Psychotherapy is undergoing a veritable revolution. And if you're not paying attention, you could miss opportunities to change attitudes, spend less, and save lives.
For nearly a century, the field of psychotherapy (which includes cognitive behavioral therapy and other modalities common in the treatment of chronic pain) has been deemed a subjective and ethereal art based on human relationships, perception of progress, and patient self-reported outcomes. Therapists argued such things couldn't be measured, objectified, or codified. This feels intuitive to most of us - how can the assessment and treatment of behaviors, thoughts, emotions, and reactions be reduced to mere data points, bar graphs, or pie charts. Contemporary medical evidence appears to suggest these modalities are efficacious and that's sufficient for most of us to accept the status quo in the field.
The latest issue of The Atlantic Monthly contains an article by Tony Rousmaniere, What Your Therapist Doesn't Know. Recognize that last name? Only after reading the article and penning the first draft of this post did it occur to me to reach out to the estimable Peter Rousmaniere to ask if Tony was any relation. In fact, Tony is Peter's oldest son. I should have guessed.
In the article, we learn about feedback-informed treatment (or FIT). In a space where 25 percent of patients drop out of therapy (likely higher among chronic pain cases, but that's just a guess on my part) and 5 to 10 percent of patients actually get worse during the course of treatment, wouldn't it be nice to be able to quantify, and perhaps even predict, patient progress? Turns out, over 50 different (and, I suppose to some extent, competing) feedback systems have been developed over the past 20 years. Most involve detailed questionnaires administered to patients and designed not only to measure progress, but also to help therapists identify blind spots (like when a patient might be offering less than truthful feedback directly to the therapist... or about to drop out of treatment... or getting worse). One such feedback system was able to predict - with 85% accuracy and after only three sessions of therapy - which patients would deteriorate.
New medical technologies, practice techniques, and methodologies can take a long time to be adopted into every day clinical application. Rousmaniere discusses the history of the thermometer - at one point, taking a patient's temperature and using that data as a tool in diagnosis was considered heretical and potentially dangerous to the practice of medicine (in that it might make doctors lazy and dull their skills as diagnosticians).
The time has clearly come for injecting data, metrics, and objective performance feedback into psychotherapy. And since payers are hearing the constant drum beat of "psychosocial... mental health... CBT...", the thought occurs to me that the least we can do, if we're going to pay for this apparently efficacious intervention, is demand feedback-informed treatment for injured workers. We would demand no less in virtually every other area of medicine.
Why settle here?
Michael
On Twitter @PRIUM1
Showing posts with label CBT. Show all posts
Showing posts with label CBT. Show all posts
Tuesday, April 11, 2017
Thursday, August 13, 2015
It's Not About the Meds, It's About the Pain
We are a nation in pain.
According to the National Health Interview Survey conducted by the Centers for Disease Control and Prevention here in Atlanta, more than 25 million of us experience pain on a daily basis for a minimum of 90 days. That's 11.2% of adults in this country. And a full 126 million adults (that's nearly 56% of us) reported some type of pain in the 90 days leading up to the interview.
We try to fix it with drugs.
Once upon a time, acetaminophen was a wonder drug. And then we realized it carries significant risk of liver damage at high doses and with long term use. At one point we thought ibuprofen was the answer. And then we learned that heart attack and stroke risk significantly increase with its use. At one point (hard as it is to believe), we thought opioids were the long-sought-after solution to the problem of pain. That's led to the largest man-made epidemic in history: thousands of overdose deaths per year, more Americans addicted to pain meds, entire generations disappearing from some towns, and a lot of other scary statistics and awful outcomes.
And when those don't work, we pin our hopes to potential future drugs.
Researchers at Memorial Sloan Kettering Cancer Center are working on an investigational compound, IBNtxA. It's an opioid derivative that appears to provide the analgesic effects of an opioid without the risk of respiratory suppression or the "high" that comes with typical opioid use. While this is great news for cancer patients (where pain medication is not only useful, but critical to compassionate treatment... which is why Sloan Kettering is working on it), it begs the question: what side effects and unintended consequences will result from the long term use of IBNtxA? And to what extent are the psychotropic effects of our current opioids the real drivers of use (vs. their perceived analgesic effect)? We have no idea, but history tells us we should proceed cautiously.
So what do we do?
We have to find ways to manage the vast majority of chronic pain without pharmacological assistance. Should some people with chronic pain be allowed to benefit from sustained use of medication therapy? Absolutely. But too many millions of patients are relying on dangerous and ineffective medications to manage an underlying issue that is only partially explained by biological factors, completely ignoring the social and psychological barriers to recovery.
Our pain, collectively and individually, is here to stay until we start thinking less about the pain and more about the person.
Michael
On Twitter @PRIUM1
According to the National Health Interview Survey conducted by the Centers for Disease Control and Prevention here in Atlanta, more than 25 million of us experience pain on a daily basis for a minimum of 90 days. That's 11.2% of adults in this country. And a full 126 million adults (that's nearly 56% of us) reported some type of pain in the 90 days leading up to the interview.
We try to fix it with drugs.
Once upon a time, acetaminophen was a wonder drug. And then we realized it carries significant risk of liver damage at high doses and with long term use. At one point we thought ibuprofen was the answer. And then we learned that heart attack and stroke risk significantly increase with its use. At one point (hard as it is to believe), we thought opioids were the long-sought-after solution to the problem of pain. That's led to the largest man-made epidemic in history: thousands of overdose deaths per year, more Americans addicted to pain meds, entire generations disappearing from some towns, and a lot of other scary statistics and awful outcomes.
And when those don't work, we pin our hopes to potential future drugs.
Researchers at Memorial Sloan Kettering Cancer Center are working on an investigational compound, IBNtxA. It's an opioid derivative that appears to provide the analgesic effects of an opioid without the risk of respiratory suppression or the "high" that comes with typical opioid use. While this is great news for cancer patients (where pain medication is not only useful, but critical to compassionate treatment... which is why Sloan Kettering is working on it), it begs the question: what side effects and unintended consequences will result from the long term use of IBNtxA? And to what extent are the psychotropic effects of our current opioids the real drivers of use (vs. their perceived analgesic effect)? We have no idea, but history tells us we should proceed cautiously.
So what do we do?
We have to find ways to manage the vast majority of chronic pain without pharmacological assistance. Should some people with chronic pain be allowed to benefit from sustained use of medication therapy? Absolutely. But too many millions of patients are relying on dangerous and ineffective medications to manage an underlying issue that is only partially explained by biological factors, completely ignoring the social and psychological barriers to recovery.
Our pain, collectively and individually, is here to stay until we start thinking less about the pain and more about the person.
Michael
On Twitter @PRIUM1
Wednesday, June 10, 2015
Cognitive Therapy, Cognitive Dissonance
One of the most frequent recommendations I see resulting from our peer-to-peer discussions on chronic pain claims is Cognitive Behavioral Therapy (CBT). CBT is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people's challenges and, thus, change the way they feel about and deal with those challenges.
Despite the growing body of evidence regarding the effectiveness of Cognitive Behavioral Therapy, it still seems to cause a great deal of cognitive dissonance in our industry. We want to mitigate chronic pain symptoms for injured workers so they can take fewer medications, have a higher quality of life, and perhaps even return to work. But we're resistant to the idea that 6-12 CBT sessions can actually help with those goals, despite what the evidence suggests.
The essential concept here is that low-cost, short-term clinical strategies that focus on how we feel, react, and deal with life experiences, including symptoms of pain, can be more effective than long-term use of medications.
An article in the New York Times this week lends more evidence to this notion. While not focused on chronic pain, the article does highlight one of the most significant side effects of chronic pain (and the opioids too often used to manage it): insomnia. Look at the medications you're paying for on a typical legacy chronic pain case and you're likely to see Lunesta, Ambien (zolpidem), Restoril, etc.
Turns out CBT by itself is more effective than both the medications as well as the medications plus CBT. Across 20 clinical trials including more than 1,000 patients, CBT yielded more sleep and higher quality sleep than the medications delivered.
Here's the bottom line: All of us, at one time or another and with varying degrees of frequency, need coping mechanisms. Life is hard. Sometimes we hurt. Sometimes, we hurt all the time. But medication therapy isn't the best option for long-term pain or insomnia or lots of other chronic conditions that fundamentally emanate from the human mind and all of its experiences and perceptions. CBT sounds simple. It's not. CBT is hard work. We're trying to rewire our brains so that we experience life in a healthier way. But it's hard work worth doing, particularly given the alternatives.
Michael
On Twitter @PRIUM1
Despite the growing body of evidence regarding the effectiveness of Cognitive Behavioral Therapy, it still seems to cause a great deal of cognitive dissonance in our industry. We want to mitigate chronic pain symptoms for injured workers so they can take fewer medications, have a higher quality of life, and perhaps even return to work. But we're resistant to the idea that 6-12 CBT sessions can actually help with those goals, despite what the evidence suggests.
The essential concept here is that low-cost, short-term clinical strategies that focus on how we feel, react, and deal with life experiences, including symptoms of pain, can be more effective than long-term use of medications.
An article in the New York Times this week lends more evidence to this notion. While not focused on chronic pain, the article does highlight one of the most significant side effects of chronic pain (and the opioids too often used to manage it): insomnia. Look at the medications you're paying for on a typical legacy chronic pain case and you're likely to see Lunesta, Ambien (zolpidem), Restoril, etc.
Turns out CBT by itself is more effective than both the medications as well as the medications plus CBT. Across 20 clinical trials including more than 1,000 patients, CBT yielded more sleep and higher quality sleep than the medications delivered.
Here's the bottom line: All of us, at one time or another and with varying degrees of frequency, need coping mechanisms. Life is hard. Sometimes we hurt. Sometimes, we hurt all the time. But medication therapy isn't the best option for long-term pain or insomnia or lots of other chronic conditions that fundamentally emanate from the human mind and all of its experiences and perceptions. CBT sounds simple. It's not. CBT is hard work. We're trying to rewire our brains so that we experience life in a healthier way. But it's hard work worth doing, particularly given the alternatives.
Michael
On Twitter @PRIUM1
Subscribe to:
Posts (Atom)