9/1/14 TOTAL CARE FOR TOTAL PAIN W. Clay Jackson, MD, DipTh Disclosure ¨  Receive consulting fees from Sunovion Pharamceuticals, Inc., Merck Pharamceuticals, Otsuka America Pharmaceutical, Inc. and Pamlab; and fees for non-CME services directly from Pamlab. 1 9/1/14 ‘Pain is a more terrible lord of mankind than even disease itself.’ Albert Schweitzer 2 9/1/14 What is Palliative Care? Management of symptoms, chiefly in patients with advanced disease in whom medical recovery is not expected ¨  Latin pallus (‘cloak’) ¨  Meet Tabitha 47 yo Caucasian female ¨  Stage IV cervical cancer ¨  Diagnosed 18 mos prior; chemotx failed ¨  In hospice for 6 weeks ¨  Uncontrolled pain, anxiety at home ¨  3 9/1/14 The Back Story An American girl takes a Dutch lover (14 yrs later) ¨  The American girl’s parents aren’t so thrilled ¨  Religious tension ¨  Cultural challenges ¨  4 9/1/14 The Technologic Imperative ‘Anything you can do, I can do better…’ ¨  Parenteral interventions ¨  ¤  IV hydromorphone ¤  IV lorazepam ¨  Upping the ante on anxiolysis and sedationhypnosis ¤  Quetiapine qhs 5 9/1/14 It is more important to know what manner of patient has the disease, than to know what manner of disease the patient has. Sir William Osler Osler, ca. 1900 CE The Law of Diminishing Returns ¨  Vacillating between two poles ¤  Comfortable and sedated ¤  Conscious and symptomatic Tabitha & Hans both unhappy ¨  Anxious and concerned family ¨  ¤  Frequent, extended visitation ¤  Intense prayers 6 9/1/14 ‘The sorrow that has no vent in tears may make other organs weep.’ Sir Henry Maudsley, MD 1835-1918 Melancholia, Degas Mind-body Connections: (or, how Cartesian duality led us down a blind path) 7 9/1/14 The mind is its own place, And in itself Can make a Heav’n of Hell, A Hell of Heav’n. John Milton, 1608-74 Neuroendocrine, Neuroimmune, and Autonomic Dysregulation in Fibromyalgia ¨  Ach=acetylcholine ¨  ACTH=adrenocorticotropic hormone ¨  BDNF=brain-derived neurotrophic factor ¨  CRH=corticotropin-releasing hormone ¨  CRF=corticotropin-releasing factor ¨  DA=dopamine ¨  Glu=glutamate ¨  IL=interleukin ¨  NE=norepinephrine ¨  NO=nitric oxide ¨  PGs=prostaglandins ¨  PVN=paraventricular nucleus ¨  SP=substance P ¨  TNFα=tumor necrosis factor-alpha ¨  5HT=serotonin Maletic V, et al. Frontiers Bioscience. 2009;14:5291-5338. 8 9/1/14 ‘No one ever told me that grief feels so like fear.’ C.S. Lewis, A Grief Observed Pain Reaches the Brain: Circuitry Involved in Pain Processing Lateral thalamic nuclei Medial thalamic nuclei Somatosensory pain processing Secondary affect: Integration of sensory and cognitive aspects of pain processing Affective pain processing SI SII Insula PPC Amygdala ACC=anterior cingulate cortex PPC=posterior parietal cortex SI, SII=primary and secondary somatosensory areas of cortex ACC Perirhinal Cortex Hippocampus Apkarian AV, et al. Eur J Pain. 2005;9:463-484; Klossika I, et al. Pain. 2006;124:264-268. 9 9/1/14 Gate Theory Input modulation by cognitive, emotional valences shape the pain experience of the individual ¨  Pain is a complex perceptual and affective experience with many determinants and modulators: ¨  ¤  Attention ¤  Anxiety ¤  Suggestion ¤  Distraction Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1962;150(3699):971-978. Emotions and Stress May Modulate Amygdala's Response to Pain ACC Thalamus Positive Emotion (music, pleasant odors, etc) Amygdala Negative Emotion Chronic stress Increases amygdala activity Inhibits amygdala activity + – Pain Modified from: Neugebauer V ,et al. Neuroscientist. 2004;10:221-234. Schloesser RJ, et al. Neuropsychopharmacology. 2008;33:110-133. 10 9/1/14 The Denouement A private conversation with Hans ¨  Restriction of family visitation ¨  Peace ¨  Rapprochement ¨  Components of Total Pain Physical ¨  Psychological ¨  Social ¨  Emotional ¨  Spiritual ¨  Dame Cicely Saunders Saunders C, Sykes N, ed. The management of terminal malignant disease. 1993; 1-14. 11 9/1/14 Multidimensionality of Total Pain Mehta A, Chan LS. Understanding the concept of total pain. J Hospice Pall Nursing 2008;10:26-32. Pain as Multidimensional Experience Quality of Life •  Physical functioning •  Ability to perform activities of daily living •  Work •  Recreation Psychological Morbidity •  Depression •  Anxiety, anger •  Sleep disturbances •  Loss of self-esteem Social Consequences •  Marital/family relations •  Intimacy/sexual activity •  Social isolation Socioeconomic Consequences •  Healthcare costs •  Disability •  Lost workdays Chaudhary , SI. Walking the Fine Line of Pain Management in Addiction. Available at: www.seclairer.com/.../Walking_the_ fine_line_of_pain_mangement_and_addiction.ppt 12 9/1/14 Why is my pain perpetual? Jeremiah 15.18 (KJV) I realized that I had nothing to offer her but myself. 13