One sentence about
each of three things
• Write them down
near bedtime
• The payoff starts after
only one week!
We see a lot more of
what we are watching
for.
Noticing moments of
positive affect!
Notice positive feelings as they occur –
content, satisfied, grateful,
compassion, joy, generous . . .
Recognize and name them.
Close your eyes and notice what they
feel like – and sink into the feeling for a
moment.
Focusing on these feelings at least six
times each day will help to
“Channelize them”. Neuroplasticity
theory describes that as laying down
the path and pave it!
The 4 7 8 Breath
After breathing out, more fully than usual,
take a quick but complete in breath to the
count of four. Then pause the breath,
gently, to the count of seven. Follow that
with another very full exhalation to the
count of eight, with the last three or four
counts being a quite active exhalation,
really pushing out as much air as is
comfortable. Use diaphragmatic breathing
throughout. Do this for four to six breaths,
at least morning and evening.
This practice rebalances the autonomic
nervous system by enhancing the (relaxing)
parasympathetic system.
Naloxone for Opioid Safety
Phillip O Coffin MD MIA
San Francisco Department of Public Health
University of California San Francisco
Disclosures
•
No financial disclosures
•
Discussion of intranasal use of
naloxone, a route of
administration not yet FDAapproved
All results are preliminary
Clinical Program
•
6 safety net clinics
•
Staff trained
•
Atomizer/brochure in
ziplock bag
•
IM or IN naloxone
prescribed (covered by
all public insurance)
•
Pharmacists trained as
needed
Indications for
Naloxone Prescription
All Patients Using Opioids Chronically
Risk-Stratification
Simple to remember
Less costly
Clinicians are poor at predicting risk
Potentially less work for clinician / clinic
Risks are based on retrospective data analyses
Patients do not perceive a risk of “overdose”
from prescribed medications1
~40% of deaths result from diverted
medications2; co-prescribed naloxone may go
with the opioids
1) Coffin PO, unpublished data; 2) Hirsch A, Proescholdbell SK, Bronson W, Dasgupta N. Prescription histories
and dose strengths associated with overdose deaths. Pain Med. 2014;15(7):1187-95.
How to Prescribe Naloxone
•
Set up the program
•
Offer naloxone / discuss opioid safety
•
Select formulation / prescribe
•
Educate patient
•
Assist pharmacy in dispensing / billing
Set up the program
•
Determine who’s in charge
•
Obtain supply of atomizers, brochures, baggies
•
Find a box to put supplies in and a place for the box
•
Determine who’s going to educate patients
Offer naloxone and discuss
opioid safety
Select formulation and prescribe
Educate patient
•
When should they use naloxone
•
How do they use the device?
•
Ensure someone else knows when and how to use it
Pharmacy dispensing/billing
Acknowledgments
•
Funded by NIDA R21DA036776; California Healthcare Foundation
•
Project team including:
•
•
Emily Behar, Diana Coffa, Michele Geier, Matthew Bald, Taylor
Cuffaro, Chris Rowe, Glenn-Milo Santos, Eric Vittinghoff
•
Site leaders Diana Coffa, Soraya Azari, Karen Deutsch, Barb
Wismer, Jan Gurley, Keith Seidel
The many people who have been lost to overdose and who have
helped save a life
Practice Integrative Tools
Section #2
Page 6 of handouts
Marsha Haller, MD
•
Head & Neck: Palpation, Scalp Massage, Acupressure points, Jaw
Release, Forearm Massage
•
Neck & Shoulder: How to locate common trigger points; Treatment
with balls and other creative tools; Sleeping positions; Heat
treatment with creative tools
•
Low Back Pain & Sciatica: Doorknob hangs for traction; Easy
stretches and trigger point massage; Positions of comfort
Support From & For
Providers
Helping patients with co-occurring substance
use and pain
Matthew Tierney, APRN
Director, Office-based Buprenorphine
Induction Clinic (OBIC)
San Francisco CA
No conflicts of interest to report
SL buprenorphine tablets are not FDA
approved for analgesia
Learning Objectives
1. Cite statistics of co-occurring pain and opioid
use disorders
2. Describe ethical imperatives in balancing the
treatment of co-occurring pain and addictive
disorders
3. To help reduce stigma, identify your local
resources for professional support in caring
for patients with co-occurring pain and
addictive disorders
Case: Ms. Q
• “51 y.o. mother of 4, with chronic spinal and arm
arthritis, referred by primary NP who stopped
prescribing Norco 10/325mg strength #60/month
in context of patient self-report of opioid
abuse/addiction.”
• Illicit opiates from street x 1-1/2 since sudden
D/C of Norco. “Norco stopped working for me.”
• PMHx: Crack addiction, abstinent from 1999.
• OH: Cosmetologist, hair salon
Ms. Q
Observations and Questions
Assess all substance use
Assess functionality
Patient strengths and motivation
Negotiate treatment: prepare the patient
for the plan
• Patient support
•
•
•
•
Substance Use Disorder
•
•
•
•
•
•
•
•
•
•
Drug taken in larger amount or longer time than intended
Desire or unsuccessful efforts to cut-down or control
Great deal of time obtaining drug or recovering from use
Craving
Use results in failure to fulfill major roles; work, home,
school
Important activities given up or reduced
Recurrent use in situations where hazardous
Continued use despite having physical or psychological
problems as a result
Tolerance
Withdrawal
APA (2013). DSM5.
Co-occurring Pain
& Drug Abuse
• Est. 46% of people with CNCP have a history of
illicit drug abuse, and 12% actively abuse opioids1,2
• Other source: rate of opioid dependence in
patients with CNCP at 35%3
• History of opioid abuse: best predictor of current
opioid abuse for patients with chronic pain4,5
1) Manchikanti L, Cash KA, Malla Y, et al. Pain Phys 2013;16:E1-13. 2) Manchikanti L, Damron KS, McManus CD, et al. Pain Phys
2004;7:431-7. 3) Boscarino JA et al (2011), Jour of Add Dis; 30:185-94. 4) Boscarino JA et al (2010), Addiction105(10): 17761782. 5) Turk et al (2008), Clin J Pain 24(6): 497-508.
Provider Feelings
• Unprepared to treat co-occurring chronic pain
and substance use disorders1,2
• Uncertain and apprehensive treating cooccurring pain and addiction: fear disciplinary
consequences.
• Uneasy prescribing opioid analgesics given
patient risks: drug abuse, diversion, addiction,
and deception.
1) Chang & Compton (2013), Addiction Science and Clinical Practice, 8:21. 2) Ling W., Mooney L.,
Hillhouse M. (2011), Drug and Alcohol Review 30:300-5.
Providers must balance:
• Risks of prescribing opioid analgesics vs.
provide effective treatment for both pain
and addiction1-4
• Dangers of drug abuse vs. dangers of
undertreated chronic pain or
undertreated substance use4
1) Ling W., Mooney L., Hillhouse M. (2011), Drug and Alcohol Review 30:300-5.
2) Oliver J, Compton P et al (2012), J of Addiction Nursing; 23(3): 210-222. 3) Passik & Kirsh (2008). Exp. Clin
Psychopharm, 16: 400-4. 4) Berg KM, et al (2009), J Gen Intern Med 24(4): 482-8.
Ms. Q
• Patient Strengths?
• Treatment recommendations?
• Thoughts about Provider
approaches?
Providers: Keep in Mind
• Treatment recommendation delivery: clear
and non-pejorative language.
• Provider support
• Warm hand-off: patients need help with
the plan and transition
• Drug mis-use can be expected until new
plan is fully in place
• Addiction: drug use that is out of control
Approaches to Change in Plan
• Have a treatment agreement
• Why did the patient overuse medication?
• “Overuse of opioids is dangerous and can lead to
overdose and death.”
• “I need to protect your safety while still helping you
manage pain”
• “I think you should try a medication that has a reduced
overdose potential”
• “Sometimes there’s a disconnect between a patient
request and what I’m willing to do”
• Prescribe an overdose reversal kit
• Refer to OBIC: 415-552-6242
• Other approaches?
If Starting Buprenorphine
OBIC: 552-6242
•
•
•
•
•
•
•
Discontinuing full opioid agonist
BUP for analgesia: TID to QID dosing
BUP 4mg may be adequate analgesic dose
OK to use with non-opioid analgesics
OK to use with other opioid analgesics?
Refill frequency: more frequent to less
Diversion
Ms. Q. Continued
Buprenorphine treatment at OBIC
• Day #9: 8mg TID “reported good effect: no opioid
use, getting restful sleep and functioning well in
roles as cosmetologist and mother of 4 children.
Reports some mild opioid withdrawal continues,
including slight ‘charlie horse’ in legs, intermittent
sweating and chills, soft stool and feeling ‘a little
tired.’ Overall is happy with transition to bup/nx,
and gets support from many friends in sustained
recovery.”
Ms. Q. Outcome
• “Continues taking bup/nx 8mg TID to good
effect: no opioid use and no opioid cravings.
Sure she has managed her bupe/nx
meticulously although has 5 tabs more than
she should at this point. Does not recall
missing any doses in the past 2 weeks but
concedes ‘life can be crazy with kids so I can’t
say for sure.’ Continues Motrin for aches and
pains and occasional headaches.”
Stigma
• Providers perceive patients as violent,
manipulative, and poorly motivated
• Providers lack adequate education, training
and support structures
• Provider attitudes diminished patients'
feelings of empowerment and subsequent
treatment outcomes
van Boekel et al. (2013) Drug Alcohol Depend;131(1-2):23-35.
Reducing Stigma:
Education Alone Not Enough!
• Among PA students1
• Among RN generalists2
• “Disease like any other” does little to
reduce public stigma—but has resulted in
support for services3
1) Crapanzano et al (2014). Acad Psychiatry 38: 420-425. 2) Ford et al (2008) J Clin Nurs 17(18):2452-62. 3)
Pescolsolido et al (2010). Am J Psychiatry 167: 1321-1330/
Stigma
& Intervention
• Intervention: Education plus support by
addiction specialists to address stigma.
van Boekel et al (2014) Drug Alcohol Depend;134:92-8.
Provider Support
•
•
•
•
•
•
•
•
Drug Info Line: 255-3705 (8:30 to 5:00 M-F)
Michelle Geier, PharmD: 415-503-4755
OBIC: 415-552-6242 (8:30 to 5:00 M-F)
TAP: 415-503-4730
Dr. Barry Zevin: 415-355-7520
Dr. Paula Lum: [email protected]
Dr. Soraya Azari: 415-206-2372
Dr. Diana Coffa: [email protected]
Provider Support
• Introduce system experts
• Identify local mentors (5-10 minutes):
–Now: Identify your local champions
–Later: create a resource list
THANK YOU!
PLEASE RETURN BY 3PM
10 MINUTE BREAK
PRACTICE INTEGRATIVE TOOLS
SECTION #3
Blue Walcer, MPH
Practice guided imagery and progressive relaxation techniques and learn
practical strategies in incorporating these non-pharmacologic
interventions.
PRACTICE TOOLS
Tension Release p.10 in handouts
Mindfulness Meditation for Pain Management p. 11 in handouts
Pain Resources SF
Safety Net
Serenity Banden, RN, MSN, NP-C
Preoperative Anesthesia Clinic
San Francisco General Hospital
UCSF Department of Anesthesia
Who are we?
Anesthesia Preoperative Clinic ([email protected])
• Laura Lang, MD
• Medical Director, Anesthesia Preop Clinic
San Francisco General Hospital
• [email protected]
• Serenity Banden, RN, MSN, NP-C
• Lead Nurse Practitioner, Anesthesia Preop Clinic
San Francisco General Hospital
• [email protected]
• 415-206-5693 – preop Clinic Main Phone number
• Candace Woo, RN, MSN, FNP-C
• Nurse Practitioner, Anesthesia Preop Clinic
• [email protected]
Who are we?
New Multidisciplinary Pain Clinic is Starting at SFGH
• Arthur Wood, MD
• Medical Director, Multidisciplinary Pain Clinic, San Francisco
General Hospital
• Assistant Clinical Professor
• University of California, San Francisco
• [email protected]
Learning Objectives
• Primary Pain Prevention in Perioperative Setting
• Pain medication prescribing in Perioperative Setting
• Acetaminophen
• Gabapentin
• Celecoxib
• PCP and surgeon follow up within 7-10 days post-op
• Multiple Resources for Chronic Pain Treatment
• Physical and movement modalities
• Behavioral/Spiritual/Traditional healing modalities
• modalities
• Pain Clinic and Specialty Management
Why are we talking
about pain?
Pain control is commonly undertreated in healthcare. Improper pain
management can cause serious side effects, prolong hospital stay and
impair patient recovery.
SFGH is committed to providing world-class patient care, but pain
scores and patient surveys suggest that our pain management is
below the national average. Only 58% of our patients report their
pain was always well-controlled. (HCAHPS)
Pain Management: Many resources
confusing & disconnected
Pain
Clinic
Massage
Therapy
Physical
Therapy
SO MANY OPTIONS!
Behavioral
Therapy
Pain
Medication
Acupuncture
Pool
Therapy
Pain Prevention in the
Perioperative Setting
• Who is affected by Perioperative Management
• Patients
• Hospital Staff
• Primary Care
• Goals of Perioperative Pain Management
• Perioperative Pain Orders
• Discharge Pain Orders & Future Directions
Patients worry about pain!
• Many patient arrive at Preop Clinic with significant anxiety in
regard to their pain medication regimen
• Many patients have pain contract and are concerned about
treatment of post-op pain in relationship to this contract
• Recovering addicts often adamantly opposed to opiates
Hospital & clinical staff worry about
pain too!
• Surgical resident writing for discharge meds (anyone from 2nd to Chief
resident)
• Surgeons and RN’s may not be aware of pain contracts
• Patient written for inappropriate dosing of opiate
• Patient complained earlier that a medication had a side effect (N/V with
opiates) wants other options
• Med “doesn’t work for me.” (can occur with any patient but often with
patients who are opiate tolerant or on methadone and resident doesn’t
realize).
• Why do I need this? Patient’s misunderstand reasons for use or how meds
will benefit them
• Residents are busy, delays in discharge because new orders need to be
written.
• Many patients who are come & go receive nerve blocks and misunderstand
when to take medication as the block wears off
• Patients are tired, and RN’s can have a difficult time with teaching
Pain Prevention in the
Perioperative Setting
Goals of Perioperative Pain Management:
• Allay patient fears about pain
• Train staff in appropriate multimodal pain management
strategies specific to perioperative medicine
• Prevent acute pain from becoming chronic pain
• Decrease need for opiates post-operatively
• Effectively treat acute and acute-on-chronic pain
• Continue already prescribed chronic pain medications
Multimodal pain relief strategy:
Preoperative Orders
• Patient’s receive
service specific nonopiate medication
cocktail ONCE, 1 hour
before surgery with
sips of water (includes
all or some of the
following):
• Acetaminophen:
1000mg
• Gabapentin: 600mg
• Celecoxib: 400mg
Continue all chronic pain medications perioperatively:
Methadone, suboxone, gabapentin, ibuprofen, etc
Acetaminophen
• Given to nearly all patients
except those with ESLD
• Pediatric (<age 12 and <40kg
child): 15mg/kg
• Adult Dose: 1000mg morning
of surgery
Celecoxib (COX-2 Inhibitor, NSAID)
• Not given to pediatric patients perioperatively
• Adult Dose: 400mg PO
• Not typically given if other NSAIDs are on board
Rheumatoid Arthritis concept map by Maha Atef, B Pharm. Version: 2.0. Last updated in: 10 June 2014
http://www.zoomout-ph.com/2012/02/rheumatoid-arthritis-concept-map.html
Preliminary SFGH Celebrex Data
Looking at the effects of Celebrex, we see a difference in pain scores, for
instance after knee arthroplasties (n=56, p=0.01 for max pain):
Preliminary SFGH Celebrex Data
Celebrex after hysterectomies (n=74, p<0.01 for both):
Gabapentin: 600mg
• Not given to pediatric
patients perioperatively
• Adult Dose: 600mg
• Large, painful surgeries AND
those staying at least one
night in the hospital
• Continue DOS for when
patients take it for chronic
pain or treatment of
neurologic conditions
Common Side Effects:
somnolence, dizziness,
fatigue, confusion, headache,
diarrhea, peripheral edema
Preliminary SFGH Gabapentin Data
The results for Gabapentin are not as impressive in
hysterectomies, but they are for max score after total knees
(p=0.002):
The Future: Discharge
Pain Management
• Create a pathway for patients, PCP‘s, and surgeons to communicate
clearly the expectation for appropriate pain mangement.
• Identify current pain medication regimen and respect current pain
contracts
• Work with PCP‘s and Surgeons to individually optimize the
medication regimen
• Write orders for pain medication in PreOp Clinic and send to the
pharmacy before surgery
• Give teaching for medications and handouts so patients have a
chance to answer questions while alert and oriented!
But my patient has chronic
pain …
Chronic Pain: Where to Turn
Many options, nearly too numerous to mention!
• Physical and movement modalities
• Aquatic Therapy (Laguna Honda Hospital)
• SFGH Wellness Center (FREE for all San Francisco residents)
• Movement and Massage
• Back Classes
• Behavioral/Spiritual/Traditional Modalities
• Pain Clinics and Specialty Management
Laguna Honda Hospital
Wellness Center: Many Resources
Contact Information
• Aquatic Therapy
• Restorative Program Wellness Center Coordinator:
Christine Hanson 415-327-2263
Aquatic Therapy
• Who is this for: patients who would benefit from an aquatic setting
to address musculoskeletal or physical mobility issues related
primarily to orthopedic or neurological injuries.
• Orthopedic Injuries (OA, RA, fractures, sprains, strains)
• Neurologic Impairments (Brain and spinal cord injury, CVA)
• Mobility/Balance Impairments not amenable to other forms of therapy
• What will they learn: an aquatic program with the goal of
performing independently (or with a caregiver) in a community pool
upon discharge.
• Specialized Care: preoperative referral (weight loss or exercise prior
to bariatric or joint replacement surgery).
LHH Aquatic Referral, 08/2015
SFGH Wellness Program
• WOW “working on wellness:” FREE to ALL in the community.
Provides weekly movement and healing classes. Classes are in
English, Spanish, and Chinese!
• Movement: Zumba, yoga, stretch, salsa
• Mind: Meditation
• Metabolism: Nutrition and Cooking demo, CSA, Garden Giveaway
• Massage/Healing Touch: biweekly chair massages in the
wellness center
• Back Class: for patients with acute or chronic low back pain
http://sfghwellness.org/
Wellness Program: Back Class
• “Interdiciplinary class offered at SFGH which provides “an alternative
to a one-on-one physical therapy session for patients with acute or
chronic low back pain (LBP).”
• This is for SFGH but any other back program could do the same.
Should teach students:
• An etiology and prognosis of LBP
• A brief review of anatomy and pain generators
• Neutral spine concepts, including demonstration of how to find neutral
spine and hold it while performing ADLs and exercising
• How to find position of comfort independently
• Instruction for using ice and heat to manage symptoms
• Importance of graded, self-directed exercise program
• Question and answer period
• Who/When/Where? English Speaking, SFGH, Main Hospital, Friday
morning
Spiritual, Behavioral,
Traditional Modalities
Acupuncture
Meditation
Behavioral
health
Options for Referral Options
For patients who pain is severe, difficult to control pain, or who might
benefit from medication or medical interventions
Orthopedic
Spine Clinic
Pain Clinics
Medication
Management
Combined Therapy Modalities
Alternative &
Nonmedication
Treatments
Medication
Management
Exercise, PT,
Pool,
Massage
Post Assessment Questions
1. What do you prescribe perioperatively to children who are
getting surgery?
2. Which medication should you be cautious in using in a
patient who is medication naive and having an outpatient
laparoscopic cholecystectomy?
Post Assessment Questions
1. 45 year old woman is planned for repair of ankle fracture.
She has a history of chronic pain and IVDU. She is taking
several pain medications: methadone 70mg daily (for IVDU
which is in remission). She is also taking gabapentin 800mg
TID, oxycodone 10mg BID (as needed but typically taking
daily). Has PRN 500mg acetaminophen although she says
she only takes this 1-2 times per week. What would/could
you advise the patient to take the morning of surgery?
Thank you! … Questions?
• Please feel contact us with questions!
• Serenity Banden, RN, MSN, NP-C
• Lead Nurse Practitioner, Anesthesia Preoperative Clinic
San Francisco General Hospital
• University of California, San Francisco
• [email protected]
• 415-206-5693
• Arthur Wood, MD
• Medical Director, Multidisciplinary Pain Clinic, San Francisco
General Hospital
• Assistant Clinical Professor
• University of California, San Francisco
• [email protected]
PROMISING
PRACTICES + TOOLS
IN PAIN
MANAGEMENT
Let’s hear from the audience!
PANEL Q&A
What are your questions?
EXPANDING YOUR
OPTIONS IN PAIN
MANAGEMENT
Where do we go from here?

Pain education as treatment

Using multimodal treatments

Treating the whole person

Promoting self-care

Reducing opioid risk
TODAY’S MAIN CONCEPTS
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsaicin)
•Opioid medications/Tramadol
•Procedural pain clinic:
• baclofen pumps, etc.
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Exercise
•Stretching
•Pacing
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
•Pain Group
•Individual therapy
•Visualization,
, meditation
•Sleep hygiene
•Gardening, being outdoors, going to
church, spending time with friends and
family, etc.
EXPANDING YOUR
OPTIONS IN PAIN
MANAGEMENT
Tools available at:
http://www.sfhp.org/providers/painmanagement/
http://www.sfhealthnetwork.org/employeephysicians/pain-management-resources/
EXPANDING YOUR
OPTIONS IN PAIN
MANAGEMENT
What will you do or try in the next
week?
Share with your neighbor.