chronic pain and the drug-seeking patient a behaviorist approach
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Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach. Glenn J. Treisman, MD, PhD Professor Director, AIDS Psychiatry Service The Johns Hopkins Medical Institutions Baltimore, MD. From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Pain. - PowerPoint PPT PresentationTRANSCRIPT
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Slide 1 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. IAS–USA
Glenn J. Treisman, MD, PhDProfessor
Director, AIDS Psychiatry ServiceThe Johns Hopkins Medical Institutions
Baltimore, MD
Chronic Pain and The Drug-Seeking PatientA Behaviorist Approach
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
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Slide 2 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Pain
• Pain is made up of 2 parts:
–A sensory experience associated with physical manipulation
–An emotional response of distress and anxiety related to the sensory information
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Slide 3 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
What do we mean by the term “Chronic Pain”?
• Chronic pain which is the result of ongoing acute injury– Pain which is provoked by ongoing chronic
injurious process such as malignancy, tissue destruction or chronic infection
• Chronic pain which is the result of an adaptation of the nervous system to injury– Pain which continues when the original injury
that provoked the initial pain has resolved
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Slide 4 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Reinforcers of healing
• Life reinforces getting well–Social–Occupational–Romantic–Sexual–Financial–Self image
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Slide 5 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Abnormal illness behavior
• The patient is not entitled to the sick role he expects
• The patient continues his expectation despite being told it is inappropriate
–Issy Pilowsky
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Slide 6 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Examples of reinforcers in abnormal illness behavior
• Positive reinforcers– Disability payments– Attention from spouses, family, doctors, lawyers– Ability to express prohibited feelings– Possibility of “lump sum” payments
• Negative reinforcers– Relief from stress, expectations and criticism– Relief from pain and discomfort
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Slide 7 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
What makes patients seek narcotics when they are not helping?
• Conditioning• Relief from distress in life• Transient relief from pain• Addiction
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Slide 8 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Addiction
Behavior RewardDe
pres
sion
Inflammation and cytokinesSympathetic activation and stress
Decreased reward sensitivityIncrease in stimulus seekingDecreased self preservationDay-night cycle disruption
HIV and HEP C
Chronic diseaseHIV and Hep CLipids
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Slide 9 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Simplified model of temperament
Percent of population
Introversion
Punishment avoidant Future directedFunction directed
Extraversion
Reward directed Present directedFeeling directed
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Slide 10 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Goals of behavioral therapy
• Not directed at elimination of pain per se• Pain may diminish because of
reconditioning and rehabilitation• Improve function• Improve quality of life• Decrease iatrogenic morbidity
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Slide 11 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Behavioral approach to chronic pain treatment
• Develop a behaviorally based plan for rehabilitation that includes a set of rewards and consequences
• Use cognitive-behavioral therapy to change behavior
• Treat psychiatric co-morbidity
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Slide 12 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Role induction
• Describe the role of the doctor and the patient
• Explanation of the diagnosis and goals of treatment
• Firm limits combined with advocacy• Focus on problems in the patient’s life• Focus on behavior and rehabilitation and
away from feelings
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Slide 13 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Target behaviors for pain treatment• Time-contingent medications (and taper)• Graded activation (exercise)• Social reinforcement (spouse)• Self control skills
–Self monitoring–Self reinforcement–Relaxation training
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Slide 14 of 14
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Treat psychiatric co-morbidity
• Depression• Personality vulnerabilities• Life experiences