PainPain

Physiology of PainPhysiology of Pain

NociceptorsNociceptors Stimulus Stimulus

TransmissionTransmission TerminationTermination ModulationModulation

Physiology of PainPhysiology of Pain

MultipleMultiple Redundant Redundant ReciprocalReciprocal ComplexComplex

Assessment of PainAssessment of Pain

Immediate PainImmediate PainPhysical FunctioningPhysical FunctioningPsychological FactorsPsychological FactorsPain BehaviorsPain BehaviorsObjective CorrelatesObjective Correlates

Assessment: Immediate PainAssessment: Immediate Pain

IntensityIntensityLocationLocationAffective ResponseAffective ResponseComposite MeasuresComposite Measures

Assessment: Physical Fx.Assessment: Physical Fx.

ImpairmentImpairmentFunctional limitationFunctional limitationDisabilityDisability

Assessment: Psych factorsAssessment: Psych factors

Influence vs. causationInfluence vs. causationMediationMediationReinforcementReinforcementResonatorsResonatorsPain beliefsPain beliefs

Assessment: Pain BehaviorAssessment: Pain Behavior

ObservationObservationRole of learningRole of learning

Composite Pain ScalesComposite Pain Scales

Attempt to measure one or more Attempt to measure one or more dimensions of the pain experiencedimensions of the pain experience

History

Intensity

QualityObjective Data

Comorbid

Side effects

Assessment: Objective IndicatorsAssessment: Objective Indicators

Ex. ElectromyographyEx. Electromyography

“Well, Phil, after years of vague complaints and imaginary ailments, we finally have something to work with.”

DiagnosisDiagnosis

CategorizationCategorizationDSM and PainDSM and PainOther Approaches to “Somatoform Pain”Other Approaches to “Somatoform Pain”

CategorizationCategorization

Acute versus ChronicAcute versus Chronic

Acute PainAcute Pain

Not just timeNot just timeClearer associationClearer association

Subtypes (ex. Recurrent?)Subtypes (ex. Recurrent?) ““nociceptive pain”nociceptive pain”

ChronicChronic

Association?Association?TypesTypes

By presumed etiologyBy presumed etiologyNeurologic painNeurologic painIdeopathicIdeopathic

By courseBy course

DSM-IVDSM-IV

The concept of Somatoform PainThe concept of Somatoform Pain

DSM and painDSM and pain

I (1952)I (1952)Psychophysiological disorders“Psychophysiological disorders“ ““Psychoneurotic Disorders”Psychoneurotic Disorders”

II (1968)II (1968)Hysterical neurosisHysterical neurosis

DSM and painDSM and pain

III (1980)III (1980)Psychogenic PainPsychogenic Pain

““incompatible” or “INXS”incompatible” or “INXS”Etiologically relatedEtiologically related

III-R (1987)III-R (1987)Somatoform painSomatoform painDropped etiology partDropped etiology part

DSM and painDSM and pain

IVIVPain DisorderPain Disorder

Pain=predominant focusPain=predominant focusSubstantial distress/impairmentSubstantial distress/impairmentPsych factors “have role”Psych factors “have role”

Onset or expressionOnset or expression

Not malingering/factitious disorderNot malingering/factitious disorder

Problems with DSMProblems with DSM

UtilityUtility How to judge?How to judge?

Physical versus Physical versus PsychologicalPsychological

EtiologyEtiology

DSM-IVDSM-IV Mind-body dichotomy Mind-body dichotomy

remainsremains Division of pain based Division of pain based

on this.on this.

True psychogenic painTrue psychogenic pain

DSM-IV pain testedDSM-IV pain tested

Psychological vs. Psychological+Medical Psychological vs. Psychological+Medical DistinctionDistinctionNo difference onNo difference on

Pain measuresPain measuresIntensityIntensityTypeTypeLevel of disabilityLevel of disability

(Aigner et al, Compr Psychiatry 1999)

Other approaches to diagnosing Other approaches to diagnosing painpain

IASPIASP

5 axis system5 axis systemI.I. Anatomical regionAnatomical region

II.II. Organ systemOrgan system

III.III. Temporal characteristics/patternsTemporal characteristics/patterns

IV.IV. Intensity, time since onsetIntensity, time since onset

V.V. EtiologyEtiology

IASPIASP

Psychological painPsychological pain ““Pain specifically attributable to the thought Pain specifically attributable to the thought

process, motional state, or personality of the process, motional state, or personality of the patient in the absence of an organic or patient in the absence of an organic or delusional cause or tension mechanism.”delusional cause or tension mechanism.”

Other approachesOther approaches

DimensionalDimensionalTake into account various aspects of painTake into account various aspects of pain

Objective findings/physical etiologyObjective findings/physical etiologyPerceptual influencesPerceptual influencesPresentationPresentation

Treatment of PainTreatment of Pain

Treatment of PainTreatment of Pain

PharmacologicPharmacologicPsychologicalPsychologicalOther somatic treatmentsOther somatic treatments Importance of MultimodalImportance of MultimodalCormorbid treatmentsCormorbid treatmentsRole of C/L PsychiatristRole of C/L Psychiatrist

Pharmacological TreatmentPharmacological Treatment

““True” AnalgesicsTrue” Analgesics Everything ElseEverything Else

“Yes Billy, but Mr. Phillips pushes legal drugs.”

““True” AnalgesicTrue” Analgesic

NSAIDSNSAIDSOpioidsOpioidsLocal agentsLocal agents

NSAIDSNSAIDS

MechanismMechanism IndicationIndicationSide effectsSide effects

NSAIDSNSAIDS

StandardStandardAcetaminophenAcetaminophenKetorolacKetorolacCOX-2 inhibitorsCOX-2 inhibitors

OpioidsOpioids

Mechanism of actionMechanism of action IndicationIndicationSide effectsSide effects

CommonCommonUncommon but problematicUncommon but problematic

Some Typical OpioidsSome Typical OpioidsOralOral ParenParen TranTran

MorphineMorphine √√ √√

Propoxyphene (Darvon)Propoxyphene (Darvon) √√

Hydromorphone (Dilaudid)Hydromorphone (Dilaudid) √√ √√

Meperidine (Demerol)Meperidine (Demerol) √√ √√

MethadoneMethadone √√ √√

Oxymorphone (Numorphan)Oxymorphone (Numorphan) √√

Fentanyl (Duragesic, Actiq)Fentanyl (Duragesic, Actiq) √√** √√ √√

Oxycodone (Percoset, Oxy--)Oxycodone (Percoset, Oxy--) √√

Combination Opioid/NSAIDsCombination Opioid/NSAIDs

NarcoticNarcotic +Acet+Acet +ASA+ASA +Ibu+Ibu

DihydrocodoneDihydrocodone DHC plus*DHC plus*

PropoxyphenePropoxyphene Darvocet,Darvocet,

WyegesicWyegesic

CodeineCodeine Tylenol w/ Codeine #2-Tylenol w/ Codeine #2-4, Fiorecet*4, Fiorecet*††

Fiorinal*Fiorinal*††

HydrocodoneHydrocodone Vicodin, Hydrocet, Vicodin, Hydrocet, Lorcet, Lortab, ZydoneLorcet, Lortab, Zydone

VicoprofenVicoprofen

OxycodoneOxycodone Percocet, TyloxPercocet, Tylox PercodanPercodan

PentazocinePentazocine‡‡ TalacenTalacen

*caffeine †† butalbital butalbital ‡ ‡agonist-antagonistagonist-antagonist

Relative PotencyRelative Potency

0.00

0.20

0.40

0.60

0.80

1.00

MS

Met

h

Hyd

ro

Oxy

c

Fent

MS

PO

Cod

Mep

Mep

(po)

Treatment ApproachTreatment Approach

Treatment ApproachTreatment Approach

MECMECRole of pharmacokineticRole of pharmacokinetic

ToxicityToxicitySlow-release prepsSlow-release preps

ConcernsConcerns

Tolerance Tolerance DependenceDependence AddictionAddiction

Overvalued ConcernsOvervalued Concerns

AddicationAddication Overdose and deathOverdose and death DisciplineDiscipline

“Damn! I suppose this means another malpractice suit.!”

Adjunctive and other medsAdjunctive and other meds

AntidepressantAntidepressant AnticonvulsantsAnticonvulsants Local AnalgesicsLocal Analgesics AntihistaminesAntihistamines AntipsychoticsAntipsychotics

BenzodiazepinesBenzodiazepines StimulantsStimulants CannabinoidsCannabinoids PlacebosPlacebos

Nonsurgical treatmentsNonsurgical treatments

Cutaneous StimulationCutaneous StimulationElectrical StimulationElectrical StimulationAcupunctureAcupunctureExerciseExercise

Surgical TreatmentsSurgical Treatments

Neural BlockadeNeural BlockadeSurgical lesionsSurgical lesionsLimitationsLimitations

Psychological TreatmentsPsychological Treatments

PsychoeducationPsychoeducationHypnosisHypnosisBehavioral TreatmentsBehavioral Treatments

Behav TxsBehav Txs

RelaxationRelaxationBiofeedbackBiofeedbackCBTCBT

FocusFocusGoalsGoals

Multidisciplinary Pain TreatmentMultidisciplinary Pain Treatment

Different levelsDifferent levelsFeatures includedFeatures included

Comorbid ProblemsComorbid Problems

DepressionDepressionAnxietyAnxiety

Problems of dual diagnosisProblems of dual diagnosis

Role of Psychiatrist in Pain MgmtRole of Psychiatrist in Pain Mgmt

Role of C/L Psychiatrist in Pain Role of C/L Psychiatrist in Pain EvalEval

““Problem Patient”Problem Patient” ““Drug Seeker”Drug Seeker” ““Just in their heads”Just in their heads” ““Pain out of proportion…”Pain out of proportion…”