Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach

of 14

From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. IAS–USA

Glenn J. Treisman, MD, PhDProfessor

Director, AIDS Psychiatry ServiceThe Johns Hopkins Medical Institutions

Baltimore, MD

Chronic Pain and The Drug-Seeking PatientA Behaviorist Approach

From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.

of 14


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

of 14


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

of 14


Reinforcers of healing

• Life reinforces getting well–Social–Occupational–Romantic–Sexual–Financial–Self image

of 14


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

of 14


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

of 14


What makes patients seek narcotics when they are not helping?

• Conditioning• Relief from distress in life• Transient relief from pain• Addiction

of 14


Addiction

Behavior RewardDe

pres

sion

Inflammation and cytokinesSympathetic activation and stress

Decreased reward sensitivityIncrease in stimulus seekingDecreased self preservationDay-night cycle disruption

HIV and HEP C

Chronic diseaseHIV and Hep CLipids

of 14


Simplified model of temperament

Percent of population

Introversion

Punishment avoidant Future directedFunction directed

Extraversion

Reward directed Present directedFeeling directed

of 14


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

of 14


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

of 14


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

of 14


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

of 14


Treat psychiatric co-morbidity

• Depression• Personality vulnerabilities• Life experiences

Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach

Documents

Transcript of Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach