>> My background is that I started out thinking a lot
about chronic pain from the perspective of, there we go,
okay, from the perspective of education.
So, I spent the first decade of my career
in a primary care residency program,
training family medicine physicians.
And just found that this idea of how to approach our patients
with chronic pain was really challenging, complex
and really confusing to my learners.
And I came of age in the time when we really were being told
that opioids were safe and effective, and we should figure
out how to use them safely and effectively.
So, that was sort of the beginning of my training
and then I started to realize, wow,
these medicines don't actually work as well
as I wish they would and I think we're causing some harm.
And so it was kind of a game changer to come
to understand this concept of centralized pain.
So, I'm going to talk a little bit about some
of the big questions and barriers that I started to think
about as I began to explore this, which was really,
is there a way we can sort of approach all of our patients
in a somewhat similar way to get
to an individualized treatment plan?
Because that patient comes in and there are so many factors
at play, that it's sometimes hard to know where to start.
My clinician trainer, learners, really brought
to me a lot of the barriers.
And so I started to think
about what are those really big barriers?
And then also, what responsibility to people
on both sides of the equation, like me as a clinician
and then my patients, who owns which pieces
of this chronic pain puzzle?
So this is a model that I came up with,
it's not rocket science, but it just allowed me to sort
of conceptualize and then offer
to my learners a conceptualization
of how we might come at appearing chronic pain.
So I really think about it
as having a few different components that lead us
to the center, which is this really multifaceted
treatment plan.
So I'm going to go through those in a little bit of detail.
And for me what I think is sort of paramount
and of the most important is really my relationship
with the patient.
So, if I'm going to get anything else to happen in the setting
of working with a patient with really complex chronic pain,
it's going to be in the setting of building
that doctor/patient relationship.
And I started to think about this
as being a little bit different than what I normally think
of as a patient coming in with a problem
and me telling them what to do about it.
Does anyone in the room rock climb?
If you've heard me give these talks,
it's one of my favorite analogies.
Because I've really started to think about instead of sort
of me being the person climbing or doing all the work
to get this patient feeling better,
the patient is actually the one doing the climbing,
and my job is the support role.
So for people who don't rock climb,
the person at the bottom whose sort of holding the rope
and has you safe while you're doing the climbing is called
the belayer.
And I think of us as the clinicians
as really the belayer.
So there's two pieces to this that I think are so awesome.
One is, we have the patient in the supportive role, right?
We're telling them, we're with you, we have you,
we're going to help you sort this
out no matter what happens next.
Something patients tell me an awful lot
in my consultative clinic,
which is in the integrative medicine space, where they come
to me to get a second opinion, is that clinicians told them,
"I don't have anything else to offer you, I'm so sorry."
Kind of, go back to your primary care doctor with your pain
because you don't need surgery
or you don't need this intervention.
So I think as a primary care clinician saying
to that patient, no matter what happens I have something else
to offer you, which is more conversation,
more brainstorming, more strategy developing,
more lifestyle management, I thick is hugely important.
The second piece is that as a person at the bottom
of the wall, like looking up at it, you can offer advice.
So for the person doing the hard work at home
to change their lifestyle, to work on their chronic pain,
they're the ones actually doing the climbing,
but they often can't see the whole wall.
So they can't see what would be next
and what would be most helpful, and I think that's where our job
as clinicians comes in.
So I see this relationship as a partnership
and I just love this analogy to sort of visualize that.
I think that we actually are a treatment, as clinicians.
I think that there's huge value in what we bring into the room
and so I tell my learners that, use yourself, whether it's
as a placebo or as an active treatment, patients feel better
when you are hopeful and positive,
and they also feel better when they understand what's happening
with their pain and that's where we come in
and can explain that to patients.
So I just think that's hugely important, I'm going to circle
to that again in a few minutes.
The second thing I think is just the echo of what Dan said,
which is understanding what you think is causing their pain.
And I think part of this is kind of the mechanism
of the physical components, but I think it's also really keeping
in mind that other factors can play a huge role
in their pain and suffering.
So when I use the word pain, I'm actually using it really broadly
in this step, which is also keeping
in mind the biopsychosocial components
of what could be impacting them in terms of their pain.
So, we've already gone through the sort of mechanistic piece
of the pain, but I think for a primary care clinician,
it's hugely important, these are my two slides I borrowed
from Dan, to give him credit.
But I think that, I use them mostly to say that I think
as a primary care clinician I have to remember
that centralized pain is on this continuum.
And that the majority of my patients have a mixed pain state
and making sure that I'm pulling out when
that central pain mechanism is largely at play,
because if I don't and I miss it, I'm not going
to be successful at really getting their pain
under control or managed.
So, I also love this slide just because,
for me that iceberg is everything I see
in my primary care clinic.
It's just all those diagnoses that don't have
that fibromyalgia label, that I really have
to pull apart what is actually impacting their pain.
Because every person's label isn't really going
to give me a true understanding for that particular patient,
which factors are at play.
So for every patient I have to pull that apart and that's
where that relationship comes into play.
I also think from a primary care perspective this idea
of the pain prone phenotype, somebody who is at risk
for developing chronic pain based on risk factors
or histories of other pain conditions, is hugely important
in primary care, because I think I can actually possibly impact
that if I have a really good relationship with my patient
and I recognize in the setting of a new pain scenario,
that they are at risk for the development of chronic pain,
there are things I can bring to the table
that can help prevent that.
And so I think as primary care clinicians we can be empowered
in that way.
The third step for me is to develop a goal
and I think those goals really have to be functional.
It took me a long time in my practice to get away
from this idea that my goal was really
to decrease someone's pain, and really to get more and more
into this idea that what I'm trying
to do is help them develop a goal to me more functional.
I know most of us are probably, hopefully familiar
with the difference between a functional goal
and a pain score goal, but just to remind ourselves
that it's really about getting them to be able to do things
that they can't do because of their pain and that that has
to be patient specific.
I think every patient is so different that it's really
in that understanding our patients to that level,
that helps us understand exactly what's going to be a good goal
for them, versus something that's unrealistic
or non-accomplishable.
And I think really understanding what our patients' attitude
toward our pain is, is going to be instrumental in that.
So all of this sort of circles back around to me, for me,
to getting to know my patient and making sure I'm really
on the same page that they are.
Which leads me to the treatment plan, which I really think
from a primary care perspective has to be multifaceted,
and I have a few things that I've developed that are kind
of my musts, in terms of my treatment plan.
I think your patient has to buy into that treatment plan
and this gets back to this partnership,
I can't just tell them what I think is going to work for them.
We have to come to it together that they agree,
that this is something they want to work on.
I also think it has to be in line
with the cause of their pain.
So it can't be something that's really directed
at a non-susceptive cause
if there's a huge central component to it.
And it has to work towards their functional goal.
I think that what's been kind of disappointing to me
as I've gone further and further into this is that the things
that we are sort of taught in terms of this understanding
of the new concepts of the physiology,
haven't always completely directly related
to huge improvements in pain.
So they haven't resulted in treatments
that have necessarily gone so far as to sort of fix pain
or really improve the pain, and it's really circled back to sort
of some of those lifestyle management pieces.
So I think we're still left with having to come at chronic pain
from a multitude of directions.
This is a conceptualization that I've thought about a lot
in my integrative practice, which was when I was trying
to get patients away from this idea
that the medicine was the only thing that was going
to help their pain, to thinking about all the other factors.
I started to use this diagram, which was, well we can talk
about pain for a few minutes, but it's only one --
sorry, medicine, pain medicine for a few minutes in this visit,
but it's only one out of like eight or nine things
that we really need to touch on, and so getting the patient
to focus in on other things was really helpful.
So, this is the way I think about approaching pain
and primary care and it's really starting at the bottom
with lifestyle practices and then moving
into more targeted therapies and finally at the very, very top,
just some meds and procedures in the patients
who aren't responding to the other steps on the pyramid.
So, for me at the very bottom, it's activity and movement,
it's their emotional regulation and stress management, diet,
and sleep, are kind of my four foundational things that I talk
to almost every patient about.
And then I start to layer in things like physical therapy,
if they need support in movement
or very targeted body-based therapies, it's behavioral
and cognitive therapies.
It's then some of those integrative therapies
that I think actually have a ton of promise and a lot
of evidence starting to accumulate
around how helpful they are.
And then only finally at the very top is it medicines
and some of those adjunct things
that we historically used way more I think.
So when I think about what actually works in my practice,
it's really largely lifestyle changes and a lot
of behavioral strategies
and then maybe some targeted medications
when I think they're really appropriate
or when someone is really flared up with their nervous system,
those can be really helpful in calming that down
so that they can get to those other components.
And I think really to get there we have to get a lot
of buy in from our patients.
So, to get that I think a lot about how I communicate
with my patients and this is probably
in primary care the thing I spend the most energy on.
So I think about how we can use empathy,
education with our patients and then how can we empower them
to really make those lifestyle changes?
So, for me communication with empathy is probably
at the heart of what I do.
I spend a lot of time listening to my patients
and really making sure that they feel
that I've heard their whole story around their pain.
Because if they don't, then it's going to be hard
to get their buy in that I'm on the same page as them
and really, we are sharing a reality
around what's causing their pain.
I throw in this kind of older study because I think to me it's
like one of my best examples
of highlighting why this relationship is so important.
So, they did this study on a Imipramine,
one of the older tricyclic antidepressants.
This was done in depression, but I think it holds
across multiple areas.
So they looked at, was this drug effective?
And it was this drug and therapy, versus placebo.
And the drug was found to be effective
in lowering rates of depression.
But then they pulled out,
"Did you think you got a good therapist
or a so-so okay therapist?"
And they actually found the effect size
from having a good therapist with placebo,
was more than if you had a bad therapist and the drug.
So, I think the good therapist won out over placebo and to me
that means we as clinicians have a ton of power
and we need to use it.
I think educating our patients
around what causes their pain is hugely important.
And I've come to realize that this is more
than just offering them sort
of the pathophysiology of centralized pain.
What it really is for me is making sure that me
and my patient are on the same page
about what's happening with their pain.
So when I think about educating, it's educating them
on what I think is causing their pain and making sure
that they agree with me.
If we can get to that, and it's not an easy sell by any means,
this isn't something I do in one visit and then it sticks
and then -- it's mostly I start the conversation in one visit
and then the next visit they tell me what they remember
and what struck them.
And over the course of multiple visits and continuity,
we develop a shared understanding of their pain.
And in mixed pain states, I just find this is really complex
and patients constantly go back to,
"But I think somethings really wrong here,
and if you don't fix it I'm going to hurt myself
with what you're suggesting, like exercise."
So, I think it's just this ongoing conversation that's
hugely important.
I think our communication has to be realistic and hopeful
and this is what I was saying about setting
up that framework to work together.
When I get to empowerment I have to recognize
that there are a lot of barriers to empowering our patient.
A huge amount of science is being done on you know,
behavior change and how we support patients
to make those lifestyle changes.
And so we could spend, you know, a whole conference on that.
I think are many of these barriers we can't actually
impact, but there a few that we can,
like trying to shift the locus of control to the patient
and getting them to have increased self-efficacy.
And also treating any co-occurring mood disorders
so that we can improve their ability to make these changes.
I think that bringing the framework
of motivational interviewing, I'm starting to think
about chronic pain as just another chronic condition
like diabetes, like hypertension.
If we bring the same models and framework to getting them
to make the lifestyle changes we know support those conditions,
we are also going to support them in feeling better
with their chronic pain.
So, I'm not going to spend a ton of time on the lifestyle changes
because other people are going to talk about those,
but I just want to highlight
that the ones I spend the most time
on in primary care practice is increasing their physical
activity, improving their sleep,
and then offering them some psychological interventions
targeting their mood, emotional regulation
and then cognitive refraining around their pain.
This is probably like my slide of my most useful interventions,
and I just bring these back around over and over
and over again in the primary care space.
So, like I said, physical activity,
we all know it has a lot of evidence.
Really what I lean on is, how can I get the patient doing more
of what they're not doing?
It's actually a really small percentage of my patients
with pain who already have a really robust movement program,
and I don't need to impact that.
It's a much higher percentage that I have
to actually just get started on movement in some way.
So patient initiated, sometimes diagnoses dependent,
those are the places where I start.
Sleep, we know that's super important so I won't spend a ton
of time on that and then you're going to get some great lectures
on nutrition and diet later, so I'm also not going
to spend a ton of time on that.
So, just to circle back to this idea that coming at a patient
in primary care from my perspective includes these
pieces, really focusing in on the doctor/patient relationship.
Making sure I have a really good solid understanding of the cause
of their pain and making sure me and the patient are
on the same page, making sure our goals are something
that is really specific to my patient
and that they buy in about.
And then that helps create this multifaceted treatment plan
that they can really buy into.
And then I think that plan has to encompass all
of these pieces, in a stepped wise fashion.
So, that's really what I have.
I have no idea what my timing is,
but maybe there's a few minutes for questions.
[ Applause ]