If psychiatrists decide to get more involved in helping patients with chronic pain (see Psychiatrists' Expertise Useful in Managing Chronic Pain), should they prescribe opioid medications?

"It is my recommendation that psychiatrists don't prescribe opioid medications [for such use], because for the most part it is outside the realm of their training," said psychiatrist and fellowship-trained pain specialist Binit Shah, M.D. He is affiliated with University Hospitals Case Medical Center in Cleveland.

However, "if psychiatrists do decide to get involved in the pharmacological management of pain and to focus heavily on opioid use, then they are going to have to be prepared for a lot of the issues that come with that," Sunil Panchal, M.D., an anesthesiologist and president of the Coalition for Pain Education Foundation in Lutz, Fla., said. "Over the past 15 years, there has been a significant liberalization in the use of opioids for chronic pain patients. And with that you have seen an increased spike in abuse and diversion. This is a societywide problem now. Studies have demonstrated that high doses of opioids make the nervous system more sensitive to pain…. We now know that testosterone levels drop even with short-term exposure to low doses of opioids. And with that drop in testosterone for both men and women, you have an increased risk of osteoporosis and bone fractures…. Immune system effects are also emerging, suggesting that cancer spreads more aggressively with the use of opioids. So if psychiatrists incorporate opioids into their treatment of pain patients, they should be aware of these long-term health risks."

And if psychiatrists do decide to prescribe opioids for pain, they should prescribe timed-release ones, Panchal stressed, because patients are not likely to get a euphoric effect from them. In other words, the timed-release ones tend to be abuse-resistant. "The one I stay away from in my practice is oxycontin because … a third of the dose comes out immediately… and you're going to get a euphoric effect," Panchal said.

Yet even if psychiatrists avoid prescribing opioids for chronic pain, they'll undoubtedly run into some opioid-pain challenges if they try to help patients with chronic pain.

For example, drug addicts who also experience chronic pain present "a big conundrum," said Igor Elman, M.D., an associate professor of psychiatry at Harvard Medical School with a special interest in pain, because of the dangers that opioid treatment for their pain will make them even more addicted than they already are.

Moreover, "We know that patients who abuse substances have higher rates of chronic pain than those who do not abuse substances," Shah noted.

"But even if patients have both an addiction and a pain problem, it should not prevent us from treating their pain and lessening their suffering," Elman stressed. "We need to come up with some evidence-based medicine and some practice guidelines for these patients. I think psychiatrists are the right people to spearhead it."

Meanwhile, psychiatrists should be aware that "procedural options exist to relieve pain and minimize the use of opioids in this at-risk population," Panchal said. "Technologies of value include radiofrequency denervation, peripheral and spinal neurostimulation, as well as intrathecal infusion therapy, which can combine many nonopioid medications, such as local anesthetics, clonidine, ziconotide, with low-dose opioids if needed."