1. Psycho-Behavioral Issues in Pain Management
Mark D. Ackerman, Ph.D.,
Licensed Clinical Psychologist
VA Medical Center & Emory University School of Medicine,
Atlanta, GA

2. Pain Management is changing
Fewer opioids
Focus on function and quality of life
Focus on safety
Team support for help in returning to a full, satisfying, productive life even if pain persists
Much has been learned in the past 20 years about the best ways of addressing pain. And too, much has been learned about the health risks and limits of benefit from opioid medications. As a result, management of chronic pain has been changing.
One of the big changes has been in the area of establishing goals of treatment for chronic pain. There is now more of an emphasis on helping the patient function better. You may have noticed in recent years that the questions asked about your pain have changed somewhat. Nurses at check-in are now asking you how pain affects your enjoyment of life and how pain has interfered with your general activity. These types of questions assess the impact pain which is difficult to understand. This is more helpful than asking only for a “pain number”.
The VA is also paying closer attention to the dosages of opioids our patients are on. What was once considered acceptable dosages we now know carries considerable risk for worse outcomes. It is important to use the lowest effective dose to help minimize the rate of poor outcomes. Research has found that higher doses of opioid medications are associated with a greater risk of dying. Beyond the risk involved, increasing doses of opioid medications do not always provide improved pain nor better functioning.
We’ve also learned that it’s essential that we focus on the “whole person” and not focus exclusively on symptoms.
Here at the VA, we have created a medical home model, or PACT teams, where care can be delivered by a consistent group of health care professionals who have opportunity to get to know their patients and learn what’s important to them.

3. Contemporary Theory of Pain
Gate Control Theory (Melzack & Wall):
A bio-psycho-social model of pain.
Views the brain as an active player in pain perception.
Provides rationale for psychological interventions for pain management.
Pain no longer simply organic or psychogenic.
DSM-IV-TR lists – Pain Disorder Assoc. w/ both Psychological Factors and a General Medical Condition

4. Bio-medical Model
The biomedical model is a framework for providing care and which focuses exclusively on biological or body components. This model does not recognize the influence of other factors.
Acute and cancer pain can reasonably be expected to be adequately addressed by a model. This model views pain and injury as the primary problem and that medical approaches are the only effective treatment.
In the past, this model has been applied to chronic pain conditions but with frustrating results. While this model works well for acute and cancer pain, it is simply not adequate to address the many factors that make up most chronic pain conditions.

5. T H E P A I N G A T E FACTS ABOUT PAIN IN THE UNITED STATES
Over 11 million people experience migraine headaches
23 million people report chronic back pain
37 million people report pain associated with arthritis
3-6 million people have been diagnosed with fibromyalgia
3.5 million people experience pain associated with cancer and cancer treatment
Annual costs (health care, disability, lost productivity) of chronic pain may exceed $125 billion a year.
Brain
Pain Gate
Pain Source

6. T H E P A I N G A T E Factors That Open the Pain Gate
Physical/Behavioral Factors
Injury
Readiness of the nervous system to send pain signals (or of the brain to receive them)
Too much physical activity (e.g., pushing yourself too far, trying to do all that you used to do when you were young/before the onset of your pain condition)
Emotional Factors
Stress/Anxiety/Worry/Tension
Depression
Anger
Mental/Thought Factors
Focusing on the pain or attending to the pain
Boredom (e.g., due to minimal involvement in life, lack of stimulation)
Negative or non-adaptive attitudes
Brain
Pain Gate
Pain Source

7. T H E P A I N G A T E Factors That Close the Pain Gate
Physical /Behavioral Factors
Medication
Counter-stimulation (e.g., heat, ice, massage, transcutaneous neural stimulation, acupuncture)
Moderate physical activity (appropriate to your ability level)
Positive activity (e.g., spending time with family/friends, playing with children/grandchildren)
Health eating
Alternative Therapies (e.g., aromatherapy)
Emotional Factors
Relaxation, rest, & stress management
Positive emotions (e.g., happiness, optimism)
Mental/Thought Factors
Increased interest and mental involvement in your life
Stimulation of your mind
Concentration and distraction
Positive or adaptive attitudes
Brain
Pain Gate
Pain Source

8. Two main categories of pain
1. Acute - is a relatively brief sensation, usually less than six months duration - usually a response to a specific trauma - forms the basis for danger warnings and subsequent learning.

9. Pain types
Acute pain = pain related to injury, disease, or medical procedure
Short lived
Expected to heal
Cancer pain = pain associated with active cancer and/or its treatment
Chronic pain = pain that persists beyond expected healing time
Likely not to resolve on its own
May be constant or episodic
I’ve mentioned chronic pain. It might be helpful at this point to explain the differences between different types of pain. Because of those differences, the way we offer help may look somewhat different.
Acute pain typically refers to pain related to an injury, disease, or medical procedure or surgery. Acute pain usually has a clear cause. Acute pain is expected to last a short time (hours, days, weeks) or until the injury heals. Certainly, healing would be expected to occur within 6 months.
Cancer pain is used to identify pain associated with active cancer. This can be from a tumor pressing on a bone, nerves or any part of the body. The pain may be from cancer treatments or surgery.
Chronic pain is used to identify long-lasting pain. It lasts beyond the time expected to heal from surgery or an injury or it could be continuing pain from a chronic disease. pain is then defined as chronic if it exceeds that period of time. Chronic pain can come from conditions such as arthritis, diabetes, nerve damage and others. Sometimes the cause is unknown. Chronic pain is not expected to resolve on its own. Chronic pain may be constant, it may come and go, and it may vary from day to day.
Acute and Cancer-related pain can usually be reduced to an acceptable level with medications in most patients. For chronic non-cancer pain, medication alone might not alleviate pain to a level that is acceptable. The goal of treatment for chronic non-malignant pain is to enable the patient be as active and pain-free as possible and to provide tools to better cope with pain. We believe that ALL patients can be helped to better cope with their pain when they actively participate in their own treatment.

10. Chronic Pain Characteristics of Symptoms last longer than 6 months
Few objective medical findings
Medication abuse
Difficulty sleeping
Depression
Manipulative behavior
Somatic preoccupation

11. APS/AAPM on Pain
As chronic noncancerous pain is often a complex biopsychosocial condition. Clinicians who prescribe continuous opioid treatment should routinely integrate psycho-therapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non-opioid therapies.

12. Pain is… IASP definition “An unpleasant sensory and
emotional experience
arising from actual or potential tissue damage
or described in terms of such damage”
IASP definition
International Association for the Study of Pain
A widely accepted definition of pain is the one used by The International Association for the Study of Pain.
This group defines pain as “An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage”
This definition helps us understand that, for any one physical problem or diagnosis, pain can vary from patient to patient. The perception of pain is influenced by physical, psychological, social, cultural, and hereditary factors.

13. PAIN Sometimes the source, or solution, is unknown or unavailable
Pain is subjective. By subjective we mean that the pain that you feel is an internal state that only you can experience. Each person’s pain is uniquely their own.
There is no objective test for pain. A person may have an abnormal test (e.g., MRI shows a "bulging disk” or a herniation) with no pain. Another person may have substantial pain with normal x-ray findings. Chronic pain can develop in the absence of significant anatomical or bodily changes detectable with current technology. This does not mean that the pain is psychogenic or arising from emotional or mental stresses.
It is not uncommon for providers to not be able to find the source of chronic pain. For instance, muscle strain and inflammation are common causes of chronic pain, yet may be extremely difficult to detect. Other painful conditions may be due to systemic or whole body problems e.g. diabetes with neuropathy. For some patients, PTSD or mood disorders like depression or anxiety may contribute to a person’s chronic pain.
Because we cannot always "see" the cause of the problem it is essential that health care providers rely on the person’s report of their pain. A patient’s self report is the most reliable way to determine the presence of pain. In 1968, nurse Margo McCaffrey defined pain as “whatever the experiencing person says it is, existing whenever he says it does."
This can be frustrating!

14. You are complex You are: More than “Pain”; Complex Balance
Social and lifestyle factors can play a significant role in altering the pain experience, e.g. closing the “pain gate.” Personality, learning (e.g. modeling), secondary gain and cultural factors can also play a role in the experience of chronic pain.
You are:
More than “Pain”;
Complex Balance

15. Bio-psycho-social Model
Explains why:
Another test may not help;
Another [something done to me] may have no effect
Contrast this with the biopsychosocial model of pain which is more appropriate for understanding and treating chronic pain.
Pain occurs within a context or a setting and develops over time.
Chronic pain, as well as other chronic conditions, often involve a number of factors. These factors can include: the physical state of the body, psychological traits and states of the person, and social and environmental factors. In other words, chronic pain can be complex in that the pain that an individual feels can be influenced as much by mood and personal experiences-- like stress-- as it can by persistent inflammation or increased pain sensitivity.
(CLICK to add overlay) The biopsychosocial model explains how a “whole person” approach to pain can be helpful. And this model demonstrates why multiple types of providers may be needed.

16. Understanding Pain http://www.youtube.com/watch?v=4b8oB757DKc

17. MANAGEMENT PLAN MUST BE BROAD AND PERSON-FOCUSED
CHRONIC PAIN IS COMPLEX
therefore
MANAGEMENT PLAN MUST BE
BROAD AND
PERSON-FOCUSED
Chronic Pain is complex. Many areas of life can be affected by pain and in turn, may worsen pain.
These areas can include:
Sleep 
Activity
Exercise
Work
Relationships
Memory and concentration
Moods
Energy level
Outlook for the future
Substance use  
Employment
So as you can see, chronic pain care involves more than just medications. Work with your provider to see what the best choices are for you.
Your involvement in your care is essential for success

18. A car with four flat tires: Getting Medications right (including Opioids) only fixes one of the four tires
Penney Cowen, founder and CEO of the American Chronic Pain Association developed a video based on a helpful analogy.
Let’s see how she compares chronic pain to a car with flat tires.
Using medications, maybe including opioids, can fix one of the tires.
There are still 3 other flat tires to address – other parts of life and other types of management besides medications or procedures.
credit: The American Chronic Pain Association

20. Pain: An Integrated Framework

21. Who is in more pain?
# # #3
What if I told you that #1 just lost his job and #3 just won the big game? This introduces important “other” factors – the psycho-social pieces of the puzzle. Discuss Beecher study.

22. Disrupt the downward spiral of chronic pain
Distress
Disability
Pain

23. We must understand the “person with pain”.
Biopsychosocial
Model
Biological
Social
Psychological
Elicit examples of each component from group. Not just the pain, or the “chronic pain patient”.
We must understand the “person with pain”.

24. Pain in a Social Context

25. Underlying Principles
Operant conditioning
Frequency and intensity of behavior increases with reinforcement and decreases with punishment.
Classical conditioning
A network of associations develops around pain, such that otherwise healthy and productive tasks are associated with pain, and thus, avoided

26. Pain in a social context
Responses from the environment can alter pain behavior, and thus, pain perception
Solicitousness
Punishing responses
These responses are associated with a lack of patient acceptance of pain
Lack of investment in self-management
Learned helplessness
Pain comes to define some patients.
(McCracken, 2005; Fordyce, 1976)

27. Patient-Centered Care
The patient should be an active participant in the development of treatment goals.
Patients should be educated about the role of other disciplines in pain care.
Patients should be educated about all appropriate treatment options.
Knowledge = perceived credibility = greater follow-through.

28. Pain
Distress
Anxiety
Avoidance
Depression
Guarding
Pleasant
Activity

29. Behavioral Strategies
As clinicians, we must be cognizant of how we might unintentionally reinforce pain behaviors
Example: quick to offer a script -> “my condition must be bad if the doctor thinks I need medications.”
Behavioral pacing
Break association between activity and pain
Pleasant activity scheduling
Work to break pattern of negative thinking about such activities
Offer to assist, don’t tell patients to “just do…..”

30. Pain School Promote self-management
Interdisciplinary: primary care provider, psychologist, clinical pharmacist, rehab medicine (PT/OT), dietitian
Topics: biopsychosocial model, mind-body connection, SMART goals, CBT, relaxation training, stress management, assertive communication, pacing, energy conservation, thermal modalities, exercise, CAM, sleep, sexual functioning, medication, nutrition

31. Typical Treatment Modules
Cognitive Modules
Self-monitoring
Cognitive Errors
Cognitive Restructuring
Anger Management
Assertiveness Training
Behavioral Modules
Relaxation Training
Activity Pacing
Pleasant Activity Scheduling
Sleep Hygiene

32. Case Examples Social Biological Psychological
How often do you know the social context from which a patient comes?