1. PILL-FREE PAIN RELIEF PILL-FREE PAIN RELIEF Maryjo R. Gavin, Ph.D Rehabilitation Psychologist Sinai-Grace Hospital Functional Recovery Program April 30, 2011

2. DMC FRP Functional Recovery Program Maryjo Gavin Program Psychologist Maury Ellenberg Medical Director

3. INTRODUCTIONS Functional Recovery Program Interdisciplinary Rehabilitation Program Started in 1990 Designed to help individuals with chronic pain manage their condition and return to optimal physical functioning

4. Objectives Discuss the differences between acute and chronic pain Discuss the problems associated with the pharmacological management of pain Review alternative approaches to manage and possibly alleviate chronic pain

5. Review 70 million people suffer from some form of recurrent or chronic pain 25% of the population Two thirds of us will have an episode of back pain at some time in our lives

6. Elusive Nature of Pain Cannot be measured objectively Subjective, Psychological experience Influenced by many things Expectations Significance Emotions Context in which it is experienced

7. PAIN ACUTECHRONIC

8. Acute verses Chronic Pain Acute Pain Specific injury Tissue damage Self-limiting Ceases once healing occurs

9. Acute verses Chronic Pain Chronic Pain Lasts beyond six months Persists beyond the usual course of acute insult, injury or disease process Hurt does not equal harm

10. PAIN CYCLE PAIN inactivity reduced flexibility deconditioning loss of strength PHYSICAL CHANGES

11. PAIN CYCLE anxiety anger PAIN depression isolation EMOTIONAL STRESSORS

12. PAIN CYCLE conflict economic stress PAIN Can’t work Reduced support PSYCHOSOCIAL STRESSORS

13. PAIN CYCLE Psychosocial Stressors Physical Changes Emotional Stressors PAIN

14. OUCH!!!... MY LIFE HURTS

16. Pain Medications – OTC analgesics Acetaminophen (Tylenol, Tempra) NSAIDS nonsteroidal anti-inflammatory drugs Aspirin (Ancin, Bayer, Bufferin) Ibuprofen (Advil, Motrin) Ketoprofen (Actron, Orudis KT) Naproxen Sodium (Aleve)

17. Pain Medication - Others Antidepressants (Tricyclics, SSRI’s) Anticonvulsants (Lyrica, Neurontin) Muscle Relaxants (Flexeril, Skelaxin) Tranquilizers (Xanex, Valium) Sedatives (Ambien, Lunesta) Others for side effects

18. Pain Medications - Opioids hydrocodone (Vicodin) oxycodone (Percocet, Oxycontin) morphine (MSContin, Kadian, Avinza) codeine (Tylenol #3, #4) transdermal fentanyl (Duragesic patch) methadone (Dolophine) meperidine (Demerol)

19. Problems? Wrong Treatment Suppresses our own endorphin system Increased rates of prescription drug abuse particularly teens (2008 ONDCP report) Drug dependence Drug addiction Accidental deaths

20. Prescription Drugs- Celebrity Deaths 1962 Marilyn Monroe 36 1965 Dorothy Dandridge 42 1973 Howard Hughes 70 1977 Elvis Presley 42 1992 Judy Garland 47 2007 Anna Nicole Smith 39 2008 Heath Ledger 28 2009 Michael Jackson 50

21. Not Just Celebrities NCHS Data Brief Increase in Fatal Poisonings Involving Opioid Analgesics In the United States, 1999-2006 # of fatal poisonings tripled(4,000 to 13,800) Opioids involved in 40% of all poisoning deaths

22. Toledo Blade 04/24/2011 Ohio city targeted for drug intervention Portsmouth, Ohio once thrived on its reputation for shoes and steel. Now it’s at the heart of a county, state and federal fight to stem prescription drug abuse. In Ohio, fatal overdoses more then quadrupled in the past decade, surpassing car crashes as the leading cause of accidental death in the state.

23. FDA unveils plan to curb opioid prescription drug abuse Pharmaceutical Companies to Produce Educational Tools for Prescribers Information on Long Acting Opioids When and How to Prescribe, How to Recognize Signs of Abuse

24. SO HOW DO WE TREAT CHRONIC PAIN? Functional Restoration Cognitive Behavioral Therapy Wean off of opioids

25. PAIN CYCLE Psychosocial Stressors Physical Changes Emotional Stressors PAIN

26. Cognitive Behavioral Model A theoretical approach that acknowledges the importance of both cognitions and behaviors in the acquisition and maintenance of behavioral patterns

27. Cognitive – Behavioral Treatment Patient as active participant – self responsibility model Structured Time limited Goal oriented Functionally focused Increase coping skills

28. Cognitive/Affective/Behavioral Interaction THINK FEEL DO

29. Practical Suggestions for the Management of Chronic Pain The first step is admitting that what we are dealing with is a chronic problem. Take responsibility for it.

30. Serenity Prayer God, grant me the serenity to accept the things I can not change, the courage to change the things I can and the wisdom to know the difference.

31. Practical Suggestions for the Management of Chronic Pain Confront the Costs and Benefits

32. Exercise is Good Medicine Weight loss, weight maintenance Lower blood pressure Reduce risk of heart disease, diabetes Reduce, relieve pain Improve sleep Increase energy Improve mood Better sex

33. Practical Suggestions for the Management of Chronic Pain EXERCISE HURT vs HARM

34. Practical Suggestions for the Management of Chronic Pain EXERCISE Stretching Strengthening Aerobics Balance

35. Practical Suggestions for the Management of Chronic Pain LEARN TO RELAX Formal relaxation Leisure activities

36. Practical Suggestions for the Management of Chronic Pain MANAGE YOUR STRESS Set limits with others Become an optimist Manage your emotions

37. Practical Suggestions for the Management of Chronic Pain QUIT SMOKING

38. Practical Suggestions for the Management of Chronic Pain GET ACTIVE Set goals Pace your activity

39. Practical Suggestions for the Management of Chronic Pain MAINTAIN A SUPPORT SYSTEM Family, Friends, Neighbors Church, Community Groups Support Groups (ACPA) Volunteer

40. Practical Suggestions for the Management of Chronic Pain FOCUS ON PLEASANT ACTIVITIES The How of Happiness – Sonja Lyubomirsky

41. Practical Suggestions for the Management of Chronic Pain KEEP YOUR PROBLEMS IN PERSPECTIVE Focus on the positive and work on the things that are under your control Pain may be inevitable but suffering is optional

42. THANK YOU