Slide 1 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. IAS–USA Glenn...

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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.

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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

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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

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Reinforcers of healing

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

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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

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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

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What makes patients seek narcotics when they are not helping?

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

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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

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Simplified model of temperament

Percent of population

Introversion

Punishment avoidant Future directedFunction directed

Extraversion

Reward directed Present directedFeeling directed

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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

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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

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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

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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

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Treat psychiatric co-morbidity

• Depression• Personality vulnerabilities• Life experiences

Slide 1 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. IAS–USA Glenn...

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