Strategies and Approaches for Education in Chronic PainBeth Brianna Hogans, M.S., M.D., Ph.D.

Associate Professor of Neurology

Dr. Hogans has no financial interests to disclose.

I have published a book on back pain for patients.

Reference may be made to off-label uses of medications in this presentation.

No pharma funding since 1998, although I like to prescribe medications, especially when safe and effective!

Learning objectivesAt the conclusion of this session, the participant will be able:

1. Discuss factors that contribute to effective education about pain

2. Describe strategies for educating patients about pain

3. Express perspectives on what they would like to incorporate in their own practice of educating patients about pain

Simple model

Target population

Content DesirableOutcomes

ProcessSetting

Educator Learner

Content

Extras

Real-life meets ProcessSetting

Educator Learner

Content

+ Extras

Tips• Try sketching – people enjoy seeing ideas ‘come to life’

• Engage your audience in putting the ideas together

• Add structure, show that you can work the framework

• Check for prior knowledge and understanding

• Start by asking questions

• Ask-tell-ask

• Avoid and eliminate extraneous material

• Use handouts to dig in to the details

Acute vs. Chronic painWhat are some of the differences between acute and chronic pain?

ACUTE PAIN CHRONIC PAIN

Short duration: hours or days Long duration: e.g. longer than expected for healing; 3 months

Cause is usually clear cut Cause may or may not be clear

Effects on behavior are usually obvious and easy to recognize

Effects on behavior can be subtle and hard to understand

Treatments are highly effective, depending on access

‘Meds’ only partially effective, multiple approaches needed

Side effects of treatment, although problematic, can be tolerated for short periods

Side effects of treatment become harder to tolerate over time and interfere with normal function

Three types of pain

NOCICEPTIVE: ‘normal’ pain sensing in response to threats in the environment; sharp

INFLAMMATORY: increased pain sensing that raises sensitivity to normal levels of pressure and activity; aching

NEUROPATHIC: abnormal pain in response to things that normally ‘do’ and ‘don’t’ hurt; burning, zinging, tingling.

PAIN

Poor sleep

Socialwithdrawal

Reduced activity

Low function

How chronic pain spirals out of control

Types of pain treatments

PAIN

Sleep ‘tune-up’

Physical therapy

Ergonomic adaptation

Conditioning

SleepProductivity

OPIOIDS

Psychological support Acupuncture,

MassageNatural defenses

Skillful living

‘Neuro-active’ medications

Pain Resistance

Injections, proceduresFocal treatment

How we evaluate pain treatments

Risks Benefits

Costs + Barriers Side effects

Types of pain medicationsNSAIDS and STEROIDS

NEURO-ACTIVE: ANTI-DEPRESS.

NEURO-ACTIVE: ANTI-CONVUL.

OPIOIDS NEURO-ACTIVE: LOCAL ANESTH. AND OTHERS

Ibuprofen, Naproxen, Etodolac, Ketorolac, etc.

Nortriptyline, amitriptyline; venlafaxine, duloxetine, etc.

Gabapentin, pregabalin, carbemazepine, topiramate, etc.

Morphine, oxycodone, codeine,Fentanyl, etc.

Lidocaine, AcetaminophenTramadol, Musc. relaxants

Work especially well for inflammatory pain but also good for mild-moderate nociceptive pain

Take time to start working but quite effective and generally safe for long-term use

Work especially well for neuropathic (nerve) pain, work well together with other agents

Work well for short periods, but effect wears off quickly and potency declines with use

Work through various pathways, often used alone or in combination with other medications

NSAIDs: GI bleeding, renalSteroids: not for long term use

Some may increase suicide risk, need to monitor use

May increase dizziness, impair thinking

Very dangerous: many deaths each year

Side effects vary but should be reported if suspected

As needed and limited courses

Must take daily for drug to work

Recommended for daily dosing

Not ideal for daily use

Dosing varies with drug

Why do drugs in the morphine family stop relieving pain over time?

Morphine

Receptor for morphine

Once the receptor for morphine binds to the drug, it is targeted for destruction. The drug then has nowhere to ‘bind’ and stops working.

‘Pain Cell’

Disposal

Potentially harmful Passive

Ineffective

Safe Self-directed

Effective

Bridge therapies

Pain killersInjections

Cycle of dependence

MassageAcupuncture

Manual therapy

MovementBreathing

PacingErgonomics

Independence

Biopsychosocial model of painadapted from Loeser

Perception(pain awareness)

Suffering

Behavior

Nociception(pain generator)

Biopsychosocial model of pain - modifiedModified to show normative function of the pain system

Perception

Nociception(pain generator)

Suffering

Event, e.g., Trauma, surgery, procedure, dressing change

Perception, in basal state, mirrors nociception

Suffering is proportional to perception

Behavior

Behavior reflects nociception and facilitates social communication of threat

T

Biopsychosocial model of painHow psychosocial factors can make pain amplified, chronic, and

difficult to diagnose and manage

Perception is heightened

Suffering

Nociception(pain generator)

Suffering is magnified Behavior is

exaggerated and difficult to manage

minor trauma

state variables, e.g., fear, hyper-vigilance

Cognitive/affective factors, e.g. depressed mood

Social factors, e.g., poor social support

InflammatoryPain Nociceptive

Pain

Neuropathic Pain

1. Diagnosis with reasonable differential

Peripheralneuropathy

Abscess Osteoarthritis

RadiculopathySpinal stenosis

Surgical pain

NSAIDs/Acetaminophen

Opioids

How do we design a pharmacological regimen?

Neuromodulating: gabapentinoidsNeuromodulating:

anti-depressants

Inflammatory Nociceptive

Neuropathic

Local anesthetics

Conclusions1. What factors do you think contribute to effective education about pain?

2. What strategies are you most likely to adopt in educating patients about pain?

3. After the conference today, what new elements would you like to incorporate into your own practice of educating patients about pain?

Thank you

Thanks to: Judy Watt-Watson, Pat Thomas, John Griffin, VA colleagues, the Johns Hopkins Pain Curriculum Development Team, and my patients!

https://www.youtube.com/watch?v=L_pY7cTDygs

BB@jhmi.edu

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