Behavioral Pain Management for Spine Surgery Patients

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:

It is estimated that 10 to 40% of lumbar spine surgery patients experience persistent post-surgical pain, which leads to emotional distress and impaired quality of life while also increasing healthcare cost. In today's episode, we're discussing a cultural shift to prioritize behavioral pain care and psychological interventions to improve outcomes for spine surgery patients. I'm your host, Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute and joining me for today's conversation is Dr. Sara Davin. Dr. Davin is a psychologist in the Cleveland Clinic Neurological Institute's Center for Spine Health. Sarah, welcome to Neuro Pathways.

Sara Davin, PsyD, MPH:

Thank you. Thanks for having me.

Glen Stevens, DO, PhD:

So Sarah, before we get started with the primary content, tell us a little bit about yourself, how long have you been at the clinic, what your practice is, your interests, those types of things.

Sara Davin, PsyD, MPH:

So I am a psychologist that sees and works with only individuals that have pain conditions and I've been doing this here at the clinic since I finished my fellowship in 2010. And over time, my responsibilities have kind of developed and my interests have developed from treating sort of the most complex chronic pain patients to also really wanting to intervene as early as possible with any individual that has a pain condition, because we know that from a public health standpoint, pain is a big problem and the costs exceed any other health condition combined. So I also have a public health background and it is really a strong interest and passion of mine to target as many people as possible who have pain so that we can reduce the number of people that become inflicted with refractory chronic pain conditions that are just so challenging and can be so devastating, but are also treatable.

Glen Stevens, DO, PhD:

Sarah, I'm so in awe of what you do. I hear a lot of people say to me, "The only pain you can stand is someone else's." And in your situation, you actually are on the other side of that, where you share the pain with the patients. Any particular reason that you are so interested in this particular aspect, I understand the public health part of it, but anything personal on your side?

Sara Davin, PsyD, MPH:

I've always liked a challenge and complex issues and to me, pain is very complex, it's definitely challenging and it's a perfect example of how the mind and the body connect. I personally have... I was a dancer for many years. I have a love of being physically active in sports and I totally understand the mind-body connection. And to me, the impact of being able to work with someone that is experiencing both physical and emotional suffering, because even if the pain has only been there for three weeks, it can impact your quality of life and there is suffering attached to that. It is one of the greatest things to see folks get better. It's incredibly rewarding and it can be challenging too at times, but you have to be willing to sort of walk with the patients and meet them where they're at and give them a safe space to

be able to not only learn and understand their pain, but be able to work through some of the unfortunate consequences that can happen personally and physically from just the experience of having pain.

Glen Stevens, DO, PhD:

Well, it sounds like the spine group and the patients are very fortunate to have you on board.

Sara Davin, PsyD, MPH:

Oh, thank you.

Glen Stevens, DO, PhD:

If no one's told you before, thank you for all you do. In the intro, we mentioned lumbar spine. I was just sort of thinking, I assume then, that although pain's still a problem, maybe less for thoracic and less for cervical for pain complications, or not?

Sara Davin, PsyD, MPH:

Lumbar spine surgery is one of the most common so I think that's why that one particular, that statistic, is related to the most common, but it's also not uncommon for folks to have multiple types of back surgeries. So they've maybe had a lumbar spine and even a cervical spine surgery. And in that range too, that 10 to 40%, it's a wide range. So I think there's some room for further investigation of really how many people do develop post-surgical pain. But to me, I actually just ran a group with surgical patients right before this, and what I said to them is I said, "Even 10%, that's not good in my eyes." We want to prevent this development of additional pain and suffering after something like a spine surgery, because when folks are at the point of wanting spine surgery, they're very motivated and oftentimes pretty desperate for relief and not expecting or wanting to have additional pain or complications post-surgery.

Glen Stevens, DO, PhD:

Yeah. I'm really excited about the proactive form of this that you're involved with. So, as we mentioned in the introduction, high likelihood of some long term complications, re-operations, pain, as you say, even if it's 10%, it's 10% too much, what factors contribute to these numbers?

Sara Davin, PsyD, MPH:

So I think that's complicated too, I can speak from what we do know in the literature more specifically related to psychosocial factors, which are a consistent thing that we see coming back to that. In particular, depression is one of the things we see the most being a pretty consistent predictor of a more challenging post-surgical outcome. Along those same lines, significant levels of anxiety or cognitive disturbance can be challenges. Any sort of substance use disorder can create challenges. So we know that there's a lot of opportunity from a psychosocial perspective. And you also have to understand the fact that it's totally understandable, I think, for folks that have chronic pain to develop some degree of depression. So, you have a condition that goes on and on and it interferes with life, most people would feel frustrated and if that goes on long enough, you can experience depression. So just knowing that and knowing that depression might be one of the biggest predictors I think tells us that we do really justifies intervening as soon as possible with folks from a broad, whole-person perspective that incorporates both the mind and the body.

Glen Stevens, DO, PhD:

So I remember from my studies many years ago that smoking nicotine really affects wound healing and can affect the healing process with spine surgery patients. Do you find that patients are open to stop? It's one of those things it's easy to say, "I don't want to smoke," but really hard to stop. How do you find the patients? I assume that's one of the risk factors that you can intervene on. What's the success?

Sara Davin, PsyD, MPH:

Yeah, actually, while smoking cessation is quite difficult, I have not encountered a ton of patients that are not willing to stop, and if they're not willing, then we try to work with them to be able to get to a place and to understand that this is a change and a challenge for you, but we want to look longer term in terms of pain relief and pain control. And usually if someone is also using nicotine or some sort of substance, it's a sign that they also could benefit from learning some other ways to relax and to sooth. Most people that smoke, they find that it calms them down. So we like to teach them some ways to calm down and relax alternatively, while they're working on something such as smoking cessation.

Glen Stevens, DO, PhD:

So as a brain tumor person, I've been involved with multidisciplinary care for almost 30 years and we exist in a multidisciplinary environment. It sounds like you do as well. Tell me how you got into it, or who's involved with the care of these patients.

Sara Davin, PsyD, MPH:

A team is essential, as you know, and we really feel this in addressing a complex, old-person condition such as chronic pain. So our team is comprised of some behavioral specialists, pain psychologists, we have a pain physician who is anesthesiology trained, but really specializes in helping people with chronic pain, we also have a psychiatrist and addictionologist to handle some complex psychiatric and medication issues, we are staffed with advanced practice nurses who both have expertise in pain and psychiatry and addiction, we have nursing and we work side by side with physical therapy and occupational therapy, which is a key part of the rehabilitation process.

Glen Stevens, DO, PhD:

So I'm sure that patients come in urgently admitted to the hospital, may need to have urgent surgery. I assume, with these patients not time for you to see them and offer, or do you still see patients in-house maybe just a day or two days before their surgery to chat with them?

Sara Davin, PsyD, MPH:

At the present time, we do not do that, but we have done that in the past. We've done inpatient consult, I think there's a lot of opportunity for inpatient works, especially with pain psychology and something, hopefully that we can get back to sooner than later. The other key piece in our team is the surgeon. So the surgeons and the psychology team work side by side and it really is important that we are a unified front and we are sending the message that we are a team because it can be confusing for any person with pain to see, "Oh, there's a psychologist involved. What does this mean? Why?" Well, no, we're not saying that this is because it's a psychological condition, it's that we are literally looking at every single angle of the person with pain. And the surgeon is a key piece of that, that's the person that's going to be operating. So we have to have a very strong alliance with the spine surgeons.

Glen Stevens, DO, PhD:

So let's say I'm the spine surgeon and I say, "Ms. Jones, I'm going to do your surgery in two weeks." She doesn't have a progressive neurologic decline, there's nothing eminent that has to be done right away, are you able to pump the brakes on that and push it out further if you feel that they need supportive care?

Sara Davin, PsyD, MPH:

We can, yes, and we would do that if we felt like it was in their best interest, but it's not the role necessarily of pain psychology to stop the surgery and sometimes patients will look at me and think, "Oh, you're the person that's going to say she can't have it or he can't have that surgery," and that's not my role. I want the person to get what they need to get well, but it's teaching them some very basic key concepts and skills that they can start using immediately and using it during the recovery period and post-surgery as well.

Glen Stevens, DO, PhD:

Yeah. That's really interesting point that you just made there, hadn't really thought about that, but I'm sure some patients do look at you as the brakes and they have to pass a test and get by you to move along versus you have to educate them that it's really a team process and what your role is because I'm sure at other institutions it's pretty uncommon that they would, if they are here for a second, third or fourth opinion that they ran into someone like you, right?

Sara Davin, PsyD, MPH:

Yes. I mean a key part of, especially the first minute that I spend with a patient, as well as the communication from every person on my team when they are looking at a person who is being considered from surgery, is helping them understand what my role is and that I am a part of your team and I'm here to support you, not to get in the way or to interfere. And it's important that the patients are honest with me about what's going on, not so that I'm going to stop the surgery, but so that we can help them have the most ideal outcome at the end of this and that's what's really important.

Glen Stevens, DO, PhD:

So help me understand the flow. You see them after a surgeon is seeing them sometime later or you may see them the same day, would you ever see people ahead of time? Tell me the flow.

Sara Davin, PsyD, MPH:

Well, the way that this is working now is that patients when they are recommended for a spine surgery, when the surgeon says, "Okay, this is what I think we should do and we want to go ahead and we recommend that you go through all of these workups or steps before you have surgery," our class is part of that standard of care and the surgeon and the nursing team says, "To get the best outcome to provide you the most comprehensive world class care, we are strongly encouraging you to attend this one time, two hour class. You only have to do it once, it's evidence based and that will really help and support you throughout the surgical period."

Sara Davin, PsyD, MPH:

Now, most commonly folks are getting this class before surgery, and it can range anywhere from a couple of months before surgery to a couple of days before surgery. And they are also welcome to take it after surgery and I've had some people come and do it after surgery. And it's interesting because the response is different because they're in a different space. Before surgery, they're just wanting to get the surgery done, they're really hoping that it is sort of easy, miraculous, understandably so. After surgery, sometimes they are surprised by how they feel. They might feel better, but they still feel vulnerable, a little apprehensive and so I think there's benefits at both time points. There was a recent systematic review that was released that actually was indicating that the postsurgical period might be more optimal for intervening from a behavioral standpoint. But I think the verdict's still out on that and I definitely see the benefit at both time points.

Glen Stevens, DO, PhD:

And can they do the class virtually or do they need to be there in-person?

Sara Davin, PsyD, MPH:

The way it's running now is it is all virtual and that's offering, I think a big layer of convenience for individuals. Although we have done this in person, in the past, pre-pandemic. I know there's some organizations that are doing similar type things, not necessarily with spine surgery, where they're offering this to large groups of patients at a time like in an auditorium or something, but we have anywhere from 10 to 12 patients per class, which I think also allows for some interaction and Q and A and getting to know each other too. So the great thing is is when these folks are in group together is they say, "I feel less alone. I feel less isolated in my condition," which is a very, very common thing among most people that I work with that have pain.

Glen Stevens, DO, PhD:

So is that a shared medical appointment then? Is that how they do it?

Sara Davin, PsyD, MPH:

Yes.

Glen Stevens, DO, PhD:

Okay.

Sara Davin, PsyD, MPH:

Yes.

Glen Stevens, DO, PhD:

And I may say this wrong, but your program is the Trek For Surgical Success, is that right? The T-R-E-K?

Sara Davin, PsyD, MPH:

Yes. Yeah. So it's Trek For Surgical Success, it's an adaptation of a class that was developed at Stanford University called Empowered Relief. I am certified in that course and we have adapted it to our treatment pathway here at the Cleveland Clinic for surgical patients, as well as for any person that has chronic pain that we see within our team. Every single person is referred to this class. So there's two formats, there's the surgical class and then there's the just general chronic pain class. And it's really a good sort of first step into the treatment pathway and we do offer a number of other types of different programs and interventions for folks if they're interested.

Glen Stevens, DO, PhD:

And do you have specific goals, endpoints for patients, timelines, things you want to... I mean, obviously different people will have different concerns, some may have anxiety, depression, other comorbid features, but talk to me about that a little bit.

Sara Davin, PsyD, MPH:

Well, so for the surgical class, it's a single session. So the way that this is built from Stanford is that it's a brief intervention that's actually been found to be equivalent to eight sessions of cognitive behavioral therapy for pain. So the idea is it's intensive, it's brief, it's low burden, it's accessible to more people, they don't have to put in a ton of time. But what I ask of them is that I teach them some basic skills, there's three to four skills, I send them a packet of information and I give them homework and I say, "You have to start doing this every single day." And then I say, "Ideally, this is a one time intervention, but what I'm asking of you is to do this on your own every single day for the next two weeks and after those two weeks, if you feel like this is impossible, you're not... you're kind of running up against roadblocks and you need additional support, then please circle back with me and we can figure out and adapt your treatment plan to meet your needs." So that's for the surgical class.

Sara Davin, PsyD, MPH:

For our general chronic pain population, this is sort of an entry point into after they have their initial evaluation and it can be one of different steps in their treatment pathway, including engaging in things like physical therapy, or we have a program for people that have low back pain called Back On Track that incorporates 10 weeks of behavioral therapy and physical therapy, and then we also have an intensive outpatient program for pain. This is for the most complex refractory patients and so there's a number of options in that regard.

Glen Stevens, DO, PhD:

So you mentioned engagement, any statistics for us?

Sara Davin, PsyD, MPH:

Yeah, so we did some preliminary analysis in terms of enhancing engagement and for the general chronic pain class enhancing engagement in other services within our department and we did see that for those folks that took the class, they were more likely to participate in other programming within our department. For people, not surprisingly, for people that no-showed, they were scheduled and they just didn't show or they canceled, they're not likely to engage in other services within our department. So what would be interesting, what we want to look at, is for those people that are no-showing, they're not opting-in initially, what are the barriers? What are the factors that are prohibiting their engagement? But we have high rates of engagement for the chronic pain class and for the surgical class, our engagement rate is around 65% of all of those patients that are scheduled.

Sara Davin, PsyD, MPH:

We'd like it to be higher, but if you look at the chronic pain population in general, engagement is an issue. Usually, and this is just kind of anecdotally, but it's consistent over time, we would schedule 10 patients for a class and 50% would always no-show or cancel. So we would over-schedule because that 50% was pretty much always there. So with that being said, 65% for a new surgical class, I think is promising. And then I can tell you, so I run the surgical class and when people actually show up and they listen and they start to talk, the receptivity is amazing. They are so grateful to get this information. And we are studying that as well, we do send out a satisfaction acceptability survey to folks after they complete the course. And most everybody is rating it very favorably and noting that they intend to use the information that they learned after the class.

Glen Stevens, DO, PhD:

So challenges, to push this out to a broader market to other institutions running it, to what kind of challenges, some seem pretty obvious, but what kind of challenges?

Sara Davin, PsyD, MPH:

We definitely need to figure out what patients are going to benefit the most from this and potentially also what format can we use because there's only so many pain psychologists and there's only so many people that can deliver this class and there's a lot of people that are having spine surgery. So being able to potentially utilize things like apps and prerecorded potentially classes might be an idea. That's another area to study further is what patients would benefit most from, in-person or virtual live instructor led class versus just receiving this information in a format that is maybe easier to access and less staff intensive.

Glen Stevens, DO, PhD:

And this is available at the Cleveland Clinic through all the various satellite hospitals or just main campus or no?

Sara Davin, PsyD, MPH:

Yeah. So any spine surgery candidate is being referred to this class across all the campuses.

Glen Stevens, DO, PhD:

Okay. And sorry, you told me it's since 2018, is that correct?

Sara Davin, PsyD, MPH:

So I started doing it in 2018 in an in-person, smaller based format and we've adapted it over time, along with some of the adaptations that Stanford has made. The first one was in-person live, then we also trialed a... it was basically like an online module where they watched a video where it was the same material, but there wasn't a live instructor. And the engagement in that was not as good, people would start the video and then they just wouldn't finish it. And then now more recently, we've adapted to this virtual format with a live instructor, which I think seems to be a nice balance because it gives people some convenience, they don't have to travel to the clinic, but yet they're also getting that kind of person to person feel.

Glen Stevens, DO, PhD:

And do you ever see patients repeat the course, the two hour course?

Sara Davin, PsyD, MPH:

I have had a few that do that, yes. And I do have patients that want to follow up with me or someone in our team as well, just kind of as refreshers, to be able to talk about how it's going in terms of using the skills that they learned.

Glen Stevens, DO, PhD:

Any specific challenges with running the program, other than what we've spoken about?

Sara Davin, PsyD, MPH:

I don't know if it's a challenge, it just took some time to kind of make... it's a cultural shift, really, what we're doing. We are the only hospital that we know at this point nationwide that's making this standard of care for all spine surgery candidates. And the messaging is really important. Our entire team had to be on the same page in terms of how to deliver this and the verbiage to use with patients when discussing the class. We don't want people to feel forced or that we're going to not do surgery on them if they don't attend, but that we really, really are encouraging them.

Sara Davin, PsyD, MPH:

The other thing is that the preoperative period is really demanding for not only the patient, but also for staff and particularly nursing. They have so many things that they have to do to get the patients ready for surgery and so we had to find a way to make this low burden for nursing who are a key part of the messaging and the workflow, to be able to not feel like they have 10 additional things that they have to do, but to be able to get the person enrolled in the class and to educate them.

Sara Davin, PsyD, MPH:

And so we use things such as an order and a referral, an automatic MyChart message, a frequently asked questions sheet. We are going to amp up even more education that we give to patients, because I think that could be... there could be some patients that are not showing up because they still don't truly understand what this class is and we want to really market it as well so we can really normalize this as part of the standard of care for surgery.

Glen Stevens, DO, PhD:

So if I'm listening to this podcast out there and I think, "Boy, I'd really like to have Sarah on my team," how do I go about doing this?

Sara Davin, PsyD, MPH:

So there is a paper that is out there that sort of documents our workflow and our process at the Cleveland Clinic of implementing this as part of standard of care and if you can get someone trained in this kind of class and be able to partner together really any sort of physician and psychologist or health psychologist, it doesn't necessarily have to be a pain psychologist, I think it's most definitely possible. There are other hospital systems that are doing this in different ways and in different conditions across the country and internationally as well.

Glen Stevens, DO, PhD:

Well, it sounds like maybe you need to start attending some of the spine conferences and presenting it, right?

Sara Davin, PsyD, MPH:

Yes, we are. In fact, there's quite a few that we have presented this at and are going to be presenting and we are gathering data as we speak. So we do hope to present further outcomes and to be able to share those with those that are interested and the stakeholders in, I think, education is a key piece of this. And certainly looking at the effectiveness, we know that it's feasible. We know that within a large healthcare system, like the Cleveland Clinic, we can make this happen. Is it perfect yet? No. But are people benefiting? I can tell you hands down.

Sara Davin, PsyD, MPH:

And it's just a matter of us continuing to do this and working out some of the kinks and then being able to demonstrate and show the success that patients are experiencing. I think a key part of this is that folks need tools, they need to feel like they have some control, that they have some things that they can do that no matter what will help them get through this experience, no matter what the outcome is. And so from that standpoint, I think we meet that goal after they finish just even that two hour class.

Glen Stevens, DO, PhD:

Well, I think that says it all right. I mean, I think that with all of us who look after some form of chronic disease, patients want some sense of control and I applaud you for allowing them to have some of that and the work that you're doing. So I really enjoyed our discussion today. I'd like to thank you for joining some Neuro Pathways and keep up the good work.

Sara Davin, PsyD, MPH:

Thank you so much. Thanks for having me.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.