Psycho-Behavioral Issues in Pain Management

Mark D. Ackerman, Ph.D.,Licensed Clinical Psychologist

VA Medical Center & Emory University School of Medicine, Atlanta, GA

Mark.Ackerman1@va.govDrMark1@bellsouth.net

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

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 307.89 – Pain Disorder Assoc. w/ both Psychological Factors and a General Medical Condition

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Bio-medical Model

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

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

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

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.

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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

Chronic Pain• Characteristics of

– Symptoms last longer than 6 months– Few objective medical findings– Medication abuse– Difficulty sleeping– Depression– Manipulative behavior– Somatic preoccupation

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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.

Pain is…

“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

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PAIN

Sometimes the source, or solution, is unknown or unavailable

This can be frustrating!

You are complex

You are: More than “Pain”;Complex Balance

Bio-psycho-social Model

Explains why:

Another test may not help;

Another [something done to me] may have no effect

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Understanding Painhttp://www.youtube.com/watch?v=4b8oB757DKc

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CHRONIC PAIN IS COMPLEX

therefore

MANAGEMENT PLAN MUST BE BROAD AND

PERSON-FOCUSED

A car with four flat tires:Getting Medications right (including Opioids)

only fixes one of the four tires

credit: The American Chronic Pain Associationhttp://www.theacpa.org/a-car-with-four-flat-tires

Pain:An Integrated Framework

Who is in more pain? #1 #2 #3

Disrupt the downward spiral of chronic pain

Disability

Social Biological

Psychological

Biopsychosocial Model

We must understand the “person with pain”.

Pain in a Social Context

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

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

(McCracken, 2005; Fordyce, 1976)

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.

Pain

Distress

Anxiety

AvoidanceDepression

GuardingPleasantActivity

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

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

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

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Social

Psychological

Biological

Case Examples