Motivational Interviewing, PTSD and Pain | Episode 201

I sat down with Dr. Joseph Cabaret MD and Dr. Kenneth Carle MD at the 25th anniversary meeting of the American Society of Interventional Pain Physicians (ASIPP). We talked about pain, addiction, PTSD and Motivational Interviewing, an evidence-based approach to behavior change. I think pain specialists will find our discussion useful.

Dr. Cabaret:

My name is Joe Cabaret. I'm an interventional pain specialist with an anesthesia background. I'm also board certified in addiction medicine by the American Board of Preventive Medicine. I practice in Camarillo, California, and I'm primarily an interventional pain physician. I don't really have an addiction practice, but I do treat some patients who come in identifying with substance use disorder. 

Dr. Hansen:

That's an important distinction to make. We are not multi-specialty. We're just resilient and have a practice that is malleable that can address different aspects of what walks through the door. 

Dr. Cabaret:

I think anybody who's prescribing a controlled substance would be well served with a little bit of education about addiction medicine because these are substances that can be problematic whether there's a substance use disorder or not. 

They lead to dependence and tolerance which is a tough place to be. The drug you're taking is making your pain worse, but you can't stop taking it. My background in addiction medicine helps me to manage patients who are taking controlled substances for their pain. 

Dr. Cabaret:

I’m a pain specialist, that’s my day job. My addiction background coming in and contaminating, or should I say enhancing, my interventional pain practice. 

I think that when a patient comes through the door, when I first meet a patient who's identifying as a pain patient, coming in and saying, I'm here for treatment of my chronic pain or my acute pain. I'm living with pain and I need help. 

It behooves us, to first and foremost, before we do anything else, try and stratify that patient in terms of their psychosocial, spiritual spectrum. Where are they on the spectrum between purely central pain and purely biomechanical peripheral pain? Most people are somewhere on that spectrum. Very few are purely one or the other. And it’s like a VAS score, you know, go from 0 to 10.  

That's the visual analog scale. That's something that sometimes pain doctors use. I'm not sure how advisable it is to use it. But nonetheless, it's one way to try and stratify a person's pain, 0 being no pain and 10 being the worst pain you could possibly imagine. 

We use a line on a piece of paper and we kind of make a mark. We ask the patient to make a mark. 

Dr. Hansen:

How long is that line? 10 centimeters. Supposed to be, it's not really. How come everybody's a 10 over 10, or 11 over 10?

Dr. Cabaret:

Why are patients 11 over 10? Because they're trying to tell you something. If the scale goes up to 10 and they're saying 11, that doesn't make any sense. And there's a lot of reasons why they might say 11 out of 10 while they're sitting there comfortably with their legs crossed discussing their pain with you. 

When you say 10 is the worst pain you can possibly imagine, we're talking you are screaming at the top of your lungs like in a horror movie or getting your legs chopped off with a chainsaw. That's a 10.  

That's why I say that this visual analog scale or numeric rating scale is another way where you use numbers is really kind of limited in its value but pain is subjective. It's hard to really get an objective measurement so we rely on these subjective reports. I think with a lot of patients who are identifying with 11 out of 10, there's other factors influencing that. They're not just describing their pain. They're trying to achieve other goals with that. 

Dr. Hansen:

Yeah, they are. And those can be something that require a walk down the curiosity pathway. What is a curiosity pathway? You're not trying to figure them out. They are patients that come to you with difficult problems. What you're trying to figure out is a complex problem. You can't see, touch, feel, or measure. And that's called pain!

Dr. Cabaret:

This feeds right into what I was talking about, Hans, central pain. We're talking about complex pain.

This isn't just I dropped a bowling ball on my foot and now my foot hurts. These are patients who are living with pain chronically and develop sometimes something called chronic pain syndrome. 

Sometimes they have predisposing factors prior to developing pain that enhance the distress that they feel about their symptoms. 

I'm talking about distress management. If you come to my office it says “interventional pain doctor” on the door. But perhaps it really should say “distress doctor”, “distress specialist”. We're not treating pain. We're treating distress related to pain. People come to the doctor because they're in distress about their symptoms. 

Dr. Hansen:

Well, is it pain or distress? 

Dr. Cabaret:

Well, it could be both, but how much of each? Is it just a biomechanical peripheral pain generator in a perfectly healthy person without any substance use disorders, without any mental health issues, perfectly well-adjusted socially, and spiritually healthy. That person doesn't really exist, but that would be the extreme example of someone with purely biomechanical pain. 

Dr. Hansen:

There you have somebody in distress. Distress comes in a lot of ways. Situational depression, anxiety, and PTSD. I know you talk about that. What is that? 

Dr. Cabaret:

I think that many of our patients have undiagnosed PTSD. 

If you take a fluoro image and show that to a lay person and say, show me the right L3 transverse process, they are not going to be able to point to it. 

If you're looking at a very osteoporotic patient, I might not even be able to see it. 

But if I know I'm looking for it, I find it. If I know what it looks like and where it should be, what it should be, we call that anatomy by expectation. I can look at that image and say there it is, I see it, because I'm looking for it, and I know what I'm looking for. 

That is similar with PTSD in our practices. A lot of patients are coming in with distress, in many cases related to a history of PTSD, especially adverse childhood experiences. 

They're bringing that distress. They were overwhelmed at some point in their lives emotionally, and it caused dysfunctional coping mechanisms and now they're bringing that to everything in their life. If they miss the bus, it's a catastrophe. If they have a personal conflict, it's catastrophic. When they have symptoms, painful symptoms, it's catastrophic. 

Dr. Hansen:

They call that catastrophizing symptoms. What a word. But you call it a spectrum disorder, probably. 

Dr. Cabaret:

Yes. This is part of that spectrum that I was discussing earlier where I think it behooves us to really sort of try to identify, and it's a fluid thing. 

At each visit I'm constantly present and adjusting my differential diagnosis on every patient. I think this should be part of our differential. We should be considering this before we consider all of our biomedical interventions that we have. 

This is also skewing the results of our studies. If I did a cataract surgery on every person who walked through the door, I probably wouldn't be able to produce very good evidence for cataract surgery being something we should do. You have to select the patients who need a cataract surgery. 

It's the same thing here. If someone comes in with pain in their foot, and I put some kind of device in to manage that on every single patient, the outcomes aren't going to be that good. We are shooting ourselves in the foot here with trying to treat everything like a nail, and we're just a hammer. 

Dr. Hansen:

That's true. So, we have a patient walk through the door, and they're 10 over 10, and we don't even know what that means. On the Mancoski scale, that is the worst pain you could possibly have. I mean you're almost unconscious. 

Or the patient comes through the door and every time they visit you they're 5 over 5. Well I just started treating him, I’ve been doing injections, I’ve been giving him medication, but your pain scale hasn't changed. What do we make of that?

Dr. Cabaret:

I don't know what to make of that, Hans. I think in each individual case, it's my job to try and understand what to make of that. That's on a case-by-case basis. 

Dr. Hansen:

You're exactly right. We look at function, quality of life, restorative sleep capacity, endurance, and range of motion. Maybe you can’t ask someone if they can touch their toes, but you can ask someone if they like to go to the grocery store, if they like to enjoy the grandchildren. But the question set, the experience that you want, is very different than sometimes what's so obvious. You're right, you individualize it, don't you? 

Dr. Cabaret:

Now I'm going to that crossover again between addiction and pain, and I agree with you, Hans, that addiction and pain are cousins. They're very similar in the way they behave. I'm talking about chronic pain right now. 

In the addiction medicine world, we have these criteria, placement criteria, treatment criteria. Based on certain patient characteristics, we use those criteria to place the patient in the appropriate level of care.

That might be in a hospital, or that might be at an outpatient intensive outpatient treatment plan program. I think something like that could apply to pain medicine as well. 

A person comes through the door and you're synthesizing all of this information, as much information as you can get about that patient:

• addiction risk screening tools
• history of mental illness
• family history of addiction
• family history of mental illness
• functional scores (whatever functional criteria you're using)
• urine screens
• Prescription Drug Monitoring Program (PDMP) reports
• diagnostic reports 
• the way you experience that patient

You are trying to formulate a stratification of that patient. 

Two patients are coming in with right foot pain, that's eight out of ten, and I might treat one patient completely differently than I treat the other patient based on these other factors. 

Dr. Hansen:

You're right. You examine history and physical. It all keeps coming back at us.

Dr. Hansen:

I'd like to introduce another physician.

Dr. Carle:

Hi, I'm Kenneth Carle. I'm a private practitioner in interventional pain medicine in Baltimore, Maryland. 

So the post-traumatic stress syndrome, I agree. Patients have a lot of psychological overlay. It's not just the pain. So what are some of the strategies you use to help the PTSD? Are there certain medications? 

Dr. Cabaret:

First of all, the main thing is picking it up. First I have to identify it. I've gotten to the point where as soon as I walk in the room, I can see hypervigilance. I can see patients who look more anxious. You can pick up a lot of psychosocial overlay quickly. 

The next thing to do, and I've talked a lot about motivational interviewing over the last few days, is try to get that patient to link their symptoms with their history of trauma. That's not an easy thing to do. 

They really love their MRIs. They love what previous physicians have diagnosed them with. They hug those diagnoses and those diagnoses hug them back. It does something for them. And so trying to rip those out of their hands is a difficult thing to do. And you don't necessarily have to. But you do have to sort of, over time, get them to link their distress over their symptoms to their history of trauma.

Dr. Carle:

It does take time, a lot of time. It takes getting to know the patient and their history and their current lifestyle, their past lifestyle. At what point do you feel like you might need some help from a psychiatrist or a psychologist? 

Dr. Cabaret:

I like to get a psychologist involved early on if I can, the right psychologist. I like a psychologist who is trauma informed and who knows how to use tools like EMDR (Eye Movement Desensitization and Reprocessing).

There are other techniques as well, but that's a simple one that can be done in a room with two people, and it can be done with tapping or with sound or with visual cues. 

It's something, a way for people to process their trauma in a safer way, in a way where they're able to dive deeper into painful memories that many of them haven't confronted for years. They're terrified to go there. 

I do like to get others involved, but there's a lot I can do without involving other specialists. The biggest hurdle is getting them to connect their trauma to their current symptoms. 

This is where motivational interviewing comes in. This is where patience comes in. I think a lot of us, including myself, we're looking for events in our lives, such as oh, do that epidural and take my pain away. Or, I want an event to come in and save me. I don't want to get involved in some lengthy process. 

Unfortunately, for a lot of our problems in life, the solution is a lengthy process, a lifelong process. If you do have PTSD, especially adverse childhood experiences, it is a lifelong process. You're never going to graduate from that program. 

Dr. Carle:

Joe, you mentioned motivational interviewing. Can you explain what that is?

Dr. Cabaret:

Motivational interviewing is a technique and they use it a lot in psychiatric medicine and addiction medicine. It can be used for any encounter you have with another human being. 

It's really sales 101. It's a way to lead people to change in behavior. The concept is you have to make it their idea to change. If I sit there and point at you and say, listen, you have got to change. People tend to put up resistance. 

There is a big thick book written by a guy named Miller. It's very dry and difficult to read, but there are a lot of online resources you can get. This works with husbands and wives and kids and patients. It works if someone isn't taking their insulin. It's a way to lead people to healthier choices by making it their idea to change. 

It involves stages and recognizing stages of change and behaving, meeting the patient where they're at. Based on where they are in terms of readiness for change, you behave differently. When you see that they are ready to make a change, you pounce.

Dr. Carle:

Yeah, I think that's going to be very valuable for me to instill in my practice. 

Dr. Hansen:

The fact of the matter is that each patient is an individual, right? They have pain, and we have to understand how it affects the brain, how it affects the stress they're experiencing. But most importantly, it is a spectrum. You’ve got to use the right interview techniques. You must end out a very short visit with goals in mind. In three, six, nine, and 12 months where are you going to be? If you don't reach those goals, you need to know why. 

Dr. Cabaret:

Kenneth asked me a really good question about what can we do if we identify PTSD or other psychosocial overlay in a patient. We can refer them to psychologists, trauma-informed psychologists, but we can also use a lot of things in our office. 

Our own personalities are oftentimes the treatment plan. I have tons of handouts in my office about meditation, handouts about books that I recommend, such as a book on trauma The Body Keeps the Score. Another book is Healing Back Pain by John Sarno.

I have tons of other resources that take me a second to hand to the patient and say, I think this is an important part of your treatment plan. It's going to enhance everything that I do. I tell them that it's best if we work as a team. You're the captain of the team and I'm the coach. If we work together, there are things I can do to make your pain go as low as possible, and there are things you can do to learn to cope with the pain that you have. If we meet in the middle somewhere, we get the best results. 

Dr. Hansen:

Thanks, Joe and Ken. We look forward to having you on again. This complex world we live in is pain, addiction, depression. It's so many things. And I can tell you, when we learn motivational interviewing, and we understand and recognize PTSD early, we get a handle on these tough problems that we have in pain medicine. We understand them as qualified pain professionals do, with the added credentials of addiction, that is a huge plus. We get places where we can use interventional procedures, and we can decrease the opioid load. 

It all comes to the best outcome to improve quality of life, just a better day and a better place to be. I thank you both for your work and everything you do.