Current Issues in Pain Management and Substance Abuse Glenn J. Treisman, MD, PhD The International AIDS Society–USA GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

For all the happiness mankind can gain, it is not in pleasure but in rest from pain. For all the happiness mankind can gain, it is not in pleasure but in rest from pain. –John Dryden

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Differential diagnosis Pain, like cough, is a symptom Pain, like cough, is a symptom Differential diagnosis Differential diagnosis Direct nerve stimulation Direct nerve stimulation Cytokine and inflammatory stimulation Cytokine and inflammatory stimulation Nerve Damage (neuropathy) Nerve Damage (neuropathy) Central pain Central pain Outflow mediated pain (sympathetic pain) (RSD) Outflow mediated pain (sympathetic pain) (RSD)

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Pain dichotomies REAL-NOT REAL REAL-NOT REAL Functional-organic Functional-organic Psychological-physiological Psychological-physiological Medical-nonmedical Medical-nonmedical Real-functional Real-functional Sensory-central Sensory-central Physical-supratentorial Physical-supratentorial Medically explained-medically unexplained Medically explained-medically unexplained Acute-chronic

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Chronic pain issues vs. acute pain issues in HIV care Chronic pain Chronic pain  Improve function  Rehabilitation  Minimize impairment  Consider behaviors Acute Pain  Relieve distress  Convalescence  Comfort  Find etiology

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Law of effect …probability of a behavior can be increased or decreased depending on its immediate consequence. Thorndyke 1913 …probability of a behavior can be increased or decreased depending on its immediate consequence. Thorndyke 1913

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Environmental exposureEnvironmental response The conditioned behavior paradigm Behavior Increased likelihood of behavior positive Decreased likelihood of behavior negative

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Rat cage preference manipulation

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Opioids for chronic pain patients with opioids-patients with no Hx of substance use-4 % develop dependence Porter patients with opioids-patients with no Hx of substance use-4 % develop dependence Porter 1980 Opioids are effective for chronic pain see Clark 2000 Opioids are effective for chronic pain see Clark 2000 There is little real data on the amount of opiate misuse in chronic pain disorders There is little real data on the amount of opiate misuse in chronic pain disorders

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Susceptibility to narcotic abuse Cold pressor pain tolerance is decreased in current opiate and cocaine users compared with former users Compton 1994 Cold pressor pain tolerance is decreased in current opiate and cocaine users compared with former users Compton 1994 Substance use history increases abuse of pain medications Savage 1993 Substance use history increases abuse of pain medications Savage 1993 Alcoholic and families of alcoholics have increased pain sensitivity and increased pain reduction by alcohol Stewart 1995 Alcoholic and families of alcoholics have increased pain sensitivity and increased pain reduction by alcohol Stewart 1995

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Doctors choice of opioids Observed pain behaviors have the highest correlation with physician prescribing Turk 1997 Observed pain behaviors have the highest correlation with physician prescribing Turk 1997

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Comobidities Diseases-DEPRESSION Diseases-DEPRESSION Endowments-PERSONALITY Endowments-PERSONALITY Life circumstances-CULTURE AND SOCIAL CONDITIONERS Life circumstances-CULTURE AND SOCIAL CONDITIONERS

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Depression Diminishes the perception and impact of positive reinforcers Diminishes the perception and impact of positive reinforcers Interferes with cognition and pain gating Interferes with cognition and pain gating Increases the sensitivity to pain Increases the sensitivity to pain Increases the likelihood a stimulus will be perceived as noxious Increases the likelihood a stimulus will be perceived as noxious Enhances addiction liability Enhances addiction liability

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Simplified model of disposition IntroversionExtroversion percent of population

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Personality interacts with pain Extraversion increases sensitivity to positive reinforcement (opiates and disability) immediate rewards, and external locus of control (unable and it is someone’s fault) Extraversion increases sensitivity to positive reinforcement (opiates and disability) immediate rewards, and external locus of control (unable and it is someone’s fault) Introversion increases avoidance of injury (deconditioning), increases worry and sensitivity to bodily sensation (rumination and avoidance) Introversion increases avoidance of injury (deconditioning), increases worry and sensitivity to bodily sensation (rumination and avoidance)

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Personality interacts with pain Instability increases emotional reaction to discomfort (catastrophic reactions) and interpretation (paranoid feelings) Instability increases emotional reaction to discomfort (catastrophic reactions) and interpretation (paranoid feelings) Stability decreases drive for change and self-criticism Stability decreases drive for change and self-criticism

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Examples of reinforcers of pain behaviors Positive reinforcers Positive reinforcers  Disability payments  Attention from spouses, family, doctors, lawyers  Ability to express prohibited feelings  Possibility of “lump sum” payments Negative reinforcers Negative reinforcers  Relief from stress, expectations and criticism  Relief from pain and discomfort

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Behavioral approach to pain Look for curable disease Look for curable disease Treat depression if present Treat depression if present Analyze reinforcers of pain behavior Analyze reinforcers of pain behavior Design a rehabilitative program that emphasizes function, quality of life, and longevity Design a rehabilitative program that emphasizes function, quality of life, and longevity Recognize temperament and adjust for it Recognize temperament and adjust for it Accept serendipity whenever you find it Accept serendipity whenever you find it

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Pharmacology of chronic pain Medications for Neuropathic Pain AntidepressantsOpioids Anticonvulsants Adjuvant Medications VanilloidsCOX-2 Inhibitors  -Adrenergic AgentsLocal Anesthetic Agents Calcium Channel BlockersNMDA Receptor Antagonists Slide courtesy of Michael Clark

GJ Treisman, MD, PhD. Presented at IAS–USA/RWCA Clinical Conference, June Pain and pain behaviors Exaggeration of personality vulnerabilities Pain and pain behaviors Personality vulnerabilities