Pain

Physiology of Pain
Nociceptors
Stimulus

Transmission
Termination
Modulation

Physiology of Pain
Multiple
Redundant
Reciprocal
Complex

Assessment of Pain
Immediate

Pain
Physical Functioning
Psychological Factors
Pain Behaviors
Objective Correlates

Assessment: Immediate Pain

Intensity
Location
Affective

Response
Composite Measures

Assessment: Physical Fx.

Impairment
Functional
Disability

limitation

Assessment: Psych factors

Influence

vs. causation
Mediation
Reinforcement
Resonators
Pain beliefs

Assessment: Pain Behavior

Observation
Role

of learning

Composite Pain Scales

Attempt

to measure one or more

dimensions of the pain experience

Histor
y
Qualit
y
Objectiv
e Data

Intensit
y
Comor
bid
Side
effects

Assessment: Objective Indicators

Ex.

Electromyography

Well, Phil, after years of vague

complaints and imaginary ailments, we
finally have something to work with.

Diagnosis
Categorization
DSM

and Pain
Other Approaches to Somatoform Pain

Categorization
Acute

versus Chronic

Acute Pain
Not

just time
Clearer association
Subtypes

(ex. Recurrent?)

nociceptive

pain

Chronic
Association?
Types
By

presumed etiology

Neurologic
Ideopathic

By

course

pain

DSM-IV
The concept of Somatoform Pain

DSM and pain

I

(1952)

Psychophysiological

disorders
Psychoneurotic Disorders
II

(1968)

Hysterical

neurosis

DSM and pain

III

(1980)

Psychogenic

Pain

incompatible

or INXS
Etiologically related
III-R

(1987)

Somatoform

pain
Dropped etiology part

DSM and pain

IV
Pain

Disorder

Pain=predominant

focus
Substantial distress/impairment
Psych factors have role
Onset

Not

or expression

malingering/factitious disorder

Problems with DSM

Utility
How

to judge?

Physical

versus
Psychological
Etiology
DSM-IV
Mind-body

dichotomy

remains
Division of pain based
on this.

True psychogenic pain

DSM-IV pain tested

Psychological

vs. Psychological+Medical

Distinction
No

difference on

Pain

measures
Intensity
Type
Level of disability

(Aigner et al, Compr Psychiatry 1999)

Other approaches to diagnosing

pain

IASP
5 axis system
I.
II.
III.
IV.
V.

Anatomical region
Organ system
Temporal characteristics/patterns
Intensity, time since onset
Etiology

IASP
Psychological
Pain

pain

specifically attributable to the thought

process, motional state, or personality of the
patient in the absence of an organic or
delusional cause or tension mechanism.

Other approaches
Dimensional
Take

into account various aspects of pain

Objective

findings/physical etiology
Perceptual influences
Presentation

Treatment of Pain

Treatment of Pain
Pharmacologic
Psychological
Other

somatic treatments
Importance of Multimodal
Cormorbid treatments
Role of C/L Psychiatrist

Pharmacological Treatment
True Analgesics
Everything

Else

Yes Billy, but Mr. Phillips pushes legal drugs.

True Analgesic
NSAIDS
Opioids
Local

agents

NSAIDS
Mechanism
Indication
Side

effects

NSAIDS
Standard
Acetaminophen
Ketorolac
COX-2

inhibitors

Opioids
Mechanism

of action

Indication
Side

effects

Common
Uncommon

but problematic

Some Typical Opioids

Oral

Paren

Morphine

Propoxyphene (Darvon)

Hydromorphone (Dilaudid)

Meperidine (Demerol)

Methadone

Oxymorphone (Numorphan)

Tran

Fentanyl (Duragesic, Actiq)

Oxycodone (Percoset, Oxy--)

Combination Opioid/NSAIDs
Narcotic

+Acet

Dihydrocodone

DHC plus*

Propoxyphene

Darvocet,
Wyegesic

Codeine

Tylenol w/ Codeine #2- Fiorinal*

4, Fiorecet*

Hydrocodone

Vicodin, Hydrocet,
Lorcet, Lortab, Zydone

Oxycodone

Percocet, Tylox

Pentazocine

Talacen

*caffeine

butalbital

agonist-antagonist

+ASA

+Ibu

Vicoprofen
Percodan

Relative Potency

Treatment Approach

Treatment Approach
MEC
Role

of pharmacokinetic

Toxicity
Slow-release

preps

Concerns
Tolerance
Dependence
Addiction

Overvalued Concerns
Addication
Overdose

and death

Discipline

Damn! I suppose this means

another malpractice suit.!

Adjunctive and other meds

Antidepressant

Benzodiazepines

Anticonvulsants

Stimulants

Local Analgesics

Cannabinoids

Antihistamines

Placebos

Antipsychotics

Nonsurgical treatments
Cutaneous

Stimulation
Electrical Stimulation
Acupuncture
Exercise

Surgical Treatments
Neural

Blockade
Surgical lesions
Limitations

Psychological Treatments
Psychoeducation
Hypnosis
Behavioral Treatments

Behav Txs
Relaxation
Biofeedback
CBT
Focus
Goals

Multidisciplinary Pain Treatment

Different

levels
Features included

Comorbid Problems
Depression
Anxiety

Problems of dual diagnosis

Role of Psychiatrist in Pain Mgmt

Role of C/L Psychiatrist in Pain

Eval
Problem

Patient
Drug Seeker
Just in their heads
Pain out of proportion