- Email: [email protected]
or psychiatrist
Techniques in Regional Anesthesia and Pain Management (2005) 9, 221-227
Pain medicine: Why and when to call for the addictionologist and/or psychiatrist Rafael V. Miguel, MD From the Pain Medicine Program, Department of Anesthesiology, University of South Florida, Tampa, Florida. KEYWORDS: Pain; Substance abuse; Psychopathology; Addiction; Depression; Anxiety
Substance abuse and psychopathology are frequently present in pain patients and often complicate pain treatment. Whereas the pain physician does not necessarily need to possess the tools needed to effectively treat these complicating conditions, it is incumbent on the pain physician to determine their presence and secure appropriate consultation. Aberrant drug behaviors may be present when patients manifest one or more of the following: continued use despite self harm, daily functionality deteriorates, impaired control over use (unable to take medications as prescribed), preoccupation with use of analgesics for non-analgesics purposes, inability to use non-opioid pain interventions, and/or preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). The most common psychopathology is depression and anxiety. The clinical presentation of depression is commonly: persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). Anxiety is somewhat different and the clinical signs are: personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression) or triggered by stressful situation (eg, chronic pain), worry out of proportion about negative results, kinesophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restlessness, and/or fatigue. Depression and anxiety (most commonly Generalized Anxiety Disorder) are most effectively treated by Cognitive Behavioral Therapies in combination with pharmacologic means. Practicing in an interdisciplinary manner, with appropriate specialty consultation, is indicative of a comprehensive pain management program which is associated with the best possible patient results when dealing with patients manifesting comorbid addiction and/or psychopathology conditions. © 2005 Elsevier Inc. All rights reserved.
Pain management has received increased attention from the medical community. This has been influenced by societal demands for more effective and comprehensive treatment. The Joint Commission on Accreditation of Health Care Organizations requires that their accredited health care organizations consider pain as “the fifth vital sign,” requiring that pain severity be documented by using a standardized pain scale. There has been a dramatic change in the medical management of pain over the past 10 years (Figure 1).1,2 The threshold for prescribing opioids has decreased and is a function as much of scientific changes as societal ones. In the US in the early 1990s, there was a national debate Address reprint requests and correspondence: Dr. Rafael V. Miguel, Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612. E-mail address: [email protected] 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2005.10.008
regarding euthanasia as an alternative to pain and suffering. The debate centered on whether there was a constitutionally provided right to take one’s life. In 1994, Oregon voters passed legislation legalizing the procedure of hastening the end of life to relieve pain and suffering (ie, Measure 16; Death With Dignity Act). In 1996, two separate Federal Circuit Court of Appeals struck down laws prohibiting euthanasia, ruling that there was no constitutional obstruction to that practice. This encouraged other states to seek changes in their laws addressing euthanasia/physician-assisted suicide. However, in 1997, the Supreme Court subsequently reversed the Federal Circuit Courts decision.3 But Supreme Court opinions accompanying rulings are often more significant than the ruling itself. With a unanimous decision, Chief Justice Rehnquist delivered and Justices O’Connor and Stevens wrote (with Justice Souter concurring) that, although taking one’s life was not protected by the Constitution, the citizenry had a right to relief from pain
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Figure 1
Global consumption of opioids from 1972 to 1995 (modified from Joranson and Gilson).1
and suffering, recognizing that the final effect in many cases will be the same. They addressed the need for laws and rules modification, which were seen as obstacles to effective pain relief, then the most common reason for selecting euthanasia as an option to life. Buoyed by this ruling, with its concomitant opinion, as much as the development of better medications to relieve pain, the use of opioids became commonplace. The purpose of this monograph is to identify substance abuse and psychopathology as frequently present in pain patients. Furthermore, their presence complicates pain treatment and likely leads to treatment failures. It is beyond the scope of this paper (and the author’s knowledge) to present an exhaustive treatise on the two topics, but that is the point of this manuscript. Although pain physicians are experts in treating pain patients, they are not necessarily experts in treating addicts and patients with psychiatric disorders. Pain physicians should be cognizant that these comorbid conditions are common in pain patients and be able to determine their existence and when they are affecting pain treatment negatively. These latter points should lead the prudent pain physician to seek and obtain prompt and appropriate specialty consultation.
Interdisciplinary versus multidisciplinary pain care It is often stated that the multidisciplinary approach to pain management is the most effective. There is little to argue against that concept. A multidisciplinary approach with a “team” concept and practice allows for the evaluation of the pain patient by various team members, each of which is a
specialist with varying skill sets. This allows for application of each member’s expertise toward the patient’s diagnosis and proposed treatment plan. Although this is undoubtedly an attractive option, it does present a series of formidable obstacles, which has prevented its widespread application. A multidisciplinary approach is often slow, difficult to organize and maintain, and poorly reimbursed. The “standard of care” practice in the US is the interdisciplinary approach. In this system, the primary pain physician performs the initial consultation and establishes the treatment plan. This physician is charged with the responsibility of securing multispecialty consultations as appropriate. This method also appears to have room for improvement, primarily by education in identifying the patient in need of multispecialty pain care. Among the commonly voiced obstructions to the interdisciplinary practice are lack of dedicated specialists, most notably addictionologists, in many communities and, again, the reality of poor reimbursement for such care. Identification of such individuals should be made in advance of their need and, by establishing this relationship, access to care may be improved. Even if an addictionologist is not available, as may occur in some smaller communities, referral to a psychiatrist willing and interested in addiction medicine or regional referral center evaluation would suffice. Cancer pain management is one of the most gratifying forms of pain management as patients less frequently are drug seekers, have secondary gains (eg, disability), and often equate reduced drug intake with an improvement in cancer status. However, effective treatment of cancer pain begins with assessing the severity, characteristics, and impact of pain. Emotional distress (especially anxiety, depression, and beliefs about pain) can easily complicate cancer
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Table 1 Beliefs and behavioral factors that complicate low back pain management ● ● ● ● ●
Back pain is harmful or disabling Fear avoidance behavior Kinesophobia Depressed mood/social withdrawal Expectation that passive, rather than active, participation in treatments will help ● Other complicating factors i. Depression ii. Anxiety iii. Unresolved occupational issues iv. Disability claims
pain management and has emerged as predictive of patient pain levels.4 Due to the enormous impact cancer has on an individual and his/her family, appropriate cancer pain management more frequently than not requires a multispecialty approach. Patient psycho-education has empowered patients to actively participate in pain control strategies. Supportive psychotherapy can assist patients in managing the stressors associated with cancer, and cognitive-behavioral therapy helps patients to recognize and modify the factors that contribute to physical and emotional distress. Patients often have preconceived notions or underlying psychopathology which complicates pain treatment.5 These have been identified in patients with chronic low back pain and are outlined in Table 1. These require identification and effective treatment, which will more likely than not be identified earlier by psychiatric consultation.
Can past substance abuse predict pain medication misuse and dependence? Patients with documented prior addiction to alcohol or controlled substances may present to the pain clinic with complaints of chronic pain. These patients present a difficult, challenging, and sometimes ethical therapeutic dilemma. Placing aside for the moment patient management, the latter concern dealing with whether to treat the patient or not with a prior history of substance abuse is a significant one. The American Academy of Pain Medicine Ethics Charter specifically points out: “patients with pain disorders who are addicted to drugs and/or alcohol deserve the same competent pain assessment and management that all other patients deserve. Physicians have an obligation to educate themselves about standards of care in addictive disease and substance abuse disorders and should make use of resources to comanage these patients, when indicated.” Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors characterized by one or more of the following behaviors: ● ● ●
Continued use despite self harm, daily functionality deteriorates; Impaired control over use, inability to take medications as prescribed; and Preoccupation with use of analgesics for nonanalgesic purposes and inability to use nonopioid pain interven-
223 tions, preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). Patients with a family history of substance abuse are at increased risk of addiction as are patients with a history of personal nonopioid and opioid (highest risk) abuse. Conversely, patients may reasonably be deemed to not becoming addicted if they manifest reasonable pain control, improved function, treatment compliance, discuss medication issues only at appointments, and have rare prescription issues. There are a series of behavioral characteristics that pain patients may exhibit which have been more predictive of controlled substance abuse. These are listed in Table 2. A recent study by Schieffer and coworkers6 addressed the issue of whether chronic pain patients with a history of substance abuse showed greater medication misuse, compared with other pain patients. These investigators assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opioid medication misuse in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. A key finding from the research is that, even though both anxiety and substance abuse history are related to medication misuse, the misusers studied believed more strongly in the potential for opioid addiction and in the need for higher doses. They also had a greater belief in the effectiveness of opioids and the importance of free access to medications. The results demonstrated that patients with a history of substance abuse, compared with those without, showed greater medication misuse despite similar dosages and self-rated opioid effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others; however, they also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors could be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Pain physicians may help patients by addressing these issues before prescribing opioids. Many pain physicians may not feel comfortable with these issues, either due to lack of training or lack of comfort
Table 2 Behavioral characteristics more predictive of the drug abusing/diverting pain patient ● Frequent loss of prescription ● Greater than once ● Lack of effectiveness of non-controlled substances ● Allergy to non-opioids ● Specific drug requests ● Drug dealing ● Stealing ● Obtaining drug from non-medical source ● Concurrent use of illicit drugs ● ETOH abuse ● Demonstrating functional deterioration ● Isolation from family/friends ● “Doctor shopping⬙/frequent ER visits for opioids ● Urine screen negative for prescribed drugs ● Positive for non-prescribed drugs
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Table 3 Guidelines for managing the pain patient with a history of substance abuse ● Maximally structured approach ● Frequent visits ● Limited supply of medications ● refill contingent on: ● office visit ● pill count ● Use long-acting opioids with low street value ● Tight use of rescue ● Urine toxicology ● Treatment agreement ● Co-manage with addictionologist ● Participate in recovery program ● Psychotherapy ● Search for psychopathology ● Involve family ● Document, document, document
with discussion of addiction issues. A history of substance abuse is associated with increased opioid medication misuse independent of differences in reported opioid effectiveness. Self-attributions regarding opioid treatment related to need for higher doses, dose control, and addiction potential may be important mediators of this relationship and interact with anxiety to produce heightened risk of opioid misuse. The authors concluded that assuming a better quality of life is associated with freer medication access and higher doses may override an individual’s recognition of addiction potential, which may lead to medication misuse. In addition, neurophysiologic changes, such as a lower threshold for pain and shorter tolerance of pain, may contribute to misusers mistakenly believing they need higher doses of opioid medication than the average patient. If the use of nonpharmacologic analgesic methods (eg, guided imagery, acupuncture, relaxation techniques, TENS, etc.) does not result in adequate pain relief, the use of noncontrolled substances should be considered. However, if the use of noncontrolled substances fails, long-acting opioids used under strict supervision may be considered. These are complex pain patients to manage and require a different approach. General overall guidelines to follow are delineated in Table 3.
Pain management physicians are not addictionologists! Patients with a history of substance abuse present an impressive therapeutic and management dilemma. These patients are not the “typical” pain patients. Patients with a history of substance abuse are in real danger of relapse and need special management with intensive oversight. Recent policy statements from the DEA continue to reinforce the requirement that abuse, diversion, and addiction issues should be sought prospectively in patients receiving Schedule II medications. The August 26, 2005 Federal Register contained the following statement by the DEA: “. . .physicians and pharmacies have a duty as DEA registrants to ensure that their prescribing and dispensing of controlled substances occur in a manner consistent with effective con-
trols against diversion and misuse.”7 These safeguards may include behavior profiling (personal, familial, and social), background screening, biological drug screens, treatment agreements, and/or others. Participating in the patient’s care closely with an addictionologist is strongly recommended for all patients with a prior history of substance abuse. Reactivating CNS satisfaction centers (altered drug reward mechanisms), possibly permanently damaged by substance abuse, carries with it an elevated incidence of relapse. This consideration combined with the knowledge that uncontrolled pain in itself is a relapse risk, demonstrates the complexities involved in attempting to manage the patient by one physician. Patients presently in a drug treatment program who present as pain patients can be treated but must be treated only as pain patients. In a letter from the DEA available on the American Society of Addiction Medicine’s Web site, Chief Patricia Good of the Liaison and Policy Office, Office of Diversion Control, Department of Justice wrote in 2000, “Although pain specialists may treat a chronic pain patient currently enrolled in a narcotic treatment program, they may only treat the patient’s pain. Care of patients fighting substance abuse requires sensitivity to the issue and careful monitoring of outcomes. As a suggestion, you may wish to obtain the patient’s permission to coordinate your pain management treatment with his/her narcotic treatment program.”
Psychopathology and pain The assessment and management of pain is difficult enough. Pain is more than a singular sensation; it is influenced by emotional, cognitive, and psychosocial factors. Comprised mainly of depression, anxiety, insomnia, and high neuroticism, comorbid psychopathology often coexist in patients with chronic pain and complicates overall pain management, worsening the prognosis.8 Multiple studies have identified concurrent psychopathology in pain patients9-11 with a 60% to 80% expression. The most common of these is depression, followed in decreasing frequency by anxiety, personality disorders, somatiform disorders, and substance abuse. Pharmacologic treatment strategies that reduce pain may result in concurrent improvements in common painassociated comorbidities; however, suboptimal treatment of the comorbid psychopathology, recognized or not, may hamper intents to improve the patient’s perception of pain relief and functional improvement. Pain patients with depression may manifest persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). These patients are anxious, have panic attacks, PTSD, see the future as bleak, no one can help them, and/or may manifest suicidal thoughts. Anxiety disorders generally present as personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression), or triggered by stressful situation (eg, chronic pain). Thirty to 60% of chronic pain patients have pathological anxiety (GAD most common). Worry and concern out of proportion to likelihood of negative effects, kine-
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sophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restless, and fatigue are all common symptoms of anxiety disorders.12,13 In patients with a history of drug dependence, psychiatric illnesses should be aggressively diagnosed and treated, because untreated symptoms increase the risk of relapse into chemical dependency.14 There are a multitude of pharmacologic methods which may improve the recovering substance abuser with comorbid psychopathology; selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. It is not known whether psychopathology is associated with diminished opioid analgesia in patients with chronic, noncancer pain. Wasan and coworkers15 studied 60 patients with discogenic low back pain not on opioids in a doubleblind, placebo-controlled, random crossover designed trial. Patients were stratified into 3 groups of psychological symptom severity (Low, Mod, and High), based on composite scores on depression, anxiety for pain, and neuroticism scales. For morphine analgesia, using a total pain relief calculation (TOTPAR), the Low group had 65.1% TOTPAR versus 41.0% in the High group (P ⫽ 0.026). For placebo analgesia, the Low group had 7.7% TOTPAR versus 23.5% in the High group (P ⫽ 0.03). Their findings support the concept that high levels of psychopathology are associated with diminished opioid analgesia in patients with discogenic low back pain. They also indicate that patients with high levels of psychopathology may have more inappropriate placebo responses. There are numerous studies demonstrating that an elevated state of anxiety (a person’s current level of anxiety) is often associated with reports of higher pain levels, whereas an increased trait anxiety (general disposition to become anxious) tends to exacerbate and complicate pain management. The combined effects of state and trait anxiety on self-rated pain had not previously been evaluated. Tang and coworkers16 recently published the results of their study in The Journal of Pain evaluating whether anxiety-reducing therapies, such as controlled breathing and other relaxation techniques, could be beneficial for relieving pain. Their findings revealed that individuals with high trait anxiety reported significantly higher pain intensity than those low trait anxiety patients. Their data also showed an additive rather than a synergistic relationship between state and trait anxiety and pain perception. The authors also noted that relaxation techniques might be most beneficial for high trait anxiety pain patients who experience more intense levels of anxiety and pain. Patients with chronic pain often complain of difficulties with cognitive functioning. These have been documented to occur without a history of head trauma or neurologic disease. McCracken and Iverson17 studied potential predictors of cognitive complaints in 275 consecutive patients referred to a university pain management center. Patients completed a brief set of self-report measures of problems with cognitive functioning, biographical information, pain severity, pain location, depression, anxiety, sleep quality, medication use, and litigation status during their first visit to the clinic.
225 Table 4 Depression in pain patient rules (modified from Haythornwaite) 1. Consider the symptoms rather than the disorder. 2. A wide range of symptoms may identify depression. 3. Periodically use a standardized measurement tool to assess treatment success. 4. Treatment of depression is part of pain treatment. 5. Have a plan, share it with the patient and family, and make it multispecialty.
The most frequently reported cognitive complaints included forgetfulness (23.4%), minor accidents (23.1%), difficulty finishing tasks (20.5%), and difficulty with attention (18.7%). Fifty-four percent of patients reported at least 1 problem with cognitive functioning. Regression analyses showed that depression accounted for the largest unique proportion of variance in cognitive complaints. Given the high frequency of complaints of impaired cognitive functioning, routine assessment appears warranted. When these complaints are encountered, initial assessment should be directed at iatrogenic drug effect. If this is ruled out as a cause, careful evaluation considering a range of neurological, social, and emotional influences is indicated and referral to a neuropsychiatrist should be considered. Unemployment is a consequence of chronic low back pain, which has considerable health and economic consequences for the individual and society and may be affected by the degree of patient psychopathology. There are multiple factors which may affect the ability to return to work and progress toward employment. Watson and coworkers18 studied 86 subjects undergoing a pain management rehabilitation program incorporating vocational focusing and advice; subjects were followed up at 6 months to determine work status. At follow up 38.4% of subjects were employed and another 23% were in voluntary work or education/ training. Subjects were divided into those who made positive progress (work, education/training, or voluntary work) and those who did not (remained unemployed, dropped out of the program, or lost to follow up). Those who failed to make positive progress were characterized by longer duration of unemployment and higher scores on somatic anxiety and depression.
Pain management physicians are not psychiatrists! Whereas the diagnosis of a prior history of substance abuse can be fairly easy to establish, assuming no intent of misleading by a patient, the diagnosis of psychopathology, may be less obvious. The aforementioned clinical reports by the patient may indicate a problem and be the call for therapy initiation. Haythornwaite19 identifies five rules to consider (Table 4) which may indicate that depression may be an issue when treating the patient in pain: 1. Consider the symptoms and not the disorder. The presence of even mild depressive symptoms may indicate a problem with depression and complicates treatment. Ignore the patient’s reasoning that his depression is due to his pain, as this is a common excuse.
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2. A range of symptoms is indicative of depression. These include, but are not limited to, lack of motivation or interest, sleep disturbances, changes in appetite, energy disturbances, negative self-attitude, thoughts of dying, concentration/memory lapses, and agitation. 3. Standardized assessment tools can predict treatment outcome. Using a tool (eg, Beck Depression Inventory®) to monitor symptoms with assess treatment progress or lack thereof. 4. The treatment of depression is part of the overall treatment plan. Explaining to the patient and family members that pain and depression frequently go hand in hand, that depression interferes with treatment, and that it has a biological basis will assist in reducing patient resistance and improves treatment efficacy. 5. Treating depression requires a plan. Behavioral cognitive therapies and pharmacological approaches should be used and reassessed periodically for determination of success. A change in the treatment plan should be implemented if no improvement is seen. A frank discussion of the plan, its goals, and expected outcomes should be included. As can easily be appreciated, the diagnosis and treatment of psychopathology in the pain patient requires a thorough understanding of its various presentations and potential combinations. The pain physician needs to be aware of the frequent expression of these disease states in his patients in order that consultation may be secured. Combining Cognitive Behavioral Therapies (eg, desensitization, behavior modification, behavioral activation, rational emotive therapy, mindfulness medication, Beck’s cognitive therapy, and acceptance/commitment therapy) with pharmacologic agents has been associated with the best results in treating depression and anxiety.
Do cancer pain patients differ from noncancer chronic pain patients in their need for secondary consultation? Cancer pain and noncancer chronic pain patients share many psychosocial features in common. Turk and coworkers20 compared the adaptation of cancer and noncancer chronic pain patients. The cancer pain patients reported comparable levels of pain severity to noncancer chronic pain patients; however, pain due to cancer was associated with higher levels of perceived disability (P ⬍ 0.004) and lower degree of activity (P ⬍ 0.04). The patients with cancer pain, particularly those with metastatic disease, reported significantly higher levels of support and solicitous behaviors from significant others, compared with noncancer chronic pain patients. Cancer patients, with (81%) and without (84%) metastatic disease and noncancer chronic pain patients (85%), could be classified into one of three psychosocial subgroups: “dysfunctional” (high levels of pain, perceived interference, affective distress, and low levels of perceived control and activity), “interpersonally distressed” (high levels of affective distress, negative responses from significant others, and low levels of perceived support), and “adaptive copers” (low levels of interference and affective distress, high levels of perceived control and activity). The heterogeneity of psychosocial adaptation to pain within
each patient group suggests the importance of psychological assessment in determining the pain management plan.
Summary The chronic pain patient, regardless of whether the origin of the pain is oncologic or not, presents a significant therapeutic dilemma due to the high incidence of comorbid psychopathology. The presence of preexisting substance abuse, be it recent or distant, carries with it a significant incidence of relapse. These complicating conditions often outstrip the treating pain physician’s knowledge base, clinical resources, and support services. Although a multidisciplinary approach would identify these issues early in the treatment scheme, the limitations of this approach restrict its utility to most pain practices. However, the judicious pain physician should have an established relationship and a low threshold for secondary consultation with an addictionologist and/or psychiatrist (these are not necessarily the same person as two separate skill sets are required), expert in pain patients and/or addiction issues to assist in managing these complex patients and improving treatment outcomes.
References 1. Joranson DE, Gilson AM: Opioid availability: diagnosis and treatment of regulatory barriers. University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Policy and Communications in Cancer Care: Madison, WI 1997 (Monograph) 2. Caudill-Slosberg MA, Schwartz LM, Woloshin S: Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 109:514-519, 2004 3. US Supreme Court; Vacco, Attorney General of New York, et al. v. Quill et al., certiorari to the US Court of Appeals for the Second Court, No. 95-1858. Argued January 8, 1997. Decided June 26, 1997. 4. Thomas EM, Weiss SM: Nonpharmacological interventions with chronic cancer pain in adults. Cancer Control 7:157-164, 2000 5. The Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain, 2001. Available at: http:// www.rcgp.org.uk/clinspec/guidelines/backpain. Accessed October 4, 2005 6. Schieffer BM, Pham Q, Labus J, et al: Pain medication beliefs and medication misuse in chronic pain. J Pain 6:620-629, 2005 7. Clarification of existing requirements under the Controlled Substances Act for prescribing Schedule II Controlled Substances. Federal Register Doc 05-16954 [Federal Register: August 26, 2005 (Volume 70, Number 165)] [Notices] [Page 50408-50409] 8. Atkinson JH, Slater MA, Wahlgren ? et al: Effects of nonadreenergic and serotoninergic antidepressants in patients with chronic low back pain intensity. Pain 83:137-145, 1999 9. Katon W, Egan K, Miller D: Chronic pain: lifetime diagnoses and family history. Am J Psy 142:1156-1160, 1985 10. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff M: Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. J Pain 26:181-197, 1986 11. Clark MR, Cox TS: Refractory chronic pain. Psy Clin NA 25:71-88, 2002 12. Fishbain DA: Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient. Med Clin NA 83:737-760, 1999 13. Gallagher RM, Verma S: Managing pain and comorbid depression: a public health challenge. Sem Clin Neuropsy 4:203-220, 1999 14. Jones EM, Knutson D, Haines D: Common problems in patients recovering from chemical dependency. Am Fam Physician 68:1971-1978, 2003
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15. Wasan AD, Davar G, Jamison R: The association between negative affect and opioid analgesia in patients with discogenic low back pain. Pain 2005 Sep 8 16. Tang J, Gibson SJ: A psychophysical evaluation of the relationship between trait anxiety, pain perception and induced state anxiety. J Pain 6:612-619, 2005 17. McCracken LM, Iverson GL: Predicting complaints of impaired cognitive functioning in patients with chronic pain. J Pain Sympt Manage 21:392-396, 2001
227 18. Watson PJ, Booker CK, Moores L, et al: Returning the chronically unemployed with low back pain to employment. Eur J Pain 8:359-369, 2004 19. Haythornwaite JA: Psychological management of difficult pain scenarios. Highlights in Pain Management: Excerpts from a Meet the Experts Roundtable. Boston, MA, American Pain Society, 2005. Available at http://www.cemedicus.com/pain. Accessed October 5, 2005 20. Turk DC, Sist TC, Okifuji A, et al: Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors. Pain 74:247-256, 1998
Pain medicine: Why and when to call for the addictionologist and/or psychiatrist Rafael V. Miguel, MD From the Pain Medicine Program, Department of Anesthesiology, University of South Florida, Tampa, Florida. KEYWORDS: Pain; Substance abuse; Psychopathology; Addiction; Depression; Anxiety
Substance abuse and psychopathology are frequently present in pain patients and often complicate pain treatment. Whereas the pain physician does not necessarily need to possess the tools needed to effectively treat these complicating conditions, it is incumbent on the pain physician to determine their presence and secure appropriate consultation. Aberrant drug behaviors may be present when patients manifest one or more of the following: continued use despite self harm, daily functionality deteriorates, impaired control over use (unable to take medications as prescribed), preoccupation with use of analgesics for non-analgesics purposes, inability to use non-opioid pain interventions, and/or preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). The most common psychopathology is depression and anxiety. The clinical presentation of depression is commonly: persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). Anxiety is somewhat different and the clinical signs are: personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression) or triggered by stressful situation (eg, chronic pain), worry out of proportion about negative results, kinesophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restlessness, and/or fatigue. Depression and anxiety (most commonly Generalized Anxiety Disorder) are most effectively treated by Cognitive Behavioral Therapies in combination with pharmacologic means. Practicing in an interdisciplinary manner, with appropriate specialty consultation, is indicative of a comprehensive pain management program which is associated with the best possible patient results when dealing with patients manifesting comorbid addiction and/or psychopathology conditions. © 2005 Elsevier Inc. All rights reserved.
Pain management has received increased attention from the medical community. This has been influenced by societal demands for more effective and comprehensive treatment. The Joint Commission on Accreditation of Health Care Organizations requires that their accredited health care organizations consider pain as “the fifth vital sign,” requiring that pain severity be documented by using a standardized pain scale. There has been a dramatic change in the medical management of pain over the past 10 years (Figure 1).1,2 The threshold for prescribing opioids has decreased and is a function as much of scientific changes as societal ones. In the US in the early 1990s, there was a national debate Address reprint requests and correspondence: Dr. Rafael V. Miguel, Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612. E-mail address: [email protected] 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2005.10.008
regarding euthanasia as an alternative to pain and suffering. The debate centered on whether there was a constitutionally provided right to take one’s life. In 1994, Oregon voters passed legislation legalizing the procedure of hastening the end of life to relieve pain and suffering (ie, Measure 16; Death With Dignity Act). In 1996, two separate Federal Circuit Court of Appeals struck down laws prohibiting euthanasia, ruling that there was no constitutional obstruction to that practice. This encouraged other states to seek changes in their laws addressing euthanasia/physician-assisted suicide. However, in 1997, the Supreme Court subsequently reversed the Federal Circuit Courts decision.3 But Supreme Court opinions accompanying rulings are often more significant than the ruling itself. With a unanimous decision, Chief Justice Rehnquist delivered and Justices O’Connor and Stevens wrote (with Justice Souter concurring) that, although taking one’s life was not protected by the Constitution, the citizenry had a right to relief from pain
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Figure 1
Global consumption of opioids from 1972 to 1995 (modified from Joranson and Gilson).1
and suffering, recognizing that the final effect in many cases will be the same. They addressed the need for laws and rules modification, which were seen as obstacles to effective pain relief, then the most common reason for selecting euthanasia as an option to life. Buoyed by this ruling, with its concomitant opinion, as much as the development of better medications to relieve pain, the use of opioids became commonplace. The purpose of this monograph is to identify substance abuse and psychopathology as frequently present in pain patients. Furthermore, their presence complicates pain treatment and likely leads to treatment failures. It is beyond the scope of this paper (and the author’s knowledge) to present an exhaustive treatise on the two topics, but that is the point of this manuscript. Although pain physicians are experts in treating pain patients, they are not necessarily experts in treating addicts and patients with psychiatric disorders. Pain physicians should be cognizant that these comorbid conditions are common in pain patients and be able to determine their existence and when they are affecting pain treatment negatively. These latter points should lead the prudent pain physician to seek and obtain prompt and appropriate specialty consultation.
Interdisciplinary versus multidisciplinary pain care It is often stated that the multidisciplinary approach to pain management is the most effective. There is little to argue against that concept. A multidisciplinary approach with a “team” concept and practice allows for the evaluation of the pain patient by various team members, each of which is a
specialist with varying skill sets. This allows for application of each member’s expertise toward the patient’s diagnosis and proposed treatment plan. Although this is undoubtedly an attractive option, it does present a series of formidable obstacles, which has prevented its widespread application. A multidisciplinary approach is often slow, difficult to organize and maintain, and poorly reimbursed. The “standard of care” practice in the US is the interdisciplinary approach. In this system, the primary pain physician performs the initial consultation and establishes the treatment plan. This physician is charged with the responsibility of securing multispecialty consultations as appropriate. This method also appears to have room for improvement, primarily by education in identifying the patient in need of multispecialty pain care. Among the commonly voiced obstructions to the interdisciplinary practice are lack of dedicated specialists, most notably addictionologists, in many communities and, again, the reality of poor reimbursement for such care. Identification of such individuals should be made in advance of their need and, by establishing this relationship, access to care may be improved. Even if an addictionologist is not available, as may occur in some smaller communities, referral to a psychiatrist willing and interested in addiction medicine or regional referral center evaluation would suffice. Cancer pain management is one of the most gratifying forms of pain management as patients less frequently are drug seekers, have secondary gains (eg, disability), and often equate reduced drug intake with an improvement in cancer status. However, effective treatment of cancer pain begins with assessing the severity, characteristics, and impact of pain. Emotional distress (especially anxiety, depression, and beliefs about pain) can easily complicate cancer
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Table 1 Beliefs and behavioral factors that complicate low back pain management ● ● ● ● ●
Back pain is harmful or disabling Fear avoidance behavior Kinesophobia Depressed mood/social withdrawal Expectation that passive, rather than active, participation in treatments will help ● Other complicating factors i. Depression ii. Anxiety iii. Unresolved occupational issues iv. Disability claims
pain management and has emerged as predictive of patient pain levels.4 Due to the enormous impact cancer has on an individual and his/her family, appropriate cancer pain management more frequently than not requires a multispecialty approach. Patient psycho-education has empowered patients to actively participate in pain control strategies. Supportive psychotherapy can assist patients in managing the stressors associated with cancer, and cognitive-behavioral therapy helps patients to recognize and modify the factors that contribute to physical and emotional distress. Patients often have preconceived notions or underlying psychopathology which complicates pain treatment.5 These have been identified in patients with chronic low back pain and are outlined in Table 1. These require identification and effective treatment, which will more likely than not be identified earlier by psychiatric consultation.
Can past substance abuse predict pain medication misuse and dependence? Patients with documented prior addiction to alcohol or controlled substances may present to the pain clinic with complaints of chronic pain. These patients present a difficult, challenging, and sometimes ethical therapeutic dilemma. Placing aside for the moment patient management, the latter concern dealing with whether to treat the patient or not with a prior history of substance abuse is a significant one. The American Academy of Pain Medicine Ethics Charter specifically points out: “patients with pain disorders who are addicted to drugs and/or alcohol deserve the same competent pain assessment and management that all other patients deserve. Physicians have an obligation to educate themselves about standards of care in addictive disease and substance abuse disorders and should make use of resources to comanage these patients, when indicated.” Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors characterized by one or more of the following behaviors: ● ● ●
Continued use despite self harm, daily functionality deteriorates; Impaired control over use, inability to take medications as prescribed; and Preoccupation with use of analgesics for nonanalgesic purposes and inability to use nonopioid pain interven-
223 tions, preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). Patients with a family history of substance abuse are at increased risk of addiction as are patients with a history of personal nonopioid and opioid (highest risk) abuse. Conversely, patients may reasonably be deemed to not becoming addicted if they manifest reasonable pain control, improved function, treatment compliance, discuss medication issues only at appointments, and have rare prescription issues. There are a series of behavioral characteristics that pain patients may exhibit which have been more predictive of controlled substance abuse. These are listed in Table 2. A recent study by Schieffer and coworkers6 addressed the issue of whether chronic pain patients with a history of substance abuse showed greater medication misuse, compared with other pain patients. These investigators assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opioid medication misuse in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. A key finding from the research is that, even though both anxiety and substance abuse history are related to medication misuse, the misusers studied believed more strongly in the potential for opioid addiction and in the need for higher doses. They also had a greater belief in the effectiveness of opioids and the importance of free access to medications. The results demonstrated that patients with a history of substance abuse, compared with those without, showed greater medication misuse despite similar dosages and self-rated opioid effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others; however, they also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors could be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Pain physicians may help patients by addressing these issues before prescribing opioids. Many pain physicians may not feel comfortable with these issues, either due to lack of training or lack of comfort
Table 2 Behavioral characteristics more predictive of the drug abusing/diverting pain patient ● Frequent loss of prescription ● Greater than once ● Lack of effectiveness of non-controlled substances ● Allergy to non-opioids ● Specific drug requests ● Drug dealing ● Stealing ● Obtaining drug from non-medical source ● Concurrent use of illicit drugs ● ETOH abuse ● Demonstrating functional deterioration ● Isolation from family/friends ● “Doctor shopping⬙/frequent ER visits for opioids ● Urine screen negative for prescribed drugs ● Positive for non-prescribed drugs
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Table 3 Guidelines for managing the pain patient with a history of substance abuse ● Maximally structured approach ● Frequent visits ● Limited supply of medications ● refill contingent on: ● office visit ● pill count ● Use long-acting opioids with low street value ● Tight use of rescue ● Urine toxicology ● Treatment agreement ● Co-manage with addictionologist ● Participate in recovery program ● Psychotherapy ● Search for psychopathology ● Involve family ● Document, document, document
with discussion of addiction issues. A history of substance abuse is associated with increased opioid medication misuse independent of differences in reported opioid effectiveness. Self-attributions regarding opioid treatment related to need for higher doses, dose control, and addiction potential may be important mediators of this relationship and interact with anxiety to produce heightened risk of opioid misuse. The authors concluded that assuming a better quality of life is associated with freer medication access and higher doses may override an individual’s recognition of addiction potential, which may lead to medication misuse. In addition, neurophysiologic changes, such as a lower threshold for pain and shorter tolerance of pain, may contribute to misusers mistakenly believing they need higher doses of opioid medication than the average patient. If the use of nonpharmacologic analgesic methods (eg, guided imagery, acupuncture, relaxation techniques, TENS, etc.) does not result in adequate pain relief, the use of noncontrolled substances should be considered. However, if the use of noncontrolled substances fails, long-acting opioids used under strict supervision may be considered. These are complex pain patients to manage and require a different approach. General overall guidelines to follow are delineated in Table 3.
Pain management physicians are not addictionologists! Patients with a history of substance abuse present an impressive therapeutic and management dilemma. These patients are not the “typical” pain patients. Patients with a history of substance abuse are in real danger of relapse and need special management with intensive oversight. Recent policy statements from the DEA continue to reinforce the requirement that abuse, diversion, and addiction issues should be sought prospectively in patients receiving Schedule II medications. The August 26, 2005 Federal Register contained the following statement by the DEA: “. . .physicians and pharmacies have a duty as DEA registrants to ensure that their prescribing and dispensing of controlled substances occur in a manner consistent with effective con-
trols against diversion and misuse.”7 These safeguards may include behavior profiling (personal, familial, and social), background screening, biological drug screens, treatment agreements, and/or others. Participating in the patient’s care closely with an addictionologist is strongly recommended for all patients with a prior history of substance abuse. Reactivating CNS satisfaction centers (altered drug reward mechanisms), possibly permanently damaged by substance abuse, carries with it an elevated incidence of relapse. This consideration combined with the knowledge that uncontrolled pain in itself is a relapse risk, demonstrates the complexities involved in attempting to manage the patient by one physician. Patients presently in a drug treatment program who present as pain patients can be treated but must be treated only as pain patients. In a letter from the DEA available on the American Society of Addiction Medicine’s Web site, Chief Patricia Good of the Liaison and Policy Office, Office of Diversion Control, Department of Justice wrote in 2000, “Although pain specialists may treat a chronic pain patient currently enrolled in a narcotic treatment program, they may only treat the patient’s pain. Care of patients fighting substance abuse requires sensitivity to the issue and careful monitoring of outcomes. As a suggestion, you may wish to obtain the patient’s permission to coordinate your pain management treatment with his/her narcotic treatment program.”
Psychopathology and pain The assessment and management of pain is difficult enough. Pain is more than a singular sensation; it is influenced by emotional, cognitive, and psychosocial factors. Comprised mainly of depression, anxiety, insomnia, and high neuroticism, comorbid psychopathology often coexist in patients with chronic pain and complicates overall pain management, worsening the prognosis.8 Multiple studies have identified concurrent psychopathology in pain patients9-11 with a 60% to 80% expression. The most common of these is depression, followed in decreasing frequency by anxiety, personality disorders, somatiform disorders, and substance abuse. Pharmacologic treatment strategies that reduce pain may result in concurrent improvements in common painassociated comorbidities; however, suboptimal treatment of the comorbid psychopathology, recognized or not, may hamper intents to improve the patient’s perception of pain relief and functional improvement. Pain patients with depression may manifest persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). These patients are anxious, have panic attacks, PTSD, see the future as bleak, no one can help them, and/or may manifest suicidal thoughts. Anxiety disorders generally present as personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression), or triggered by stressful situation (eg, chronic pain). Thirty to 60% of chronic pain patients have pathological anxiety (GAD most common). Worry and concern out of proportion to likelihood of negative effects, kine-
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sophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restless, and fatigue are all common symptoms of anxiety disorders.12,13 In patients with a history of drug dependence, psychiatric illnesses should be aggressively diagnosed and treated, because untreated symptoms increase the risk of relapse into chemical dependency.14 There are a multitude of pharmacologic methods which may improve the recovering substance abuser with comorbid psychopathology; selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. It is not known whether psychopathology is associated with diminished opioid analgesia in patients with chronic, noncancer pain. Wasan and coworkers15 studied 60 patients with discogenic low back pain not on opioids in a doubleblind, placebo-controlled, random crossover designed trial. Patients were stratified into 3 groups of psychological symptom severity (Low, Mod, and High), based on composite scores on depression, anxiety for pain, and neuroticism scales. For morphine analgesia, using a total pain relief calculation (TOTPAR), the Low group had 65.1% TOTPAR versus 41.0% in the High group (P ⫽ 0.026). For placebo analgesia, the Low group had 7.7% TOTPAR versus 23.5% in the High group (P ⫽ 0.03). Their findings support the concept that high levels of psychopathology are associated with diminished opioid analgesia in patients with discogenic low back pain. They also indicate that patients with high levels of psychopathology may have more inappropriate placebo responses. There are numerous studies demonstrating that an elevated state of anxiety (a person’s current level of anxiety) is often associated with reports of higher pain levels, whereas an increased trait anxiety (general disposition to become anxious) tends to exacerbate and complicate pain management. The combined effects of state and trait anxiety on self-rated pain had not previously been evaluated. Tang and coworkers16 recently published the results of their study in The Journal of Pain evaluating whether anxiety-reducing therapies, such as controlled breathing and other relaxation techniques, could be beneficial for relieving pain. Their findings revealed that individuals with high trait anxiety reported significantly higher pain intensity than those low trait anxiety patients. Their data also showed an additive rather than a synergistic relationship between state and trait anxiety and pain perception. The authors also noted that relaxation techniques might be most beneficial for high trait anxiety pain patients who experience more intense levels of anxiety and pain. Patients with chronic pain often complain of difficulties with cognitive functioning. These have been documented to occur without a history of head trauma or neurologic disease. McCracken and Iverson17 studied potential predictors of cognitive complaints in 275 consecutive patients referred to a university pain management center. Patients completed a brief set of self-report measures of problems with cognitive functioning, biographical information, pain severity, pain location, depression, anxiety, sleep quality, medication use, and litigation status during their first visit to the clinic.
225 Table 4 Depression in pain patient rules (modified from Haythornwaite) 1. Consider the symptoms rather than the disorder. 2. A wide range of symptoms may identify depression. 3. Periodically use a standardized measurement tool to assess treatment success. 4. Treatment of depression is part of pain treatment. 5. Have a plan, share it with the patient and family, and make it multispecialty.
The most frequently reported cognitive complaints included forgetfulness (23.4%), minor accidents (23.1%), difficulty finishing tasks (20.5%), and difficulty with attention (18.7%). Fifty-four percent of patients reported at least 1 problem with cognitive functioning. Regression analyses showed that depression accounted for the largest unique proportion of variance in cognitive complaints. Given the high frequency of complaints of impaired cognitive functioning, routine assessment appears warranted. When these complaints are encountered, initial assessment should be directed at iatrogenic drug effect. If this is ruled out as a cause, careful evaluation considering a range of neurological, social, and emotional influences is indicated and referral to a neuropsychiatrist should be considered. Unemployment is a consequence of chronic low back pain, which has considerable health and economic consequences for the individual and society and may be affected by the degree of patient psychopathology. There are multiple factors which may affect the ability to return to work and progress toward employment. Watson and coworkers18 studied 86 subjects undergoing a pain management rehabilitation program incorporating vocational focusing and advice; subjects were followed up at 6 months to determine work status. At follow up 38.4% of subjects were employed and another 23% were in voluntary work or education/ training. Subjects were divided into those who made positive progress (work, education/training, or voluntary work) and those who did not (remained unemployed, dropped out of the program, or lost to follow up). Those who failed to make positive progress were characterized by longer duration of unemployment and higher scores on somatic anxiety and depression.
Pain management physicians are not psychiatrists! Whereas the diagnosis of a prior history of substance abuse can be fairly easy to establish, assuming no intent of misleading by a patient, the diagnosis of psychopathology, may be less obvious. The aforementioned clinical reports by the patient may indicate a problem and be the call for therapy initiation. Haythornwaite19 identifies five rules to consider (Table 4) which may indicate that depression may be an issue when treating the patient in pain: 1. Consider the symptoms and not the disorder. The presence of even mild depressive symptoms may indicate a problem with depression and complicates treatment. Ignore the patient’s reasoning that his depression is due to his pain, as this is a common excuse.
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2. A range of symptoms is indicative of depression. These include, but are not limited to, lack of motivation or interest, sleep disturbances, changes in appetite, energy disturbances, negative self-attitude, thoughts of dying, concentration/memory lapses, and agitation. 3. Standardized assessment tools can predict treatment outcome. Using a tool (eg, Beck Depression Inventory®) to monitor symptoms with assess treatment progress or lack thereof. 4. The treatment of depression is part of the overall treatment plan. Explaining to the patient and family members that pain and depression frequently go hand in hand, that depression interferes with treatment, and that it has a biological basis will assist in reducing patient resistance and improves treatment efficacy. 5. Treating depression requires a plan. Behavioral cognitive therapies and pharmacological approaches should be used and reassessed periodically for determination of success. A change in the treatment plan should be implemented if no improvement is seen. A frank discussion of the plan, its goals, and expected outcomes should be included. As can easily be appreciated, the diagnosis and treatment of psychopathology in the pain patient requires a thorough understanding of its various presentations and potential combinations. The pain physician needs to be aware of the frequent expression of these disease states in his patients in order that consultation may be secured. Combining Cognitive Behavioral Therapies (eg, desensitization, behavior modification, behavioral activation, rational emotive therapy, mindfulness medication, Beck’s cognitive therapy, and acceptance/commitment therapy) with pharmacologic agents has been associated with the best results in treating depression and anxiety.
Do cancer pain patients differ from noncancer chronic pain patients in their need for secondary consultation? Cancer pain and noncancer chronic pain patients share many psychosocial features in common. Turk and coworkers20 compared the adaptation of cancer and noncancer chronic pain patients. The cancer pain patients reported comparable levels of pain severity to noncancer chronic pain patients; however, pain due to cancer was associated with higher levels of perceived disability (P ⬍ 0.004) and lower degree of activity (P ⬍ 0.04). The patients with cancer pain, particularly those with metastatic disease, reported significantly higher levels of support and solicitous behaviors from significant others, compared with noncancer chronic pain patients. Cancer patients, with (81%) and without (84%) metastatic disease and noncancer chronic pain patients (85%), could be classified into one of three psychosocial subgroups: “dysfunctional” (high levels of pain, perceived interference, affective distress, and low levels of perceived control and activity), “interpersonally distressed” (high levels of affective distress, negative responses from significant others, and low levels of perceived support), and “adaptive copers” (low levels of interference and affective distress, high levels of perceived control and activity). The heterogeneity of psychosocial adaptation to pain within
each patient group suggests the importance of psychological assessment in determining the pain management plan.
Summary The chronic pain patient, regardless of whether the origin of the pain is oncologic or not, presents a significant therapeutic dilemma due to the high incidence of comorbid psychopathology. The presence of preexisting substance abuse, be it recent or distant, carries with it a significant incidence of relapse. These complicating conditions often outstrip the treating pain physician’s knowledge base, clinical resources, and support services. Although a multidisciplinary approach would identify these issues early in the treatment scheme, the limitations of this approach restrict its utility to most pain practices. However, the judicious pain physician should have an established relationship and a low threshold for secondary consultation with an addictionologist and/or psychiatrist (these are not necessarily the same person as two separate skill sets are required), expert in pain patients and/or addiction issues to assist in managing these complex patients and improving treatment outcomes.
References 1. Joranson DE, Gilson AM: Opioid availability: diagnosis and treatment of regulatory barriers. University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Policy and Communications in Cancer Care: Madison, WI 1997 (Monograph) 2. Caudill-Slosberg MA, Schwartz LM, Woloshin S: Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 109:514-519, 2004 3. US Supreme Court; Vacco, Attorney General of New York, et al. v. Quill et al., certiorari to the US Court of Appeals for the Second Court, No. 95-1858. Argued January 8, 1997. Decided June 26, 1997. 4. Thomas EM, Weiss SM: Nonpharmacological interventions with chronic cancer pain in adults. Cancer Control 7:157-164, 2000 5. The Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain, 2001. Available at: http:// www.rcgp.org.uk/clinspec/guidelines/backpain. Accessed October 4, 2005 6. Schieffer BM, Pham Q, Labus J, et al: Pain medication beliefs and medication misuse in chronic pain. J Pain 6:620-629, 2005 7. Clarification of existing requirements under the Controlled Substances Act for prescribing Schedule II Controlled Substances. Federal Register Doc 05-16954 [Federal Register: August 26, 2005 (Volume 70, Number 165)] [Notices] [Page 50408-50409] 8. Atkinson JH, Slater MA, Wahlgren ? et al: Effects of nonadreenergic and serotoninergic antidepressants in patients with chronic low back pain intensity. Pain 83:137-145, 1999 9. Katon W, Egan K, Miller D: Chronic pain: lifetime diagnoses and family history. Am J Psy 142:1156-1160, 1985 10. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff M: Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. J Pain 26:181-197, 1986 11. Clark MR, Cox TS: Refractory chronic pain. Psy Clin NA 25:71-88, 2002 12. Fishbain DA: Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient. Med Clin NA 83:737-760, 1999 13. Gallagher RM, Verma S: Managing pain and comorbid depression: a public health challenge. Sem Clin Neuropsy 4:203-220, 1999 14. Jones EM, Knutson D, Haines D: Common problems in patients recovering from chemical dependency. Am Fam Physician 68:1971-1978, 2003
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15. Wasan AD, Davar G, Jamison R: The association between negative affect and opioid analgesia in patients with discogenic low back pain. Pain 2005 Sep 8 16. Tang J, Gibson SJ: A psychophysical evaluation of the relationship between trait anxiety, pain perception and induced state anxiety. J Pain 6:612-619, 2005 17. McCracken LM, Iverson GL: Predicting complaints of impaired cognitive functioning in patients with chronic pain. J Pain Sympt Manage 21:392-396, 2001
227 18. Watson PJ, Booker CK, Moores L, et al: Returning the chronically unemployed with low back pain to employment. Eur J Pain 8:359-369, 2004 19. Haythornwaite JA: Psychological management of difficult pain scenarios. Highlights in Pain Management: Excerpts from a Meet the Experts Roundtable. Boston, MA, American Pain Society, 2005. Available at http://www.cemedicus.com/pain. Accessed October 5, 2005 20. Turk DC, Sist TC, Okifuji A, et al: Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors. Pain 74:247-256, 1998