The Psychology of Chronic Pain - lechnyr.com · pain and mood (serotonin and norepinephrine) Neurotransmitter, Substance P, sends pain signals up the spinal column into the brain

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The Psychology of The Psychology of Chronic PainChronic Pain

Catriona Buist, Psy.D.Western Pain Society & Pain Society of Oregon

Meeting Pain Where It Hurts:Physical, Psychological & Social Solutions

April 25, 2008

Progressive Rehabilitation AssociatesPRAPRA

Goals of this PresentationGoals of this Presentation

Present the Biopsychosocial Model of Chronic PainPresent the Biopsychosocial Model of Chronic Pain

Highlight the impact of psychological and socioeconomic Highlight the impact of psychological and socioeconomic g g e pac o psyc o og ca a d soc oeco o cg g e pac o psyc o og ca a d soc oeco o cfactors on chronic painfactors on chronic pain

Explore impact of depression, anxiety, and PTSD on painExplore impact of depression, anxiety, and PTSD on pain

Present psychological assessments used in treatmentPresent psychological assessments used in treatment

Discuss the benefits of multidisciplinary pain management Discuss the benefits of multidisciplinary pain management programsprograms

Definition of PainDefinition of Pain

Pain:Pain: an unpleasant sensory and an unpleasant sensory and emotional experience associated with emotional experience associated with actual or potential tissue damage (IASP*)actual or potential tissue damage (IASP*)

Acute Pain < 3 monthsAcute Pain < 3 monthsChronic Pain > 3 monthsChronic Pain > 3 months

*IASP = International Association for the Study of Pain*IASP = International Association for the Study of Pain

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Costs of Chronic PainCosts of Chronic Pain

Pain affects over 50 million AmericansPain affects over 50 million AmericansCosts more than $70 billion annually in Costs more than $70 billion annually in health care costs and lost productivityhealth care costs and lost productivityA t f 80% f ll h i i i itA t f 80% f ll h i i i itAccounts for >80% of all physician visitsAccounts for >80% of all physician visitsAssociated with major comorbid Associated with major comorbid psychiatric disorders and emotional psychiatric disorders and emotional sufferingsuffering

Gatchel, R. J.

Old Model of Chronic PainOld Model of Chronic Pain

Dualistic view that conceptualized the Dualistic view that conceptualized the mind and body as functioning separately mind and body as functioning separately and independently.and independently.Specificity theory Specificity theory –– the amount of pain the amount of pain p y yp y y ppshould be directly proportional to the should be directly proportional to the amount of tissue pathologyamount of tissue pathologyOnce the physical pathology has resolved Once the physical pathology has resolved the pain should subsidethe pain should subsideTherefore, treat the cause of the painTherefore, treat the cause of the pain

Gate Control Theory of Pain (1965)Gate Control Theory of Pain (1965)First theory to integrate physiological and First theory to integrate physiological and psychological factors in pain.psychological factors in pain.Changed thinking about pain perceptionChanged thinking about pain perception“Gating system” in CNS opens or closes to let “Gating system” in CNS opens or closes to let pain messages through or blockpain messages through or block

Melzack & Wall, 1965

pain messages through or blockpain messages through or blockClose gateClose gate: nerve impulses, endorphins, : nerve impulses, endorphins, narcotics, stimulation, TENS, acupuncture, narcotics, stimulation, TENS, acupuncture, biofeedback, positive thoughts, humorbiofeedback, positive thoughts, humorOpen gateOpen gate: negative emotional exp, : negative emotional exp, stress, fatigue, anxiety, depression, stress, fatigue, anxiety, depression, focus on painfocus on pain

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Role of Operant Conditioning in Role of Operant Conditioning in Chronic Pain Chronic Pain -- Fordyce (1976)Fordyce (1976)

When pt is exposed to stimulus that causes When pt is exposed to stimulus that causes tissue damage, the immediate response is tissue damage, the immediate response is withdrawal or attempt to escapewithdrawal or attempt to escape

A id f ti it b li d t iA id f ti it b li d t iAvoidance of activity believed to cause pain Avoidance of activity believed to cause pain ––leads to generalization of avoidance of all leads to generalization of avoidance of all activitiesactivities

Pain behaviors (complaining, inactivity) Pain behaviors (complaining, inactivity) reinforced through attention or avoidance of reinforced through attention or avoidance of undesirable activities such as workundesirable activities such as work

Role of Social Learning in Chronic PainRole of Social Learning in Chronic Pain

Pain behaviors may be acquired through Pain behaviors may be acquired through observational learning and modeling observational learning and modeling (Bandura, 1969).(Bandura, 1969).

The perception and interpretation ofThe perception and interpretation ofThe perception and interpretation of The perception and interpretation of symptoms and physiological processes (to symptoms and physiological processes (to ignore or to overrespond) can be learned ignore or to overrespond) can be learned (Pennebaker, 1982)(Pennebaker, 1982)

Culturally acquired perception and Culturally acquired perception and interpretation of symptoms determine how interpretation of symptoms determine how people deal with illness people deal with illness (Nerenz & Leventhal, 1983)(Nerenz & Leventhal, 1983)

Role of Fear and Harm AvoidanceRole of Fear and Harm AvoidanceFear of pain and what we do about it is more disabling Fear of pain and what we do about it is more disabling than the pain itself than the pain itself (Waddell et al., 1993, p. 164).(Waddell et al., 1993, p. 164).

Fear avoidance is one of the most powerful predictors Fear avoidance is one of the most powerful predictors of chronic disability in back pain patients of chronic disability in back pain patients (Klenerman et al, 1995)(Klenerman et al, 1995)

Strong association between painStrong association between pain--related fear and related fear and increased physiological arousalincreased physiological arousal (Vlaeyen Haazen et al 1995;(Vlaeyen Haazen et al 1995;increased physiological arousal increased physiological arousal (Vlaeyen, Haazen, et al, 1995; (Vlaeyen, Haazen, et al, 1995; Vlaeyen, KoleVlaeyen, Kole--Snijders, Boeren, & van Eck, 1995).Snijders, Boeren, & van Eck, 1995).

Physiological arousal might contribute to maintenance Physiological arousal might contribute to maintenance and increase in pain severity and increase in pain severity (Flor & Turk, 1989)(Flor & Turk, 1989)

Chronic pain pts with elevated painChronic pain pts with elevated pain--related anxiety related anxiety tend to anticipate higher levels of pain than those with tend to anticipate higher levels of pain than those with low anxiety and anticipation of pain often results in low anxiety and anticipation of pain often results in poorer behavioral performance poorer behavioral performance (McCracken, Gross, Sorg, & (McCracken, Gross, Sorg, & Edmands, 1993).Edmands, 1993).

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Biopsychosocial Model of PainBiopsychosocial Model of Pain

Central Processes

Biological Cognitive

Somatic Affective---------------------------------------------------

Efferent Feedback Afferent Feedback

Activities of Daily Living

Environmental Stressors

Interpersonal Relationships

Family Environment

Social Support/Isolation

BIO PSYCHO SOCIAL

A conceptual model of the biopsychosocial interactive processes involved in health and illness. From “Comorbidity of Chronic Mental and Physical Health Conditions: The Biopsychosocial Perspective

by R. J. Gatchel, American Psychologist, 59, 792-805. 2004

----------------------------------------------------Peripheral Processes

Autonomic Endocrine

Immune Systems

-----------------------------------------------------Genetic Predispositions

Social Expectations

Cultural Factors

Medicolegal/Insurance Issues

Previous Treatment Experience

Work History

Pain Sensitization HypothesisPain Sensitization Hypothesis(1990’s)(1990’s)

-- Initial stimuli sensitizes host. Lowered threshold Initial stimuli sensitizes host. Lowered threshold results in an amplified responses to future stimuli results in an amplified responses to future stimuli exposure.exposure.

-- Chronic Pain develops from sensitization of Chronic Pain develops from sensitization of peripheral and central pathways (dorsal horn, peripheral and central pathways (dorsal horn, cingulum)cingulum)

-- Maladaptive response to stressors (difficulty Maladaptive response to stressors (difficulty sleeping, somatic complaints, depression, sleeping, somatic complaints, depression, anxiety, irritability, lethargy)anxiety, irritability, lethargy)

(Sullivan, Clinical & Environmental Health and Toxic Exposures, 2001)(Sullivan, Clinical & Environmental Health and Toxic Exposures, 2001)

The Neuromatrix Theory of Pain The Neuromatrix Theory of Pain (Melzack, 1999)(Melzack, 1999)

Pain is multiPain is multi--faceted experience produced by a faceted experience produced by a widely distributed brain neural network called the widely distributed brain neural network called the bodybody--self neuromatrixself neuromatrixOutput patterns of the neuromatrix engage Output patterns of the neuromatrix engage perceptual, behavioral, and homeostatic perceptual, behavioral, and homeostatic p pp psystems in response to injury and chronic stresssystems in response to injury and chronic stressPain is a consequence of the outputPain is a consequence of the outputCan help explain phantom limb pain since it Can help explain phantom limb pain since it requires no actual sensory input to produce requires no actual sensory input to produce experiences of the body.experiences of the body.Theory helps explain the multidimensional Theory helps explain the multidimensional experience of painexperience of pain

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Congress Declared 2001 Congress Declared 2001 --20102010

Decade of Pain Control and Research

Current Research in Pain (2005)Current Research in Pain (2005)

Mackey found that using realMackey found that using real--time functional time functional MRI to guide training, that subjects were able to MRI to guide training, that subjects were able to learn to voluntarily control activation in the learn to voluntarily control activation in the rostral anterior cingulate cortex, which is rostral anterior cingulate cortex, which is putatively involved in pain perception and putatively involved in pain perception and

l til tiregulation. regulation. ((deCharms, Maeda, Glover, Ludlow, Pauly, Soneji, Gabrieli, & Mackey. Control over brain activation and pain learned by using real-time functional MRI. PNAS, vol 102, no. 51, 2005)

Coghill found the magnitude of pain perception is partly determined by expectations about the pain. (Coghill, R.C. Thinking the Hurt Away, Science News, September, Vol 168, p 164, 2005)

Homeostasis and HypothalamicHomeostasis and Hypothalamic--PituitaryPituitary--Adrenal (HPA) Axis DysregulationAdrenal (HPA) Axis Dysregulation

Chronic pain threatens the organismChronic pain threatens the organismStress active the autonomic nervous Stress active the autonomic nervous system and HPA axissystem and HPA axisStressStress release cortisol which leads to:release cortisol which leads to:Stress Stress –– release cortisol which leads to:release cortisol which leads to:–– atrophy of muscle tissueatrophy of muscle tissue–– impairment of growth and tissue repairimpairment of growth and tissue repair–– immune system suppressionimmune system suppression–– morphological alterations of brain structures.morphological alterations of brain structures.

Gatchel, RJ., Peng, Peters, Fuchs, & Turk. The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions.

Psychological Bulletin, vol 133, No 4, 581-624. 2007

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“Pain is a complex perceptual “Pain is a complex perceptual experience influenced by a wide experience influenced by a wide range of psychosocial factors, range of psychosocial factors, including emotions, social and including emotions, social and environmental context, socicultural environmental context, socicultural background, the meaning of pain to background, the meaning of pain to the person and beliefs attitudesthe person and beliefs attitudesthe person, and beliefs, attitudes, the person, and beliefs, attitudes, and expectations, as well as and expectations, as well as biological factors. Chronic pain will biological factors. Chronic pain will influence all aspects of a person’s influence all aspects of a person’s functioning: emotional, functioning: emotional, interpersonal, vocational and interpersonal, vocational and physical”physical” (Turk & Okifuji, 2002)(Turk & Okifuji, 2002)

How do Psychiatric Disorders How do Psychiatric Disorders Impact Pain Perception?Impact Pain Perception?

6060--80% pain clinic pts have psychiatric 80% pain clinic pts have psychiatric illness as dx by DSM illness as dx by DSM (Clark & Cox, 2005; Katon, Egan, & Miller, 1985; (Clark & Cox, 2005; Katon, Egan, & Miller, 1985; Fishbain, Goldberg, Meagher, Steele, Rosomoff, Male, 1986)Fishbain, Goldberg, Meagher, Steele, Rosomoff, Male, 1986)

Improvement in psychiatric illness results in Improvement in psychiatric illness results in decreased pain levels greater acceptancedecreased pain levels greater acceptancedecreased pain levels, greater acceptance decreased pain levels, greater acceptance of pain, improved function, and improved of pain, improved function, and improved quality of life quality of life (Wasan, 2005)(Wasan, 2005)

Psychiatric DO increase pain and suffering, Psychiatric DO increase pain and suffering, magnification of disability, interfere with magnification of disability, interfere with physiotherapy and rehabilitation, and lead to physiotherapy and rehabilitation, and lead to noncompliance noncompliance (Hauser, Sonntag, Tiber, Egle, 2002)(Hauser, Sonntag, Tiber, Egle, 2002)

CatastrophizingCatastrophizingDefined as a set of negative emotional and Defined as a set of negative emotional and cognitive processes cognitive processes (Sullivan et al, 2001)(Sullivan et al, 2001)

–– Magnification of painMagnification of pain--related symptomsrelated symptoms–– Rumination about painRumination about pain–– Feelings of helplessnessFeelings of helplessness–– Pessimism about painPessimism about pain--related outcomes related outcomes

(Edwards et al, 2006)(Edwards et al, 2006)

Influences pain perception through altering Influences pain perception through altering attention and anticipation and heightening attention and anticipation and heightening emotional response to painemotional response to pain

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Physiological Link Between Physiological Link Between Depression and PainDepression and Pain

Pain and depression share common pathways in the Pain and depression share common pathways in the emotional (limbic) region of the brainemotional (limbic) region of the brainThe same chemical messengers are involved in regulating The same chemical messengers are involved in regulating pain and mood (serotonin and norepinephrine)pain and mood (serotonin and norepinephrine)Neurotransmitter, Substance P, sends pain signals up the Neurotransmitter, Substance P, sends pain signals up the spinal column into the brain and plays a role in moodspinal column into the brain and plays a role in moodspinal column into the brain and plays a role in moodspinal column into the brain and plays a role in moodHormonal and biochemical responses to bodily injury and Hormonal and biochemical responses to bodily injury and emotional disturbance are mediated by the hypothalamus and emotional disturbance are mediated by the hypothalamus and the pituitarythe pituitary--adrenal axis, with similar consequences adrenal axis, with similar consequences (Cleghorn, 1965)(Cleghorn, 1965)

Antidepressants often help decrease pain Antidepressants often help decrease pain (analgesic effect of (analgesic effect of antidepressant is mediated by the blockade of reuptake of NE and SE)antidepressant is mediated by the blockade of reuptake of NE and SE)Vicious cycle Vicious cycle -- Depression can increase response to pain or Depression can increase response to pain or the suffering and chronic pain is stressful and depressing the suffering and chronic pain is stressful and depressing Chronic pain and chronic depression can alter the functioning Chronic pain and chronic depression can alter the functioning of the nervous system and perpetuate itself (ex. Fibromyalgia)of the nervous system and perpetuate itself (ex. Fibromyalgia)

Anxiety Disorders & PainAnxiety Disorders & PainAnxiety disorders include: generalized anxiety Anxiety disorders include: generalized anxiety disorder, panic disorder, obsessive compulsive disorder, panic disorder, obsessive compulsive disorder, and Postdisorder, and Post--traumatic stress disorder (PTSD)traumatic stress disorder (PTSD)3030--60% pts with chronic pain have diagnosis of 60% pts with chronic pain have diagnosis of anxiety (Koenig & Clark, 1996; Katon, Egan & anxiety (Koenig & Clark, 1996; Katon, Egan & Miller 1985; Gallagher Verma 1999)Miller 1985; Gallagher Verma 1999)Miller, 1985; Gallagher Verma, 1999)Miller, 1985; Gallagher Verma, 1999)Anxiety amplifies pain perception through Anxiety amplifies pain perception through sympathetic arousal, excessive cognitive focus on sympathetic arousal, excessive cognitive focus on pain symptoms, and poor coping skills (Wasan, pain symptoms, and poor coping skills (Wasan, 2005)2005)Anxiety sx: restlessness, fatigue, irritability, poor Anxiety sx: restlessness, fatigue, irritability, poor concentration, muscle tension, and sleep concentration, muscle tension, and sleep disturbancedisturbanceBest tx: CBT, relaxation therapy, biofeedback, medsBest tx: CBT, relaxation therapy, biofeedback, meds

PTSD and Chronic PainPTSD and Chronic PainPrevalence of PTSD is substantially elevated in pts with Prevalence of PTSD is substantially elevated in pts with chronic pain (15chronic pain (15--35%) compared to those who do not 35%) compared to those who do not have chronic pain (2%) have chronic pain (2%) (Asmundson, Bonin, Frombach, & Norton, 2000)(Asmundson, Bonin, Frombach, & Norton, 2000)

For those with history of abuse, having chronic pain can For those with history of abuse, having chronic pain can feel like being abused again. Anxiety, vulnerability, lack feel like being abused again. Anxiety, vulnerability, lack of control, and not being believed can magnify pain of control, and not being believed can magnify pain , g g y p, g g y pemotionally and physically emotionally and physically (Caudill, MA., 2002)(Caudill, MA., 2002)

The pain may serve as a reminder of the traumatic The pain may serve as a reminder of the traumatic event, which will tend to exacerbate the PTSD event, which will tend to exacerbate the PTSD (DeCarvalho, L. T.(DeCarvalho, L. T. http://www.ncptsd.va.gov/facts/problems/fs_chronichttp://www.ncptsd.va.gov/facts/problems/fs_chronic--pain.htmlpain.html))

Important to treat the PTSD and the painImportant to treat the PTSD and the pain

EMDREMDR

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Premorbid Premorbid StageStage

Crisis buildCrisis build--upup Demanding work, job dissatisfaction, situational stress, poor Demanding work, job dissatisfaction, situational stress, poor general coping skills, social model for disabilitygeneral coping skills, social model for disability

Stage 1Stage 1 The accidentThe accident Relationships among the nature of the accident, the severity Relationships among the nature of the accident, the severity of the injury, & the claimed inability to work are often weak.of the injury, & the claimed inability to work are often weak.

Stage 2Stage 2 Medical interventionMedical intervention Following recovery from the injury, pt fails to return to normal Following recovery from the injury, pt fails to return to normal social roles & productivity. Repeated medical interventions social roles & productivity. Repeated medical interventions may be performed, leading to possible iatrogenic may be performed, leading to possible iatrogenic complications chronicity & learned pain behaviorcomplications chronicity & learned pain behavior

Stages in the Development of Disability

complications, chronicity, & learned pain behaviorcomplications, chronicity, & learned pain behavior

Stage 3Stage 3 Stabilization of Stabilization of chronicitychronicity

Confusion, anger & hostility; increasing dependency & Confusion, anger & hostility; increasing dependency & idleness; economic preoccupation & difficulty; decline in idleness; economic preoccupation & difficulty; decline in competence for gainful employment.competence for gainful employment.

Stage 4Stage 4 Legal interventionLegal intervention Lack of systematized documentation to support proof of Lack of systematized documentation to support proof of disability & the adversary system further foster attitudes of disability & the adversary system further foster attitudes of passivity, exaggerated illness behavior, & possibly passivity, exaggerated illness behavior, & possibly malingering.malingering.

Stage 5Stage 5 Learned Learned helplessnesshelplessness

Sick role solidifies; loss of hope for health recovery; Sick role solidifies; loss of hope for health recovery; generalized incompetent coping, frequently irreversible.generalized incompetent coping, frequently irreversible.

Brena SF, Chapman, SL. Pain and litigation. In Wall PD, Melzack R, eds. Tesxtbook of Pain. Edinburgh: Churchill Livingstone; 1989

Helpful Questions When Assessing Helpful Questions When Assessing for Suicidefor Suicide

Have you been so depressed that you’ve Have you been so depressed that you’ve felt life is not worth living? Have you felt life is not worth living? Have you thoughts of harming yourself?thoughts of harming yourself?Have you thought about how you mightHave you thought about how you mightHave you thought about how you might Have you thought about how you might take your own life?take your own life?Have you ever done anything to hurt Have you ever done anything to hurt yourself or come close to it?yourself or come close to it?What stops you from killing yourself?What stops you from killing yourself?

Therapeutic Insights: Management of Major Depressive Disorder in Primary Care American Medical Association., December 2008.

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Screen for Anxiety Disorders in Screen for Anxiety Disorders in Primary CarePrimary Care

Over the last two weeks, how often have Over the last two weeks, how often have you been bothered by:you been bothered by:

–– Feeling nervous, anxious or on edge?Feeling nervous, anxious or on edge?

–– Not being able to stop or control worrying?Not being able to stop or control worrying?

Kroenke, K, Spitzer, R.L, Williams, J.B., Monahan, P.O, Lowe, B.Anxiety disorders in primary care: prevalence, impairment, co-morbidity and detection

Ann Intern Med, 2007, 146(5): 317-325.

Assessment of Patients for Bipolar Assessment of Patients for Bipolar Disorder: “Disorder: “DIGFASTDIGFAST” Mnemonic” MnemonicAre there periods of time when you Are there periods of time when you experience:experience:–– DDistractibility istractibility –– poorly focused, multipoorly focused, multi--taskingtasking–– IInsomnia nsomnia –– decreased need for sleepdecreased need for sleeppp–– GGrandiosity randiosity –– inflated selfinflated self--esteemesteem–– FFlight of Ideas light of Ideas –– complaints of racing thoughtscomplaints of racing thoughts–– AActivities ctivities –– increased goalincreased goal--directed activitiesdirected activities–– SSpeech peech ––pressured or more talkativepressured or more talkative–– TThoughtlessness houghtlessness –– “risk“risk--taking” behaviors taking” behaviors

(sexual, financial, travel, driving)(sexual, financial, travel, driving)

Therapeutic Insights: Management of Major Depressive Disorder in Primary Care American medical Association., December 2007.

CAGE CAGE QuestionsQuestions

Have you ever felt you ought to Have you ever felt you ought to CCut down ut down on your drinking?on your drinking?Have people Have people AAnnoyed you by criticizing nnoyed you by criticizing your drinking?your drinking?your drinking?your drinking?Have you ever felt bad or Have you ever felt bad or GGuilty about uilty about your drinking?your drinking?Have you ever had an Have you ever had an EEyeye--opener to opener to steady nerves in the morning?steady nerves in the morning?

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“Where many remedies exist you b th i ”can be sure there is no cure”

Chekhov

Recurrent Errors in the Diagnosis Recurrent Errors in the Diagnosis and Treatment of Chronic Painand Treatment of Chronic Pain

Insufficient diagnostics at onsetInsufficient diagnostics at onsetRelying exclusively on patient reportRelying exclusively on patient reportProlonged inactivity and disuseProlonged inactivity and disuseOveruse or underuse of opiate medicationOveruse or underuse of opiate medicationOveruse or underuse of opiate medicationOveruse or underuse of opiate medicationInadequate assessment of psychological, social, Inadequate assessment of psychological, social, or vocational factorsor vocational factorsOver reliance on a single modalityOver reliance on a single modalityCurative treatment vs rehabilitationCurative treatment vs rehabilitationProlonged treatment intervalsProlonged treatment intervalsVocational input underutilizedVocational input underutilized

New Paradigm for Pain Practice New Paradigm for Pain Practice ––Treat Chronic Pain like Chronic IllnessTreat Chronic Pain like Chronic IllnessPatient has chronic illness (pain or diabetes)Patient has chronic illness (pain or diabetes)PCP provides basic managementPCP provides basic managementCondition exacerbates (severe unrelieved pain Condition exacerbates (severe unrelieved pain or “brittle”diabetic control)or “brittle”diabetic control)or brittle diabetic control)or brittle diabetic control)Specialist intervenes (pain physician or Specialist intervenes (pain physician or diabetologist)diabetologist)Subspecialist may be consulted (pain program, Subspecialist may be consulted (pain program, interventionalist or ICU physician)interventionalist or ICU physician)Condition normalizes with change in planCondition normalizes with change in planPCP maintains altered management planPCP maintains altered management plan

Lema MJ. Presented at: 21st Annual Meeting of the AAPM; Feb 24-27, 2005.; Palm Springs, Ca.

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Primary Care ProviderPrimary Care ProviderMultidisciplinary Team should be:Multidisciplinary Team should be:

Integrated, Coordinated, InterdisciplinaryIntegrated, Coordinated, Interdisciplinary

Primary

Pain Specialist

S

Laboratory tests

Complementary therapy

From Gordon Irving, MD Keynote Presentation at Solutions for Pain Management talk at Pain Society of Oregon annual meeting, 4/14/07

Primary Care

Provider

Psychologist

Neurologist

Psychiatrist

Physical TherapistPhysiatristOccupational Therapist

Community support groups

Radiography

Surgeon

Recommendations for Health Care ProvidersRecommendations for Health Care Providers

Gather thorough biopsychosocial historyGather thorough biopsychosocial historyDo risk assessment for suicidal & homicidal ideationDo risk assessment for suicidal & homicidal ideationAsk about misuse of substancesAsk about misuse of substancesAssess and refer for depression anxiety PTSD andAssess and refer for depression anxiety PTSD andAssess and refer for depression, anxiety, PTSD and Assess and refer for depression, anxiety, PTSD and psychiatric disorderspsychiatric disordersHelp build up or stabilize social support network Help build up or stabilize social support network ––helps buffer stress (include family in treatment)helps buffer stress (include family in treatment)Help pt restore sense of control and empowermentHelp pt restore sense of control and empowerment

DeCarvalho, L. T. The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers and Patientshttp://ncptsd.va.gov/facts/problems/fs_chronic-pain.html

The most potent medications reduce The most potent medications reduce pain in fewer than 50% of patients and pain in fewer than 50% of patients and

only by approximately 35%!only by approximately 35%!Turk, DC. Pain Management in:

The Need for CPR in American Pain Society Bulletin, Fall 2005.

Opioid treatment of chronic pain is not achieving the key goal of improving pain,

function and quality of life.Eriksen, J., Sjogren, P., Bruera, E., Ekholdm, O., & Rasmussen, N.

Critical issues on opiods in chronic non-cancer pain: An epidemiological study. Pain. 125 (2006). 172-179.

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Opioid Therapy

Common Side Effectsof Opioid Therapy

Emerging Side Effectsof Opioid Therapy

SedationConstipation

Difficulty initiating urinationHypotension: falls

Cognitive impairment

ImmunosuppressionEndocrine deficiencies

Sleep disorderHyperalgesia

From Gordon Irving, MD Keynote Presentation at Solutions for Pain Management talk at Pain Society of Oregon annual meeting, 4/14/07

Addiction Pseudoaddiction

Makes last appointment of the day. After hour appt request. Urgent need for apt

Makes the first appointment of the day

“Loses” medications. Specific narcotic required, significant knowledge of narcotics

“Hordes” medications

Decreased functional benefit from medications

Increased functional benefit from medications

Unwilling to try alternative methods of pain control

Willing to try alternative methods of pain control

Narrinder Duggal, M.D., R.Ph. University of Washington & Timothy Tyre, MD, Waukesha Memorial Hospital Pain INstitute

Role of Cognitive Behavioral Therapy Role of Cognitive Behavioral Therapy (CBT) in Pain Management(CBT) in Pain Management

“CBT is based on the premise that perceptions “CBT is based on the premise that perceptions and observable displays of pain are influenced and observable displays of pain are influenced by complex interactions between environmental by complex interactions between environmental events and individuals’ emotional, physiological, events and individuals’ emotional, physiological, behavioral, and cognitive responses. Effective behavioral, and cognitive responses. Effective interventions for chronic pain must address the interventions for chronic pain must address the emotional, cognitive, and behavioral dimension emotional, cognitive, and behavioral dimension of pain, and must also help patients become of pain, and must also help patients become active participants in learning new methods of active participants in learning new methods of responding to their problems.” responding to their problems.”

Bradley, L.A. Cognitive-Behavioral Therapy for Chronic Pain in Psychological Approaches to Pain Management:. A Practitioner’s Handbook Gatchel, R.J. & Turk, D. C. Eds.

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Psychological Factors that Predict Psychological Factors that Predict LongLong--Term DisabilityTerm Disability

Maladaptive attitudes and beliefsMaladaptive attitudes and beliefsLack of social supportLack of social supportHeightened emotional reactivityHeightened emotional reactivityg yg yJob dissatisfactionJob dissatisfactionSubstance abuseSubstance abuseCompensation statusCompensation statusPrevalence of pain behaviors Prevalence of pain behaviors (Turk, 1997)(Turk, 1997)

Psychiatric diagnosis Psychiatric diagnosis (Gatchel & Epker, 1999)(Gatchel & Epker, 1999)

Psychological Barriers for Pain Psychological Barriers for Pain Management TreatmentManagement Treatment

History of anxiety and depression History of anxiety and depression Personality disordersPersonality disordersHistory of alcohol and substance abuseHistory of alcohol and substance abuseMaladaptive coping skillsMaladaptive coping skillsMaladaptive coping skillsMaladaptive coping skillsSomatically focusedSomatically focusedDisability convictedDisability convictedPerceived stressPerceived stressHistory of Posttraumatic Stress DisorderHistory of Posttraumatic Stress DisorderHistory of trauma (abuse/neglect)History of trauma (abuse/neglect)

The Downward Spiral or The Downward Spiral or Black HoleBlack Holeof of Chronic Pain Chronic Pain

“Chronic pain is a thief, it breaks into your body “Chronic pain is a thief, it breaks into your body and robs you blind. With lightning fingers, it can and robs you blind. With lightning fingers, it can take away your livelihood, your marriage, your take away your livelihood, your marriage, your friends, your favorite pastimes and big chunks of friends, your favorite pastimes and big chunks of your personality Left unapprehended it willyour personality Left unapprehended it willyour personality. Left unapprehended, it will your personality. Left unapprehended, it will steal your days and your nights until the world steal your days and your nights until the world has collapsed into a cramped cell of suffering.”has collapsed into a cramped cell of suffering.”

“The Right and Wrong Way to Treat Pain”, “The Right and Wrong Way to Treat Pain”, Time Magazine by Claudia Wallis, February 2005Time Magazine by Claudia Wallis, February 2005..

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GUARDING(increased muscle tension

Poor sleep)PAIN

PHYSICAL DECONDITIONING

DYSFUNCTION(reduced activity)

DECONDITIONING(decreased flexibility

and strength)

Cycle of pain, Guarding, Dysfunction, and Deconditioning(Fibromyalgia, Arthritis Foundation, 1997)

PAIN(hurt = harm)

STAGE 1(initial psychological distressfear, anxiety, worry, etc)

STAGE 2(development or exacerbation of psychological problems)

MENTAL DECONDITIONING

STAGE 3(acceptance of “sick role” abnormal illness behavior)

A Conceptual Model of the Transition from Acute to Chronic Pain Where Physical Deconditioning Leads to Mental Deconditioning

(Gatchel, 1991; Copywright 1991 by Lea & Febiger)

Anxiety

Dependence

Guilt

Depression

Anger

Family Problems

Stress

Cognitive Distortions

Medical Uncertainty

Financial Problems

Job Dissatisfaction

Pain

Factors Magnifying the Stress-Pain Cycle (Mayer & Gatchel, 1988)

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PACINGNOT PACING PACING

OveractivityModerateActivity

The ActivityThe Activity--Rest Cycle in Chronic Pain Rest Cycle in Chronic Pain (Gil, Ross, & keefe, 1988)

Prolonged Rest

Extreme Pain

Limited Rest

Depression InventoriesDepression Inventories

Beck Depression Inventory IIBeck Depression Inventory II (1996)(1996)–– 21 item self report 21 item self report –– Most widely used depression inventoryMost widely used depression inventory

Zung SelfZung Self--Rating Depression ScaleRating Depression Scale–– 20 item self report20 item self report

Hamilton Depression Rating ScaleHamilton Depression Rating Scale (1967)(1967)

The Pain Anxiety Symptoms ScaleThe Pain Anxiety Symptoms Scale40 item measures anxiety associated with 40 item measures anxiety associated with chronic painchronic pain4 subscales: 4 subscales: –– Cognitive anxietyCognitive anxiety (racing thoughts and impaired (racing thoughts and impaired

concentration)concentration)concentration)concentration)

–– Fearful appraisalFearful appraisal (fearful thoughts and expected negative (fearful thoughts and expected negative consequences of pain)consequences of pain)

–– Escape/avoidanceEscape/avoidance (overt behaviors that reduce pain)(overt behaviors that reduce pain)

–– Physiological anxietyPhysiological anxiety (physiological response to pain)(physiological response to pain)

McCracken, L. M., & Gross, R. T. Innovations in Clinical Practice: A Source Book (Vol. 14). 1995

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Pain Self Efficacy QuestionnairePain Self Efficacy Questionnaire

10 questions10 questionsRate how confident they feel to do things Rate how confident they feel to do things despite the paindespite the painE “I ith i ith tE “I ith i ith tEx. “I can cope with my pain without Ex. “I can cope with my pain without medication.” medication.” (0=not at all confident, 6=completely confident)(0=not at all confident, 6=completely confident)

Techniques that enhance mastery Techniques that enhance mastery experiences the most will be the most experiences the most will be the most powerful tools for bringing about behavior powerful tools for bringing about behavior change change (Bandura, 1977).(Bandura, 1977).

Nicholas (1994)

Pain Stages of Change QuestionnairePain Stages of Change Questionnaire

RelapseMaintenance

Permanent Exit

Kerns, R, Rosenberg, R., Jamison, R., Caudill, M., & Haythornthwaite,, J. Pain 72 (1997) 227-234.

Contemplation

Preparation

ActionPre-Contemplation

Acceptance of Chronic Pain Acceptance of Chronic Pain QuestionnaireQuestionnaire

Acceptance of chronic pain is more successful in Acceptance of chronic pain is more successful in reducing pain, depression, disability, pain reducing pain, depression, disability, pain related anxiety, physical and vocational related anxiety, physical and vocational functioning than other measures of coping functioning than other measures of coping (McCracken & Eccleston 2003)(McCracken & Eccleston 2003)(McCracken & Eccleston, 2003).(McCracken & Eccleston, 2003).

2 Factors:2 Factors:–– Activities EngagementActivities Engagement (pursuit of life activities despite pain)(pursuit of life activities despite pain)

–– Pain WillingnessPain Willingness (not necessary to control or avoid pain in (not necessary to control or avoid pain in order to pursue goals)order to pursue goals)

McCracken, L. M., Vowels, K.E. & Eccleston, C. Pain. 107 (2004) 159-166.

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“People don’t hurt if they have something better to do.”g

W. Fordyce, Ph.D.

BiofeedbackBiofeedback

Stress management Stress management through relaxationthrough relaxation

Diaphragmatic breathingDiaphragmatic breathingHeart Rate Variability Heart Rate Variability Muscle tension reductionMuscle tension reductionAutonomic system Autonomic system balancingbalancing

What Indicates Progress in Treatment?What Indicates Progress in Treatment?“Understand that prior to patients being able to come “Understand that prior to patients being able to come

to an acceptance about the permanence of their to an acceptance about the permanence of their condition, they will be feeling very much out of condition, they will be feeling very much out of control, and this can sometimes be difficult, control, and this can sometimes be difficult, particularly when treatments don’t seem to help or particularly when treatments don’t seem to help or the patient’s support system is weak. There may the patient’s support system is weak. There may be times when they become outwardly angry orbe times when they become outwardly angry orbe times when they become outwardly angry or be times when they become outwardly angry or depressed. Restoring some sense of control and depressed. Restoring some sense of control and empowering the patient is a fundamental part of the empowering the patient is a fundamental part of the treatment process.” treatment process.” DeCarvalho, L. T. The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers and Patients http://ncptsd.va.gov/facts/problems/fs_chronic-pain.html

“When successful rehabilitation occurs, there is an important cognitive shift from beliefs about helplessness and passivity to resourcefulness and ability to function regardless of pain” (Jensen, Romano, Turner, 1999; Tota-Faucette, Gil, Williams, 1993; Williams & Thorn, 1989)

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Comparative Outcomes Lit ReviewComparative Outcomes Lit ReviewIn 2002 Denis Turk looked at the clinical effectiveness and In 2002 Denis Turk looked at the clinical effectiveness and costcost--effectiveness of various tx (pharmacological, effectiveness of various tx (pharmacological, conservative, surgery, spinal cord stimulator, implantable drug conservative, surgery, spinal cord stimulator, implantable drug delivery systems and pain rehabilitation programs) for delivery systems and pain rehabilitation programs) for patients with chronic pain. patients with chronic pain. –– Pain rehabilitation programs were more effective than other tx to Pain rehabilitation programs were more effective than other tx to

reduce or eliminate opiates reduce health care utilization increasereduce or eliminate opiates reduce health care utilization increasereduce or eliminate opiates, reduce health care utilization, increase reduce or eliminate opiates, reduce health care utilization, increase functional activities, improve chances for return to work and claim functional activities, improve chances for return to work and claim closure.closure.

–– Pain rehabilitation programs were more costPain rehabilitation programs were more cost--effective than the effective than the alternative treatments (alternative treatments (Clinical Effectiveness & CostClinical Effectiveness & Cost--effectiveness of TX for Patients with effectiveness of TX for Patients with Chronic Pain . Turk; Clinical Journal of Pain, 2002)Chronic Pain . Turk; Clinical Journal of Pain, 2002)

A substantial proportion of pts who undergo spinal surgery A substantial proportion of pts who undergo spinal surgery continue to report considerable pain, functional impairment, continue to report considerable pain, functional impairment, and experience complications following tx (and experience complications following tx (Turk, DC; Pain Management: The Need for CPR In APS Bulletin, Fall 2005)

The Journal of the American The Journal of the American Medical Association (2/2008)Medical Association (2/2008)

65% increase in costs for spine tx since 199765% increase in costs for spine tx since 1997Spine problems spend $6,000 in medical Spine problems spend $6,000 in medical care in 2005 ($3,500 if no spine problem)care in 2005 ($3,500 if no spine problem)$20 billi d t f b k d k$20 billi d t f b k d k$20 billion on drug tx for back and neck $20 billion on drug tx for back and neck (increase of 171% from 1997)(increase of 171% from 1997)Costs increased: (outpt 74%, ER 46%, Costs increased: (outpt 74%, ER 46%, surgery 25%)surgery 25%)Why increase in cost for tx? Marketing drugs, Why increase in cost for tx? Marketing drugs, surgical devices, and diagnostic imaging surgical devices, and diagnostic imaging

New Treatment Guidelines for Low Back New Treatment Guidelines for Low Back Pain from APS Conducted at OHSUPain from APS Conducted at OHSU

Should not routinely obtain imaging or other dx Should not routinely obtain imaging or other dx tests in pts with nontests in pts with non--specific LBP, except for specific LBP, except for neurologic or spinal disordersneurologic or spinal disordersConduct hx and physical that includes assess for Conduct hx and physical that includes assess for psychosocial risk factors which predict risk for psychosocial risk factors which predict risk for chronic disabling back painchronic disabling back painAdvise pts to remain active and provide info about Advise pts to remain active and provide info about selfself--care optionscare optionsConsider medications, but also interdisciplinary Consider medications, but also interdisciplinary Rehab, exercise, acupuncture, massage, Rehab, exercise, acupuncture, massage, chiroprac, yoga, CBT, and progressive relaxationchiroprac, yoga, CBT, and progressive relaxation

http://www.ohsu.edu/epc/pain/index.htmAnnals of Internal Medicine, October 2007

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Hierarchy of Pain Treatment Hierarchy of Pain Treatment Developed by WHO (2006)Developed by WHO (2006)

Nerve ablation Implanted pumpsSpinal stimulationSurgeryBehavioral treatments

finish

Behavioral treatmentsNerve blocks and other injectionsNarcotics and other oral analgesicsMuscle relaxantsPhysical and occupational therapy,

Chiropractic, AcupunctureNon-steroidal anti-inflammatoriesOver-the-counter medicationsstart

ABC’s pf Pain Relief and Treatment: Advances, Breakthroughs, and Choices. Dr. Tim Sams (2006)

Feb 2005

Multidisciplinary Pain ProgramsMultidisciplinary Pain Programs

PhysiciansPhysiciansPsychologistsPsychologistsRegistered NursesRegistered NursesPhysical TherapistsPhysical TherapistsOccupational TherapistsOccupational TherapistsVocational CounselorVocational CounselorCase ManagerCase ManagerBiofeedback SpecialistsBiofeedback Specialists

The Commission on Accreditation of Rehabilitation Facilities

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Treatment Outcome for Patients in Treatment Outcome for Patients in Multidisciplinary Pain ProgramsMultidisciplinary Pain Programs

Improve Self

Management of Pain Functional

RestorationRestoration& RTW

ReducePsychological

distress

Improve QOL

Turk, D

Psychology ServicesPsychology ServicesDecrease fear of RTW and claim closureDecrease fear of RTW and claim closureAddress issues that are barriers to progress Address issues that are barriers to progress Decrease depression and anxietyDecrease depression and anxietyIncrease selfIncrease self--confidence & selfconfidence & self--esteemesteemHelp move to active stage of behavior Help move to active stage of behavior changechangeTeach stress/pain management classesTeach stress/pain management classesFlare up management Flare up management Relapse preventionRelapse prevention

ResourcesResourceswww.Chronicpainnetwork.comwww.Chronicpainnetwork.com

Pain Society of OregonPain Society of Oregon–– 541541--345345--7300 or 5037300 or 503--804804--30723072–– www.painsociety.comwww.painsociety.com

Western Pain SocietyWestern Pain Society–– 541541--345345--7300 7300 –– [email protected]@painsociety.com–– www.ampainsoc.org/societies/wps/ www.ampainsoc.org/societies/wps/

American Pain SocietyAmerican Pain Society–– http://www.ampainsoc.org/http://www.ampainsoc.org/

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