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Pain Physiology of Pain Nociceptors Nociceptors Stimulus Transmission Stimulus Transmission Termination Termination Modulation Modulation.

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Presentation on theme: "Pain Physiology of Pain Nociceptors Nociceptors Stimulus Transmission Stimulus Transmission Termination Termination Modulation Modulation."— Presentation transcript:

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2 Pain

3 Physiology of Pain Nociceptors Nociceptors Stimulus Transmission Stimulus Transmission Termination Termination Modulation Modulation

4 Physiology of Pain Multiple Multiple Redundant Redundant Reciprocal Reciprocal Complex Complex

5 Assessment of Pain Immediate Pain Immediate Pain Physical Functioning Physical Functioning Psychological Factors Psychological Factors Pain Behaviors Pain Behaviors Objective Correlates Objective Correlates

6 Assessment: Immediate Pain Intensity Intensity Location Location Affective Response Affective Response Composite Measures Composite Measures

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11 Assessment: Physical Fx. Impairment Impairment Functional limitation Functional limitation Disability Disability

12 Assessment: Psych factors Influence vs. causation Influence vs. causation Mediation Mediation Reinforcement Reinforcement Resonators Resonators Pain beliefs Pain beliefs

13 Assessment: Pain Behavior Observation Observation Role of learning Role of learning

14 Composite Pain Scales Attempt to measure one or more dimensions of the pain experience Attempt to measure one or more dimensions of the pain experience

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16 History Intensity Quality Objective Data Comorb id Side effects

17 Assessment: Objective Indicators Ex. Electromyography Ex. Electromyography “Well, Phil, after years of vague complaints and imaginary ailments, we finally have something to work with.”

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19 Diagnosis Categorization Categorization DSM and Pain DSM and Pain Other Approaches to “Somatoform Pain” Other Approaches to “Somatoform Pain”

20 Categorization Acute versus Chronic Acute versus Chronic

21 Acute Pain Not just time Not just time Clearer association Clearer association Subtypes (ex. Recurrent?) Subtypes (ex. Recurrent?) “nociceptive pain” “nociceptive pain”

22 Chronic Association? Association? Types Types By presumed etiology By presumed etiology Neurologic pain Neurologic pain Ideopathic Ideopathic By course By course

23 DSM-IV The concept of Somatoform Pain

24 DSM and pain I (1952) I (1952) Psychophysiological disorders“ Psychophysiological disorders“ “Psychoneurotic Disorders” “Psychoneurotic Disorders” II (1968) II (1968) Hysterical neurosis Hysterical neurosis

25 DSM and pain III (1980) III (1980) Psychogenic Pain Psychogenic Pain “incompatible” or “INXS” “incompatible” or “INXS” Etiologically related Etiologically related III-R (1987) III-R (1987) Somatoform pain Somatoform pain Dropped etiology part Dropped etiology part

26 DSM and pain IV IV Pain Disorder Pain Disorder Pain=predominant focus Pain=predominant focus Substantial distress/impairment Substantial distress/impairment Psych factors “have role” Psych factors “have role” Onset or expression Onset or expression Not malingering/factitious disorder Not malingering/factitious disorder

27 Problems with DSM Utility Utility How to judge? How to judge? Physical versus Psychological Physical versus Psychological Etiology Etiology DSM-IV DSM-IV Mind-body dichotomy remains Mind-body dichotomy remains Division of pain based on this. Division of pain based on this.

28 True psychogenic pain

29 DSM-IV pain tested Psychological vs. Psychological+Medical Distinction Psychological vs. Psychological+Medical Distinction No difference on No difference on Pain measures Pain measures Intensity Intensity Type Type Level of disability Level of disability (Aigner et al, Compr Psychiatry 1999)

30 Other approaches to diagnosing pain

31 IASP 5 axis system I. Anatomical region II. Organ system III. Temporal characteristics/patterns IV. Intensity, time since onset V. Etiology

32 IASP Psychological pain Psychological pain “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.” “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”

33 Other approaches Dimensional Dimensional Take into account various aspects of pain Take into account various aspects of pain Objective findings/physical etiology Objective findings/physical etiology Perceptual influences Perceptual influences Presentation Presentation

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36 Treatment of Pain

37 Pharmacologic Pharmacologic Psychological Psychological Other somatic treatments Other somatic treatments Importance of Multimodal Importance of Multimodal Cormorbid treatments Cormorbid treatments Role of C/L Psychiatrist Role of C/L Psychiatrist

38 Pharmacological Treatment “True” Analgesics “True” Analgesics Everything Else Everything Else “Yes Billy, but Mr. Phillips pushes legal drugs.”

39 “True” Analgesic NSAIDS NSAIDS Opioids Opioids Local agents Local agents

40 NSAIDS Mechanism Mechanism Indication Indication Side effects Side effects

41 NSAIDS Standard Standard Acetaminophen Acetaminophen Ketorolac Ketorolac COX-2 inhibitors COX-2 inhibitors

42 Opioids Mechanism of action Mechanism of action Indication Indication Side effects Side effects Common Common Uncommon but problematic Uncommon but problematic

43 Some Typical Opioids OralParenTran Morphine√√ Propoxyphene (Darvon) √ Hydromorphone (Dilaudid) √√ Meperidine (Demerol) √√ Methadone√√ Oxymorphone (Numorphan) √ Fentanyl (Duragesic, Actiq) √*√√ Oxycodone (Percoset, Oxy--) √

44 Combination Opioid/NSAIDs Narcotic+Acet+ASA+Ibu Dihydrocodone DHC plus* PropoxypheneDarvocet,Wyegesic Codeine Tylenol w/ Codeine #2- 4, Fiorecet* † Fiorinal* † Hydrocodone Vicodin, Hydrocet, Lorcet, Lortab, Zydone Vicoprofen Oxycodone Percocet, Tylox Percodan Pentazocine ‡ Talacen † butalbital ‡ agonist-antagonist *caffeine † butalbital ‡ agonist-antagonist

45 Relative Potency

46 Treatment Approach

47 MEC MEC Role of pharmacokinetic Role of pharmacokinetic Toxicity Toxicity Slow-release preps Slow-release preps

48 Concerns Tolerance Tolerance Dependence Dependence Addiction Addiction

49 Overvalued Concerns Addication Addication Overdose and death Overdose and death Discipline Discipline “Damn! I suppose this means another malpractice suit.!”

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51 Adjunctive and other meds Antidepressant Antidepressant Anticonvulsants Anticonvulsants Local Analgesics Local Analgesics Antihistamines Antihistamines Antipsychotics Antipsychotics Benzodiazepines Benzodiazepines Stimulants Stimulants Cannabinoids Cannabinoids Placebos Placebos

52 Nonsurgical treatments Cutaneous Stimulation Cutaneous Stimulation Electrical Stimulation Electrical Stimulation Acupuncture Acupuncture Exercise Exercise

53 Surgical Treatments Neural Blockade Neural Blockade Surgical lesions Surgical lesions Limitations Limitations

54 Psychological Treatments Psychoeducation Psychoeducation Hypnosis Hypnosis Behavioral Treatments Behavioral Treatments

55 Behav Txs Relaxation Relaxation Biofeedback Biofeedback CBT CBT Focus Focus Goals Goals

56 Multidisciplinary Pain Treatment Different levels Different levels Features included Features included

57 Comorbid Problems Depression Depression Anxiety Anxiety

58 Problems of dual diagnosis

59 Role of Psychiatrist in Pain Mgmt

60 Role of C/L Psychiatrist in Pain Eval “Problem Patient” “Problem Patient” “Drug Seeker” “Drug Seeker” “Just in their heads” “Just in their heads” “Pain out of proportion…” “Pain out of proportion…”

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