10-Minute Mini Lesson Three:  Goal Setting

10-Minute Mini Lesson Three is designed to provide a basic understanding of how to help members set achievable goals as part of their pain management treatment.

WHAT MAKES GOAL-SETTING DIFFICULT?

Most of us are good at identifying changes we would like to see in our lives. However, effecting these changes is often more difficult than identifying what they are — easier said than done, as they say!

Sometimes we feel overwhelmed by the size of the goal before us, and we simply do not know where to start. Other times we try to achieve a goal, but it just doesn’t work out. In these situations, it’s easy to feel discouraged and give up.

USING THE ACRONYM “SMART”:

The acronym SMART can be an important part of identifying appropriate goals and steps. This stands for:

Specific. Suggest patients be as specific as possible so they can tell when they have completed a goal or step. “Get more exercise” is vague, but “Walk around the block on Monday, Wednesday, and Friday” can be easily checked off.

Measurable. Suggest they make goals and steps measurable. Then they can track their progress over time. In the example above, specifying the “3 days” gives them a way to measure any change in their exercise habits.

Achievable. Make sure they pick a goal they can actually be attained. If it is NOT achievable then suggest they select a smaller step. For example, “Walk to the corner and back on Monday and Friday”

THE PRIMARY LAW OF CHANGE: If they are NOT achieving their goal, they haven’t selected a SMALL ENOUGH step.

Relevant. Make sure the goal they have chosen is in line with what they want to accomplish overall. Learning to be a better public speaker is a great goal, but perhaps not the most relevant if your greater aim is to make more friends.

Timely. Make sure that now is a good time to work toward their goal. For example, are they physically able to walk to the corner or around the block? This may have to wait until they have a walker or more strength in their legs.

HERE IS AN EXAMPLE OF GOAL SETTING:

Tom has been very athletic in the past and is very depressed about being relegated to his recliner because of his pain. He comes in with the goal of being able to take his usual five-mile run in the morning.

1. ACKNOWLEDGE HIS OVERALL GOAL of returning to his usual exercise regime.
2. Help him IDENTIFY A START POINT. He needs to be honest and ask himself, “Where do things stand now?” His answer: I can walk to the bathroom or kitchen. I need to rest after 5 minutes of walking or the pain is too much.
3. Help him break down his “goal” by IDENTIFYING ALL OF THE STEPS it would take to get from his start point to his goal. Suggestions that could be made to Tom:
4. Track how many times you walk to the bathroom or kitchen. Increase that by 2-3 more trips each day. Remember that EACH trip matters as a step toward your goal. These early steps are important. Congratulate yourself.
5. Add walking outside (e.g., to the backyard, front yard, or outdoor hallway) but limit it to 5 minutes. Do this with a partner if it seems scary to you.
6. Time your trips and add ONE minute each day. This means you would more than double your stamina in less than a week.
7. Track all your trips and times. This is your training schedule and will help you reach your goal.
8. Once a day, do more than what you think you can do. Then you can feel proud of yourself for going above and beyond.
9. Help him CONSIDER POTENTIAL OBSTACLES and how to work through or around them:
10. He says, “I can’t imagine going outside.” Suggestion: Suit up, put on your walking shoes, and just stand outside your front door. This is the trick: Almost everyone goes for the walk once they are outside their front door.
11. He says, “But it hurts too much.” Suggestion: Remind him that the pain could lessen once he gets his body more active or that he can hurt on a walk as easily as he can hurt in his recliner and it will be more fun and more distracting from the pain. Ask what he’d like to see on his walk—a good way to encourage getting outside.
12. He says, “I’m afraid I’ll fall.” Suggestion: This is a realistic concern. Offer to help him obtain whatever walking aid would decrease his fears.

CAN GOAL SETTING HELP IN ADDRESSING EMOTIONAL OR BEHAVIORAL DIFFICULTIES?

Goal setting can also be helpful when addressing emotional or behavioral difficulties. For example, someone who is depressed and isolated may work toward a goal of increasing the number and strength of his friendships. Someone experiencing anxiety related to her job may work toward exploring a career change or making time more often for relaxation and leisure. Because goal setting strategies are often used in CBT, this therapeutic approach is particularly helpful for those struggling to meet their goals, regardless of what those goals may be.

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AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

1. PCP is best qualified to understand Member’s medical history and current needs.
2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
5. Improved self-management—Reliance on self rather than others to provide solutions
6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

FUTURE BLOGS on CBT for Chronic Pain in the PRIMARY CARE OFFICE:

10 Minute Mini Lesson Four – Scheduling Fun, Enjoyment, and Achievement

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

My last blog was about the life of a mosquito and Zika concerns.  Now how to avoid mosquito bites

“He told many remarkable things about those lawless insects. Among others, said he had seen them try to vote.” – Mark Twain, Life on the Mississippi

According to the Travel site of the CDC here is some advice.

General avoidance and protection.

Don’t go there.  No really, don’t go there.  – avoid travel to outbreak areas.  The CDC traveler’s website has information.   An unfortunate intersection for the Brazil Summer Olympics.

Avoid peak traffic hours – some mosquitos are dawn and dusk feeders, crepuscular.  But others, including the concerning Aedes albopictus (Asian tiger mosquito), a possible vector for Zika is a daytime feeder.

Protective clothing – obvious enough.  There are also available topically applied clothing (tent, shoes, camping gear) repellants and manufacturer infused insect repellant clothing.  These repellants contain permethrin and the manufacturer infused brands can remain active through several washings.   The topical permethrins have shorter activity.

Spatial protection

Spatial repellants and insecticides have been available and new products are available.  Spatial preventive measures intercept mosquitos prior to human approach.  Closing the doors and windows are an example as are mosquito netting in malarial environs.  Fans discourage the weak flying mosquito and disperse the chemical into which they home.

Spatial repellants and insecticides have been available and new products are available.  Devices that envelop an area or individual in repellent clouds.  Big clouds, small clouds, walking, wind, bug density …  These include coils, candles, foggers and personal devices that vaporize repellants such as metofluthrin.  These devices have not been fully reviewed but under the right conditions likely are helpful.

There are also electronic insect repellent devices which produce sounds that were developed to keep away mosquitos. No EPA or other scientific research has ever sought evidence that these are effective.

Topical Repellants

“I am rather like a mosquito in a nudist camp; I know what I ought to do, but I don’t know where to begin.” – Stephen Bayne

These are the familiar agents.  Off, Cutter, Sawyer, Ultrathon, Skin So Soft, and the like.  Protection time varies by agent, form, ambient temperature, activity level, exposure to sweat and water and abrasion.

The best known repellant is DEET (N,N-diethy-m-tolua-mide).  The CDC recommends using products with > 20% DEET, with effectives that plateaus at about 50%.  Micronized formulations may last longer.  Other products registered with the EPA include those is picaridin, IR3535 and some oil of lemon eucalyptus (formulated as a repellant) and para-methane-diol (artificial OLE) products. Researchers at New Mexico State University tested ten commercially available products for their effectiveness at repelling mosquitoes.  On the mosquito Aedes aegypti, the vector of Zika virus, only one repellent that did not contain DEET had a strong effect for the duration of the 240 minutes test: a lemon eucalyptus oil repellent. All DEET-containing mosquito repellents were active.

The CDC recommendations for repellants

• Apply only to exposed skin and clothing (not under clothing)
• Never to open, irritated skin
• Never to eyes, mouth and sparingly to the ears (for the face apply to hands then transfer to face). The same transfer to apply to kid
• Have kids wash their hands afterwards
• Just enough to cover –thick application does not last longer
• Wash when protection is no longer needed or in case of an allergic reaction

EPA registered products can be used by kids and pregnant or nursing women according to labelling.  DEET should not be used in children under 2 months of age and OLE products on kids less than 3 years old.

You can use both sunscreen (first applied) and repellant at the same time although the reapplication times may make this tricky and the same applies to combination products where the sunscreen may wear off first.

Ironically, the high pitched whine of the mosquito (The Mosquito) has been used as deterrent to human loitering and in high crime areas.  High pitched emissions target a younger, and presumably more delinquent, group with more acute hearing. The Council of Europe considers the device degrading and discriminatory to youngsters and has targeted the U.K. having more that 3,500 such devices in the country.  So that’s why the Brexit!

“Even a mosquito doesn’t get a slap on the back until it starts to work.”

Anyone who thinks that they are too small to make a difference has never tried to fall asleep with a mosquito in the room  – Christine Todd Whitman

Not to confuse, or perhaps to confuse etymology and entomology when you put together the Spanish for fly – mosca and the diminutive suffix –ito together you get mosquito.  A topic, an insect, of great interest in this, the possible summer of Zika.

The mosquito species of interest are the Aedes species – aegypti and albopictus (Asian tiger mosquito).  The former as a known vector of arboviruses in the United States with a limited geographic range and albopictus as a possible, unquantified vector but with a wider range.

The range of the mosquito is limited by winter temperatures – isotherms – but exceptions exist, particularly in urban areas where species can winter in protected environments.

In the vector map below by Gardner, et. al., the solid circles represent the suitable habitat and relative risk for Aedes aegypti and clear circles Aedes albopictus with larger concentric circles representing higher total estimated relative risk.  If you want to be mosquito free, move to Iceland, where both the cold temperatures and weather unpredictability are hostile to establishing a mosquito population.

The life-cycle of the mosquito runs the typical egg-larvae-pupae- adult stages.  The Aedes species can breed in casual puddles such as artificial water containers, cupped leaves, bromeliad axils or notoriously in abandoned spare tires (with the curious physics that have them become upright in marshes).  The eggs are also resistant to drying out and can enter diapause for several months if they dry out.  The male of the species is a nectar feeding insect as is the female, until it is time to breed.  A blood meal is needed to produce eggs.  Different species prefer different hosts such as animals, birds, cold-blooded animals, insects, even fish.

Female mosquitos hunt their hosts by detecting CO2, visual recognition and body chemicals, in particular octenol produced by the host.  Some unfortunate people are just genetically predetermined targets for mosquitos (we all know these people if you are not one of them).  Preferred targets include type O blood, heavy breathers, those with a lot of skin bacteria, body heat and the pregnant.   The antennae of mosquitos have 72 types of odor receptors, 27 are represented by chemicals in sweat.  The male mosquito has bushy auditory receptors to hear the whine of the female (this paraphrase is from Wikipedia- really).

Most mosquitoes are crepuscular hunters – dawn and dusk – ominously the Asian tiger mosquito (a potential Zika vector) is a daytime feeder.   Upon feeding the mosquito injects saliva as an anticoagulant.  This serves as the transmission fluid for arboviruses such as Zika.  The irritating and itchy bite is the result of histamine release in response to the bite.

Next Blog – How to protect yourself from mosquitos

Generic medications play an important role in healthcare cost savings.  For FDA approval, a generic drug must be identical in strength, dosage form, and route of administration and be bioequivalent.  In other words, the generic drug for all intents and purposes must be the same as the brand reference drug.  A biosimilar, on the other hand is approved if it shows that it is highly similar to an FDA-approved biologic product known as a reference product.  In addition, a biosimilar is not labeled as bioequivalent to the reference drug.  Thus, unlike a generic medication, a biosimilar is not interchangeable with the reference drug without the prescriber’s approval.

So how does a biosimilar fit into the healthcare spending equation?  Biosimilar are expected to be 15-30% less expensive than the originator drugs.  However, to benefit fully from this potential cost savings, the biosimilar needs to be interchangeable with its reference drug.   The ability to interchange a biosimilar with its reference drug allows the pharmacist to dispense a biosimilar when the prescription is written for the reference drug, much similar to how generics are dispensed for brand name products.  If a biosimilar is not interchangeable with its reference drug, it will certainly not be as readily dispensed since each request to change to a biosimilar will require the prescriber’s approval.

Currently, there are 2 biosimilars approved in the United States.  Zarxio, a biosimilar version of filgrastim and Inflextra, a biosimilar to Remicade.  Biosimilar for a few other blockbuster drugs such as Enbrel and Humira are expected to be approved by the FDA later this year.  Experts believe biosimilars will lead to a $40 billion dollars savings over the next 10 years.  To see this savings, doctors, patients, payors, and legislators will need to have a better understanding of biosimilars and how best to expand its access to patients.  With the skyrocketing cost of biologic medications, biosimilars may be our knight in shining armor to rescue us from this specialty drug distress.

Submitted by Stan Leung PharmD, PHC Director of Pharmcy

Many of us have questions about the end of life option act and how it may affect our practices.  When the CMA first surveyed this matter last year, about 20% of physicians who answered the survey were supportive of the legislation and 20% were very opposed to the idea.  The law was passed and signed and will take effect on June 9, 2016.  The following is a basic outline of what is required to work within the End of Life Option Act.

For more information, please see the excellent legal brief by the California Medical Association:  CMA ON-CALL document #3459 “The California End of Life Option Act” published in January 2016.

Eligible individuals:

• Adult 18 years of age or older
• Capacity to make medical decisions
• Terminal disease

The following conditions must all be met:

• Individual’s attending physician has diagnosed the individual with a terminal disease
• The individual has voluntarily expressed the wish to receive the aid-in-dying drug
• The individual is a resident of California
• The individual documents his or her request on the Request form specified in the act
• The individual has the physical and mental capacity to self-administer the drug

The request:

• The individual submits two oral requests directly to the attending physician 15 days apart
• The individual submits one written request directly to the physician
• The physician has to document each oral and written request in the medical record
• The form must be signed and dated by the individual and have two witnesses

The witnesses:

• Attest that they know the individual or verify proof of identity
• Attest the individual voluntarily signed the form in their presence
• Attest the individual appears to be of sound mind
• Witnesses cannot be the attending or consulting physician or mental health specialist
• Only one witness can be related to the individual

Medical record documentation:

• The attending physician documents the diagnosis and prognosis and that the individual has capacity and is acting voluntarily
• The consulting physician documents the diagnosis and prognosis and that the individual has capacity and is acting voluntarily
• Mental health specialist’s evaluation if performed
• Attending physician must document informing the patient that he or she can withdraw the request at the time of the second oral request
• Attending physician’s note that all requirements have been met and documentation of the drug prescribed
• All documentation has to be sent to the California Department of Public Health
• There are five forms specified in the Act that have to be filled out

Five specific forms are required (no substitutes):

• Request for an Aid in Dying Drug to End my Life in a Humane and Dignified Manner
• Final Attestation for an Aid-in-Dying Drug to End my Life in a Humane and Dignified Manner
• Attending Physician Checklist and Compliance Form
• Consulting Physician Compliance Form
• Attending Physician Follow-up Form

Who is the attending physician?

The “attending physician” is the physician who has primary responsibility for the health care of the requesting patient and treatment of the patient’s terminal disease.

Who is a consulting physician?

The “consulting physician” must be independent from the attending physician and who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding the patient’s terminal disease. The consulting physician cannot be a witness to the written request.  The consultant must review the medical records and examine the patient.  The consultant must determine that the individual has capacity to make medical decisions and that the individual is acting voluntarily.

Participation:

Physicians are free to choose whether to participate in this Act. The health care provider who diagnoses a patient with a terminal illness must inform the patient about the right to information about the end-of-life option, but the law states: “a person that elects for reasons of conscience, morality, or ethics, not to engage in activities is not required to take any action in support of an individual’s decision under this law.”  The physician does not have to advise or counsel a patient about participation in aid-in-dying activities.  Providing a patient, upon request, with a referral to another provider for purposes of participating in this act is not considered “participation” in the Act.

10 Minute Mini Lesson One is designed to provide a basic understanding of the CBT concept of Cognitive Restructuring.

Help them fill in the CBT Cycle Diagram to show what happened, what they were THINKING, how they FELT emotionally and physically, and how they BEHAVED:

HERE ARE SUGGESTED QUESTIONS TO ASK. Have patient if able write answer next to appropriate label in Diagram:

1. WHAT HAPPENED?

Q:  Tell me about a specific, recent time when your pain increased.

A:  I got upset because I had too much back pain to even do the dishes.

Q:  When?

A: I guess it was 2 days ago

Q:  What time of day? (Or other questions like ‘where were you?’ to increase specificity.)

A:  In the afternoon

2. WHAT WERE THEIR THOUGHTS:

Q:  What was running through your mind when [the event] happened?

A:  I’ll never be able to do anything normal and my husband will leave me.

Typical THOUGHTS of chronic pain patients:

• Catastrophising
• Unhelp beliefs, e.g., I should always rest, I need to get rid of the pain (vs. manage the pain)
• Hypervigilance, e.g., paying too much attention to one’s body
• Self Criticism

3. WHAT WERE THEIR FEELINGS:

Q:  How did that make you feel?

A:  I felt worthless and hopeless.

Q:  Did you have other feelings like [anger, fear, sadness]?

A:  Well, I guess anger because this has been going on so long.

Typical FEELINGS of chronic pain patients

• Low mood
• Anger and frustration
• Anxiety and worry

1. HOW DID THEIR BODY FEEL?

Q: How did your body feel?

A: My back was on fire. I felt like I couldn’t stand up.

Typical BODY FEELINGS of chronic pain patients

• Pain, weakness, and stiffness
• Lethargy and fatigue
• Poor sleep
• Nervous symptoms

2. WHAT DID THEY DO?

Q: What did you do at that point?

A:  I took an extra pain pill but it didn’t help, so I called for an appointment.

Typical BEHAVIORS of chronic pain patients

• Sighing and groaning, talking about pain
• Reduced activity; excessive rest
• Social isolation and withdrawalTHIS IS HOW THE CBT CYCLE DIAGRAM MIGHT NOW LOOK:

  

  HELP PATIENT FIND NEW WAY OF THINKING ABOUT EVENT:

  Explore using yourself as a model. Use the patient’s own words as much as possible. Help the patient make their own connections and discoveries. Your main goal is to get the patient to THINK DIFFERENTLY about their situation. Much of this THINKING may occur at home after the visit.

  OFFER COGNITIVE EMPATHY: If I thought I wasn’t ever going to be normal and my spouse would leave me, I would also feel hopeless and worthless and angry and want the doctor to fix me.

  SUGGEST COGNITIVE RESTRUCTURING or REFRAMING:

  Q: Is there something different you could THINK about [event}?

  THIS IS HOW THE CBT CYCLE DIAGRAM MIGHT NOW LOOK:

  

  HELP PATIENT FIND NEW WAY OF THINKING ABOUT EVENT:

  Explore using yourself as a model. Use the patient’s own words as much as possible. Help the patient make their own connections and discoveries. Your main goal is to get the patient to THINK DIFFERENTLY about their situation. Much of this THINKING may occur at home after the visit.

  OFFER COGNITIVE EMPATHY: If I thought I wasn’t ever going to be normal and my spouse would leave me, I would also feel hopeless and worthless and angry and want the doctor to fix me.

  SUGGEST COGNITIVE RESTRUCTURING or REFRAMING:

  Q: Is there something different you could THINK about [event}?

  A:  I need to find a different way to get this done. Dirty dishes are not the end of the world.

  COACH on possible answers if they don’t come up with any on their own.

  Q: How might you FEEL if you thought that about the dishes?

  A: I’d be happy that I had a good idea. I wouldn’t worry about it as much.

  Q:  How would your BODY FEEL?

  A:  Maybe I wouldn’t feel so tense.

  Q:  What would you DO differently?

  A:  I’d wash five dishes and then go watch my favorite soap for 10 minutes.

  HOMEWORK ASSIGNMENT: Ask patient to fill out a new CBT Cycle Diagram AT HOME with the NEW thoughts, emotional and physical feelings, and behaviors (which might look like this). Encourage patient to use this new skill at least once a day (supply them with blank CBT Cycle Diagram forms). Ensure them that regular practice will lessen their pain, improve their mood and self-confidence, and make them less dependent on medications.

  NEXT CBT Mini Lesson: Mindfulness and Relaxation Exercises

   

   

This is a five part series on integration of cognitive behavioral therapy (CBT) into primary care practice written by Karen Stephens PhD, Continue reading →

Every adult in the U.S. knows what happens on April 15. But do you know the significance of the following day? April 16 is National Healthcare Decisions Day. It is a day designated to highlight the importance of people filling out their own Advance Directive (AD), no matter how young and healthy they are. The theme for 2016 is “It Always Seems Too Early. Until It’s Too Late.” The idea is to let people know that something catastrophic can happen to anyone at any time. That is why filling out an AD is important for everyone.

Physicians understand the importance of ADs. But our profession has not been that successful in getting our patients to make their wishes known and fill out these forms. The time available during appointments is limited and usually filled with other pressing issues. Talking about end-of-life wishes can be uncomfortable for patient and clinician alike. But it is an important issue to address periodically with every adult patient, as important as reviewing standard medical screening tests, updating vaccinations, and talking about healthy lifestyle.

Here are several ideas to make the discussion of Advance Directives a bit easier:

• Have a supply of Advance Directives available in your exam room. Being able to hand your patient the form will make it more likely the patient will fill it out.
• Make use of April 16 as National Healthcare Decisions Day as a way to introduce the subject.
• Make sure you and everyone in your family has filled out an AD. Being able to tell patients you yourself have filled out your own AD, as has your spouse and adult children, can help make the issue less daunting. It can reassure patients that you are not bringing it up because you are worried about their health, but because you are as concerned about them as you are about your own family.
• Identify one or more people on your staff who can be educated on how to talk with patients about the importance of ADs, and build time in to office work flow for them to talk with patients about this issue. The responsibility does not need to rest exclusively on the PCP.

We will never get 100% of our patients to fill out ADs, just like we will never get all our patients fully compliant with all their needed health screenings. But by working to normalize this sensitive subject, we can get more of our patients to make known their wishes for end-of-life care. Even though April 16 is now in the past for this year, the importance of getting our patients to fill out their ADs is a year-round challenge.

Cancer remains one of the most prevalent and deadly diseases in California as they are in the United States. Continue reading →

“If end-of-life discussions were an experimental drug, the FDA would approve it.”  Continue reading →