Why? Musculoskeletal pain is more prevalent in patients with panic disorder than the general population. 35% of chronic pain patients meet criteria for anxiety disorder (18% general population) People with back/neck pain 2-3x more likely to have anxiety disorder in past 12mo. Women with Fibromyalgia 4-5x more likely to have had a anxiety disorder in their lifetime. 30-80% of patients with PTSD report chronic pain Asmundson and Katz, 2009
Pre-op anxiety plays a role in development of Chronic post-surgical pain (CPSP) Theunissen, etal. 2012 Meta-analysis – 29 studies Pre-operative anxiety and catastrophizing CPSP 3mo after surgery Moderate evidence that pre-op anxiety and catastrophizing play a role in CPSP Judge et al. 2012 1991 patients Total Knee Replacement 2005-2008 Pre-op Anxiety/Depression EQ5D 6 month post-operative Oxford Knee Score Pre-operative anxiety depression led to worse pain at 6 mo. Not associated with function at 6 mo. Masslelin-Dubois et al. 2013 189 patients TKA for OA and breast surgery for CA Data pre-surgery and 3 mo. Post Spielberger State-Trait Anxiety Inventory, Pain Catastrophizing Scale, and Brief Pain Inventory. State anxiety, independent predictor pain at 3 mo. No dependence on surgical model.
Common factor or predisposition Genetically influenced COMT-catechol-O-methyltransferase –regulation of neurotransmitters Psychological Vulnerability Anxiety Sensitivity-Fear of anxiety based on belief that it may have harmful consequences injury sensitivity Life event Trauma or injury Threshold for alarm (stress response)
Pain (Chronic MSK) Anxiety (PTSD) Somatic hypervigilance Startle rx Emotional numbness Avoidance Dysregulation of stress response and pain modulation systems
Limbic System Area of the brain that regulates emotion and memory Influences emotions, the visceral responses to those emotions, motivation, mood, and sensations of pain and pleasure brain’s anxiety “switch”
Recognize and treat both. Let’s look at some case studies…
Julia Anderson 66 y.o. Hospitalized POD #1 R TKA for OA Hx of anxiety Regular appointment with psychotherapist Sertraline 100mg daily Alprazalam 0.5mg TID PRN Fibromyalgia
Julia Anderson Julia reports she is fearful of taking opioids, requests Tramadol. Would this be an appropriate intervention? No. Concurrent use of SSRI and Tramadol would put Julia at risk for Serotonin Syndrome.
Julia Anderson Multimodal pain management Opioid Naïve dosing of Opioids Opioid Sparing medications Tylenol Topicals such as Lidocaine, Icy Hot, NSAID Vistaril Muscle relaxant Make sure she is on her chronic anxiety regime “How many Xanax do you take a day?” – schedule it +PRN “What non-medicine strategies have you discussed with your psychologist to manage this pain, your anxiety?”
Julia Anderson - Fibromyalgia Chronic pain condition characterized by widespread pain both sides of body, above and below the waist, fatigue and somatic, affective and cognitive symptoms. “Experience 5 x more pain than patient without fibromyalgia.” Though a disorder of “pain regulation, “ no longer MSK Genetics Non-restorative sleep Autonomic dysfunction Neuroendocrine abnormalities Abnormal function in CNS structures
Julia Anderson- Pre-op Gabapentin/Pregabalin? Gonano et al., 2011 40 outpatints elective partial meniscectomy under general anesthesia 300mg pregabalin vs placebo pre-op pre-op anxiety No change in pain scores but reduction in opioid use in PACU by half Clarke et al., 2012 50 females – anxiety ≥5/10, non-cardiac surgery 1200mg Gabapentin vs placebo pre-op pre-op anxiety and pain catastrophizing Possible delayed post-op discharge??
Bryan Smith 23y.o. Shoulder sprain while playing ultimate Frisbee. Able to function and participates in initial rest and then physical therapy. Using more opioid pain medications than expected, frequent requests for refills, longer than expected pain trajectory.
Bryan Smith- co-existing addiction? 6.4 million US citizens used psychotherapeutics for non-medical use (SAMHSA, 2006) Assessment Addictive behaviors noted between visits/within the visit Opioid Risk Tool (ORT) family history, personal history, age, history of preadolescent sexual abuse,, any psychological disease and depression. Pain Contract, pill counts, urine toxicology screens, dispense in small quantities.
Bryan Smith – co-existing anxiety? Consider Bryan has underlying anxiety disorder? Opioids are downers – self medication? over-arousalirritability poor concentration poor sleeping worry about several areas most of the time
Jay Newton 43y.o. with chronic back pain on disability On chronic opioid therapy from primary MD for many years PTSD related to building falling on him when he was volunteering for Hurricane Katrina clean-up Admitted to hospital with same pain, same location, increased intensity. Work-up for acute cause is negative. 4 th admission to hospital, 12 th ED visit in last 6 months
Jay Newton- “flare” Goals of managing pain flare Rule out new or serious underlying condistion Not to escalate opioid therapy Management of symptom and coping with crisis Reassurance not indication of serious condition Manage contributing factors (i.e. cough) Manage comorbidities (insomnia, anxiety, depression) Self control/ coping skills Reasonable Expectations
Jay Newton – Cognitive Behavioral Therapy (CBT) Referral for Comprehensive Pain Management with CBT Influence pain via one’s own thoughts Alter perception of painful stimuli, not alter painful stimulus directly
Selected References Asmundson, J.G. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the- art.Depression and Anxiety, 26, 888-901. Clarke, H., Kirkham, K., Orser, B., Katznelson, R., Mitsakakis, N., Ko, R., Snyman, A., & Ma, M. (2013). Gabapentin reduces preoperative anxiety and pain catastophizing in highly anxious patients prior to major surgery: A blinded randomized placebo-controlled trial. Canadian Journal of Anesthesia, 60, 432-443. Gonano, C., Latzke, D., Sabeti-Aschraf, M., Kettner, S., Chiari, A., Gustorff, B.,,, &, (2011). The axiolytic effet of pregabalin in outpatients undergoing minor orthopedic surgery. Journal of Psychopharmacology, 25(2), 249-253. Jordan, K., & Okifuji, A. (2011). Anxiety disorders:differential diagnosis an their relationship to chronic pain. Journal of Pain & Palliative Care Pharmacotherapy, 25, 231-245. doi: 10.3109/15360288.2011.596922 Judge, A., Arden, N., Cooper, C., Kassim, J., Carr, A., Field, R., Dieppe, P., &, (2012). redictors of outcomes of total knee replacement surgery.Rhematology, 51 (10), 1804-13. Masselin-Dubois, A., Attal, N., Fletcher, D., Jayr, C., Albi, A., Fermanian, J., Bouhassira, D., & Baudic, S. (2013). Are psychological preditors of chronic postsurgical pain dependant on the surgical model? a comparison of total knee arthroplasty and breast surgery for cancer. The Journal of Pain, 14(8), 854-864. National Institute for Health and Clinical Excellence, (2007).Anxiety:management of anxiety in adults in primary, secondary and community care (1-84629-400-2). London: Abba Litho Sales Limited. St. Marie, B. (2010). Core curriculum for pain management nursing. (2nd ed.). US: Kendall Hunt. Theunissen, M., Peters, M., Bruce, J., Gramke, H., Marcus, M.,,,,, &, (2012). Preoperative anxiety and catastrophizing: A systematic review and meta-analysis of the association with chronic postsurgical pain. Clinical Journal of Pain, 28(9), 819-841.