Psychiatrists' Expertise Useful in Managing Chronic Pain

An astonishing number of Americans suffer from chronic pain. The number was 70 million in 2006, according to the U.S. Department of Health and Human Services—that is, 23 percent of a population of 300 million. Other surveys have yielded similar results.

Moreover, as the U.S. population ages, the number of chronic pain sufferers will undoubtedly soar even more since 50 percent of community-dwelling seniors and 80 percent of nursing-home residents are estimated to experience chronic pain.

Credit: McLean Hospital

Yet, "We are not doing very well as a group of health care specialists in providing the many patients who have pain with great benefits," David Borsook, M.D., a neurologist and director of the Center for Pain and the Brain at McLean Hospital in Belmont, Mass., said during a recent interview with Psychiatric News.

Eliot Gardner, Ph.D., chief of the Neuropsychopharmacology Section at the National Institute on Drug Abuse and a chronic pain patient himself for six years, holds even more vehement views on the subject. "Having been a medical school professor for 33 years, … I was appalled at the level of misinformation about pain management among the medical practitioners I encountered," he said. "And I was equally appalled at the poor level of care given to chronic pain patients."

"The prevalence of pain in psychiatric patients [alone] is huge," Igor Elman, M.D., an associate professor of psychiatry at Harvard Medical School with a special interest in pain, attested. "The problem is that these patients fall between the cracks. Psychiatrists don't want to deal with these issues because they don't know much about pain, whereas our [other] medical colleagues don't like treating psychiatric patients because there is stigma attached to them."

Complicating this situation further is the fact that sometimes people experience chronic pain as a result of mental illness, whereas other times they experience mental illness as a result of chronic pain. For example, knee pain in the elderly may be due to depression (Psychiatric News, May 6). Yet chronic pain can also lead to depression and anxiety.

So the question is this: should psychiatrists be doing more to help chronic pain patients? Some pain experts believe that they should.

"There are tremendous opportunities for psychiatrists to be more involved in the management of patients with chronic pain," Michael Clark, M.D., director of the chronic pain treatment program in the Department of Psychiatry at Johns Hopkins Medical Institutions, declared. "I think one of the things that psychiatrists bring to the care of patients with chronic pain is a more comprehensive or holistic approach. We appreciate the individuals and who they are, how disease can impact them, and recognize that living with it can make them vulnerable to all sorts of behavioral disorders."

Chronic Pain Is ‘Disease of the Brain’

"There is no question in my mind that psychiatrists are perfectly poised to handle this problem," Borsook asserted. "Chronic pain is now considered a disease of the brain … . Psychiatrists are an already perfectly trained group in terms of brain disease. They just need a few extra lessons, if you will, in adapting to treating chronic pain conditions."

Yet if psychiatrists should be doing more to help chronic pain patients, where can they start?

Perhaps by focusing on the types of psychiatric patients who tend to be predisposed to pain, Elman suggested. For example, those with anxiety or depression tend to be especially vulnerable, whereas those with schizophrenia or other psychoses tend not to be. Indeed, "It has been estimated that up to 60 percent of patients with primary depression end up with a generalized pain syndrome," Borsook noted. These are patients who did not have chronic pain before, but the depression alters their brains, and these alterations in turn lead to pain, he said.

Or perhaps psychiatrists might concentrate on those types of pain that they could be especially adept at treating, such as headaches, back pain, diabetic neuropathy, or other kinds of neuropathic pain, Elman proposed. Neuropathic pain is a type of pain caused by damage to, or dysfunction of, the nervous system.

In any event, psychiatrists have a great deal of knowledge about a lot of the medications that can relieve pain, Binit Shah, M.D., a psychiatrist and pain specialist at University Hospitals Case Medical Center in Cleveland, reported. They include the tricyclic antidepressants, SNRI antidepressants, anticonvulsant medications, and mood stabilizers.

For example, one of the medications that has been shown to be effective for neuropathic pain due to multiple sclerosis, stroke, or spinal-cord injury is the anticonvulsant lamotrigine, which psychiatrists may prescribe for bipolar depression, Shah said. The SNRI antidepressant duloxetine has been approved to treat two more kinds of neuropathic pain—fibromyalgia and low back pain. The mood stabilizer carbamazapine, which psychiatrists use to treat bipolar disorder and sometimes as an add-on for personality disorders or schizophrenia, has been shown to be helpful for yet another type of neuropathic pain—trigeminal neuralgia.

The anticonvulsants gabapentin and pregabalin are also effective against neuropathic pain, Elman pointed out. Indeed, Gardner found them "superbly analgesic … [even] better than morphine" during his six-year ordeal with chronic back pain.

The tricyclics, SNRIs, mood stabilizers, and anticonvulsants work not just against neuropathic pain, but against nociceptive pain, Sunil Panchal, M.D., explained. Nociceptive pain is pain caused by an injury—say, heat—that stimulates pain receptors located on the tips of nerves. The nerves then send the pain signals through the nervous system. Panchal is an anesthesiologist and president of the Coalition for Pain Education Foundation in Lutz, Fla.

"In most chronic pain conditions, you have a little bit of both going on," Panchal said. For instance, someone who has chronic osteoarthritis of the knee is going to have neuropathic pain superimposed on nociceptive pain.

Antipsychotics May Help

Some of the antipsychotic medications that psychiatrists use can likewise counter pain, Elman indicated. For example, several years ago, a study at Memorial Sloan-Kettering Cancer Center in New York showed that olanzapine could counter cancer patients' pain to such an extent that they could reduce their use of opioid medications by 75 percent.

Still another point worth noting is that "antidepressants—say, the tricyclics or the SSRIs—can boost the analgesic potency of opioids," Gardner said.

Psychotherapies to the Rescue

Just as psychiatrists can deploy several psychotropic medications to help chronic pain patients, so can they use various psychotherapies for this purpose.

"When patients are first learning to deal with pain, supportive psychotherapy can be useful," Shah said. "But after that, it is time to use cognitive-behavioral therapy to address and modify any negative thoughts that patients have that potentiate chronic pain, such as, ‘I'll never be able to reduce this pain’ or ‘There's no way I can live or do what I want to anymore.’ For example, you might help a patient realize, ‘OK, maybe I can't play basketball for two hours like I did before, but I can play for 15 minutes and then take a break.’ Actually, an impressive number of chronic pain patients exhibit tremendous personal strength and function, work, and contribute like the rest of us."

Psychotherapies used with chronic pain patients should be based "not on the type of pain, but on the type of patient," Elman said. The most important goal is to help the patient develop healthy mechanisms for dealing with pain. Incidentally, he pointed out, one study showed that of all nonpharmacological interventions for pain, the most effective was muscle relaxation.

If psychiatrists believe that certain cases of chronic pain are beyond their expertise to handle, they should refer these patients to pain specialists who have completed accredited fellowship training in that field, Panchal advised. "There are many doctors who do not have this specialized training who call themselves pain specialists just because they are willing to write controlled-substance prescriptions," he cautioned. Fellowship-trained pain specialists, he explained, are physicians who completed a residency in anesthesiology, neurology, physical medicine and rehabilitation, or psychiatry and who were then accepted into a fellowship program accredited by the Accrediation Council for Graduate Medical Education. In this program, they were formally trained in the specialty of pain medicine.

For instance, suppose a psychiatrist has a patient suffering from chronic pelvic pain and thereby impaired sexual activity. The psychiatrist could refer the patient to a fellowship-trained pain specialist. The specialist could then use a technique that blocks the nerve supply to the pelvic organs, thus providing the patient with dramatic pain relief, he said.

All in all, if psychiatrists get more involved in helping patients with chronic pain, they will find it immensely gratifying, pain experts predict.

"It offers us a chance to get back into the medical mainstream and be equal partners with the rest of the medical team," Elman ventured.

"When I treat patients with chronic pain, I view them as patients who have chronic mental illnesses," Shah said. "It is something they struggle with, it can sometimes be lifelong, and it's about managing rehabilitation and living a life of quality and meaning despite having a disease process. So the paradigm by which we psychiatrists approach patients with mental illnesses can also be used to help patients with chronic pain. And the rewards from treating the latter can be just as great."