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Chronic Pain and Serious Mental Illnesses: An Appr ...
Presentation and Q&A
Presentation and Q&A
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Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and Health Systems Expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, Chronic Pain and Serious Mental Illness, An Approach to Diagnosis and Management. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers, one Nursing Continuing Professional Development Contract Hour. Credit for participating in today's webinar will be available until September 5th, 2022. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now, I'm very happy to introduce you to the faculty for today's webinar, Dr. Snehal Bhatt. Snehal Bhatt is a board-certified physician in general psychiatry and addiction psychiatry. He's an associate professor at the University of New Mexico, where he serves as the Chief of Addiction Psychiatry and the Fellowship Director for the Addiction Psychiatry Program. He is currently involved in a number of federal grants aimed at improving access to OUD treatment, including ED-initiated buprenorphine and low-threshold buprenorphine. Additionally, he is the site PI for a Phase II study exploring psilocybin as a treatment for alcohol use disorder, a Phase II study evaluating a novel NMDA antagonist as a treatment for opioid withdrawal, and a NIDA CTN study evaluating ways to optimize outcomes for patients with opioid use disorders. His team has been partnering with CDC and the Indian Health Service to improve pain care in the community, including work with populations with serious mental illness. Dr. Bhatt, thank you for leading today's webinar. Hey, everyone. Thank you so much for having me. It's an honor to be here and talk about something that's very important to me professionally and has been a growing area of interest, and to be a part of such a wonderful forum that I know I've utilized as a great clinical resource. It really is an honor to be here today. As I begin, I have no disclosures, no financial conflicts of interest to report as I go through this presentation. We're going to do a few things today. Over the next—and again, I'm going to take about 40, 45 minutes to go over it. I want to really present, sort of start with just an overview of the kind of how chronic pain and serious mental illness co-occur, what the implications of that co-occurrence are, and then really delve into what some of the mechanisms may be, and based upon that, what are some evidence-based treatment approaches, and what are some evidence-based ways of communicating with our patients with chronic pain and serious mental illness, and specifically using motivational interviewing, which can create a wonderful tool for that patient-provider preparation for clinician communication. So those are some things I want to do. I've included a lot of detail in the slides, a caveat even as I begin, because I hope that these slides can serve as a reference, keeping in line with really what SMI Advisor does so well, that hopefully the participants can have some reference slides. I will not go over everything listed in the slides in great detail, but I'll cover a fair amount of it, and then we'll open it up for questions, and where I really want to also hear from the collective experience from the participants today. So with that, let's begin. So I will begin with a de-identified case based upon a patient that I've been working with recently here at the University of New Mexico, but all potentially identifying details of course have been changed. So this is a 45-year-old female with a history of bipolar affective disorder type 1, chronic pain, along with alcohol and stimulant use disorders, both in full sustained remission. And she sees me, she's reporting insomnia, irritability, anxiety, and depressed mood, all of those things. She tells me, well, I've been on Lamotrigine before, but I wound up in the hospital with Stevens-Johnson syndrome. So please don't put me on that again, understandably. She reports, as I get the history, a history of migraine-type headaches, kind of very classic, right, you know, where it began with menarche. She's had auras associated with it, photophobia, worse with movement, relief with rest, et cetera. And over the years, she has controlled it by taking ibuprofen and triptans as needed, often four to five times a week. And now as I kind of talk to the patient, she reports that headaches have become more frequent and also somehow some seem different. They don't always seem like kind of classic migraines she has always experienced. They're more generalized, they seem weird, they're more frequent. And then in top of that, she gives a history of a complex regional pain syndrome that got diagnosed and developed following a bunion removal on toe. And she's been diagnosed with that, and certainly on clinical exam kind of meets kind of some of the characteristics of CRPS, including kind of color changes, temperature differences, pain, inflammation, et cetera. She denies thoughts of harming self or others, has a history of suicide attempts and hospitalizations, no family history, and reports remote history of heavy alcohol and methamphetamine use, but no current use. She said, I don't do that anymore. I'm doing well from that standpoint. She's been treated with oxycodone, APAP, 10 over 3, 25, four times a day. Primary care provider takes it as prescribed. We checked her prescription monitoring program. There are no aberrant behaviors. Also takes temazepam, 15 milligrams a night for sleep, insomnia, but doesn't feel it really helps her, hasn't tried anything else. So let's keep this case in mind as we go through our slides and we'll periodically return to this patient to hopefully apply some of the knowledge that we're picking up to this patient. And I'll begin with definitions, right? And I take this quote from Dr. Ed Covington, who's just done so much work in the area of sort of pain as a biopsychosocial phenomenon. And he says, pain is characterized not only by location and quality, but also in emotional terms, terrifying, unbearable, agonizing. Pain has an essential duality. It is both sensation and emotion. This is an old quote. I think he published this about two decades ago, but to me, it's just one of these really vivid description of the pain experience. And it's very consistent with the definition of pain by the International Association for the Study of Pain. Their revised definition, which just was published a year or two ago, very consistent with what Dr. Covington just mentioned in his quote. IASP definition also focuses on the fact that, sure, pain is a sensory phenomenon, but it's also an emotional experience. That's right there in the definition of pain. The definition then goes on to focus on the fact that the pain is a personal experience that's influenced by biological, psychological, and social factors. It distinguishes between nociception, just that conduction of the pain, the sensory neurons, to the overall pain experience, that they're not the same. There may be overlap, but pain as an experience goes beyond it, including life experiences. In fact, there have been at least a couple of studies in the last year or two that really focused on and found that prior experiences with pain can impact how a patient, how an individual might perceive, might experience pain experience in the future. So our past experiences shape the experience of pain. It talks about the fact that that personal report needs to be respected. I think in the medical field, we sometimes don't do such a good job of it. Patients with pain are often stigmatized. IASP's definition really hopes to counter that. It says that pain may serve an adaptive role, but certainly in many cases, chronic pain has adverse effects on function as well as overall psychological, social well-being, and the fact that people communicate pain in different ways. Verbal communication is a part of it, but there may also be other ways that patients communicate with it. And this definition is also very consistent with what's been termed total pain. This is a term that was actually, I believe, created by Dame Cicely Saunders, who's considered the founder of the kind of the modern hospice movement. And she came up with this idea of total pain about three decades ago. And she mentions again that, sure, pain can have a physical component that's related to the disease activity, the pathology, but there are also other factors, right? Emotional and psychological pain. Worrying about what's going to happen because of my pain. How am I going to pay the bills? How is it going to affect my children, my family? What does it mean for me if I can't do what I've always done because of my pain? What does that say about myself? How does that impact my self-image? The social pain, changing social roles, which often come, right, with chronic pain. Lack of support system, which is certainly something I see a lot with my patients. And finally, existential or spiritual pain, those important big questions. Why is this happening to me? Why me? Spiritual concerns, afterlife concerns. Am I being punished? So all of these things, when put together, contribute to the overall pain experience, right? So physical pain is just a part of it. And that's what that definition from Dr. Covington says. That's what the total pain concept says. And that's what the definition by IASP also says. And this is, I really like this graphic representation that when I speak to my patients with pain, to them pain is the problem. That's dominating it. But the total pain concept, which is also consistent with pain self-management view, is that pain is one piece of the overall experience of the patient. That can include substance use, that can include psychological and social concerns, family dynamics, right? And that's why I think it makes a lot of sense to approach chronic pain in a holistic manner to address all of these in an integrated way. So with that, let's go a little bit into epidemiology. I don't want to spend too much time with it, but I do want to highlight that serious mental illnesses and chronic pain coexist and this worsens outcomes. So even if you guys tune out for the next five or seven minutes, right there in the title slide is what those slides are really going to talk about, right? That these conditions occur at high rates. And when they co-occur, they worsen the outcomes of each other. Pain is very prevalent. So this is the estimates from CDC in their famed report from 2016, showing that about 20% of the U.S. population had chronic pain and 8%, which is about 20 million individuals, had high impact chronic pain, meaning pain that impacts their daily functioning. So something that's obviously we should care about. And it's been linked to a number of kind of bad outcomes, including poor mental health. So pain can impact mental health. That's sort of one other important thing to bring up. Suicide. I'll get to that in a little bit in a couple of slides, but all types of pain, according to recent literature, are independently linked to risk of suicide, suicidal behaviors, as well as completed suicide. Dependence on opioids, right? Serious mental illness, as well as chronic pain, of course, are both linked with, you know, kind of opioid misuse. And it's also been shown that individuals with chronic pain who have serious mental illnesses are unfortunately prescribed a disproportionate amount of opioids. So as we sort of, as a nation, as communities, grapple with the opioid epidemic, we can't lose sight of the interconnectedness of all of these things. Poor perceived health, poor quality of life, and significant financial costs to the healthcare system. So when we think about this, so if you look at, you know, patients with chronic pain, up to 60% in some studies will meet criteria for major depression. And as this slide points out as a reference, it might differ depending upon the type of chronic pain an individual has. But in general, the risks of depression are significantly elevated in individuals with chronic pain. And, you know, the more the sites that the pain experiences, the higher the likelihood that the patient also has depression. So for example, the patient in our vignette, who has, you know, migraines, who has pain related to CRPS, so with that type of multi-site pain, some of the data suggests that that patient may be over three and a half times more likely to have depression. So very clear. And at the same time, the relationship also holds true going the other way, with people with depression being almost two times as likely to have a chronic pain diagnosis. Studies have looked at it, and ultimately what they find is that pain and depression have a strong bi-directional relationship. And the relationship is equally strong going one direction or the other. Similarly, individuals with anxiety disorder, according to some estimate, almost half of people with chronic pain meet criteria for an anxiety disorder, again, a bi-directional relationship. And importantly, what you find when it comes to anxiety disorders is that it's not the specific anxiety disorder. So no one specific anxiety disorder is, you know, linked with chronic pain. All of them are. It's really how severe the anxiety is, as far as the number of anxiety disorders an individual may have, that increases the likelihood of them having chronic pain. And when chronic pain and depression co-occur, outcomes worsen. Outcomes worsen for depression. Outcomes worsen for mental health. Outcomes worsen for chronic pain, for disability, for quality of life, functioning, right? So as this, you know, exhaustive list points out, functioning really goes, and this is why we should care, because when these things happen together, our patients do worse. In fact, there's this, it's an older study, but I've cited it here by Casey, because it's an important study. So the study was done in an acute pain clinic. So patients come in to the clinic with acute pain. They're there for three months. If after three months their pain is resolved, the patients go back to their primary care provider. But if the pain still persists, they get transitioned to a chronic pain treatment program. So kind of an ideal setting to carry out some of this research works. And what this study from 2008 found is that depression, depressive symptoms were the strongest independent predictor of pain going on to become chronic. And they also predicted disability. It wasn't the location of the pain. It wasn't the ideology of the pain. The strongest independent predictor was actually depression. So that really highlights for me, just the kind of the interaction and why I think this topic is so pertinent to SMI Advisor. And the more the diagnosis, the worse people do. So again, this study by Bayer from 2008 showed that patients who had pain plus depression plus anxiety had the greatest pain severity as well as pain-related disability. Coming on to bipolar affective disorder. So you also find that people with bipolar affective disorders significantly more likely to have chronic pain or twice as likely compared to general population. And again, it seems to make the pain experience where having bipolar illness seems to worsen the pain experience as well as lead to more functional limitations. And let's see going forward, the link with schizophrenia is a little bit more complicated. And I will get to this as we go through this presentation. In general, some studies have found that people with schizophrenia are at least as, or maybe even slightly more likely than the general population to have a chronic pain diagnosis. But the link is not as strong as that for depression or bipolar spectrum disorder or even anxiety, but the link is clearly there. And it's been shown or people have sort of argued that this is likely an under detection for some reasons that again, I will come to as we move forward. Chronic pain impact on serious mental illness. Well, they impact each other adversely, as I mentioned, right? When people have both occurring together, the pain outcomes worsen and so do the outcomes related to their mental illness, including lower global functioning. And this has been shown in some recent research, decreased physical health, reduced quality of life, increased severity of psychiatric symptoms, and increased risk of suicide, as well as higher rates of opioid prescribing. So this is, I think, why we should care. And especially as suicide is something, again, many communities are grappling with. We know again that chronic pain itself is a risk factor for suicide and co-occurring depression seems to compound that risk. So hopefully I sort of highlighted some of the reasons why this is important to begin this presentation. I'm going to quickly glance at the time. We are doing okay. So I am going to move forward to some of the models of explanation. So how do we explain why these things co-occur, right? Why mental illnesses and chronic pain co-occur and worsen the outcomes? What is the link? So that's really what I want to go into. And I think because this has implications on treatment. So this slide comes from, it's a wonderful article by Michael Houghton out of Mayo. It's a paper that he published about five, six years ago. It's a review article. And this and the next slide are both courtesy of that article. And it's a wonderful article and I've listed it in references, of course. And this really lays out the pain matrix. And this is a concept that's been around for a little bit longer than that, which really shapes how an individual experiences pain. So as you can see, and for me, this is important because I mentioned earlier that nociception is not all of it. That's not the whole story. And that's really what this slide is getting at, right? So if you see initially, so say I'm walking around barefoot as I'm prone to do around my house, unfortunately, and I step on a rock or step on a nail, those nerve fibers, the C nerve fibers are gonna pick up the pain, carry it to the dorsal horn of the spinal cord, at which point the internal neuron is gonna carry it to the contralateral side and the spinal thalamic track is gonna carry that stimulus up to the thalamus. I know I have some trainees on today, so for you guys who are on, that pathway should make sense from your neurology courses, right? And that's that initial pain stimulus, that first level of processing, the nociceptive processing, but that's not the full story. As you can see, once the stimulus has reached the brain, it then goes through a second tier of processing where that pain, that stimulus that's been perceived is modulated by attentional factors, by cognitive factors. And people have looked at what some of those may be. So one of them is sleep, for example. So if someone is chronically sleep deprived, that may modulate, right, that experience. Another thing that's sort of been looked at, for example, is the activity of the default mode network or the salience network. That's been looked at and it's been shown that in people with chronic pain, as well as interestingly in patients with other certain mental illnesses, including depression and anxiety, the connectivity patterns within those networks may be different. And then as if that's not enough, that stimulus then goes through yet another level of processing, right? Where that stimulus, that experience is then affected by emotional context, by individual's prior life experiences, adverse childhood events, right? And the epigenetic changes that might result as a means of that. Individual's life view, the attribution patterns, all of those things then further modulate that pain, that initial stimulus. So you can see just how much processing happens. And I think for me, again, really highlights the importance of us looking beyond simply nociception and looking at these factors. And importantly and pertinently, some studies have suggested that individuals with certain SMIs are more likely to pay attention to those emotional contexts in their pain experience. So it may be that that third tier of processing is different in individuals with SMI compared to people who don't have mental illnesses. On a similar note, I think there's quite a bit of an overlap. This is sort of another model of chronic pain, sort of a psychological model where an individual experiences pain. Pain catastrophizing, as you can see here, has been correlated in multiple studies as playing a role in worsening the pain outcomes, right? And catastrophizing is exactly what it sounds like. The person saying, my pain's never gonna get better. I'm never gonna be able to make anything of my life. I'm never gonna be able to meet my goals. That's the catastrophizing. And we know that when people have that, outcomes worsen significantly. And that catastrophizing then leads to fear of pain, something that's been called kinesiophobia, again, associated with a number of adverse outcomes. So when people start fearing pain, because pain now means something bad, right? Pain is not the body's attempt at healing, but pain is the sign of impending doom. And when that happens, physical activity limits, deconditioning sets in, and physical deconditioning happens and outcomes worsen. So a lot of our psychological approaches at treating individuals with chronic pain focus on this model, right? The fear avoidance model of pain, it has been true. So let's come back to our case. So as we talk to our patient, she says, you know, I used to be quite active, but over the years, I've severely, I just don't do much, because I think my pain will get worse if I do any activity. She reports that her constant pain leads to her feeling increasingly irritable, which in turn leads to quote unquote, isolating. She's given up, she used to be quite an avid hiker, runner, doesn't do any of that, which has led to significant weight gain, which has made her feel depressed, right? So our patient clearly reports this cycle. She believes her pain will never go away, something that's been called pain permanence beliefs, also correlated in literature with worsened outcomes. What is the point? Nothing has worked. Reports poor sleep due to pain, and a sleep study recently showed obstructive sleep apnea, which is right now untreated, right? So I'm gonna go forward here, looking at the time, good, we're doing okay. I wanna focus for a couple of minutes on schizophrenia and chronic pain, because I think this topic deserves special considerations. There is quite a bit of literature on this topic, and hopefully I will try to summarize some salient points when it comes to this. So again, there's been this raging debate in literature, discussion in literature, that do individuals with schizophrenia somehow express pain differently, or experience pain differently? Both of those, express and experience. So let's look at that. So some authors have suggested that, you know, individuals with schizophrenia may have reduced expression of pain. They just don't report pain unless you specifically ask about pain, right? Because of cognitive impairment, because of negative symptoms. And I think that is clear clinical, and I would say even ethical implications, that when we're working with patients with schizophrenia, you know, we may need to think about specifically asking, knowing that, you know, the patient may be less likely to spontaneously report it, specifically asking may be a very important tool, because if it's there, we know, as we've talked about, it's going to worsen outcomes, including some very serious adverse consequences. So you wanna recognize it and provide treatment for it. So I think that is very clear clinical and ethical concerns. It's also been reported in literature though, that individuals with schizophrenia may have reduced perception of pain. Again, there's robust literature, and I would encourage anyone interested to research that, or if you're super busy, feel free to reach out to me, and I can point towards certain papers or literature. It's been shown, for example, that, you know, individuals with schizophrenia may have lower perceived intensity of nociceptive stimuli, but not of other types of stimuli, right? It's also been shown that people with schizophrenia may be more sensitive to acute pain, but less sensitive to chronic pain. At least one study pointed towards the role of beta-endorphins. I'm not entirely convinced by this, but, you know, because I don't think there's been enough study, but regardless, my point here is that there is a lot to be gleaned from it, but very likely, it seems that what we see in individuals with schizophrenia is that, A, they may perceive pain in a different pattern, and they may also be less likely to express their pain, right? And antipsychotic use itself may also alter the pain perception. And that's really been talked about in literature. So when you put all this together, again, we must specifically ask our patients for pain, right? Are you in any pain? Do you experience any pain? How does that affect your life? Because even if they're experiencing it differently, perceiving it differently, even if they're not expressing it spontaneously, the pain is, if it's there, is going to impact their life. Remember, pain is a total experience. There is a deeply psychological component to it, and that is important. There was at least this one study a couple of years ago that talked about this concept of psychic, right, this psychic pain, which may be associated with suicidal behaviors, for example, in individuals with serious mental illness. We know that depressive symptoms in individuals with schizophrenia modulate the pain intensity and may even raise it. So we should ask about that, do a thorough assessment, and make sure we're providing optimal treatment, which we'll get to in the next section in just a couple of slides. And this is a quote from a recent paper. "'Pain can be delusionally perceived, "'and it can also be delusionally denied.'" Right, so we don't want to generalize and really think about individualizing the treatment we provide. Next, I'm gonna focus for the next about 15 minutes or so on assessment and treatment, right? We're right on time. This is kind of where I wanted to be at this point. And this is a quote from George Engel, which I think holds true across medicine, across clinical encounters, that the interview is the most powerful, encompassing, and versatile instrument available to the physician. And I think let's keep that in mind as we go over. So some general approach to patient-centered interview when we're talking about individuals with pain, again, specifically ask about pain, and listen actively, listen empathically. Lot of questions, right? Kind of a patient-centered interview that we talk about, we learn about, I think certainly applies here. I find that it gives me a lot more information and also appreciation for that patient's experience than simply asking a lot of closed-ended questions. Acknowledge that pain is real, right? I think there's individuals that we're talking about in this presentation carry with them many experiences of stigma. Pain is stigmatized, right? Chronic pain is stigmatized. Chronic pain is often not even seen as real. Similarly, if you think about our psychiatric conditions, right, substance use disorders, again, things that all happen often concurrently are all stigmatized. And also our patients often have had other experiences which may have imposed layers upon layers of stigma. So very important to acknowledge that this experience is real, that their experience is their experience. I might be the medical expert, but the patient is the expert on her own life. And really actively working towards creating an anti-stigma environment I think is crucial. Assessing function. Increasingly when we're talking about pain assessment, we're not just asking, right, about that pain from a scale of zero to 10. We're talking about functioning. How does this impact your life? What are the things you want to do that you're no longer able to do because of your experience, because of your pain? And how does that affect your life? Just asking those questions just allows us to understand the patient, I think, so much more profoundly. Provide education. In many of these models of, for example, pain self-management, acknowledge, educate, and empower are really keys. And by education, I mean kind of talking about the physiologic pathways of pain, but also about how these other things, like your living situation, your depression, right, your fears about the future can impact the pain. Because by doing so, you're really also stepping, creating a bridge to treatment. Because the message you want to be giving about treatment is that, you know, it's the answer is not just in opioids. That's not the full answer. There's so many other things we can do. So I think this education starts creating a bridge to when we start talking about treatment. Now, so that's important. Understand your patient. What is it like for you to live with persistent pain? How does the pain affect your life? What do you think should be done? What has worked? What hasn't worked? What are your ideas about what would help you? What are your goals for pain? What are your functional goals? What is your view of how I can be of help? How we as a program, as a clinic can help you? What experiences have you had with prior treatment? Does the pain lead to feelings of depression, of anxiety? How does it affect your life? And as we have this discussion, I find that it's very helpful to stay rooted in sort of principles of motivational interviewing, the spirit of motivational interviewing, right? Sometimes learning the specific techniques of MI takes a little bit of practice. But the spirit of motivational interviewing is that we're staying patient-centered. We're being open-ended. We're allowing the patient to share their experience. We're eliciting that story. And we're being respectful. And these are some of the things that we can do even as we learn these specific techniques, which allows us to stay rooted within motivational interviewing spirit, including asking open-ended questions, directly affirming and supporting the client, listening reflectively, periodically summarize what they've said, right? And always being on the lookout for stages of change. What are the things that the patient is saying they wish to change? And when you hear that, really capitalizing on it, following up on it is very important. And remember, again, that as we assess for pain in our patients with SMIs, we wanna keep in mind the concept of total pain, that pain is a biopsychosocial experience. Certainly the biological is important. We wanna know how the pain started, right? What made it worse, how it is now, right? We wanna do a good diagnostic evaluation. We wanna know what's leading to the pain, what the ideology is. But, and that includes kind of what are often, again, our students may have heard about or read about or practice on a stimulated patient, the seven dimensions of pain, the location, severity, exacerbating and relieving factors, timing, other symptoms, radiation, of course important. But what I really wanna emphasize is that we wanna go beyond it. The pain story, the pain experience also includes the psychological. How does the patient affect the patient's emotional health? Some of the questions that we talked about right earlier in my earlier slide, including I kind of think about, what are the chronic stressors that affect your life? And that starts getting into the psychosocial, right? The effect of the patient's pain in the context of their home, work, recreational environments. ACEs stands for adverse childhood experiences, which again, studies are showing impacts a patient's pain experience. What is the support system like? How can we provide support? As well as the maladaptive practices the patient may be using to cope with the pain, including substance use, including avoidance, which as part of the fear avoidance model is one of the center pieces of intervention. We wanna establish, once we've sort of elicited the story, we wanna start getting into the patient's functional goals and objectives. How has your pain changed your life? How has it impacted your life? If your pain were better controlled, how would your life be different? How can we work together to make your life different? And setting goals, both short and long-term, right? Which we can periodically revisit as we work with the patient to know if the patient is working. And part of that education and empowerment, again, is helping the patient move towards this idea that, sure, they experience pain, and sure, it's a profound experience, but they're also much more than just their pain. And these are just some things that may apply. So I think that's an important part. And that's why I wanted to spend a little bit of time on it as we go into treatment, because this is the dialogue, this is the conversation that's gonna allow us to understand our patients and set up towards treatment. So as we talk about treatments, of course it's important to start by talking about the CDC guidelines, right? And initially published in 2016, recently revised. But these are some of the pertinent points within the document. Opioids are not the first-line therapy for chronic pain outside of active cancer treatment. Palliative care and end-of-life care. Patients with pain should receive treatment that provides the greatest benefit, right? Evidence suggests that non-opioid treatments, including non-opioid medications and non-pharmacological therapies can provide relief to those suffering from chronic pain and are safer, and focus on functional goals and improvement, engaging patients actively in their pain management. So let's keep these guidelines in mind as we talk about some treatment options of chronic pain, especially in the context of SMI, right? For the patients who may have a mental illness and chronic pain. I think cognitive behavioral therapy, you know, many of, when I think about treating that patient, such as the patient in the vignette, for first line, once I've done a good, elicited the patient's story, provided education, established functional goal, often the first thing that I'm gonna turn to is a combination of cognitive behavioral therapy, along with what's termed pain self-management. And we're gonna cover both, right? Starting with CBT, which really should be a part of the overall treatment plan, if at all available. And CBT, and that's why I pointed out the fear avoidance model earlier, because CBT for pain, that's what it focuses on. It revolves around that fear avoidance model that we talked about. And it targets some of those psychological mechanisms that we focused on, such as catastrophizing, such as that kinesiophobia, the fear of movement, the avoidant belief, avoidant behaviors. And it works towards, at the same time, developing coping strategies, and confronting threats posed by pain. And some of the core elements of CBT include graded exposure, cognitive restructuring, kind of really targeting some of those, you know, mild adaptive beliefs or cognitions. There is often a relaxation component as well. Activity pacing. So instead of setting a specific goal that I'm gonna walk from here to the store, which if it doesn't work, can actually be kind of demoralizing for the patient. Instead, setting a time-based goal, that I am going to try to walk for five minutes today. And then processing, how did it go? What worked, what didn't work? How can we do things differencing, right? And working towards extinguishing some of those pain behaviors that may not be so helpful. In general, CBT has, you know, the level of evidence isn't strong. The effect sizes tend to be small to very small, but the effect sizes are consistent, right? And people do experience with CBT, long-term improvements in a number of things, including pain intensity, disability, quality of life, pain-related coping, as well as depression, and healthcare-seeking behavior. So again, a great way to engage our patients with SMI. And we know that CBT is helpful, right? For our patients with many types of mental illnesses, but it's also helpful for patients with pain. So CBT principles can really be a good way to engage our patients who have both. In the world of sort of pain management, over the last several years, acceptance-based interventions have also become increasingly utilized. And that includes mindfulness-based stress reduction, but also something like acceptance and commitment therapy, or ACT. And the approach is different, right? In CBT, we're saying, well, these are your cognitions around pain that aren't really helping, that may in fact be making your life worse, and we're gonna challenge them. We're thinking about reframing them. In something like in the acceptance-based intervention, the approach is a little bit different. What we're saying is that, sure, you live with pain, right? Sure, it's not a pleasant experience, it impacts your life, but let's work towards kind of non-judgmental mindfulness, mindful awareness of that pain. At the same time in acceptance and commitment therapy, you're working with the client to identify their values. What are the things that are really important to you? What are the things that are meaningful to you? And how can we work towards living a life where you have pain, and yet you can set goals and work towards goals that are consistent with those life values. There is, you know, the data is a little bit more mixed with acceptance-based interventions compared to CBT. It's not as consistent from my reading of the literature, but in general, you do see helpful, you know, effects on a number of outcomes, both pain-related as well as depression, anxiety, quality of life and physical wellbeing. So again, you know, something to think about, right? Now, other things that have been looked at, including supportive psychotherapy, which may be especially important in individuals with serious mental illnesses, relaxation, biofeedback, again, some evidence, but not as much for many of these approaches. And just to highlight how important our non-pharmacological approaches are in the treatment of individuals with chronic pain and SMIs, right? Or even just for individuals with chronic pain, these are actually all the non-pharmacological treatments, in addition to the ones I'm specifically mentioning, that are endorsed by the American College of Physicians for lower back pain. And you can see that all of these things, right? So again, the idea being this integrative, holistic treatment, if we're at all able to provide it. I mentioned pain self-management. Really ought to be a part of the overall care plan of someone with SMI and chronic pain. Pain self-management is really this approach that allows the patient to take charge, right? Be responsible for their experience, and engages them in a multidisciplinary manner, towards basically making lifestyle changes and practices that are important in someone who's living with a chronic condition that might improve their wellbeing. Again, the idea is active engagement. It involves gaining confidence, knowledge. There's quite a bit of education. It starts with education. Again, that education, empowerment, and teaching specific skills to manage physical, social, and emotional aspects of life. And these are, again, the reference slide. These are some of the things that often pain self-management programs focus on. So including diet, including exercise, the importance of medications, right? Mindfulness, managing fatigue, insomnia, leaning into resources. So all of those things are in it. And in fact, it's quite helpful. So there was a major multi-site study that was done called the SCAMP trial. There's always like great acronyms, right? For some of these trials that look specifically at individuals with depression and chronic pain. And the active intervention was a specific, kind of an optimized antidepressant regimen, right? For people with depression. So there was an algorithm, and that combined with self-management wound up improving outcomes significantly in terms of pain, in terms of depression, as well as in terms of overall quality of life. So again, these are nice tools because they can be combined with our medications. There is also multidisciplinary pain rehabilitation, which is generally outpatient. It's quite intense, you know, almost like an IOP type of a model, right? Intensive outpatient type of a model. Usually combines group-based intervention, and has also been shown to be effective in terms of variety of pain outcomes, as well as quality of life. So in the next four minutes or so, I just wanna go into pharmacotherapy approaches for patients with chronic pain and serious mental illnesses. This is a reference slide, really to point out again that opioids are generally not first line, right? And you can see that the medications we use, right, as psychiatrists often, antidepressants, antiepileptic drugs play, you know, and this is again according to the CDC, play a major role even as a first line medication in many types of pain. So I'm gonna return to the case quickly and then review the medications, right? So at this point, as we talk about it, we have our keep a headache diary, and the patient goes, oh my gosh, like, you know, the medications, the more medications I'm taking, those NSAIDs and triptans, maybe my headaches are getting even worse. In fact, she's experiencing what we call medication overuse headaches. We talk about and provide education on the link between the insomnia, the mood, the pain, the social isolation. Fortunately, we have a, you know, very robust multidisciplinary pain clinic at UNM, where she started on greater exposure physical therapy for her CRPS, begins CBT at our clinic with a therapist for both her mental illness and for pain, continues to be in remission from substances, and we start working with her gradually to see if she can start like a very structured exercise program, and can she identify one or two people to connect with? I've included some reference slides here. In general, when we talk about pharmacotherapy, you know, this is the approach I take. If a patient with depression or anxiety is already on an SSRI medication, and this is consistent with the SCAMP algorithm, you're gonna wind up optimizing it. Optimize that therapy if it helps the depression, if it helps the anxiety, that might improve the pain experience. But if that's not enough, if that's not helpful, or if the patient is not on any medications, right, for depression or anxiety, then the two classes of medications to consider are SNRIs, serotonergic noradrenergic reuptake inhibitors, or our tricyclic antidepressants, because they carry much more evidence for treatment of pain compared to the SSRI medications. And a lot of the effect on analgesia seems to be independent of their effect on treating mental illnesses. And often, for example, for tricyclic antidepressants, we wind up using much, much lower doses of these medications when we're using them to treat pain. Tricyclics carry by far the largest evidence base in the treatment of pain. You know, if you look at across various conditions, painful conditions, you wind up getting a number needed to treat of about four to five, for 30 to 50% pain reduction, depending on the study, which is quite impressive. But of course, it's the side effects that limit their use, right, their orthostatic hypotension, the QT prolonging effects, the sedation with something like amitriptyline, and also the risk of overdose. So we gotta be mindful of that. So SNRI medications, they'll often become much more widely used in the treatment of these patients, right, because they're safer. Less research, less robust data, but they tend to be a lot safer. For duloxetine, a dose of 60 milligrams a day, you know, is kind of the standard dose. For venlafaxine, if you want to have nociceptive effect, analgesic effect, we got to think about getting the dose up to at least 150 milligrams for that noradrenergic reuptake inhibition to kick in. So think about that. The TCAs, the two most commonly used ones are amitriptyline and nortriptyline. And again, at much lower doses than the doses we might be used to in the world of psychiatry. So if I'm gonna start amitriptyline in a patient with chronic pain, I might start at 10 milligrams or 25 milligrams and gradually titrate to 50 or 75 milligrams. I don't need to go to those very high doses. So this is a reference slide, again, from the Houtan article that lists some of these numbers needed to treat, which you can see, especially for these tricyclics, are quite impressive. Some tips, be mindful of serotonin syndrome. So for example, in our patient who's taking a tryptan, it's gonna be raising serotonin levels. Same with tramadol. So we gotta be mindful of serotonin syndrome and educate our patients on it. Drug-drug interactions, for example, NSAIDs and lithium in our patients with bipolar affective disorders, right, to be mindful of. And of course, if a patient has bipolar affective disorders, such as the patient in the vignette, you wanna be very careful about using antidepressants and really be mindful about that. For patients with schizophrenia, there is some evidence that some antipsychotics, particularly olanzapine, may be helpful with analgesia, but that data is much less robust. So one thing that's a clear recommendation is optimized treatment of depression in our patients with schizophrenia, if they're concurrently have chronic pain, because doing so is likely to improve their chronic pain experience. Avoid benzodiazepines, optimize treatment to improve sleep, both pharmacological as well as non-pharmacological, such as CBT, insomnia protocols. Don't deprive our patients of opioids. That would not be ethical. But if opioids are used, not first line, only after a thorough risk-benefit assessment and with ongoing monitoring for aberrant behaviors and with naloxone prescription. And although not the focus of this presentation, something near and dear to my heart as an addiction psychiatrist, make sure we're treating co-occurring substance use disorders in an integrated fashion. And these things can be done together. I think this is the last slide I have, and then I'll stop, is combining our medications with self-management can help, again, both the depression severity and the pain severity, for example, which in turn winds up improving quality of life, functional goals, et cetera. So with our patient, after talking to her, she started on valproate to target bipolar affective disorder as well as underlying migraines. She receives a CPAP. We talk about risk of opioids and benzos, and she's weaned off of the benzo, off the temazepam, which wasn't helping her anyway. And she instead finds strazodone and mirtazapine at kind of low doses. They're tried, but they're ineffective. So very cautiously, we actually wound up putting her on amitriptyline 10 milligrams. Once she was stable on valproate, and eventually at 25 milligrams, she's able to tolerate it and finds it helpful. And she's using far fewer abortive medications for her migraines. So I will leave it here. There are supplemental slides that I've included. Again, for reference, CDC recommended treatments for various pain syndromes. And I will stop here, and references are here as well. Thank you. Thanks so much, Dr. Bhatt. That was really terrific presentation. Before we shifted to Q&A, I want to make sure to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events. Complete mental health rating scales, and you can even use the Q&A feature to complete mental health rating scales, and you can even submit questions directly to our team of SMI experts. Download the app now at smivisor.org forward slash app. So I had many questions. It was really thought-provoking presentation. One kind of big picture question. In the medical model, we're often taught that the goal is to fully treat symptoms, but you mentioned that some psychotherapeutic approaches, as well as this kind of total pain perspective, might argue a little bit more about kind of shifting the focus from zero pain to something more about kind of contextualization, perhaps, of pain. I wonder if you have a few words about that for clinicians and how they might think about taking that stance. Yeah, thank you, Dr. Drost. And yeah, that's so consistent with what we're learning from our patients, from literature, and also from the CDC guidelines, that it may, in fact, even be an unrealistic goal for many of our patients if their goal is that I'm gonna go to a scale of zero, right? And that leaves room for a lot of just disappointment and the demoralization that may come with it. And also, again, considering the subjective nature of pain, that adds another layer of sort of uncertainty to that. So really, the recommendation is that, that kind of having that discussion, shifting it from that number from zero to 10, which we, I think, all learned to do back in the 90s, right, to really going towards how is it impacting your life? What is it that you would love to be able to accomplish if our treatment is successful? Maybe it's like, I wanna be able to play ball with my grandkid on weekends, right, or go out and walk to the local store, whatever it is, really setting those individual goals and revisiting them when we meet, that what is the progress, what have been the barriers? And that might also allow us to hone the treatment. There are also some scales that we recommended, which were kind of beyond the scope of this presentation, but can be an excellent ally. So for example, the brief pain inventory. It's something that we really use a lot for our patients with SMI and chronic pain that really hones in on some of the, kind of the functional aspects of the pain experience. And that can also allow us, in a more objective way, to track this. Does that kind of address your question, Dr. Dressler? Yeah, yeah, and perhaps building on that a bit, I mean, you mentioned CBT, motivational interviewing, as being these kind of core building blocks for the psychotherapeutic piece of pain management. And I'm wondering, to what degree do you see kind of those as being kind of people being able to apply their generic CBT, MI skills that they've learned versus the need to kind of learn a more specialized approach to take with pain? Yeah, thank you. And maybe the answer is a little bit different, right, between MI and CBT. Where I think with motivational interviewing, I find that, and maybe it's my bias, right? I did my fellowship at the University of New Mexico. I've practiced here for about 14 years at this point. So maybe it's my bias. But I actually really find that those principles are gonna apply across conditions, right? Some of those same, some of that spirit of motivational interviewing, and we can start applying it even during the assessment, and that allows us to establish just a deeper rapport and understand our patients better. I think with CBT, I think it's a little bit different because some of the principles that are used are very specific to the fear avoidance model, right? So in some cases, there's an overlap, right? So for example, we talk about that with kind of anxiety disorders, kind of a similar in the role of avoidance. And so those techniques are the same, but the practice becomes really how do we kind of, I guess, transpose them to this? So I think if someone has that basic sort of background or training in cognitive behavioral therapy, it's an easily transferable skill. But I think the piece that needs to be emphasized or learned maybe is the pain physiology, the pain experience, because that's critical, if that makes sense or if I'm communicating that well. Yeah, yeah, totally, that's very helpful, thanks. And then maybe one just little quick final question that I had looking at the list of some of the pharmacological treatments and also looking at some of your expertise. I didn't see buprenorphine there, and I'm wondering how you think either about kind of, does it, is it, can you use it for pain? Is it just something that will end up being concurrent because someone may have an opiate use disorder? Is that, where does that fit in the bigger picture? Yeah, thank you for bringing that up. I mean, I actually had a bunch of slides on that and then wound up taking them out just to keep the presentation more focused, right? But there's obviously a role. I think, because there is such an overlap, right? I think certainly, I think there is, I mean, if you look at some of the recent literature, there's this idea of kind of complex persistent dependence, which are people who may not have developed, people with chronic pain on opioids who may not have developed an opioid use disorder, but they're displaying some risk factors. Their doses have escalated when you try to taper them, they're functioning persons, right? And aberrant behaviors emerge. And importantly, there are at least two recent studies that I've read this year that show that people who have chronically been on opioids, when you start tapering their opioids, the outcomes don't always get better. And in some cases that get worse. I think both of these studies found increased mental health emergencies, very pertinent to this topic, and more use of illicit substances when the opioids were tapered. And my sense is, from what I see, these may be the patients who may have developed that complex persistent dependence, a term that we're also now applying in recent literature to benzodiazepines, right? I think there was a paper in JAMA Psychiatry just this week on it. So I think for that group, switching them over to buprenorphine, I think there's clearly a role in it, right? And going beyond just the people with opioid use disorder, this group of people who chronically been on opioids, they're maybe displaying some aberrant behaviors, their concerns, their doses have escalated, or they're using other substances and it's unsafe. Switching to buprenorphine is likely to be far safer. And in many cases, although not universally, may also help the pain experience. So we do that quite a bit here, as do institutions, I think at this point, pretty widely. So we certainly use that. But of course, the barriers become insurance, if you're gonna use the sublingual formulation, it's not specifically approved for chronic pain, as well as kind of the formality or the legalities with the ex-waiver. So I think those become the other practical considerations. In that case, some of the buccal formulations or transdermal formulations become other option. Does that address at least? Yes, yes. I'm sorry on the time, but I hope it at least touches. I wish we could keep going, but I do wanna keep everyone on schedule. But yeah, thank you again. And just to go through the remaining housekeeping slides first. If there are any topics covered in this webinar that you'd like to discuss with colleagues in the mental health field, you can post a question or a comment on SMI Advisor's webinar roundtable topics discussion board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisor's national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It's completely free and confidential service. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next in advance and complete the program evaluation before claiming your credit. Please join us on July 29th as Dr. Kim Tojomi presents Transgender-Informed Psychiatry. Again, this free webinar will be July 29th from 12 to 1 p.m. on Friday, July 29th. Thank you all for joining us. Until next time, take care. Thank you.
Video Summary
The video is a webinar titled "Chronic Pain and Serious Mental Illness: An Approach to Diagnosis and Management." Dr. Benjamin Druss, Professor and Roselyn Carter Chair in Mental Health at Emory University, presents the webinar, which aims to help clinicians implement evidence-based care for individuals living with serious mental illness and chronic pain. The webinar is part of the SMI Advisor initiative, which focuses on providing support to clinicians in delivering evidence-based care for serious mental illness. Dr. Druss introduces the webinar and discusses the credits available for participants. He then introduces the guest speaker, Dr. Snehal Bhatt, who is an expert in addiction psychiatry. Dr. Bhatt discusses the co-occurrence of chronic pain and serious mental illness, the mechanisms behind this co-occurrence, and evidence-based approaches to diagnosis and management. He emphasizes the importance of taking a holistic approach to pain management and understanding the total pain experience, which includes psychological, social, and emotional factors. Dr. Bhatt highlights the prevalence of chronic pain and its impact on mental health, functioning, and quality of life. He discusses various treatment options, including cognitive behavioral therapy, acceptance and commitment therapy, pain self-management, and multidisciplinary pain rehabilitation. Dr. Bhatt also addresses the use of medications for pain management, including SSRIs, SNRIs, and tricyclic antidepressants. He discusses the importance of individualized treatment and setting functional goals with patients. The webinar concludes with a case study and a discussion on the use of buprenorphine for pain management. Overall, the webinar provides valuable insights and recommendations for clinicians working with individuals with chronic pain and serious mental illness.
Keywords
Chronic Pain
Serious Mental Illness
Diagnosis
Management
Evidence-based Care
SMI Advisor
Co-occurrence
Holistic Approach
Total Pain Experience
Treatment Options
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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