PTSD, Opioid Dependence, and EMDR: Treatment Considerations for

Chronic Pain Patients

W. Allen Hume, Ph.D.,C.D.P. Licensed Psychologist www.drallenhume.com

October 2, 2007

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COD client with PTSD seeking services in a Pain Center

“We’re not bad people, we’re just human

beings who need help with pain. If nothing else we need more help.”

Male, aged 23

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Goals of the Presentation

Define Posttraumatic Stress Disorder and identify the symptoms of trauma.

Identify the prevalence rates of PTSD and opioid dependence in pain patients.

Outline a general approach to treating chronic pain patients with PTSD.

Discuss the use of Eye Movement Desensitization and Reprocessing (EMDR).

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Posttraumatic Stress Disorder (PTSD) Defined (DSM-IV-TR, 2000)

Exposure to a traumatic event The person experienced or witnessed an event

that involved death or serious injury Response involved intense fear, helplessness or

horror

3 Main Clusters of Symptoms Re-experiencing the traumatic event Avoidance Arousal

Symptoms present for at least 1 mo.

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Post-traumatic stress (PTS) vs. Post-traumatic stress disorder (PTSD)

PTS - traumatic stress that continues following a traumatic incident (Rothschild, 1995)

PTSD - traumatic stress that produces the symptoms of PTSD & implies a level of daily dysfunction

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Two Types of Trauma (Shapiro, 1995)

Big “T” trauma - major traumas War, assaults, rape, physical violence, etc.

Small “t” traumas - minor traumas or life disturbances Ridiculed, humiliated, “high school”

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Prevalence of PTSD (Sharp, 2004)

20% of people will develop PTSD after a traumatic incident (van der Kolk, 1995).

In the general population, PTSD ranges between 7%-12% (Seedat et al, 2001).

Between 10-50% of chronic pain patients meet criteria for PTSD.

Mediating variables – age, preparation, belief system, internal resources, hx of trauma, support, degree of trauma, & fear/level of threat

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PTSD Prevalence Rates Continued

PTSD varies across selected samples (Sharp, 2004) 39% in MVA 39% of assault victims 7% of homicide survivors 15.2% of male and 8.5% of female Vietnam Vets

80% of patients with PTSD meet criteria for at least one other psychiatric diagnosis (Asmundson et al, 2002). Major depression - most common Anxiety disorders Substance abuse & Somatoform disorders

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Rate of PTSD Among Individuals with Opioid Dependence Mills et al. (2005)

Among 459 subjects in opioid treatment, 42 % had PTSD

Cost of treatment approximately same over a 12 month period

PTSD clients had a poorer outcome in occupational, physical and mental health functioning as well as more overdose.

More relapse, readmissions, ongoing use

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Pain Definitions Oaklander, A.K. (1999)

Acute Pain Adaptive, beneficial response necessary for

preservation of tissue integrity

Chronic Pain Traditionally defined as > 6 months It is pain that has outlived its usefulness

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Prevalence of Opioid Usage Turk (2007)

Most commonly prescribed med in US 3% of non-cancer population (8.1M) 9.4 Billion dosage units per year Approximately 3.8-4% of chronic pain

patients abuse their medications Aberrant drug behaviors Issue of pseudoaddiction Co-morbid disorders

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Opioid Use Trends NIDA Research Report

1999 – 2.6 million misused pain meds 1990-98 – 181% increase in usage Oxycodone prescriptions rose 359% since

1997 (DASA, 2005)

Methadone for non-opiate substitution rose 312% since 1997 (DASA, 2005)

WA state – 74 deaths related to heroin OD & 138 from “other opiates” in 2005 (DASA, 2006)

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Most Used Opioids

Oxycontin and other oxycodone preparations (60%)

Hydrocodone combined with acetaminophen (Vicodin like drugs)

Morphine

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Do Opioids Work for Pain?

WHO reports that opioids are effective in controlling moderate to severe pain

Turk (2007) – Medications are central in pain management, they are not a panacea, nor cure. On average across studies they reduce pain by approximately 30% in 40-50% of patients.

Carefully select patients for optimal outcome based on history and response.

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Prevalence of Addictive Disorders Among Pain Patients

General Population: 3-18% Chronic Pain Population: 3.2-24% Hospitalized Population: up to 26% Trauma Population: 40-62% Cancer-related Population: up to 27% or

more

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Chronic Pain in Addicted Populations

MMT patients: 61.3% (Jamison, 2000) MMT patients: 80%, with 37% severe

(Rosenblum, Joseph, et al, 2003) Among Inpatient Substance Use

Treatment patients: 78% (Rosenblum, Joseph, et al, 2003)

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Approach to Trauma Treatment

Evaluation and Assessment Type of trauma & Type of trauma client Safety Risk assessment Mental status & co-morbid disorders Medical History Family and occupational functioning Medication

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Approach to Trauma Treatment

Psychoeducation about trauma Coordination of care with medical providers Affect management skills

Safe place exercise, grounding Container method

Calming the body down Meditation, breathing Yoga, chanting

Integration of Traumatic Memories via EMDR

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What is Eye-Movement Desensitization and Reprocessing (EMDR)?

A type of psychotherapy for treating emotional difficulties that are caused by disturbing life experiences, ranging from traumatic events such as combat stress, assaults to upsetting events.

EMDR is also being used to alleviate performance anxiety, generalized anxiety, sleep disturbances, phobias, grief, relapse prevention, and performance enhancement.

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Adaptive Information Processing: A Theoretical Model

(Parnell, 2007; Shapiro, 1995)

We all have an information processing system through which new experiences and information are processed to an adaptive state.

Trauma or disturbing experiences become “trapped” in the nervous system.

In EMDR, we ask the patient to focus on a target memory.

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Adaptive Information Processing Continued

When information stored in memory networks related to a distressing or traumatic experience is not fully processed it gives rise to dysfunctional reactions.

Eye movements or BLS stimulates accelerated information processing.

The goal is to reach “adaptive resolution” - reduce vivid imagery and related affect & shift negative beliefs about oneself.

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The Eight Phases of EMDR Treatment

The 8 phases of the EMDR protocol represent a comprehensive treatment approach. 1. Client History and Treatment Planning 2. Client Preparation 3. Assessment

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The Eight Stages of EMDR Treatment Continued

4. Desensitization 5. Installation 6. Body Scan 7. Closure 8. Reevaluation

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Assessment Phase

Target Memory Picture Negative Cognition Positive Cognition Validity of Cognition (VoC) Emotions Subjective Units of Distress (SUDs) Body Sensations

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Case Example

23 year old single male, withdrawn from college, history of oxycontin, marijuana, and alcohol abuse in remission prior to a serious MVA that resulted in dental/facial injury, PTSD, and uncontrolled pain.

Presenting issue: Atypical dental/facial pain, history of DV relationship with previous partner, unable to access social/family support, and non-narcotic pain meds have been unhelpful for pain.

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EMDR is a Widely Accepted Treatment

American Psychological Association American Psychiatric Association U.S. Department of Veterans Affairs and

Department of Defense United Kingdom Department of Health (2001) Israeli National Council for Mental Health

(2002) Dutch National Steering Committee

Guidelines for Mental Health Care (2003).

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Summary Points

Acute and chronic pain can be treated in the context of addiction, but optimally…

Patient must be willing to engage in assessment and treatment of pain, addiction, and psychiatric issues

In my experience, EMDR appears to be helpful in the treatment of PTSD in addicted, chronic pain populations