Well, hello, everybody. Today myself, Michael Clark, and my colleague, Rachel Noble, will be discussing with you the management of pain without opioids. I'm currently the chair of the Department of Psychiatry and Behavioral Health at the Inova Health System in Fairfax, Virginia, and I'm the former director of the Pain Treatment Program in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins Medicine. I have no financial relationships to disclose for this presentation, and our objectives today are to utilize a comprehensive framework for formulating an individualized treatment plan for those patients with disabling and refractory chronic pain syndromes, and we'll discuss prescribing a variety of non-opioid therapies for the treatment of specific disorders based on the individualized case formulations. If you think about what happens to the typical patient with chronic pain and depression, I think you'll see that this is a familiar course for the patient, and unfortunately, usually disappointing for both the patient and the practitioners involved. So let's start with the usual case, a 53-year-old woman with low back pain and depression. She complains of pain in her legs, greater on the right than the left, but essentially hurts everywhere. Her mood is sad, frustrated, and angry, and she feels that she really cannot do anything at this point. What typically follows is a series of surgeries, a discectomy, a laminectomy, and then finally a fusion. The patient no longer is able to work. The husband is distant in the relationship, and her friends have moved on to other people who are more functional. She takes opioids on a variable schedule that makes the pain less horrible, in her opinion, but provides no lasting relief, and various injections help for a while, but not for long, and she's failed multiple medications. She cannot tolerate physical therapy and essentially stays home. Her primary care physician has started her on an SSRI without any significant benefit. And then we can catalog the treatments that she's likely to receive. She has a team of consultants, the surgeon who is now considering removing the hardware and extending her fusion, an anesthesiologist who will continue the injections and consider a spinal cord stimulator. Her primary care physician will continue the SSRI, add muscle relaxants, and eventually a sleeping pill. The physical therapist will consider a gym membership to initiate exercise. The psychologist will help her to learn better coping skills and attend a support group. In the emergency room, they accuse the patient of abusing drugs and ask her not to return. Her attorney is now applying for disability and considering suing the surgeon. They provide a holy grail of causes and a magic bullet of treatment. And as you might expect, the usual outcome is that her pain and depression persist and worsen, the medications increase in number and dose, her psychosocial condition deteriorates, her healthcare utilization increases, disability is eventually received but constantly challenged, and an ongoing stress for the patient. She's referred for urgent psychiatry consultation because of suicidality. But overall, she spends more time online telling her own horrible story and hearing others' even worse stories. She refuses advice of consultants to pursue interdisciplinary pain rehabilitation, and we all hope that she is one of the 35% of patients that get 35% better in the randomized controlled trials that have been published. Overall, not a very satisfying outcome for anyone. So I'd like to walk us through variations of this case to differentiate some of the presentations and underlying causes of the problems that the patients are experiencing and then how the treatments should follow from that formulation. We'll start off with a perspective of diseases in which these cases have abnormalities in structure or function of bodily parts and have parts, in quotes, that require fixing or at least trying to repair them as best we can. This is the classic medical model where we see a clinical syndrome that has been produced by underlying pathology that's been caused by specific etiologies. And so now we're back to our original stem of a 53-year-old woman with low back pain and depression, pain in her legs, greater on the right than left, hurting everywhere with increasing weakness. Her mood is sad, frustrated, angry, and she still can't function. But now on closer examination, we see that pain follows the L5 dermatome on the right with a burning quality. Her depression is unresponsive to positive life events, and she exhibits anhedonia. Since being on increased amounts of opioids, her depression is actually worse rather than better. And a low-dose SSRI improved her mood and motivation, but that waned over time. Both gabapentin and pregabalin have decreased her pain but caused intolerable sedation. So how should we tailor the treatment of this patient? Here I think it becomes more obvious that we can diagnose major depression and a radicular neuropathic pain. The plans for any further surgery and interventions are put on hold. The ineffective medicines that she's been taking that lack specificity are slowly tapered and discontinued. And now an SNRI, a serotonin norepinephrine reuptake inhibitor, is started and titrated over several weeks. An anticonvulsant is added for augmentation and titrated with serum-level monitoring when available. And as a result, her husband becomes more encouraged and more supportive upon seeing the improvements that she's starting to experience. There's a spontaneous increase in her activities of daily living and a return to exercising. And finally, discussions get initiated with her employer about possibly returning to part-time work. Some of the therapies that are involved in this case really center around the medications that are available to us for treating conditions like major depression as well as neuropathic pain syndromes. Tricyclic antidepressants are the old gold standard. And they are still very effective but have some complications in management and some potential toxicities or other side effects that may be problematic. The SSRIs have been overly relied on in pain management circles because of their ease of use and fewer side effects, and yet they have less efficacy in neuropathic pain and ultimately major depression remains undertreated and underrecognized. Now the SNRIs are the current focus and they have independent efficacy for both chronic pain that is neuropathic in origin as well as major depressive disorder. And just like the tricyclic antidepressants, the norepinephrine component appears to be a critical cofactor in the efficacy that we see with neuropathic pain syndromes. It is important to emphasize that regardless of the approach, helping a patient with major depression and chronic pain achieve remission of those depressive symptoms will ultimately have the greatest impact on an improvement in their pain and their functioning. And so here we see a more optimistic outcome. Depression remits with positive emotions, optimism, and energy returning. The pain has decreased in intensity with the residual pain that remains described by the patient as not interfering with her functioning. Now her activity increases with a gradual disappearance of secondary myofascial pain. Active exercise normalizes her body mechanics and increases her strength, helping her to function even better. Previous success in work is used as a rationale to return to work full-time, which she's looking forward to, and the marital stress and financial problems improve as the patient and her husband begin to work together and to see that functional improvement is on the horizon. Her socialization with friends increases and is reinforced by a returned network of support. And now she no longer has time for doctor's appointments and internet chat rooms and can return to a more productive and satisfying life. Let's take this in contrast to a case that we can view from a dimensional perspective. Dimensions focus on quantifiable and measurable personal traits. Those traits have inherent strengths and vulnerabilities, which become potentials for us depending on the demands of our situation. Those demands then provoke a response, a response of one where we feel capable if they are well-matched or in which we feel as if we are incapable and become distressed. And so we're back to our original stem. But now the pain is described more as a dull ache with a tightness that runs from the hip down the outer thigh to the knee. The patient has multiple somatic symptoms, and her review of systems is virtually pan-positive. Her depression is described more as anger with the lack of progress and anxiety over her persistent symptoms. And most of her medications cause side effects and lead to further distress because she believes they're just masking the cause. She spends an excessive amount of time cataloging her symptoms and exercising to stay fit. And she requests additional consultations to find the broken part and fix it. As we think about tailoring her treatment, we start with ruling out the presence of an affective or anxiety disorder, which might put us back into the disease perspective. As the pain workup is reviewed for completeness and documenting a lack of new signs, this reassures the patient that we are taking her seriously and being thorough. As we get to know her, we are able to explain that her pre-morbid personality is one of an unstable introvert, one that has strengths and weaknesses, but important traits for her to appreciate and to consider how a better fit might be obtained with her situation and what she's trying to accomplish. She is provided a detail-oriented formulation of persistent post-operative pain. She likes details and the wealth of information is appreciated. Added to the usual strengths of her ability to organize and solve problems, it's important for her to recognize that these strengths have now turned into vulnerabilities. She's having trouble organizing information and keeping track of everything, particularly those items that are unfamiliar or unknown, and she hasn't been able to fix the problem. And as a result, anxiety is provoked and she feels that she's failing herself. She's now directed to stop collecting information because she's adding to a body of information that is diminishing the signal-to-noise ratio. She's hoping that this information will help consultants to find the cause, but in fact, it's just blurring their ability to do that. She's referred to a psychologist for biofeedback and relaxation training, and the frequency of her follow-up is increased so that she can be demonstrated that her condition is on track and also to limit excessive consultations. If we think about her as an introvert, what is it that she needs the most help and support with at this time? She needs extra time for the practitioner to listen to her. She needs that more detailed information than other patients who might not be so inclined. She needs to be redirected from utilizing the internet because it's too much information and too many choices that are unstructured. She does need help with anxiety reduction, and she takes to the techniques because of her ability to utilize structure and follow directions. She appreciates a careful physical examination because this is hands-on, something that she can experience in real time, and be reassured by that people are paying attention to the individual aspects of her body. Consultations need to be minimized for all of the above reasons. They add too much noise, and they diminish her focus on the signal. Comprehensive plans are provided to her with predictable follow-ups so that she has a sense of what's to come in the future rather than worrying that there is no plan and wondering how she's going to get a hold of someone in the event that her situation deteriorates. And overall, what you're trying to convey to her is that the body is not just a machine that is easily fixed, but there are other aspects of her functioning as a person that you can help with. And so here, the optimistic outcome is a bit different. She's actually impressed by the referral to an expert in biofeedback. She focuses on learning those relaxation techniques perfectly because that's what she likes to accomplish. As a result, anxiety and somatic symptoms actually decrease as she learns to scan her body and take into context what she's experiencing. She's rejected external information sources because now she recognizes that they're not specific to her, and that's what she's looking for. The more frequent appointments to update her doctor reassure her and give her a sense of being in partnership with her care. And as pain and other symptoms recede, it becomes more obvious that she has an iliopsoas tendinitis and an iliotibial band syndrome. Now these diagnoses allow the physical therapist to prescribe a specific regimen that includes rest, stretching, and massage because her over-exercising is actually aggravating those problems and sustaining them. Now the patient has a sense of validation that there actually was something wrong and that there is an approach to fixing it and that the outcome will be good. And as she improves, she asks to decrease the frequency of appointments to focus on her work and other activities in her life. Now we turn to the behavioral perspective. Thinking about patients with chronic refractory and disabling chronic pain syndromes, usually accompanied by aspects of distress and depression, have to be considered in a context in which patients are making choices and that their actions are motivated, motivated by a variety of different reasons and goals and reinforced by a number of choices that they are making. Over time, they learn, whether they are aware of it or not, how to behave in different ways to accomplish their goals. Sometimes those goals are not helpful for them and not productive, and yet they're not doing this necessarily on purpose. They're doing it because it is the best coping strategy they can come up with given their resources and abilities. So it's important for us to try to disentangle some of those complex behaviors, looking for the motivations and goals and how the patient is making choices that we could help them to change so that the outcome is better. We're back to our stem, but now the variation on the theme is that her pain is centered in the low back, described as sharp and exacerbated by movement. Her depression is more of a sense of feeling scared and fearful of injuring herself. Her attempts to be functional make the pain much worse, in her opinion, and any activity leads to extended rest and more medications. Her behaviors are marked by inconsistency and noncompliance. She's unpredictable at best, and when confronted, she usually feels overwhelmed and unable to cope with further deterioration in her functioning. How do we approach this patient and tailor her therapy? We demonstrate to her that there is concern about a lack of a systematic approach. This is someone who needs more structure and to follow a plan that makes sense. She doesn't know how to do that, and motivational interviewing is utilized to begin to initiate that process of change and to help her see that not only is this a goal that she has for herself, but that she does have the ability within herself to begin making small changes and to utilize the help that's being offered to her. A plan is developed for stabilizing her medication use so that she is taking opioids and benzodiazepines on a standing schedule rather than an as-needed one. This is really just to get us a stability and to minimize the fluctuations in her presentation and her symptoms. Now she is able to understand the syndrome of opioid-induced hyperalgesia and accept that medications may actually be making her symptoms worse rather than better. In addition, the elements of rebound symptoms and withdrawal from medications are added to the discussion, once again emphasizing that medications have a downside and more is not better in all circumstances. Instead of focusing on medications to sleep, she begins to be taught the skills of basic sleep hygiene and visual imagery and self-hypnosis are added to these techniques to further help her with reducing her anxiety and stress. She's referred to an active physical therapist to begin a process of desensitizing her to movement and exercise in general and to slowly increase her range of motion. And she's referred to an addiction medicine specialist for group therapy because it's clear that her use of medications has now become a problem in and of itself. As we think about what happens to people that develop substance use disorders, in the world of chronic pain, it is important for patients to hear that it's not that we are blaming them or calling them an addict, it's that we're recognizing that the substances are now further causing their function to be disordered. You can recognize the elements of being unable to resist the urge of taking medications when you're in pain as a compulsive element to their behavior. You can see that they lose control in their use of medications because they continue to take them, and they continue to take them despite adverse outcomes, which they oftentimes don't attribute to the medications. And as you usually listen to these patients, you will hear a sense of craving as they're preoccupied with their medications and whether or not they're accomplishing pain relief and needing more medications to try to chase that goal. And so now in the behavioral perspective with this patient, the optimistic outcome becomes that the patient can acknowledge wanting to change, but having a sense that she lacks the skills to do that. The skills can be suggested, pointed out, and even offered, but the goal is to keep her engaged and her thinking about how she can do things differently so that she can become more successful in her choices and the outcomes of her actions. The standing schedules of benzodiazepines are implemented for a period of time, and long-acting opioids are utilized to further stabilize her use of medications and to avoid the withdrawal, rebound, and just constant roller coaster of medications in her system. As the adverse effects of medications decrease, her engagement increases and becomes more focused. Her sleep actually improves without additional medications and the medications are gradually able to be tapered. Her anxieties improve as she masters relaxation techniques and she gets a sense of satisfaction for doing that. There's an increase in energy and her improved self-confidence facilitates her ability to progress in physical therapy. Group therapies offer the opportunity for others who have similar problems to reinforce new behaviors and when she relapses or struggles to be confronted by peers who have been through similar circumstances rather than feel that she is being blamed by an autocratic or dictatorial therapist. She acknowledges that medications were a poor coping strategy and as I've said before, those medications are more easily tapered once she has a sense of improvement, being more stable, and more skilled in how she's approaching her rehabilitation. Finally, we come to the life story perspective. All of our patients have a unique story and the events in their life and those difficulties that they encounter are meaningful to them. They interpret them both in terms of success as well as failure and oftentimes are coming to us with a sense that failure has truly occurred and may be irreversible. And so in their head, they have a particular setting, sequence of events, and now a very negative outcome. It's up to us to help them to reformulate that and to see that there is a path forward, that the outcome can be optimistic. And so as we think about the grief that these patients encounter and the catastrophizing that they often engage in, we want to appreciate those as meaningful outcomes of the events that they've experienced. If we move from our previous STEM into this presentation, the pain is more variable. At times, the patient is pain-free and at other times, quite severe. There's a sense of overwhelming fatigue that accompanies her pain. Her depression tends to be more episodic. At times, she's crying and very distressed, primarily when she remembers what it was like to be healthy and those aspects of her life that she enjoyed. At her worst, she feels that the pain is uncontrollable and the situation is hopeless. And she has essentially alienated her support system with intrusive distress. Her husband now adds that she flies off the handle for no reason. And her previous work was a source of pride and validation of her success, which she has lost. If we think about how we will approach treatment in this individual, we start with a foundation of explaining to her the reactive state of demoralization and grieving that she's going through, given the losses that she suffered and what she's trying to regain. We validate those negative feelings as legitimate and normal, not something that she should try to suppress and ignore. And we introduce the concepts of acceptance and value-based goals, helping her to see what it is that's meaningful to her and how it is that she can accept the circumstances that she's in to move beyond them. The various PRN medications that she's taking, like muscle relaxants, NSAIDs, sleep aids, and Tramadol, are all discontinued. They're ineffective, they're utilized in an unpredictable fashion, and they're simply adding side effects to her story. She's referred for interpersonal therapy that would include her husband and focus on rebuilding that relationship. And she's redirected her work skills in sales to learning about catastrophizing and how to manage it. Problem-solving is emphasized, and self-talk that is more positive and effective is meant to replace her rumination and feelings of helplessness about her situation. Ultimately, she's referred to occupational therapy and vocational rehabilitation, again, to build skills and to think about how to return to functioning in a gradual fashion that's planned out. And she finds a support group for people who are changing careers in midlife. This is a patient who has to think about grief therapy as work that needs to be done. And various people have described the task therapy of grief in which the reality of the loss is accepted, that the experience of pain really is a form of grief, and that they need to adjust to what has become a changed world. This is most obvious when someone experiences the loss of a partner, a relative, because that world will not change back to the way it was. It does present itself, though, as a challenge that the patient needs to engage with and accept so that they can move forward. And eventually, the emotional energy is withdrawn and reinvested in others and other activities so that it becomes a useful enterprise rather than a waste of energy. The individual period of action is not necessarily a process of just waiting out a series of predictable emotional transitions. We want the patient to think about their role, their abilities, and how they can re-script their situation. They are reconstructing a personal world of meaning for us, and ultimately for themselves. They are trying to make sense of how their world has changed and the challenges that have been presented to them, and accepting and affirming that while their life is different and perhaps forever changed by losses that they've experienced, that there's still a sense of renewing oneself with the work that they're doing and to realize achievements built around those efforts. And so the optimistic outcome for this patient is that over time, with that work, her grief improves. There's fewer crying spells and less of a sense that she's losing control. She re-scripts her life story with a focus on how she now does have potential for success and that her life is not a failure. She has built a support network of professional women who are part of her group, now sharing techniques about changing jobs and utilizing the skills and experience that she had prior to becoming sick. She's able to start her own business and a nonprofit resource center for patients that have chronic pain and have been through similar circumstances. She focuses her marital therapy on themes of complementary strengths with her husband and how they can work together more effectively. She decides to settle her workman's comp claim to eliminate distractions and stress that have really not produced any lasting benefit for her. She's able to stop medication, citing confidence in herself that she can do this and do it well. And through all of the work that she's done, she develops a toolkit for pacing herself to avoid depleting her gas tank of the energy and resources that she needs on a daily basis to cope with her situation. And so as we think about these different cases and the perspectives under which we've formulated them, I'm hoping that it's obvious that it is the formulation that guides the treatment plan. And as we think about the different perspectives that we've worked through today, diseases really are built around the idea that something is dysfunctional within the body. And if we can repair it or compensate for it, we can restore the functioning and eliminate many of the symptoms that the patient is experiencing. Within the dimensional realm, we are trying to guide people towards their inherent strengths and restore a balance with what the patient is trying to do and whether or not they have the skills to actually do it well. It's important to remember that this is a form of paternalism in the same way that as we treat a disease, all repairs have the ability to cause further damage. That's why it's important to think about all of these therapies as having both an upside and yet some inherent risks. For example, in the behavioral realm, we're really trying to interrupt the actions that a patient is engaged in that are not productive and help them to restore more appropriate drives and define more appropriate goals so that they can make different choices and engage in different actions. And yet at the same time, as we're telling someone to stop doing what they're doing, it stigmatizes that activity. And the patients will often resist those efforts, feeling that they have a right to behave and make choices in any way that they want. And so it really is more of a persuasion of helping them to see that their choices and actions are not very productive. Finally, in the life events category, we are helping people to interpret and change the meanings that they associate with their circumstances. And we're helping them to move through that process so that they can restore a sense of mastery and feel as if their life is in control and that they are able to achieve satisfaction. We have to let them create the meanings though, because if we provide the interpretation for them and insist that it is a particular way, they will view those efforts as hostile and misunderstanding them. And that will distract us from the work we need to do. I wanna thank you for attending this session today. I will now turn us over to the next session with my colleague, Rachel Noble, who will provide some introduction and background about herself for you. Hi, Michael, thank you so much for that. You did a great job. And I just wanna take a moment to let everyone know that I had the privilege of being trained under Michael Clark up at Hopkins. And the time that I spent there was just incredible getting to watch patients that came in with completely debilitating chronic pain in ways that you just can't imagine. These folks would come in literally with like a grocery store bag, like a Walmart bag full of meds, uncontrollably weepy, can't get through three minutes without a pain movement or a pain comment. And after spending time up at Hopkins and the inpatient chronic pain program, they'd leave better and they would leave feeling okay. And they would leave off of all of those opioids and they would leave feeling like they can take control over their life again. And the experiences they have there and the physicians and the care team, and it really does take a whole team to make these people better, to help these people get better, was just, it's just incredible. So I just always love to take a moment to say thank you to Michael and thank you for that opportunity at Hopkins to get to learn about this care and about how to really help these people that have had their lives just washed out from under them by all of this. So a little bit about me. So again, my name is Rachel Noble. I am a therapist and I do specialize in chronic pain. Just to get us going, I have no conflicts of interest with this, financial relationships or any kind that impact this work or this presentation. Smidge about me. So I do work at Inova now with Michael and I am the director of the Women's Behavioral Health Program. I am a licensed therapist and I do actually still see patients. I have one day a week I see patients and all of my patients are chronic pain, chronic medical concerns. They're really a challenging bunch. I also write on mental health issues for various outlets for the general public, whether it's newspapers, magazines, what have you. Let's see. So that's just, so one of the articles I wrote, if you guys are, if anyone's interested, ran in the Washington Post and this was not that long ago, but it was around the time that Jennifer Aniston's movie called Cake came out, which is about living in chronic pain. And it's actually, if anyone wants a nice image or understanding of what these patients look like, she's sort of classic what Michael's described with his formulations and what I've witnessed and worked with. So just to take a big step back for half a minute, just so we can all get a little perspective on this. And we know about this because we hear about it in the papers and we see it in the media, but about a hundred million Americans suffer from chronic pain. And that's just a staggering number. That's more people than those that suffer from cancer, diabetes and heart attack and stroke combined, more so suffer with chronic pain. And the challenges with chronic pain, physicians are pretty uncomfortable with treating chronic pain patients and the pain and they don't, they kind of don't know what to do with them. They get frustrated with them. They wind up on opioids. These are challenging patients. These are patients that often you'll see this relationship between what's going on with them physically and it decompensates them emotionally and psychologically. And you wind up with these frustrations on both sides with the patient and with the providers. And of course, as we all know, there's that sort of stair step down into opioid addiction. And again, Michael pointed this out earlier too. You want to be cautious with that word addiction with this population because they're often not, they don't have that addictive personality per se. They didn't go into this and start this because they wanted to be addicted to something. They were ill. They were prescribed a medication. Their body became dependent on it. They built a tolerance and they needed more. That's what that looks like. But I'll get to that a little bit more later. So definition, I have to say, when I went into the chronic pain program, I was really straight up one day, like, so what's the difference? What is chronic pain? I've been injured. I've fallen down and gotten hurt and hurt my knee or whatever, and I had pain, but what's the difference between that and chronic pain? And when you're talking about the definition straight up, it's acute pain that lasts longer than 12 weeks. So if you have a pain, injury, insult, I don't know, surgery, something, and that normal pain then lasts longer than 12 weeks, it's gonna morph into what we know as chronic pain. But it's not quite that simple either. Chronic pain, once it becomes chronic pain, you wind up with this distorted central nervous system. And what is experienced, again, as a normal pain, it has like this greater intensity. You see more impaired function. And over time with this limited use because of the impaired function, you'll have muscle wasting. You'll have this pain that starts in one part of the body, like for example, if I fell and hurt my knee, and it'll migrate to other parts of the body away from the original site. And this is part of this chronic pain syndrome and the distorted central nervous system. I remember a patient saying to me, actually, I was talking with her and her husband, and her husband was really aggravated with her because they were sitting on the sofa last night and he went and just touched her back, put his hand on her back and she jumped and it hurt. And he's like, what? I'm just touching, it's not even your back, it's your leg, what are you doing? And she just cried and she's like, I don't know, but it hurts. And it really does hurt. These pain receptors, they get amplified. And so again, what's perceived as a light touch can be painful. And you wind up with this mood impairment. You have to appreciate that pain and mood are so intertwined. They both run on the same system. They run on this central nervous system. And you can't, it's hard to tease them apart. So if you have a spike in pain, you're gonna have, it's gonna have an impact on your mood and vice versa. You'll see people that'll have a drop in their mood and they'll have an increase in their pain. So when you have, when your normal pain has morphed into chronic pain, you have this point where we have all as just sort of humans on earth have been trained that when you hurt or you don't feel good or you're sick, the standard healing model is, you know, I'm hurt, so I'm gonna, or I'm sick and I'm gonna stay on the couch and I'm gonna watch TV and I'm gonna take my meds and I'm gonna do this for a few days and then I'm gonna get better and then I can go on with my life. And that just doesn't work. With that model does not work with chronic pain. That actually all those things make your chronic pain worse. It's gonna make for various reasons and I'll get into that. And so we have to help patients see that we need to tackle this illness differently. And it really does require a multidisciplinary team to come together to do what needs to be done to get people where they need to be. What you find with these patients is what I like to call the trifecta. They have, they always have. Every one of the chronic pain patients I've ever worked with have three things. They have a trauma history in their life somewhere. They have something in their life story that was traumatic. And if you ask them, tell me about your trauma history, they almost, they boom right away. They'll be able to tell you, oh my God, this horrible thing happened when I was a whatever, a kid, a teenager. And then they'll have a history of some sort of mood disorder. What usually, what I see in this area is a lot of high anxiety, but you also see a history of depression or some other type of mood disorder. And then they'll have this illness or this insult to their body. And it's almost like the trauma history and the mood disorder, it's like they prime the pump and get that central nervous system almost kind of like amped up so that when you have this insult or injury to the body, you're not gonna just have this normal pain. It's gonna morph into chronic pain because the central nervous system is already distorted. The impact, I apologize for this being so little, but I can send this out. I'll send this out with my slides if people would like to see this. There's this great quality of life scale that looks at the measure of function with people with chronic pain. And I use this with patients all the time and I really love it because it doesn't just get to the kind of physicality of what's going on with them. Really what it gets to is what they can and can't do with their day. And if you look at the zero, we're talking about someone that stays in bed all day and they feel hopeless and helpless about life and the pain is high. But when we go all the way to the bottom, we kind of inch our way down. So around five, we have someone's able to do simple chores around the house, minimal activities outside the home, like one to two days a week. And then the goal when I get chronic pain patients in is they'll come into me pretty low. They'll come in close to one or two. They don't really get out of bed or they don't get dressed or what have you. And my goal is to help them get to where seven, eight, nine, 10 is really optimistic, but that's my goal. By the way, I also need to say, I took a second and wrote down Michael's phrase, optimistic outcomes when he was going through his slides because I love that because that is really always the goal. We have to have optimistic outcomes for these patients because they get to a point where they're just not seeing that themselves. I find, and I'll hark on this again later on in these slides. I find with these patients that when they're first handed to me, when they first come over, it's my job to see hope for them. It's my job to hold on to that hope for them because their hope is lost. They don't see it. They can't feel it. They kind of think I'm a little nuts for having it, but we eventually get to where they start to see that hope too. And then they start to believe it. And then they start to progress. And then I can sort of hand it off to them and then they can go on and continue to build their life. So what these patients look like. This chronic pain syndrome, the whole thing altogether, it really destroys lives. I'll see families that are torn apart because the person just decompensates. These people are often also frustrated with not just where their life is, but with the medical community. They have been often misdiagnosed before they get to where they need to be. They're misunderstood. They're really unhappy. One of the challenges I have and one of the big parts of my job is to help them re-engage in a healthy way with doctors and providers, practitioners, because there's a lot of mistrust. Their friends and families are really sick of them. They're tired of listening to them talk about pain. They're tired of the complaints. These patients will often say themselves they're sick of talking about it, but it's so omnipresent. They can't, it's like they can't see anything else. Their identities get so altered. This is just not the person that they were before. And they become again, isolated, over-medicated, depressed, and their life just doesn't have meaning. A nice example I like to share is a patient of mine who was a dentist and he actually was a very successful, very successful practice in a metropolitan area. He was like one of the top docs in his area and stuff. And he had injured himself when he was traveling with his wife in Paris. And that injury turned into exactly what Michael said, you know, treatments, surgeries, unsuccessful surgeries, medications, doped up, detached, and very impaired mood. And by the time he made it to me, he actually read my article in the Post and reached out to me. And by the time he made it to me, he was about to close his practice, his dental practice, and go on disability. And he was upstairs in his, they were having a party for him. It was one of his birthdays and his family had come for his birthday and he has kids and grandkids and stuff and a very tight family actually, but he was having a bad pain day during this day and he went upstairs to his room to lay down for a minute. And at one point when he was laying down, he could hear his family downstairs singing happy birthday and they had just gone on without him and they wanted to have the cake without him. And he just started to cry because he just felt like his whole life was just slipping away. And I can say after a few years, took us some time, but we actually got him, I got him back where he needed to be with a lot of work, a lot of help. This was not just me. This is always a collaborative effort, multidisciplinary team, but help, I did help build the team and help get him where he needs to be. And his practice is going great. And actually last year, he had his most financially successful year he's ever had. So there is hope this can be done. The other example I like that I have down here is a patient who, this is someone I'd worked with before also who described his life. He had been a pilot and he got injured. And he describes when I met him that his life basically all he did was stay in the basement and watch old rush videos and concerts. And that was pretty much all he did. And his wife and kids just, it's like they just live separate existences. So again, diminished quality of life. One of the phrases that patients really connect with is this notion of an invisible prison. They live in an invisible prison. One of the problems with pain is that people can't see it. It's hard for people to understand. You know, if your leg is broken and you got a big old cast on your leg, it's easy for people to understand that. But this, it doesn't make sense. There's a lot of shame around being in chronic pain. I talk to patients all the time that have such contentious relationships with their pharmacists because the pharmacists just treat them like drug addicts or they have a hard time getting their medications. And this just isn't the person they thought they were gonna be. I'm thinking of a patient who injured herself when riding horses when she was about 14 and ended up on opioids, dependent on opioids. And then when this whole opioid crisis came about and the doctor started to pull them, she switched to heroin because it's a sister med to opioid and it's similar and you get similar properties and it's easy to get. And so she ended up a heroin addict by the time she was about 25. So, you know, this, again, you wind up with these people who are isolated. They have limited mobility, damaged relationships, lost employment, lack of interest in activity, hopelessness. And as you can imagine, there's a high suicide rate. This is a really challenging illness and it's one as mental health care providers we really need to take seriously. This vicious cycle of the byproducts of chronic pain, rehab, depression, anxiety, self-isolating behavior and benzodiazepine and opioid use, they all just spin on each other. So the more opioids you take, we all know they're depressants, they bring your mood down, they make the pain worse. And so all of these kind of stack on top of each other to make that pain worse. And they all run on this same distorted central nervous system. Again, so most, when you're working to help take care of these patients, you really have to, what I find, again, usually once they come to me, the mood is so off, the mood is so distorted that you really have got to take care of that mood first and get their depression and anxiety managed so that they can then problem solve. Because they just can't see it. They can't see hope, they can't see options, they can't see anything except this darkness of depression, anxiety and pain. About three quarters of all chronic pain sufferers have depression and anxiety. And as we all know what those symptoms look like with low mood, weight issues, sleep problems, hopelessness, so on and so forth. The good news is though, and Dr. Clark harked onto this also was that the mood stabilizing meds also can help with pain, which is nice. And so it's a nice, you sort of get that one-two punch or impact of helping to stabilize the mood and helping to reduce the pain. So let me just take one second, one little side and explain tolerance. And I know a lot of folks I'm talking to today are MDs and you guys know what this looks like and so on and so forth, but not everyone fully understands what this is. And I loved how it was explained to me one time when I was up at Hopkins. So we all know, you take a med like an opioid and it knocks the pain out and that's great. But with chronic pain, it makes that pain worse and it because it blocks that pain signal. So if I have a pain in my foot and that pain signal is trying to get to my brain, I take an opioid, right? And it creates a block. So it's gonna block that signal. It's like a wall, but the pain in my foot is still there. And that signal is still trying to get up to my brain. So it's just gonna crank up the volume. It's just gonna make that signal louder and louder and louder. And it's gonna push through that block. So, okay, fine. So it pushed through that block. So what do I do? I gotta take more opioids. I gotta build a stronger block. I gotta build a higher wall so that that pain signal gets blocked. And so what happens is you wind up with this central nervous system that gets more and more distorted. It also, you know, other side of that is also impacting your mood. So we're gonna take more opioids. That's gonna impact your mood. All of these things are working to just bring that mood down. These, you wind up also with the opioids, and we all know this as well, which is clouded thinking, depressed mood, encouraged isolation and problem solving just goes out the window. You know, I wind up with people that just have the hardest time seeing options and seeing choices and trying to figure out which way to go next. So the goal is for us as providers, I don't think I did a slide on this, but I just need to take a second and say, one of the big things that we need to do is try to help people trust healthcare providers again, get them to engage in a very trusting relationship with them because we're gonna be talking with them about doing some stuff that for them is scary and counterintuitive. We're talking about them coming off of opioids and benzos, which they're afraid to do, and coming on antidepressants, anti-anxieties and anti-neuroleptics, which they might not think that they need. We're eventually gonna add in physical therapy and occupational therapy, and of course be doing this with mental health care or therapy all along the way. I wanna add a little point about the physical therapy and occupational therapy, and I know Michael had harked on this a few times too. This is something that you wanna bring in, but you wanna bring it in. What I have found is once people's mood is starting to stabilize a little bit, and once their pain is starting to get even tiny smidge under control, because if you do it too soon or too aggressively, you don't always wind up with good outcomes, and it can become very frustrating for patients. And also you wanna make sure that you're working with physical therapists and occupational therapists that really understand what a chronic pain patient looks like and how to work with them, because sometimes you don't want them going to a gym. Don't go to a gym. Gym's the worst because when they go to the gym, they're gonna wind up with a trainer that's gonna push them too hard and make something worse, but you definitely wanna work with a physical therapist that understands chronic pain. So again, getting back to this idea of a multidisciplinary team, it's your job as a provider who works with this population to really build that network of folks that you know and trust so you can send them, send patients, and you know you're putting them in good hands. So with the mental health therapy, what we're working to do is to manage those mood disorders, and they're gonna be there, and they're strong, and they're loud and in charge. You wanna help patients learn how to become an advocate for themselves again in a way that's actually healthy and not harmful. You wanna help build that multidisciplinary team and make sure that you're working with providers that you trust that have good experience with chronic pain patients. You really wanna help patients reframe their illness so they can, again, sort of like Michael said, not be focusing on sort of what's failed and what's not working well for them and help them remember their strengths and see their skills and figure out new possible ways to apply them to help rebuild their life. Recognize that they have choice. You know, a lot of these patients really, they kind of feel like, I don't know, the whole world just failed them epically and that they're just stuck in this space and that they really don't have choice or control over their day, and that's just not true. We're working to help rebuild their identities, repair relationships, and process that trauma history. That trauma history is back there with them and you don't wanna do it right away. You wanna wait and do it once you get people a little bit more stable, but that's a big part of this. And their historic trauma history, but then also the grief and loss that they've been going through in their loss of functioning and their impairments. Psychiatry, again, I can't say this one enough. I love working with my psychiatrist that I work with in this field because you've got to get that mood stabilized first. We have to get even a little bit stabilized first or people are not gonna get where they need to be. I've found this doesn't work well with just Zoloft or just OneMed or anything. What seems to work best is to work with a psychiatrist that understands how to put together that antidepressant, anti-anxiety, and antianaleptic when needed. Find a good list and help, again, we need to get people stable enough so that they can then begin to problem solve and then they will start to see that hope. And that's my favorite day in therapy when I get someone where we've come in so low and we're at that point where they can start to see that hope too and I can start to hand it off to them. Again, these patients have been through the medical mill and when you validate their pain as a provider, when you're trying to build that trust, when you validate their pain, that goes a long way. They often have a lot of distrust of healthcare providers and honestly, one of the challenges is if they will interact at some point when they've gone from doc to doc, they're gonna act with at least one that will question whether or not their pain is real, will completely invalidate them and make them feel like they've been gaslit and nobody really believes them and so on and so forth. And that becomes something that we have to work to try to heal with them to figure out, okay, how can they figure out how to advocate for themselves and speak with providers in a way that they're gonna be heard? And it takes some time, it's a shift. Again, this multidisciplinary team, once they're improving their communication with providers and this is something I actively work with people on, you want that psychiatrist on board first, early. We need good psychiatrists that know how to get those moods stable in our patient with these chronic pain individuals because they can be very challenging. You want them working with a good counselor to help sort of be that quarterback and that one to help sort of process everything they're experiencing so they can go through and continue to progress. This is a long-term relationship, this isn't gonna happen overnight. So you want that strong therapeutic relationship. Physical therapists, you're gonna wanna get them on board pretty early, not right now immediately, but soon. Complementary services, I find that people, once they're really starting to feel stable, Michael mentioned this too, once they're starting to feel stable, if we start to introduce something like whether they wanna try yoga or they wanna try biofeedback or they wanna try, I don't know, acupuncture or what have you, these complementary services, they'll often, once they can get some level of music therapy, art therapy, they get really excited about them because they're in this healing point and the process in their healing point where they're really starting to feel better, a little bit better at least. And then when you add this, whichever one of these complementary services is helpful for them, and again, I kind of explain to patients, I'm like, okay, this is sort of a smorgasbord, let's see what you feel like is gonna resonate with you and let's try some things. And they'll latch on to whatever that thing is and develop mastery over it and they'll love it and it'll sort of take them to that next level of healing. You also want to, when people do have an underlying something's wrong, they have some wonky syndrome that's hard to diagnose or they have some, oh gosh, often they have multiple illnesses that are sort of playing together in some kind of horrible way, but haven't been really well managed because these people have sort of stopped communicating well with their providers or over communicating with their providers. You do wanna try to get them accurately diagnosed, get a team on board that's gonna help with whatever's going on with that underlying illness or injury or insult or whatever's going on with their body. If something can be done, sometimes we're at a point where everything has been done and now it's just a matter of us trying to help the patient build the best new norm they can. But I say all that, but I need to just add, occasionally there are people with just a mood-based pain disorder. I have seen this before where someone really didn't have an injury or illness to the body. It really is just a mood-based pain. And once you get that mood stabilized, the pain alleviates, which is fabulous. It's just, those can be really challenging patients too. When again, when we're reframing this illness, you need to validate that pain. You need to help be rebuilt within this new norm while always striving to heal. I always say that to people, they'll be like, am I gonna get better? I'm like, oh yeah, we're gonna get you better. We're gonna get you a little bit better and then we're gonna get you a lot better, but we're always striving towards healing. We might not get you to 100%, but if we can get you 60, 70, 80%, that's a good thing. One of the big challenges with these patients is this invalid role. Often they have slipped into this invalid role because it satisfies some part of them. And I don't, there's all kinds of reasons why, and they all have different stories and so on and so forth, but regardless of how they got there, it's our job to help them let that go and replace those automatic negative thoughts with some positive ones, let go of whatever those secondary gains are and see that that hope for them and that possibility to rebuild that life is more powerful and more enticing than any gains that they got from that invalid role. And one of the things I find with these patients is that when we get them to the other side of this and when we get them better and when we get them healed, that new perspective that they have on their life and that new perspective that they have on their day after they've been through this hell, this personal hell, it becomes a bit of a gift. I'll see people do some really incredible things with their lives when they get to the other side of this because they feel like they were given sort of a second chance at life or they were given this beautiful gift of a normal day back. And that can become very powerful and very inspiring for them. But again, this is one of those things I try to share with people early on when they're not seeing that hope, when they're not seeing that that's a possibility. And I try to hold onto that hope and hold it up for them and say, this is what it can look like. And it helps keep them moving forward. Purpose. Everyone needs purpose. When we really do need to help them rebuild their identity, whether it's just increasing their participation within the household, going to events, when I'm trying to encourage people to go to events that haven't done things for a while, we strategize, we talk about, okay, we're gonna go to this thing, you're gonna go to this thing, but you wanna have a planned out and that's okay. And even just giving people that permission often encourages them to go and then they'll go and be happy and have a great time. Volunteer work, part-time work, if they need to re-engage in that, and then eventually working full-time. I do a lot of help getting people get accommodations if they need accommodations to help them participate in whatever their full-time career was again. Or sometimes this is an opportunity to talk about a career change or a career shift and engage in something that they can do with their new, whatever their limitations might be. But at the core of all of this, and this is a conversation you wanna start early on with these patients, is that they have choice. They always have choice. I'll say to them point blank, you can sit on your couch at home and you can hurt on your couch, or you can go outside and go for a walk and hurt out there. You're gonna hurt at home or you're gonna hurt out there. You may as well at least go out there because it's gonna help rebuild your mood. Folks that have their structure that has deteriorated, you wanna help rebuild that for sure. Again, be careful when you're helping them select doctors and choose their activities. And help people when they're rebuilding their relationships, keep people close to them that are helpful for them and not harmful for them, and avoid the people that have historically been hurtful for them. There's gonna be a lot of space and time for people to be rebuilding relationships with this. You'll often see, again, people get tired of dealing with chronic pain patients. And even when they start to feel better, there's repair that needs to happen. They need to slowly start to socialize again, not slowly, actively socialize again. Join support groups, be careful with those too. Sometimes they're really helpful support groups, but sometimes they're really just kind of formalized pity parties and they make things worse. So we really wanna be sure that we're suggesting ones judiciously. You really wanna help people learn how to change their conversations away from their pain with their support people. They can keep the pain conversations in therapy. We can talk in detail about their pain because as therapists, we're helping them, we're helping to redirect those conversations into helpful land. But when they're building those relationships with peers and with loved ones, again, they need to have conversations about the other people. And I always encourage people, if you feel like you don't know what to say, because they'll say to me, I don't know what to talk about. It's like, well, then you look at somebody else and you ask them, how are you? Tell me about your life, what's going on with you? And that helps to get people out of their heads. Couples therapy, you're gonna see this a lot. Michael mentioned it more than once. It's definitely a strong part of therapy. Make sure that you have a good couples therapist that you like to refer to. One of the big parts of this healing with people also is for them to learn how to ask forgiveness. Forgiveness of others, forgiveness of themselves. They often feel like they have failed in some pretty big way. And they need to figure out how to take a breath, recognize kind of what they went through, forgive every little inch along the way that they feel like they need to, and then move on and let it go and put it down and move on. And then let it go and let it go and let it go and let it go, because it'll be okay. And again, there's space to process that trauma history. There's always family mood disorder histories with these patients. I talk to patients and hear it right away, what's going on, what mom suffers with, dad suffers with, grandma, grandpa, whatever. Process how that's impacted them and then process their grief and loss in what they've experienced with this illness and help them return to normal. And I think about what the goals were when I first met him, and he's like some fancy pants CEO of something downtown. And he just said to me with tears in his eyes, I just wanna mow my lawn again. And it took us about eight months before we got him. He wasn't really, really horrible, but he was pretty bad. We got him to where he did mow his lawn again, and he was happy again, and he was re-engaged in his life and in his day. He was able to achieve that and more. Make sure you know what to keep in your back pocket. One of the ways I can engage with these patients and still be able to sleep at night, I get the scariest people in front of me that are suicidal, homicidal, ready to cut limbs off that hurt all the time, so on and so forth. And I'm pretty good now at quickly assessing, can we manage this in the outpatient world or do we need to lean on something like the Hopkins Inpatient Program? Hopkins has an incredible inpatient chronic pain program. The average length of stay is 23 days. Be warned, it's a locked unit, which freaks patients out, so you have to do a lot of conversation with them around that about what that's like, but how it's gonna help get them better. One of the things they love about being there is that they're not alone, and then they can come out the other side and then we can really help rebuild their life. But you wanna understand what those kind of programs look like. Mayo has one, Hopkins has one, I think there's one somewhere in Florida, I forget where it is, but there's not many, there's not that many out there, but you wanna know that they're there. So when you have those patients that just feel way beyond your care, what will you feel like you can pull off in the outpatient world, you need to know those inpatient programs are there. And it's not just an inpatient program, be careful, because there's some that are out there that are advertising that they're chronic pain programs, but all they are is detox. They just get people off of opioids, but they don't add the mood stabilizing meds and they don't add those other parts that really are the things that are gonna keep people safe and help them heal longterm. And this is the last thing I'll say about all this, about the inpatient programs. When you're working with a patient to get them into an inpatient program, please, please, please, please, please. I do this with my patients all the time, I say to them, don't Prince, don't Prince on me. I don't know how many of you guys know the story of Prince. The singer, the musician, however you wanna describe him, artist, he died. We all know he died. He died, he had chronic pain, he lived in chronic pain. He was addicted to opioids or dependent on opioids. He was going into a program like Hopkins, but right before he went, like the day before he went, he says, well, I know they're gonna take my meds away, so he took as much as he could. That's how he overdosed. And I've seen, we've all, any of us who have worked in these large programs like this, I've seen this. Patients come in and they know they're gonna, they're afraid they're gonna get their meds taken away, which by the way, we don't take their meds away right away. There's this weaning process. And so they'll try to put as much in their system as they can, and sometimes they can tolerate it and sometimes they can't. So that's just something, that's my only hesitation, but otherwise I love, I haven't had a patient have that problem, but just know that that's a possibility. But places like the Hopkins Inpatient Chronic Pain Program, they're just truly miracle workers. They're incredible. It's incredible to see what happens and what can be done. So if you ever have a chronic pain patient in front of you and you just are thinking, this one's too much, call Hopkins and see what you can do. Once again, ongoing care, once they're out of somewhere like that, you're gonna have therapy. You're gonna be working with a psychiatrist afterwards. You need to keep them active, purpose, and relationships. I've had a few patients say to me once they got out of Hopkins and they're on now, they're not on opioids, but they're on their mixture of mood stabilizing meds. And they'll say to me, well, when can I get off these? How long is this gonna take? And the answer to that one is that you're gonna start to taper off those meds after about six months of being pain-free. People, it sort of varies on whether or not they can get all the way off those meds eventually or not, and how long it takes for their central nervous system to heal, but it's something that's an ongoing conversation after they're out. So that's it, that's my presentation. And again, thank you very much for your time. And I'll see you next time.

pain management

opioids

chronic pain

personalized treatment

multidisciplinary approach

physical aspects

psychological aspects

treatment plans

mood stabilization

complementary services

inpatient programs