Pain and the Hospitalized Patient

Pain is omnipresent in the hospital, but its degree and presentation are variable. A consultation-liaison (C-L) psychiatrist can help identify how and why pain may be affecting a patient’s medical illness and recovery.

Patients in pain whom a C-L psychiatrist may encounter in the hospital include the following:

• People who have difficulty expressing what they are feeling (children, the elderly, those with an intellectual disability or communication difficulties, etc.).

• People who have chronic pain in addition to acute pain.

• People who are behaving in a negative or difficult manner as a result of their pain.

• People who have substance use disorder, especially opioid use disorders, who now have acute pain.

Case Example

James is a 34-year-old man with a history of generalized anxiety disorder, fibromyalgia, and gout. Around age 25, he started using heroin in the context of pain due to repeated gout flares. He subsequently entered substance use treatment and was able to stop heroin use. At age 33 he started having what he thought were severe gout flares again and visited the emergency room multiple times for knee pain. Due to ongoing pain, his friend offered him a fentanyl tablet. It helped the pain so much more than the methadone he had been taking as part of his heroin treatment that he stopped taking methadone and started taking fentanyl. Over the next year his use increased to 20 fentanyl tablets a day. Still, his knee pain worsened, and after coming to the hospital, he was found to have a septic joint necessitating an above-the-knee amputation. The primary team placed him on methadone 40 mg and as needed hydromorphone. After two days he started yelling at the team that he wanted to leave and was found with fentanyl tablets in his room. The C-L psychiatry team was consulted because of the patient’s problems coping with his amputation, his anger, and his desire to leave against medical advice.

Discussion

A C-L psychiatrist aids the primary team in recognizing pain’s influence on patient behavior by elucidating how pain can manifest as anger, acting out, entitlement, despair, and/or dependency, potentially mimicking new-onset personality disorders or even psychosis. Understanding patients’ personality traits is crucial, as they significantly shape their response to illness and guide constructive engagement by treatment teams.

Patients with substance use disorders, especially opioid use disorders, often face undertreatment during acute pain episodes due to stigmatization and the misconception of “drug seeking.” In reality, individuals on maintenance therapies like methadone or buprenorphine, as well as those using illegal opioids, may require higher opioid doses to achieve adequate pain control due to cross-tolerance. Undertreated pain and not appropriately managed pain fuel addiction and raise the risk of patient attrition and posthospital discharge opioid overdose. The need to consult psychiatrists, pain specialists, or palliative care experts and consider augmentation modalities including patient-controlled analgesia pumps, diphenhydramine, or ketamine become pertinent. Exploring nonopioid avenues such as scheduled oral acetaminophen, anti-inflammatory medications, topical agents, gabapentinoids, antiepileptics, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, should be prioritized based on pain type and comorbidities. In chronic pain scenarios, initiating nonopioid strategies alongside opioids at the onset is recommended due to their slower onset.

A C-L psychiatrist’s role extends to comprehending patients’ external opioid use reasons (pain, withdrawal, craving) and advising against retaliatory responses. Communication of procedure or boundary changes should occur calmly and nonpunitively. Ethical considerations and guidelines should be kept in mind to prevent a paternalistic approach, particularly with regard to patients not inclined to quit illegal substances.

Despite disagreements, the C-L psychiatrist’s primary role remains treating the patient for the present ailment and preventing harm, including withdrawal. Educating patients and treatment teams about opioid-induced hypersensitivity, particularly in chronic opioid users, is vital. In some instances, reducing the use of opioids and increasing augmentation strategies might be the answer.

Outcome

In the case presented here, the C-L psychiatry team assessed James and concluded that due to fentanyl addiction, his pain was undertreated, and the team recommended an increase in methadone. They also determined that his untreated anxiety and fibromyalgia were worsening his ability to cope and started him on extended-release venlafaxine. James was also fearful that the team was going to judge him and treat him differently because he had used fentanyl in the hospital, and that is why he wanted to leave. Working with the team on addressing this concern allayed his fears, and medication changes allowed him to stop using fentanyl in the hospital; improved his anger, pain, and anxiety; and enabled him to commit to staying in the hospital for treatment. ■

Corina Freitas, M.D., is a clinical assistant professor at George Washington University School of Medicine and chair of the Department of Psychiatry and medical director at MedStar Southern Maryland Medical Center. She has contributed to research in a number of areas, including consultation-liaison psychiatry.

Helena Winston, M.D., is an accomplished academician, having written book chapters and peer-reviewed articles that have appeared in such journals as the Journal of Neuropsychiatry and Clinical Neuroscience.

Devinalini Misir, M.D., is a clinical assistant professor at the University at Buffalo School of Medicine and Biomedical Sciences with a wide clinical focus that includes addiction and behavioral pharmacology, substance use disorders, and maternal-fetal medicine.