Pain

1. Pain

2. Physiology of Pain • Nociceptors • Stimulus Transmission • Termination • Modulation

3. Physiology of Pain • Multiple • Redundant • Reciprocal • Complex

4. Assessment of Pain • Immediate Pain • Physical Functioning • Psychological Factors • Pain Behaviors • Objective Correlates

5. Assessment: Immediate Pain • Intensity • Location • Affective Response • Composite Measures

10. Assessment: Physical Fx. • Impairment • Functional limitation • Disability

11. Assessment: Psych factors • Influence vs. causation • Mediation • Reinforcement • Resonators • Pain beliefs

12. Assessment: Pain Behavior • Observation • Role of learning

13. Composite Pain Scales • Attempt to measure one or more dimensions of the pain experience

15. History Intensity Comorbid Quality Objective Data Side effects

16. Assessment: Objective Indicators • Ex. Electromyography “Well, Phil, after years of vague complaints and imaginary ailments, we finally have something to work with.”

18. Diagnosis • Categorization • DSM and Pain • Other Approaches to “Somatoform Pain”

19. Categorization • Acute versus Chronic

20. Acute Pain • Not just time • Clearer association • Subtypes (ex. Recurrent?) • “nociceptive pain”

21. Chronic • Association? • Types • By presumed etiology • Neurologic pain • Ideopathic • By course

22. DSM-IV The concept of Somatoform Pain

23. DSM and pain • I (1952) • Psychophysiological disorders“ • “Psychoneurotic Disorders” • II (1968) • Hysterical neurosis

24. DSM and pain • III (1980) • Psychogenic Pain • “incompatible” or “INXS” • Etiologically related • III-R (1987) • Somatoform pain • Dropped etiology part

25. DSM and pain • IV • Pain Disorder • Pain=predominant focus • Substantial distress/impairment • Psych factors “have role” • Onset or expression • Not malingering/factitious disorder

26. Problems with DSM • Utility • How to judge? • Physical versus Psychological • Etiology • DSM-IV • Mind-body dichotomy remains • Division of pain based on this.

27. True psychogenic pain

28. DSM-IV pain tested • Psychological vs. Psychological+Medical Distinction • No difference on • Pain measures • Intensity • Type • Level of disability (Aigner et al, Compr Psychiatry 1999)

29. Other approaches to diagnosing pain

30. IASP 5 axis system • Anatomical region • Organ system • Temporal characteristics/patterns • Intensity, time since onset • Etiology

31. IASP • Psychological pain • “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”

32. Other approaches • Dimensional • Take into account various aspects of pain • Objective findings/physical etiology • Perceptual influences • Presentation

35. Treatment of Pain

36. Treatment of Pain • Pharmacologic • Psychological • Other somatic treatments • Importance of Multimodal • Cormorbid treatments • Role of C/L Psychiatrist

37. Pharmacological Treatment • “True” Analgesics • Everything Else “Yes Billy, but Mr. Phillips pushes legal drugs.”

38. “True” Analgesic • NSAIDS • Opioids • Local agents

39. NSAIDS • Mechanism • Indication • Side effects

40. NSAIDS • Standard • Acetaminophen • Ketorolac • COX-2 inhibitors

41. Opioids • Mechanism of action • Indication • Side effects • Common • Uncommon but problematic

42. Some Typical Opioids

43. Combination Opioid/NSAIDs *caffeine † butalbital ‡agonist-antagonist

44. Relative Potency

45. Treatment Approach

46. Treatment Approach • MEC • Role of pharmacokinetic • Toxicity • Slow-release preps

47. Concerns • Tolerance • Dependence • Addiction

48. Overvalued Concerns • Addication • Overdose and death • Discipline “Damn! I suppose this means another malpractice suit.!”

50. Antidepressant Anticonvulsants Local Analgesics Antihistamines Antipsychotics Benzodiazepines Stimulants Cannabinoids Placebos Adjunctive and other meds