Adjunctive Psychiatric Pain Management Treatment
Research has shown that comprehensive pain treatment is most effective in reducing pain and increasing functioning in our patients with chronic pain.1,2 When patients see a team of providers—which might include a pain medicine physician, a psychiatrist/psychologist, a physical therapist, and an alternative medicine practitioner—each component of treatment can add something to the whole. As well, each practitioner can focus on what he or she does best, knowing that the other parts of treatment are in place. This can help patients appropriately use the expertise of each member of their team so that practitioners do not get over-whelmed trying to treat problems they are not equipped for.
However, when you refer your patient to a pain management psychiatrist or psychologist, clearly telling patients in what ways they may benefit will increase the number who actually attend treatment, practice skills, and thus benefit from psychiatric pain management therapy. This article will review the benefits of this modality.
Benefits of psychiatric pain management include:
- Psychiatric evaluation
- Diagnosis and treatment of psychiatric disorders
- Evaluation of psychiatric medication for pain
- Psychological pain management skills
- Positive behavioral changes
- Positive psychological changes
- Supportive therapy
- Group therapy
- New brain-based treatments
A psychiatric pain management evaluation assesses:
- Prior psychiatric functioning and psychiatric diagnoses. If psychiatric disorders were present prior to a pain disorder diagnosis, there is increased risk for recurrence.
- Current psychiatric symptoms. There is a high level of psychiatric co-morbidity with chronic pain. For example, depression occurs in 8-50% of patients with pain,3 anxiety in 19-50%,4,5 PTSD in 10%,6 sleep disturbance in 50% or more,7 and drug and alcohol problems in 3-19%.8 If multiple disorders are present, it is necessary to treat them all. For example, if someone has depression and pain, treating just one does not necessarily mean the other will go away. As well, neither condition may get better unless you treat both.
- Psychiatric interactions with medications. Many drugs used for pain cause psychiatric symptoms, including sedation and depression. Differentiating side effects and underlying psychiatric illness is crucial and medication recommendations to decrease side effects can be helpful. Some pain medications cause unusual or serious side effects.
For example, NMDA receptor antagonists can cause significant anxiety, hallucinations, or cognitive problems. Psychiatric input can help evaluate or treat these side effects.
Diagnosis and Treatment of Psychiatric Disorders
After assessing psychiatric symptoms, a psychiatric diagnosis is made. Psychiatric symptoms should not be dismissed as “expected” or attributed solely to pain. In addition to the psychiatric disorders mentioned above, suicidal ideation is assessed in a psychiatric evaluation. Rates of suicidal ideation may be two to four times greater in chronic pain patients than in the general population9 and are crucial to identify.
Treatment for any disorders which are present may include therapy, medication or both. Since patients with chronic pain are often already on multiple medications, using therapy or sleep hygiene techniques may be preferred. When psychiatric medications are indicated, using ones with pain-relieving qualities—or knowing how to take advantage of side effects—may give added benefit.
Substance use or abuse may be a concern of others on the team and an area in which a mental health practitioner can shed light. One important area is differentiating substance use and addiction (either abuse or dependence) from tolerance to pain medication. “Pseudo-addiction,” the presence of behavior which appears to indicate addiction but is caused instead by the under-treatment of pain, can also be determined.
Psychiatric Medication for Pain
Many medications originally used in psychiatry can also be helpful for chronic pain itself, separately from treating any psychiatric illness. Antidepressants and anticonvulsants are two such categories of medication.10,11 SNRI’s (serotonin-norepinephrine reuptake inhibitors) have been shown to be helpful in both diabetic peripheral neuropathy and fibromyalgia. Tricyclic antidepressants (TCA’s) such as amitriptyline and nortriptyline have been shown to help in many different pain disorders, although none are FDA-approved to treat pain. The use of SSRI’s (selective serotonin reuptake inhibitors) for migraines and chronic daily headache is supported by some research, although evidence has been mixed. Although anticonvulsants are FDA-approved for a few select pain conditions such as diabetic peripheral neuropathy, fibromyalgia, post-herpetic neuralgia, and trigeminal neuralgia, they are more widely used for other pain conditions as well.
When using an antidepressant, it is helpful to clarify for patients that this does not mean their pain is “in their head” or imagined. A second point is that pain often exists along with psychiatric disease. As antidepressants also target depression, anxiety, panic, PTSD and sleep disturbance, using a single medication to target multiple diseases can be wise.
Patients can learn psychological skills that can help them both decrease and cope with pain. Breathing, relaxation and visualization help in several ways, including: 1) increasing relaxation and decreasing anxiety, 2) decreasing the stress response associated with pain, 3) improving sleep, and 4) indirectly helping decrease pain by increasing relaxation and distraction. Guided imagery and hypnosis, where suggestions of decreasing pain are paired with imagery, help in the same previously mentioned ways and can also directly decrease pain through the use of suggestion. These skills are taught to patients so they can practice them regularly on their own.
On HowToCopeWithPain.org, there is a series of on-line classes which teach these skills, as well as others such as stress management and improving sleep.
Positive Behavioral Changes
Patients can be supported in making behavioral changes to help themselves live better and get better. In addition to decreasing pain, if possible, an important pain management treatment goal is increased functioning. Psychiatric pain management introduces concepts such as pacing, and helps patients implement a schedule of regular, positive activities, as well as any assigned physical therapy exercises.