The prevalence of undiagnosed cognitive impairment and prevalence of undiagnosed depressive
Managing Pain - The Marfan Foundation · Pain is common Pain is undiagnosed 41% Pain is ubiquitous...
Transcript of Managing Pain - The Marfan Foundation · Pain is common Pain is undiagnosed 41% Pain is ubiquitous...
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Assistant Professor, Department of Psychiatry and Behavioral Sciences
Managing Pain
in Marfan Syndrome
Traci J. Speed, MD PhD
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No financial disclosures
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Objectives
• Define pain
• Discuss the role of comorbid conditions that worsen
pain
• Describe effective interventions for the treatment of
chronic pain
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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
Frida Kahlo Without Hope 1945
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How academics think about pain?
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How individuals think about pain?
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Pain is
common Pain is
undiagnosed
41%
Pain is ubiquitous in MFS Head
33%
Jaw
15%
Chest
28%
Abdomen
18%
Hands
25%
Feet
49%
Knees
43%
Hips
46%
Back
78%
Shoulders
45%
Legs
37%
Adapted from Nelson
Clin J Pain 2015
Speed Am J Med Genet 2017
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Pain
Hopelessness
Apathy
Demoralization
Disability
Social isolation
Opioid/Benzo dependence
Fatigue
Anhedonia
Insomnia
Risk Behavior
Poor adherence
Chronic pain has consequences
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Pain in Marfan syndrome
89%
pain
28% pain
at onset
44% pain
spreads
Speed Am J Med Genet 2017
N = 245
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Why is it important to address pain?
• Relationships (spouse / partner, children, friends)
• Work
• Finances
• Energy
• Social activities
• Physical health
• Mental health
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Where to begin?
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Diagnosis: Comorbidities
• Bereavement/grief
• Demoralization
• Stressful life events
• Major Depression
• Bipolar Disorder
• Anxiety Disorder
• Substance Use Disorder
• Insomnia Disorder
• Temperamental strengths/weaknesses
Central
Sensitization
Coping skills
Personality
Mood
Self-efficacy
Substances
Sleep
Culture
Genetics
Life events
Individual
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Why diagnose Depression?
• Major Depression – uncouples the reward system
– increases reliance on avoidance coping
– increases vulnerability to medication overuse
– increases pain sensitivity
30-60% pain depression
Walker AK Pharmacol Rev 2014
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Symptoms of Major Depression
• Depressed or irritable
mood [or feeling nothing]
• Decreased interest or
pleasure in activities
(anhedonia)
• Change in appetite or
weight
• Sleeping more or less than
usual
• Psychomotor agitation or
retardation
• Fatigue or loss of energy
• Decreased concentration
• Feelings of guilt or
worthlessness
• Recurrent thoughts of
death or suicide
• Hallucinations and
delusions possible
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Why consider substance abuse?
(alcohol, opioids)
– Increase liability to medication overuse
– Decrease social networks and support
– Decrease motivation to get well
– Diminish the baseline experience of being well
30-80% pain substance
abuse
Sullivan Pain 2013
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PRE-M ORBID ACUTE EARLY CHRONIC
BEHAVIORAL MODEL OF INSOMNIA
PERPETUATING FACTORS
PRECIPITATING FACTORS
PREDISPOSING FACTORS
THRESHOLD
Spielman et al. 1987
Pain and sleep frequently comorbid
50-80% pain insomnia
Finan et al 2015
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Treatment strategies
• Medications
• Psychotherapy
• Interventions/Stimulators
• Education
• Physical therapy
• Group therapy
• Exercise
• Family therapy
N = 218 Current (%) Past (%)
Over the counter meds 53.2 64.7
Opioids 33.9 49.5
Non-opioid medications 21.6 32.1
Physical therapy 17.4 54.1
Complementary/alternative 16.5 37.2
Psychology pain interventions 12.8 35.8
Procedures 10.6 38.1
Herbal supplements 4.1 11.9
Occupational therapy 2.8 14.2
Speed et al 2017 (accepted)
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Antidepressants
Opioids
Acetaminophen
Anticonvulsants
NMDA antagonists
Opioids
Alpha2 agonists
Local Anesthetics
Alpha2 agonists
Anti-inflammatory drugs
Anti-inflammatory drugs
Topical Anesthetics
Acetaminophen
Ibuprofen
Nerve medicines
SNRIs
TCAs
Anti-seizure medications
Opioids
Pain education
Non-medication
therapies
Multimodal therapy
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Toolbox of therapies
• Behavioral Approaches
• Relaxation
• Imagery
• Self hypnotic analgesia
• Distraction techniques
• Graded physical recovery exercises
• Assertiveness training
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Cognitive Behavioral Therapy
Desire to feel a certain way to do a certain thing
More likely to do a certain thing
After a while it will make you feel a certain way
Adapted from Turk 2000
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Relaxation Training
• Relaxation Therapies
• Abdominal (Diaphragmatic) Breathing
• Progressive Muscle Relaxation
• Guided Imagery
• Yoga & Mindfulness Meditation
• reduce inflammation
Behavioral Sleep
Medicine Specialist
*practice during a time of relative low pain
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Self efficacy
Belief in capability to perform a goal affects:
• the energy invested in the endeavor
• the persistence in the face of obstacles
• and the anxiety and demoralization in coping with
stressors related to the endeavor
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Final thoughts
• Individual pain experience is unique
• All individuals benefit from structure, hope, and advocacy
• Accept serendipity wherever you can find it
• Goal is functioning despite pain