Understanding and Managing Pain. Insensitivity to pain = many injuries.
Understanding Pain
description
Transcript of Understanding Pain
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Understanding Pain
William P. Wattles, Ph.D.Francis Marion UniversityPsy 314 Behavioral Medicine
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Primary Prevention Advantages
Saves money Saves suffering and lost
time from life More effective than
repairing the damage Little potential for harm Maintains quality of life
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Health Care Spending Exhibit 1
Total Health Expenditure per Capita, U.S. and Selected Countries, 2008
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What is pain? Simply put, pain is usually nature’s
unpleasant way of telling you that a part of your body needs your immediate attention, or that you’re using parts of your body beyond their limits.
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What Is Pain? Clinical Pain
– Pain that requires some form of medical treatment
Most people experience an average of 3 to 4 different kinds of pain each year
Pain is the most common reason people seek medical treatment
Annual costs may reach $100 billion
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Is pain good or bad?
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Acute versus chronic pain Acute pain is
ordinarily beneficial: it warns that something is wrong.
Chronic pain never has a biological benefit.
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40 Million Americans suffer from chronic pain such as:
Lower back problems Arthritis Cancer Repetitive stress injuries Migraine headaches
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What percent of Americans suffer chronic pain?
A. 5%B. 13%C. 30%D. 50%E. 80%
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What percent of Americans suffer chronic pain?
A. 5%B. 13%C. 30%D. 50%E. 80%
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What is the current population of America?
50 million 100 million 150 million 300 million 1 billion
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Subdivisions of the vertebrate nervous system
Central Nervous System– Brain– Spinal Cord
Peripheral Nervous System– All neurons outside the brain and spinal
cord are part of the peripheral nervous system
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Peripheral Nervous System Somatic nervous System
– Sensory Neurons (afferent)– Motor Neurons (efferent)
Autonomic Nervous System» Sympathetic division» Parasympathetic division
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The Meaning of Pain Pain sometimes
thought to be a direct consequence of physical injury.
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Specificity Theory of Pain Specific pain fibers and pathways
exist Pain = tissue damage
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Nociception is the sensation of pain in normal
people
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The perception of pain Not a direct relationship between
tissue damage and the perception of pain.
Personal perception mediates the experience of pain.
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Suffering An affective or emotional response
triggered by a nociceptive-pain event or some other aversive stimulus.
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Pain due to two factors:– The sensation
(Nociception)– The individual’s
reaction to that sensation
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=/=nociception Pain=/=
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Gate Control Theory Injury without pain. Pain without injury (phantom limb) Pain components
– sensory– motivational – emotional
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The Gate Control Theory of Pain
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Nociception Nociceptive Of, causing or reacting to pain. Definitions of pain in terms of tissue
damage relay on known physiology of the body’s pain sensors (free nerve endings called nociceptors) and neural transmission of pain signals to the CNS, a process called nociception.
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Pain chemistry Prostaglandins, chemicals released
by damaged tissue and involved in inflammation.
Pain is produced by neurons that must be energized via neurotransmitters.
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The Physiology of Pain Unlike other senses, pain is not triggered
by only one type of stimulus, nor does it have a single type of receptor
Free Nerve Endings — sensory receptors found throughout the body that respond to temperature, pressure, and painful stimuli
Nociceptor — a specialized neuron that responds to painful stimuli
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The Physiology of Pain Fast Nerve Fibers
– Large, myelinated nerve fibers that transmit sharp, stinging pain
Slow Nerve Fibers– Small, unmyelinated nerve fibers that
carry dull, aching pain
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Pain Pathways
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Measuring Pain There are no
objective measures of pain.
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Measuring Pain Psychophysiological Measures
– Psyche (mind) – physike (body)– Electromyography (EMG) — assess the
amount of muscle tension experienced by pain sufferers
– Indicators of autonomic arousal — using measures of heart rate, breathing rate, blood pressure, etc
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Measuring Pain Behavioral Measures
– Pain Behavior Scale»Target behaviors include vocal
complaints, facial grimaces, awkward postures, mobility
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Measuring Pain Self-Report Measures
– Structured interviews (When did the pain start? How has it progressed?)
– Pain rating scales (numerical ratings or a pain diary)
– Standardized pain inventories » McGill Pain Questionnaire (MPQ): sensory
quality, affective quality, evaluative quality of pain
» Pain Anxiety Symptoms Scale (PASS)
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Stages of pain Acute pain. adaptive lasts less than
six months. Prechronic pain. critical period to
overcome pain. Chronic pain endures beyond the time
of healing.
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Chronic Pain Chronic recurrent pain- episodic Chronic intractable benign pain-
always present but not always severe.
Chronic progressive pain. Omnipresent
Chronic pain frequently associated with psychopathology.
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Headache 29 Million Americans suffer from
sever, disabling headache 18% of women and 7% of men report
at least one migraine a year.
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Muscle tension headache Causes
– stress– posture and
muscle habits– lack of flexibility– lack of strength
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Treating muscle-tension headache
Diaphragmatic breathing
Progressive muscle relaxation
Temperature and EMG biofeedback
Without some behavioral and cognitive coping skills training this procedure may be palliative
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Migraine headache Causes
– Stress– Muscle tension– Genetics– Diet– Weather changes
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Treating migraine headaches
Caused by excessive vasoconstriction and vasodilatation.
Thus, controlling blood flow via biofeedback training may be able to help.
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Treatment of Migraine headaches
16.5%
65.1%
51.8% 52.7%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%
Thermaland
Autogenics
Thermalonly
Relaxationonly
Placebo
Method
Pe
rce
nt
imp
rov
ed
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Physical Treatment of pain Analgesic drugs
relieve pain without loss of consciousness.
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NSAIDs Nonsteroidal anti-
inflammatory drugs. Act at the site of the
injury rather than in the brain.
Have anti-inflammatory properties
Aspirin, Ibuprofen (Advil,
Motrin)
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Tylenol (acetaminophen) Acetaminophen has negligible anti-
inflammatory activity, and is strictly speaking not an NSAID.
The medicine in Tylenol is not an NSAID. It’s a pain reliever that works differently. – http://www.tylenol.com/
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Aspirin Known since 500 B.C. Comes from bark of willow tree 1899 Bayer began marketing aspirin
acetylsalicylic acid
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NSAID’s unlike opioids, they do not produce
sedation, respiratory depression, or addiction.
They work by inhibiting an enzyme that helps produce prostaglandins.
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Aspirin The most popular uses of aspirin are
for:– prevention of heart disease (37.6
percent), – arthritis (23.3 percent), – headache (13.8 percent), – body ache (12.2 percent) and – other pain uses (14.1 percent).
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Pain treatment Opiate drugs block pain by occupying the
sites where the neurotransmitters would attach.
No other type of drug produces more complete pain relief.
Potential for addiction. Oxycodone (Oxycontin) Hydrocodone (Vicodin) Morphine, Codeine,
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Endorphins Endorphins (endogenous morphine)
naturally occurring neurochemical which work like opiates.
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Chronic Pain Pain is subjective Secondary gains can be
considerable Pain difficult to measure Many may be malingering Others may be “faking”
unintentionally
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Malingering Feigning illness or other incapacity
in order to avoid duty or work
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“Faking” unitentionally
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Signal Detection Theory Threshold is that point at which we
can detect the signal. Below that we don’t detect it above that we do.
It turns out that motivation plays a roll in what we detect.
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55Strength of Sensation
Percent
detect0%
100%
weak Strong
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56Strength of Sensation
Percent
detect0%
100%
weak Strong
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pain No painreport pain hit false alarm
no pain miss correct rejection
truth
Signal Detection Theory
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Vioxx Approved in 1999 for the treatment
of acute pain and chronic pain from arthritis and other problems.
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VIOXX the Science “Merck has always believed that
prospective, randomized, controlled clinical trials are the best way to evaluate the safety of medicines.”
Prospective Randomized Controlled
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VIOXX the Science Risk of heart attack,
stroke and blood clots after 18 months.– VIOXX 15 per
thousand– Placebo 7.5 per
thousand– “Although the
absolute risk may be rather small, the relative risk is high. “
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VIOXX the market “Marginal efficiency, heightened risk,
excessive cost.” Vioxx provides about the same relief
as aspirin though patients are less likely to develop ulcers or gastrointestinal bleeding.
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VIOXX
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Cox-2 inhibitor Aspirin blocks the
production of prostaglandins, key hormones that are used to carry local messages.
Cyclooxygenase (cox-1, cox-2) performs the first step in the creation of prostaglandins
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VIOXX Private enterprise Capitalism
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Vioxx
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VIOXX advertising In the first 6 months of this year
alone Merck spent $45 million advertising Vioxx.
“Terrifying testimony to the power of marketing.”
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Health Belief Model
Beliefs contribute to behavior Perceived:
– susceptibility– severity– benefits– barriers
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Sociocultural Factors Culture and Ethnicity
– Groups differ greatly in their response to pain
– Through social learning, groups establish norms for the degree to which suffering should be openly expressed and the form that pain behaviors should take
Pain tolerance versus pain threshold
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A Pain-Prone Personality? Acute and chronic pain sufferers show
elevated scores on two MMPI scales: – Hysteria (tendency to exaggerate symptoms
and use emotional behavior to solve problems)
– Hypochondriasis (tendency to be overly concerned about health and to overreport body symptoms)
Chronic pain sufferers also score high in depression
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A Pain-Prone Personality? Placebo responsiveness may be a
situational trait rather than a dispositional trait– No consistent personality differences in
placebo responders and nonresponders
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Types of Pain Patients (Turk & Nash)
Dysfunctional patients– report high levels of pain, feel they have little
control over their lives, and are extremely inactive
Interpersonally distressed patients– perceive little social support and feel other
people in their lives don’t take their pain seriously
Adaptive copers– report lower levels of pain and distress and
continue to function at a high level
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Operant conditioning Behavior
– Go to the doctor Consequence
– Pain of a shot added
Behavior tends to decrease
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Generous sick leave Two and a half
years later, she is still on government-paid sick leave, resting at her comfortable home.
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with breaks for stretching drills in her living room, restorative walks through pine woods and the occasional round of golf.
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Malingering 62 percent of
the employees interviewed said they had taken sick leave when they were not really sick and that they felt there was nothing wrong in doing so.
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Doctor’s excuse physicians
routinely approve sick leaves solely at a patient's request.
"It takes 30 seconds to write a doctor's note, It can take an hour to convince someone that he is ready to go back to work, and meanwhile your waiting room is filling up."
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Correlation In 1998, the
government's benefit increased from 75 percent to 80 percent of salary, and the average number of days spiked upward each year thereafter, from 11.1 in 1997 to 24.4 in 2001.
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Employees get time off when they want it
Employers gain a way of moving underperforming workers
The government can claim one of the lowest rates of unemployment
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Somatoform Pain disorder Significant pain Presumed psychological factors play
a role in course Not due to malingering or factitious
disorder.
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The End