Transcript Chapter 10 - Dr. Saadia McLeod

Chapter Ten:
The
Management
of Pain and
Discomfort
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Pain: Health Epidemic
30% of Adults in Developed nations suffer
from chronic pain
-40% in Underdeveloped Nations
25% of Children in US experience Chronic Pain
Increased 4x since 1999 – Multibillion Pharma
Addiction to prescriptive pain meds/opiates
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Biomedical Model
• Narrow view of tx
• Medication management of Pain
• Only moderately effective!
• Addiction to pain meds/overdoses
• Psychological interventions a promising
addition
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Cause of Epidemic of Addiction
• 25 years ago a major academic paper stated that pain
patients were wholly mismanaged. Described a cruel
and blind medical field that was neglecting and
undermedicating pain.
• Change in medical school training/health psych
• Focus of pain as a major vital sign – upping use of pain
meds
• 1996 introduction of Oxycontin : Pharma touted no
addiction and low side effects
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Opiate Addiction
• 1999: sale of opiates 4x
• 44 die of opiate addiction daily
• States with no monitoring: Alabama,
Tennessee, W. Virginia, Florida (worst)
Maine and New Hampshire: highest dosage of
Oxycontin
• Lowest Use: Hawaii, California, Colorado
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Demand for Change
• Keys to changing tide of opiate addiction:
1. Identify the Pill Mills
2. Retrain Doctors treating pain
3. Regulate Pain Management Claims
– Role of Heroin?
– Most common fatalities: (1) Vicodin (2) Oxycontin
(3) Fentanyl, (4) Methadone
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Demand for Change
• Restrictions on how opiates prescribed (2014)
- Require face to face
- no call-in scripts
• Role of Psychological interventions
• Alternatives: accupuncture, massage, relaxation,
exercise, electrical stim
• Problem: not widespread in application
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Chronic Pain
• Addiction to Opiates contributes to worsening
of chronic pain
• Worsens the experience of pain over time
• Chronic Pain becomes a major risk factor to a
lifetime of opiate addiction
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Effect of Pain
• Provides feedback about the functioning of
our bodily systems
• Can lead a person to seek treatment
• Inadequate relief from pain is the most
common reason for requests for euthanasia
or assisted suicide
– Ethics of Physician Assisted Suicide: product of inadequate tx?
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Purpose of Pain
• Adaptive: Protective mechanism to bring
tissue damage into conscious awareness
• Accompanied by motivational and behavioral
responses
• Problem with intense reactions: Negative
emotions exacerbate pain and vice versa
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Measuring Pain
• Verbal reports - Large, informal vocabulary
that people use for describing pain
• Pain questionnaires - Ask about the nature of
pain and its intensity
• Observation of Behavior: can be most useful
with severe pain
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Measuring Pain
• Pain behaviors: Arise from chronic pain
Not acute pain
• Used to assess how pain has disrupted a patient’s
life
• Can have secondary gains – promote
underfunctioning and increase pain
• Complicates treatment
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Pain Modification
• Descending: Reinterpret pain signals (context,
culture)
• Ascending: modification of pain happens in
the peripheral nervous system (Pain-Gate
Theory elaborates)
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Elusive Nature of Pain
• Degree to which pain is felt depends on:
– How it is interpreted
– Context in which it is experienced
– Cultural component - Members from some
cultures react more intensely to it than those from
other cultures
– Gender differences - Women show greater
sensitivity to pain
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Pain in the Brain
• No single Pain Center
– Frontal Lobe
– Insula – assess seriousness of pain
– Limbic System: emotional reaction
– Periductal Grey: relieves pain/cancer tx
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Gate Control Theory of Pain
• First scientific understanding of pain
• Receptors sense injury and release chemical
messengers to the spinal cord
• A-delta fibers - Small, myelinated fibers
– Transmit sharp, brief pains rapidly
– Turns on the “off switch” nerve
– Only short bursts of pain
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Gate Control Theory of Pain
• C-fibers - Unmyelinated nerve fibers
– Involved in polymodal pain
– Transmit dull, aching pain
– Closes gate to the transmission of sharp pain
– Exp: Accupuncture, Rubbing, etc.
– Discovery of the ascending modification of pain
perception (from bottom to brain)
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Stress Response: Pain Inhibition
• Stress-induced analgesia (SIA) - Phenomenon
where acute stress reduces sensitivity to pain
• Enkaphalin/Endorphin: Released by Pituitary
• Effect of Chronic Stress: dulls pain –
complicates pain assessment in low ses pts
• Ascending modification: Top-Down
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Acute and Chronic Pain
• Acute pain: Results from a specific injury that
produces tissue damage
– Disappears when the tissue is repaired
– Short in duration, lasting for 6 months or less
• Chronic pain: Begins with an acute episode but
does not decrease with treatment and the
passage of time
• – Pain intensifies Pain, underfx, addictions
• Note: interventions most effective for Acute
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Acute versus Chronic Pain
• Both have different psychological profiles
• Chronic pain
– Depression/Anxiety/Suicidality complicates
diagnosis and treatment
– Patients develop maladaptive coping strategies –
overdependency/addiction
– Pain becomes Dysregulated
• Pain control techniques are not effective
• Pain meds increase pain sensitivity
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Types of Chronic Pain
Chronic benign pain
• Persists for 6 months or longer
• Relatively unresponsive to treatment
• Severity of pain varies
Recurrent acute pain
• Intermittent episodes of pain that are acute in character but
chronic in condition
• Recurs for more than 6 months
Chronic progressive pain
• Persists longer than 6 months and severity increases over time
• Associated with malignancies or degenerative disorders
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Table 10.1 - Common Sources of
Chronic Pain
Source: National Institute of Neurological Disorders and Stroke, 2007.
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Chronic Pain Patient
• Pain is exacerbated by:
– Misdiagnosis: exp. Fibro Myalgia
– Inappropriate prescriptions of medications
• Lifestyle: Secondary Losses
– Quit jobs and abandon leisure activities
– Withdraw from families and friends
– Require loss of independence
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Chronic Pain Patient
– Experience loss of self-esteem/identity
– Receive compensation
• Increases pain as it provides an incentive for being in
pain
• Relationships
– Family relationships get affected
– Marital Decline in Intimacy
– Positive attention from spouse may maintain the
pain
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Chronic Pain Patient
• Behaviors - Alterations in lifestyle interfere
with successful treatment
– Sedentary, Poor diet, hopelessness
• Stress: intensifies pain, difficult to manage
– Factors in treating the total pain experience
• Understanding the pain behaviors
• Knowing whether they persist after treatment
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Pain and Personality
• Pain-prone personality: Predispose a person
to experience chronic pain
• Personality attributes associated with chronic
pain
• Neuroticism
• Introversion
• Use of passive coping strategies
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Pain Profiles
• Conditions that increase the perception of
pain
• Depression and anger suppression (avoidance of
feelings)
• Efforts to suppress pain (family norm, culture)
• Anxiety disorders, substance use disorders, and
other psychiatric problems
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What is Pain Control?
• Cessation of Pain: Surgery / nerve block
effective
• Tolerance of Pain: use of alternative
techniques most effective with increasing
tolerance
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Pharmacological Control of Pain
Administration of drugs
• Most common method of controlling pain
Types of drugs
• Local anesthetics - Affect the transmission of pain impulses from
peripheral receptors to the spinal cord
• Spinal blocking agents
• Antidepressants - Affect the downward pathways from the brain
that modulate pain
Drawbacks
• Undesirable side effects
• Addiction
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Surgical Control of Pain
• Disrupt the conduct of pain from the
periphery to the spinal cord
• Interrupt the flow of pain sensations from the
spinal cord upward to the brain
• Drawbacks
– Effects are short-lived and it is very expensive
– Surgery damages the nervous system
– Cancer Pain
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Sensory Control of Pain
• Counterirritation: Inhibiting pain in one part
of the body by stimulating or mildly irritating
another area
• Exercise and other ways of increasing mobility
help the chronic pain patient
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Psychological Control of Pain
Requires patients to actively participate and learn
More effective for managing slow-rising pains
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Biofeedback
• Providing bio-physiological feedback to a
patient about some bodily process of which
the patient is unaware
• Target function to be controlled is identified
and tracked by a machine
– Patient attempts to change the bodily process
with the help of continuous feedback
• Heart rate, Blood Pressure, Muscle Tension, Sweat
response (Galvanic Skin Response)
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Relaxation Techniques
• Shifting the body into a state of low arousal by
progressively relaxing different parts of the
body using controlled breathing
• Beneficial physiological effects are due to the
release of endogenous opioid mechanisms
• Yoga, Meditative Behaviors
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Distraction
• Turning attention away from pain by:
– Focusing on an irrelevant and attention-getting
stimulus
– Distracting oneself with a high level of activity
• Most effective for coping with low-level pain
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Coping Skills Training
• Helps chronic pain patients manage pain
1) Take inventory of current coping
2) Assess efficacy of current coping
3) Expand to new approaches
- Social support
- Self-Care
- Self-efficacy
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Cognitive-Behavioral Therapy
• Reconceptualizes a problem from
overwhelming to manageable
– Eliminate Catastrophic thinking
– Patients:
– Believe that the required skills will be taught to
them
– Become competent individuals aiding in the
control of pain
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Cognitive-Behavioral Therapy
– Learn to break up maladaptive behavioral
syndromes
– Learn to make adaptive responses to pain
– Are encouraged to attribute their success to their
own efforts
– Are taught relapse prevention
– Are trained to control their emotional responses
to pain (Anx/Anger/Sadness)
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Mindfulness Training
• Address HOW patient experiences pain, not
the antecedents or consequences
– Understand the emotional regulation while
experiencing pain
– Not on Cognitive Regulation (CBT)
– Learning to self-soothe
– Contemporary addition to CBT
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Pain Management Programs
• Interdisciplinary efforts, bringing together
neurological, cognitive, behavioral, and
psychological expertise concerning pain
• Steps
– Initial evaluation
– Individualized treatment
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Pain Management Programs
• Components
– Patient education
– Involvement of family
– Relapse prevention
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