Terri A. LewisSIU-Carbondale, REHB Institutetlm7291@siu.edu

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What is the difference between acute and

chronic pain?

How do medical models exert influence on the

development of the disease ?

What are the return to work implications for

treatment options, coexisting disorders?

How do multi-axial treatment models, frame

the role for Counselors?2

How is pain defined?

Incidence & prevalence in the population

How does chronic pain develop?

How many syndromes are associated with

chronic pain?

How is chronic pain classified?

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Pain - an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Acute pain - pain that terminates or eases when conditions of illness terminate or surgical interventions heal, generally does not persist for more than a few days, even if it recurs. Chronic pain - a state in which pain persists beyond the usual course of an acute disease or healing of an injury - may or may not be associated with an acute or chronic pathologic process, persists for three to six months or more beyond the onset of an illness or recovery from healing of surgical procedures or trauma

Breakthrough pain - pain that acutely elevates in response to known or unknown stressors or reductions in medication levels between available dosages.

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Etiologic specific chronic pain is the type of pain that

results from a specific event or illness.

Neuro-biological pain is chronic pain that is

persistent, residual beyond the expected healing

period and becomes secondary in its’ development to

the originating trigger.

Frequently co-morbid with the secondary

development of generalized anxiety disorders,

depression, and post-traumatic stress disorder5

Leading cause of disability in this country (Mayday Fund, 2009)

Incidence > than diabetes, heart disease and cancer

combined (American Pain Foundation [APF], 2009; McCaffery & Ferrell, 1999, 2010).

70 – 76 million Americans, w/ 9% reporting

moderate to severe levels of intensity (National Institute of Health

[NIH], 1998; Mayday Fund, 2009)

Economic toll of chronic pain at $100 billion a year

in the United States (National Institute of Health [NIH], 1998)

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Two categories, occur independently or together -

(a) pain that develops due to actual damage to peripheral nerves or the central nervous system (CNS)

(b) nociceptor (neural) pain resulting from nerve tissue irritation or damage in which pain mechanisms become hardened and involve related endocrine system dysfunction.

These may occur independently or together.7

Crohn’s Disease Spinal Pain Fibromyalgia Failed Back

Surgery Post Epidural

Syndrome Inflammatory

disorders 200+ syndromes

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The chronic pain experience may be seen as the result of a dynamic interaction between pathophysiological, psychosocial,

social, and treatment (or prolonged lack of treatment) variables.

Minorities remain largely untreated Cultural barriers to care Different patterns in seeking treatment Effects of age bias Undertreatment due to

pseudoaddiction Distribution of resources Length of suffering avgs 5 years without

intervention Return to work statistics are alarming

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Acute pain usually resolves within 3 monthsChronic pain is still present at 3 mos post onset, hardened by 6 mos

Four Medical Models of Care

The Biomedical Model, the primary care practice model

The Sequelae of Care Biomedical model

The Multidisciplinary, Biobehavioral Pain Center model

The Biopsychosocial/Neurobehavioral model

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338.0 Central pain syndrome,

338.21 Chronic pain due to trauma,

338.22 Chronic post-thoracotomy pain,

338.28 Other chronic postoperative pain,

338.29 Other chronic pain,

338.4 Chronic pain syndrome with

significant psychosocial dysfunction,

780.96 Generalized pain.14

Electronic health records (EHR) are NOT programmed with logic models for the diagnosis of either - Orphan disorders (500+) or Chronic pain syndrome (CPS) Counselors should be on the look out

for repeated complaints of pain after even the most innocuous of triggering events….

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Axis 1 – Mental Illness

Axis 2 – Personality Disorders, Intellectual

Disability

Axis 3 - General Medical Condition

Axis 4 – Psychosocial & Environmental

Stressors

Axis 5 – General Assessment of Functioning

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Mood disorder due to generalized

medical condition 293.83

Generalized Anxiety Disorder due to a

medical condition 293.84

Post Traumatic Stress Disorder (PTSD),

Acute or chronic 309.81

Acute stress disorder 308.3 19

Borderline Personality DisorderConduct DisorderObsessive Compulsive DisorderHypochondriasisAttention seeking behaviorDrug seeking behavior

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Chronic Pain due to a general medical condition 307.89

Chronic Pain NOS 338.xx

Chronic Pain due to trauma 338.21

Chronic Pain with psychosocial dysfunction 338.4

Neuroendocrine disorders:

Thyroid dysfunction; Diabetes; Low levels of testosterone; Elevated

levels of cortisol and other stress hormones

Sleep disorder due to medical condition, 327.xx

Substance abuse; Substance dependence (with physiological dependence or

without physiological dependence); Alcohol dependence 303.90 or Alcohol

Abuse 305.00; Cannabis dependence 304.30 or Cannabis abuse 305.20;

Nicotine dependence 305.1; Opioid Dependence 304.00 or Opioid Abuse

305.50; Polysubstance dependence 304.80; 21

Job loss or unemployment

Loss of community/family roles and

functions

Divorce and family disruption

Lack of family support

Financial stressors

Undertreatment of chronic pain syndrome

Access to care failure 22

GAF Score

0 – 49 Impaired

50 – 100 Significantly impaired

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Prevention Planning for vocational supportContinued treatment for chronic painCommunity/family supports Integrated counseling modalities

Adjustment Medication supports Alternative therapies Lifestyle changes

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Informed consent counseling Prevention and psychoeducation Integrated treatment modalities Alternative therapies combined

Meditation, biofeedback, yoga Pain reduction tools – stimulators and

pumps Medication protocols Stress management Wellness medical supports

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AdvocacyCollaboration with other

professionalsReferralConfidentialityMulticultural awareness

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Prevention Resiliency training Psychoeducation Adjustment training Suicidal ideation & rational suicide

counseling Collaboration with other treatment

providers Advocacy Access to appropriate treatment

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