Non-Pharmacological Management of Chronic Pain Afton L. Hassett, Psy.D. Associate Research Scientist, Department of Anesthesiology Chronic Pain & Fatigue Research Center University of Michigan, Ann Arbor, MI

Disclosures Research funded by Bristol-Myers Squibb and Pfizer Inc. Consultant to Bristol-Myers Squibb, Pfizer Inc. and Lexicon Pharmaceuticals.

Non-Pharmacological Pain Management Topics   The evidence for some of the most commonly encountered non- pharmacologic (behaviorally-oriented) treatments.   Organizing the approach - addressing the six “ExPRESS” domains.   Cases: Conceptualizing and tailoring non-pharmacological treatment.   Building your “tool box” – tossing in a few strategies for building resilience!

Non-Pharmacological Pain Management

Complexity: Multiple Symptoms Most common complaints: Chronic widespread pain Fatigue Sleep disturbance Poor mood Cognitive difficulties Muscle stiffness Frequently occurring complaints: Gastrointestinal symptoms Headache Genitourinary Numbness and tingling Dizziness/loss of balance Weakness Skin changes Clauw DJ. JAMA 2014;311; Mease et al. Arthritis Rheum 2008;59(7):952-60

Complexity: High Rates of Co-Morbidity   Comorbidity with other chronic pain states 42-70% of patients with FM also meet criteria for CFS 32-80% of patients with FM meet criteria for IBS 42% of back pain patients meet criteria for FM Aaron & Buchwald. Ann Intern Med 2001;134:868–81 Brummett, Goesling, Tsodikov, Meraj, Wasserman, Clauw &Hassett. Arthritis Rheum 2013;65:   Co-Morbidity with chronic systemic disease Rheumatoid arthritis, lupus, inflammatory bowel disease Lee et al. Ann Rheum Dis 2013;72: Bliddal et al. Best Prac Res Clin Rheumatol 2007;21: Schlesinger, Hassett et al. Ann Rheum 2009   Psychiatric co-morbidity – mostly anxiety and depression.

Depression and pain commonly occur. Approximately half of patients with depression report pain. 1 Between 30-60% of individuals with pain report having comorbid depression. 2,3,4 1) Katona et al. Clin Med. 2005;5:390-5; 2) Bair et al. Arch Intern Med 2003;163: ) Hassett et al. Curr Pain Headache Rep. 2014;418:36; 4) Arnold et al. J Clin Psychiatry 2006;67:

Neurobiological perspective. Brain regions associated with physical pain overlap with psychological pain processing: Sensory discriminative dimension – –Somatosensory cortices (S1, S2) – –Dorsal posterior insula Affective emotional dimension – –Anterior insula – –Prefrontal cortex – –Anterior cingulate cortex – –Thalamus – –Amygdala – –Hippocampus Goesling, Clauw & Hassett. Curr Psychiatry Rep. 2013;15:421

Neurobiological perspective. Neurotransmitters – pain Serotonin Norepinephrine Glutamate GABA Neurotransmitters - depression Serotonin Norepinephrine Glutamate GABA  Similar neurotransmitter anomalies exist.  Both respond to SNRIs, but SSRIs provide little pain relief.  SNRIs might be better thought of as “neuromodulators.”  Pain relief with SNRIs is often independent of changes in depression. Ablin, Buskila & Clauw. Curr Pain Headache Rep 2009;13:343-9

Merging of pain and emotion results in significant clinical challenges! A 44 yo Caucasian male presents with severe chronic low back pain that began in college seemingly due to a football injury. He has undergone multiple back surgeries, none resulting in adequate pain relief. The most recent surgery was complicated by sepsis nearly resulting in the patient’s death. He is currently prescribed multiple analgesics yet the pain persists. In addition, is under the care of an orthopedist, urologist, otolaryngologist and endocrinologist and carries additional diagnoses of irritable bowel syndrome (that began in childhood) and adulthood chronic prostatitis, headache, myofascial pain syndrome, reactive depression and insomnia. The GI symptoms at times are severe enough to cause total incapacitation, yet are second to the back pain which plagues him constantly.

Be Patient with Your Patients   Perspective – feel terrible, usually a little frightened, searching for answers, often feel dismissed and alone.   A relatively small but difficult subgroup of patients, primarily those with personality pathology, provoke the greatest levels of healthcare provider frustration (others are guilty by association)   A hardy subgroup of patients exists with no history of psychopathology, high positive affect, less catastrophizing and less dysfunction and in some cases, higher levels of pain! Giesecke et al. Arthritis Rheum 2003;48: Hassett et al. Arthritis Rheum 2008;59: Toussaint, Vincent, McAllister, Oh & Hassett. Scand J Pain;2014;5:

Non-Pharmacological Interventions

The Evidence for Behavioral Interventions   Education and educational/support programs   Behavioral Therapies (e.g., CBT, ACT, self-management, positive activities)   Physical Activity/Exercise   Movement Therapies (Yoga, Tai Chi)   Mindfulness Meditation

Non-Pharmacological Interventions Education Neck pain: very low quality evidence for education alone 1 Arthritis: knowledge and compliance improved short- and long-term, but health status changes were minimal 2 FM: Education associated with some improvement in physical function but best combined with a multimodal intervention 3 Educational interventions typically include group sessions, videos, pamphlets, etc. with information about the illness and self-care, activation strategies, pain coping, and workplace ergonomics 1) Gross et al. Cochrane Database Sest Rev 2012 Epub. 2) Niedermann et al. Arthritis Rheum 2004;51: ) Hassett & Gevirtz. Rheum Dis Clin N Am 2009;35:

Non-Pharmacological Interventions Geneen et al. Syst Rev 2015;4:132 Education “The evidence base is limited by the small numbers of studies, their relatively small sample sizes, and the diversity in types of education studied.” Education is an important aspect of treatment and building a good working relationship. Educational programs alone are likely not enough.

Non-Pharmacological Interventions Cognitive–Behavioral Therapy CBT exists for many illnesses – –Mental illnesses e.g., depression, OCD, phobia, PTSD, generalized anxiety – –Physical illnesses e.g., cardiovascular disease, diabetes, asthma, cancer, obesity, chronic pain. Skills vary based on disorder Common underlying principles Beck. Cognitive Therapy: Basics and Beyond. 1995; Craighead. Behavior Modification: Principles, Issues, and Applications. 1981; Meichenbaum. Cognitive-Behavioral Modification

CBT: Event => Thoughts => Feelings => Behavior Event Thoughts about the event Emotions Behaviors

CBT: Event => Thoughts => Feelings => Behavior Event Thoughts about the event Emotions Behaviors

Non-Pharmacological Interventions Cognitive –Behavioral Therapy (CBT) A wide variety of skills are taught as platforms to promote adaptation through: – –New learning and behavioral change – –New cognitive formulations of the problem/solutions Target: Pain, fatigue, sleep, cognition, mood and functioning. Williams, DA (2010). Pain and painful syndromes. In J. Suls, KW Davidson, & RM Kaplan (Eds), Handbook of Health Psychology and Behavioral Medicine. New York, NY: The Guilford Press;

Non-Pharmacological Interventions

CBT Evidence Based on numerous RCTs, reviews and meta- analyses, there is strong support for the efficacy of CBT for improving pain, physical functioning and mood in many chronic pain states.

Non-Pharmacological Interventions CBT Evidence CBT superior to other psychological treatments for pain reduction in FM. Effect size for pain 0.60 Dose response Improvement in other symptoms (e.g., sleep, mood) and functioning.

Non-Pharmacological Interventions CBT Access a Problem Medical school curricula do not devote sufficient attention to non-pharmacological approaches Reimbursement is typically challenging Stigma associated with “psychological” treatments delivered by mental health professionals Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:

Non-Pharmacological Interventions

CBT Access a Problem = Web-based Interventions Living Well with Fibromyalgia Study Avera Research Institute – Sioux Falls, SD 54 clinics, catchment radius of 500 miles WEB (n=59) TAU (n=59) Endpoint: 6 months Williams DA et al. Pain. 2010

Non-Pharmacological Interventions CBT Access a Problem => Web-based Interventions Pain Responders: 30% improvement WEB: 29% TAU: 8% NNT: 5 Williams DA et al. Pain. 2010

Non-Pharmacological Interventions Between Class Comparisons of FDA Approved Medications for Fibromyalgia (All Doses Pooled) NNT for 30% reduction in pain – –Duloxetine 7.2 (95% CI 5.2, 11.4) – –Milnacipran 19.0 (95% CI 7.4, 20.5) – –Pregabalin 8.6 (95% CI 6.4, 12.9) – –Living Well Online CBSM: 5.0 Häuser W et al. J Pain. 2010; 11: ; Williams DA et al. Pain. 2010

Living Well with FM expanded to “FibroGuide”

Non-Pharmacological Interventions Acceptance & Commitment Therapy (ACT) Based on acceptance and mindfulness Get to know unpleasant feelings, learn not to act on them, do not avoid situations Meta-Analysis: When ACT was compared to various forms of CBT a non-significant effect size of 0.16 was obtained. However, an evidence-base evaluation showed that ACT is probably efficacious for chronic pain Ost. Behav Res Ther 2014;61:

Non-Pharmacological Interventions CBT Access: American Psychological Association

Non-Pharmacological Interventions Physical Activity Over 80 studies evaluating exercise interventions. Multiple reviews and meta- analyses, and professional society guideline statements. Leave little doubt that exercise is broadly considered to be an effective treatment for patients with chronic pain. Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:

Non-Pharmacological Interventions Physical Activity Evidence-based “exercise” can be aerobic or more focused on increasing strength and flexibility Can be of high intensity and frequency or involve only adding a few steps each day. Land- or water-based, whole-body exercise to cycling Structured approaches: yoga, Pilates and Tai Chi. Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:

Non-Pharmacological Interventions Physical Activity - Exercise Aerobic training at moderate intensity can improve pain, fatigue, depressed mood and physical limitations – –Attrition rates can be high (range: 27-90%) – –Fitness gains not always associated with symptom improvement – –Increase time and intensity slowly (start low, go slow). Strength training may decrease pain, and depression, and improve overall well-being – –Need more high-quality studies Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25: Hauser et al. Arthritis Res Ther 2010;12:R79. Jones et al. Rheum Dis Clin North Am 2009;35: Arnold. Psychiatr Clin North Am. 2010;33:

Non-Pharmacological Interventions Physical Activity – Exercise Graded, low-to-moderate intensity (under supervision) Adherence an important hurdle (fun, access, interest) High-risk patients may require prior evaluation 30 minutes of moderate intensity exercise 2-3 times per week, 10 weeks or more Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25: Hauser et al. Arthritis Res Ther 2010;12:R79. Jones et al. Rheum Dis Clin North Am 2009;35: Arnold. Psychiatr Clin North Am. 2010;33:

Non-Pharmacological Interventions Physical Activity Does not necessarily mean going to the gym! Hassett & Williams. Best Pract Res Clin Rheumatol 2011;25:

Non-Pharmacological Interventions Peng. Reg Anes Pain Med 2012;37: *Wang et al. N Engl J Med 2010;363: Movement Therapies Tai Chi: –Improves balance, well-being, and fitness, maintain BMD –Studies mostly of low quality –Some evidence for pain relief in FM*, RA, headache and LBP –5 RCTs in OA “strong evidence” for pain relief, improved physical functioning and psychological well-being. Tai Chi is an ancient martial and health art that involves flowing circular movement of the upper limbs and weight shifting of lower limbs. Meditation, breathing, moving qi and learning mind-body control

Non-Pharmacological Interventions Movement Therapies Yoga: – –Attention to posture, deep breathing, gentle movement, strength building and ROM. – –Arthritis 4 RCTs evidence for decreased disease symptoms (tender/swollen joints) – –Meta analysis in FM effects on pain, fatigue, depression and HRQOL (short term). – –Meta analysis in pain (OA, RA, LBP, FM) 17 studies: improvement in pain and functioning Yoga involves theories and practices that originated in ancient India. Refers to mind/body integration. Physical practice of yoga is referred to as “hatha” which was intended to help prepare for meditation. Specific bodily postures or poses. Haaz & Bartlett. Rheum Dis Clin North Am. 2011:37:33-46.; Langhorst et al. Rheumatol Int 2012 Epub. Ward et al. Musculoskeletal Care 2013;11:

Non-Pharmacological Interventions Mindfulness Meditation Stress reduction (MBSR) and MB cognitive therapy (MBCT) Decreases stress and improves depression and anxiety in many populations. Some evidence that MBSR can decrease pain, improve insomnia and increase pain coping and acceptance. Mindfulness meditation involves a state of consciousness where the focus is on attention, awareness and moment-by- moment experience. Have an attitude of curiosity, openness, and acceptance. Decrease analytical self-referential rumination, “This pain is not me.” Exposure, self-regulation. Marchand. J Psychiatr Pract 2012;18: *Wetherell et al. Pain 2011;15(9):

Non-Pharmacological Interventions Mindfulness Meditation Meta-Analysis using 16 RCTs. In 10 of 16, there was significantly decreased pain intensity in the MBI group. Results from follow-up assessments reveal that reductions in pain intensity were generally well maintained. Mindfulness meditation involves a state of consciousness where the focus is on attention, awareness and moment-by- moment experience. Have an attitude of curiosity, openness, and acceptance. Decrease analytical self-referential rumination, “This pain is not me.” Exposure, self-regulation. Reiner et al. Pain Med 2013;14:230-42

Interventions that enhance positive emotions and resilience!

Negative emotions associated with chronic pain Numerous studies linking negative affect to key factors in chronic pain: – Higher pain report – Worse weekly pain – Lower pain tolerance – Increased experimental pain sensitivity – Hyperalgesia – Greater use of pain medication – Worse analgesia (pentazocine) – Pain-related disability – Increased fatigue – More physical symptoms – Higher levels of psychiatric comorbidity – Poor quality of life – Poor self-efficacy for pain management Abeare et al. Clin J Pain 2010;26:683-9 Cogan et al. J Behav Med 1987;10: Carcoba et al. J Addict Dis 2011;30: Fillingim et al. Biol Psychol 2005;69: Finan et al. Psychosom Med 2009;71: Finan et al. Health Psychol 2010;29: Finan et al. Psychosom Med 2013; 75: Hamilton et al., Ann Behav Med 2005;29: Hanssen et al. Pain 2013;154:53-8 Hassett et al., Arthritis Rheum 2008; 59: Hassett et al., Arthritis Rheum 2008; 59: Hirsch et al. Qual Life Res 2012;21:18794 Kamping et al. Pain 2013; Epub ahead of print Kenntner-Mabiala et al. Biol Psychol 2008;78: Krok and Baker. J Health Psychol 2013; In Press Parrish et al. Health Psychol 2008;27: Schon et al. Psychophysiology 2008;45: Seeback et al. Pain 2012;153: Siblile et al. Clin J Pain 2012;28:410-7 Smith et al. Pain 2008;138: Staud et al. Pain 2003;105: Staud. Curr Pain Heachache : Stran et al. J Psychosom Res;60: Tang et al. Pain 2008;138: Vwesteeg et al. Qual Life Res 2009;18: Wesler et al. J Psychosoc Oncol 2013;31: Zautra et al. Pain 2007;128; Zautra et al. J Consult Clin Psychol 2005;73:212-20

Positive emotions might even be more important! Solid prospective and experimental studies found PE related to: –Lower overall pain ratings –Lower pain intensity scores –Decreased same day pain report –Decreased subsequent day pain report –Decreased subsequent week pain report –Increased induced pain tolerance –Decreased induced pain sensitivity –Longer tolerance to pain –Evoked potential moderation –Decreased use of pain medication –Lower post-op pain ratings –Greater walking times post-surgery –Length of stay in colorectal cancer surgery Adams et al. Activities, Adaptation and Aging 1986;8: Alden et al. Appl Psychophysiol Biofeedback 2001;26: Avia et al. Cognit Ther Res 1980;4:73-81 Bruel et al. Pain 1993;54: Chaves et al., J Abnorm Psychol 1974;83: Clum et al. Pain 1982;12: Cogan et al. J Behav Med 1987;10: Connelly et al., 2007;131: Finan et al. Psychosom Med 2009;71: Finan et al. Health Psychol 2010;29: Finan et al. Psychosom Med 2013; 75: Gil et al., Health Psychol 2004;23: Hamilton et al., Ann Behav Med 2005;29: Hanssen et al. Pain 2013;154:53-8 Hertel et al. Psychol Rec 1994;33: Horan et al. Percept Mot Skills 1974;39: Hudak et al. Psychol Rep 1991;69: Kamping et al. Pain 2013; Epub ahead of print Kenntner-Mabiala et al., Biol Psychol 2008;78: Meagher et al., Psychosom Med 2001;63:79-90 Meulders et al. J Pain 2014;15: Morgan et al. Percept Mot Skills 1978;47:27-39 Pickett et al. J Consult Clin Psychol 1982 ;50: Powell et al., Rehabil Psychol 2009;54:83-90 Rosenbaum et al. J Abnorm Psychol 1980;89: Sharma et al., Colorectal Dis 2008;10:151-6 Stevens et al. Psychol Rep 1989;64:284-6 Strand et al., J Psychosom Res 2006;60: Tang et al., Pain 2008;138: Weaver el al. Percept Mot Skills 1994;78:632-4 Weisenberg et al. Pain 1998;76: Worthington et al. J Couns Psychol 1981;28:1-6 Zautra et al. J Consult Clin Psychol 2005;73: Zelman et al. Pain 1991;36:105-11

Interventions that enhance resilience Social Support Round Robin Make eye contact with somebody sitting next to you. Give him or her a fist bump. Take a moment and think about something you really like about that person. Choose something special about him or her that is generally seen as a character strength (creativity, intelligence, integrity, courage, sense of humor, perseverance). If this person is a stranger, choose something about his or her presentation or demeanor. If this person is somebody with whom you have a conflict, all the more important to identify something you like and/or respect. Now, tell the person what it is that you appreciate and/or admire.

Interventions that enhance resilience Keeping a Gratitude Diary 1. 1.Every day, write down 3 things for which you are grateful. It can be anything - feeling the sunshine on your face, happy that a friend phoned, receiving a present, being able to take a walk, anything. Work out a time to do this. Ideally, around the same time every day works best Make a commitment to yourself that you will write down 3 things every day - this is very important The 3 things MUST be DIFFERENT each time. Never repeat anything Smile as you write them down. This will help you to feel grateful You can write a lot about each thing, get really detailed, write why you are grateful for it. Or if you don't have time, just write one line.

Interventions that enhance resilience Savoring a Beautiful Day: Set aside a block of time for your own pleasures. Set aside a minimum of one hour or a maximum of a full eight-hour day. A half-day is just about perfect for the first time you do this exercise Block that time out on your calendar now, and do not let anything interfere, if possible. Next plan one activity or, even better, a sequence of activities that brings you real pleasure, and carry them out as you planned them Here is the further twist. Savor each of the activities using all of your senses and with feelings of gratitude and optimism. Adapted from: Seligman, Park & Peterson

Interventions that enhance resilience Three Good Things Every night for the next week, right before you go to bed, write down three things that went particularly well on that day. These things can be ordinary and small in importance or relatively large in importance. Next to each positive event in your list, answer the question, “Why did this good thing happen?” Seligman ME, Rashid T, Parks AC. Positive psychotherapy. The American psychologist. Nov 2006;61(8): Seligman et al. American psychologist2005;60(5):

Positive Piggy Bank Every evening think about the people, things or events that made you happy that day. You may make a list if you like. Pick one of these and spend a moment savoring it. What made it so special to you? Now, write down this moment on a “currency” slip. Use enough detail that you can immediately recall what happened later. Next, add the date, fold up your happy memory “currency,” and drop it in the piggy bank. You will make these happy memory “deposits” in the same way every evening for the next 30 days. At the end of 30 days, you will “close your account.” This means that you will withdraw all of the “currency” from your piggy bank and read each and every one of the deposited happy memories. As you read them, try to recall details of the happy event and what made it so special to you at the time. Enjoy! Hassett et al. Studies underway

Positive Piggy Bank Preliminary Data! General population, adults 18-80, English speaking, able to give consent and low levels of depressive symptoms (PHQ9 ≤ 9). Completed questionnaires and were randomized to PPB or WLC. Hassett et al. Preliminary data.

Positive Piggy Bank Preliminary Data! All participants with pre- and post-intervention data (n=89): Psychologically healthy sample (PA: 34.8±7.0; NA: 15.6±6.0) Significant improvement in life satisfaction (t[87] = -1.98, p = 0.050) Significant improvement in life satisfaction in those with depressive symptoms (PHQ ≥3; n=38) could be more pronounced (t[87] = -2.16, p = 0.037) Hassett et al. Preliminary data.

ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35: Putting it all together: The six things you need to think about when treating patients with chronic pain.

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Exercise ExPRESS Factors: Exercise –Don’t feel good (pain!) –Limited energy/time –Low motivation (fun?) –Obese, embarrassed –Stress and poor habits

Graded Exercise Increase activity gradually:   Ask the patient for an activity they enjoy doing. “ Walking ”   Ask patient, “What would be a reasonable amount of walking in minutes to achieve in the next month?” “ 20 minutes a day ”   Negotiate down from patient’s stated goal. “ 15 mins. day 5 x wk”   Begin with the smallest of steps (No Fail scenario) “5 mins day 3 x wk”   Encourage keeping a daily log   Emphasize, exercise regardless of symptoms! Graded tasks – Break tasks down into small manageable bits, too.

Exercise Resistant to starting formal program? Begin with extra steps commitment. Activity trackers – Fitbit ($100) and pedometers can be found for as little as $10. Every day beat the day before by 50 steps. Healthy: 10,000 steps a day (18 – 1,900 steps in a mile)

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Pain, Depression and Sleep Triad Pain Depression(anxiety/stress)Sleep

Psychiatric Co-Morbidity   Use screening tools like the PHQ-9 for depression and GAD-7 for anxiety. Checklists and VAS for “Depression” or “Anxiety.”   Consider treating more mild conditions – most patients choose not to follow up with psychiatric referrals.* * *Arnold LM. Management of fibromyalgia and comorbid psychiatric disorders. J Clin Psychiatry 2008;69 (suppl 2):14-19.

Normalize psychiatric co-morbidity. “In most chronic illnesses like heart disease, diabetes and chronic pain, depression is common and important to treat. It can be really tough dealing with pain and all of the changes these illnesses cause. Plus, depression makes symptoms like pain and fatigue worse. So it’s important that we address your depression, too.” Psychiatric Co-Morbidity

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Regaining Function Identify Achievable Goals: 1) Functional improvement not cure. 2) Increased ability to live with and decrease symptoms. Obtain baseline data for later comparisons (VAS, PROMIS, FIQ) Improved functioning, return to some previous activities – –Identify specific activity, “Tending to my roses” or “Returning to work.” – –Poor goals = “feel better” or “not have pain like I do today” Graded tasks – –“What is one thing you are willing to do between today and our next appointment to start moving you towards your goal?”

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Education Provide basic education without jargon and deliver 3 key messages: Message 1 - Psychiatric co-morbidity is normal: “People with chronic pain also often experience stiffness, fatigue, sleep disturbance and depression (or anxiety when applicable).” Message 2 – I believe you: “Current research suggests that some chronic pain conditions may be the result of changes in the central nervous system. Somehow the pain signal has become amplified.” Message 3 – We are partners in treatment: “The good news is that there are things you can do to get better, but you will need to be an active partner in your treatment.”

Education Arthritis Foundation arthritis.org

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Pain, Depression and Sleep Triad Pain Depression(anxiety/stress)Sleep

Sleep Hygiene “Sleep and sleep hygiene” DHHS 64 million Americans have chronic insomnia (> 20%) Disrupting slow wave sleep over several nights in sedentary middle- aged females (without reducing total sleep efficiency) results in a decreased pain threshold, increased discomfort, and fatigue. Lentz et al., J Rheumatol 1999, 26(7), In FM, >75% report sleep disturbances. Insomnia up to 65%, snoring and arousals up to 78%, RLS up to 41%, excessive daytime sleepiness up to 93%. FM with sleep studies = obstructive sleep apnea ~ 80% Abad et al., Sleep Med Rev 2008;12:211-28

Sleep Hygiene   Get up and go to bed at about the same time every day.   Do not take naps.   Stay away from caffeine, nicotine, and alcohol 6 hours before bed.   No exercise at least 4 hours before bed.   Take a hot bath 90 minutes before bed (core temperature drops).   Develop sleep rituals like having a light snack, brush teeth, set alarm.   The bedroom should be quiet, comfortable and dark.   The bed should be used only for sleeping (no critters, no eating).   Go to bed only when feeling sleepy.   If sleep does not come within 20 mins, get up and do something boring until sleepy again.   Do not clock watch – cover it if necessary!

ExPRESS Factors: Exercise Psychiatric Co-Morbidity Regaining Function Education Sleep Hygiene Stress Management ExPRESS Approach for Chronic Pain Hassett & Gevirtz. Rheum Dis Clin North Am 2009;35:

Stress Reduction Decrease the psychophysiological response to stress: Relaxation techniques – – Slow breathing – in through nose/out through pursed lips – – Progressive muscle relaxation – – Imagery and visualization Biofeedback (esp. HRV) Hassett et al. Appl Psychophysiol Biofeedback 2007;32(1):1-10 Meditation, Yoga, Qigong Exercise programs (walking, yoga and aqua therapy) Cognitive strategies – new things to think instead Positive Psychology interventions – – Gratitude lists, pleasant activity scheduling, savoring, mindfulness activities, piggy bank

Non-Pharmacological Interventions

Cases to Consider Claire is a 45 yo marketing consultant who has struggled with a life-long series of medical conditions. Chronic abdominal pain in childhood, severe PMS in adolescence, IBS in adulthood and now, insomnia, OA and widespread musculoskeletal pain. She has been treated for depression off and on over her lifetime and has begun to experience panic attacks that are “completely unnerving!” Claire has tried numerous medications for her pain and other symptoms with little relief and feels frustrated by the medical community. Today her affect seems a little brighter when she poses that maybe she should consider trying yoga. – –What do you tell her?

Non-Pharmacological Interventions

Cases to Consider Lisa is a 27 year old graduate student with SLE. Her disease is well-controlled but she continues to report “achiness” deep in her muscles. She also describes severe fogginess at times and fatigue almost always. She indicates that school has been stressful and her dissertation chair does not like her. She confided that she feels like a failure and that everything she does is not good enough. Now, her pain is so bad that she feels like she should just drop out of school.

Non-Pharmacological Interventions

Cases to Consider James is a 58 yo small business owner who had been in good health until the past year when he was in an automobile accident. He was treated for whiplash and currently reports persistent severe neck and back pain. The pain has made it difficult for him to run his shipping business and he appears increasingly withdrawn and irritable. He reports giving up golf and no longer goes to the gym. He has put on 20 pounds in 4 months. When asked what troubles him the most about his condition, he states it’s his “restless mind – I can never just stop. It’s so stressful.”

Non-Pharmacological Interventions

Robert is a 78 yo retired high school history teacher with a 15-year history of OA of the hip. THA two years ago but has persistent hip pain in both hips and is considering THA in the other hip. You determine that the pain is widespread and increasingly worse since he stopped exercising. He sleeps 8 hours but does not feel refreshed in the morning. He has a history of past depression. – –What else would you want to know? – –Is he a good candidate for a second THA? Cases to Consider

N=655 participants undergoing arthroplasty Pain outcomes assessed at 6 months. Fibromyalgia survey score was a robust predictor of poorer arthroplasty outcomes, even among individuals whose score falls well below the threshold for the categorical diagnosis of fibromyalgia (estimate -0.25, SE 0.044; P < ). Cases to Consider Brummett, Urquhart, Hassett et al. Arthritis Rheum 2015;67:

Difficult Patient Subgroup

David is a 42 yo electrical engineer with chronic low back pain. He states that he can no longer work and wants you to sign his disability papers, “Now.” He is clearly depressed but refuses to seek mental health care (I’m NOT crazy! If you people could fix my pain I’d be fine). He is often hostile to your front desk staff and refuses to see anybody but you (you’re the only one who understands his special case). He has been taking high doses of Oxycontin for almost two years but still reports pain as being an 8 on a 1-10 scale (getting worse over time). He has been going through his medication too fast and leaves multiple messages with the nursing staff demanding refills and to speak with you. You have sent him to PT and he refuses to go regularly because he thinks the physical therapist does not respect him. Cases to Consider

Psycho – Physiological Continua HIGH LOW HIGH Neurobiological Dysfunction Psychological Dysfunction

Personality Disorders (N=72) 38.9% in FM (vs. 21.1% controls)   Histrionic (19.4%) and Narcissistic (8.3%) Exaggerated personality traits Underlying raw emotional processes of rage, fear, hate, dependency and shame. Cognitive distortions and poor coping. Self-defeating or self-destructive behaviors. Manipulative, charming, disarming, dangerous. Personality Disorders Hassett et al. Am J Med 2009;122:843-50

Medical setting behavior: Demanding and entitled. Become easily enraged (two year old-like tantrum) Medical illnesses can be a blow to his/her sense of self (threatening). Reinforce that they are respected and deserving of the best treatment available. Set limits on demanding behavior. Do not give in to the urge to strike back verbally or become defensive. Narcissistic Personality Disorder-Criteria

Know when to hold ‘em… $64,000 question: “If we could magically heal all of your symptoms today, what would you do tomorrow?”

Acknowledgments Daniel J. Clauw, MD Chad M. Brummett, MD Jenna Goesling, Ph.D. Richard E. Harris, Ph.D. Steven E. Harte, Ph.D. Ronald Wasserman, MD David A. Williams, Ph.D. Alex Tsodikov, Ph.D. Stephanie Moser, Ph.D. Jennifer Wolfe, MA Meghan McCloe, BA Natalie Gulau, BA Andrew Clauw, BA Emily Hogan Funding: National Institute of Mental Health Bristol-Myers Squibb, Inc. American Society of Regional Anesthesia & Pain Medicine Metzger Family Foundation University of Michigan, Department of Anesthesiology Follow