PTSD, Opioid Dependence, and EMDR: Treatment Considerations for Chronic Pain Patients

PTSD, Opioid Dependence, and

EMDR: Treatment Considerations for

Chronic Pain Patients

W. Allen Hume, Ph.D.,C.D.P.

Licensed Psychologist

www.drallenhume.com

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COD client with PTSD seeking

services in a Pain Center

“We’re not bad people, we’re just human

beings who need help with pain. If nothing

else we need more help.”

Goals of the Presentation



Define Posttraumatic Stress Disorder

and identify the symptoms of trauma.



Identify the prevalence rates of PTSD

and opioid dependence in pain patients.



Outline a general approach to treating

chronic pain patients with PTSD.

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Posttraumatic Stress Disorder (PTSD)

Defined



Exposure to a traumatic event

 The person experienced or witnessed an event that involved death or serious injury

 Response involved intense fear, helplessness or horror



3 Main Clusters of Symptoms

 Re-experiencing the traumatic event

 _Avoidance  Arousal

traumatic stress (PTS) vs.

Post-traumatic stress disorder (PTSD)



PTS - traumatic stress that continues

following a traumatic incident



PTSD - traumatic stress that produces the

symptoms of PTSD & implies a level of

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Two Types of Trauma



Big “T” trauma - major traumas

 War, assaults, rape, physical violence, etc.



Small “t” traumas - minor traumas or life

disturbances

Prevalence of PTSD

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

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

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

 Mediating variables – age, preparation, belief system, internal resources, hx of trauma,

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PTSD Prevalence Rates Continued



PTSD varies across selected samples

(Sharp, 2004)

 39% in MVA

 39% of assault victims

 7% of homicide survivors

 15.2% of male and 8.5% of female Vietnam Vets

 80% of patients with PTSD meet criteria for at least one other psychiatric diagnosis

(Asmundson et al, 2002).

 Major depression - most common

 Anxiety disorders

Rate of PTSD Among Individuals

with Opioid Dependence



Among 459 subjects in opioid treatment,

42 % had PTSD



Cost of treatment approximately same

over a 12 month period



PTSD clients had a poorer outcome in

occupational, physical and mental health

functioning as well as more overdose.

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Pain Definitions



Acute Pain

 Adaptive, beneficial response necessary for preservation of tissue integrity



Chronic Pain

 Traditionally defined as > 6 months

Prevalence of Opioid Usage



Most commonly prescribed med in US



3% of non-cancer population (8.1M)



9.4 Billion dosage units per year



Approximately 3.8-4% of chronic pain

patients abuse their medications

 Aberrant drug behaviors

 Issue of pseudoaddiction

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Opioid Use Trends



1999 – 2.6 million misused pain meds



1990-98 – 181% increase in usage



Oxycodone prescriptions rose 359% since

1997



Methadone for non-opiate substitution

rose 312% since 1997

Most Used Opioids



Oxycontin and other oxycodone

preparations (60%)



Hydrocodone combined with

acetaminophen (Vicodin like drugs)

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Do Opioids Work for Pain?



WHO reports that opioids are effective in

controlling moderate to severe pain



Turk (2007) – Medications are central in

pain management, they are not a

panacea, nor cure. On average across

studies they reduce pain by approximately

30% in 40-50% of patients.



Carefully select patients for optimal

Prevalence of Addictive Disorders

Among Pain Patients



General Population: 3-18%



Chronic Pain Population: 3.2-24%



Hospitalized Population: up to 26%



Trauma Population: 40-62%

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Chronic Pain in Addicted

Populations



MMT patients: 61.3% (Jamison, 2000)



MMT patients: 80%, with 37% severe

(Rosenblum, Joseph, et al, 2003)



Among Inpatient Substance Use

Approach to Trauma Treatment



Evaluation and Assessment

 Type of trauma & Type of trauma client

 Safety

 Risk assessment

 Mental status & co-morbid disorders

 Medical History

 Family and occupational functioning

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Approach to Trauma Treatment

 Psychoeducation about trauma

 _{Coordination of care with medical providers}  Affect management skills

 Safe place exercise, grounding

 Container method

 Calming the body down

 Meditation, breathing

 Yoga, chanting

What is Eye-Movement Desensitization

and Reprocessing (EMDR)?

 A type of psychotherapy for treating

emotional difficulties that are caused by disturbing life experiences, ranging from traumatic events such as combat stress, assaults to upsetting events.

 EMDR is also being used to alleviate

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Adaptive Information Processing: A

Theoretical Model

(Parnell, 2007; Shapiro, 1995)

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

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

Adaptive Information Processing

Continued

 When information stored in memory networks related to a distressing or traumatic

experience is not fully processed it gives rise to dysfunctional reactions.

 Eye movements or BLS stimulates accelerated information processing.

 The goal is to reach “adaptive resolution” -

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The Eight Phases of EMDR Treatment



The 8 phases of the EMDR protocol

represent a comprehensive treatment

approach.

 1. Client History and Treatment Planning

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Assessment Phase

Target Memory

Picture

Negative Cognition

Positive Cognition



Validity of Cognition (VoC)



Emotions



Subjective Units of Distress (SUDs)

Case Example

 23 year old single male, withdrawn from college, history of oxycontin, marijuana, and alcohol

abuse in remission prior to a serious MVA that resulted in dental/facial injury, PTSD, and

uncontrolled pain.

 Presenting issue: Atypical dental/facial pain,

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EMDR is a Widely Accepted Treatment

 American Psychological Association

 _{American Psychiatric Association}

 U.S. Department of Veterans Affairs and Department of Defense

 United Kingdom Department of Health (2001)

 Israeli National Council for Mental Health (2002)

 Dutch National Steering Committee

Summary Points



Acute and chronic pain can be treated in

the context of addiction, but optimally…



Patient must be willing to engage in

assessment and treatment of pain,

addiction, and psychiatric issues



In my experience, EMDR appears to be

helpful in the treatment of PTSD in