Understanding and Living Well with Chronic Pain Pierre Morin, MD, PhD

1. Understanding and Living Well with Chronic PainPierre Morin, MD, PhD

2. Basel

4. Medical Models • Bio-medical model • Social determinant model • Bio-psycho-social model • Psychodynamic model • Positive psychology (Seligman), Positive health model (Antonovsky) • Indigenous model • Recovery/Self-management model • Process model (Mindell)

5. Bio-medical model Environment Psychology •  • Biologic predisposition Disease  Clinical Outcome •  Illness • Characteristics: unilinear; disease fully explains the illness; biological determinants are both necessary and sufficient for disease its diagnosis and cure; psychology may be a secondary influencing factor. There is no explanation for illness without disease.

6. Social determinant model Diseases are influenced and caused by social processes: Social status, Rank, Social dynamics of prejudice and marginalization based on gender, race, sexual orientation etc… create ongoing stress which cause disease.

7. Bio-psycho-social model • Environment Psychosocial modifiers •  • Biologic/ predisposition Disease  Clinical Outcome • Psychological  Illness • Illness and disease result from simultaneously interacting systems at the cellular, tissue, organ, and interpersonal and environmental levels

8. Psychodynamic model Illness and disease have an adaptive function. They are meaningful processes that are embedded in a person’s individual and collective life and environment. They are the best solution so far and promote healing and growth. Physiologic states are metaphors for individual and social processes.

9. Positive psychology/ Positive health model What prevents us from getting ill physically and mentally? What are the characteristics of people who stay healthy despite adverse circumstances? What are the strengths and virtues that act as buffers against illness? How do we amplify and foster these strengths and virtues? Instead of focusing on curing/treating pathologies positive psychology/health sees health as a continuum and is interested in the factors (resilience, sense of coherence, meaningfulness) that give our lives purpose, allow us to stay healthy and cope with our limited health.

10. Indigenous model • Relationship to Nature, the ancestors, the spirit world is relevant for staying healthy. • Relationship dynamics are a relevant factor for causing disease: jealousy, the evil eye, being “outcasted” by the tribe etc…

11. Recovery/Self-Management Model I Recovery is an individual’s journey of healing and transformation to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential.

12. Recovery/Self-Management Model II • Clients have primary control over decisions • Based on concepts of strength and empowerment • Provide education • Living with Symptoms instead of getting rid of them • A meaningful life is possible despite serious/chronic symptoms • Adaptation to issues of diversity

13. Recovery/Self-Management Model III • Increasing knowledge about illness • Engaging in activities that promote health • Coping more effectively and reducing distress from symptoms • Reducing social exclusion • Increasing self-confidence

14. Process Model of Medicine • Procrustes and his bed: ignoring/marginalizing dreamlike and creative qualities of life allows us to create a consensual everyday reality and function in life. Marginalized realities reappear imbedded in things we call problems and symptoms.

15. Pain

16. Pain/Chronic Pain Definition • An unpleasant sensation and an emotional experience associated with a real or potential damage to tissue, or the equivalent of such damage. • Pain without apparent biological value that has persisted beyond the normal tissue healing time (usually taken to be 3 months)

17. Names Amplified Musculoskeletal Pain, Reflex Neurovascular Dystrophy, Reflex Sympathetic Dystrophy, Sympathetically Maintained Pain, Fibromyalgia, Algodystrophy, Complex Regional Pain Syndrome Types I and II, Causalgia, Sudeck’s Atrophy, Shoulder-Hand Syndrome, Repetitive Strain Injury, Plantar Fasciitis, Localized or Diffuse Idiopathic Musculoskeletal Pain, Neuropathic Pain, Central Pain, Psychogenic Pain, Psychosomatic Pain

18. Epidemiology/Prevalence/Impact • 9 - 11% of the U.S. population suffer from moderate to severe chronic pain. • Women are more likely to suffer chronic pain than men. • On average it is present almost 6 days in a typical week. • Only ½ of chronic pain sufferers say their pain is pretty much under control. • Chronic pain is the most common complaint made by patients to their Primary Care Providers. • It accounts for an estimated $75-$100 billion a year in the U.S. in lost productivity and health care costs.

19. Specificity Theory of Pain: • The intensity of pain is directly related to the amount of associated tissue injury. For instance, pricking one’s finger with a needle produces minimal pain, whereas cutting one’s hand with a knife causes more tissue injury and is more painful. This theory is generally accurate when applied to certain types of injuries and the acute pain associated with them. It is inadequate to explain chronic pain.

20. Gate Control Theory: • Perception of physical pain is not a direct result of activation of pain receptor neurons, but instead is modulated by interaction between different neurons. Before they can reach the brain pain messages encounter “nerve gates” in the spinal cord that open or close depending upon a number of factors (possibly including instructions coming down from the brain). When the gates are opening, pain messages “get through” more or less easily and pain can be intense. When the gates close, pain messages are prevented from reaching the brain and may not even be experienced.

21. Loesser’s Onion Theory of Pain: • This says that the pain mechanism is a series of nested layers, like the ones of an onion. The nerve stimulus or damage is at the centre, the next layer is the perception of pain, then come suffering, pain behavior, and finally interaction with the environment.

22. Nociceptive Pain: • Pain that is a result of tissue irritation, impending injury, or actual tissue injury sensed by pain receptors. Pain receptors are the nerves which sense and respond to parts of the body which suffer from damage. When activated, they transmit pain signals (via the peripheral nerves as well as the spinal cord) to the brain. The pain is typically well localized, constant, and often with an aching or throbbing quality. Visceral pain is the subtype of nociceptive pain that involves the internal organs. It tends to be episodic and poorly localized.

23. Neuropathic Pain: • Can occur as a result of injury or disease to the nerve tissue itself. This can disrupt the ability of the sensory nerves to transmit correct information to the thalamus, and hence the brain interprets painful stimuli even though there is no obvious or known physiologic cause for the pain. Neuropathic pain is the disease of pain. It is not the sole definition for chronic pain, but does meet its criteria.

24. Referred Pain: • Is a phenomenon used to describe pain perceived at a site adjacent to or at a distance from the site of an injury's origin. One of the best examples of this is during heart attack. Even though the heart is directly affected the pain is often felt in the neck, shoulders and back rather than the chest.

25. Sympathetically Maintained Pain: • This condition used to be called a reflex sympathetic dystrophy. It is also known as algodystrophy, Sudeck’s atrophy and a host of other names. It is now called, by the International Association for the Study of Pain, a “complex regional pain syndrome”. Sympathetically maintained pain is believed to be maintained by the sympathetic nervous system or by circulating catecholamine.

26. Peripheral and Central Sensitization: • Amplification of pain stimuli produces secondary heightened sensitivity.

27. Hyperalgesia: • Lowered pain threshold, which in one form is caused by damage to pain receptors in the body's soft tissues. Conditioning studies have established that it is possible to experience a learned hyperalgesia.

28. Allodynia: • Meaning "other pain", is the perception of pain caused by usually nonpainful stimuli, such as touch or vibration. An example of allodynia is when a person perceives light pressure or the movement of clothes over the skin as painful, whereas a healthy individual will not feel pain. Several studies suggest that injury to the spinal cord might lead to loss and re-distribution of pain receptors and pain modulating neurons leading to the new response.

29. Pain and Memory: • Conditioning and sensitization can be seen as a learning process at different levels. In addition, memory traces of pain get stuck in the brain’s prefrontal cortex which controls emotion and learning. Abnormal implicit memories of pain and emotional associations will influence associative learned behaviors, e.g. avoiding certain movements which will increase the chance to develop chronic pain.

30. Hebbian or Associative Learning • Any two cells or systems of cells that are repeatedly active at the same time will tend to become 'associated', so that activity in one facilitates activity in the other.

31. Long-term Potentiation • Long-lasting enhancement in communication between two neurons that results from stimulating them simultaneously. Since neurons communicate via chemical synapses, and because memories are believed to be stored within these synapses, LTP and its opposing process, long-term depression, are widely considered the major cellular mechanisms that underlie learning and memory.

32. Fear-Avoidance Model

33. Pain and Trauma/Abuse • Beliefs that trauma and pain are unpredictable and uncontrollable. • Sense of feeling victimized by pain. • Fears and avoidance of activities that will be painful. • Avoidance behaviors lead to inactivity that will worsen pain.

34. Regaining Ownership/Control • Chronic pain as a trauma that needs to be re-conquered. • Integrating “Painmaker” and “Traumatizer” • Like Native Americans used to inflict themselves with a wound once they had been wounded by an adversary.

35. Psychological Assessments • Pain Questionnaire/Inventory • Depression/Learned Helplessness • Anxiety Sensitivity (fear of anxiety-related bodily sensations) • Cognitive & Behavioral Avoidance • Coping Styles • Beliefs and Expectations • Self-efficacy/Sense of Coherence • PTSD Checklist/Abuse

36. DSM IV/Somatoform Disorder • Conversion disorder, hypochondriasis, body dysmorphic disorder, pain disorder, undifferentiated somatoform disorder, somatization disorder. • (Not factitious disorder, malingering).

37. Multidisciplinary Pain Treatment/Management • Medication/Pharmacotherapy • Physical Therapy, Occupational Therapy • Psychology • Retraining the Nervous System • Alternative/Complementary Medicine • Interventional Medicine • Self-management/Education

38. Medication • Over the Counter Medication (Acetaminophen, Tylenol, Paracetamol) • NSAID (Ibuprofen/Advil) • Narcotics/Opioids (Morphine, Methadone, Oxycodone, Oxycontin, Fentanyl) • N-Type Ca-Channel Blocker (Sea snail venom) • Na-Channel Blockers (Antikonvulsant) • Vanilloid/Capsaicin Receptor Blockers (Chili pepper) • Antidepressants

39. Interventional Pain Management • Nerve Blocks • Spinal Cord Stimulation • Implantable Opioid Pumps

40. Ramachandran/Phantom limb/Mirror box • A mirror box is a box with two mirrors in the center (one facing each way) to help alleviate pain. • The non-painful limb is projected onto the hurting side in order to retrain the brain, and thereby eliminate the learned paralysis/pain.

41. Retraining the Brain • Vigorous exercise and talk therapy are used to retrain pain patient’s brain to recognize pain signals differently.

42. Self-management • Allopathic Medicine • Complementary Medicine • Allostasis/Stress-management/Relaxation • Advocacy/Empowerment/Rank/Leadership • Education/Behavioral changes • Family/Peer/Community support • Psychology/Picking up the energy (painmaker/traumatizer)

44. Hierarchy and Health • Marmot’s Whitehall Study of British Civil Servants • Hierarchy and Social Inequality leads to more illness and early death • Allostasis/Allostatic Load: The burden of cumulative adversity • Coping: Sense of Coherence

46. Health Disparity • Relative poverty • Disparity between the rich and the poor: High gap correlates with poor population health. • Social comparison: Feelings of humiliation, resignation and shame affect our stress physiologies.

47. Health Olympics/US Ranking • Life Expectancy: 29 • Teen Birth: 28 • Educational Opportunities: 21 • Child Poverty: 25 • Child Abuse Death Rates: 26 • Child Injury Death Rates: 23

48. Rank • Rank reflects the underlying power differences of the many hierarchies we use on a daily basis to compare ourselves (Fuller, 2003). • Conscious or unconscious, social or personal ability or power emerging from areas of socio-cultural influence, personal psychology, and/or spiritual ties (Mindell, 1995) .

49. Subjective Rank and Health

50. Rank Dimensions • Social Rank • Psychological Rank • Spiritual/Transpersonal Rank • Contextual Rank