Pilot Program

Conjoint Sessions With Clinical Pharmacy and Health Psychology for Chronic Pain

Fed Pract. 2017 April;34(4):35-41

References

1. Brooks PM. The burden of musculoskeletal disease—a global perspective. Clin Rheumatol. 2006;25(6):778-781.

2. Haskell SG, Heapy A, Reid MC, Papas RK, Kerns RD. The prevalence and age-related characteristics of pain in a sample of women veterans receiving primary care. J Womens Health (Larchmt). 2006;15(7):862-869.

3. Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2(1):106-116.

4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.

5. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-582.

6. Wall PD. The gate control theory of pain mechanisms: a re-examination and re-statement. Brain. 1978;101(1):1-18.

7. Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301(12):1242-1252.

8. Von Korff, Moore JC. Stepped care for back pain: activating approaches for primary care. Ann Intern Med. 2001;134(9, pt 2):911-917.

9. Oslund S, Robinson RC, Clark TC, et al. Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care. Proc (Bayl Univ Med Cent). 2009;22(3):211-214.

10. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford). 2008;47(5):670-678.

11. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol. 2014;69(2):119-130.

12. McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine (Phila Pa 1976). 2002;27(22): 2564-2573.

13. Jeffery MM, Butler M, Stark A, Kane RL. Multidisciplinary Pain Programs for Chronic Noncancer Pain. Comparative Effectiveness Technical Briefs, No 8. Rockville, MD: Agency for Healthcare Research and Quality; 2011.

14. Ehde DM, Dilworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153-166.

15. Dorflinger L, Kerns RD, Auerbach SM. Providers’ roles in enhancing patients’ adherence to pain self management. Transl Behav Med. 2013;3(1):39-46.

16. Pellico LH, Gilliam WP, Lee AW, Kerns RD. Hearing new voices: registered nurses and health technicians experience caring for chronic pain patients in primary care clinics. Open Nurs J. 2014;8:25-33.

17. Rollnick S, Miller WR, Butler CC, eds. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press; 2008.

18. Kerns RD, Habib S. A critical review of the pain readiness to change model. J Pain. 2004;5(7):357-367.19. Kerns RD, Burns JW, Shulman M, et al. Can we improve cognitive-behavior therapy for chronic back pain treatment engagement and adherence? A controlled trial of tailored versus standard therapy. Health Psychol. 2014;33(9):938-947.

20. Kearney LK, Post EP, Zeiss A, Goldstein MG, Dundon M. The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs. Transl Behav Med. 2011;1(4):624-628.

21. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51(3):390-395.

22. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-1114.

23. Ryan P. Integrated theory of health behavior change: background and intervention development. Clin Nurse Spec. 2009;23(3):161-172.

24. Evans DD , Blanchard EB. Prediction of early termination from the self-regulatory treatment of chronic headache. Biofeedback Self Regul. 1988;13(3):245-256.

25. Maguen S, Hoerster KD, Littman AJ, et al. Iraq and Afghanistan veterans with PTSD participate less in VA’s weight loss program than those without PTSD. J Affect Disord. 2016;193:289-294.

26. Bloor LE. Improving weight management services for female veterans: design and participation factors with a women only program, and comparisons with gender neutral services. Med Res Arch. 2015;2.

Methods

With the above concepts in mind, VAAAHS offered veterans conjoint sessions involving a health psychologist and clinical pharmacy specialist during a 3-month period while this resource was available. The conjoint sessions were part of a preexisting pharmacist-run pain medication clinic embedded in primary care. The conjoint session was presented to patients as part of general clinic flow to reduce stigma of engagement in psychological services and allow for the dissemination of BPS information.

Participants

The electronic health records (EHR) of 24 veteran patients with chronic pain, who participated in a conjoint health psychology/pain pharmacy session, were reviewed for the current study. Most of the patients were male (95.8%) and non-Hispanic white (91.7%); the remaining participants did not disclose their ethnicity. The mean age was 60.6 years (SD 7.1; range 50-80). A total of 75% had a mental health diagnosis, and 41.7% were in mental health treatment at the time of the conjoint appointment. Among the sample, 20.8% had a current diagnosis of a substance use disorder (SUD), and no individuals were in treatment for a SUD at the time of the conjoint appointment. Patients received an average of 1.5 conjoint sessions (SD 0.7; range 1-3).

Procedure

The veterans for this project were chosen from a panel of patients followed by the pain medication clinical pharmacy specialist in the primary care pain medication clinic. The selected veterans were offered a joint session with their clinical pharmacy provider and the health psychology resident during their scheduled visit in the pain medication clinic. Each veteran was informed that the goal of the joint visit was to enhance self-directed nonpharmacologic chronic pain management skills as an additional set of tools in the tool kit for particularly difficult pain days. Veterans were assured that their usual care would not be compromised if they declined the session.

During the encounter(s), the health psychologist contributed to the veteran’s care by using MI and CBT for chronic pain skills. The health psychologist further assessed concerns and needs and guided the discussion as appropriate. With veteran readiness, these discussions explored the degree of knowledge and cognitive and behavioral coping skills the patient used. These conjoint sessions also documented the types of discussions and degree of engagement in the encounter(s) as well additional referrals, complementary services, and/or offered follow-up services for either additional conjoint sessions or further health psychology-related services.

A total of 24 EHRs from these conjoint and subsequent encounters were reviewed for evidence of the procedures by a psychology intern involved in chronic pain management services. Of these 24 records, 6 also were reviewed by a board-certified health psychologist for consensus building and agreement on coding (Sidebar, Record Coding).

Using the coding system and SPSS Version 2.1 (IBM, Armonk NY), descriptive statistics were used to examine conjoint session content and new- or re-engagement in health psychology services following the conjoint sessions. For those patients who followed up with additional services, the content, type, and outcome of these services were explored. Next, linear regression was used to determine whether number of conjoint sessions was associated with a qualitative treatment outcome, and 2 logistic regressions were used to determine whether the number of sessions was associated with the likelihood of accepting services and follow-through with services after accepting them. An additional logistic regression examined whether having a mental health diagnosis (yes/no) was associated with whether the individual accepted additional health psychology services. Finally, independent sample t tests examined differences between those who accepted services vs those who declined follow-up services in substance use diagnosis, mental health diagnosis, and previous health psychology services engagement. Of note, given the small sample size, the Levene’s test for equality of variances was conducted and unequal variances were assumed.

Results

All 24 patients agreed to have the conjoint session with the clinical pharmacy specialist and health psychologist. Of the participants, 62.5% had no previous interaction with health psychology services. Among those who had previous encounters with health psychology services, 12.5% had participated in 1 or more group sessions, another 12.5% had participated in 1 or more individual sessions, and an additional 12.5% had been referred for health psychology services but had not followed through. A total of 10 participants represented a new- or re-engagement in health psychology services following the conjoint appointment. Two patients were referred for additional services as a result of their conjoint appointment (1 to specialty mental health and another to Primary Care-Mental Health Integration [PC-MHI]), and 1 of the participants followed through with the referral. Finally, with regard to the content of the initial session, 37.5% of the sessions contained some form of psychoeducation, 54.2% contained a functional assessment, and 41.7% contained an introduction of skills.