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Slide 1 of 14
Chronic Pain and
The Drug-Seeking Patient
A Behaviorist Approach
Glenn J. Treisman, MD, PhD
Professor
Director, AIDS Psychiatry Service
The Johns Hopkins Medical Institutions
Baltimore, MD
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
IAS–USA
Slide 2 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 3 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 4 of 14
Reinforcers of healing
• Life reinforces getting well
– Social
– Occupational
– Romantic
– Sexual
– Financial
– Self image
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 5 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Examples of reinforcers in
abnormal illness behavior
Slide 6 of 14
• 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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 7 of 14
What makes patients seek narcotics
when they are not helping?
•
•
•
•
Conditioning
Relief from distress in life
Transient relief from pain
Addiction
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 8 of 14
Addiction
Behavior
Reward
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Chronic disease
HIV and Hep C
Lipids
Slide 9 of 14
Simplified model of temperament
Percent of
population
Introversion
Extraversion
Punishment avoidant
Future directed
Function directed
Reward directed
Present directed
Feeling directed
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 10 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 11 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 12 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 13 of 14
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
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.
Slide 14 of 14
Treat psychiatric co-morbidity
• Depression
• Personality vulnerabilities
• Life experiences
From GJ Treisman, MD, at San Francisco, Ca: March 29, 2013, IAS-USA.