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The clinical specialty unit: The use of the psychiatry inpatient unit to treat chronic pain syndromes
The Clinical Specialty Unit: The Use of the Psychiatry Inpatient Unit to Treat Chronic Pain Syndromes Jeffrey L. Houpt, M.D. Professorand Chairman,
Deparfment
of Psychiatry,
Emory School of Medicine
Francis J. Keefe, Ph.D. Assistant
Professor,
Department
of Psychiatry,
Mary Trainor Snipes, Head Nurse, Clinical Specialty
Duke Medical Center
R.N. Unit, Duke Hospital
The authors describe a 25-bed psychiatry inpatient unit, the Clinical Specialty Unit (CSUI, designed to treat patients with chronic pain syndromes. They argue that the use of psychiatry beds for this purposeis appropriate, given the nature ofthe chronic pain disorder, but is not without its liabilities. The administrative structure and roles of the multidisciplina y team are described. Abstract:
Pain is the most common symptom for which people seek medical care; thus, attempts to alleviate it are the physician’s most frequent task. Pain, as a chronic symptom, becomes a disorder of its own. Chronic pain often persists long after what might be predicted from the initial physiologic insult. Modalities effective with the acute symptom of pain are often ineffective with chronic pain, and the effects of cumulative ineffective treatments add to the patient’s discomfort. From a psychologic perspective, the individual responds by attempting to incorporate the significance of the pain into his Responses of family, emmental functioning. ployers, insurance agencies, and the courts, in some instances, further influence this process. When confronted with a chronic pain patient, the physician must apply many lenses to the clinical situation in order to bring it into focus. Most commonly, these lenses include definition of the preC;ozeri~i Hqvtd
incapacity, the correspondence of the physiologic incapacity with known syndromes, the behavioral patterns surrounding the pain disorder, the degree and quality of affective disturbance, the range of family involvement, the impact of disfinancial standing, and proability settlements, spective litigation, as well as the patient’s personality dynamics. Given the complexity of the patient’s disorder, treatment is multidisciplinary. This paper describes the administrative structure and program of an inpatient unit designed to treat patients with chronic pain: the Clinical Specialty Unit (CSU). This 15-bed ward is Iocated on the Psychiatry service in Duke Hospital. The remainder of this paper outlines the rationale, administrative structure, and the research and treatment program of this ward.
Rationale The impetus for the CSU was initiated by faculty members working in consultation-liaison psychiatry who desired an inpatient ward for treatment and research. As a result, it was decided to develop an inpatient unit to treat chronic pain syndromes. Utilizing psychiatry beds for chronic pain patients has both positive and negative consequences. On the positive side, the use of psychiatry beds
Pzyc-lr~ufr,y 6, 65-713, 19X4
Elsevier Science Publishing Co., Inc. 1984 52 Vanderbilt Avenue, New York, NY 10017
C
sent physiologic
65 ISSN0163.X343:84/$3.00
J. L. Houpt, F. J. Keefe, and M. Trainor Snipes
meets several requirements: 1) behavioral and psychotropic interventions can be provided, 2) a length of stay can be arranged that is generally longer than one on medical or surgical wards, 3) the experience of psychiatrists in coordinating care can be utilized, 4) the expertise of psychiatric nurses can be used in developing a milieu, and 5) various medical consultants are available. However, by locating the unit on Psychiatry, certain potential problems are also raised. The most important is the patient and the family’s insistence that their pain problem be perceived as a physical disorder and their consequent expectation that the approach to treatment be consistent with the general approach taken with medical patients. A second problem involves third party reimbursement and peer review, which is discussed at the end of this paper. Given both these positive and negative concerns, the ward was developed as follows.
Administrative Structure A psychiatrist serves as medical director of the unit and the nursing staff is comprised of psychiatric nurses. A psychologist with special expertise in behavioral approaches consults and coordinates the pain management program. A psychiatrist acts as the patient’s primary physician and consults with anesthesiologists, neurosurgeons, internists, and other specialists. Psychiatric residents provide house staff coverage. Patients are referred for inpatient care from various medical and surgical specialists, the Duke Pain Clinic, or the Duke Behavioral Physiology Lab. The Pain Clinic is a diagnostic outpatient clinic whose staff includes anesthesiologists, neurosurgeons, and psychiatrists. The Behavioral Physiology Lab provides feedback and other behavioral approaches to a wide range of disorders. This lab is staffed with faculty from medical psychology. When the patient is referred from a Duke clinic or physician, the referring physician becomes the consultant and the psychiatrist assumes the primary care function. The ward is called the Clinical Specialty Unit to encourage greater acceptance by the patient and the family.
Research Program A committee was formed comprised of several of the attending psychiatrists, the consulting ward psychologist, and the head nurse. This committee reviews all research proposals for scientific merit,
impact on the milieu, and the cost implications. In order to meet cost concerns, all studies must be consistent with effective treatment approaches and cannot delay the patient’s discharge. As a result, much of the research is carried out during the initial assessment phase (for example, correlations between biologic and psychologic indicators of depression and pain, evaluation of pain behavior patterns, etc.). Groups of patients are recruited by faculty who work as collaborators in research.
Treatment Program Assessment Phase Nursing, Psychology, Anesthesiology, Neurosurgery, Orthopedics, Physical Therapy, Recreation Therapy, and other medical consultants all participate in developing the treatment plan. The following section outlines the general nature of their input. Nursing. Nurses provide information on the patient’s pain-related behavior, baseline use of medications, interactions with other patients on the ward, family interactions, and observations relative to depression or psychiatric disorders. Because the nurses observe patients in a variety of settings, their observations are most pertinent relative to pain behavior. They observe for grimacing, guarding, bracing, and rubbing. Since patients also keep their own records of these behaviors, nurses’ observations can be compared with those records kept by the patient. Impressions as to whether the level of pain behavior is disproportionately high and whether patients show more pain behavior in certain situations or not are also noted. Nurses also record the baseline measures of medication intake, and include in that assessment the patient’s behavior regarding the use of pain medication. They observe for the type and quality of interactions with other patients on the ward as well as with the family. They also report on affective states, mental status changes, or other cognitive and psychomotor signs of depression. Psychology. Psychology provides a behavioral analysis of the patient’s problem as well as psychometric testing. The behavioral analysis includes a description of coping skills and physical functioning, a video-taped assessment of pain behavior, and a review of the patient’s activity records. Psychometric testing includes the h4MPI and self-re-
Clinical Specialty Unit
port measures of mood. This assessment is described in greater detail in the paper by Keefe and Bradley in this section. Anesthesiology/neurosurgery/orthopedics. Physicians representing one or more of these specialties evaluate all patients, depending on the preadmission workup. Particular attention is paid to whether nerve blocks, transcutaneous or implanted neurostimulators, or more definitive surgical procedures are indicated. The use of these modalities are described in greater detail in the paper by Urban in this section. Physical therapy. These evaluations focus on posture, mobility, and muscle strength. They provide a baseline from which progress can be defined, and outline physical approaches to improving the patient’s functional capacity. Recreation therapy. This assessment concerns itself with the recreational activities of the patient during the hospital stay as well as his use of leisure time prior to hospitalization. Activities are geared to targeted physical capacities. Within this realm, discharge planning begins immediately since the assessment is aimed at determining the degree of progress necessary in order for the person to resume leisure activities upon discharge. Other provided needs.
consultations. Other consultations are dependent upon the patient’s individual
Psychiatry. The psychiatrist assesses the patient’s intrapsychic and interpersonal dynamics, his need for psychotropic medication, and whether or not drug addiction is a problem for the patient. In addition, the psychiatrist performs a coordinating function by calling a team meeting at the end of the formal assessment period. The goals of the treatment plan are outlined to the patient on the CSU in a straightforward manner, just as a course of steroids or other medical treatment might be outlined to a patient on medicine or surgery. The patient is encouraged to participate in setting the goals for treatment and an attempt is made to outline the anticipated length of treatment. Provisional plans for discharge are discussed at this meeting as well. If the patient is considered either unwilling or unable to make a commitment to the required treatment plan, the patient may be discharged at this time. In contrast to standard operating procedures
on some psychiatry inpatient units, the length of stay is not usually extended for the purpose of overcoming patient resistence to the treatment program.
Treatment
Phase
Nursing. The primary function of nursing is to create and support a carefully designed milieu. Within this milieu, nurses carry out conventional nursing roles and functions, as well as ones specialized in the treatment of this population. Conventional nursing functions include carrying out treatments, administering medication, and charting and making observations. Nurses continuously assess the patient’s compliance with all aspects of his program. An attempt to develop a relationship with the patient serves as a means for enhancing patient compliance. Certain nursing functions are specific to the nature of the problem treated on the ward, and are in contrast to nursing roles on traditional psychiatric services. For example, patients may be encouraged to rest in bed and many of the physical tasks necessary for personal hygiene or the making of beds are performed by the nurses rather than the patients. Nurses tend to respond more directly to patient inquiries and deal less with the latent meaning in patient communication. Nurses take an active role in explaining the nature of the ward and, particularly regarding admission, the reason that the pain ward is a psychiatry ward. As a relationship develops with the patient, nurses encourage their patients to problem solve, improve communication skills, and understand the relationship between stress and pain; the nurse actively rewards desired behaviors. All of these approaches are considerably more active than the usual posture assumed by most psychiatric nurses on traditional psychiatry wards. Psychology. The ward’s consulting psychologist is actively involved in implementing behavior therapy techniques. Both operant conditioning and self-control techniques are used. While these techniques are considered in more detail in the paper by Keefe and Bradley, the practical applications of these principles are highlighted here. The working hypothesis supporting the operant conditioning approach is that the patient’s pain behaviors are maintained by social consequences (e.g., attention from a solicitous spouse or family, avoidance of unwanted work or home respon67
J. L.
Houpt, F. J. Keefe, and M. Trainor Snipes
sibilities) rather than underlying tissue damage. Operant conditioning methods are used for patients who a) have minimal or no physical findings to account for their pain, b) show a disproportionately high level of pain behavior, c) demonstrate dramatic variability in behavior from one time to another, d) are extremely inactive (less than 5-6 hr per day out of bed) and, e) are dependent on pain medication. In order to modify pain behavior patterns using operant conditioning, the social consequences for pain and “well behaviors” are manipulated on the ward. Our operant conditioning programs focus on two goals: 1) increasing activity, and 2) decreasing narcotic intake. Patients are placed on a structured activity program in which they are required to be up and out of bed during a scheduled number of minutes per hour. Time spent up and out of bed (uptime), leads to attention and praise from nursing staff and other treatment team members. The uptime goals are increased slightly each day. By avoiding high levels of activity, the likelihood that patients will exhibit excessive pain behavior is reduced. If pain behaviors do occur, they are given minimal attention. Medications are also given in a “pain cocktail” (see below) that is delivered on a time-contingent basis rather than linked to a pain complaint (PRN). As patients progressively become more active, the social reinforcement for well behavior is decreased. At this point, patients are expected to take more responsibility for their treatment program and they typically begin to participate more fully in self-control programs designed to teach them how to do so. Self-control methods are useful for a broad spectrum of chronic pain patients. These methods attempt to teach patients how to exert control over their own behavioral, affective, and physiologic reactions to pain. In order that these methods work, patients must have the resources and motivation to attend to and practice training procedures. Training in self-control is carried out in two major settings: the Biofeedback Lab and the Pain Management Group. Biofeedback training is carried out by a trained technician in a lab on the unit. In biofeedback training, patients are trained to recognize and modify inappropriate anxiety and muscle tension responses associated with simple movements. EMG biofeedback training is used to heighten the patient’s awareness of muscle tension. Biofeedback is coupled with progressive relaxation training in order to reduce anxiety responses. Records kept by patients over the course of training help them chart progress in learning to relax in the specific situations (e.g., sitting, walking, standing) with which 68
they have difficulty. These records are reviewed daily and help correct patients’ distortions about their own performance capabilities. The records encourage them to focus on positive signs of progress. The Pain Management Group is a structured behavior therapy group designed to train patients in how to define, measure, and change daily activity patterns affected by pain. The group involves a series of 10 sessions plus follow-up (Alumni) meetings aimed at helping patients initiate and maintain behavior change. Table 1 depicts the topics covered and typical homework assignments. Assignments are reviewed in the group at each session. The Table 1. Pain management group Topic outline Homework Session #
assignment
Topic Introduction overview
&
Defining the problem
Measurement methods
Analysis of baseline data Overview of four behavioral treatment options
Positive reinforcement
Activity-rest cles
cy-
Cognitive pain control strategies
Write a description of activities in a typical day prior to hospitalization Write a definition of a behavioral problem to be targeted for modification Choose and begin to use a method to measure the target problem Graph data that has been collected Select one treatment approach and begin applying it on a daily basis Draw up a list of positive reinforcers that can be used to facilitate behavior change Write a description of how brief rest periods can be used to facilitate behavioral improvement Practice with several cognitive strategies
(continued)
Clinical Specialty Unit
Table 1. (Continued)
Session 9 10
11
#
Topic Review of patient projects Establishing a home pain management program Alumni group meetings (postdischarge)
Homework assignment Continue treatment Write an activity schedule for a home program Bring home records review
emphasis is not so much on what patients say about their pain, but on what steps they are taking to alter daily coping patterns. Typical behavior-change goals worked on by patients in the group include increasing the tolerance for sitting or standing, and time spent in social acpleasant activities, tivities, as well as in decreasing nighttime sleep problems. The patient’s self-control is consistently emphasized by encouraging patients to make their own choices as to target problems, measurement methods, and treatment strategies. Spouse and family members are encouraged to attend group sessions with patients. At the end of hospitalization, patients “graduate” from the group and are encouraged to attend an “alumni meeting” of the group at follow-up. These alumni meetings provide an excellent opportunity to review home compliance with treatment recommendations with the patient and family members.
Anesthesiology/neurosurgery/orthopedics. Several patients have received nerve blocks or transcutaneous stimulators while on the CSU. The paper by Urban reviews these procedures in greater detail. Patients are not transferred to surgical units for these procedures; rather, they are done with the patient remaining on the ward. Most frequently, the procedures are done early in the course of treatment, but there are instances where a patient’s depression has been treated prior to one of these procedures on the assumption that the depression would rule against a successful outcome. In a rare instance, treatment of the psychiatric disorder has permitted more accurate assessment of the underlying physiologic damage and major surgery has been done. In keeping with the high utilization of physical procedures, there is no effort on our part to convince the patient that physical factors have been ruled out.
Physical therapy. Patients are seen daily on an individual basis in physical therapy. Most patients show deficits in strength and endurance and are thus placed on aerobic exercise programs involving bicycling, swimming, or walking. Physical measures are also used to attempt to reverse the effects of pain-avoidance posturing on muscle function and tone. Chronic low back pain patients are typically given a series of flexion and extension exercises designed to stretch, mobilize, and strengthen muscles affected by pain. Patients having chronic pain affecting other body areas are given similar exercises appropriate to their problems. Modalities used to decrease muscle spasm include heat, transcutaneous electrical stimulation, and ultrasound. A central component of all physical therapy interventions is education of the patient about the relationships between posture, exercise, and pain. With such education, the patient is taught to assume greater responsibility for managing the effects of pain on their physical condition. Recreation therapy. For most patients, recreational therapy is a means of increasing their involvement in a much wider range of pleasant activities. For others, it may be a social laboratory to try out new behaviors and communication skills. Still others may find that physical activity may aid in tension release, weight control, or general fitness. The recreation therapist for the CSU participates in the team conferences as an active team member. Psychiatry. The psychiatrist’s major function is that of coordinating the overall care of the patient, prescribing the psychotropic medication, and in selected instances, pursuing individual or family psychotherapy. Pharmacotherapy is a major facet of treatment on the ward. Addiction is present in approximately 20% of the patients seen; thus, attention is directed at this problem. Most addiction problems are treated with a pain cocktail that consists of an analgesic issued in cherry syrup. After a baseline analgesic requirement is determined, it is then incorporated into the syrup and decreased slowly over time. The patient is told that his narcotic will be decreased, but not the rate at which it is done. Withdrawal generally occurs at a rate slower than physiologically required and often takes two weeks. The addition of antidepressants or Tylenol with Vistaril have been useful as an adjunct while withdrawal is taking place. Pain cocktails are often used as the prescribed means of getting a steady blood level of analgesics, 69
J. L. Houpt, F. J. Keefe, and M. Trainor Snipes
even when narcotic abuse is not a problem. Some patients have shown considerable improvement by simply offering a steady analgesic blood level. The use of antidepressant drugs is quite common even in patients without endogenomorphic depression. In our experience, two categories of patients must be recognized. The first group of patients are those who have a major depressive disorder in which the pain represents one of the symptoms of the depression. They are in a minority. These people tend to respond to the usual therapeutic levels of tricyclics and the pain improves as the depression does. However, there are a larger number of patients who simply have chronic pain disorders with a certain amount of dysphoria and without endogenomorphic depression. In our experience, these patients respond in 2 or 3 days to low doses (about 75 mg of amitriptyline) of antidepressants. Our experience seems to suggest that amitriptyline has some superiority over other drugs, but this is obviously open to investigation. Haldol and other neuroleptics have been suggested in chronic pain disorders as well. Given the chronic nature of the pain disorder, we are reluctant to do this because of the potential hazard of tardive dyskinesia. Only in those circumstances when there has been previously severe narcotic use and no response to tricyclics, has Haldol been added. For a more extensive discussion of these issues, see the paper by France et al. in this section. Individual psychotherapy is used selectively. Major indications involve those patients for whom their psychopathology interferes with the ability to participate in the program. As mentioned earlier, some of these patients are not accepted into treatment initially; others, however, are accepted and then with improvement, dormant conflicts become more readily accessible. In these cases, individual and/or family psychotherapy is utilized.
Discussion Formal evaluation of the program is in progress. Certain preliminary findings suggest the program’s efficacy. Most patients show a decrease in pain
70
behavior and medication intake and an increase in activity level after 7 days of admission to the ward. Our length of stay has decreased from 3% to approximately 2 weeks, with the same apparent results. Whereas patients are discharged prior to a level of stabilized improvement, there seems to be continued improvement for 6 months after discharge. Physician approval and nursing acceptance has been good as well. However, a cautionary note is required. These patients are depressed and demanding at times. There is an enormous weight placed on the nursing staff as well as the physicians and consultants who care for these patients. This is particularly true for staff who are accustomed to utilizing insight in their dealings with patients, and who now cannot engage the patient in that manner. Finally, this approach to treating chronic pain patients raises issues relative to PSRO reviews and reimbursement by third-party payers. PSRO reviewers tend to perceive inpatient stays of medical disorders only in terms of physical decompensation or stabilization. Attempts to actively treat chronic disorders require discussion with the reviewers. Finally, reimbursement problems arise with thirdparty payers. Stated most simply, patients on psychiatric wards must display psychiatric disorders in order to receive benefits; also, psychiatric benefits are frequently less than medical ones; certain patients may be, therefore, unable to receive care. Whereas the total functional disability is obvious in these patients, the degree contributed by the specific psychiatric component is often not that dramatic, thus creating problems for reimbursement. Both of these latter issues are best handled by appropriate progress notes that document what is being done and why it is being done, as well as discussions with the persons involved. Direct reprint requests to:
Jeffrey L. Houpt, M.D. Department of Psychiatry Emory University School of Medicine Room 162-A, Georgia Mental Health Institute 1256 Briarcliff Road, N. E. Atlanta, Georgia 30306
Deparfment
of Psychiatry,
Emory School of Medicine
Francis J. Keefe, Ph.D. Assistant
Professor,
Department
of Psychiatry,
Mary Trainor Snipes, Head Nurse, Clinical Specialty
Duke Medical Center
R.N. Unit, Duke Hospital
The authors describe a 25-bed psychiatry inpatient unit, the Clinical Specialty Unit (CSUI, designed to treat patients with chronic pain syndromes. They argue that the use of psychiatry beds for this purposeis appropriate, given the nature ofthe chronic pain disorder, but is not without its liabilities. The administrative structure and roles of the multidisciplina y team are described. Abstract:
Pain is the most common symptom for which people seek medical care; thus, attempts to alleviate it are the physician’s most frequent task. Pain, as a chronic symptom, becomes a disorder of its own. Chronic pain often persists long after what might be predicted from the initial physiologic insult. Modalities effective with the acute symptom of pain are often ineffective with chronic pain, and the effects of cumulative ineffective treatments add to the patient’s discomfort. From a psychologic perspective, the individual responds by attempting to incorporate the significance of the pain into his Responses of family, emmental functioning. ployers, insurance agencies, and the courts, in some instances, further influence this process. When confronted with a chronic pain patient, the physician must apply many lenses to the clinical situation in order to bring it into focus. Most commonly, these lenses include definition of the preC;ozeri~i Hqvtd
incapacity, the correspondence of the physiologic incapacity with known syndromes, the behavioral patterns surrounding the pain disorder, the degree and quality of affective disturbance, the range of family involvement, the impact of disfinancial standing, and proability settlements, spective litigation, as well as the patient’s personality dynamics. Given the complexity of the patient’s disorder, treatment is multidisciplinary. This paper describes the administrative structure and program of an inpatient unit designed to treat patients with chronic pain: the Clinical Specialty Unit (CSU). This 15-bed ward is Iocated on the Psychiatry service in Duke Hospital. The remainder of this paper outlines the rationale, administrative structure, and the research and treatment program of this ward.
Rationale The impetus for the CSU was initiated by faculty members working in consultation-liaison psychiatry who desired an inpatient ward for treatment and research. As a result, it was decided to develop an inpatient unit to treat chronic pain syndromes. Utilizing psychiatry beds for chronic pain patients has both positive and negative consequences. On the positive side, the use of psychiatry beds
Pzyc-lr~ufr,y 6, 65-713, 19X4
Elsevier Science Publishing Co., Inc. 1984 52 Vanderbilt Avenue, New York, NY 10017
C
sent physiologic
65 ISSN0163.X343:84/$3.00
J. L. Houpt, F. J. Keefe, and M. Trainor Snipes
meets several requirements: 1) behavioral and psychotropic interventions can be provided, 2) a length of stay can be arranged that is generally longer than one on medical or surgical wards, 3) the experience of psychiatrists in coordinating care can be utilized, 4) the expertise of psychiatric nurses can be used in developing a milieu, and 5) various medical consultants are available. However, by locating the unit on Psychiatry, certain potential problems are also raised. The most important is the patient and the family’s insistence that their pain problem be perceived as a physical disorder and their consequent expectation that the approach to treatment be consistent with the general approach taken with medical patients. A second problem involves third party reimbursement and peer review, which is discussed at the end of this paper. Given both these positive and negative concerns, the ward was developed as follows.
Administrative Structure A psychiatrist serves as medical director of the unit and the nursing staff is comprised of psychiatric nurses. A psychologist with special expertise in behavioral approaches consults and coordinates the pain management program. A psychiatrist acts as the patient’s primary physician and consults with anesthesiologists, neurosurgeons, internists, and other specialists. Psychiatric residents provide house staff coverage. Patients are referred for inpatient care from various medical and surgical specialists, the Duke Pain Clinic, or the Duke Behavioral Physiology Lab. The Pain Clinic is a diagnostic outpatient clinic whose staff includes anesthesiologists, neurosurgeons, and psychiatrists. The Behavioral Physiology Lab provides feedback and other behavioral approaches to a wide range of disorders. This lab is staffed with faculty from medical psychology. When the patient is referred from a Duke clinic or physician, the referring physician becomes the consultant and the psychiatrist assumes the primary care function. The ward is called the Clinical Specialty Unit to encourage greater acceptance by the patient and the family.
Research Program A committee was formed comprised of several of the attending psychiatrists, the consulting ward psychologist, and the head nurse. This committee reviews all research proposals for scientific merit,
impact on the milieu, and the cost implications. In order to meet cost concerns, all studies must be consistent with effective treatment approaches and cannot delay the patient’s discharge. As a result, much of the research is carried out during the initial assessment phase (for example, correlations between biologic and psychologic indicators of depression and pain, evaluation of pain behavior patterns, etc.). Groups of patients are recruited by faculty who work as collaborators in research.
Treatment Program Assessment Phase Nursing, Psychology, Anesthesiology, Neurosurgery, Orthopedics, Physical Therapy, Recreation Therapy, and other medical consultants all participate in developing the treatment plan. The following section outlines the general nature of their input. Nursing. Nurses provide information on the patient’s pain-related behavior, baseline use of medications, interactions with other patients on the ward, family interactions, and observations relative to depression or psychiatric disorders. Because the nurses observe patients in a variety of settings, their observations are most pertinent relative to pain behavior. They observe for grimacing, guarding, bracing, and rubbing. Since patients also keep their own records of these behaviors, nurses’ observations can be compared with those records kept by the patient. Impressions as to whether the level of pain behavior is disproportionately high and whether patients show more pain behavior in certain situations or not are also noted. Nurses also record the baseline measures of medication intake, and include in that assessment the patient’s behavior regarding the use of pain medication. They observe for the type and quality of interactions with other patients on the ward as well as with the family. They also report on affective states, mental status changes, or other cognitive and psychomotor signs of depression. Psychology. Psychology provides a behavioral analysis of the patient’s problem as well as psychometric testing. The behavioral analysis includes a description of coping skills and physical functioning, a video-taped assessment of pain behavior, and a review of the patient’s activity records. Psychometric testing includes the h4MPI and self-re-
Clinical Specialty Unit
port measures of mood. This assessment is described in greater detail in the paper by Keefe and Bradley in this section. Anesthesiology/neurosurgery/orthopedics. Physicians representing one or more of these specialties evaluate all patients, depending on the preadmission workup. Particular attention is paid to whether nerve blocks, transcutaneous or implanted neurostimulators, or more definitive surgical procedures are indicated. The use of these modalities are described in greater detail in the paper by Urban in this section. Physical therapy. These evaluations focus on posture, mobility, and muscle strength. They provide a baseline from which progress can be defined, and outline physical approaches to improving the patient’s functional capacity. Recreation therapy. This assessment concerns itself with the recreational activities of the patient during the hospital stay as well as his use of leisure time prior to hospitalization. Activities are geared to targeted physical capacities. Within this realm, discharge planning begins immediately since the assessment is aimed at determining the degree of progress necessary in order for the person to resume leisure activities upon discharge. Other provided needs.
consultations. Other consultations are dependent upon the patient’s individual
Psychiatry. The psychiatrist assesses the patient’s intrapsychic and interpersonal dynamics, his need for psychotropic medication, and whether or not drug addiction is a problem for the patient. In addition, the psychiatrist performs a coordinating function by calling a team meeting at the end of the formal assessment period. The goals of the treatment plan are outlined to the patient on the CSU in a straightforward manner, just as a course of steroids or other medical treatment might be outlined to a patient on medicine or surgery. The patient is encouraged to participate in setting the goals for treatment and an attempt is made to outline the anticipated length of treatment. Provisional plans for discharge are discussed at this meeting as well. If the patient is considered either unwilling or unable to make a commitment to the required treatment plan, the patient may be discharged at this time. In contrast to standard operating procedures
on some psychiatry inpatient units, the length of stay is not usually extended for the purpose of overcoming patient resistence to the treatment program.
Treatment
Phase
Nursing. The primary function of nursing is to create and support a carefully designed milieu. Within this milieu, nurses carry out conventional nursing roles and functions, as well as ones specialized in the treatment of this population. Conventional nursing functions include carrying out treatments, administering medication, and charting and making observations. Nurses continuously assess the patient’s compliance with all aspects of his program. An attempt to develop a relationship with the patient serves as a means for enhancing patient compliance. Certain nursing functions are specific to the nature of the problem treated on the ward, and are in contrast to nursing roles on traditional psychiatric services. For example, patients may be encouraged to rest in bed and many of the physical tasks necessary for personal hygiene or the making of beds are performed by the nurses rather than the patients. Nurses tend to respond more directly to patient inquiries and deal less with the latent meaning in patient communication. Nurses take an active role in explaining the nature of the ward and, particularly regarding admission, the reason that the pain ward is a psychiatry ward. As a relationship develops with the patient, nurses encourage their patients to problem solve, improve communication skills, and understand the relationship between stress and pain; the nurse actively rewards desired behaviors. All of these approaches are considerably more active than the usual posture assumed by most psychiatric nurses on traditional psychiatry wards. Psychology. The ward’s consulting psychologist is actively involved in implementing behavior therapy techniques. Both operant conditioning and self-control techniques are used. While these techniques are considered in more detail in the paper by Keefe and Bradley, the practical applications of these principles are highlighted here. The working hypothesis supporting the operant conditioning approach is that the patient’s pain behaviors are maintained by social consequences (e.g., attention from a solicitous spouse or family, avoidance of unwanted work or home respon67
J. L.
Houpt, F. J. Keefe, and M. Trainor Snipes
sibilities) rather than underlying tissue damage. Operant conditioning methods are used for patients who a) have minimal or no physical findings to account for their pain, b) show a disproportionately high level of pain behavior, c) demonstrate dramatic variability in behavior from one time to another, d) are extremely inactive (less than 5-6 hr per day out of bed) and, e) are dependent on pain medication. In order to modify pain behavior patterns using operant conditioning, the social consequences for pain and “well behaviors” are manipulated on the ward. Our operant conditioning programs focus on two goals: 1) increasing activity, and 2) decreasing narcotic intake. Patients are placed on a structured activity program in which they are required to be up and out of bed during a scheduled number of minutes per hour. Time spent up and out of bed (uptime), leads to attention and praise from nursing staff and other treatment team members. The uptime goals are increased slightly each day. By avoiding high levels of activity, the likelihood that patients will exhibit excessive pain behavior is reduced. If pain behaviors do occur, they are given minimal attention. Medications are also given in a “pain cocktail” (see below) that is delivered on a time-contingent basis rather than linked to a pain complaint (PRN). As patients progressively become more active, the social reinforcement for well behavior is decreased. At this point, patients are expected to take more responsibility for their treatment program and they typically begin to participate more fully in self-control programs designed to teach them how to do so. Self-control methods are useful for a broad spectrum of chronic pain patients. These methods attempt to teach patients how to exert control over their own behavioral, affective, and physiologic reactions to pain. In order that these methods work, patients must have the resources and motivation to attend to and practice training procedures. Training in self-control is carried out in two major settings: the Biofeedback Lab and the Pain Management Group. Biofeedback training is carried out by a trained technician in a lab on the unit. In biofeedback training, patients are trained to recognize and modify inappropriate anxiety and muscle tension responses associated with simple movements. EMG biofeedback training is used to heighten the patient’s awareness of muscle tension. Biofeedback is coupled with progressive relaxation training in order to reduce anxiety responses. Records kept by patients over the course of training help them chart progress in learning to relax in the specific situations (e.g., sitting, walking, standing) with which 68
they have difficulty. These records are reviewed daily and help correct patients’ distortions about their own performance capabilities. The records encourage them to focus on positive signs of progress. The Pain Management Group is a structured behavior therapy group designed to train patients in how to define, measure, and change daily activity patterns affected by pain. The group involves a series of 10 sessions plus follow-up (Alumni) meetings aimed at helping patients initiate and maintain behavior change. Table 1 depicts the topics covered and typical homework assignments. Assignments are reviewed in the group at each session. The Table 1. Pain management group Topic outline Homework Session #
assignment
Topic Introduction overview
&
Defining the problem
Measurement methods
Analysis of baseline data Overview of four behavioral treatment options
Positive reinforcement
Activity-rest cles
cy-
Cognitive pain control strategies
Write a description of activities in a typical day prior to hospitalization Write a definition of a behavioral problem to be targeted for modification Choose and begin to use a method to measure the target problem Graph data that has been collected Select one treatment approach and begin applying it on a daily basis Draw up a list of positive reinforcers that can be used to facilitate behavior change Write a description of how brief rest periods can be used to facilitate behavioral improvement Practice with several cognitive strategies
(continued)
Clinical Specialty Unit
Table 1. (Continued)
Session 9 10
11
#
Topic Review of patient projects Establishing a home pain management program Alumni group meetings (postdischarge)
Homework assignment Continue treatment Write an activity schedule for a home program Bring home records review
emphasis is not so much on what patients say about their pain, but on what steps they are taking to alter daily coping patterns. Typical behavior-change goals worked on by patients in the group include increasing the tolerance for sitting or standing, and time spent in social acpleasant activities, tivities, as well as in decreasing nighttime sleep problems. The patient’s self-control is consistently emphasized by encouraging patients to make their own choices as to target problems, measurement methods, and treatment strategies. Spouse and family members are encouraged to attend group sessions with patients. At the end of hospitalization, patients “graduate” from the group and are encouraged to attend an “alumni meeting” of the group at follow-up. These alumni meetings provide an excellent opportunity to review home compliance with treatment recommendations with the patient and family members.
Anesthesiology/neurosurgery/orthopedics. Several patients have received nerve blocks or transcutaneous stimulators while on the CSU. The paper by Urban reviews these procedures in greater detail. Patients are not transferred to surgical units for these procedures; rather, they are done with the patient remaining on the ward. Most frequently, the procedures are done early in the course of treatment, but there are instances where a patient’s depression has been treated prior to one of these procedures on the assumption that the depression would rule against a successful outcome. In a rare instance, treatment of the psychiatric disorder has permitted more accurate assessment of the underlying physiologic damage and major surgery has been done. In keeping with the high utilization of physical procedures, there is no effort on our part to convince the patient that physical factors have been ruled out.
Physical therapy. Patients are seen daily on an individual basis in physical therapy. Most patients show deficits in strength and endurance and are thus placed on aerobic exercise programs involving bicycling, swimming, or walking. Physical measures are also used to attempt to reverse the effects of pain-avoidance posturing on muscle function and tone. Chronic low back pain patients are typically given a series of flexion and extension exercises designed to stretch, mobilize, and strengthen muscles affected by pain. Patients having chronic pain affecting other body areas are given similar exercises appropriate to their problems. Modalities used to decrease muscle spasm include heat, transcutaneous electrical stimulation, and ultrasound. A central component of all physical therapy interventions is education of the patient about the relationships between posture, exercise, and pain. With such education, the patient is taught to assume greater responsibility for managing the effects of pain on their physical condition. Recreation therapy. For most patients, recreational therapy is a means of increasing their involvement in a much wider range of pleasant activities. For others, it may be a social laboratory to try out new behaviors and communication skills. Still others may find that physical activity may aid in tension release, weight control, or general fitness. The recreation therapist for the CSU participates in the team conferences as an active team member. Psychiatry. The psychiatrist’s major function is that of coordinating the overall care of the patient, prescribing the psychotropic medication, and in selected instances, pursuing individual or family psychotherapy. Pharmacotherapy is a major facet of treatment on the ward. Addiction is present in approximately 20% of the patients seen; thus, attention is directed at this problem. Most addiction problems are treated with a pain cocktail that consists of an analgesic issued in cherry syrup. After a baseline analgesic requirement is determined, it is then incorporated into the syrup and decreased slowly over time. The patient is told that his narcotic will be decreased, but not the rate at which it is done. Withdrawal generally occurs at a rate slower than physiologically required and often takes two weeks. The addition of antidepressants or Tylenol with Vistaril have been useful as an adjunct while withdrawal is taking place. Pain cocktails are often used as the prescribed means of getting a steady blood level of analgesics, 69
J. L. Houpt, F. J. Keefe, and M. Trainor Snipes
even when narcotic abuse is not a problem. Some patients have shown considerable improvement by simply offering a steady analgesic blood level. The use of antidepressant drugs is quite common even in patients without endogenomorphic depression. In our experience, two categories of patients must be recognized. The first group of patients are those who have a major depressive disorder in which the pain represents one of the symptoms of the depression. They are in a minority. These people tend to respond to the usual therapeutic levels of tricyclics and the pain improves as the depression does. However, there are a larger number of patients who simply have chronic pain disorders with a certain amount of dysphoria and without endogenomorphic depression. In our experience, these patients respond in 2 or 3 days to low doses (about 75 mg of amitriptyline) of antidepressants. Our experience seems to suggest that amitriptyline has some superiority over other drugs, but this is obviously open to investigation. Haldol and other neuroleptics have been suggested in chronic pain disorders as well. Given the chronic nature of the pain disorder, we are reluctant to do this because of the potential hazard of tardive dyskinesia. Only in those circumstances when there has been previously severe narcotic use and no response to tricyclics, has Haldol been added. For a more extensive discussion of these issues, see the paper by France et al. in this section. Individual psychotherapy is used selectively. Major indications involve those patients for whom their psychopathology interferes with the ability to participate in the program. As mentioned earlier, some of these patients are not accepted into treatment initially; others, however, are accepted and then with improvement, dormant conflicts become more readily accessible. In these cases, individual and/or family psychotherapy is utilized.
Discussion Formal evaluation of the program is in progress. Certain preliminary findings suggest the program’s efficacy. Most patients show a decrease in pain
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behavior and medication intake and an increase in activity level after 7 days of admission to the ward. Our length of stay has decreased from 3% to approximately 2 weeks, with the same apparent results. Whereas patients are discharged prior to a level of stabilized improvement, there seems to be continued improvement for 6 months after discharge. Physician approval and nursing acceptance has been good as well. However, a cautionary note is required. These patients are depressed and demanding at times. There is an enormous weight placed on the nursing staff as well as the physicians and consultants who care for these patients. This is particularly true for staff who are accustomed to utilizing insight in their dealings with patients, and who now cannot engage the patient in that manner. Finally, this approach to treating chronic pain patients raises issues relative to PSRO reviews and reimbursement by third-party payers. PSRO reviewers tend to perceive inpatient stays of medical disorders only in terms of physical decompensation or stabilization. Attempts to actively treat chronic disorders require discussion with the reviewers. Finally, reimbursement problems arise with thirdparty payers. Stated most simply, patients on psychiatric wards must display psychiatric disorders in order to receive benefits; also, psychiatric benefits are frequently less than medical ones; certain patients may be, therefore, unable to receive care. Whereas the total functional disability is obvious in these patients, the degree contributed by the specific psychiatric component is often not that dramatic, thus creating problems for reimbursement. Both of these latter issues are best handled by appropriate progress notes that document what is being done and why it is being done, as well as discussions with the persons involved. Direct reprint requests to:
Jeffrey L. Houpt, M.D. Department of Psychiatry Emory University School of Medicine Room 162-A, Georgia Mental Health Institute 1256 Briarcliff Road, N. E. Atlanta, Georgia 30306