Psych interventions in pain control Flashcards
Multidimensional model of pain in terminal illness
- Interaction of cognitive, emotional, and socioenvionmental factors with nociceptive aspects of pain
Nociception interfaces with:
- Cognition (meaning of the pain)
- Emotion (suffering associated with the pain, loss, etc.)
- Socioenvironmental aspects (social support, etc.)
Somatic therapies can be used to treat the nociceptive aspects of pain, while psychosocial therapies can target cognition, emotion, and socioenvironmental aspects
Psychological factors in the experience of pain
- Women with metastatic breast cancer experience more intense pain if they were depressed and believed the pain represented the cancer spreading
- in ambulatory patients with AIDS, pain associated with depression, functional impairment, disability, and negative pain-related thoughts were associated with greater pain intensity and disability
Higher levels of pain linked to:
- impaired ADLs
- Experience of unpredictable painful episodes
- Negative thoughts about personal or social competence
- Cognitions about the cause of pain
- Greater anxiety or depressed mood
- Existential concerns (fear of future)
Addressing psychological factors is essential to pain management, though medical options for pain control must be explored first with pain control considered a pre-requisite to the assessment and management of other sources of distress.
Variables that affect pain-related quality of life
- Physical well-being
- Psycholgoical wellbeing
- Interpersonal well being
Psychiatric disorders and pain
- Psychiatric disorders are associated with chronic pain in cancer patients
- Most commonly, adjustment disorders, depression, or anxiety
- Advanced disease itself is associated with high prevalence of depression and delirium
Pain and suicide
- Uncontrolled pain is a major factor in suicide and suicidal ideation in the medically ill patients
- Relatively few cancer patients commit suicide, but the are at increased risk
- Suicidal thoughts may be relatively common in advanced illness (“If it gets to bad, there is a way out”), though persistent suicidal thoughts are likely infrequent
- Pain associated with desire for hastened death, particularly when associated with depression and hopelessness
Inadequate pain management
Studies suggest:
- Cancer pain is under treated
- Pain is AIDS is dramatically under treated
- Under treatment may be more likely in women, lower levels of education, history of substance abuse, or those who express patient-related barriers to opioid treatment
- Adjuvant agents (such as antidepressants) underutilised
Causes of inadequate pain management
- Inability to assess pain in all dimensions
- Psychological variables may be ignored
- Psychological variables may be used to explain pain when medical variables have not been adequately addressed
- Lack of physician knowledge re: pharmacologic interventions
- Focus on prolonging life rather than symptom management
- Poor communication between doctor and patient
- Physician anxiety around opioid medications, abuse, diversion, or toxicity
- Limited expectations of patients in achieving pain relief
- Overestimation of opioid risks
Impact of high intensity pain on communication
- Team members may struggle to empathize with high intensity pain
- Clinician ability to assess level of pain becomes unreliable after pain is >7
Impact of active drug use on pain management
Compromised pain management by:
- High tolerance to opioid analgesics
- Drug seeking and manipulative behaviour
- Lack of adherence
- Lack of reliable patient history
- Risk of spreading blood borne infections (e.g. HIV)
Undertreatment is a risk when clinicians expect patients to lie as part of drug-seeking behaviour.
In the context of a terminal stages of illness, appropriate for a clinician to err on the side of believing a patient when they complain of pain and presenting a bias toward treatment, unless there is clear evidence of diversion or self-destructive behaviours.
Psychotherapy for Pain
Goals:
1. Support (provide continuity and supportive care with crisis intervention)
- Knowledge - provide information to both patient and family
- Skills - relaxation, cognitive coping, communication, use of analgesics. Can take the form of group therapy where patients can share experiences and identify helpful coping strategies
Short term supportive psychotherapy for pain
- Focussed on the crisis created by the medical illness
- Therapist provides support, continuity, information, and assists in adaptation
- Focus on emphasising past strengths, supporting previously successful coping strategies, and teaching new coping skills (relaxation training, CBT approaches, self-monitoring, assertiveness, communication skills)
- Provides an opportunity for patients to talk openly about life and experiences, but also to talk or ask questions about death or pain and suffering
Psychotherapy in advanced illness
- Loss of cognitive function or speech deficits may make pyschotherapy challenging
- Support may shift to the family to help balance pain control with sedation, family dynamics around appropriate treatment, and work related to bereavement can begin
Group psychotherapy for advanced illness
May include individual patients, spouses, couples, or family
Goals:
- Share experiences
- Identify successful coping strategies
Limitations:
- Patient physically comfortable enough to participate
- Cognitive capacity to participate
Cognitive Behavioural Techniques for patients with pain
- Psychoeducation
- Preparatory information
- Self monitoring (may include development of a pain journal to identify provoking/palliative factors, etc.) - Relaxation
- Passive breathing
- Progressive muscle relaxation - Distraction
- Focussing
- Mental imagery
- Cognitive distraction
- Behavioural distraction - Combined techniques
- Passive breathing/PMR with mental imagery
- Systematic desensitization
- Meditation
- Hypnosis
- Biofeedback
- Music therapy - Cognitive therapies
- Cognitive distortion
- Cognitive restructuring - Behavioural therapies
- Modelling
- Graded task management
- Contingency management
Behavioural rehearsal
Behavioural therapy for pain
- Use of techniques from experimental analysis of behaviours
Examples:
- Learning and conditioning for the evaluation, prevention, and treatment of physical disease or physiological dysfunction
- e.g. tracking with a pain journal to understand and modify triggers, enhancing behaviours that provide relief or better sense of wellbeing
Cognitive therapy for pain
- A focused intervention targeted at changing maladaptive beliefs and dysfunctional attitudes
- Therapist engages with the patient in a process of collaboration, where underlying beliefs are challenged and corrected
- E.g. targetting automatic thoughts that may worsen the pain experience, like “The intensity of my pain will never diminish.” “I cannot control my pain.” Patients might be taught to identify and interrupt these thoughts with more productive and empowering views
Operant pain - definition
Notion that there are two types of pain behaviour - operant and respondent.
Operant pain behaviours result from operant learning or conditioning. Leads to pain behaviour being reinforced and amplified or continuing because of secondary gain (e.g. increased attention and caring). May evolve to be independent from respondent pain.
E.g. Pain related to cancer is initially respondent, but then may gain an operant component as the patient finds there is secondary gain from the shift in attitude of their family members.
Respondent pain - definition
Notion that there are two types of pain behaviour - operant and respondent.
Respondent pain behaviours result from respondent learning or conditioning. Stimuli associated with prior painful experiences may elicit increased pain and avoidance behaviour.
Often Pavlovian or ‘reflex’ behaviour - e.g. seeing a needle immediately evokes a response. Or - a physiologic response (e.g. pain from bony mets).
Cognitive restructuring for pain
- Redefinition of some or all aspects of the patient’s interpretation of pain
- Negative thoughts about pain can be significantly related to pain intensity, degree of psychological distress, and level of interference in functional activities
Requires:
- Identification of dysfunctional automatic thoughts and underlying beliefs (e.g. I cannot control or improve my pain)
- Challenging these dysfunctional thoughts (e.g. Am I able to take medication that controls the pain? Am I able to alter my activities to mitigate the impact of this pain?)
- Identifying them as they happen and interrupt such thoughts with a more appropriate view (e.g. My pain might be intense now, but I can take my medication to help control it and there will be relief)
Self-monitoring techniques for pain
- Pain diary
- Written (or audiotaped) chronicle that describes specific agreed upon characteristics associated with pain
- Allows physicians to gauge impact of interventions and trajectory of pain over time
- Allows patients to see common triggers or palliating factors
- Provides foundation for more effective management, particularly in the identification of incident pain (pre-medication!), modification of certain activities to better manage pain, and titrating of medication
May also be used in conjunction with cognitive restructuring (e.g. tracking automatic thoughts associated with pain)
Contingency management for pain
Focussing the patient and family responses that either reinforce or inhibit specific behaviours exhibited by the patient.
Method involves reinforcing desired ‘well’ behaviours - e.g. graded exercise, as opposed to treating nociceptive pain.
- Suspect not appropriate for most of our patients - used more commonly in addictions medicine or with patients whose pain behaviour is related to operant behaviour (e.g. secondary gain associated with pain).
- Poor evidence on lit search
Grade task assignments for pain
Creation of a hierarchy of tasks (e.g. physical, cognitive, and behavioural) which are broken down and performed sequentially in more manageable steps to achieve an identified goal
- Useful for patients whose pain creates a sense of overwhelm or difficulty executing/completing tasks
Systematic desensitization for pain
Relaxation and distraction exercises paired with a hierarchy of anxiety-arousing stimuli presented through mental imagery or presented in vivo, resulting in control of fear
- Essentially exposure therapy. Provides patients with tools and empowerment that allows them to better manage anticipatory anxiety that may lead to avoidant behaviours.
Patient selection for CBT interventions for pain
Consider:
- Intensity of the pain
- Mental clarity of the patients
- Level of rapport with patient
Ideal candidates:
- Mild to moderate pain at baseline, or due to effective pharm management
- Capacity to engage in therapy (minimal confusion)
Barriers to CBT interventions
Patient
- Lack of trust or confidence in techniques or physician
- Fear of judgment from physician (e.g. do they think the pain is all in my head)
Physician/practitioner
- Discomfort with therapies
- Greater complexity than pharmacologic interventions
- Doubt around effectiveness for patients
Practical approach to implementing CBT techniques with patients
- Assess the symptoms
- Are CBT interventions appropriate
- Pain history and impact on the patient/family - Identify appropriate behavioural strategies
- Appropriate strategies for the behaviour/experience
- Appropriateness for the patient - Prepare the patient and the setting
Progressive muscle relaxation for pain
- Progressive and active tensing and relaxing of various muscle groups in the body
- Focus upon the sensation of tensing and relaxing
Poor evidence for pain, but studies suggest can reduce some pain scores and more clearly has a positive effect on anxiety.
Resources for relaxation techniques with patients
Scripts are available for:
- Passive relaxation (focussed breathing)
- Progressive muscle relaxation (Anxiety BC has good resources)
- Guided imagery (typically, have the patient describe a ‘safe space’ in great detail to the clinician, with the clinician then guiding the patient in engaging experientially with the imagined scene - eg. feel the wind on your face)
Hypnosis for pain management
Definition: “A state of inner absorption, concentration, and focussed attention” that may be used to manipulate the perception of pain
- 1/3 of patients are not ‘hypnotizable’
Three principals:
- Use self-hypnosis
- Relax, do not fight the pain
- Use a ‘mental filter’ to ease the pain. E.g. patients may be able to alter sensations in a painful area
1996 review of evidence found that relaxation and hypnosis are effective in reducing chronic pain
Biofeedback for pain management
- Behavioural therapy
- Teaches patients to gain awareness and control over physiological functions
E.g. use of a pulse oximeter as ‘feedback’ for the patient to alter thinking, emotions, and behaviours with support to achieve the desired physiologic changes
Good evidence in anxiety management, which may help some patients with chronic pain
Music, aroma, and art therapies for pain management
Music
- Enhances well-being, reduces stress, distracts patients from unpleasant symptoms
- Exerts direct physiologic effects through the autonomic nervous system
- May result in decreased need for pain medicine (evidence mixed)
Aromatherapy
- Evidence is limited
Art therapy
- May enhance overall sense of well-being and decrease fear, anxiety, stress, and pain
- May be a vehicle to explore issues relating to loss of control, helplessness, and hopelessness
- Particularly useful for children or less verbally skilled adults
SSRIs for pain
- First line for depression, anxiety, eating disorders
- More tolerable than other agents (on initiation, may have some GI side effects, some may find sexual side effects or increased anxiety)
- May help to manage mood symptoms in palliative patients, but limited evidence to support any one agent
- Not preferred when the primary goal is for pain management, but useful for anxiety/depression in patients with longer prognosis
SNRIs for pain
- Inhibit reuptake of serotonin AND norepi (similar to TCAs)
- Include venlafaxine and duloextine
- Good evidence for analgesic efficacy (especially duloxetine)
- Large studies lacking for advanced cancer, but smaller studies for efficacy in tx of neuropathic syndromes following chemo and surgery for cancer
TCAs for pain
- Inhibit reuptake of serotonin and norepi
- Variability according to agent of potency at each site and affinity at receptor sites
Tertiary amines (amitriptyline and imipramine) - More side effects, especially anticholinergic
Secondary amines (nortriptyline, desipramine)
SNRIs are generally preferred given better side effect profile, but substantial evidence for primary analgesic effects for diverse painful conditions. Limited evidence for advanced illness specifically.
MAOIs for pain
- Typically only used for refractory depression
- Significant side effects (orthostatic hypotension) and interactions (with serotonergic agents and potential for hypertensive crisis with certain meds or foods containing tyramine)
No evidence to support their use for pain
Mirtazapine for pain
- Antagonist at presynaptic alpha2 receptors on noradrenergic neurons
- Enhances appetite and promotes sedation at lower doses
- May reduce nausea
- Little evidence to use it for pain
Bupropion for pain
- Enhances effects of norepi and dopamine
- Indications for depression, smoking cessation, ADHD
- Activating, well tolerated, less sexual dysfunction
- Lowers seizure threshold
- Little evidence for analgesic efficacy
Trazodone for pain
- Serotonin antagonist
- Indications for the treatment of depression and anxiety, but typically relegated to the treatment of insomnia due to tendency to cause sedation
- Little evidence to support its use for pain management
Antiepileptics for neuropathic pain
- Gabapentinoids are considered first line agents for neuropathic pain
Anxiolytics for pain
- Clonazepam is the only anxiolytic used commonly for pain
- Limited evidence of efficacy
- Consider for circumstances in which anxiety complicates significant neuropathic pain
Antipsychotics for pain
- No significant support for their use in treatment of pain, with the exception of methotrimeprazine
- Methotrimeprazine may be useful as an adjuvant (weak evidence)
