plain for treatment of patient with chronic pain, psychiatry and psychology are two approaches very important to have a proper treatment for pain disorders

1. CHRONIC PAIN
MANAGEMENT
By Heba Essawy
Prof Of Psychiatry

2. Assessment
• Psychological assessment?
• Mood
• Interests
• Changes in function

3. Treatment Objectives
*Decrease the frequency or severity of the pain
*General sense of feeling better
*Increased level of activity
*Return to work
*Decreased health care utilization
*Elimination or reduction in medication usage

4. Pain 101 –Sessions
1) Pain Education
2) Reducing tension
3) Mindfulness meditation
4) Pacing / Goal setting
5) Depression and negative thinking
6) Sleep
7) Coping with stress and anxiety
8) Communication and pain behaviour
9) Managing setbacks
10)Chronic pain and your life

5. Pain Education
• Patients should be given as much information as
possible about care provided, if possible before
any procedures
• Patients should also be educated in using their
analgesics appropriately
• An emphasis should be placed on taking
medications as scheduled, not only when pain
emerges, and patients‟ concerns regarding side
effects, including any addiction potential, should
be addressed

6. What works best for Neuropathic Pain?
• Drug class Odds ratio for Rx
Success
• New Anticonvulsants 2.35
– Lamictal, Neurontin, etc
• Classic Anticonvulsants 5.33
– Valproate, Carbamazepine
• Tricyclics 22.4
(Wong. BMJ 2007;)

7. Antidepressants
• Tricyclic antidepressants
– Analgesic effects separate from anti-depressant effects.
– Amitriptyline: most studied, but most side effects
– Nortriptyline & desipramine: better tolerated, less well studied
• SSRIs: little evidence of analgesic effect.
• SNRI‟s
– inhibit both norepinephrine and serotonin reuptake
– efficacy in neuropathic pain syndromes or pain associated
with depression (duloxetine [Cymbalta®], venlafaxine
[Effexor®])

8. Tricyclic Antidepressants

9. Utility in pain management
• Most useful in neuropathic pain
• Used frequently in variety of settings
• Amitriptyline most widely studied
• Anti-depressant effects may alleviate depression
associated with chronic pain
• May have synergy with opioids
• Switching TCA‟s based on effect and/or side
effects can be tried

10. Mechanism of action
• Generally unknown
•
• Theories involve action on serotonin, norepinephrine
receptors (TCAs with the greatest effect upon
serotonin seem to have the greatest analgesic effect)
• May potentiate endogenous opioid system
• Potent SSRIs have no analgesic effect of their own

11. Side effects
• Anticholinergic (amitriptyline > nortriptyline)
• Sedation.
• Anticholinergic and CNS effects may diminish in
days to weeks – “ride it out”

12. SSRI/SNRI
• Often tried when TCA side effects limit utility
• May be treating depression – not an uncommon
consequence with chronic pain
• Venlafaxine has been shown to be similar to
imipramine in one study of painful neuropathy
• Duloxetine approved for diabetic peripheral
neuropathy
• Depression is probably undertreated in chronic pain
patients in general (cancer and non-cancer pts)

13. Anticonvulsants

14. Utility in pain management
• Can be very effective, particularly in neuropathic pain
• Wide variation in use among pain specialists, except
with carbamazepine for trigeminal neuralgia
• Gabapentin is frequently a first choice as levels do not
need monitoring

15. Mechanism of action
• Theories include membrane stabilization (phenytoin),
• Inhibition of repeated neuronal discharges
(carbamazepine),
• GABA inhibition enhancement (valproic acid,
clonazepam),
• GABA mimetics (gabapentin, pregabalin).

16. Anticonvulsants
• Agents for neuropathic pain
– gabapentin (Neurontin®)
– pregabalin (Lyrica®)
– clonazepam (Klonopin®)
• Start low, go slow
• Watch for side effects
• Monitor serum levels, if available

17. Adjuvant medications

18. Benzodiazepines
• Good choice when anxiety complicates pain
management (cancer patients)
• Clonazepam particularly useful in neuropathic pain
(GABA potentiation)
• Drawbacks :
– Addictive potential is significant
– Potentiates sedation and respiratory depression

19. Antispasmodics
• Painful muscle spasm, myoclonic jerks can
accompany a variety of pain conditions (and
opioids)
– toxicity of morphine
• Mechanism of action may reflect their sedative
effects more than direct muscle effect
• Commonly used – cyclopenzaprine, carisoprodol,
baclofen, methcarbamol

20. •
Non Medical intervention

21. Relaxation : Diaphragmatic Breathing
• Inform patients that physiological arousal can
increase pain signals, and that relaxation
strategies can reduce this arousal
• Ask patients to assume a comfortable position
and to place one hand over their abdomen
• Instruct patients to inhale deeply through their
nose, bringing air into the bottom of their
lungs, then to exhale through their mouth
• Repeat this for two or three breaths, then request
that they practice this regularly, for three to five
minutes at a time

22. Relaxation : Distraction
• Discuss the role of thoughts on patients‟ sense of
coping with pain, and their relationship to
physiological arousal
• Encourage patients to generate and practice
positive self-talk that emphasizes their ability to
cope with the pain
• Patients should also be reassured that the pain
episode is of limited duration, and that they can
remind themselves that it will pass

23. Psychological Treatment
• No treatment that consistently and permanently
alleviates pain for all patients
• Management of chronic pain often depends on
the abilities of the client
• Primary goal is to improve function rather than
alleviate pain
• Effective management is achieved most readily
using a multidisciplinary approach
• Should be customized to the patient
• Treatment varies, but is usually planned for about
10 to 12 sessions
(Turk, 1990)

24. Psychological Treatment
• An active, time-limited treatment, with patients
guiding their own progress rather than passively
receiving care
• For patients that are not candidates for
treatment, a consultative resource to facilitate
existing treatment
• Assessment and treatment emphasizes a
biopsychosocial model
(Matthew Bailly)

25. Patients Likely to Benefit from
Psychological Treatment
• Psychological factors are obviously a primary
concern
• Patient understands what psychology can offer,
but maintains a unidimensional view of pain
• Patient is unmotivated/resistant, or experiencing
too much distress (relationship distress,
substance abuse) to maintain regular involvement
with treatment

26. Diagnostic Interview
• Typically uses one or two 1-hour sessions
• Includes obtaining a history of the presenting
problem and a brief medical and psychological
history, followed by an assessment of functioning
within the following domains…
• Educational and vocational
• Social and recreational
• Family, including brief developmental history
• Mental status and current psychological
functioning

27. Formal Assessment
• Involves administration of instruments measuring
personality, impact of illness, coping, beliefs and
expectations about pain and injury, and
psychological distress
• May be completed in one or two 1-hour testing
sessions

28. Definitons of Terms
Psychotherapy - set of clinical techniques use to improve mental
health.
Counseling = psychotherapy.
Behavior Therapy (Behavior Modification Therapy) - changing
somebody's behavior
Classical Conditioning - creation of response to stimulus (Pavlov's
dogs)
Operant Conditoning - learning through positive and negative
reinforcement
Cognitive Therapy - psychotherapy aimed at changing way of
thinking. Several approaches to cognitive-behavioral therapy
Rational Emotive Behavior Therapy
Rational Behavior Therapy
Rational Living Therapy
Cognitive Therapy
Dialectic Behavior Therapy

29. Cognitive Behavioral Therapy

30. “Big” Names associated with Cognitive
Behavioral Therapy
1. Epictetus, Greek philosopher. Observed
that people are not disturbed by things that
happen but by the view they take of things
that happen.
2. Albert Ellis, Ph.D. “grandfather of cognitive
behavioral therapy.”
3. Aaron Beck, MD, a psychiatrist (University
of Pennsylvania)

31. Characteristics of
Cognitive-Behavioral Therapies:
1. Thoughts cause Feelings and Behaviors.
2. Brief and Time-Limited.
Average # of sessions = 16 VS
psychoanalysis = several years
3. Emphasis placed on current behavior.

32. 4. CBT is a collaborative effort between the
therapist and the client.
Client role - define goals, express concerns,
learn & implement learning
Therapist role - help client define goals, listen,
teach, encourage.
5. Teaches the benefit of remaining calm or
at least neutral when faced with difficult
situations. (If you are upset by your
problems, you now have 2 problems: 1) the
problem, and 2) your upsetness.

33. 6. Based on "rational thought." - Fact not
assumptions.
7. CBT is structured and directive. Based on
notion that maladaptive behaviors are the
result of skill deficits.
8. Based on assumption that most emotional
and behavioral reactions are
learned. Therefore, the goal of therapy is to
help clients unlearn their unwanted reactions
and to learn a new way of reacting.
9. Homework is a central feature of CBT.

34. Rational Emotive Behavioral Therapy
A form of cognitive-behavioral therapy in which
somebody is encouraged to examine and change
irrational thought patterns (irrational thinking) and
beliefs in order to reduce dysfunctional behavior.
What is irrational thinking?
What types of thinking are problematical for human
beings?

35. The Self-Defeating Rules (Irrational Beliefs)
Ellis suggested that a small number of core beliefs underlie most unhelpful emotions
and behaviours. Core beliefs are underlying rules that guide how people react
to the events and circumstances in their lives. Here is a sample list of such of
these:
1. I need love and approval from those around to me.
2. I must avoid disapproval from any source.
3. To be worthwhile as a person I must achieve success at whatever I do.
4. I can not allow myself to make mistakes.
5. People should always do the right thing. When they behave obnoxiously,
unfairlyor selfishly, they must be blamed and punished.
6. Things must be the way I want them to be.
7. My unhappiness is caused by things that are outside my control – so there is
nothing I can do to feel any better.
8. I must worry about things that could be dangerous, unpleasant or frightening –
otherwise they might happen.
9. I must avoid life‟s difficulties, unpleasantness, and responsibilities.
10. Everyone needs to depend on someone stronger than themselves.
11. Events in my past are the cause of my problems – and they continue to influence
my feelings and behaviours now.
12. I should become upset when other people have problems, and feel unhappy
when they‟re sad.
13, I shouldn‟t have to feel discomfort and pain.
14, Every problem should have an ideal solution.

36. Two Types of Disturbance
Ego disturbance:
- emotional tension resulting from the perception that
one‟s „self‟ is threatened – and lead to other
problems such as avoidance of situations where
failure, disapproval might occur.
- looking to other people for acceptance; and
unassertive behaviour through fear of what others
may think.
Discomfort disturbance:
- results from demands about others (e.g. „People must
treat me right‟) and about the world (e.g. “The
circumstances under which I live must be the way I
want”).

37. Discomfort disturbance - two types:
Low frustration-tolerance (LFT) results from
demands that frustration not
happen, followed by catastrophizing when
it does. It is based on beliefs like: “The
world owes me contentment and
happiness.”
Low discomfort-tolerance (LDT) arises from
demands that one not experience
emotional or physical discomfort, with
catastrophizing when discomfort does
occur. It is based on beliefs like: “I must
be able to feel comfortable all of the time.”

38. ABC’s of REBT
A →B → C
A = Activating Event
B =
Beliefs, Thoughts, Attitudes, Assumptions
C =
Consequences, Feelings, Emotions,
Behaviors, Actions

39. Outcomes
• Increased function
• Increased work/school attendance
• Improved sleep
• Increased social activities
• Decreased anxiety and depression
• Reduced pain

40. THANKS

42. Psychological Treatment
(Turk, 2002)
• Problem-oriented
• Educational
• Collaborative
• Uses clinic and home practice for skill-building
• Encourages expression and management of
feelings that impair rehabilitation
• Addresses relationships among thoughts,
feelings, behaviour, and physiology
• Anticipates setbacks and teaches clients how to
manage these

43. Psychological Treatment
• Involves evaluating and correcting maladaptive
beliefs, appraisals, and schemas to alleviate
mood symptoms and increase coping behaviour
• Training in relaxation techniques, such as
abdominal breathing, visualization, and
progressive muscle relaxation to reduce anxiety
that typically magnifies pain signals
• Treatment attempts to increase behaviours
associated with pain self-management, such as
adaptive coping, exercise program participation,
and improved communication with providers
• Focuses on increasing self-efficacy

46. Cognitive-Behavior Therapy
• Emphasizes the important role of thinking in mood
and actions.
• Based on the idea that thoughts cause feelings
and behaviors, not external factors
(people, situations, and events)
• Thus, one can change mood and actions even if
situation does not change.

72. Typical Patient
• It is not understood what degree psychological
factors play a role
• Patient agrees to pursue assessment and
treatment, but may need more education
regarding what psychology can provide
• Patient may or may not receive
treatment, depending on the assessment

73. World Health Organization
(WHO) Step Ladder Approach
Mild Pain 1-3/10
Moderate Pain 4-6/10
Severe Pain 7-10/10
ASA, Tylenol,
NSAIDS
Weak opioids +/- non-
opioids (e.g. Tylenol #3®)
Potent opioids (e.g.
morphine) +/-
non-opioids
(Mellar P Davis)