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Pain PowerPoint Presentation

Pain

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Pain

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Presentation Transcript

  1. Pain

  2. Physiology of Pain • Nociceptors • Stimulus Transmission • Termination • Modulation

  3. Physiology of Pain • Multiple • Redundant • Reciprocal • Complex

  4. Assessment of Pain • Immediate Pain • Physical Functioning • Psychological Factors • Pain Behaviors • Objective Correlates

  5. Assessment: Immediate Pain • Intensity • Location • Affective Response • Composite Measures

  6. Assessment: Physical Fx. • Impairment • Functional limitation • Disability

  7. Assessment: Psych factors • Influence vs. causation • Mediation • Reinforcement • Resonators • Pain beliefs

  8. Assessment: Pain Behavior • Observation • Role of learning

  9. Composite Pain Scales • Attempt to measure one or more dimensions of the pain experience

  10. History Intensity Comorbid Quality Objective Data Side effects

  11. Assessment: Objective Indicators • Ex. Electromyography “Well, Phil, after years of vague complaints and imaginary ailments, we finally have something to work with.”

  12. Diagnosis • Categorization • DSM and Pain • Other Approaches to “Somatoform Pain”

  13. Categorization • Acute versus Chronic

  14. Acute Pain • Not just time • Clearer association • Subtypes (ex. Recurrent?) • “nociceptive pain”

  15. Chronic • Association? • Types • By presumed etiology • Neurologic pain • Ideopathic • By course

  16. DSM-IV The concept of Somatoform Pain

  17. DSM and pain • I (1952) • Psychophysiological disorders“ • “Psychoneurotic Disorders” • II (1968) • Hysterical neurosis

  18. DSM and pain • III (1980) • Psychogenic Pain • “incompatible” or “INXS” • Etiologically related • III-R (1987) • Somatoform pain • Dropped etiology part

  19. DSM and pain • IV • Pain Disorder • Pain=predominant focus • Substantial distress/impairment • Psych factors “have role” • Onset or expression • Not malingering/factitious disorder

  20. Problems with DSM • Utility • How to judge? • Physical versus Psychological • Etiology • DSM-IV • Mind-body dichotomy remains • Division of pain based on this.

  21. True psychogenic pain

  22. 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)

  23. Other approaches to diagnosing pain

  24. IASP 5 axis system • Anatomical region • Organ system • Temporal characteristics/patterns • Intensity, time since onset • Etiology

  25. 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.”

  26. Other approaches • Dimensional • Take into account various aspects of pain • Objective findings/physical etiology • Perceptual influences • Presentation

  27. Treatment of Pain

  28. Treatment of Pain • Pharmacologic • Psychological • Other somatic treatments • Importance of Multimodal • Cormorbid treatments • Role of C/L Psychiatrist

  29. Pharmacological Treatment • “True” Analgesics • Everything Else “Yes Billy, but Mr. Phillips pushes legal drugs.”

  30. “True” Analgesic • NSAIDS • Opioids • Local agents

  31. NSAIDS • Mechanism • Indication • Side effects

  32. NSAIDS • Standard • Acetaminophen • Ketorolac • COX-2 inhibitors

  33. Opioids • Mechanism of action • Indication • Side effects • Common • Uncommon but problematic

  34. Some Typical Opioids

  35. Combination Opioid/NSAIDs *caffeine † butalbital ‡agonist-antagonist

  36. Relative Potency

  37. Treatment Approach

  38. Treatment Approach • MEC • Role of pharmacokinetic • Toxicity • Slow-release preps

  39. Concerns • Tolerance • Dependence • Addiction

  40. Overvalued Concerns • Addication • Overdose and death • Discipline “Damn! I suppose this means another malpractice suit.!”

  41. Antidepressant Anticonvulsants Local Analgesics Antihistamines Antipsychotics Benzodiazepines Stimulants Cannabinoids Placebos Adjunctive and other meds