Behavioral conditioning concepts in chronic pain

S164 C O N T I N G E N C Y M A N A G E M E N T M E T H O D S IN T R E A T M E N T OF | 199 Plen C H R O N I C PAIN. A.H. Roberts, B e h a v i o r a l M e d i c i n e I ThursdQy Program, Scripps Clinic and Research Foundation, La Jolla, CA, USA C o n t i g e n c y m a n a g e m e n t methods apply the p r i n c i p a l s of operant c o n d i t i o n i n g to the m a n a g e m e n t of chronic pain. Instead of a t t e m p t i n g to alter a p r e s u m e d u n d e r l y i n g source of n o c i o c e p t i o n or alter an alleged e m o t i o n a l or m o t i v a t i o n a l state, c o n t i g e n c y m a n a g e m e n t focuses d i r e c t l y upon the behaviors of p a t i e n t s and their spouses. The immediate and long term goal is to r e h a b i l i t a t e the patient rather than to alleviate the pain. The methods are equally applicable to chronic pain w h e t h e r its origin is p r e s u m e d to be organic or functional. Instead of a t t e m p t i n g to d e t e r m i n e the cause of the pain and a t t e m p t i n g to remove it, these methods focus upon b e h a v i o r s of the p a t i e n t which are maladaptive, the env i r o n m e n t a l events that c u r r e n t l y support these m a l a d a p t i v e behaviors, w h a t a p p r o p r i a t e a l t e r n a t i v e b e h a v i o r s are available, and w h a t changes can be introduced s y s t e m a t i c a l l y in the form of r e i n f o r c i n g events in order to e l i m i n a t e m a l a d a p tive b e h a v i o r s and increase d e s i r a b l e behaviors. Specific goals include i n c r e a s i n g p h y s i c a l activities; e l i m i n a t i n g all n o n e s s e n t i a l m e d i c a t i o n s i n c l u d i n g pain medications, muscle r e l a x a n t s and p s y c h o a c t i v e medications; a s s u m i n g normal emp l o y m e n t and r e s p o n s i b i l i t i e s ; and e l i m i n a t i n g health care u t i l i z a t i o n for pain. In this kind of t r e a t m e n t program, attempts to d e c r e a s e pain by means of d e c r e a s i n g or substituting m e d i c a t i o n instead of e l i m i n a t i n g it, biofeedback, e l e c t r i c a l stimulation, nerve blocks, etc. tend to be count e r p r o d u c t i v e since use of these techniques implies to the p a t i e n t that attempts are being made to a l l e v i a t e the pain. Instead, the more a p p r o p r i a t e c o m m u n i c a t i o n to the p a t i e n t is that he or she is being taught to live a normal life without m e d i c a t i o n even though pain may still be present. Applying these m e t h o d s to severely disabled, m e d i c a t i o n d e p e n d e n t p a t i e n t s w i t h chronic pain, more than two thirds of those accepted for and a g r e e i n g to t r e a t m e n t can be taught to live normal lives w i t h o u t the use of any pain m e d i c a t i o n s w h a t s o ever. A s u b s t a n t i a l number of the r e m a i n i n g patients can be s i g n i f i c a n t l y improved. This level of outcome requires the i n v o l v e m e n t of close family m e m b e r s throughout treatment. P r e s s i n g future needs include the d e v e l o p m e n t of o u t p a t i e n t p r o g r a m s to a c c o m p l i s h the same goals, the d e v e l o p m e n t of valid ways of i d e n t i f y i n g new pain p a t i e n t s at risk for becoming chronic pain patients, and the d e v e l o p m e n t of brief, c o s t - e f f e c t i v e p r e v e n t i o n p r o g r a m s for newly injured patients who are identified as being at risk for d i s a b i l i t y due to pain.