Beth Gilbert

Pain syndromes are commonly associated with other comorbid conditions, including personality disorders. Understanding and effectively treating a patient’s underlying personality disorder can greatly improve pain control and outcomes.

During a morning session on the final day of the 2013 American Academy of Pain Medicine annual meeting, held April 12-14 in Fort Lauderdale, FL

 Ravi Prasad, PhD, Stanford University Medical Center in Redwood, CA, provided an overview of personality disorders and explained how they can impact and complicate efforts to provide effective pain management. He said personality disorders typically begin in adolescence or young adulthood, and are associated with inflexibility and pervasiveness. Theses conditions are typically stable over time and lead to disturbances and impairment. Patients typically present with an evolving pattern of behavior, which differs from cultural norms.

Prasad discussed the different clusters of personality disorders, as outlined by the DSM IV. He said there are three clusters of personality disorders: cluster A, cluster B, and cluster C. Cluster A patients are typically “odd and have an eccentric presentation,” he said. Cluster A disorders include paranoid personality disorder, schizoid, and schizotypal. Individuals with paranoid personality disorder are typically distrusting, suspicious of others, and reluctant to confide but do not present with psychotic features. Individuals with schizoid presentation are detached from social situations and relationships and are commonly isolated and solitary. Individuals with schizotypal disorder do not like close relationships and have social anxiety. They typically question the loyalty of others but have magical thinking and can present with odd speech.

Prasad said cluster B patients are typically dramatic, emotional, and erratic. Disorders characterized as cluster B include antisocial, borderline, histrionic and narcissistic personalities. Individuals with an antisocial personality have a disregard for the law and safety. They can be deceitful, show a lack of remorse, and present with aggressive behavior. Individuals with borderline personality disorder have a fear of abandonment, commonly have instability in relationships, and are reckless, impulsive, and often engage in self mutilation. Individuals with histrionic personality types need to be the center of attention and commonly are very dramatic. They overvalue relationships and engage in seductive and provocative behavior. Individuals with a narcissistic personality are grandiose, arrogant, jealous, and aggressive. They commonly lack empathy and are excessive fanatics about power.

Cluster C patients are anxious and fearful upon presentation. Disorders characterized as cluster C include avoidant, dependent, and obsessive/compulsive. Individuals with an avoidant personality are fearful of rejection and engage in low-risk behaviors. They commonly feel inadequate and engage in avoidance behavior. An individual with a dependent personality has low self-confidence, constantly needs advice, and goes to extreme lengths for support. Individuals with obsessive/compulsive disorder are preoccupied with order and details. They are obsessed with perfectionism and inflexible and commonly rigid and miserly upon presentation.

Prasad said that many individuals exhibit some of these personality traits but do not meet enough criteria to be clinically classified as having a personality disorder. While drug therapy is an option for treatment of some of these personality disorders, Prasad said cognitive behavior therapy (CBT) is an effective option for patients. The foundation of CBT lies in being aware of thoughts and understanding how thoughts can influence behaviors. By encouraging patients to understand this, CBT aims to shift dysfunctional thoughts into more positive behaviors that provide for better outcomes in thinking and other comorbid conditions such as pain.

Beth Darnall, PhD, of Stanford University in Redwood, CA, further expanded on CBT and discussed how patients can self-manage pain by being aware of their thoughts, feelings, and behaviors. Darnall discussed recent studies that demonstrated the efficacy of CBT in improving pain, disability, mood, and catastrophizing.

Another option for treating pain and personality disorders is mindfulness mediation, which involves “paying attention on purpose,” in the present moment, without judgment. It is an acquired skill that focuses on everyday activities. There are different approaches to mindfulness mediation, including Zen meditation, mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT).

MBSR is typically done as a part of program that involves several weeks of treatment and includes a body scan, mindful yoga, sitting mediation, guided mindfulness recordings, and homework for mindfulness in daily activities. While this approach can be expensive, it has demonstrated improvements in attention, rumination, emotional activity, and self-compassion. It has also been associated with decreased blood pressure, improved immune function, reduced cortisol levels, and increased cognition. Darnall said MBSR is an excellent monotherapy for stress management but more effective as an adjunct to treatment for patients with anxiety, depression, and chronic pain.

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Understanding and addressing these disorders can improve the patient's mental health as well as their chronic pain and other comorbid conditions. Incorporating cognitive behavioral therapy and mindfulness-based cognitive therapy into the management of chronic pain has been shown to improve pain outcomes.

Underlying Personality Disorders Can Complicate Chronic Pain Management

Complex regional pain syndrome (CRPS) is a chronic pain condition that involves pain most commonly in the arms and legs but can affect all areas of the body. Approximately 50,000 new cases of CRPS occur annually and there remains a need for improved treatment options.

During a morning session on the final day of the 2013 American Academy of Pain Medicine annual meeting, being held April 12-14 in Fort Lauderdale, Florida

 Joshua Prager, MD, MS, of the University of California in Los Angeles, moderated a session focusing on treatment options for CRPS. Prager began by discussing the International Association for the Study of Pain (IASP) CRPS treatment algorithm that includes the WHO analgesic ladder, anticonvulsants, tricyclics, free radical scavengers, vasodilatory medications, vitamin C, ketamine, neurostimulation, and neuroablation.

Salim Hayek, MD, PhD, of Case Western University in Cleveland, OH, provided an overview of the evidence available for CRPS treatment options. He said that while the disease was previously categorized into three stages, current medical practice looks at the disease as a continuum, with only 10% of cases progressing.

Hayek also discussed several pharmacologic and non-pharmacologic treatment options for CRPS. In terms of pharmacologic management, he said there is no single drug that completely addresses the overall condition. Typically, physicians should be prepared to use a variety of options to help control the pain and other symptoms associated with the condition. There is very little evidence that NSAIDs are effective for the treatment of CRPS. In addition, TNF-alpha blockers have only demonstrated some anecdotal evidence of effectiveness. However, treatment with dimethylsulfoxide 50% (DMSO) and n-acetylcysteine (NAC) has been shown to be relatively effective in the management of CRPS.

While opioids can be effective in some patients with CRPS, there is very little evidence that supports the use of these drugs in this patient population. Hayek noted there is also little evidence that antidepressants aid in pain relief associated with CRPS. NMDA antagonists and ketamine have shown some efficacy in the treatment of the condition. There is very little evidence that antihypertensives work. He also said there is conflicting evidence surrounding bisphosphonates, though intravenous immunoglobulin (IVIG) has shown some promise.

In terms of interventional procedures, sympathetic blocks, continuous infusion techniques, spinal cord stimulation (SCS), bupivacaine, baclofen, and botox have all been shown to be effective to varying degrees, though highly patient-specific. However, sympathectomy has been removed from the treatment algorithm due to the high risk of neuralgia.

Prager concluded the session by reviewing several new approaches to treating CRPS, with a focus on the importance on individualizing treatment for each patient. He noted that intrathecal baclofen should be used for dystonia and provided a compelling case study that demonstrated major improvements in motor skills over a two year period. Other promising approaches currently being incorporated into the CRPS treatment algorithm include ketamine, physiological/occupational therapy, vitamin C, and SCS.

Overall, an integrated approach to the treatment of CRPS should be followed that includes rehabilitation, pain management, and psychological management. According to Prager, physicians should think about CRPS management as a continuum that requires a flexible treatment approach. They should use opioids only to help patients get through physical therapy. Physicians should find the best method of pain and/or motor control to get the patient through physical therapy, as this combination will likely lead to more successful patient outcomes.

Successful CRPS management should be viewed as a continuum that requires a flexible treatment approach that incorporates pharmacologic and nonpharmacologic components. 

Advances in the Management of Complex Regional Pain Syndrome

Pain is a common complication associated with all types of cancer. However, management of cancer pain varies from physician to physician and patient to patient, as pain can be attributed to a number of factors, including disease process, treatment, and presence of other comorbid conditions. Effectively managing pain associated with cancer can improve outcomes as well as survival.

During a morning session on the final day of the 2013 American Academy of Pain Medicine annual meeting, held April 12-14 in Fort Lauderdale, Florida

 Vitaly Gordin, MD, of Penn State Hershey Medical Center in Pennsylvania, moderated a session focusing on improvements in the management and diagnosis of pain associated with cancer.

During the session, Gordin discussed the incidence of cancer pain, noting that approximately 10% of cancer patients with pain fail to achieve adequate pain control according to the WHO guidelines. In addition, approximately 30% have poor pain control. Addressing pain is becoming a more important part of treatment, as more patients are surviving for longer and cancer is becoming more of a chronic condition.

Gordin also discussed the types of cancer pain syndromes, including those caused by the disease process, psychological factors, and drug therapy. He said there are two types of pain syndromes — somatic and neuropathic pain syndrome. Neuropathic pain syndromes include chemotherapy-induced neuropathic pain (CINP), radiation-induced pain, and tumor-induced pain. Although severe pain associated with the disease and/or treatment can hinder cancer treatment, which can decrease survival, Gordin said that unfortunately the trend has been to exclude pain specialists from cancer pain management. Greater involvement of pain specialists in the cancer team and more focus on cancer pain management is essential for improvement of quality of life and survival.

Allen W. Burton, MD, of Houston Pain Associates in Texas, further expanded upon the unmet need in the management of cancer pain. He said studies have shown that approximately 20-30% of cancer is poorly controlled, and some physicians are not aware of the effectiveness of interventional pain approaches. Interventional approaches may be an option in patients with pain that is refractory to medical management or in patients who are unable to tolerate the side effects of drug therapy. It may also be an option for patients with focal pain or who are contraindicated for standard medical management.

There are a variety of options including neuraxial therapy, vertebral augmentation, celiac plexus block, nerve block, radiofrequency, and simple injections. Burton said that cancer pain management is becoming much more like chronic pain management and it should be understood that physicians do not have to follow a traditional pain treatment protocol, as they should design a pain management approach that fits with the patient’s individual needs.

In the last presentation of the session, Larry Driver, MD, of MD Anderson Cancer Center, University of Texas in Houston, discussed some of the difficulties confronting clinicians who try to provide effective cancer pain management, noting that one of the biggest challenges is the sheer number of types and causes of cancer pain, including acute pain, chronic pain, persistent pain, episodic pain, basal pain, breakthrough pain, pain related to disease or treatment, nociceptive, neuropathic, and/or inflammatory pain.

Opioids are commonly used to manage cancer pain. However, opioids can be associated with several severe side effects, including sweating, constipation, dry mouth, nausea and vomiting, and sedation. Less commonly, opioids can also be associated with respiratory depression, pruritus, decreased testosterone levels, opioid-induced neurotoxicity, and opioid-induced endocrinopathy. Driver said that methadone is a longer acting opioid that is ideal in cancer pain management due to its potency. However, methadone can be hard to prescribe due to the drug’s long elimination half-life and associated cardiac issues.

Fentayl is another option for the treatment of breakthrough pain and is available in various forms including tablet, spray, lozenge, film, and sublingual tablets. Driver recommended rotating among opioids and fentanyl formulations, as some approaches may be better suited for each patient’s particular needs.

Pain is a common side effect of cancer that can be caused by the disease itself, treatment, and other factors. Greater awareness of the causes and types of cancer pain, knowledge of available treatments, and willingness to consult pain specialists are the keys to providing effective cancer pain management. 

Overcoming the Challenges to Effective Cancer Pain Management

Pain has been associated with a number of conditions, including addiction, depression, and anxiety. Pain, as a separate condition, is very difficult to treat, but layer in the effects of depression, anxiety, and/or addiction; it can be even more complicated to treat. A key to treating pain is also treating depression, anxiety, and addiction. A strong understanding of the medications available and how to most effectively utilize them in clinical practice is essential.

During a morning session at the 2013 American Academy of Pain Medicine annual meeting, held April 12-14 in Fort Lauderdale, FL, Binit J. Shah, MD, and Christina M. Delos Reyes, MD, of Case Western University School of Medicine in Cleveland, OH , provided an overview of psychopharmacology and pharmacology for addiction and other conditions.

During the session, Shah discussed the epidemiology of depression and provided an overview of the medications available to treat depression. While some antidepressants are only effective for pain and anxiety, some are also effective in managing comorbid pain. The good thing with antidepressants is that they work, said Shah. Recent studies have demonstrated that 50-70% of patients that take an antidepressant experience symptom improvement. While suicidal thoughts and ideation are a risk with some of the antidepressants, the risk is minimal and limited mainly to patients under 25 years of age.

Shah walked through the types of antidepressants, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin—norepinephrine reuptake inhibitors (SNRIs), and other agents. He provided insight into the different types of drugs in each of these categories and provided information on associated side effects, effective dosing for depression and pain, as well as management and expectations of treatment. 

Duloxetine has the most indications for pain and has dosing for both mood/anxiety as well as for pain. Milnacipran is approved in the United States for the treatment of fibromyalgia but may also have anti-depressive effects because it is approved in the European Union for depression. SSRIs have been disappointing in the management of pain relief but very effective for treating mood and anxiety. Benzodiazepines are typically overprescribed and less effective in practice than had originally been thought. Most society guidelines do not recommend benzodiazepines for anxiety, post traumatic stress disorder, panic disorder, and general anxiety disorder.

Other agents are available for treating pain and associated comorbidities, and understanding where to start is important. Typically, for patients who present with pain and depression, duloxetine is a good first line approach, followed by escitalopram or sertraline (SSRIs). If neither of those approaches work then switching to another SSRI may provide better outcomes. If that still doesn’t provide any relief of pain or mood symptoms then using a combination or augmented therapy approach may be another option. However, patients being put on a combination or augmented therapy approach should be referred to specialist who can monitor them more closely.

Reyes further expanded upon pharmacology for addiction and provided an overview of the epidemiology of addiction. Approximately 15.9% of individuals in the United States will experience drug abuse at some point in their lives and approximately 31% will experience risky use of drugs, including binge drinking and drunk driving. There is a large treatment gap in addiction, with only one in 10 people with addiction getting the treatment that is needed.

There are a number of agents available for the treatment of alcohol dependence, opioid dependence, and nicotine dependence. Agents available for alcohol dependence include disulfiram, which breaks down alcohol and is an action stage treatment; acamprosate, which reduces withdrawal after refraining from drinking; and naltrexone, which is available as an oral medication and injection and used for both opioid addiction and alcohol dependence. Other agents that can be used for alcohol dependence include topiramate, which would be considered off label, nalmetone, and ondansetron, which is commonly used in younger alcoholics and decreases the number of days of drinking per month.

Agents available for opioid dependence include naltrexone, methadone, and buprenorphine, which can be difficult to prescribe due to regulations on the number of patients a physician can treat with the medication. Other agents used for nicotine addiction including nicotine replacement therapy with the patch, bupropion, nortriptyline, rimonabant, nicotine vaccine (not FDA approved), and varenicline.

Pain has been associated with a number of conditions, including addiction, depression, and anxiety. Greater awareness of concurrent comorbid conditions and the options available to treat them produces better outcomes in chronic pain patients. 

Beth Gilbert

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