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Title: Understanding and Living Well with Chronic Pain Pierre Morin, MD, PhD


1
Understanding and Living Well with Chronic
Pain Pierre Morin, MD, PhD
2
Basel
3
(No Transcript)
4
Medical Models
  • Bio-medical model
  • Social determinant model
  • Bio-psycho-social model
  • Psychodynamic model
  • Positive psychology (Seligman), Positive health
    model (Antonovsky)
  • Indigenous model
  • Recovery/Self-management model
  • Process model (Mindell)

5
Bio-medical model
  • Environment Psychology
  • ? ?
  • Biologic predisposition? ?
    Disease ? Clinical Outcome
  • ? Illness
  •  
  • Characteristics unilinear disease fully
    explains the illness biological determinants are
    both necessary and sufficient for disease its
    diagnosis and cure psychology may be a secondary
    influencing factor. There is no explanation for
    illness without disease.

6
Social determinant model
  • Diseases are influenced and caused by social
    processes Social status, Rank, Social dynamics
    of prejudice and marginalization based on gender,
    race, sexual orientation etc… create ongoing
    stress which cause disease.

7
Bio-psycho-social model
  • Environment
    Psychosocial modifiers
  • ?? ??
  • Biologic/ predisposition? ? Disease ?
    ? Clinical Outcome
  • Psychological ??
    Illness
  • Illness and disease result from simultaneously
    interacting systems at the cellular, tissue,
    organ, and interpersonal and environmental levels

8
Psychodynamic model
  • Illness and disease have an adaptive function.
    They are meaningful processes that are embedded
    in a persons individual and collective life and
    environment. They are the best solution so far
    and promote healing and growth. Physiologic
    states are metaphors for individual and social
    processes.

9
Positive psychology/ Positive health model
  • What prevents us from getting ill physically and
    mentally? What are the characteristics of people
    who stay healthy despite adverse circumstances?
    What are the strengths and virtues that act as
    buffers against illness? How do we amplify and
    foster these strengths and virtues? Instead of
    focusing on curing/treating pathologies positive
    psychology/health sees health as a continuum and
    is interested in the factors (resilience, sense
    of coherence, meaningfulness) that give our lives
    purpose, allow us to stay healthy and cope with
    our limited health.

10
Indigenous model
  • Relationship to Nature, the ancestors, the spirit
    world is relevant for staying healthy.
  • Relationship dynamics are a relevant factor for
    causing disease jealousy, the evil eye, being
    outcasted by the tribe etc…

11
Recovery/Self-Management Model I
  • Recovery is an individuals journey of healing
    and transformation to live a meaningful life in a
    community of his or her choice while striving to
    achieve maximum human potential.

12
Recovery/Self-Management Model II
  • Clients have primary control over decisions
  • Based on concepts of strength and empowerment
  • Provide education
  • Living with Symptoms instead of getting rid of
    them
  • A meaningful life is possible despite
    serious/chronic symptoms
  • Adaptation to issues of diversity

13
Recovery/Self-Management Model III
  • Increasing knowledge about illness
  • Engaging in activities that promote health
  • Coping more effectively and reducing distress
    from symptoms
  • Reducing social exclusion
  • Increasing self-confidence

14
Process Model of Medicine
  • Procrustes and his bed ignoring/marginalizing
    dreamlike and creative qualities of life allows
    us to create a consensual everyday reality and
    function in life. Marginalized realities reappear
    imbedded in things we call problems and symptoms.

15
Pain
16
Pain/Chronic Pain Definition
  • An unpleasant sensation and an emotional
    experience associated with a real or potential
    damage to tissue, or the equivalent of such
    damage.
  • Pain without apparent biological value that has
    persisted beyond the normal tissue healing time
    (usually taken to be 3 months)

17
Names
  • Amplified Musculoskeletal Pain, Reflex
    Neurovascular Dystrophy, Reflex Sympathetic
    Dystrophy, Sympathetically Maintained Pain,
    Fibromyalgia, Algodystrophy, Complex Regional
    Pain Syndrome Types I and II, Causalgia, Sudecks
    Atrophy, Shoulder-Hand Syndrome, Repetitive
    Strain Injury, Plantar Fasciitis, Localized or
    Diffuse Idiopathic Musculoskeletal Pain,
    Neuropathic Pain, Central Pain, Psychogenic Pain,
    Psychosomatic Pain

18
Epidemiology/Prevalence/Impact
  • 9 - 11 of the U.S. population suffer from
    moderate to severe chronic pain.
  • Women are more likely to suffer chronic pain than
    men.
  • On average it is present almost 6 days in a
    typical week.
  • Only ½ of chronic pain sufferers say their pain
    is pretty much under control.
  • Chronic pain is the most common complaint made by
    patients to their Primary Care Providers.
  • It accounts for an estimated 75-100 billion a
    year in the U.S. in lost productivity and health
    care costs.

19
Specificity Theory of Pain
  • The intensity of pain is directly related to the
    amount of associated tissue injury. For instance,
    pricking ones finger with a needle produces
    minimal pain, whereas cutting ones hand with a
    knife causes more tissue injury and is more
    painful. This theory is generally accurate when
    applied to certain types of injuries and the
    acute pain associated with them. It is inadequate
    to explain chronic pain.

20
Gate Control Theory
  • Perception of physical pain is not a direct
    result of activation of pain receptor neurons,
    but instead is modulated by interaction between
    different neurons. Before they can reach the
    brain pain messages encounter nerve gates in
    the spinal cord that open or close depending upon
    a number of factors (possibly including
    instructions coming down from the brain). When
    the gates are opening, pain messages get
    through more or less easily and pain can be
    intense. When the gates close, pain messages are
    prevented from reaching the brain and may not
    even be experienced.

21
Loessers Onion Theory of Pain
  • This says that the pain mechanism is a series of
    nested layers, like the ones of an onion. The
    nerve stimulus or damage is at the centre, the
    next layer is the perception of pain, then come
    suffering, pain behavior, and finally interaction
    with the environment.

22
Nociceptive Pain
  • Pain that is a result of tissue irritation,
    impending injury, or actual tissue injury sensed
    by pain receptors. Pain receptors are the nerves
    which sense and respond to parts of the body
    which suffer from damage. When activated, they
    transmit pain signals (via the peripheral nerves
    as well as the spinal cord) to the brain. The
    pain is typically well localized, constant, and
    often with an aching or throbbing quality.
    Visceral pain is the subtype of nociceptive pain
    that involves the internal organs. It tends to be
    episodic and poorly localized.

23
Neuropathic Pain
  • Can occur as a result of injury or disease to the
    nerve tissue itself. This can disrupt the ability
    of the sensory nerves to transmit correct
    information to the thalamus, and hence the brain
    interprets painful stimuli even though there is
    no obvious or known physiologic cause for the
    pain. Neuropathic pain is the disease of pain. It
    is not the sole definition for chronic pain, but
    does meet its criteria.

24
Referred Pain
  • Is a phenomenon used to describe pain perceived
    at a site adjacent to or at a distance from the
    site of an injury's origin. One of the best
    examples of this is during heart attack. Even
    though the heart is directly affected the pain is
    often felt in the neck, shoulders and back rather
    than the chest.

25
Sympathetically Maintained Pain
  • This condition used to be called a reflex
    sympathetic dystrophy. It is also known as
    algodystrophy, Sudecks atrophy and a host of
    other names. It is now called, by the
    International Association for the Study of Pain,
    a complex regional pain syndrome.
    Sympathetically maintained pain is believed to be
    maintained by the sympathetic nervous system or
    by circulating catecholamine.

26
Peripheral and Central Sensitization
  • Amplification of pain stimuli produces secondary
    heightened sensitivity.

27
Hyperalgesia
  • Lowered pain threshold, which in one form is
    caused by damage to pain receptors in the body's
    soft tissues. Conditioning studies have
    established that it is possible to experience a
    learned hyperalgesia.

28
Allodynia
  • Meaning "other pain", is the perception of pain
    caused by usually nonpainful stimuli, such as
    touch or vibration. An example of allodynia is
    when a person perceives light pressure or the
    movement of clothes over the skin as painful,
    whereas a healthy individual will not feel pain.
    Several studies suggest that injury to the spinal
    cord might lead to loss and re-distribution of
    pain receptors and pain modulating neurons
    leading to the new response.

29
Pain and Memory
  • Conditioning and sensitization can be seen as a
    learning process at different levels. In
    addition, memory traces of pain get stuck in the
    brains prefrontal cortex which controls emotion
    and learning. Abnormal implicit memories of pain
    and emotional associations will influence
    associative learned behaviors, e.g. avoiding
    certain movements which will increase the chance
    to develop chronic pain.

30
Hebbian or Associative Learning
  • Any two cells or systems of cells that are
    repeatedly active at the same time will tend to
    become 'associated', so that activity in one
    facilitates activity in the other.

31
Long-term Potentiation
  • Long-lasting enhancement in communication between
    two neurons that results from stimulating them
    simultaneously. Since neurons communicate via
    chemical synapses, and because memories are
    believed to be stored within these synapses, LTP
    and its opposing process, long-term depression,
    are widely considered the major cellular
    mechanisms that underlie learning and memory.

32
Fear-Avoidance Model
33
Pain and Trauma/Abuse
  • Beliefs that trauma and pain are unpredictable
    and uncontrollable.
  • Sense of feeling victimized by pain.
  • Fears and avoidance of activities that will be
    painful.
  • Avoidance behaviors lead to inactivity that will
    worsen pain.

34
Regaining Ownership/Control
  • Chronic pain as a trauma that needs to be
    re-conquered.
  • Integrating Painmaker and Traumatizer
  • Like Native Americans used to inflict themselves
    with a wound once they had been wounded by an
    adversary.

35
Psychological Assessments
  • Pain Questionnaire/Inventory
  • Depression/Learned Helplessness
  • Anxiety Sensitivity (fear of anxiety-related
    bodily sensations)
  • Cognitive Behavioral Avoidance
  • Coping Styles
  • Beliefs and Expectations
  • Self-efficacy/Sense of Coherence
  • PTSD Checklist/Abuse

36
DSM IV/Somatoform Disorder
  • Conversion disorder, hypochondriasis, body
    dysmorphic disorder, pain disorder,
    undifferentiated somatoform disorder,
    somatization disorder.
  • (Not factitious disorder, malingering).

37
Multidisciplinary Pain Treatment/Management
  • Medication/Pharmacotherapy
  • Physical Therapy, Occupational Therapy
  • Psychology
  • Retraining the Nervous System
  • Alternative/Complementary Medicine
  • Interventional Medicine
  • Self-management/Education

38
Medication
  • Over the Counter Medication (Acetaminophen,
    Tylenol, Paracetamol)
  • NSAID (Ibuprofen/Advil)
  • Narcotics/Opioids (Morphine, Methadone,
    Oxycodone, Oxycontin, Fentanyl)
  • N-Type Ca-Channel Blocker (Sea snail venom)
  • Na-Channel Blockers (Antikonvulsant)
  • Vanilloid/Capsaicin Receptor Blockers (Chili
    pepper)
  • Antidepressants

39
Interventional Pain Management
  • Nerve Blocks
  • Spinal Cord Stimulation
  • Implantable Opioid Pumps

40
Ramachandran/Phantom limb/Mirror box
  • A mirror box is a box with two mirrors in the
    center (one facing each way) to help alleviate
    pain.
  • The non-painful limb is projected onto the
    hurting side in order to retrain the brain, and
    thereby eliminate the learned paralysis/pain.

41
Retraining the Brain
  • Vigorous exercise and talk therapy are used to
    retrain pain patients brain to recognize pain
    signals differently.

42
Self-management
  • Allopathic Medicine
  • Complementary Medicine
  • Allostasis/Stress-management/Relaxation
  • Advocacy/Empowerment/Rank/Leadership
  • Education/Behavioral changes
  • Family/Peer/Community support
  • Psychology/Picking up the energy
    (painmaker/traumatizer)

43
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44
Hierarchy and Health
  • Marmots Whitehall Study of British Civil
    Servants
  • Hierarchy and Social Inequality leads to more
    illness and early death
  • Allostasis/Allostatic Load The burden of
    cumulative adversity
  • Coping Sense of Coherence

45
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46
Health Disparity
  • Relative poverty
  • Disparity between the rich and the poor High gap
    correlates with poor population health.
  • Social comparison Feelings of humiliation,
    resignation and shame affect our stress
    physiologies.

47
Health Olympics/US Ranking
  • Life Expectancy 29
  • Teen Birth 28
  • Educational Opportunities 21
  • Child Poverty 25
  • Child Abuse Death Rates 26
  • Child Injury Death Rates 23

48
Rank
  • Rank reflects the underlying power differences of
    the many hierarchies we use on a daily basis to
    compare ourselves (Fuller, 2003).
  • Conscious or unconscious, social or personal
    ability or power emerging from areas of
    socio-cultural influence, personal psychology,
    and/or spiritual ties (Mindell, 1995) .

49
Subjective Rank and Health
50
Rank Dimensions
  • Social Rank
  • Psychological Rank
  • Spiritual/Transpersonal Rank
  • Contextual Rank

51
Social Rank
  • Depends on ones position in regard to
    mainstream values in the areas of socio-cultural
    influence like gender, sexual orientation, age,
    class, health/disability, religion, ethnic
    identity/race etc…

52
Psychological Rank
  • Includes self-love, self-confidence and
    self-knowledge. It also stresses good
    relationships skills, high in-group status, and a
    loving support network.

53
Spiritual or Transpersonal Rank
  • Reflects ones sense of connectedness with
    something spiritual and divine or with something
    greater than yourself (e.g. God, Nature).

54
Contextual Rank
  • Derives from ones momentary roles in a given
    situation as a teacher, health care provider,
    parent, bank teller etc...

55
Signals of the Clinicians Higher Rank
  • An attitude of
  • I know what is wrong with you!
  • You are sick, I am in good health!
  • I decide about the content, the setting and the
    course of our interaction or therapy!
  • I can be empathic!
  • I decide how much of myself I reveal in the
    relationship!
  • Detached and objective tone of voice, that
    reflect our sense of superiority,
    self-confidence, self-esteem.

56
Signals of the Clinicians Higher Rank
  • In our capacity to sit back and relax feel at
    ease, comfortable and confident.
  • In our capacity to be verbally articulate and
    expressive.
  • In our feeling of entitlement.
  • When we marginalize or dismiss our patients
    thoughts and feelings, in comments like don't
    take it so personally, you are too sensitive,
    etc.
  • When relationship issues arise and we think it is
    the patients problem. We can't understand. We
    think the patient is crazy, illogical, disturbed
    or angry.

57
Signals of the Patients Lesser Rank
  • A tendency to settle for the way things are.
  • Feeling cloudy and unable to think.
  • Self-doubt, blame and insecurity, low self-esteem
    and feeling of inferiority.
  • Adaptive behavior.
  • A tendency to placate, elevate, and compliment
    the other person.
  • Signals of fear, like shaking, sweating, not able
    to look the other in the eye.
  • Feelings of paranoia.
  • Body signals of agitation.
  • Feelings of revenge, jealousy, and anger.
    Tendency to be emotional, upset, angry, loud, to
    feel misunderstood, and to feel emotionally
    desperate.

58
Signals of the Patients Lesser Rank
  • Difficulty in taking a stand for oneself.
  • One feels overlooked, neglected and unnoticed.
  • One feels like ones position is insignificant
    and no one else feels the same.
  • Little or no eye contact.
  • Shy or reserved.
  • Many pauses in the speech flow or not much
    talking at all.
  • Poor motivation and compliance.
  • Stubbornness or insistence on ones position.

59
Circumstances with Innate Rank Issues
  • With women who feel underprivileged in their
    relationships.
  • With foreigners from underprivileged parts of the
    world.
  • With people with the sexual orientation of a
    minority.
  • With people with an obvious physical sign that
    characterizes them as belonging to a
    disenfranchised group of society (e.g. skin
    color, other physical stigmas)
  • With children and adolescents
  • With people suffering from chronic pain or other
    chronic health problems

60
Barriers to Effective Pain Management
Patient Attitudes
Clinician Attitudes
Cultural/Societal Attitudes
61
Cultural and Personal Context of Chronic Pain
  • Pain as a sub-culture experience
  • Chronic pain patients feel marginalized from
    mainstream culture
  • Loss of social rank/status is a co-factor in
    chronic pain
  • Sense of feeling traumatized by pain past
    history of abuse/trauma

62
Somebodies and Nobodies
  • Sense of being a nobody in social comparison to
    others
  • Loss of status/rank because of illness and other
    marginalizing processes
  • Sense of shame and humiliation, loss of respect
    and dignity
  • Independent of individual psychology
  • Power of internalized social values

63
Cultural Metaphors
  • Blameworthy ill-health versus responsible health
  • Health and illness as an individual process
  • Juvenile good-looking body equals success
    metaphor for fitness and attractiveness and
    standard for social acceptance and recognition
  • The body as a commodity

64
Biases and Stereotypes
  • Beliefs about addiction/Opiophobia
  • Beliefs about functional versus real disease
  • Beliefs about health and healing
  • Beliefs about how much pain is ok
  • Beliefs about other healing modalities
  • Beliefs about good patient and bad patient

65
Clinician-Patient Relationship
  • Cultural competence/sensitivity
  • Rank awareness
  • Awareness of ones biases/stereotypes
  • Communication skills
  • Awareness of individual and social beliefs

66
Difficult/Complex Patient/Client
  • Hostile or defiant patient
  • Demanding patient
  • Patient with multiple chronic problems
  • Patient who somatizes
  • Patient with functional/ psychological overlay

67
Clinical Competency in Chronic Pain Treatment
  • Knowledge of systemic and social determinants.
  • Knowledge of beliefs and barriers to treatment.
  • Ability to mediate and facilitate complex issues.
  • Works as part of a multidisciplinary team.
  • Is an expert in communicative and interpersonal
    skills.
  • Educates and chares decision making.

68
REFERENCES
  • Institute for Clinical Systems Improvement
    (ICSI). Assessment and management of chronic
    pain. Bloomington (MN) Institute for Clinical
    Systems Improvement (ICSI) 2005 Nov. 77 p.
  • Assessment and Treatment of Chronic Pain By
    John Mark Disorbio, EdD,
  • Daniel Bruns, PsyD,and Giancarlo Barolat, MD.
    Practical Pain Management, March 2006.
  • Provider-Patient Interaction Understanding
    Unconscious Interpersonal Defensive Responses in
    a Chronic Pain Practice to Improve Interactions.
    By Ron Lechnyr, Ph.D., DSW Terri Lechnyr, MSW,
    LCSW. Practical Pain Management, Mar/Apr 2004.
  • Fuller, R.W. Somebodies and Nobodies. Overcoming
    the Abuse of Rank. Gabriola Island, BC New
    Society Publishers, 2003.
  • Mindell, A. Sitting in the Fire Portland Lao
    Tse Press, 1995.
  • pierre_at_creativehealing.org www.creativehealing.or
    g
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