What’s a clinician to do when your client’s are dealing with chronic pain?

1. Are Your Clients in Chronic Pain ?
Whats’ A Clinician To Do ???
Stanger,2018

2. Louise Stanger Ed.D, LCSW, CDWF

3. Thank you to
James Flowers
PhD,LPC-S

5. To close your eyes
Soften Your Gaze

8. Objectives
• Review and Discuss the site of
Chronic Pain today
• Discuss how Substance Abuse
and Anxiety and Depression
intertwines with Chronic Pain
• Discuss the relationship of the
Brain to Chronic Pain
• Discuss Alternative and
Complementary Strategies

9. Objectives
• Describe and Discuss What is
Similar and what is Different
between Families who
experience Chronic Pain and
Families who experience
Substance Abuse
• Identify Evidence Based
Strategies used with Chronic
Pain Families
• Give Case Examples

10. 100 Million- One in Ten
Americans - 1.5 Billion
Globally

11. Chronic Pain affects over
133 million Americans or
over 1/3 of our population
Annual cost of $635 million
More common among
women then men
More common among older
persons

12. Concussions
Facial pain
Neck Pain
Accidents -Driving, Texting
Exercising, Weekend
Warrior Tasks
Hips, Knees , Shoulders

13. Low back pain
Osteoarthritis
Rheumatoid Arthritis
Migraines
Fibromyalgia
Pelvic Pain
Carpel Tunnel Syndrome

14. Common Types of Chronic
Pain
• 28% Low Back Pain
• 15% Migrane or Headache
• 15 % Neck Pain
• 4 % Facial Pain
• #1 Cause of long term
disability

15. Pain that lasting longer then
12 weeks
For the most part pain has
been treated in terms of
body parts
Scientists are now
rethinking chronic pain

18. Is Chronic Pain-The Brain Game
?
Neuroimaging shows that
chronic pain alters the size of
certain brain regions
And the way certain brain
regions talk to one another
becomes abnormal
It effects the dorsolateral
prefrontal lobe - cognition
motor planning and memory

20. With chronic pain the
neurotransmitters
Prevent certain regions from
turning off when they should
Result the brain is overly
sensitive to pain and
stimulates a feed-forward
cycle that reinforces the
chronic pain state

21. Young People and Chronic
Pain
• Treated as if Health issues
can’t possibly be chronic
• Are told they are too young to
have Chronic Pain
• Worry they will never find a
romantic partner
• Worry they will never finish
school
• Sit by and watch as others their
age participate in activities that
they cannot do.

22. Work and Chronic Pain
• Cost estimated 62.1 billion
Jama
• Employers Believe:
• They are unreliable
• They are less productive
• They use pain as a excuse

23. Pain Patient becomes out of
control with medications
Becomes drug seeking -
quality of life decreases
Medication will continue or
increase despite side
effects .
Hyperalgesia

24. Impact of Chronic Pain on
Families
• Person with Pain
• - Pain that does not show
• -Fluctuating Activity Levels
• -Isolation in home and income
• -Unpredictable Mood Swing
• Doubt about reality of Pain
• Loss of friends, job, productivity
• Loss of plans , hope for the future
• Family Members
• -Inability to see or feel pain
• Increased responsibility for
maintaining home and income
• Loss of personal support
system
• Emotional Outbursts of person
with pain’Added Daily stress
• Loss of plans and hope for the
future

25. Families’ Responsibilities
• Responsible for daily care
• Dealing with insurance and
doctors
• Sometimes responsible for
income, food and lodging
• Responsible for being
Cheerleaders even when they
don’t want to cheer

26. Your Clients

27. Your Clients
May be Person with
Chronic Pain
Caretaker - Family
Other Relative
Employer

28. Emotional Consequences of
Chronic Pain
• Loss of Sexual Expression and
Intimacy
• 83 percent of spouses of mates
with CP report Depressive
symptoms
• Approach -avoidance -anger
guilt and hostility between
couples
• Pain becomes organizing force
which families coals around
• Perception of Pain can sustain
or enhance healing

29. The Power of Language
• What you say about Pain
Reflects on how you feel
• Affects how you feel
• SELF-FULLING PROPHECIES
• CATASTROPHIZING
• PROJECTING
• TEACHING ONE TO BE
THEIR OWN CEO-

30. COMMUNICATION
• HOW WE TALK AND LISTEN
MATTERS
• IMPORTANCE OF HUMOR
AND LAUGHTER
• CONNECTION BETWEEN
MIND- BODY AND OTHERS

31. Chronic Pain as
Homostaistis
• Stabilizing force in maintaining
family homeostasis
• Interpersonal conflicts are
overshadowed by dealing with
“sick” person this yielding “sick-
role “ Homeostasis”
• Pain can serve as an attention
getter- - a mother may feel
abandoned by her grown
children her chronic pain is an
attention getter
• A young adult child gets more
attention then siblings

32. Other Considerations
• Pain is never good without an
audience- excused from
chores, work etc
• People don’t hurt as much if
they have something better to
do
• Work and activities to set
goals, not to pain tolerance
• Empowerment/Goaling
Process
• Exercise

33. When we add Addiction & Mental
Health Issues to Chronic Pain
• A Losing Trifecta
• Put in PBS ARTICLE

35. Efficacious Modalities
Mindfulness- Meditation
ACT
CBT
MI - SFT
DBT
EDMR- Havening etc

36. Trauma

37. Traumatic Injury
Back& Neck Disorders
Complex Regional Pain Syndrome
Headaches and Migraines
Opiate hyperalgesia
CNS
Arthritis
Oro-Facial Pain
Fibromyalgia
Other Disabling Impairments

38. Definitions of Trauma
Overwhelming experiencing
that cannot be integrated
and elicit animal defensive
mechanisms and
dysregulated arousal
“A stress that causes
physical or emotional harm
that you cannot remove
yourself from”
Larke Huang , Director of
Health Care Equity at
SAMSHA

39. Trauma is objective
What happened ( I was
date raped , humiliated
, I fell of a ladder, had
a concussion, was in a
terrible accident etc

40. Trauma is subjective :
How do I perceive the situation ?
Relationship to early
child- hood experiences -
and Alcoholism
Adverse Childhood
Experience- 17,000
patients -Kaiser- effects
of trauma are cumulative
and one of most
destructive forms is
recurrent calling and
humiliation

41. What do your Clients Say about
Trauma and Chronic Pain ????
Verbal abuse
Physical abuse
Witnessing a tragedy
Accidents
Divorce
Death

42. Over Lapping Features of Chronic
Pain & Addiction
Trauma
Loss of Control
Loss of Mastery
Loss of Sense of Self
Cognitive Error
Overinterpretation
Catastrophizing
Personalization
Daily Life Alters
Trauma
Loss of Mastery
Loss of Control
Loss of Sense of Self
Loss of Self-efficacy
Cognitive Error
Denial
Daily Life Alters

43. “YOU CANNOT HEAL WHEN YOU
ARE STRESSED ALL THE TIME. “

44. As clinicians
You need to know what is
wrong with client
Obtain consent form to
speak with other
professionals
Be prepared to do a pain
assessment
Be Prepared to do a Family
Map as another way in to
Bio=psych Social

45. Understand the Role of
Complementary Therapies
Breathing
Mindfulness
Heart -Math

48. Qi-“Subtle breath”,Gong-“Vital
energy
Slow movements warm
tendons, muscles and
ligaments & Muscles, Promote
circulation of body fluids
Effective for chronic illness ,
emotional frustration, stress
and spiritual crisis etc (NQA)

49. Mind-body practice
Low Back Pain
Arthritis
2011studies
military

50. Music
Fibromyalgia, arthritis , joint pain , nerve disorder

51. Chronic Back pain, (2010-
2012)
Joint pain, (osteooarthritis)
Knee and Hip pain
Headaches/Migraine
Fibermyalgia
Detoxification

52. PT, Naturopaths,
Osteopathic Physicians,
Chiropractors
AHRQ -Low Back Pain
withers as effective as
medications
Headaches
Neck Pain

53. Aquatic Therapy

56. Let’s Talk Food
Reduce Pain and Inflammation

60. Meet Helen - 62 y.o
Female
Hip replacement
Knee replacement’
Shoulder
Constant pain-anxiety
Cancer survivor
Tried to commit suicide
Angry Husband & Family
Addicted

61. IN THE
BEGINNING
Not able to take breaths -
use of Heart Math
Self Esteem was missing
Smile was gone
Only memories of what
once was

62. I Have Lost
Relationships
Money
Self Esteem
Ability to Walk
Smile

63. Strategies
15 day detox- Pain still 20% due to
Hyperalgesia
Education
Cognitive Behavioral Therapy
Mindfulness
Mediation
Yoga etc - Canoeing- walking
Peer Support

64. Who would of ever thought
Canoeing

65. Meet Doug

66. Back Pain Severe-Not able to lift young children- possible candidate spine surgery
Mother Dying -house full of edibles and pills
Previous treatment for substance abuse
Unemployed
Stealing from wife and mother
Isolating
Lying
Family History- Ethoh and Pills
Co-Ocurring
About Doug

67. What’s working!

68. High Ropes Course

69. Showing Up

70. Meet Maddi
10 operations - 6 treatment centers

71. First major accident age 14
Family History of SA , MH and
Molestation
Pain Body
For past 9 years has been in and out of
treatment centers
Walking on crutches or not walking at all

72. Maddi gains trust with primary clinician
Maddi gains trust with exercises
Maddi Starts to talk to therapist
Family is confronted with their substance
abuse and their need to detach
Maddi experiences a difference in family
Maddi experiences a Community Integration
Approach
Maddi could be your next client

73. Accepted to premed

75. Families Learn
• Their History
• Their Ways of Communicating
• To take Care of Themselves
• To Discover Curiosity
• To Discover Joy
• To try Out New Ways of
Relating

76. Families Learn
• Chronic Pain , Addiction ,
Mental Health are all Diseases
• Boundary Setting-Responding
Not Reacting
• Caretaking is not always helpful
• Chronic Pain is 80% Emotion
• Join in the Solution

77. R, L. Nahim, Estimates of pain prevalence and severity in adults,
2012, “j Pain, vol.16, no 8 pp789-80
A. May, “Structural Brain Imaging. A Window into Chronic Pain", The
Neuroscientist,vol17,No 2,pp.2019-220, 2011
Napadow& R.E. Harris ,”what has functional connectivity and
chemical neuroimaging in fibromyalgia taught us about the
mechanisms and management of centralized pain ? Arthritis Research
and Therapy .vol 16
Ingemanson, Morgan PHD , “Chronic Pain Lives in the Brin, April 17,
2017 Vox Brain Map http://evoxbrainmap.com/chronic-pain-lives-
brain/

78. Nahin, R. ,Boineau, R, Partap. S. K.,
Stussman, Weber, N.D. Evidence -Based
Evaluation of Complementary Health
Approaches for Pain Management in the
Inited States , Sept. 2016
Why Goldilocks is my Rehab Heroine
https://meduim.com/cheryllee-98816/why-
goldilocks-is-my-rehab-heroine

79. Nahin, R. ,Boineau, R, Partap. S. K.,
Stussman, Weber, N.D. Evidence -Based
Evaluation of Complementary Health
Approaches for Pain Management in the
Inited States , Sept. 2016
Why Goldilocks is my Rehab Heroine
https://meduim.com/cheryllee-98816/why-
goldilocks-is-my-rehab-heroine

80. Resources
Driftwood Recovery https://www.driftwoodrecovery.com
http://www.nbcnews.com/nightly-news/video/louisville-kentucky-
sees-spike-in-heroin-overdoses-876423747884
Achenbach, Joel.The Washington Post, Dec.23, 2016. An opioid
epidemic is what happens when only treated with pills.
Gebelhoff, R. The opioid epidemic can turn into a pandemic if we
are not careful. The Washington Post .Feb. 9, 2017
https://www.washingtonpost.com/news/in-
theory/wp/2017/02/09/the-opioid-epidemic-could-turn-into-a-
pandemic-if-were-not-careful/?utm_term=.d7f5c8218e3c

81. Resources
Stanger articles https://www.allaboutinterventions.com/pain-
management-and-opioid-
addiction/http://www.huffingtonpost.com/entry/
Stanger, Porter, Flowers Huffington Post-Trauma and
Addiction http://www.huffingtonpost.com/entry/trauma-
addiction-whats-the-
difference_us_58d14912e4b0e0d348b347f3
Flowers Articles,https://www.thriveglobal.com/authors/3611-
james-s-flowers-phd-lpc-s-and-angela-harris-msw-candidate
Stanger,https://www.allaboutinterventions.com/current-
news/