Pain vs. Anxiety - Orthopedics Magazine

Pain vs. Anxiety
Amy C. Klopp MS, RN-BC, CNS, ACHPN
Musculoskeletal pain is
more prevalent in
patients with panic
disorder than the
general population.
35% of chronic pain
patients meet criteria
for anxiety disorder
(18% general
Women with
Fibromyalgia 4-5x
more likely to have
had a anxiety disorder
in their lifetime.
People with back/neck
pain 2-3x more likely
to have anxiety
disorder in past 12mo.
30-80% of patients
with PTSD report
chronic pain
Asmundson and Katz, 2009
Pre-op anxiety plays a role in development of
Chronic post-surgical pain (CPSP)
Theunissen, etal. 2012
• Meta-analysis – 29
• Pre-operative anxiety
and catastrophizing
• CPSP 3mo after surgery
• Moderate evidence that
pre-op anxiety and
catastrophizing play a
role in CPSP
Judge et al. 2012
Masslelin-Dubois et al. 2013
• 1991 patients Total
Knee Replacement
• Pre-op
• 6 month post-operative
Oxford Knee Score
• Pre-operative anxiety
depression led to worse
pain at 6 mo.
• Not associated with
function at 6 mo.
• 189 patients TKA for OA and
breast surgery for CA
• Data pre-surgery and 3 mo.
• Spielberger State-Trait Anxiety
Inventory, Pain Catastrophizing
Scale, and Brief Pain Inventory.
• State anxiety, independent
predictor pain at 3 mo.
• No dependence on surgical
Mutual Maintenance
Clinical Psychology Review 2001; 21(6):857-77, p.870
Common factor or predisposition
• Genetically influenced
• COMT-catechol-O-methyltransferase –regulation of neurotransmitters
• Psychological Vulnerability
• Anxiety Sensitivity-Fear of anxiety based on belief that it may have
harmful consequences
• injury sensitivity
• Life event
• Trauma or injury
•  Threshold for alarm (stress response)
(Chronic MSK)
Startle rx
Dysregulation of
stress response and
pain modulation
Spinal-thalamic Tract
Limbic System
• Area of the brain that regulates
emotion and memory
• Influences emotions, the
visceral responses to those
emotions, motivation, mood,
and sensations of pain and
• brain’s anxiety “switch”
Recognize and treat both.
Let’s look at some case studies…
Julia Anderson
• 66 y.o. Hospitalized POD #1 R TKA for OA
• Hx of anxiety
• Regular appointment with psychotherapist
• Sertraline 100mg daily
• Alprazalam 0.5mg TID PRN
• Fibromyalgia
Julia Anderson
Julia reports she is fearful of taking opioids,
requests Tramadol.
Would this be an appropriate intervention?
No. Concurrent use of SSRI and Tramadol
would put Julia at risk for Serotonin
Julia Anderson
Multimodal pain management
• Opioid Naïve dosing of Opioids
• Opioid Sparing medications
• Tylenol
• Topicals such as Lidocaine, Icy Hot, NSAID
• Vistaril
• Muscle relaxant
• Make sure she is on her chronic anxiety regime
• “How many Xanax do you take a day?” – schedule it +PRN
• “What non-medicine strategies have you discussed with your
psychologist to manage this pain, your anxiety?”
Julia Anderson - Fibromyalgia
• Chronic pain condition characterized by widespread pain both
sides of body, above and below the waist, fatigue and somatic,
affective and cognitive symptoms.
• “Experience 5 x more pain than patient without fibromyalgia.”
• Though a disorder of “pain regulation, “ no longer MSK
function in CNS
Julia Anderson- Pre-op Gabapentin/Pregabalin?
Gonano et al., 2011
• 40 outpatints elective partial
meniscectomy under general
• 300mg pregabalin vs placebo
•  pre-op anxiety
• No change in pain scores but
reduction in opioid use in PACU
by half
Clarke et al., 2012
• 50 females – anxiety ≥5/10,
non-cardiac surgery
• 1200mg Gabapentin vs placebo
•  pre-op anxiety and pain
• Possible delayed post-op
Bryan Smith
• 23y.o. Shoulder sprain while playing ultimate
• Able to function and participates in initial rest
and then physical therapy.
• Using more opioid pain medications than
expected, frequent requests for refills, longer
than expected pain trajectory.
Bryan Smith- co-existing addiction?
• 6.4 million US citizens used psychotherapeutics for
non-medical use (SAMHSA, 2006)
• Assessment
• Addictive behaviors noted between visits/within the visit
• Opioid Risk Tool (ORT) family history, personal history, age, history of
preadolescent sexual abuse, , any psychological disease and
• Pain Contract, pill counts, urine toxicology screens,
dispense in small quantities.
Bryan Smith – co-existing anxiety?
• Consider Bryan has underlying anxiety disorder?
Opioids are downers – self medication?
poor sleeping
worry about
several areas
most of the
Jay Newton
• 43y.o. with chronic back pain on disability
• On chronic opioid therapy from primary MD for many
• PTSD related to building falling on him when he was
volunteering for Hurricane Katrina clean-up
• Admitted to hospital with same pain, same location,
increased intensity. Work-up for acute cause is negative.
• 4th admission to hospital, 12th ED visit in last 6 months
Jay Newton- “flare”
• Goals of managing pain flare
• Rule out new or serious underlying condistion
• Not to escalate opioid therapy
• Management of symptom and coping with crisis
Reassurance not
indication of
serious condition
factors (i.e.
(insomnia, anxiety,
Self control/
coping skills
Jay Newton – Cognitive Behavioral Therapy (CBT)
Referral for Comprehensive Pain Management
with CBT
• Influence pain via one’s own thoughts
• Alter perception of painful stimuli, not alter painful
stimulus directly
Selected References
Asmundson, J.G. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-theart .Depression and Anxiety, 26, 888-901.
Clarke, H., Kirkham, K., Orser, B., Katznelson, R., Mitsakakis, N., Ko, R., Snyman, A., & Ma, M. (2013).
Gabapentin reduces preoperative anxiety and pain catastophizing in highly anxious patients prior to major
surgery: A blinded randomized placebo-controlled trial. Canadian Journal of Anesthesia, 60, 432-443.
Gonano, C., Latzke, D., Sabeti-Aschraf, M., Kettner, S., Chiari, A., Gustorff, B., , , & , (2011). The axiolytic
effet of pregabalin in outpatients undergoing minor orthopedic surgery. Journal of Psychopharmacology, 25(2),
Jordan, K., & Okifuji, A. (2011). Anxiety disorders:differential diagnosis an their relationship to chronic
pain. Journal of Pain & Palliative Care Pharmacotherapy, 25, 231-245. doi: 10.3109/15360288.2011.596922
Judge, A., Arden, N., Cooper, C., Kassim, J., Carr , A., Field, R., Dieppe, P., & , (2012). redictors of outcomes
of total knee replacement surgery.Rhematology, 51 (10), 1804-13.
Masselin-Dubois, A., Attal, N., Fletcher, D., Jayr, C., Albi, A., Fermanian, J., Bouhassira, D., & Baudic, S.
(2013). Are psychological preditors of chronic postsurgical pain dependant on the surgical model? a comparison
of total knee arthroplasty and breast surgery for cancer. The Journal of Pain, 14(8), 854-864.
National Institute for Health and Clinical Excellence, (2007).Anxiety:management of anxiety in adults in
primary, secondary and community care (1-84629-400-2). London: Abba Litho Sales Limited.
St. Marie, B. (2010). Core curriculum for pain management nursing. (2nd ed.). US: Kendall Hunt.
Theunissen, M., Peters, M., Bruce, J., Gramke, H., Marcus, M., , , , , & , (2012). Preoperative anxiety and
catastrophizing: A systematic review and meta-analysis of the association with chronic postsurgical
pain. Clinical Journal of Pain, 28(9), 819-841.