Healing Tool Series: Integrating Self-Management Training to Prevent or Relieve Chronic Pain and Addiction

Online training program and massive open online course (MOOC; free or with a CEU fee) for patients and providers to integrate self-management with evidence-based treatment in transformative chronic pain care.

“Healing Tools” summaries are a collection of evidence-based resources to help providers and patients use integrative health approaches to improve health and well-being.

This tool is for:

These tools was created by:

  • James Fricton, DDS, MS, with faculty and clinicians from the University of Minnesota, Minnesota Head and Neck Pain Clinic, HealthPartners Institute, the International MYOPAIN Society, and grant support from the National Institutes of Health

SUMMARY

Chronic pain is the #1 reason patients seek medical care and the #1 cause of disability and addiction. The highest driver of health care costs, chronic pain costs more than cancer, heart disease and diabetes.[1]

More than half of all patients with pain that lasts more than 30 days still have pain 5 years later, despite treatment.[2] This leads to higher-risk treatments such as opioids, multiple drugs, surgery, or extensive medical and dental treatment.[3]  

Not addressing patient-centered risk factors is the primary cause of chronic pain. These risk factors include poor ergonomics, repetitive strain, inactivity, prolonged sitting, injury, stress, sleep disorders, anxiety, depression, abuse, and many others.

Role of Providers in Self-Management

The Institute of Medicine, the National Pain Strategy, the Institute for Clinical System Integration and other health care leaders recommend integrating self-management into clinical practice to prevent chronic pain and addiction.[5]

Providers’ primary role in chronic pain should be guiding, coaching and assisting patients in self-management, according to the Institute of Medicine.[6] This rarely happens, however, due to lack of reimbursement, lack of time, inadequate training skills, lack of care coordination, fragmented care, poor communication and conflicting treatments.

Both the Personalized Activated Care and Training (PACT) program and the Preventing Chronic Pain: A Human Systems Approach course are designed to overcome these barriers. Dr. Fricton calls this “a transformative model of health care” that integrates self-management training with evidence-based pain treatments to transform the patient and the health care system.

Personalized Activated Care and Training (PACT) Program for Patients

PACT is an online program to relieve and prevent chronic pain by engaging, empowering and educating people to reduce their risk factors and promote protective actions. The eight-week program consists of:

  • Assessments: Patients evaluate the location and severity of their pain and their use of health care; risk factors, protective factors, and self-management skills; readiness to change; and self-efficacy.
  • Training: Experiential lessons to reduce risk factors and promote protective factors are based on the assessments.
  • Telehealth coach: A certified health coach reviews the assessments and supports the goals of self-management training to help patients stay motivated, and understand and complete PACT. Many health plans are supporting health coaching. Some patients may have to pay a fee for coaching.

PACT has nine modules. Modules 3-9 explore the seven realms of life that can play a role relieving and preventing chronic pain:

  1. Understanding pain
  2. Initial self-care for specific pain conditions
  3. Mind: Thoughts and attitudes
  4. Body: Physical structures and their function
  5. Lifestyle: Daily behaviors
  6. Emotions: Feelings
  7. Spirit: Purpose and energy
  8. Social life: Relationships
  9. Environment: The world we interact with

Each module has:

  • A self-assessment
  • Recommended 10- to 15-minute video lessons
  • A story to illustrate the concepts
  • An action plan
  • A calming relaxation lesson
  • Guides for quick review
  • Worksheets

Patients develop an action plan for each module focused on:

  • Healthy HABITS:
    • Taking time each day to work on enhancing protective actions in order to decrease risk factors. Protective actions include activities such as exercise, sleep, diet, healthy substance use, balanced posture, activity level, optimism, positive emotions, and safe living.
  • Daily PAUSEs:
    • Practicing mindfulness by taking a brief time-out to check-in and notice how you are doing right now in a non-judgmental way.
  • CALM practice:
    • Spending a few minutes each day doing a brief relaxation technique, such as meditation to calm the brain, relax the muscles and joints, and sooth the nerves.

How Providers Can Use PACT

Providers complete training in PACT, either through:

  • The Coursera course Preventing Chronic Pain: A Human Systems Approach
  • A one-day certification seminar offered through the International MYOPAIN Society several times a year

Providers then:

  • Inform patients that they will provide treatment, but that the treatment will be more successful if the patients also participate in self-management training
  • Register patients who agree to do the training, and PACT sends each patient an email with instructions
  • Use the PACT dashboard to support patients in self-management and to track their progress and outcomes

Preventing Chronic Pain: A Human Systems Approach, Coursera course for providers

  • Free version
  • CEU available with paid version:
    • Physicians: Up to 24.0 AMA PRA Category 1 Credits
    • Nurses: Up to 24.0 ANCC contact hours.
    • Other health care professionals: Check with the appropriate accrediting organizations or state boards for consideration of credit.

This 10-week online course taught by Dr. Fricton and other faculty enables participants to understand chronic pain and how to apply a human systems approach to self-management strategies to reduce risk factors, enhance protective actions and prevent chronic pain.

Although the course was designed primarily for health care professionals and students, many people with pain also participated. This led Dr. Fricton to develop PACT for patients.

How does this contribute to an integrative approach?

Combining conventional medicine, self-care, and complementary and alternative medicine can help patients achieve optimal healing and health. These tools focus on integrating self-management with evidence-based conventional medicine. PACT helps patients understand the important role they play in managing their pain.

What does the evidence say about this tool?

Systematic reviews of components of PACT and studies of PACT conducted by Dr. Fricton and colleagues provide evidence of the effectiveness of integrating self-management with evidence-based conventional treatment.

Systematic Reviews of PACT components  

Systematic reviews of chronic pain self-management show that training to reduce risk factors and strengthen protective factors has clear, positive outcomes.[7]

Systematic reviews also provide evidence of:

  • Significant improvements in chronic pain with healthy habits[8]
  • Significant reduction of chronic pain with mindfulness-based stress reduction[9] and meditation and relaxation training
  • Improvements in functional recovery from chronic pain with health coaching and social support[11]
  • Engaging, empowering and educating patients in long-term self-management for chronic pain using computer and online interventions[12]

Studies of PACT

An early version of PACT was offered as part of the Coursera course Preventing Chronic Pain: A Human Systems Approach. Dr. Fricton et al. analyzed data from 771 participants with pain who did the online training (93% of whom completed the entire program):

  • 93% of the participants changed their life to improve their pain
  • 85% changed their care plan to include self-management[13]

With funding from the National Institutes of Health’s (NIH’s) National Institute of Dental and Craniofacial Research (April 2016 to April 2017), Dr. Fricton evaluated PACT compared to usual care in 81 patients with temporomandibular disorder:

  • PACT: 40 patients
  • Usual care: 41 patients

Preliminary results (as of September 2017) include:[14]

  • Patients who took PACT showed more improvement in pain outcomes (pain severity, jaw function, and pain interference with daily living) than usual care patients at 8 weeks.
  • PACT was both feasible and acceptable for patients:
    • Patients who took PACT were more engaged (they accessed the program 12 times) than patients who had usual care (they used usual care 5 times).
    • 100% of PACT patients completed the baseline, and 94% completed the 8-week outcome measures.
    • Patients indicated general satisfaction with PACT’s functionality and ease of use and understanding of PACT content.
  • In other research, risk factors at baseline associated with progression in pain at 18 months, included depression, fibromyalgia, muscle-tensing habits, somatization (expressing psychological distress as physical symptoms), and catastrophizing (believing that things are worse than they are).

HealthPartners Institute, where Dr. Fricton is a senior research investigator, received the NIH grant.

Dr. Fricton continues to improve PACT based on the results of qualitative and quantitative research.

What are the drawbacks to using PACT?

  • PACT takes time. Participants must practice healthy habits, pauses, and calming on a regular basis. It is not a quick fix for chronic pain – but it works.
  • Reimbursement for providers to monitor patients enrolled in PACT and to health coaches is variable. Some insurers and health plans cover it and some do not.

Who created these tools?

James Fricton, DDS, MS, a professor of dentistry at the University of Minnesota and a pain specialist at the Minnesota Head and Neck Pain Clinic, developed these tools with other faculty and clinicians based on 30 years of working with pain patients and conducting pain research. The development team included faculty and clinicians from medicine, dentistry, health psychology, nursing and physical therapy at the University of Minnesota.

Dr. Fricton is also a senior research investigator for HealthPartners Institute and the author of five books and more than 150 publications and abstracts.

PACT Program

With funding from the NIH’s National Institute of Dental and Craniofacial Research to HealthPartners Institute, Dr. Fricton developed the PACT program as part of the International MYOPAIN Society’s Campaign for Preventing Chronic Pain and Addiction.

Providers: Preventing Chronic Pain: A Human Systems Approach

Patients: International MYOPAIN Society’s Preventing Chronic Pain website

Sources:

[1] Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC; National Academies Press, 2011.

[2] Institute for Clinical Systems Improvement and research published in Brain Res Rev, Eur J Pain Suppl., Eur Spine J, Journal of the American Board of Family Medicine, Semin Arthritis Rheum, and Pain.

[3] Research published in Brain Res Rev, Eur Spine J, Journal of the American Board of Family Medicine, and Semin Arthritis Rheum.

[4] Institute for Clinical Systems Improvement and research published in Brain Res Rev, Eur J Pain Suppl., Eur Spine J, Journal of the American Board of Family Medicine, Semin Arthritis Rheum, and Pain.

[5] Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC; National Academies Press, 2011; and U.S. Department of Health and Human Services. National Pain Strategy. Accessed September 12, 2017.

[6] Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC; National Academies Press, 2011.

[7] Based on many studies published in journals such as Ann Intern Med, Br J Pain, J of Pain Management, Pain, Pain Week Journal, and Systematic Reviews.

[8] Based on studies published in Ann Intern Med, Bri J Pain, Clin J Pain, Healthcare, Pain, Sleep, and Systematic Reviews.

[9] Based on studies published in Ann Behav Med, J Altern Complement Med. J Psychosom Res, and J Pain Management.

[10] Based on studies published in J Consult Clin Psychol, J Nurs Scholarsh, and Systematic Reviews.

[11] Based on studies published in Br Med J, European J Pain, and Int J Clin Pract.

[12] Based on many studies published in journals such as Ann Intern Med, Br J Pain, J of Pain Management, Pain, Pain Week Journal, and Systematic Reviews.

[13] Fricton, JR, Anderson K, Clavel A, et al. “Preventing Chronic Pain: A Human Systems Approach—Results From a Massive Open Online Course.” Global Adv Health Med. 2015;4(5):23-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4563888/

[14] Preliminary results provided by Dr. Fricton, 9/18/17.

 


ABOUT THESE INTEGRATIVE HEALTH TOOLS

At Samueli Integrative Health Programs, we believe that achieving optimal health and wellbeing requires an integrative health approach—one that combines and coordinates conventional medicine, self-care, and complementary and alternative medicine.

Translating Evidence into Action

The goal of these summaries is to help providers and patients learn about and access evidence-based integrative health tools. Each featured tool has been vetted by Samueli Integrative Health Programs. Read about more Healing Tools.

Disclosures:

Samueli Integrative Health Programs is a public service of H&S Ventures and does not profit from any of the tools featured in these summaries.

Patients: Contact your provider before starting any new health program.  Show him/her these resources.