1. Chapter Ten: The Management of Pain and Discomfort

2. Pain: Health Epidemic
30% of Adults in Developed nations suffer from chronic pain
-40% in Underdeveloped Nations
25% of Children in US experience Chronic Pain
Increased 4x since 1999 – Multibillion Pharma
Addiction to prescriptive pain meds/opiates

3. Biomedical Model Narrow view of tx Medication management of Pain
Only moderately effective!
Addiction to pain meds/overdoses
Psychological interventions a promising addition

4. Cause of Epidemic of Addiction
25 years ago a major academic paper stated that pain patients were wholly mismanaged. Described a cruel and blind medical field that was neglecting and undermedicating pain.
Change in medical school training/health psych
Focus of pain as a major vital sign – upping use of pain meds
1996 introduction of Oxycontin : Pharma touted no addiction and low side effects

5. Opiate Addiction 1999: sale of opiates 4x
44 die of opiate addiction daily
States with no monitoring: Alabama, Tennessee, W. Virginia, Florida (worst)
Maine and New Hampshire: highest dosage of Oxycontin
Lowest Use: Hawaii, California, Colorado

6. Demand for Change Keys to changing tide of opiate addiction:
Identify the Pill Mills
Retrain Doctors treating pain
Regulate Pain Management Claims
Role of Heroin?
Most common fatalities: (1) Vicodin (2) Oxycontin
(3) Fentanyl, (4) Methadone

7. Demand for Change Restrictions on how opiates prescribed (2014)
- Require face to face
- no call-in scripts
Role of Psychological interventions
Alternatives: accupuncture, massage, relaxation, exercise, electrical stim
Problem: not widespread in application

8. Chronic Pain
Addiction to Opiates contributes to worsening of chronic pain
Worsens the experience of pain over time
Chronic Pain becomes a major risk factor to a lifetime of opiate addiction

9. Effect of Pain
Provides feedback about the functioning of our bodily systems
Can lead a person to seek treatment
Inadequate relief from pain is the most common reason for requests for euthanasia or assisted suicide
Ethics of Physician Assisted Suicide: product of inadequate tx?

10. Purpose of Pain
Adaptive: Protective mechanism to bring tissue damage into conscious awareness
Accompanied by motivational and behavioral responses
Problem with intense reactions: Negative emotions exacerbate pain and vice versa

12. Measuring Pain
Verbal reports - Large, informal vocabulary that people use for describing pain
Pain questionnaires - Ask about the nature of pain and its intensity
Observation of Behavior: can be most useful with severe pain

13. Measuring Pain Pain behaviors: Arise from chronic pain
Not acute pain
Used to assess how pain has disrupted a patient’s life
Can have secondary gains – promote underfunctioning and increase pain
Complicates treatment

14. Pain Modification
Descending: Reinterpret pain signals (context, culture)
Ascending: modification of pain happens in the peripheral nervous system (Pain-Gate Theory elaborates)

15. Elusive Nature of Pain Degree to which pain is felt depends on:
How it is interpreted
Context in which it is experienced
Cultural component - Members from some cultures react more intensely to it than those from other cultures
Gender differences - Women show greater sensitivity to pain

16. Pain in the Brain No single Pain Center Frontal Lobe
Insula – assess seriousness of pain
Limbic System: emotional reaction
Periductal Grey: relieves pain/cancer tx

17. Gate Control Theory of Pain
First scientific understanding of pain
Receptors sense injury and release chemical messengers to the spinal cord
A-delta fibers - Small, myelinated fibers
Transmit sharp, brief pains rapidly
Turns on the “off switch” nerve
Only short bursts of pain

18. Gate Control Theory of Pain
C-fibers - Unmyelinated nerve fibers
Involved in polymodal pain
Transmit dull, aching pain
Closes gate to the transmission of sharp pain
Exp: Accupuncture, Rubbing, etc.
Discovery of the ascending modification of pain perception (from bottom to brain)

19. Stress Response: Pain Inhibition
Stress-induced analgesia (SIA) - Phenomenon where acute stress reduces sensitivity to pain
Enkaphalin/Endorphin: Released by Pituitary
Effect of Chronic Stress: dulls pain – complicates pain assessment in low ses pts
Ascending modification: Top-Down

20. Acute and Chronic Pain
Acute pain: Results from a specific injury that produces tissue damage
Disappears when the tissue is repaired
Short in duration, lasting for 6 months or less
Chronic pain: Begins with an acute episode but does not decrease with treatment and the passage of time
– Pain intensifies Pain, underfx, addictions
Note: interventions most effective for Acute

21. Acute versus Chronic Pain
Both have different psychological profiles
Chronic pain
Depression/Anxiety/Suicidality complicates diagnosis and treatment
Patients develop maladaptive coping strategies – overdependency/addiction
Pain becomes Dysregulated
Pain control techniques are not effective
Pain meds increase pain sensitivity

22. Types of Chronic Pain Chronic benign pain Recurrent acute pain
Persists for 6 months or longer
Relatively unresponsive to treatment
Severity of pain varies
Chronic benign pain
Intermittent episodes of pain that are acute in character but chronic in condition
Recurs for more than 6 months
Recurrent acute pain
Persists longer than 6 months and severity increases over time
Associated with malignancies or degenerative disorders
Chronic progressive pain

23. Table 10.1 - Common Sources of Chronic Pain
Source: National Institute of Neurological Disorders and Stroke, 2007.

24. Chronic Pain Patient Pain is exacerbated by:
Misdiagnosis: exp. Fibro Myalgia
Inappropriate prescriptions of medications
Lifestyle: Secondary Losses
Quit jobs and abandon leisure activities
Withdraw from families and friends
Require loss of independence

25. Chronic Pain Patient Relationships
Experience loss of self-esteem/identity
Receive compensation
Increases pain as it provides an incentive for being in pain
Relationships
Family relationships get affected
Marital Decline in Intimacy
Positive attention from spouse may maintain the pain

26. Chronic Pain Patient
Behaviors - Alterations in lifestyle interfere with successful treatment
Sedentary, Poor diet, hopelessness
Stress: intensifies pain, difficult to manage
Factors in treating the total pain experience
Understanding the pain behaviors
Knowing whether they persist after treatment

27. Pain and Personality
Pain-prone personality: Predispose a person to experience chronic pain
Personality attributes associated with chronic pain
Neuroticism
Introversion
Use of passive coping strategies

28. Pain Profiles Conditions that increase the perception of pain
Depression and anger suppression (avoidance of feelings)
Efforts to suppress pain (family norm, culture)
Anxiety disorders, substance use disorders, and other psychiatric problems

29. What is Pain Control?
Cessation of Pain: Surgery / nerve block effective
Tolerance of Pain: use of alternative techniques most effective with increasing tolerance

30. Pharmacological Control of Pain
Most common method of controlling pain
Administration of drugs
Local anesthetics - Affect the transmission of pain impulses from peripheral receptors to the spinal cord
Spinal blocking agents
Antidepressants - Affect the downward pathways from the brain that modulate pain
Types of drugs
Undesirable side effects
Addiction
Drawbacks

31. Surgical Control of Pain
Disrupt the conduct of pain from the periphery to the spinal cord
Interrupt the flow of pain sensations from the spinal cord upward to the brain
Drawbacks
Effects are short-lived and it is very expensive
Surgery damages the nervous system
Cancer Pain

32. Sensory Control of Pain
Counterirritation: Inhibiting pain in one part of the body by stimulating or mildly irritating another area
Exercise and other ways of increasing mobility help the chronic pain patient

33. Psychological Control of Pain
Requires patients to actively participate and learn
More effective for managing slow-rising pains

34. Biofeedback
Providing bio-physiological feedback to a patient about some bodily process of which the patient is unaware
Target function to be controlled is identified and tracked by a machine
Patient attempts to change the bodily process with the help of continuous feedback
Heart rate, Blood Pressure, Muscle Tension, Sweat response (Galvanic Skin Response)

35. Relaxation Techniques
Shifting the body into a state of low arousal by progressively relaxing different parts of the body using controlled breathing
Beneficial physiological effects are due to the release of endogenous opioid mechanisms
Yoga, Meditative Behaviors

36. Distraction Turning attention away from pain by:
Focusing on an irrelevant and attention-getting stimulus
Distracting oneself with a high level of activity
Most effective for coping with low-level pain

37. Coping Skills Training
Helps chronic pain patients manage pain
Take inventory of current coping
Assess efficacy of current coping
Expand to new approaches
Social support
Self-Care
Self-efficacy

38. Cognitive-Behavioral Therapy
Reconceptualizes a problem from overwhelming to manageable
Eliminate Catastrophic thinking
Patients:
Believe that the required skills will be taught to them
Become competent individuals aiding in the control of pain

39. Cognitive-Behavioral Therapy
Learn to break up maladaptive behavioral syndromes
Learn to make adaptive responses to pain
Are encouraged to attribute their success to their own efforts
Are taught relapse prevention
Are trained to control their emotional responses to pain (Anx/Anger/Sadness)

40. Mindfulness Training
Address HOW patient experiences pain, not the antecedents or consequences
Understand the emotional regulation while experiencing pain
Not on Cognitive Regulation (CBT)
Learning to self-soothe
Contemporary addition to CBT

41. Pain Management Programs
Interdisciplinary efforts, bringing together neurological, cognitive, behavioral, and psychological expertise concerning pain
Steps
Initial evaluation
Individualized treatment

42. Pain Management Programs
Components
Patient education
Involvement of family
Relapse prevention