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Pain. Physiology of Pain. Nociceptors Stimulus Transmission Termination Modulation. Physiology of Pain. Multiple Redundant Reciprocal Complex. Assessment of Pain. Immediate Pain Physical Functioning Psychological Factors Pain Behaviors Objective Correlates.

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Presentation Transcript

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Physiology of Pain

  • Nociceptors

  • Stimulus Transmission

  • Termination

  • Modulation


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Physiology of Pain

  • Multiple

  • Redundant

  • Reciprocal

  • Complex


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Assessment of Pain

  • Immediate Pain

  • Physical Functioning

  • Psychological Factors

  • Pain Behaviors

  • Objective Correlates


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Assessment: Immediate Pain

  • Intensity

  • Location

  • Affective Response

  • Composite Measures


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Assessment: Physical Fx.

  • Impairment

  • Functional limitation

  • Disability


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Assessment: Psych factors

  • Influence vs. causation

  • Mediation

  • Reinforcement

  • Resonators

  • Pain beliefs


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Assessment: Pain Behavior

  • Observation

  • Role of learning


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Composite Pain Scales

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


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History

Intensity

Comorbid

Quality

Objective Data

Side effects


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Assessment: Objective Indicators

  • Ex. Electromyography

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


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Diagnosis

  • Categorization

  • DSM and Pain

  • Other Approaches to “Somatoform Pain”


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Categorization

  • Acute versus Chronic


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Acute Pain

  • Not just time

  • Clearer association

    • Subtypes (ex. Recurrent?)

  • “nociceptive pain”


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Chronic

  • Association?

  • Types

    • By presumed etiology

      • Neurologic pain

      • Ideopathic

    • By course


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DSM-IV

The concept of Somatoform Pain


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DSM and pain

  • I (1952)

    • Psychophysiological disorders“

    • “Psychoneurotic Disorders”

  • II (1968)

    • Hysterical neurosis


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DSM and pain

  • III (1980)

    • Psychogenic Pain

      • “incompatible” or “INXS”

      • Etiologically related

  • III-R (1987)

    • Somatoform pain

    • Dropped etiology part


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DSM and pain

  • IV

    • Pain Disorder

      • Pain=predominant focus

      • Substantial distress/impairment

      • Psych factors “have role”

        • Onset or expression

      • Not malingering/factitious disorder


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Problems with DSM

  • Utility

  • How to judge?

    • Physical versus Psychological

    • Etiology

  • DSM-IV

    • Mind-body dichotomy remains

    • Division of pain based on this.



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DSM-IV pain tested

  • Psychological vs. Psychological+Medical Distinction

    • No difference on

      • Pain measures

      • Intensity

      • Type

      • Level of disability

(Aigner et al, Compr Psychiatry 1999)



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IASP

5 axis system

  • Anatomical region

  • Organ system

  • Temporal characteristics/patterns

  • Intensity, time since onset

  • Etiology


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IASP

  • Psychological pain

    • “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”


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Other approaches

  • Dimensional

    • Take into account various aspects of pain

      • Objective findings/physical etiology

      • Perceptual influences

      • Presentation



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Treatment of Pain

  • Pharmacologic

  • Psychological

  • Other somatic treatments

  • Importance of Multimodal

  • Cormorbid treatments

  • Role of C/L Psychiatrist


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Pharmacological Treatment

  • “True” Analgesics

  • Everything Else

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


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“True” Analgesic

  • NSAIDS

  • Opioids

  • Local agents


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NSAIDS

  • Mechanism

  • Indication

  • Side effects


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NSAIDS

  • Standard

  • Acetaminophen

  • Ketorolac

  • COX-2 inhibitors


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Opioids

  • Mechanism of action

  • Indication

  • Side effects

    • Common

    • Uncommon but problematic



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Combination Opioid/NSAIDs

*caffeine † butalbital ‡agonist-antagonist




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Treatment Approach

  • MEC

  • Role of pharmacokinetic

    • Toxicity

    • Slow-release preps


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Concerns

  • Tolerance

  • Dependence

  • Addiction


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Overvalued Concerns

  • Addication

  • Overdose and death

  • Discipline

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


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Antidepressant

Anticonvulsants

Local Analgesics

Antihistamines

Antipsychotics

Benzodiazepines

Stimulants

Cannabinoids

Placebos

Adjunctive and other meds


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Nonsurgical treatments

  • Cutaneous Stimulation

  • Electrical Stimulation

  • Acupuncture

  • Exercise


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Surgical Treatments

  • Neural Blockade

  • Surgical lesions

  • Limitations


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Psychological Treatments

  • Psychoeducation

  • Hypnosis

  • Behavioral Treatments


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Behav Txs

  • Relaxation

  • Biofeedback

  • CBT

    • Focus

    • Goals


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Multidisciplinary Pain Treatment

  • Different levels

  • Features included


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Comorbid Problems

  • Depression

  • Anxiety




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Role of C/L Psychiatrist in Pain Eval

  • “Problem Patient”

  • “Drug Seeker”

  • “Just in their heads”

  • “Pain out of proportion…”


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