PTSD, Opioid Dependence, and EMDR: Treatment Considerations for Chronic Pain Patients

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PTSD, Opioid Dependence, and EMDR Treatment
Considerations for Chronic Pain Patients

• W. Allen Hume, Ph.D.,C.D.P.
• Licensed Psychologist
• www.drallenhume.com
• October 2, 2007

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COD client with PTSD seeking services in a Pain
Center

• Were not bad people, were just human beings
  who need help with pain. If nothing else we need
  more help.
• Male, aged 23

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Goals of the Presentation

• Define Posttraumatic Stress Disorder and identify
  the symptoms of trauma.
• Identify the prevalence rates of PTSD and opioid
  dependence in pain patients.
• Outline a general approach to treating chronic
  pain patients with PTSD.
• Discuss the use of Eye Movement Desensitization
  and Reprocessing (EMDR).

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Posttraumatic Stress Disorder (PTSD) Defined
(DSM-IV-TR, 2000)

• Exposure to a traumatic event
• The person experienced or witnessed an event that
  involved death or serious injury
• Response involved intense fear, helplessness or
  horror
• 3 Main Clusters of Symptoms
• Re-experiencing the traumatic event
• Avoidance
• Arousal
• Symptoms present for at least 1 mo.

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Post-traumatic stress (PTS) vs. Post-traumatic
stress disorder (PTSD)

• PTS - traumatic stress that continues following a
  traumatic incident (Rothschild, 1995)
• PTSD - traumatic stress that produces the
  symptoms of PTSD implies a level of daily
  dysfunction

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Two Types of Trauma (Shapiro, 1995)

• Big T trauma - major traumas
• War, assaults, rape, physical violence, etc.
• Small t traumas - minor traumas or life
  disturbances
• Ridiculed, humiliated, high school

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Prevalence of PTSD (Sharp, 2004)

• 20 of people will develop PTSD after a traumatic
  incident (van der Kolk, 1995).
• In the general population, PTSD ranges between
  7-12 (Seedat et al, 2001).
• Between 10-50 of chronic pain patients meet
  criteria for PTSD.
• Mediating variables age, preparation, belief
  system, internal resources, hx of trauma,
  support, degree of trauma, fear/level of threat

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PTSD Prevalence Rates Continued

• PTSD varies across selected samples (Sharp, 2004)
• 39 in MVA
• 39 of assault victims
• 7 of homicide survivors
• 15.2 of male and 8.5 of female Vietnam Vets
• 80 of patients with PTSD meet criteria for at
  least one other psychiatric diagnosis (Asmundson
  et al, 2002).
• Major depression - most common
• Anxiety disorders
• Substance abuse Somatoform disorders

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Rate of PTSD Among Individuals with Opioid
Dependence Mills et al. (2005)

• Among 459 subjects in opioid treatment, 42 had
  PTSD
• Cost of treatment approximately same over a 12
  month period
• PTSD clients had a poorer outcome in
  occupational, physical and mental health
  functioning as well as more overdose.
• More relapse, readmissions, ongoing use

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Pain Definitions Oaklander, A.K. (1999)

• Acute Pain
• Adaptive, beneficial response necessary for
  preservation of tissue integrity
• Chronic Pain
• Traditionally defined as gt 6 months
• It is pain that has outlived its usefulness

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Prevalence of Opioid Usage Turk (2007)

• Most commonly prescribed med in US
• 3 of non-cancer population (8.1M)
• 9.4 Billion dosage units per year
• Approximately 3.8-4 of chronic pain patients
  abuse their medications
• Aberrant drug behaviors
• Issue of pseudoaddiction
• Co-morbid disorders

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Opioid Use Trends NIDA Research Report

• 1999 2.6 million misused pain meds
• 1990-98 181 increase in usage
• Oxycodone prescriptions rose 359 since 1997
  (DASA, 2005)
• Methadone for non-opiate substitution rose 312
  since 1997 (DASA, 2005)
• WA state 74 deaths related to heroin OD 138
  from other opiates in 2005 (DASA, 2006)

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Most Used Opioids

• Oxycontin and other oxycodone preparations (60)
• Hydrocodone combined with acetaminophen (Vicodin
  like drugs)
• Morphine

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Do Opioids Work for Pain?

• WHO reports that opioids are effective in
  controlling moderate to severe pain
• Turk (2007) Medications are central in pain
  management, they are not a panacea, nor cure. On
  average across studies they reduce pain by
  approximately 30 in 40-50 of patients.
• Carefully select patients for optimal outcome
  based on history and response.

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Prevalence of Addictive Disorders Among Pain
Patients

• General Population 3-18
• Chronic Pain Population 3.2-24
• Hospitalized Population up to 26
• Trauma Population 40-62
• Cancer-related Population up to 27 or more

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Chronic Pain in Addicted Populations

• MMT patients 61.3 (Jamison, 2000)
• MMT patients 80, with 37 severe (Rosenblum,
  Joseph, et al, 2003)
• Among Inpatient Substance Use Treatment patients
  78 (Rosenblum, Joseph, et al, 2003)

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Approach to Trauma Treatment

• Evaluation and Assessment
• Type of trauma Type of trauma client
• Safety
• Risk assessment
• Mental status co-morbid disorders
• Medical History
• Family and occupational functioning
• Medication

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Approach to Trauma Treatment

• Psychoeducation about trauma
• Coordination of care with medical providers
• Affect management skills
• Safe place exercise, grounding
• Container method
• Calming the body down
• Meditation, breathing
• Yoga, chanting
• Integration of Traumatic Memories via EMDR

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What is Eye-Movement Desensitization and
Reprocessing (EMDR)?

• A type of psychotherapy for treating emotional
  difficulties that are caused by disturbing life
  experiences, ranging from traumatic events such
  as combat stress, assaults to upsetting events.
• EMDR is also being used to alleviate performance
  anxiety, generalized anxiety, sleep disturbances,
  phobias, grief, relapse prevention, and
  performance enhancement.

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Adaptive Information Processing A Theoretical
Model (Parnell, 2007 Shapiro, 1995)

• We all have an information processing system
  through which new experiences and information are
  processed to an adaptive state.
• Trauma or disturbing experiences become trapped
  in the nervous system.
• In EMDR, we ask the patient to focus on a target
  memory.

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Adaptive Information Processing Continued

• When information stored in memory networks
  related to a distressing or traumatic experience
  is not fully processed it gives rise to
  dysfunctional reactions.
• Eye movements or BLS stimulates accelerated
  information processing.
• The goal is to reach adaptive resolution -
  reduce vivid imagery and related affect shift
  negative beliefs about oneself.

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The Eight Phases of EMDR Treatment

• The 8 phases of the EMDR protocol represent a
  comprehensive treatment approach.
• 1. Client History and Treatment Planning
• 2. Client Preparation
• 3. Assessment

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The Eight Stages of EMDR Treatment Continued

• 4. Desensitization
• 5. Installation
• 6. Body Scan
• 7. Closure
• 8. Reevaluation

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Assessment Phase

• Target Memory
• Picture
• Negative Cognition
• Positive Cognition
• Validity of Cognition (VoC)
• Emotions
• Subjective Units of Distress (SUDs)
• Body Sensations

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Case Example

• 23 year old single male, withdrawn from college,
  history of oxycontin, marijuana, and alcohol
  abuse in remission prior to a serious MVA that
  resulted in dental/facial injury, PTSD, and
  uncontrolled pain.
• Presenting issue Atypical dental/facial pain,
  history of DV relationship with previous partner,
  unable to access social/family support, and
  non-narcotic pain meds have been unhelpful for
  pain.

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EMDR is a Widely Accepted Treatment

• American Psychological Association
• American Psychiatric Association
• U.S. Department of Veterans Affairs and
  Department of Defense
• United Kingdom Department of Health (2001)
• Israeli National Council for Mental Health (2002)
  
• Dutch National Steering Committee Guidelines for
  Mental Health Care (2003).

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Summary Points

• Acute and chronic pain can be treated in the
  context of addiction, but optimally
• Patient must be willing to engage in assessment
  and treatment of pain, addiction, and psychiatric
  issues
• In my experience, EMDR appears to be helpful in
  the treatment of PTSD in addicted, chronic pain
  populations