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Psychiatrists Should Take a More Active Role in Treating Pain

June 17, 2016

Dictionary entry for the word pain

The recent opioid-prescribing guidelines from the CDC have renewed attention of health care providers to the epidemic of chronic pain, with which the opioid crisis is closely intertwined. The recommendation to move away from opioids as the first line of treating many types of chronic noncancer pain has generated an understandable outcry from some pain patients who fear that medications they need will no longer be available to them. Many people suffering from chronic pain are also expressing despair at their physicians (and the larger health care system) suddenly seeing them as part of the opioid problem and as potential addicts. These legitimate concerns have fed the hopelessness felt by many of the 50 million Americans who suffer from moderate to severe chronic pain.

Reducing opioid prescribing is not solely to address opioid misuse and overdose deaths. The rise in opioid prescribing in the late 1990s occurred despite virtually no research that had evaluated the effectiveness of these medications when administered for pain over the long term (i.e., for chronic pain). In fact, there is evidence that chronic opioid administration may worsen pain (hyperalgesia), raising the question of whether opioid overprescribing could have contributed to the increases in the prevalence of chronic pain in our country (something future research will need to address). But obviously, reducing the reliance on opioids for the management of chronic noncancer pain does not mean that we can just walk away from the pain problem. It is urgent that we find new solutions and make better use of other treatments in our existing toolkit.

Thus far, psychiatrists have not taken an active role in addressing the problem of chronic pain, but they have an important role to play here, for multiple reasons. First, cognitive-behavioral therapy is one of the most effective pain treatments; assisting patients in learning to change their pain-related thoughts, emotions, and behaviors is going to help with their condition, regardless of other pharmacological interventions. It is also necessary for psychiatrists to become involved in pain because chronic pain is closely linked to multiple psychiatric problems. For example, with chronic pain comes a high risk for suicide and depression. Pain also impacts sleep, which independently can be a factor in mental (as well as physical) health. And these psychiatric conditions bear on the effectiveness of adjunctive pain therapies such as exercise and meditation, which may be difficult to implement when a person is also suffering from depression, for example.

Addiction researchers also need to be more attentive to pain, going forward. The need for trials of non-opioid treatments is obvious and includes studies of compounds targeting the endocannabinoid system, a promising avenue for new medication development. Similarly, the use of repeated transcranial magnetic stimulation (rTMS), which is approved for the treatment of depression, has been shown in preliminary trials to be helpful in managing pain. And even in clinical trials looking at treatments for other conditions, researchers should be measuring pain to find out the extent to which it factors into how well the treatment works. For instance, the prevalence of pain is higher in people suffering from substance use disorders, but most studies don’t measure it; pain might be one of the confounders making it difficult to treat addiction. The same could be true for other psychiatric conditions.

It is crucial that we not lose sight of the reality and complexity of chronic pain as management of chronic noncancer pain moves toward greater caution around opioid medication. This should not be solely an issue for primary care medicine or neurology, but also for specialties such as psychiatry that have much to offer people who are suffering from complex disorders in which physical symptoms merge with psychological distress.

This page was last updated June 2016

Comments

Alternative Pain Treatments

Pain management has increased the use of opioids manifolds. Now the need of the hour is to focus on alternative treatments like cognitive behavioral therapy, meditation, mindfulness and more.

leave legitimate noncancer pain patients alone already

Give patients more credit and power to chose opiate therapy or TENs or whatever they feel helps . Chronic pain is a life-destroyer. Patients with daily pain have already lost enough. Taking their pills is degrading. Don't take away their dignity as well.

CBT for pain control

Seriously? CBT is one of the most effective treatments for pain control? As a psychiatrist licensed since 1991 that really makes me lol.
Maybe a few small studies with highly trained therapists and a few motivated subjects (who arent even close to a representative sample of of pain patients) might show some benefit from CBT.
Those types of academic studies are far removed from the real world of clinical medicine here in the trenches.
However I do commend the author for bringing up several important subjects.

CBT is Passive, VR is here!

" it’s never easy making neat science out of the often nebulous encounter we call psychotherapy. "
Absolutely on point! CBT has been a go-to treatment for most of the patients seeking psychological aid and to relieve pain.
However, in recent times certain other treatments have also proven to be helpful. These include using Virtual Reality as an aid to carry out treatments of psychological illness.
CBT is an important part of psychological aid, but these new treatments should be carefully studied and made use of too!
Thanks

Chronic Pain

I think treatment if chronic pain is not in the realm of psychiatric services. Unless the Dr is an addictionologist. Which is rarely the case. Psychiatrists treat DSM Criteria. They rarely understand chronic pain or its management.

Pain Management by Psychiatrists?

Personally, CBT for bone pain is ineffective. Is there any science? I think internists, pain medicine soecialists and acupuncturists can be helpful.

chronic pain/opiods

I am an RN who has worked with both addicts and patients with severe chronic pain. I have also been a chronic pain patient for the last decade. I have never seen cognitive therapy help anyone with SEVERE chronic pain of long duration unless they had an underlying psychiatric reason for their ongoing pain and with the exception of possibly helping them to deal with the associated stress of living with chronic pain. To assume that this should be a consideration RATHER than the use of narcotic medicines shows an underlying ignorance of chronic pain itself. Inadequately treated severe chronic pain almost always causes depression because of the way it rewires the connections in the brain. It causes deterioration of the brain in particular patterns according to the source and severity of the pain which which can be seen on MRI and which can be easily equal to 20 years of aging of the brain. It is currently not known whether any of this can be reversed when it is of long standing duration EVEN WHEN THE PAIN IS COMPLETELY RELIEVED! Having chronic pain can result in significant hyperalgesia and can become more severe and more widespread over time. Long term narcotic use can also cause hyperalgesia but I am a bit puzzled as to how it was decided this was due to the narcotics alone in those situations rather than the pain since those patients would have had chronic pain in order to receive such a prescription and we have long known pain itself can independently lead to this. My own experience with chronic pain from a spinal cord injury and associated long term problems as well as that of information from other chronic pain patients is that not only are doctors NOT over prescribing pain medicine but that acute and chronic pain are very under treated in our country and this is especially true of chronic non cancer pain. I have had doctors bluntly tell me they won't prescribe narcotics because they are afraid of being investigated for "over prescribing" (translation... prescribing for chronic non cancer pain) not because they believe it is a best practice for those patients. We now know that undertreating acute pain will in itself cause the development of chronic pain in a significant subset of patients because of their particular genetics and have identified at least 17 genes associated with this. If we are looking at prescribing rates we need to also look at populations. We have a population that is living longer and therefore more susceptible to many of the diseases leading to chronic pain and we also have a population that is increasingly obese and obesity itself will over time lead to many medical conditions which cause chronic pain such as the nerve pain associated with diabetes. We also need to understand that for those doctors who have kept up with research in the field of pain in the last 10 or so years there is more awareness of what long term pain will do to the body such as the brain deterioration and increased suicide rate.There has also been a better understanding of the biological difference between "dependence" which is easily treated with gradual dose reduction and which is a physiological adaptation of the body, and true addiction which is biologically different and manifests as a craving for the substance sometimes for years after it is stopped. Lastly, chronic pain, is coming to be recognized by researchers in the field as a chronic disease in itself not as the symptom of a disease or injury. It is often a disease of the brain and spinal cord and it must be treated as such once it has reached that stage rather then by simply trying to ameliorate a peripheral cause for it. There are no perfect answers and no cure but we deserve to be treated with everything that is currently in the arsenal of the practitioner and unless there is an active or previous history of addiction that should include narcotics when nothing else has controlled it. Those with an addiction can be treated with narcotics if it is by someone versed in treating patients with addiction and chronic pain if absolutely needed! I have undergone multiple painful and risky procedures to try to help control my chronic pain including having devices implanted in my spine and NOTHING has worked as well as narcotics! I have taken them for years and have never misused or taken them not as directed a single time even with a great deal of pain but if I walk in the emergency room I know from having worked as a nurse that I will immediately be suspected of being a seeker of pain meds and a fake no matter what the history is because of their use. It is way past time to start treating us like you would a cardiac or kidney patient and giving us the best of what treatment there is in spite of the fact that their are addicts out there who want the same medicine to get high.If you do not refer all your heart and kidney patients for cognitive therapy in treating their disease why would you do it for the chronic pain patient? The underlying premise is either that the pain is not physical but psychological or that they should "buck up" and learn to deal with it without medication because they might be an addict or might become one and of course, it can't really be THAT bad if they don't have cancer! A urine test, a perusal of medical records or chat with their doctor, and if necessary, a perusal of their legal history will separate the pain patient from the one with an ongoing or history of addiction. If, in fact, doctors are being persecuted for their empathy in doing the right thing for their patient it is way past time to STOP! What I see is that pain patients are not being treated and addicts who have a harder time getting a prescription for pain medicine to mix with other substances and get high are just using heroin and NO ONE is being helped by all the recent hysteria regarding the "over prescribing" of pain medicine.

My Dad is Over Prescribed

This issue is closer than most people think. My father has had 3 back surgeries and the pain has not decreased. So he daily takes pain killers. Luckily my father is smart and only takes the necessary amount to keep his pain at bay. He is prescribed 180 pills a month but only takes 90. I think this is because I own a drug rehab service and he knows the addictive side seeing it first hand with my clients.
We need to make a stand before this causes us more deaths and more money as a country.

15 surgeries

I have had 15 surgeries almost every joint in my body hurts, I want to cry right now writing about it. I was getting OxyContin before my four hip surgeries because there were complications, I got an infection. I have had my knees done one foot fused the other needs to be done, one knee I have had three surgeries before it was replaced. Both my wrists for carpal tunnel. Two back surgeries due to scoliosis, I have had it from being in pain, both shoulders need replacing as well. The FDA sent my PCP who was prescribing me the OxyContin a notice and told her to send me to a specialist. They will give me Neurontin which is a joke if you are in pain. I have a strong threshold for pain I can handle a lot, Im not an addict I could stop anytime if I were out of pain. I just can't take anymore. One norco every eight hours just doesn't do it along with 600mg of Neurontin, and on top of that I take four Advil. I'm going to a pain specialist tomorrow we will see what he says.

Never mentioned

Pills and doctors are always at the forefront of any issue an individual has but hardly ever is proper nutrition and exercise. It's amazing what can happen once the body is fed what it needs and is used for what it's intended to be used for.

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