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I would say "ditto" for addiction but both service lines are difficult to scale:
Clinical Pain Medicine
AUGUST 18, 2016
Importance of Integration of Psychology Into Pain Practices
By Joe H. Browder, MD
A growing body of evidence shows that an interdisciplinary approach to the treatment of chronic painful conditions is most beneficial to patients. A combination of medications coupled with psychological services, functional therapies and procedural approaches provides the best outcomes for patients. A full history and physical examination, including previous treatments, determines which of these approaches is appropriate for the patient. A diagnosis supported by clinical testing is essential.
This commentary focuses on the integration of psychological services into an interdisciplinary practice. Having a psychologist on-site in the clinical setting is by far the most effective mode of integrating psychology into a practice. This allows for easy communication and consultation concerning patients. The very presence of a psychologist as a colleague is a constant reminder of the need for inclusion of psychological services into any treatment plan. This also provides for crisis intervention, should it arise.
The most commonly employed method of having on-site psychological services is for the psychologist to be an employee of the practice. At Pain Consultants of East Tennessee, we have created a fairly unique situation in which the psychologist is an independent contractor who leases a small office, and is integrated into the scheduling and medical records of the practice. This arrangement allows the chronic pain practice to focus on its areas of expertise without worrying about the intricacies of billing, the capital expense of a salary or management of the psychologist.
The two psychologists we have are in the practice full time. Very few psychologists have formal training in chronic pain management. Those who do have training usually are familiar with cognitive-behavioral therapy but have little experience with other pain psychology issues, such as opioid risk assessment, addiction and medication abuse. Thus, establishing a process for on-the-job training is key. While formal training is helpful, the most important ingredient for a successful team is for the psychologist to be willing to learn and to have a strong team focus. The important caveat in having a psychologist with a background in addiction is that pain treatment is not a branch of addictionology. The vast majority of pain patients are not addicted.
The Role of Psychology
Psychological services are important in helping with medication compliance, attendance of functional therapies and completion of interventional procedures. Also essential are meetings of core members of the team, not necessarily to discuss patients but to go over the process of integration of all aspects of the practice. In our practice, psychological services include a formal psychological assessment, group education classes and short-term (four to six) individual sessions, either for crisis intervention or for specific personal or family issues. All of these psychological services include an evidence-based risk assessment for opioid and psychological comorbidities that could affect the overall treatment of the painful condition. Quick risk screens such as the Opioid Risk Tool exist, but many of these are essentially worthless in clinical practice.
Optimal is an hour- or 45-minute-long assessment by a psychologist using written tools, such as the Brief Risk Interview and mental health screening tools. A much less comprehensive, but still valid, risk tool that can be administered by a medical assistant is the Brief Risk Questionnaire (BRQ) consisting of 12 items, and can provide an accurate assessment of risk for opioid misuse. The BRQ is more helpful because it covers a wider array of psychological variables relating to risk than traditional risk tools. Psychological assessment should include opioid risk assessment, assessment of catastrophizing, depression, sleep, kinesiophobia, readiness for change and anxiety. The psychologist also assesses the need for referral to a psychiatrist for medication management for suboptimally treated bipolar disease, major depression, anxiety or other psychological comorbidities.
Our psychologist-led classes include an opioid medication class during which the risks, benefits and details of medication agreements are discussed. Also included in this discussion are expectations about pain management treatment and the need for increased function as opposed to simply a decrease in pain. This session helps patients have appropriate expectations for medications and overall pain treatment. We also offer a psychological skills class in which the five essential skills for coping with chronic pain are taught through one brief intervention session. These skills are understanding, accepting, calming, balancing and coping. Individual sessions to treat a patient’s specific problems, such as grief, anger or cognitive-behavioral therapy, are utilized. However, these individual sessions are limited by the reality of reimbursement and time management. Integrated psychological services offer key assessment, education and brief intervention services that are often lacking in single-modality pain services.
Single-disciplinary approaches, such as medication management or procedural blocks alone, are simply not effective in treating the vast majority of chronic painful conditions. Our interdisciplinary approach has been successful for over 15 years. As it has evolved, we have found that utilizing medication management, functional rehabilitation therapies, procedural interventions and psychological treatments is not only effective but cost-effective in a nonacademic outpatient setting. As our lead psychologist Ted Jones, MD, has said, “Psychological aspects are always involved in treating chronic pain, whether or not you have a psychologist available or not.” We have found that having integrated psychological services on-site is a very effective way for outpatient pain programs to offer high-quality, multidisciplinary treatment without financial loss.
Joe H. Browder, MD, is senior partner at Pain Consultants of East Tennessee (PCET), in Knoxville. He has practiced pain medicine since the early 1990s, and founded PCET in 1998. He is triple board certified in pain medicine (as a diplomate of the American Board of Anesthesiology with Added Qualifications in Pain Medicine, a diplomate and fellow of the American Board of Pain Medicine, and a diplomate of the American Board of Interventional Pain Physicians). He also is a Fellow of Interventional Pain Practice from the World Institute of Pain. PCET is an American Pain Society Clinical Center of Excellence in Pain Management and can be found online at www.painconsultants.com.
Clinical Pain Medicine
AUGUST 18, 2016
Importance of Integration of Psychology Into Pain Practices
By Joe H. Browder, MD
A growing body of evidence shows that an interdisciplinary approach to the treatment of chronic painful conditions is most beneficial to patients. A combination of medications coupled with psychological services, functional therapies and procedural approaches provides the best outcomes for patients. A full history and physical examination, including previous treatments, determines which of these approaches is appropriate for the patient. A diagnosis supported by clinical testing is essential.
This commentary focuses on the integration of psychological services into an interdisciplinary practice. Having a psychologist on-site in the clinical setting is by far the most effective mode of integrating psychology into a practice. This allows for easy communication and consultation concerning patients. The very presence of a psychologist as a colleague is a constant reminder of the need for inclusion of psychological services into any treatment plan. This also provides for crisis intervention, should it arise.
The most commonly employed method of having on-site psychological services is for the psychologist to be an employee of the practice. At Pain Consultants of East Tennessee, we have created a fairly unique situation in which the psychologist is an independent contractor who leases a small office, and is integrated into the scheduling and medical records of the practice. This arrangement allows the chronic pain practice to focus on its areas of expertise without worrying about the intricacies of billing, the capital expense of a salary or management of the psychologist.
The two psychologists we have are in the practice full time. Very few psychologists have formal training in chronic pain management. Those who do have training usually are familiar with cognitive-behavioral therapy but have little experience with other pain psychology issues, such as opioid risk assessment, addiction and medication abuse. Thus, establishing a process for on-the-job training is key. While formal training is helpful, the most important ingredient for a successful team is for the psychologist to be willing to learn and to have a strong team focus. The important caveat in having a psychologist with a background in addiction is that pain treatment is not a branch of addictionology. The vast majority of pain patients are not addicted.
The Role of Psychology
Psychological services are important in helping with medication compliance, attendance of functional therapies and completion of interventional procedures. Also essential are meetings of core members of the team, not necessarily to discuss patients but to go over the process of integration of all aspects of the practice. In our practice, psychological services include a formal psychological assessment, group education classes and short-term (four to six) individual sessions, either for crisis intervention or for specific personal or family issues. All of these psychological services include an evidence-based risk assessment for opioid and psychological comorbidities that could affect the overall treatment of the painful condition. Quick risk screens such as the Opioid Risk Tool exist, but many of these are essentially worthless in clinical practice.
Optimal is an hour- or 45-minute-long assessment by a psychologist using written tools, such as the Brief Risk Interview and mental health screening tools. A much less comprehensive, but still valid, risk tool that can be administered by a medical assistant is the Brief Risk Questionnaire (BRQ) consisting of 12 items, and can provide an accurate assessment of risk for opioid misuse. The BRQ is more helpful because it covers a wider array of psychological variables relating to risk than traditional risk tools. Psychological assessment should include opioid risk assessment, assessment of catastrophizing, depression, sleep, kinesiophobia, readiness for change and anxiety. The psychologist also assesses the need for referral to a psychiatrist for medication management for suboptimally treated bipolar disease, major depression, anxiety or other psychological comorbidities.
Our psychologist-led classes include an opioid medication class during which the risks, benefits and details of medication agreements are discussed. Also included in this discussion are expectations about pain management treatment and the need for increased function as opposed to simply a decrease in pain. This session helps patients have appropriate expectations for medications and overall pain treatment. We also offer a psychological skills class in which the five essential skills for coping with chronic pain are taught through one brief intervention session. These skills are understanding, accepting, calming, balancing and coping. Individual sessions to treat a patient’s specific problems, such as grief, anger or cognitive-behavioral therapy, are utilized. However, these individual sessions are limited by the reality of reimbursement and time management. Integrated psychological services offer key assessment, education and brief intervention services that are often lacking in single-modality pain services.
Single-disciplinary approaches, such as medication management or procedural blocks alone, are simply not effective in treating the vast majority of chronic painful conditions. Our interdisciplinary approach has been successful for over 15 years. As it has evolved, we have found that utilizing medication management, functional rehabilitation therapies, procedural interventions and psychological treatments is not only effective but cost-effective in a nonacademic outpatient setting. As our lead psychologist Ted Jones, MD, has said, “Psychological aspects are always involved in treating chronic pain, whether or not you have a psychologist available or not.” We have found that having integrated psychological services on-site is a very effective way for outpatient pain programs to offer high-quality, multidisciplinary treatment without financial loss.
Joe H. Browder, MD, is senior partner at Pain Consultants of East Tennessee (PCET), in Knoxville. He has practiced pain medicine since the early 1990s, and founded PCET in 1998. He is triple board certified in pain medicine (as a diplomate of the American Board of Anesthesiology with Added Qualifications in Pain Medicine, a diplomate and fellow of the American Board of Pain Medicine, and a diplomate of the American Board of Interventional Pain Physicians). He also is a Fellow of Interventional Pain Practice from the World Institute of Pain. PCET is an American Pain Society Clinical Center of Excellence in Pain Management and can be found online at www.painconsultants.com.
