The “Pain” of TreatingChronic Pain

P. Joseph Frawley ,M.D.

September 17 ,2008

CAMFT

Main Goals for This Talk

• 1. Understand the difference between acute and chronic pain

• 2. Understand the role of an altered nervous system in the maintenance of chronic pain

• 3. Understand principles of treatment of chronic pain

Apply this information to three common causes of chronic pain

Low Back PainFibromyalgia

Migraine Headache

Definition of Pain

• 1. Sense of the physiological condition of ourselves (well being, mood, stress, feelings)

• 2. Elicits responses to feelings/wellbeing/

• body state

• 3. Encoded differently than vision/touch/ hearing and deeply linked with the limbic endocrine and autonomic nervous systems

Acute vs Chronic Pain

• Acute Pain• -Self limited, pain system is responding

appropriately, related to injury• -(Fire Alarm)• Chronic Pain• -Prolonged, pain system is altered, no longer

represents injury, cross connections, up regulation

• -(Fire alarm continues after fire is put out)

Measurement of Pain

1. Scale 0----------4---------------------7-------------10

none worst

Can Ignore Must Manage Can’t stand

2. Faces

Smile----------------------------------------------Cry

Three Parts of Pain

1. The Injury

2. The body’ Response to Injury

3. The impact of the injury on the person

Pain System has Ascending and Descending Circuits

• Brain

• Spinal Cord

• Nerve

Somatosensory Brain: Where Is It?

Limbic Brain: What is It?

• How does it

• Relate to survival:

• Past

• Present

• Future

Chronic Pain: Mechanical Factors

1. Arthritis/Tendonitis/Compression Fractures

2. Neuropathy

3. Complex Regional Pain Syndrome-(Nerve Injury)

4. Spinal Cord

Chronic Peripheral Pain

Arthritis

Neuropathy

Complex Regional Pain Syndromes

• The injury generates a hyperarousal response of somatic and sympathetic systems:

• Results in pain, swelling, changes in skin texture, temperature, loss of hair and hypersensitivity.

Spinal Disorders

• Multiple Sclerosis

• Trauma

Migraine Headaches

• Migraine Headaches• Headaches that may be preceded by an aura,

but are characterized by:• A. Usually one Sided• B. Throbbing• C. Photophobia, Sonophobia, • D. Nausea• E. Wanting to go an isolate

The Course of the Headache

Epidemiology of Migraine

• Data from: Lipton, RB, Bigal, ME, Diamond, M, et al. Migrane prevalence, disease burden, and the need for preventative therapy. Neurology 2007; 68:343.

•

Treatment of Migraine

• Preventing the Headache: (if >2 per month)– A. Anti-Seizure Meds– B. Tricyclics– C. Calcium Channel Blockers– D. NMDA Receptor blockers

• Aborting the Headache(as soon as possible)– A. NSAIDs– B. Triptans, DHT, – C. Opiates,Fiorinal

Tension Headaches• These are characteristically:• A. Bilateral• B. Temple or posterior head location• C. Pressure Sensation/Sharp

• Treatment:• A. NSAIDs, Ice, Massage, • B. Opiates, Benzos.• C. Stress reduction

Migraine Headaches and PTSD

• Patients with Migraine do not have a higher percentage of patients with PTSD than the general population.

• N= 92 consecutive pts with Migraine• Those with Trauma 16.3%• Those with PTSD 6.5%

• Gal Iferganea, Dan Buskilab, Nino Simiseshvelyb, Alan Jotkowitzb, , , ZeevKaplanc and Hagit Cohenc

Frequency of Transformed Migraine and PTSD

• Episodic Migraine Chronic Migraine • (<15 days per month) (>15 days per month)

N = 32 N = 28 • Depression 22% 54%• Trauma No dif• PTSD 9.5% 43% (p <0.0059)

• PTSD may be a risk factor for chronic migraine

B. Lee Peterlin, DO; Gretchen Tietjen, MD; Sarah Meng, DO; Jeffrey Lidicker, MSc; Marcelo Bigal, MD, PhD , Headache, April 2008.

Post Traumatic Headache and PTSD

• Patients with chronic post traumatic headache.

• 30% had PTSD• Those with PTSD had more depression and

suppressed anger and a greater hx of headache prior to the trauma.

• John T. Chibnall , M.S. Paul N. Duckro Ph.D.

Medication Overuse Headache• Mostly evolves from Migraine or Episodic

Tension type headaches.

• 28 CTTH 89 MOHPre ETTH 31 Pre-Migraine 58

Co-morbid Psych Disorder11 21 3131% 67.75 53.7%

• (Incr mood disorder)

• European journal of pain (London, England); 2005 Jun 1;9(3)

Fibromyalgia2% of the populationFemale: usually age 20- 65Chronic, Generalized PainFatigue 90% (70% meet criteria for CFS)Sleep and Mood DisturbancesHeadachesIrritable Bowel SyndromeMultiple Tender areas of muscle and TendonsBilateral and Upper and Lower Body (11 of 18

points)Uptodate: Goldenberg, June ,2008.

Course, Co-morbidity and Genetics

• 50% start after some form of physical or emotional trauma or flu-like illness.

• 30% with major depression at the time of presentation.

• Lifetime : depression 74%, anxiety 60%

• First degree relatives of FMS are 8.5 times more likely to have FMS than relatives of patients with RA

• 28% of offspring of mothers with FMS have FMS also (Uptodate:Goldenberg, June ,2008)

Laboratory Findings

• Elevated Substance P in CSF• Assoc with increased excitatory amines in CSF• Abnormal Hypothalamic-Pituitary,Adrenal,gonald

and Growth hormones(varies)• Elevated Hyaluronic acid (assoc w/ AM stiffness)• Upregulation of opioid receptors in periphery and

reduced brain opioid receptors• Differences in activation of pain-sensitive areas in

the brain on fMRI• (Uptodate: Goldenberg, June, 2008)

Fibromyalgia Treatment

FDA Approved Medicationsa. Duloxetine(Cymbalta)b. Pregabalin(Lyrica)

Other Meds:a. Tizanidineb. Baclofenc. Tramadol,Acetominophen, opiatesd. Tricyclics(Elavil, Flexeril)e. Other Anti-depressants

Sodium Oxybate(Xyrem)

Multidisciplinary Treatment• 2004 systematic review found strong evidence

for effectiveness of – A. Cardiovascular exercise

– B. Cognitive Behavioral Therapy

– C. Patient Education(just giving a diagnosis helps)

– D. Multidisciplinary use of above(Uptodate: Goldenberg, June ,2008)

Better Prognosis• Beliefs associated with better outcome• 1. An increased sense of control over pain• 2.A belief that one is not disabled• 3. That pain is not a sign of damage

• Behaviors associated with better outcome• 1. Seeking help from others• 2. Decreased guarding during examination• 3. Exercise more• 4. Pacing activities• (Uptodate: Goldenberg, June, 200*)

• 154 women: Self-care and energy conservation reduced pain at 6 months (p<0.06)

• (International journal of behavioral medicine.; 2006 1 1;13(2)

Poorer Prognosis

• 1. Catastrophizing about the pain->increased brain response to painful stimulation on MRI

• 2. 156 women with FMS

• Psychological distress predicted to poorer outcome at 6 months( p<0.01)(International journal of behavioral medicine.; 2006 1 1;13(2)

PTSD and Fibromyaglia• 1312 women in NYC + NJ pre-9/11 had F/U

• 6 months after 9/11

• PTSD was 3 x greater after 9/11 in women with FM symptoms

• (Pain Medicine 2004; 5(1): 33-41)

• 29 PTSD and 37 controls. Fibromyalgia was

• 29% in PTSD group and 0 in controls• Journal of psychosomatic research 1997, vol. 42, no 6 (113 p.) (29

ref.), pp. 607-613

Trauma, PTSD and Fibromyalgia

• Twin Study shows PTSD symptoms are strongly linked to Chronic Widespread pain

• (p<0.0001) Journal To Go email; 2006 Sep 1;124(1-2)

• During 6 hour monitoring of CSF Substance P levels, Patients with PTSD and Depression have higher levels of Substance P than controls at baseline and in the PTSD group the levels of Substance P goes up 90-169% in response to watching Trauma Videos compared to watching neutral videos.

• The American journal of psychiatry 2006, vol. 163, no4, pp. 637-643

Long Term Course

• 14 year follow-up• Little change in symptoms of pain and fatigue• 66% working full time and fibromyalgia interfered

only modestly in their lives• (Uptodate: Goldenberg, June 2008)

• 538 patients at 6 referral centers- no change over 8 years.

• 141 patients from Community Survey• 35% still had chronic pain after two years.• (uptodate: Goldenberg, Jue, 2008)

Low Back Pain

• Up to 84% of us have some low back pain at one time

• 90% of those seen in primary care did not seek care at 3 months (but often may have some back pain at one year later)

• 90% back to work in 4 weeks• If not reassess:• Subacute back pain: 4-12 weeks• Chronic back pain: 12 or more weeks• (Uptodate: Chou May 2008)

Factors Associated with Chronic Pain

• Chronic Pain at one year:

• 1. Increasing age

• 2. Female Gender

• 3. Having a prior episode of low back pain

• 4. Pre-existing psychological factors:

• (Uptodate: Wheeler, Feb 2008)

Factors associated with development of Chronic Disability

• 1. Pre-existing psychological conditions

• 2. Other types of chronic pain

• 3.Job dissatisfaction

• 4. Dispute over Compensation issues

• 5% of people with back pain disability account for 75% of the costs.

• (Uptodate: Chou, May 2008)

Radiology and Low Back Pain

1. You cannot tell pain from an Xray,MRI,CT etc.

2. It can help a surgeon see a lesion that can be operated on and may help to relieve pain(e.g. a disk pushing on a nerve with symptoms and findings that go along with that)

3. Operations for leg pain are more successful than operations for back pain.

Treatment of Chronic Low Back Pain

• Assuming no severe spinal stenosis, disk on nerve, cancer, etc.

• 1. Exercise- individualized, stretch, strengthen, supervised. Yoga,\

• 2. Limit Bed rest• 3. NSAIDs (opiates if severe for short term

flare)• 4. Identify and treat depression• (Uptodate: Chou, April, 2008)

Treatment for Chronic Severe Low Back Pain

• 1. Individualized exercise program(Supervision, Stretching, Strengthening, Yoga,)

• 2. NSAIDs

• 3. Debatable (Opiates, Muscle relaxants)

• 4. Treat Depression

• 6. Spinal manipulation, massage

• 7. CBT and Progressive Relaxation

Multidisciplinary Bio-Psycho-Social Treatment Programs

• 10 Randomized Trials (1964 Patients)• Strong evidence programs with a functional

restoration approach improved function better when compared to inpatient or outpatient non-multimodality treatments.

• Moderate evidence that such programs improved pain.

• Contradictatory evidence regarding vocational outcomes

• (Cochrane Database Syst Rev: 2002(1)

The Role of Mood Disorders and Chronic Pain

• 1. Grief• 2. Depression• 3 Anxiety• 4. Anger• 5. Stress• 6. PTSD

Mood affects Pain and Pain affects Mood

Tension Myositis Syndrome

• The pain is due to TMS, not structural damage

• Due to mild O2 deprivation

• Caused by repressed emotions, principally anger

• TMS serves to distract from emotion

• Back is normal, so can resume activity

• Shift attention from pain to emotional issues

• Jack Sarno,M.D. Healing Back Pain. 1991

Limbically Augmented Pain Syndrome

• Patients w/ depression, behavioral dysfunction, heightened sensitivity to internal and external stimuli

• Pain: chronic,often atypical, resistant to analgesics

• Assoc w/ disturbed mood, sleep, energy, libido, memory/concentration/behavior

• Amplification,spontaneity,anatomicspreading,cross sensitization.(Covington,2004)

Childhood Trauma and Chronic Painand the role of PTSD

1. ACOA

2. Adultified Child

3. Abandonment/Child Abuse

Baby Mammals

Three Responses

to

Stress

Mammalian Response to Stress

• When two mammals confront each other there are three options:

• 1. Fighting Anger

• 2.Submission Accommodation

• 3. Fleeing Anxiety

Baby Mammals

1. They can flee on their own

2.They can accommodate

3.But they need an adult to

Set boundaries for safety-

To enforce anger.

Baby Mammals

Children of Abuse/Neglect

• Overdeveloped anxiety and accommodation, but underdeveloped boundary setting.

Stages of Alarm to Threat

• Irritability

• Tension

• Anxiety

• Anger

• Pain Panic

Boundaries, Anger and Chronic Pain

1. Pain as a stage of Alarm

2. Anger-the emotion of setting boundaries and serves as the barrier to pain and panic

3. Anger does not mean resentment

Pain and Opiate Addiction

1. Drugs that cross the boundary between mood and pain

2. Function of drugs in addiction3. Assessing for Addiction4. Function of drugs in pain5. Drugs and Function6. Drugs and Pain Perception7. Drugs and Tolerance8. Pseudoaddiction

Figure 1: Percentage of emergency department pain-related visits for which a doctor prescribed an opioid analgesic by race/ethnicity and survey

year (adapted from Pletcher, Kertesz, Kohn, & Gonzales, 2008)

Tolerance to Opiates in Non-Malignant Pain

• 1. Stabilize the initial dose of medication to assist with pain management and improved function.

• 2. Tolerance after that is often related to the impact of anxiety, depression, stress and PTSD on pain.

• 3. Acute Flares can occur due to mechanical injuries or stress.

Risk of Addiction

• Lifetime prevalence of addictive disease ranges from 3-16%

• Risk is influenced by

• a. Genetics

• b. Presence of psychiatric disorders

• c. History of drug experience/addiction

• d. Social support

DSM-IV Diagnosis of AddictionPain Patients vs Opioid Abuser

(Wesson et al, 1993)

• DSM-IV Criteria Pain Patient Opioid Addict

• 1. Opioids often taken in Patient able to ration Unable to store away and

• larger amounts or over medication between ration use over days or

• a longer period than the planned visits to weeks

• person intended. Prescribing M.D.

• 2. Persistent desire or May want to decrease use, Relapses to drug use

• one or more unsuccessful but when pain becomes after detoxification

• efforts to cut down or worse, reluctantly agrees

• control opioid use to continue medication

• 3. A great deal of time spent in May spend large amounts of Life is consumed with

• activities necessary to get the time going to physicians. Is acquiring money to

• opioids,taking opioids, or generally cooperative with purchase drugs, drug use

• recovering from their effects physician about non-opioid and drug-related activities

• pain control strategies. Is Most of recreational time

• disabled without medication. Is spent with other drug

• users.

DSM-IV DDX: Continued• DSM-IV Criteria Pain Patient Opioid Addict• 4. Frequent intoxication or withdrawal Rarely, if ever, occurs Common Occurrence• symptoms when expected to fulfill • major role obligations at work, school,• or home.

• 5. Important social, occupational, or Activities given up primarily Activities not relating to drug• recreational activities given up or because of pain. May be more use cease to be interesting or• reduced because of opioid use. Active on opiod medication. Important.

• 6. Continued opioid use despite know- May continue medication Drug use continues despite• ledge of having recurrent social, psych- despite concerns about arrests, family fights, divorce,• ological, or physical problem. Addiction expressed by loss of children, loss of job,• friends or family. And adverse health

consequences.

•

DSM-IV DDX: Continued

• DSM-IV Criteria Pain Patient Opioid Addict• 7. Marked tolerance: need for May be present Usually present• markedly increased amounts of• the opioid(I.e., at least 50%) in order• to achieve intoxication or desired• effect, or markedly diminished• effect with continued use of the• same amount.

• 8. Opioid Withdrawal Symptoms Present when opioids stopped Present when opioids stopped• abruptly. Abruptly.

• 9. Opioids often taken to relieve Opioid use primarily in Opioid withdrawal symptoms• or avoid withdrawal symptoms response to pain. Precipitate frantic drug

seeking• behavior.

Three Categories of Addiction

• 1. Currently addicted(Still Using)

• 2. Used to be addicted but in abstinence recovery

• 3. On Opioid Maintenance but abstaining from other addictive drugs

Evaluation of Pain

1. Listen to the patient

2. Examine the patient

3. Observe the patient

4. Inform the patient about what is wrong

5. Monitor treatment

6. Do no harm

7. Go to higher level of care as needed

Treatment of Chronic PainThe Body

1. Address mechanical issues2. Physical therapy/Exercise3. Optimize therapy/medication to stabilize

a. Painb. Moodc. Sleepd. Function

5. Procedures to reduce pain

Treatment of Chronic Pain-Pain Management

1. Pain and Mood Logs

2. Pacing themselves

3. Boundaries with others

4. Grieving who you were/Respecting who you are

Treatment of Chronic Pain –The Limbic System

1. Address the PTSD

2. Treat Mood Disorders

3. Teach how to manage anxiety

4. Teach how to manage anger

5. Assist with Grieving process

Treatment of Chronic Pain-Addiction Management

1. Time Out, Share, Ask for help

2. Opiate Maintenance vs Abstinence

3. 12 Step Program and Spirituality

4. Break out of isolation/shame

The “Pain” of Treating Chronic Pain is the Frustration we have with a

Chronic Illness

1. You can’t measure pain- Only the patient can2. But, You can measure function3. Recognize Acute vs Chronic Pain4. If it is chronic, what is going on in the

nervous system5. Function vs Pain relief6. Multidisciplinary Approach

We Have A Lot More to Learn

Thank You