1. Slide 1 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. IAS–USA Glenn J. Treisman, MD, PhD Professor Director, AIDS Psychiatry Service The Johns Hopkins Medical Institutions Baltimore, MD Chronic Pain and The Drug-Seeking Patient A Behaviorist Approach From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.

2. Slide 2 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Pain 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

3. Slide 3 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. What do we mean by the term “Chronic Pain”? Chronic pain which is the result of ongoing acute injury – Pain which is provoked by ongoing chronic injurious process such as malignancy, tissue destruction or chronic infection Chronic pain which is the result of an adaptation of the nervous system to injury – Pain which continues when the original injury that provoked the initial pain has resolved

4. Slide 4 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Reinforcers of healing Life reinforces getting well – Social – Occupational – Romantic – Sexual – Financial – Self image

5. Slide 5 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Abnormal illness behavior The patient is not entitled to the sick role he expects The patient continues his expectation despite being told it is inappropriate – Issy Pilowsky

6. Slide 6 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Examples of reinforcers in abnormal illness behavior Positive reinforcers – Disability payments – Attention from spouses, family, doctors, lawyers – Ability to express prohibited feelings – Possibility of “lump sum” payments Negative reinforcers – Relief from stress, expectations and criticism – Relief from pain and discomfort

7. Slide 7 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. What makes patients seek narcotics when they are not helping? Conditioning Relief from distress in life Transient relief from pain Addiction

8. Slide 8 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Addiction BehaviorReward Depression Inflammation and cytokines Sympathetic activation and stress Decreased reward sensitivity Increase in stimulus seeking Decreased self preservation Day-night cycle disruption HIV and HEP C Chronic disease HIV and Hep C Lipids

9. Slide 9 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Simplified model of temperament Percent of population Introversion Punishment avoidant Future directed Function directed Extraversion Reward directed Present directed Feeling directed

10. Slide 10 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Goals of behavioral therapy Not directed at elimination of pain per se Pain may diminish because of reconditioning and rehabilitation Improve function Improve quality of life Decrease iatrogenic morbidity

11. Slide 11 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Behavioral approach to chronic pain treatment Develop a behaviorally based plan for rehabilitation that includes a set of rewards and consequences Use cognitive-behavioral therapy to change behavior Treat psychiatric co-morbidity

12. Slide 12 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Role induction Describe the role of the doctor and the patient Explanation of the diagnosis and goals of treatment Firm limits combined with advocacy Focus on problems in the patient’s life Focus on behavior and rehabilitation and away from feelings

13. Slide 13 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Target behaviors for pain treatment Time-contingent medications (and taper) Graded activation (exercise) Social reinforcement (spouse) Self control skills – Self monitoring – Self reinforcement – Relaxation training

14. Slide 14 of 14 From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA. Treat psychiatric co-morbidity Depression Personality vulnerabilities Life experiences