Transcript Chronic Pain and Spirituality 2015 - St. Luke`s Physicians` Guild of

Pain, Suffering, and
Spirituality:
How the Catholic Faith can
Help Chronic Pain Patients
Robert Hauptman BMSc, MD, MCFP
Pain Consultant
President AMA Section of Chronic Pain
Objectives
● To discuss the problem of chronic pain in Canada
● To briefly look how the nervous system changes in
chronic pain
● To discuss treatment options
● To discuss suffering and pain and how the Catholic
Church can help our patients cope with their pain
The Problem of Pain
● Chronic non-cancer pain (CNCP) affects substantial and growing
numbers of Canadians
● The prevalence of CNCP in the general population is about 20 to
30%
● Visits for chronic pain are a substantial proportion of a family
physician’s schedule, given the prevalence
● Low-back pain is among the most common cause of CNCP
● Given the fact that Canada’s population is aging, chronic pain will
likely become a more significant public health issue in the near
future
National Opioid Use Guideline Group (NOUGG), 2010.
Epidemiology of chronic pain from three large, high
quality surveys of adult general populations
✓Blyth et al PAIN (2001): N = 17 543 Australia
pain most days for 3 months:
✓Eriksen et al PAIN (2003): N = 20 000 Denmark
18.5%
pain lasting more than 6 months: 19 %
✓Breivik et all EJP (2004): N = 30 701 in 12 European countries
pain >6 months > 5/ 0-10 pain scale =
18%
Impact of CNCP
● Individuals with chronic pain fare worse vs. the healthy population in
terms of quality of life, diminished functional status, and lost productivity1
● Average duration of pain: 10.7 years (range 9.4–13.2 years)2
● Almost 50% unable to attend social and family events2
● Prevalence of concomitant depression in individuals with CNCP is more
than 30%3
● Mean number of days absent from work over 1 year due to chronic
pain: 9.32
1. Whitten CE, et al. Perm J. 2005;9(2):41-8.
2. Moulin DE, et al. Pain Res Manag. 2002;7(4):179-84.
3. Rashiq S, et al. Pain Res Manag. 2009;14(6):454-60.
Chronic Pain: Societal Costs
Work losses:
$42 Billion / yr
Health Care:
$11 Billion / yr
Total:
$53 Billion / yr
This is more than diabetes, cancer and heart
disease combined!!
Schopflocher, 2011
“Chronic pain affects an estimated 116 million
American adults – more than the total affected by
heart disease, cancer and diabetes combined.
Pain also costs the nation up to $635 billion each
year in medical treatment and lost productivity”
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What Patients Tell Us
● Not believed
● Not heard
● Accused of addiction
● Abandoned
● Alone
What is Pain?
● Pain is the physiological process that warns us of
potential or actual danger
● Generally pain is associated with tissue damage
● Pain is a sign of a healthy brain
● Pain is protective
● Normal pain is not a disease but a symptom
● Acute pain = healthy brain
What is Chronic Pain?
● Pain that lasts longer than 6 months or beyond normal
tissue healing
● Not associated with tissue damage
● Chronic pain is a symptom of an unhealthy brain
● Rewiring and amplification of the nervous system
● Chronic pain = unhealthy brain
● Chronic pain is a disease
Acute Pain Pathways
Descending
excitation/inhibition
Tissue damage
Inflammation
Nerve compression
5-HT, Bradykinin, Cytokines,
Histamine, Prostaglandins
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Attention
Expectation
Affect
Dynorphin A, CCK
5-HT, NE, GABA
EAAs NMDA receptors
SubP, NGF, NK1, CGRP, NO
CCK = cholecystokinin; 5-HT = 5-hydroxytryptamine; NE = norepinephrine; GABA = γ-aminobutyric acid; EEA = excitatory amino acid; NMDA = Nmethyl d-aspartate; SubP = substance P; NGF = nerve growth factor; NK1 = neurokinin 1; CGRP = calcitonin gene-related peptide; NO = nitric oxide.
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Chronic Pain Pathways
Impaired Descending
Pathways
No tissue damage
Abnormal Na Channels
Spontaneous pain
Altered
Perception
Impaired Pain
Processing
Dynorphin A, CCK
5-HT, NE, GABA
Neuronal
plasticity
5-HT, Bradykinin, Cytokines,
Histamine, Prostaglandins
Peripheral
EAAs NMDA receptors
SubP, NGF, NK1, CGRP, NO
Sensitization
Central
CCK = cholecystokinin; 5-HT = 5-hydroxytryptamine; NE = norepinephrine; GABA = γ-aminobutyric acid; EEA = excitatory amino acid; NMDA = Nmethyl d-aspartate; SubP = substance P; NGF = nerve growth factor; NK1 = neurokinin 1; CGRP = calcitonin gene-related peptide; NO = nitric oxide.
How Do You Explain Pain to Patients?
Hardware vs. Software
Hardware:
• Nerves, spinal cord and brain
• Measured with MRI, CT, X-ray
Software:
• Program which runs the
hardware
• Measured with brush,
pin prick
Pain and Suffering
N
O
C
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C
E
P
T
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N
Emotions
P
A
Cognition
I
N
Environment
SUFFERING
The Experience of Chronic Pain
● Physical
● The location and cause of the pain
● Fibromyalgia, OA, chronic back pain
● Cognitive
● What the patient thinks about the pain
● Influenced by previous experiences and up bringing
● Emotional
● The feelings a patient has around their pain
● Spiritual
● The deeper meanings of pain and suffering
Social
Behaviours
Suffering
Pain
Nociception
“Pain is something that
happens to a body…
Suffering is something that
happens to a person.”
How do we assess suffering?
● The NRS Pain Scale
● Pain Catastrophizing Scale
● History
● Collateral information
● “What are you doing for fun in your life?”
CNCP Management: The Six
Pillars
● Lifestyle modification – exercise, sleep and nutrition
● Psychological interventions
● Physical therapies
● Optimizing medications
● Interventional therapies
● Spirituality and Faith
CNCP Management: The Six
Pillars
● Lifestyle modification – exercise, sleep and nutrition
● Psychological interventions
● Physical therapies
● Optimizing medications
● Interventional therapies
● Spirituality and Faith
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● “Every problem we experience has a spiritual
dimension, bot often we leave the spiritual dimensions
of things unconsidered”
Matthew Kelly “Rediscover Jesus”
Religious beliefs
might engage
descending
inhibitory pain
systems via the
DLPFC
Wiech K. et al. Pain 2008;
139:467-476
● Adverse emotions (chronic anger, etc) are associated
with increased pain and with increased opioid
requirements (Bruehl et al. 2002)
● Lack of forgiveness is associated with low back pain
(Carson et al. 2005)
St. John Paul II
● Mother died when he was in third grade
● His only sibling – his older brother – died 3 years later
● He discovered his father dead on the floor in their
apartment
● He did hard labor in a stone quarry in WWII
● He was run down by a German truck and nearly died
● He was shot by an Islamic assassin when 60
● He suffered from debilitating Parkinson’s disease
Salvifici Doloris:
On the Christian Meaning of Human Suffering
● St. John Paul II’s apostolic letter on the meaning of
suffering
● Human suffering is a reality and a great mystery
● The story of humanity is the story of Jesus Christ
● We must look to Jesus to answer the question of
suffering
The Purpose of Suffering
● Charity
● Humility
● Transformation
● Punishment
Charity
● Sometimes suffering makes an important good possible
● If God eliminated suffering, the corresponding good also
would be eliminated
● “We could say that suffering…is present to unleash love
in the human person, that unselfish gift of one’s “I” on
behalf of other people, especially those who suffer.”
(SD 29)
Humility
● Suffering can bring us closer to what is good and draw
us away from obstacles to achieving happiness
● Pain can turn us away from evil and draw us closer to
others and to God (SD 12)
● Suffering breaks down our desire to be God
● “To suffer means to become particularly susceptible,
particularly open to the working of the salvific powers
of God offered to humanity in Christ. In Him God has
confirmed his desire to act especially through
suffering” (SD 23)
Transformation
● History provides many examples of sinners transformed
to saints through suffering
● “Down through the centuries and generations it has
been seen that in suffering there is concealed a
particular power that draws a person interiorly close to
Christ” (SD 26)
Punishment
● Sometimes sinful actions lead directly to painful
repercussions and suffering
● However, “While it is true that suffering has a meaning
of punishment when it is connected with a fault, it is
not true that all suffering is a consequence of a fault”
(SD 11)
Jesus Christ and Suffering
● Christ endured the greatest suffering of all
● Not only was his suffering physical and mental but
deeply spiritual
● He endured the greatest pain of all – alienation from the
heavenly Father caused by the totality of human sin
● “And about the ninth hour Jesus cried with a loud voice,
saying: Eli, Eli lamma sabacthani? that is, My God, my
God, why hast though forsaken me?” Matt 27:46
Suffering and Salvation
● Suffering has a purpose – a higher call
● Through the suffering of Christ man is not only
redeemed but suffering is given a purpose (SD 24)
● The sufferer can share in the redemptive work of Christ
(SD 19)
● “A source of joy is found in the overcoming of the sense
of the uselessness of suffering … The discovery of the
salvific meaning of suffering in union with Christ
transforms this depressing feeling … the suffering person
“completes what is lacking in Christ’s affliction” … the
certainty that in the spiritual dimension of the work of
redemption he is serving the salvation of his brothers
and sisters” (SD 27)
● Colossians 1:24
● “… man can endure anything if he has reason to live.
Conversely, man can endure nothing if he does not.”
● Christopher Kaczor Professor of Philosophy
Catholic Answers
The Protestant’s Dilemma:
The Cross without Suffering
Back to our Chronic Pain Patients
● Pain is a number – a description of a feeling
● Suffering is how pain affects our patients spiritually,
physically, mentally and emotionally
● Our job is not as much to relieve pain but to relieve
suffering
● Hope is found in dealing with all dimensions of pain
including the spiritual
Practical Tips
● Help patients to reflect on how pain and their choices
have affected their lives
● Explore positive ways to reclaim back their lives
including SMART goals
● Explore the deeper meaning of pain and spirituality
including how pain can give us a new purpose and
deeper meaning of our lives
● Remember the Cross – we don’t have to suffer in vain
● The sacraments of reconciliation and eucharist
SMART goal setting
● Specific
● Measurable
● Achievable
● Realistic
● Timely
Patient Resources
● “The Tears of God: Going on in the Face of Great
Sorrow or Catastrophe” Father Benedict Groeschel
● “The Problem of Pain” CS Lewis
● “The Rhythm of Life” Matthew Kelly
● Web based resources:
● People in Pain Network
● painAction.com
Conclusions
● Chronic pain is a common condition caused by changes
in the neurological system
● Although our patients present with pain, it is their
suffering that we need to address
● Suffering involves considering the whole person
including their spiritual side
● The Catholic Church offers hope and meaning in those
who suffer through the Cross of Christ
●[email protected]