PTSD, Opioid Dependence, and PTSD, Opioid Dependence, and EMDR: Treatment Considerations for EMDR: Treatment Considerations for

Chronic Pain PatientsChronic Pain Patients

W. Allen Hume, Ph.D.,C.D.P. W. Allen Hume, Ph.D.,C.D.P. Licensed PsychologistLicensed Psychologist

www.drallenhume.comwww.drallenhume.com

October 2, 2007October 2, 2007

22

COD client with PTSD seeking COD client with PTSD seeking services in a Pain Centerservices in a Pain Center

“ “We’re not bad people, we’re just human We’re not bad people, we’re just human beings who need help with pain. If nothing beings who need help with pain. If nothing else we need more help.”else we need more help.”

Male, aged 23Male, aged 23

33

Goals of the PresentationGoals of the Presentation

Define Posttraumatic Stress Disorder Define Posttraumatic Stress Disorder and identify the symptoms of trauma.and identify the symptoms of trauma.

Identify the prevalence rates of PTSD Identify the prevalence rates of PTSD and opioid dependence in pain patients.and opioid dependence in pain patients.

Outline a general approach to treating Outline a general approach to treating chronic pain patients with PTSD.chronic pain patients with PTSD.

Discuss the use of Eye Movement Discuss the use of Eye Movement Desensitization and Reprocessing Desensitization and Reprocessing (EMDR).(EMDR).

44

Posttraumatic Stress Disorder (PTSD) Posttraumatic Stress Disorder (PTSD) Defined Defined (DSM-IV-TR, 2000)(DSM-IV-TR, 2000)

Exposure to a traumatic event Exposure to a traumatic event The person experienced or witnessed an event The person experienced or witnessed an event

that involved death or serious injurythat involved death or serious injury Response involved intense fear, helplessness or Response involved intense fear, helplessness or

horrorhorror

3 Main Clusters of Symptoms 3 Main Clusters of Symptoms Re-experiencing the traumatic event Re-experiencing the traumatic event AvoidanceAvoidanceArousalArousal

Symptoms present for at least 1 mo. Symptoms present for at least 1 mo.

55

Post-traumatic stress (PTS) vs. Post-Post-traumatic stress (PTS) vs. Post-traumatic stress disorder (PTSD)traumatic stress disorder (PTSD)

PTS - traumatic stress that continues PTS - traumatic stress that continues following a traumatic incident following a traumatic incident (Rothschild, (Rothschild, 1995)1995)

PTSD - traumatic stress that produces the PTSD - traumatic stress that produces the symptoms of PTSD & implies a level of symptoms of PTSD & implies a level of daily dysfunctiondaily dysfunction

66

Two Types of Trauma Two Types of Trauma (Shapiro, 1995)(Shapiro, 1995)

Big “T” trauma - major traumasBig “T” trauma - major traumasWar, assaults, rape, physical violence, etc.War, assaults, rape, physical violence, etc.

Small “t” traumas - minor traumas or life Small “t” traumas - minor traumas or life disturbancesdisturbancesRidiculed, humiliated, “high school”Ridiculed, humiliated, “high school”

77

Prevalence of PTSD Prevalence of PTSD (Sharp, 2004)(Sharp, 2004)

20% of people will develop PTSD after a 20% of people will develop PTSD after a traumatic incident (van der Kolk, 1995).traumatic incident (van der Kolk, 1995).

In the general population, PTSD ranges between In the general population, PTSD ranges between 7%-12% (Seedat et al, 2001).7%-12% (Seedat et al, 2001).

Between 10-50% of chronic pain patients meet Between 10-50% of chronic pain patients meet criteria for PTSD. criteria for PTSD.

Mediating variables – age, preparation, belief Mediating variables – age, preparation, belief system, internal resources, hx of trauma, system, internal resources, hx of trauma, support, degree of trauma, & fear/level of threatsupport, degree of trauma, & fear/level of threat

88

PTSD Prevalence Rates ContinuedPTSD Prevalence Rates Continued

PTSD varies across selected samples PTSD varies across selected samples (Sharp, 2004)(Sharp, 2004) 39% in MVA39% in MVA 39% of assault victims39% of assault victims 7% of homicide survivors7% of homicide survivors 15.2% of male and 8.5% of female Vietnam Vets15.2% of male and 8.5% of female Vietnam Vets

80% of patients with PTSD meet criteria for at 80% of patients with PTSD meet criteria for at least one other psychiatric diagnosis least one other psychiatric diagnosis (Asmundson et al, 2002).(Asmundson et al, 2002). Major depression - most commonMajor depression - most common Anxiety disordersAnxiety disorders Substance abuse & Somatoform disordersSubstance abuse & Somatoform disorders

99

Rate of PTSD Among Individuals Rate of PTSD Among Individuals with Opioid Dependence with Opioid Dependence Mills et al. (2005)Mills et al. (2005)

Among 459 subjects in opioid treatment, Among 459 subjects in opioid treatment, 42 % had PTSD42 % had PTSD

Cost of treatment approximately same Cost of treatment approximately same over a 12 month periodover a 12 month period

PTSD clients had a poorer outcome in PTSD clients had a poorer outcome in occupational, physical and mental health occupational, physical and mental health functioning as well as more overdose.functioning as well as more overdose.

More relapse, readmissions, ongoing useMore relapse, readmissions, ongoing use

1010

Pain Definitions Pain Definitions Oaklander, A.K. (1999)Oaklander, A.K. (1999)

Acute PainAcute PainAdaptive, beneficial response necessary for Adaptive, beneficial response necessary for

preservation of tissue integrity preservation of tissue integrity

Chronic PainChronic PainTraditionally defined as > 6 monthsTraditionally defined as > 6 months It is pain that has outlived its usefulnessIt is pain that has outlived its usefulness

1111

Prevalence of Opioid Usage Prevalence of Opioid Usage Turk (2007)Turk (2007)

Most commonly prescribed med in USMost commonly prescribed med in US3% of non-cancer population (8.1M)3% of non-cancer population (8.1M)9.4 Billion dosage units per year9.4 Billion dosage units per yearApproximately 3.8-4% of chronic pain Approximately 3.8-4% of chronic pain

patients abuse their medicationspatients abuse their medicationsAberrant drug behaviorsAberrant drug behaviors Issue of pseudoaddictionIssue of pseudoaddictionCo-morbid disordersCo-morbid disorders

1212

Opioid Use Trends Opioid Use Trends NIDA Research ReportNIDA Research Report

1999 – 2.6 million misused pain meds1999 – 2.6 million misused pain meds1990-98 – 181% increase in usage1990-98 – 181% increase in usageOxycodone prescriptions rose 359% since Oxycodone prescriptions rose 359% since

1997 1997 (DASA, 2005)(DASA, 2005)

Methadone for non-opiate substitution Methadone for non-opiate substitution rose 312% since 1997 rose 312% since 1997 (DASA, 2005)(DASA, 2005)

WA state – 74 deaths related to heroin OD WA state – 74 deaths related to heroin OD & 138 from “other opiates” in 2005 & 138 from “other opiates” in 2005 (DASA, 2006)(DASA, 2006)

1313

Most Used Opioids Most Used Opioids

Oxycontin and other oxycodone Oxycontin and other oxycodone preparations (60%)preparations (60%)

Hydrocodone combined with Hydrocodone combined with acetaminophen (Vicodin like drugs)acetaminophen (Vicodin like drugs)

MorphineMorphine

1414

Do Opioids Work for Pain?Do Opioids Work for Pain?

WHO reports that opioids are effective in WHO reports that opioids are effective in controlling moderate to severe paincontrolling moderate to severe pain

Turk (2007) – Medications are central in Turk (2007) – Medications are central in pain management, they are not a pain management, they are not a panacea, nor cure. On average across panacea, nor cure. On average across studies they reduce pain by approximately studies they reduce pain by approximately 30% in 40-50% of patients. 30% in 40-50% of patients.

Carefully select patients for optimal Carefully select patients for optimal outcome based on history and response.outcome based on history and response.

1515

Prevalence of Addictive Disorders Prevalence of Addictive Disorders Among Pain PatientsAmong Pain Patients

General Population: 3-18%General Population: 3-18%Chronic Pain Population: 3.2-24%Chronic Pain Population: 3.2-24%Hospitalized Population: up to 26%Hospitalized Population: up to 26%Trauma Population: 40-62%Trauma Population: 40-62%Cancer-related Population: up to 27% or Cancer-related Population: up to 27% or

moremore

1616

Chronic Pain in Addicted Chronic Pain in Addicted PopulationsPopulations

MMT patients: 61.3% (Jamison, 2000)MMT patients: 61.3% (Jamison, 2000)MMT patients: 80%, with 37% severe MMT patients: 80%, with 37% severe

(Rosenblum, Joseph, et al, 2003)(Rosenblum, Joseph, et al, 2003)Among Inpatient Substance Use Among Inpatient Substance Use

Treatment patients: 78% (Rosenblum, Treatment patients: 78% (Rosenblum, Joseph, et al, 2003)Joseph, et al, 2003)

1717

Approach to Trauma TreatmentApproach to Trauma Treatment

Evaluation and Assessment Evaluation and Assessment Type of trauma & Type of trauma clientType of trauma & Type of trauma clientSafetySafetyRisk assessmentRisk assessmentMental status & co-morbid disorders Mental status & co-morbid disorders Medical History Medical History Family and occupational functioningFamily and occupational functioningMedication Medication

1818

Approach to Trauma TreatmentApproach to Trauma Treatment

Psychoeducation about trauma Psychoeducation about trauma Coordination of care with medical providersCoordination of care with medical providers Affect management skillsAffect management skills

Safe place exercise, groundingSafe place exercise, grounding Container methodContainer method

Calming the body downCalming the body down Meditation, breathingMeditation, breathing Yoga, chantingYoga, chanting

Integration of Traumatic Memories via EMDRIntegration of Traumatic Memories via EMDR

1919

What is Eye-Movement Desensitization What is Eye-Movement Desensitization and Reprocessing (EMDR)?and Reprocessing (EMDR)?

A type of psychotherapy for treating A type of psychotherapy for treating emotional difficulties that are caused by emotional difficulties that are caused by disturbing life experiences, ranging from disturbing life experiences, ranging from traumatic events such as combat stress, traumatic events such as combat stress, assaults to upsetting events.assaults to upsetting events.

EMDR is also being used to alleviate EMDR is also being used to alleviate performance anxiety, generalized anxiety, performance anxiety, generalized anxiety, sleep disturbances, phobias, grief, relapse sleep disturbances, phobias, grief, relapse prevention, and performance enhancement.prevention, and performance enhancement.

2020

Adaptive Information Processing: A Adaptive Information Processing: A Theoretical Model Theoretical Model

(Parnell, 2007; Shapiro, 1995)(Parnell, 2007; Shapiro, 1995)

We all have an information processing system We all have an information processing system through which new experiences and information through which new experiences and information are processed to an adaptive state.are processed to an adaptive state.

Trauma or disturbing experiences become Trauma or disturbing experiences become “trapped” in the nervous system.“trapped” in the nervous system.

In EMDR, we ask the patient to focus on a target In EMDR, we ask the patient to focus on a target memory.memory.

2121

Adaptive Information Processing Adaptive Information Processing ContinuedContinued

When information stored in memory networks When information stored in memory networks related to a distressing or traumatic related to a distressing or traumatic experience is not fully processed it gives rise experience is not fully processed it gives rise to dysfunctional reactions.to dysfunctional reactions.

Eye movements or BLS stimulates Eye movements or BLS stimulates accelerated information processing.accelerated information processing.

The goal is to reach “adaptive resolution” - The goal is to reach “adaptive resolution” - reduce vivid imagery and related affect & shift reduce vivid imagery and related affect & shift negative beliefs about oneself.negative beliefs about oneself.

2222

The Eight Phases of EMDR TreatmentThe Eight Phases of EMDR Treatment

The 8 phases of the EMDR protocol The 8 phases of the EMDR protocol represent a comprehensive treatment represent a comprehensive treatment approach.approach.1. Client History and Treatment Planning1. Client History and Treatment Planning2. Client Preparation2. Client Preparation3. Assessment3. Assessment

2323

The Eight Stages of EMDR Treatment The Eight Stages of EMDR Treatment ContinuedContinued

4. Desensitization4. Desensitization5. Installation5. Installation6. Body Scan6. Body Scan7. Closure7. Closure8. Reevaluation8. Reevaluation

2424

Assessment PhaseAssessment Phase

Target MemoryTarget MemoryPicturePictureNegative CognitionNegative CognitionPositive CognitionPositive CognitionValidity of Cognition (VoC)Validity of Cognition (VoC)EmotionsEmotionsSubjective Units of Distress (SUDs)Subjective Units of Distress (SUDs)Body SensationsBody Sensations

2525

Case ExampleCase Example

23 year old single male, withdrawn from college, 23 year old single male, withdrawn from college, history of oxycontin, marijuana, and alcohol history of oxycontin, marijuana, and alcohol abuse in remission prior to a serious MVA that abuse in remission prior to a serious MVA that resulted in dental/facial injury, PTSD, and resulted in dental/facial injury, PTSD, and uncontrolled pain. uncontrolled pain.

Presenting issue: Atypical dental/facial pain, Presenting issue: Atypical dental/facial pain, history of DV relationship with previous partner, history of DV relationship with previous partner, unable to access social/family support, and non-unable to access social/family support, and non-narcotic pain meds have been unhelpful for pain. narcotic pain meds have been unhelpful for pain.

2626

EMDR is a Widely Accepted TreatmentEMDR is a Widely Accepted Treatment

American Psychological AssociationAmerican Psychological Association American Psychiatric Association American Psychiatric Association U.S. Department of Veterans Affairs and U.S. Department of Veterans Affairs and

Department of DefenseDepartment of Defense United Kingdom Department of Health (2001)United Kingdom Department of Health (2001) Israeli National Council for Mental Health Israeli National Council for Mental Health

(2002) (2002) Dutch National Steering Committee Dutch National Steering Committee

Guidelines for Mental Health Care (2003).Guidelines for Mental Health Care (2003).

2727

Summary PointsSummary Points

Acute and chronic pain can be treated in Acute and chronic pain can be treated in the context of addiction, but optimally…the context of addiction, but optimally…

Patient must be willing to engage in Patient must be willing to engage in assessment and treatment of pain, assessment and treatment of pain, addiction, and psychiatric issuesaddiction, and psychiatric issues

In my experience, EMDR appears to be In my experience, EMDR appears to be helpful in the treatment of PTSD in helpful in the treatment of PTSD in addicted, chronic pain populationsaddicted, chronic pain populations