PAINWeek Highlights: Coping Skills, Insomnia, and Opioid Abuse Deterrence
Coping Skills Key To Pain Management
Practical coping skills are often an overlooked element of pain management. Ideally, pain management incorporates areas of interventional therapies, medical management, and self-care skills. And “like a three-legged stool, all three are integral components—without one, the stool will tip over,” noted Ted W. Jones, PhD, CPE, Behavioral Medicine Institute, during his lecture at PAINWeek.
However, getting patients to see a pain psychologist—a key step in teaching them coping skills—presents challenges, including the stigma and inconvenience of making additional appointments outside of their monthly visits to their pain specialist. To address some of these barriers, Dr. Jones teamed up with his colleagues at the Pain Consultants of East Tennessee, Knoxville, to teach coping skills within the practice.
Through trial and error, Dr. Jones and his colleagues settled on a program that offers pain patients a single, 2-hour, group session. “These single sessions are billed as a treatment for their medical condition [CPT 96153, 8 units], and a single session is easier to sell and mandate to patients,” noted Dr. Jones. The sessions focus on teaching the five key pain coping skills:
- Understanding includes providing educational information to the patients about how pain works (types of pain and an explanation of pain gates) as well as understanding specific treatment options. The difference between pain and suffering is also highlighted.
- Acceptance uses cognitive behavioral concepts to help patients have realistic expectation about therapy and reduce catastrophizing, a key variable in outcomes. Dr. Jones noted that many pain patients blame themselves for being a burden to their families, etc. The “shoulds” are a real problem ... “I should be able to do xyz,” noted Dr. Jones. Helping patients move from a “why me” attitude to “what now” is key to successful outcomes. Gratitude and acceptance are really important elements in recovery.
- Calming emphasizes the need to relax the body. Stress can amp up pain and by decreasing stress—through Tai Chi, meditation, relaxation techniques, and biofeedback—patients can help to reduce their pain. Proper breathing techniques is the number one skill patients can learn to help decrease stress. Dr. Jones demonstrated a simple 30-second breathing exercise, which helps patients “become belly breathers instead of shoulder breathers.”
- Balancing focuses on teaching patients how to get into helpful routines. “The goal is to establish a lifestyle that works for the long run,” noted Dr. Jones, including changing from “sprinters to marathoners.” He emphasizes proper sleep hygiene, saying “no,” time management, and activity pacing. The latter strategy can help break the cycle of “crash and burn, where patient over-do it when they are feeling good, and then spend the next two days in bed. We emphasis being the tortoise, not the hare. Slow down, and have enough energy in the evenings to be there for your family.”
- Coping helps patients ask “what kind of pain am I having?” and then teaching them ways to lessen the pain. This is particularly true for myofascial pain, which, when properly addressed by patients, can be lessened significantly. Dr. Jones also emphasizes distraction techniques to help patients get through a painful episode, including playing video games, doing crossword puzzles, and the like.
A single group session, also demonstrates to patients that “it’s not all about injections and pills,” he said. Plus, group therapy is cost-effective and convenient for patients and physicians. Patients also really benefit from being in a group together and seeing that they are not alone.
Lastly, “offering this class can transform a pain practice into a multidisciplinary pain program,” Dr. Jones concluded.
Insomnia Still Plagues Pain Patients
Insomnia is a common complaint among Americans, affecting 10% to 15% of the general population. But among chronic pain patients, insomnia is a double-edged sword—pain increases a patient’s risk of developing insomnia, and insomnia can worsen pain, according to Michael T. Smith, PhD, CBSM, Professor, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Aside from pain itself, sleep disturbances are one of the most common symptoms associated with chronic pain conditions. Insomnia is defined as sleep disturbances week for at least one month. Experimental and epidemiologic studies have demonstrated that far from being a simple consequence of pain, insomnia and sleep loss also may play a role in the transition from acute to chronic pain, induce hyperalgesia, and contribute to poor psychology and medical outcomes, noted Dr. Smith, who presented a number of cognitive behavior therapies that can be targeted for chronic pain patients.
The first line of treatment is to target the driving forces—stimulation control and sleep restriction. Dr. Smith emphasized that the bedroom only should be used for sleep and sex. “Many people use their bedrooms to eat, read, relax, and watch TV, but for patients with insomnia, one needs to re-establish the bedroom as a place just for sleep and sex.”
To help patient re-establish good sleep patterns, Dr. Smith first establishes a wake-up time for patients—this should be the same time every day, even on the weekends. Once this is established, then the bedtime can be pushed back later or earlier depending on the situation. Restricting sleep actually builds-up the “drive to sleep.” He noted, however, that initially patients may have more fragmented sleep, but gradually (over 2-4 weeks) patients will sleep for longer periods of time and wake up feeling more rested.
Dr. Smith also emphasized the use of good sleep hygiene practices, including aerobic exercise (4 times a week), having quiet time before bed (relaxation, meditation), and increasing internal body temperature. “Taking a hot bath before bed has a two-fold effect, it is a ritual way to wind-down and relax, as well as increase core body temperature, which helps produce slow-wave sleep,” noted Dr. Smith.
For patients whose circadian rhythms have been altered, he recommends the use of a light box, either in the morning or evening, depending on their condition. For example, for someone who is falling asleep too early, expose them to bright light three hours before bed. Night owls, on the other hand, should be exposed to bright light early in the morning. Dr. Smith cautioned about the use of illuminated e-readers, like iPad’s and other tablets, which can delay sleep (and annoy sleeping partners).
Opioid Abuse-Deterrent Technology
A number of posters at this year’s PAINWeek focused on new drug developments. A clear trend emerged—drug-deterrent technology. Lynn Webster, MD, co-founder and chief medical director of Lifetree Clinical Research, Salt Lake City, Utah, sat down with Practical Pain Management to discuss his work with one agent—MNK-785, which is being developed by Mallinckrodt Pharmaceuticals.
PPM: Why the need for yet another opioid medication?