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.
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
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
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
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
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
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
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
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
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
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
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
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