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The Pain Of Treating Chronic Pain
1. The “Pain” of Treating
Chronic Pain
P. Joseph Frawley ,M.D.
September 17 ,2008
CAMFT
2. 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
3. Apply this information to three
common causes of chronic pain
Low Back Pain Migraine
Fibromyalgia Headache
4. 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
5. 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• -Prolonged, pain system is altered, no longer
represents injury, cross connections, up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)
6. Measurement of Pain
1. Scale 0----------4---------------------7-------------10
none worst
Can Ignore Must Manage Can’t stand
2. Faces
Smile----------------------------------------------Cry
7. Three Parts of Pain
1. The Injury
2. The body’ Response to Injury
3. The impact of the injury on the person
8. Pain System has Ascending and
Descending Circuits
• Brain
• Spinal
Cord
• Nerve
13. 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.
15. 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
17. 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.
•
18. 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
19. 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
20. 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, , , Zeev
Kaplanc and Hagit Cohenc
21. 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.
22. 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.
23. Medication Overuse Headache
• Mostly evolves from Migraine or Episodic
Tension type headaches.
• 28 CTTH 89 MOH
Pre ETTH 31 Pre-Migraine 58
Co-morbid Psych Disorder
11 21 31
31% 67.75 53.7%
• (Incr mood disorder)
• European journal of pain (London, England); 2005 Jun 1;9(3)
24. Fibromyalgia
2% of the population
Female: usually age 20- 65
Chronic, Generalized Pain
Fatigue 90% (70% meet criteria for CFS)
Sleep and Mood Disturbances
Headaches
Irritable Bowel Syndrome
Multiple Tender areas of muscle and Tendons
Bilateral and Upper and Lower Body (11 of 18
points)
Uptodate: Goldenberg, June ,2008.
25. 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)
26. 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)
27. Fibromyalgia Treatment
FDA Approved Medications
a. Duloxetine(Cymbalta)
b. Pregabalin(Lyrica)
Other Meds:
a. Tizanidine
b. Baclofen
c. Tramadol,Acetominophen, opiates
d. Tricyclics(Elavil, Flexeril)
e. Other Anti-depressants
Sodium Oxybate(Xyrem)
28. 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)
29. 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)
30. 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)
31. 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
32. 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
33. 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)
34. 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)
35. 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)
36. 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)
37. 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.
38. 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)
39. 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
40. 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)
41. 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
42. 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
46. Mammalian Response to Stress
• When two mammals confront each other
there are three options:
• 1. Fighting Anger
• 2.Submission Accommodation
• 3. Fleeing Anxiety
47. 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.
50. Stages of Alarm to Threat
• Irritability
• Tension
• Anxiety
• Anger
• Pain
Panic
51. 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
52. Pain and Opiate Addiction
1. Drugs that cross the boundary between mood
and pain
2. Function of drugs in addiction
3. Assessing for Addiction
4. Function of drugs in pain
5. Drugs and Function
6. Drugs and Pain Perception
7. Drugs and Tolerance
8. Pseudoaddiction
53. 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)
54. 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.
55. 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
56. DSM-IV Diagnosis of Addiction
Pain 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.
57. 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.
•
58. 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.
59. 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
60. 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
61. Treatment of Chronic Pain
The Body
1. Address mechanical issues
2. Physical therapy/Exercise
3. Optimize therapy/medication to stabilize
a. Pain
b. Mood
c. Sleep
d. Function
5. Procedures to reduce pain
62. 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
63. 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
64. 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
65. The “Pain” of Treating Chronic Pain is
the Frustration we have with a
Chronic Illness
1. You can’t measure pain- Only the patient can
2. But, You can measure function
3. Recognize Acute vs Chronic Pain
4. If it is chronic, what is going on in the
nervous system
5. Function vs Pain relief
6. Multidisciplinary Approach
