PTSD, Opioid Dependence, and EMDR: Treatment Considerations for Chronic Pain Patients W. Allen Hume, Ph.D.,C.D.P. Licensed Psychologist October 2, 2007

2 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.” “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

3 Goals of the Presentation Define Posttraumatic Stress Disorder and identify the symptoms of trauma. Define Posttraumatic Stress Disorder and identify the symptoms of trauma. Identify the prevalence rates of PTSD and opioid dependence in pain patients. Identify the prevalence rates of PTSD and opioid dependence in pain patients. Outline a general approach to treating chronic pain patients with PTSD. Outline a general approach to treating chronic pain patients with PTSD. Discuss the use of Eye Movement Desensitization and Reprocessing (EMDR). Discuss the use of Eye Movement Desensitization and Reprocessing (EMDR).

4 Posttraumatic Stress Disorder (PTSD) Defined (DSM-IV-TR, 2000) Exposure to a traumatic event Exposure to a traumatic event The person experienced or witnessed an event that involved death or serious injury The person experienced or witnessed an event that involved death or serious injury Response involved intense fear, helplessness or horror Response involved intense fear, helplessness or horror 3 Main Clusters of Symptoms 3 Main Clusters of Symptoms Re-experiencing the traumatic event Re-experiencing the traumatic event Avoidance Avoidance Arousal Arousal Symptoms present for at least 1 mo. Symptoms present for at least 1 mo.

5 Post-traumatic stress (PTS) vs. Post- traumatic stress disorder (PTSD) PTS - traumatic stress that continues following a traumatic incident (Rothschild, 1995) 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 PTSD - traumatic stress that produces the symptoms of PTSD & implies a level of daily dysfunction

6 Two Types of Trauma (Shapiro, 1995) Big “T” trauma - major traumas Big “T” trauma - major traumas War, assaults, rape, physical violence, etc. War, assaults, rape, physical violence, etc. Small “t” traumas - minor traumas or life disturbances Small “t” traumas - minor traumas or life disturbances Ridiculed, humiliated, “high school” Ridiculed, humiliated, “high school”

7 Prevalence of PTSD (Sharp, 2004) 20% of people will develop PTSD after a traumatic incident (van der Kolk, 1995). 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). In the general population, PTSD ranges between 7%-12% (Seedat et al, 2001). Between 10-50% of chronic pain patients meet criteria for PTSD. 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 Mediating variables – age, preparation, belief system, internal resources, hx of trauma, support, degree of trauma, & fear/level of threat

8 PTSD Prevalence Rates Continued PTSD varies across selected samples (Sharp, 2004) PTSD varies across selected samples (Sharp, 2004) 39% in MVA 39% in MVA 39% of assault victims 39% of assault victims 7% of homicide survivors 7% of homicide survivors 15.2% of male and 8.5% of female Vietnam Vets 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). 80% of patients with PTSD meet criteria for at least one other psychiatric diagnosis (Asmundson et al, 2002). Major depression - most common Major depression - most common Anxiety disorders Anxiety disorders Substance abuse & Somatoform disorders Substance abuse & Somatoform disorders

9 Rate of PTSD Among Individuals with Opioid Dependence Mills et al. (2005) Among 459 subjects in opioid treatment, 42 % had PTSD Among 459 subjects in opioid treatment, 42 % had PTSD Cost of treatment approximately same over a 12 month period 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. PTSD clients had a poorer outcome in occupational, physical and mental health functioning as well as more overdose. More relapse, readmissions, ongoing use More relapse, readmissions, ongoing use

10 Pain Definitions Oaklander, A.K. (1999) Acute Pain Acute Pain Adaptive, beneficial response necessary for preservation of tissue integrity Adaptive, beneficial response necessary for preservation of tissue integrity Chronic Pain Chronic Pain Traditionally defined as > 6 months Traditionally defined as > 6 months It is pain that has outlived its usefulness It is pain that has outlived its usefulness

11 Prevalence of Opioid Usage Turk (2007) Most commonly prescribed med in US Most commonly prescribed med in US 3% of non-cancer population (8.1M) 3% of non-cancer population (8.1M) 9.4 Billion dosage units per year 9.4 Billion dosage units per year Approximately 3.8-4% of chronic pain patients abuse their medications Approximately 3.8-4% of chronic pain patients abuse their medications Aberrant drug behaviors Aberrant drug behaviors Issue of pseudoaddiction Issue of pseudoaddiction Co-morbid disorders Co-morbid disorders

12 Opioid Use Trends NIDA Research Report 1999 – 2.6 million misused pain meds 1999 – 2.6 million misused pain meds – 181% increase in usage – 181% increase in usage Oxycodone prescriptions rose 359% since 1997 (DASA, 2005) Oxycodone prescriptions rose 359% since 1997 (DASA, 2005) Methadone for non-opiate substitution rose 312% 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) WA state – 74 deaths related to heroin OD & 138 from “other opiates” in 2005 (DASA, 2006)

13 Most Used Opioids Oxycontin and other oxycodone preparations (60%) Oxycontin and other oxycodone preparations (60%) Hydrocodone combined with acetaminophen (Vicodin like drugs) Hydrocodone combined with acetaminophen (Vicodin like drugs) Morphine Morphine

14 Do Opioids Work for Pain? WHO reports that opioids are effective in controlling moderate to severe 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. 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. Carefully select patients for optimal outcome based on history and response.

15 Prevalence of Addictive Disorders Among Pain Patients General Population: 3-18% General Population: 3-18% Chronic Pain Population: % Chronic Pain Population: % Hospitalized Population: up to 26% Hospitalized Population: up to 26% Trauma Population: 40-62% Trauma Population: 40-62% Cancer-related Population: up to 27% or more Cancer-related Population: up to 27% or more

16 Chronic Pain in Addicted Populations MMT patients: 61.3% (Jamison, 2000) MMT patients: 61.3% (Jamison, 2000) MMT patients: 80%, with 37% severe (Rosenblum, Joseph, et al, 2003) MMT patients: 80%, with 37% severe (Rosenblum, Joseph, et al, 2003) Among Inpatient Substance Use Treatment patients: 78% (Rosenblum, Joseph, et al, 2003) Among Inpatient Substance Use Treatment patients: 78% (Rosenblum, Joseph, et al, 2003)

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

18 Approach to Trauma Treatment Psychoeducation about trauma Psychoeducation about trauma Coordination of care with medical providers Coordination of care with medical providers Affect management skills Affect management skills Safe place exercise, grounding Safe place exercise, grounding Container method Container method Calming the body down Calming the body down Meditation, breathing Meditation, breathing Yoga, chanting Yoga, chanting Integration of Traumatic Memories via EMDR Integration of Traumatic Memories via EMDR

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

20 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. 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. Trauma or disturbing experiences become “trapped” in the nervous system. In EMDR, we ask the patient to focus on a target memory. In EMDR, we ask the patient to focus on a target memory.

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

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

23 The Eight Stages of EMDR Treatment Continued 4. Desensitization 4. Desensitization 5. Installation 5. Installation 6. Body Scan 6. Body Scan 7. Closure 7. Closure 8. Reevaluation 8. Reevaluation

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

25 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. 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. 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.

26 EMDR is a Widely Accepted Treatment American Psychological Association American Psychological Association American Psychiatric Association American Psychiatric Association U.S. Department of Veterans Affairs and Department of Defense U.S. Department of Veterans Affairs and Department of Defense United Kingdom Department of Health (2001) United Kingdom Department of Health (2001) Israeli National Council for Mental Health (2002) Israeli National Council for Mental Health (2002) Dutch National Steering Committee Guidelines for Mental Health Care (2003). Dutch National Steering Committee Guidelines for Mental Health Care (2003).

27 Summary Points Acute and chronic pain can be treated in the context of addiction, but optimally… 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 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 In my experience, EMDR appears to be helpful in the treatment of PTSD in addicted, chronic pain populations