Mel Pohl MD Medical Director

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Mel Pohl MDMedical Director

• Chronic Pain and the Family

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Politics Involved in Chronic Pain Management

• Marketing campaigns from drug makers spent 30
  billion in 2005
• Retail sales of painkillers rose 90 between
  1997 and 2005
• Oxycontin sales rose 6 times between 1997 and
  2005
• ASAM 2007, 5 courses on pain management and
  only one was not about prescribing opiates

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Chronic Pain Patients and their Families Have in
Common

• Efforts to feel better ultimately lead to feeling
  worse
• Patients cling to lifestyles which cause misery
• Enabling is a critical component to both
• Misguided efforts of others to be helpful, makes
  the situation worse
• Both struggle over control
• The more helpless the patient feels, the more
  they struggle to control, to dominate, or to
  manipulate others

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Families

• Sick role works for both
• Drop the patient off fix them
• Trauma history recreate unhealthy family
  roles
• Fear of giving up family role SABOTAGE
• Who am I without his/her pain

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Pain vs. Suffering

• Pain (Biological)
• Tells us something is wrong
• Suffering (Psychological/Emotional)
• The brains interpretation of pain
• Stress, anxiety, and fear cause increase in
  pain perception

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Pain vs. Suffering

• The acute stimulus is not the problem
• The residual feelings are the problem
• Suffering describes ones feeling state

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When touched with a feeling of pain, the
ordinary uninstructed person sorrows, grieves,
and laments, beats his breast, becomes
distraught. So he feels two pains, physical and
mental. Just as if they were to shoot a man with
an arrow and, right afterward, were to shoot him
with another one, so that he would feel the pains
of two arrows
The Buddha
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SUFFERING PAIN x RESISTANCE
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Patient with Pain
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Patient with Pain
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Patient with Chronic Pain Behavior
Loeser
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Suffering in the Families of Chronic Pain Patients

• Their lives are controlled by someone elses
  illness
• Feel obligated to give, give, give and receive
  little
• Feel helpless and depressed, their own lives
  become unmanageable
• Family discord becomes a major source of stress
  for the pain patient
• What happens for the patient happens for the
  family

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Similarities Between Pain and HIV Caregivers

• Helper-helplessness syndrome
• Burnout
• Bereavement overload
• I didnt sign up for this
• I want/need to help and I cant

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Pain Caregiver Required to

• Scientist/doctor
• Insurance expert
• Financier breadwinner
• Patient advocate
• Educator of others run interference
• Grief counselor
• Life-Sexual Partner

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Seddon Savage, M.D.
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Sleep Disturbance
Secondary Discomforts
Drug Dependence
Addiction
Pain
Functional Disability
Depression
Anxiety
Increased Stresses
Seddon Savage, M.D.
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Chronic Pain Treatment Obstacles

• Unbelievable denial shared by patient and
  family
• I never do drugs only medicine which is
  prescribed by my doctor
• Hes not an addict he has a medical problem
• Adequate treatment is difficult to find for pain
  and drug dependence

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Treatment Obstacles

• Failure to recognize coexisting disorders
• Grief and Loss
• Depression
• Trauma
• Judgmental Healthcare Providers
• Minimize the seriousness of the pain or
• Overmedicate with inappropriate medications
• Social/Cultural
• Role assigned to the person in pain
• Family and cultural beliefs about pain

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Secondary Gains are a major Obstacle to Wellness

• The Pain Patient
• Financial incentive to stay sick, like
  disability or workers compensation
• Family enabling - If everything is being done
  for him or her, why change
• I have a legitimate medical problem and have to
  take my meds.

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Secondary Gains

• The Family
• Enabling sometimes gives sense of worth.
• He/she is under the care of the doctor and
  thats that
• I need him/her to be sick for my sense of SELF!
• Were doing just fine, so dont rock the boat

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Secondary Gains

• The Physician
• Financial gains to maintain the patient on mood
  altering medication
• Lack of understanding of problems associated
  with long-term opiate use in Chronic Pain
  Patients.
• Low turn over of patients and long retention
• Lobbied by pharmaceutical companies that long
  term opiate use is the treatment of choice with
  chronic pain patients

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Clarify Physician (Family) Role With Treating
(Living with) Chronic Pain

• We are treating Pain Behaviornot just Pain!
• Acute Pain is totally different from Chronic
  Pain!
• Chronic Pain is a totally different disease.
• Chronic Pain patients have totally different
  needs.
• Chronic Pain needs a totally different model
• Curative Model
• vs.
• Rehabilitative/Restorative Model
• Paul Farnum, MD
• Physician Health Program, BC

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Physician (Family) at Risk

• Obsessive-Compulsive controlling style
• Perfectionist
• Exaggerated sense of responsibility
• Equate self-worth with success
• Care-aholic
• Strong relationship with patient
• Paul Farnum, MD
• Physician Health Program, BC

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Physician (Family) at Risk

• Family of origin issues
• A strong and deep need to help
• Orientation toward immediate symptom relief that
  overshadows a consideration of long- term
  consequences
• A touch of grandiosity and omnipotence Only I
  statements
• Inability to handle own feelings if requested
  treatment is withheld
• Paul Farnum, MD
• Physician Health Program, BC

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Physician (Family) at Risk

• Burnt out
• Transitions
• Life crises
• The special patient
• Inability to set limits
• Unresolved rescue fantasies
• Paul Farnum, MD
• Physician Health Program, BC

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Learning that Pain can Elicit Reward

• A noxious electrical stimulation was given to
  patients with chronic back pain who were known
  to have a solicitous spouse
• Compared pain intensity and cingulate
  activation by EEG in the presence and absence
  of the spouse
• The presence of the solicitous spouse increased
  pain intensity and more than doubled cingulate
  activation from the electrical stimulus when the
  stimulus was presented to the back, but not to
  the finger

Flor et al, 2003. Society for Neuroscience Annual
Mtg
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The pain experience can be conditioned to
increase in the presence of rewards for pain
behaviors

• This demonstrates that social reward can
  reinforce the experience of pain - ENABLING
• Being regularly rewarded for experiencing pain
  will increase the amount of pain one
  experiences.
• This is especially important for patients who
  stand to gain from their pain disability -
  receiving benefits for having pain can make
  the pain more intense and frequent.
• Note that this is a simple physiological learning
  process
• Involves no conscious deceit or exaggeration on
  the part of the patient.
• They truly experience more pain if they are being
  rewarded for it

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Empathy for Pain

• Watching pain delivered to other person
  increased EEG SEP in Somatosensory Cortex
• Displayed AVERSION to perceived pain in others
• No response to benign touch
• S1 involved in social cognition-discomfort
  due to anothers pain
• Bulfari Cerebral Cortex 2007. 17(11)

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Compassionate Brain

• Seeing another experiencing pain causes insula
  and cingulate cortex response
• FMRIs
• More intense with estimates of intensity of
  other persons pain

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Treatment Example

• Staff witnessed patients in Chemical dependency
  treatment were bringing food to a pain patients
  room
• This patient did not ask for anything, but by
  the way she limped and the expression on her
  face the other patients took care of her
• Just like her family
• She had skill
• She was suffering

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Physicians may be unaware of the deleterious
effects of drugs they are prescribing

• Families who witness unwanted drug effects may
  believe them to be
• Unavoidable
• Preferable to unrelieved suffering
• Experience tells us that patients, their
  families and their physicians are surprised at
  the reduction in pain and suffering that occurs
  after gradual elimination of the drug

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Meditation/ Body Scan

• Burmese practice called sweeping
• Jon Kabot Zinn, Ph.D
• Self Cat Scan
• Observers attitude bearing witness to the
  pain awareness of the pain is not the pain
• Utilize Compassion and kindness towards self.

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Behavior Modification The Family

• Critical to reduce or eliminate reinforcement of
  pain behavior
• Unnecessary codling promotes invalidism
• Change the environmental consequences of pain
  behavior
• Reinforce healthy non pain behaviors while
  ignoring pain behaviors

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Family Education Necessary for Successful Outcome

• Family needs to reduce the mystery and
  uncertainty about the causes of pain
• Education on chronic pain causes and treatments
  can reduce family enabling
• Family needs insight about suffering and
  methods to reduce suffering.
• Family needs extensive aftercare when the
  patient returns to the home environment

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Family Education Continued

• Important so they do not promote unwarranted
  regression
• Misunderstand the nature of pain
• Which activities are harmful and which are
  helpful
• Need to understand that the worst treatment is
  rest and that activity is beneficial
• The family as well as the patient need continual
  reinforcement to stay on track
• Any regression by any family member places the
  entire system at substantial risk to return to
  old behaviors

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Other Issues

• Both patient and spouse with Pain and/or Drug
  Dependence
• Spouse wants to leave had enough
• Disability and Workmans Compensation cases
  complicated motivations
• What about the children?

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Recommendations for Families

• Tell the truth
• Be with them where they are
• Life style modifications unhealthy behaviors
  (smoking, diet, exercise)
• Pre-conceived notions and thinking

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Recommendations for Families

• Empathic response- awareness without judgment
• Be aware of Denial
• Caring and empathy
• Support for self self-care from others
• Insight work on self

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Cases

• JH
• NR
• AE
• HW

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To Summarize

• Families of pain patients suffer from massive
  malignant codependency
• Families need extensive treatment
• Families need longer term case management to
  stay on track

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Questions??? Thank You! Mel Pohl, MD,
FASAM 702-515-1373 mpohl_at_centralrecovery.com