Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach

1. Chronic Pain and The Drug-Seeking PatientA Behaviorist Approach Glenn J. Treisman, MD, PhDProfessorDirector, AIDS Psychiatry ServiceThe Johns Hopkins Medical InstitutionsBaltimore, MD From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.

2. Pain • Pain is made up of 2 parts: • A sensory experience associated with physical manipulation • An emotional response of distress and anxiety related to the sensory information

3. What do we mean by the term “Chronic Pain”? • Chronic pain which is the result of ongoing acute injury • Pain which is provoked by ongoing chronic injurious process such as malignancy, tissue destruction or chronic infection • Chronic pain which is the result of an adaptation of the nervous system to injury • Pain which continues when the original injury that provoked the initial pain has resolved

4. Reinforcers of healing • Life reinforces getting well • Social • Occupational • Romantic • Sexual • Financial • Self image

5. Abnormal illness behavior • The patient is not entitled to the sick role he expects • The patient continues his expectation despite being told it is inappropriate • Issy Pilowsky

6. Examples of reinforcers in abnormal illness behavior • Positive reinforcers • Disability payments • Attention from spouses, family, doctors, lawyers • Ability to express prohibited feelings • Possibility of “lump sum” payments • Negative reinforcers • Relief from stress, expectations and criticism • Relief from pain and discomfort

7. What makes patients seek narcotics when they are not helping? • Conditioning • Relief from distress in life • Transient relief from pain • Addiction

8. Addiction Behavior Reward Depression Inflammation and cytokines Sympathetic activation and stress Decreased reward sensitivity Increase in stimulus seeking Decreased self preservation Day-night cycle disruption HIV and HEP C Chronic disease HIV and Hep C Lipids

9. Simplified model of temperament Percent of population Introversion Punishment avoidant Future directed Function directed Extraversion Reward directed Present directed Feeling directed

10. Goals of behavioral therapy • Not directed at elimination of pain per se • Pain may diminish because of reconditioning and rehabilitation • Improve function • Improve quality of life • Decrease iatrogenic morbidity

11. Behavioral approach to chronic pain treatment • Develop a behaviorally based plan for rehabilitation that includes a set of rewards and consequences • Use cognitive-behavioral therapy to change behavior • Treat psychiatric co-morbidity

12. Role induction • Describe the role of the doctor and the patient • Explanation of the diagnosis and goals of treatment • Firm limits combined with advocacy • Focus on problems in the patient’s life • Focus on behavior and rehabilitation and away from feelings

13. Target behaviors for pain treatment • Time-contingent medications (and taper) • Graded activation (exercise) • Social reinforcement (spouse) • Self control skills • Self monitoring • Self reinforcement • Relaxation training

14. Treat psychiatric co-morbidity • Depression • Personality vulnerabilities • Life experiences