CHRONIC PAIN MANAGEMENT

By Heba Essawy

Prof Of Psychiatry

Assessment

• Psychological assessment?

• Mood

• Interests

• Changes in function

Treatment Objectives

*Decrease the frequency or severity of the pain

*General sense of feeling better

*Increased level of activity

*Return to work

*Decreased health care utilization

*Elimination or reduction in medication usage

Pain 101 –Sessions

1) Pain Education

2) Reducing tension

3) Mindfulness meditation

4) Pacing / Goal setting

5) Depression and negative thinking

6) Sleep

7) Coping with stress and anxiety

8) Communication and pain behaviour

9) Managing setbacks

10)Chronic pain and your life

Pain Education

• Patients should be given as much information as possible about care provided, if possible before any procedures

• Patients should also be educated in using their analgesics appropriately

• An emphasis should be placed on taking medications as scheduled, not only when pain emerges, and patients’ concerns regarding side effects, including any addiction potential, should be addressed

What works best for Neuropathic Pain?

• Drug class Odds ratio for Rx Success

• New Anticonvulsants 2.35– Lamictal, Neurontin, etc

• Classic Anticonvulsants 5.33– Valproate, Carbamazepine

• Tricyclics 22.4

(Wong. BMJ 2007;)

Antidepressants• Tricyclic antidepressants

– Analgesic effects separate from anti-depressant effects.– Amitriptyline: most studied, but most side effects– Nortriptyline & desipramine: better tolerated, less well studied

• SSRIs: little evidence of analgesic effect.• SNRI’s

– inhibit both norepinephrine and serotonin reuptake– efficacy in neuropathic pain syndromes or pain associated

with depression (duloxetine [Cymbalta®], venlafaxine [Effexor®])

Tricyclic Antidepressants

Utility in pain management

• Most useful in neuropathic pain• Used frequently in variety of settings• Amitriptyline most widely studied• Anti-depressant effects may alleviate depression

associated with chronic pain• May have synergy with opioids• Switching TCA’s based on effect and/or side

effects can be tried

Mechanism of action

• Generally unknown• • Theories involve action on serotonin, norepinephrine

receptors (TCAs with the greatest effect upon serotonin seem to have the greatest analgesic effect)

• May potentiate endogenous opioid system• Potent SSRIs have no analgesic effect of their own

Side effects

• Anticholinergic (amitriptyline > nortriptyline)

• Sedation.

• Anticholinergic and CNS effects may diminish in days to weeks – “ride it out”

SSRI/SNRI

• Often tried when TCA side effects limit utility• May be treating depression – not an uncommon

consequence with chronic pain• Venlafaxine has been shown to be similar to

imipramine in one study of painful neuropathy• Duloxetine approved for diabetic peripheral

neuropathy• Depression is probably undertreated in chronic pain

patients in general (cancer and non-cancer pts)

Anticonvulsants

Utility in pain management

• Can be very effective, particularly in neuropathic pain

• Wide variation in use among pain specialists, except with carbamazepine for trigeminal neuralgia

• Gabapentin is frequently a first choice as levels do not need monitoring

Mechanism of action

• Theories include membrane stabilization (phenytoin),

• Inhibition of repeated neuronal discharges (carbamazepine),

• GABA inhibition enhancement (valproic acid, clonazepam),

• GABA mimetics (gabapentin, pregabalin).

Anticonvulsants

• Agents for neuropathic pain– gabapentin (Neurontin®)– pregabalin (Lyrica®)– clonazepam (Klonopin®)

• Start low, go slow• Watch for side effects• Monitor serum levels, if available

Adjuvant medications

Benzodiazepines

• Good choice when anxiety complicates pain management (cancer patients)

• Clonazepam particularly useful in neuropathic pain (GABA potentiation)

• Drawbacks :– Addictive potential is significant– Potentiates sedation and respiratory depression

Antispasmodics

• Painful muscle spasm, myoclonic jerks can accompany a variety of pain conditions (and opioids)– toxicity of morphine

• Mechanism of action may reflect their sedative effects more than direct muscle effect

• Commonly used – cyclopenzaprine, carisoprodol, baclofen, methcarbamol

•

Non Medical intervention

Relaxation : Diaphragmatic Breathing

• Inform patients that physiological arousal can increase pain signals, and that relaxation strategies can reduce this arousal

• Ask patients to assume a comfortable position and to place one hand over their abdomen

• Instruct patients to inhale deeply through their nose, bringing air into the bottom of their lungs, then to exhale through their mouth

• Repeat this for two or three breaths, then request that they practice this regularly, for three to five minutes at a time

Relaxation : Distraction

• Discuss the role of thoughts on patients’ sense of coping with pain, and their relationship to physiological arousal

• Encourage patients to generate and practice positive self-talk that emphasizes their ability to cope with the pain

• Patients should also be reassured that the pain episode is of limited duration, and that they can remind themselves that it will pass

Psychological Treatment

• No treatment that consistently and permanently alleviates pain for all patients

• Management of chronic pain often depends on the abilities of the client

• Primary goal is to improve function rather than alleviate pain

• Effective management is achieved most readily using a multidisciplinary approach

• Should be customized to the patient• Treatment varies, but is usually planned for about

10 to 12 sessions (Turk, 1990)

Psychological Treatment

• An active, time-limited treatment, with patients guiding their own progress rather than passively receiving care

• For patients that are not candidates for treatment, a consultative resource to facilitate existing treatment

• Assessment and treatment emphasizes a biopsychosocial model

(Matthew Bailly)

Patients Likely to Benefit from Psychological Treatment

• Psychological factors are obviously a primary concern

• Patient understands what psychology can offer, but maintains a unidimensional view of pain

• Patient is unmotivated/resistant, or experiencing too much distress (relationship distress, substance abuse) to maintain regular involvement with treatment

Diagnostic Interview

• Typically uses one or two 1-hour sessions• Includes obtaining a history of the presenting

problem and a brief medical and psychological history, followed by an assessment of functioning within the following domains…

• Educational and vocational• Social and recreational• Family, including brief developmental history• Mental status and current psychological

functioning

Formal Assessment

• Involves administration of instruments measuring personality, impact of illness, coping, beliefs and expectations about pain and injury, and psychological distress

• May be completed in one or two 1-hour testing sessions

Definitons of Terms Psychotherapy - set of clinical techniques use to improve mental

health.

Counseling = psychotherapy.

Behavior Therapy (Behavior Modification Therapy) - changing somebody's behavior

Classical Conditioning - creation of response to stimulus (Pavlov's dogs)

Operant Conditoning - learning through positive and negative reinforcement

Cognitive Therapy - psychotherapy aimed at changing way of thinking. Several approaches to cognitive-behavioral therapy

Rational Emotive Behavior Therapy

Rational Behavior Therapy

Rational Living Therapy

Cognitive Therapy

Dialectic Behavior Therapy

Cognitive Behavioral Therapy

“Big” Names associated with Cognitive Behavioral Therapy

1. Epictetus, Greek philosopher. Observed that people are not disturbed by things that happen but by the view they take of things that happen.

2. Albert Ellis, Ph.D. “grandfather of cognitive behavioral therapy.”

3. Aaron Beck, MD, a psychiatrist (University of Pennsylvania)

Characteristics of Cognitive-Behavioral Therapies:

1. Thoughts cause Feelings and Behaviors.

2. Brief and Time-Limited.

Average # of sessions = 16 VS psychoanalysis = several years

3. Emphasis placed on current behavior.

4. CBT is a collaborative effort between the therapist and the client.

Client role - define goals, express concerns, learn & implement learning

Therapist role - help client define goals, listen, teach, encourage.

5. Teaches the benefit of remaining calm or at least neutral when faced with difficult situations. (If you are upset by your problems, you now have 2 problems: 1) the problem, and 2) your upsetness.

6. Based on "rational thought." - Fact not assumptions.

7. CBT is structured and directive. Based on notion that maladaptive behaviors are the result of skill deficits.

8. Based on assumption that most emotional and behavioral reactions are learned.  Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting.

9. Homework is a central feature of CBT.

Rational Emotive Behavioral Therapy

A form of cognitive-behavioral therapy in which somebody is encouraged to examine and change irrational thought patterns (irrational thinking) and beliefs in order to reduce dysfunctional behavior.

What is irrational thinking?

What types of thinking are problematical for human beings?

The Self-Defeating Rules (Irrational Beliefs)

Ellis suggested that a small number of core beliefs underlie most unhelpful emotions and behaviours. Core beliefs are underlying rules that guide how people react to the events and circumstances in their lives. Here is a sample list of such of these:

1. I need love and approval from those around to me.2. I must avoid disapproval from any source.3. To be worthwhile as a person I must achieve success at whatever I do.4. I can not allow myself to make mistakes.5. People should always do the right thing. When they behave obnoxiously,

unfairlyor selfishly, they must be blamed and punished.6. Things must be the way I want them to be.7. My unhappiness is caused by things that are outside my control – so there is

nothing I can do to feel any better.8. I must worry about things that could be dangerous, unpleasant or frightening –

otherwise they might happen.9. I must avoid life’s difficulties, unpleasantness, and responsibilities.10. Everyone needs to depend on someone stronger than themselves.11. Events in my past are the cause of my problems – and they continue to influence

my feelings and behaviours now.12. I should become upset when other people have problems, and feel unhappy

when they’re sad.13, I shouldn’t have to feel discomfort and pain.14, Every problem should have an ideal solution.

Two Types of Disturbance

Ego disturbance:

- emotional tension resulting from the perception that one’s ‘self’ is threatened – and lead to other problems such as avoidance of situations where failure, disapproval might occur.

- looking to other people for acceptance; and unassertive behaviour through fear of what others may think.

Discomfort disturbance:

- results from demands about others (e.g. ‘People must treat me right’) and about the world (e.g. “The circumstances under which I live must be the way I want”).

Discomfort disturbance - two types:

Low frustration-tolerance (LFT) results from demands that frustration not happen, followed by catastrophizing when it does. It is based on beliefs like: “The world owes me contentment and happiness.”

Low discomfort-tolerance (LDT) arises from demands that one not experience emotional or physical discomfort, with catastrophizing when discomfort does occur. It is based on beliefs like: “I must be able to feel comfortable all of the time.”

ABC’s of REBT

A →B → C A = Activating Event

B = Beliefs, Thoughts, Attitudes, Assumptions

C = Consequences, Feelings, Emotions, Behaviors, Actions

Outcomes

• Increased function• Increased work/school attendance• Improved sleep• Increased social activities• Decreased anxiety and depression• Reduced pain

THANKS

Psychological Treatment(Turk, 2002)

• Problem-oriented• Educational• Collaborative• Uses clinic and home practice for skill-building• Encourages expression and management of

feelings that impair rehabilitation• Addresses relationships among thoughts,

feelings, behaviour, and physiology• Anticipates setbacks and teaches clients how to

manage these

Psychological Treatment

• Involves evaluating and correcting maladaptive beliefs, appraisals, and schemas to alleviate mood symptoms and increase coping behaviour

• Training in relaxation techniques, such as abdominal breathing, visualization, and progressive muscle relaxation to reduce anxiety that typically magnifies pain signals

• Treatment attempts to increase behaviours associated with pain self-management, such as adaptive coping, exercise program participation, and improved communication with providers

• Focuses on increasing self-efficacy

Cognitive-Behavior Therapy

• Emphasizes the important role of thinking in mood and actions. 

• Based on the idea that thoughts cause feelings and behaviors, not external factors (people, situations, and events) 

• Thus, one can change mood and actions even if situation does not change.

 

Typical Patient

• It is not understood what degree psychological factors play a role

• Patient agrees to pursue assessment and treatment, but may need more education regarding what psychology can provide

• Patient may or may not receive treatment, depending on the assessment

World Health Organization (WHO) Step Ladder Approach

Mild Pain 1-3/10

Moderate Pain 4-6/10

Severe Pain 7-10/10

ASA, Tylenol,NSAIDS

Weak opioids +/- non-opioids (e.g. Tylenol #3®)

Potent opioids (e.g.morphine) +/-non-opioids

(Mellar P Davis)