CHALLENGES OF PAIN MANAGEMENT

1. CHALLENGES OF PAIN MANAGEMENT JERRY L. DENNIS, M.D. MEDICAL DIRECTOR RIVERSIDE COUNTY DEPARTENT OF MENTAL HEALTH December 2009

2. PAIN: Scope of the Problem • THE 21th CENTURY HEALTH CARE DISASTER: • Chronic Pain: Lifetime Prevalence 60-80% • Back-Related Disability of Epidemic Proportions • Psychological, Social and Cultural Factors Play Prominent Roles in Pain and Pain-Related Disability • Pain Promotes Emotional and Behavioral Regression, and Inhibits Ability to Cope • Pain Often Initiates Cycles of Narcotic Addictions

3. PAIN: Scope of the Problem Back pain is the most prevalent medical disorder in industrialized societies Affects ~6 million Americans each year 70% of people with acute back pain recover within one month

4. Psychological Components of Chronic Pain • Disease Onset: • Job Dissatisfaction and Poor Performance Appraisals Predict Pain: • Dissatisfied with work: 2X as likely to seek Tx for pain • Feel underpaid: 4X as likely to seek Tx for pain • Lowest socioeconomic status: 5X as likely to seek Tx for pain • First back injury at work: Predicts physical work stress and psychological intolerance of the job

5. Psychological Components of Chronic Pain • Disease Progression: • Chronic low back pain is the leading cause of disability in industrialized nations • Progression from acute to chronic pain is more dependent demographic, psychological and occupational factors than on medical pathology • Blue collar jobs • Labor beyond individual’s capacity • Job dissatisfaction • Poor performance ratings • High job stress • Somatization and Depression promote progression to chronic pain • Sickness payments and litigation reinforce chronic pain

6. Psychological Components of Chronic Pain • Workers Compensation Systems Issues: • Delays in Dx and Tx • Continually must prove sickness to obtain care and compensation • Patients receiving compensation benefits fare worse with virtually any and all interventions attempted • Study of 2000 back pain patients: • 100% returned to work except • Those in litigation 0% • The longer the duration of sick/disability leave, the less likely it is that the person will ever return to work

7. Psychological Components of Chronic Pain • Good Tx Outcome Associated with: • Hx of good coping skills – Resiliency • Psychological strengths • Belief in self-efficacy • Higher socioeconomic status • Higher job satisfaction • Poor Tx Outcome • Patients with active addictions and pain have the worst outcome and are prone to: • Inordinate disability • Symptoms exaggeration • Excessive health care utilization

8. Chronic Non-Malignant Pain (CNMP) Syndrome • Persistent Pain • Not associated with progressive tissue destruction • Substantial psychological overlay • US Commission on Pain (1987): • Intractable pain of 6 months duration or more • Marked alteration of behavior with depression or anxiety • Marked restriction of daily activities • Excessive use of medication and frequent use of medical services • No clear relationship to organic disorder • Hx of multiple, nonproductive tests, Tx and surgeries

9. Psychological Components of Chronic Pain • Chronic Pain Syndrome: • Predominantly a behavioral syndrome • Affects the minority of chronic pain patients • Preceding psychiatric illness and personality disorder : 75% • Less objective physical impairment • Degree of disability varies with: • Psychological strengths of the individual • Stress of the workplace • Incentive and disincentives for recovery

10. Cognitive Factors in Pain • Maladaptive Cognitions: • Self-destructive thinking becomes automatic and habitual • Catastrophic Thinking: the worst case scenario • Increases dysfunction • Increases pain • Hinders coping • Learned Helplessness: • Think they are unable to control events in their lives • Depression and passivity increase disability and pain

11. Cognitive Factors in Pain • Locus of Control: • Internal locus of control = better functioning • External locus of control (government, employer, family, doctors, lawyers) = • Depression and anxiety • Feel helpless to deal with pain • Rely of maladaptive coping mechanisms • Blaming others for pain/injury = • More mood and behavioral disturbance • Poorer response to Tx • Lowered expectations for future benefits of Tx

12. Behavioral Components of Pain • Operant Conditioning: • Behavior that is reinforced increases the frequency of the behavior • Elimination of reinforcement leads to “extinction” of behavior • Much pain behavior and dysfunction are maintained by environmental rewards: “Secondary Gain” • Caretaking, drugs, money • Incentives: • Financial compensation associated with greater pain and reduced efficacy of Tx • Tertiary Gain: Others defend person’s disability and support helplessness

13. Cycle of Fear and Deconditioning

14. Behavioral Components of PainAffective Distress

15. Psychiatric Disorders in Pain Patients • Chronic Pain Patients: • Most common psychiatric illnesses : • Anxiety • Depression • Substance Abuse • Depression (10 - 83%) • Marked variation related to setting and overlap of symptoms of pain and depression • * Somatic pain is a common symptom of Major Depression • Depression in Chronic Pain Syndromes is highly responsive to non-pharmacological interventions • Chronic Pain Rehab Unit Study (1989) • 98% resolved by discharge and recovery persisted at 1-yr f/u

16. Psychiatric Disorders in Pain Patients • Anxiety Disorders: • Anxiety itself is mostly painless • Panic attacks often present with chest or abdominal pain • Autonomic arousal: • Moist palms, tremors, tight facial muscles, rapid pulse • Because chronic pain is often associated with trauma, PTSD is commonly co-occurring • Severe trauma promotes somatization and anxiety • Somatoform Disorders: • Non-physiological pain and “Psychogenic” pain • Pain of various sorts that do not correlate well with actual anatomical findings and known pathophysiology

17. Somatoform Disorders Psychogenic Pain • Psychogenic pain: • Analogous to Conversion Disorder • (Hysterical blindness, aphonia, paralysis) • Person may appear euthymic, animated and sleeps well, or may experience extreme dysfunction, suffers and may become suicidal • May be dramatic, claim extreme denial of non-medical problems, and appear cheerful despite perceived disability • Demonstrate behaviors that are incompatible with the degree of impairment they claim • Reliable indicator: Patient’s inability to discuss non-somatic issues

18. Dx and Tx of Fibromyalgia • Dx: • Pervasive unexplained physical Sx: • Involving at least 3 of 4 body quadrants • Of at least 3 months durations • Point tenderness at 9 bilateral locations • Chronic pain and pain behavior • Distorted ambulation • Rubbing painful body parts • Increased “Down time” • Pain behaviors are reinforced and maintained by others response to the patient • Strong Operant Conditioning • Become stuck in the “sick role”

19. Dx and Tx of Fibromyalgia • Report of Sx, functional limitations and psychological dysfunctions: • Fatigue 78% • Sleep disturbance 76% • Stiffness 76% • Headaches 54% • Depression and anxiety 45% • Irritable bowel disorders 36% • Plus • Cognitive impairments • Malaise • Patients often do not accept possible psychological basis; Not psychologically minded • 70+% meet criteria for depression • 85% % report some degree of anger

20. Dx and Tx of Fibromyalgia • Dx • Insidious onset without identifiable cause • Course is chronic and non-progressive • Sx fluctuate in severity and worse under stress • Report decreased sense of well-being • High utilizers of healthcare services • Pain does not follow known neuro-anatomical pain pathways • Labs and radiologicals are normal • Feel “exhausted” and “burned-out” • Have a low pain threshold • Hypersensitive to cold, noise and environmental irritants

21. Dx and Tx of Fibromyalgia • Tx: No known cure • Tx focused on: • Relieving pain, improving sleep and physical/emotional functioning • Non-medication Tx • Lyrica (Pregabalin) – FDA approved • Neurontin (Gabapentin) – generic alternative Rx • NSAIDS • Antidepressants • Sedative-hypnotics or non-addictive medication alternatives for insomnia • Anticonvulsant Mood Stabilizers (Depakote, etc.) Avoid any PRN medications • TX OF FIBROMAYALGIA SHOULD NEVER REQUIRE OPIATE NARCOTICS!

22. Addiction in Pain Syndromes • Prevalence of Addictive Disorders in Chronic Pain Syndromes: • Difficult to determine: • Estimate 25% have a current Substance Use Disorder • Every chronic pain evaluation should include a screen for substance use disorders • Patients of conceal substance abuse by substituting prescription drugs • Less negative perception if taking/using prescribed analgesics, benzodiazepines and sedatives (“muscle relaxants” or “sleep aids”) • Dx is hindered by lack of consensus as to what constitutes appropriate use of opioids and sedatives • DENIAL, DENIAL, DENIAL

23. PAIN AND ADDICTIVE BEHAVIOR Physiological Pain Behavior Pain and Addictive Behavior Physical S/Sx of pain proportionate to anatomical/physiological findings No S/Sx of intoxication Manages/rations medication supplies between f/u appts Physical complains may be exaggerated Frequent intoxication: slurred speech, sedation Impaired coordination Irritability and mood changes Taking too many pills at once Forgetting how many pills taken Requesting increasing dosages, early or more frequent refills needed

24. PAIN AND ADDICTIVE BEHAVIOR Physiological Pain Behavior Pain and Addictive Behavior More attentive to personal/self care Functions better with pain Tx Rejects “sick role” Family/SO/Caretakers note less irritability and mood changes Inattention to hygiene, inappropriate behaviors Functioning may be worse or does not improve “Sick role” disproportionate to pathology Family/SO/Caretaker concerns Prescriptions from multiple providers

25. Pain and Malingering • Willful deception is quite uncommon?? • 20-46% of people surveyed said they considered purposeful misrepresentation of compensation claims to be acceptable (Weintraub 1995) • No good information how frequently this occurs • More common in individuals seeking compensation or opioids than in those seeking other treatments

26. Developmental Trauma and Pain • Hx of: • Neglect loss • Abuse • Molestation • Excessive Early Responsibility • Children of Alcoholics/Drug Addicts • May lead to difficulties with: • Anger • Dependency • Helplessness • Low Self-Esteem • Women with Hx of: • Physical abuse > 5X increase in C/O pronounced pain • Sexual abuse > 4X increase in C/O pronounced pain

27. Trauma and Pain • Marked Adult Trauma, e.g.,: • Military combat • Natural disasters • Serious accidents and injuries • Significant personal losses • Etc. • Any significant physical or emotional trauma can lead to somatization and increased pain

28. Diagnosing Psychogenic Components of Pain • Functional Impairment: • Patient’s own pain drawing/diagram • Assessment of “down time”: • Hrs/day spent reclining • House-bound, bed-bound, couch-bound • Spending days in night clothes • Emotional Symptoms: • Ask about S/Sx of depression, anxiety, irritability • Refer to DSM-IV criteria for Major Depression, Generalized Anxiety Disorder, PTSD, Panic Attacks, Agoraphobia • Ask about Hx of trauma: • Childhood/Developmental • Adult

29. Diagnosing Psychogenic Components of Pain • Family, SO, Caregiver Response: • Supportive, encouraging function • VERSUS • Enabling, promoting “sick role” • Identify Stressors • Litigation/Pursuing Disability?

30. Diagnosing Psychogenic Components of Pain • Collateral Information: • Actively seek info from other sources • **HIPAA: • Supports/allows for direct provider to provider communications without release • Does not limit ability to listen and ask questions of those who call

31. Diagnosing Psychogenic Components of Pain • Physical Examination and Testing: • Impairment should not exceed pathology • Do observed signs of impairment change with distraction? • Obtain and review actual reports of labs, radiologicals, MRI/CT scans • Don’t depend of patient reports of findings • Obtain reports from other providers: • Ask about pain medication prescriptions • MSE: • Is affect appropriate and congruent with the degree of pain alleged? • Check for cognitive impairments/memory loss

32. Diagnosing Psychogenic Components of Pain • Internal vs. External Locus of Control • Does patient accept responsibility to actively participate in his/her recovery? • Is everything contingent upon the government, the company, doctors, lawyers, spouse? • Psychogenic pain patients focus more on blame, retribution, and compensation than recovery • Is there a Hx of non-compliance with reasonable medical expectations or lack of active effort to recover? • Presence of secondary gain does not validate psychogenic nature of pain • Presence of secondary gain does not invalidate organic basis of pain

33. Diagnosing Psychogenic Components of Pain • Psychological Testing: • MMPI may be useful to identify psychological components or validate observed findings • Personality styles, S/Sx of mental disorders • Neuropsychological Assessments: • Most helpful in sorting out cognitive impairments and perceptual abnormalities • Results still must be correlated with actual physical findings and clinical observations

34. Psychological Approaches to Pain Tx • Non-pharmacological Treatment: • Physical Therapy: • Chronic pain causes deconditioning • PT is a form of systematic desensitization • Helps overcome “Learned Helplessness” • Pt actively participates in rehab to achieve success and is empowering • Behavioral Modification: • Behavioral changes are initiated by changing the environmental consequences of pain • Rewards, social reinforcements contingent upon healthy behaviors • In PT, praise, rest and other “rewards” follow actual completion of a goal, not just for trying.

35. Psychological Approaches to Pain Tx • Behavioral Modification: • Family/SO/Caregiver may promote invalidism by unnecessary coddling, over-accommodating pain behaviors • Must learn to ignore pain behaviors and get out of caretaker role • Reinforce patient self-sufficiency and change roles from caregiver to companion, friend, partner • Education: • Pathology of pain including the brain • Difference between “hurt” and “harm” • Reconditioning programs may initially increase pain • Family/SO/Caregiver: • Worst Tx is rest/inactivity; Activity is beneficial

36. Psychological Approaches to Pain Tx • Cognitive Behavioral Therapy: • Patient learns to identify negative, harmful and inappropriate patterns of thinking • Patient learn to challenge these thoughts and substitute more positive, self-supportive and helpful thoughts • Patient learns to gradually alter automatic inappropriate thinking and their resulting negative behaviors • Patient learns to develop an internal locus of control that helps empower success in rehab

37. Psychological Approaches to Pain Tx • Stimulus Reinterpretation: • Learn to replace catastrophic thinking and statements with more realistic, rational thinking • Assertiveness Training: • Positive self expression helps overcome remaining in the “sick role”

38. Psychological Approaches to Pain Tx • Biofeedback/Relaxation Training: • Various methods/electronic devices helps regulate skeletal muscle tension, GI motility and pulse, e.g. TENS units • Thermal Biofeedback: • Training in warming extremities (Raynaud’s Syndrome) • EMG Biofeedback • Progress Muscular Relaxation Training • Meditation, Yoga, Tai Chi • Self-Hypnosis • Family Therapy: • Family members learn to overcome being controlled by illness, impairment and disability

39. Psychological Approaches to Pain Tx • Self-Help Groups: • American Chronic Pain Association • Multidisciplinary Pain Rehabilitation Programs/Clinics: • Multiple modalities of treatment tailored to maximize comfort and improving functioning • Results of studies: • 14-60% reduction in pain • Up to 75% reduction in opioid use • Dramatic increase in functioning • 43% more were working after Tx • 90% reduction in physician visits • 50-65% fewer surgeries • 65% fewer hospitalizations • Major health care cost savings

40. Non-Opioid Medications in Pain Tx • Non-Opioid Analgesics: • NSAIDS: • Most widely used for mild-moderate pain • Used alone or in conjunction with opioids • Mechanism of action: Prostaglandin inhibition • Ceiling level beyond which increasing dose is not effective • GI side effects: Nausea, vomiting, GI bleeding • Renal and hematological toxicity • Antidepressants: • Efficacy better demonstrated for TCAs; SSRIs less effective • Analgesic effects independent of antidepressant action: • Enhance opioid effect at opioid receptors • Most effective for neuropathic pain

41. Non-Opioid Medications in Pain Tx • TCA antidepressants: • Side effects great; Often poorly tolerated: • Dry mouth, burred vision, constipation, sedation, orthostatic hypotension, cardiac arrhythmias • Anticonvulsants or Anti-Epileptic Drugs: • Mechanism of action unknown • Most effective for paroxysmal or lancinating pain, e.g., Trigeminal Neuralgia, Post-Herpetic Neuralgia • Medications: • Carbamazepine, Valproic Acid, Gabapentin • Clonazepam (Benzo and Anticonvulsant): Painful Spasms • Alfa-Adrenergic Agonist: • Clonidine: Limited use for neuropathic pain

42. Non-Opioid Medications in Pain Tx • Muscle Relaxants: • Spasmolytic Agents: • Baclofen, Tizanidine, Benzodiazepines • Useful in MS and upper motor neuron lesions from trauma, CV disease, degenerative disease • Cyclobenzaprine: Sedating; short term use only • Methocarbamol, Carisoprodol, and Chlorzoxazone: • Abuse potential with no demonstrated efficacy

43. Sleep and Pain: • Pain interfere with sleep • Sleep deprivation increases pain intensity • Sleep problems worsen other emotional difficulties: depression and anxiety • Insomnia needs to be addressed to help decrease pain and suffering: • Educate patient on sleep hygiene • Avoid combining benzos + opiates! • Instead try: • NSAIDS • Hydroxyzine • Diphenhydramine • Trazadone

44. Interventional Procedures • Anesthetic Infusions • Trigger Point Injections • Local Nerve Blocks • Spinal Steroid Injections and Facet Injections • Sympathetic Nerve Blockade • Spinal Cord Stimulation • Physical Medicine and Rehab Therapies • Heat • Cold • TENS (Transcutaneous Electrical Nerve Stimulation) • Massage • Exercise • Acupuncture • Botulinum Toxin

45. Opioids in Pain Management • **Concerns: • Physical dependence • Tolerance • Addiction • Abuse • Diversion • Physical Dependence: • Occurs 2-10 days after continuous use • Characteristic withdrawal syndrome: • Diarrhea, piloerection, sweating, mydriasis, mild increased BP and P, CNS arousal, irritability, anxiety, insomnia • Abdominal cramps, deep bone pain, diffuse muscle aching • Intense craving to relieve withdrawal syndrome • Intensification of pain

46. Pathophysiology of Addiction • Mesolimbic Dopaminergic System of the brain is the primary site of dysfunction caused by abused drugs • Substitution of a drug reward for a natural reward: • Biological rewards (e.g., sex) • Cultural rewards (e.g., stable relationships) • Effects of drugs in the Amygdala involve multiple neurotransmitters • Dopamine (D-2) • Opioid Peptides • Serotonin (5-HT) • GABA • Glutamate

47. Pathophysiology of Addiction • Most drugs cause reward/pleasure by: • Disinhibiting the dopamine system • Increasing dopamine stimulation • Increasing glutamate release • Affect the mid-brain and limbic structures: • Ventral Tegmental Area (VTA) • Amygdala/Nucleus Accumbens • Cortical Connections • Pre-frontal Cortex

48. Pathophysiology of Addiction • Mu Opioid Receptors: • High concentration in the Ventral Tegmental Area (VTA), Amygdala and Nucleus Accumbens GABA-ergic neurons • Progressive drug use causes changes in structure and function of the Mesolimbic circuitry • Progressive drug exposure cause changes in neuroplasticity leading to addition/addictive behaviors

50. Pathophysiology of Addiction • Stimulation of Mu Opioid Receptors : • Inhibits release of GABA • Increases firing of Dopamine neurons in the Nucleus Accumbens • Increased levels of Dopamine in the Nucleus Accumbens elicits behaviors characteristic of addiction • Drug (Opiate)-Induced neuroplasticity changes sustain behaviors characteristic of addiction (craving, increase tolerance, affect drug satiety)