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Pain, Addiction and the Complicated Patient

R. Corey Waller MD, MS, FACEP, ABAMDirector, Center for Integrative MedicineSUD Medical Director, Network180Chief, Division of Pain Management

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PAIN

Pain

“If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.”

― Marcus Aurelius, Meditations

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Pain Treatment

• Opioids

• NSAIDS

• α2δ (alpha2delta) modulators (gabapentin, pregabalin)

• SNRIs

• Tricyclic's

• ASA

• Actaminophen

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The Android Effect

Behavioral

• Mindfulness, Meditation• Brain Mechanisms Supporting the modulation of pain by Mindfulness

Meditation. F. Zeidan et al. Journal of Neuroscience, Vol. 31, No.14, 5540-5548; April 6, 2011

• Operant, CBT, DBT, MET etc.• Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S,

Assendelft WJJ, Main CJ. (2010). Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews (7)

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Addiction(now SUD - mild, moderate or severe)

Addiction

“I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom.”

― Edgar Allan Poe

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Short Definition of Addiction:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

What is driving addiction?

Positive Reinforcement - rewards that strengthen a conditioned response after it has occurred, such as the feeling of euphoria after taking a hit

Negative Reinforcement – stimuli (e.g., stress) that are removed when the desired response (e.g., drug use) has been obtained

■ Escape conditioning - learning to escape an unpleasant or aversive stimulus (using drugs to reduce stress)

■ Avoidance conditioning – Learning to avoid an aversive stimulus (e.g., stress) before it occurs (e.g., using drugs before going to a stressful mtg)

Addiction

Pain

Medication assisted treatment

Opioids Methadone, Suboxone, Vivitrol

Alcohol Vivitrol, acamprosate, disulfiram, topiramate

Stimulants Citalopram, Modafinil

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DBS for Addiction

Central and Lateral bed of the Amygdala

Anterior cingulate gyrus (ACG)

Nucleus Accumbens (NAc)

Ventral Tegmental Area (VTA)

Anterior Cingulate Gyrus

Behavioral

Self Help

CBT

MET

Mindfulness

Solution Based Therapy

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The Complicated

Patient

Confounding Issues

Early Life Trauma

Superimposed MI

Social Instability

Familial Predisposition

The Current Health Care System

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What Next?

Truly Integrated behavioral and medical care

Payment System Reform

Standards of Care for the treatment of MI and SUD

My own personal therapist22

Questions?

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