1 Understanding Pain William P. Wattles, Ph.D. Francis Marion UniversityPsy 314 Behavioral Medicine

2

3 Primary Prevention AdvantagesSaves money Saves suffering and lost time from life More effective than repairing the damage Little potential for harm Maintains quality of life

4 Health Care Spending Exhibit 1 Total Health Expenditure per Capita, U.S. and Selected Countries, 2008

5 Facebook-Delaware/Lehigh Trail

6

7

8 What is pain? Simply put, pain is usually nature’s unpleasant way of telling you that a part of your body needs your immediate attention, or that you’re using parts of your body beyond their limits.

9 What Is Pain? Clinical PainPain that requires some form of medical treatment Most people experience an average of 3 to 4 different kinds of pain each year Pain is the most common reason people seek medical treatment Annual costs may reach $100 billion

10 Is pain good or bad?

11 Acute versus chronic painAcute pain is ordinarily beneficial: it warns that something is wrong. Chronic pain never has a biological benefit.

12 40 Million Americans suffer from chronic pain such as:Lower back problems Arthritis Cancer Repetitive stress injuries Migraine headaches

13 What percent of Americans suffer chronic pain?5% 13% 30% 50% 80%

14 What percent of Americans suffer chronic pain?5% 13% 30% 50% 80%

15 What is the current population of America?58 million 118 million 158 million 318 million 1 billion

16 Subdivisions of the vertebrate nervous systemCentral Nervous System Brain Spinal Cord Peripheral Nervous System All neurons outside the brain and spinal cord are part of the peripheral nervous system 4

17 Peripheral Nervous SystemSomatic nervous System Sensory Neurons (afferent) Motor Neurons (efferent) Autonomic Nervous System Sympathetic division Parasympathetic division 4

18 The Meaning of Pain Pain sometimes thought to be a direct consequence of physical injury.

19 Specificity Theory of PainSpecific pain fibers and pathways exist Pain = tissue damage

20 Nociception is the sensation of pain in normal people

21 The perception of pain Not a direct relationship between tissue damage and the perception of pain. Personal perception mediates the experience of pain.

22 Suffering An affective or emotional response triggered by a nociceptive-pain event or some other aversive stimulus.

23

24 nociception Pain =/= =/=

25 Gate Control Theory Injury without pain.Pain without injury (phantom limb) Pain components sensory motivational emotional

26 The Gate Control Theory of Pain

27 Nociception Nociceptive Of, causing or reacting to pain.Definitions of pain in terms of tissue damage relay on known physiology of the body’s pain sensors (free nerve endings called nociceptors) and neural transmission of pain signals to the CNS, a process called nociception.

28 Pain chemistry Prostaglandins, chemicals released by damaged tissue and involved in inflammation. Pain is produced by neurons that must be energized via neurotransmitters.

29 The Physiology of Pain Unlike other senses, pain is not triggered by only one type of stimulus, nor does it have a single type of receptor Free Nerve Endings — sensory receptors found throughout the body that respond to temperature, pressure, and painful stimuli Nociceptor — a specialized neuron that responds to painful stimuli

30 The Physiology of Pain Fast Nerve Fibers Slow Nerve FibersLarge, myelinated nerve fibers that transmit sharp, stinging pain Slow Nerve Fibers Small, unmyelinated nerve fibers that carry dull, aching pain

31 Pain Pathways

32 Measuring Pain There are no objective measures of pain.

33 Measuring Pain Psychophysiological MeasuresPsyche (mind) – physike (body) Electromyography (EMG) — assess the amount of muscle tension experienced by pain sufferers Indicators of autonomic arousal — using measures of heart rate, breathing rate, blood pressure, etc

34 Measuring Pain Behavioral Measures Pain Behavior ScaleTarget behaviors include vocal complaints, facial grimaces, awkward postures, mobility

35 Measuring Pain Self-Report MeasuresStructured interviews (When did the pain start? How has it progressed?) Pain rating scales (numerical ratings or a pain diary) Standardized pain inventories McGill Pain Questionnaire (MPQ): sensory quality, affective quality, evaluative quality of pain Pain Anxiety Symptoms Scale (PASS)

36 Stages of pain Acute pain. adaptive lasts less than six months.Prechronic pain. critical period to overcome pain. Chronic pain endures beyond the time of healing.

37 Chronic Pain Chronic recurrent pain- episodicChronic intractable benign pain-always present but not always severe. Chronic progressive pain. Omnipresent Chronic pain frequently associated with psychopathology.

38 Headache 29 Million Americans suffer from sever, disabling headache18% of women and 7% of men report at least one migraine a year. 11

39 Muscle tension headacheCauses stress posture and muscle habits lack of flexibility lack of strength 13

40 Treating muscle-tension headacheDiaphragmatic breathing Progressive muscle relaxation Temperature and EMG biofeedback Without some behavioral and cognitive coping skills training this procedure may be palliative 14

41 Migraine headache Causes Stress Muscle tension Genetics DietWeather changes 15

42 Treating migraine headachesCaused by excessive vasoconstriction and vasodilatation. Thus, controlling blood flow via biofeedback training may be able to help. 16

43 17

44 Physical Treatment of painAnalgesic drugs relieve pain without loss of consciousness.

45 NSAIDs Nonsteroidal anti-inflammatory drugs.Act at the site of the injury rather than in the brain. Have anti-inflammatory properties Aspirin, Ibuprofen (Advil, Motrin)

46 Tylenol (acetaminophen)Acetaminophen has negligible anti-inflammatory activity, and is strictly speaking not an NSAID. The medicine in Tylenol is not an NSAID. It’s a pain reliever that works differently.

47 Aspirin Known since 500 B.C. Comes from bark of willow tree1899 Bayer began marketing aspirin acetylsalicylic acid

48 NSAID’s unlike opioids, they do not produce sedation, respiratory depression, or addiction. They work by inhibiting an enzyme that helps produce prostaglandins.

49 Aspirin The most popular uses of aspirin are for:prevention of heart disease (37.6 percent), arthritis (23.3 percent), headache (13.8 percent), body ache (12.2 percent) and other pain uses (14.1 percent).

50 Pain treatment Opiate drugs block pain by occupying the sites where the neurotransmitters would attach. No other type of drug produces more complete pain relief. Potential for addiction. Oxycodone (Oxycontin) Hydrocodone (Vicodin) Morphine, Codeine,

51 Endorphins Endorphins (endogenous morphine) naturally occurring neurochemical which work like opiates.

52 Chronic Pain Pain is subjective Secondary gains can be considerablePain difficult to measure Many may be malingering Others may be “faking” unintentionally 18

53 Malingering Feigning illness or other incapacity in order to avoid duty or work

54 “Faking” unitentionally

55 Signal Detection TheoryThreshold is that point at which we can detect the signal. Below that we don’t detect it above that we do. It turns out that motivation plays a roll in what we detect. 19

56 100% Percent detect 0% weak Strength of Sensation Strong

57 100% Percent detect 0% weak Strength of Sensation Strong

58 Signal Detection Theory20

59 Sociocultural FactorsCulture and Ethnicity Groups differ greatly in their response to pain Through social learning, groups establish norms for the degree to which suffering should be openly expressed and the form that pain behaviors should take Pain tolerance versus pain threshold

60 A Pain-Prone Personality?Acute and chronic pain sufferers show elevated scores on two MMPI scales: Hysteria (tendency to exaggerate symptoms and use emotional behavior to solve problems) Hypochondriasis (tendency to be overly concerned about health and to overreport body symptoms) Chronic pain sufferers also score high in depression

61 A Pain-Prone Personality?Placebo responsiveness may be a situational trait rather than a dispositional trait No consistent personality differences in placebo responders and nonresponders

62 Types of Pain Patients (Turk & Nash)Dysfunctional patients report high levels of pain, feel they have little control over their lives, and are extremely inactive Interpersonally distressed patients perceive little social support and feel other people in their lives don’t take their pain seriously Adaptive copers report lower levels of pain and distress and continue to function at a high level

63 Operant conditioning Behavior Consequence Behavior tends to decreaseGo to the doctor Consequence Pain of a shot added Behavior tends to decrease

64 Generous sick leave Two and a half years later, she is still on government-paid sick leave, resting at her comfortable home.

65 with breaks for stretching drills in her living room, restorative walks through pine woods and the occasional round of golf.

66 Malingering 62 percent of the employees interviewed said they had taken sick leave when they were not really sick and that they felt there was nothing wrong in doing so.

67 Doctor’s excuse physicians routinely approve sick leaves solely at a patient's request. "It takes 30 seconds to write a doctor's note, It can take an hour to convince someone that he is ready to go back to work, and meanwhile your waiting room is filling up."

68 Correlation In 1998, the government's benefit increased from 75 percent to 80 percent of salary, and the average number of days spiked upward each year thereafter, from 11.1 in 1997 to 24.4 in 2001.

69 Employees get time off when they want itEmployers gain a way of moving underperforming workers The government can claim one of the lowest rates of unemployment

70 Pill Mill https://www.youtube.com/watch?v=c0Dw1ZPKFIkhttps://www.youtube.com/watch?v=-sGbSN_bIKk

71 Somatoform Symptom DisorderOne or more somatic symptoms. Excessive thoughts related to symptoms Persistent (more than six months) Specify if with predominant pain

72 The End

73 Vioxx Approved in 1999 for the treatment of acute pain and chronic pain from arthritis and other problems.

74 VIOXX the Science “Merck has always believed that prospective, randomized, controlled clinical trials are the best way to evaluate the safety of medicines.” Prospective Randomized Controlled

75 VIOXX the Science Risk of heart attack, stroke and blood clots after 18 months. VIOXX 15 per thousand Placebo 7.5 per thousand “Although the absolute risk may be rather small, the relative risk is high. “

76 VIOXX the market “Marginal efficiency, heightened risk, excessive cost.” Vioxx provides about the same relief as aspirin though patients are less likely to develop ulcers or gastrointestinal bleeding. Traditional NSAIDs work by nonselectively blocking the cyclooxygenase (COX) pathway, inhibiting prostaglandin production. By not inhibiting COX-1 at therapeutic blood levels, the COX-2--specific inhibitors avoid causing GI damage.

77 VIOXX

78 Cox-2 inhibitor Aspirin blocks the production of prostaglandins, key hormones that are used to carry local messages. Cyclooxygenase (cox-1, cox-2) performs the first step in the creation of prostaglandins

79 VIOXX Private enterprise Capitalism

80 Vioxx

81 VIOXX advertising In the first 6 months of this year alone Merck spent $45 million advertising Vioxx. “Terrifying testimony to the power of marketing.”