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3/5/2014
Psychiatric Factors in the
Management of Chronic Pain
John Hendrick, MD, DFAPA
Chief of Psychiatry
Mountain Home VAMC
and
Associate Professor of Psychiatry
East Tennessee State University
John Hendrick, MD
Acute Pain
Chronic Pain
Mood and Affect
Coping Skills
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Pain Assessment and
Management: Current Status
Chronic pain
– Prevalence: 15%-20% of adult
population1
– Very diverse presentations in the elderly1
– Undertreatment is common2
– Rational selection of single modality or
multimodality treatment strategy requires
a comprehensive assessment2
Pain and Suffering:
Not the Same
Pain
• Nociceptive Input
• Prior Injury
• Inflammation
Suffering
Meaning of Pain
• Disease Process
• Physical Disability
• Social
• Financial
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Opioid Therapy: Drug Selection
Critical issue is that of setting effective and appropriate
boundaries
Long-acting opioid “around-the-clock” plus a short-acting
opioid “rescue” dose “PRN”
– Preferred approach for patients with cancer pain and
selected others with chronic pain
– Rescue dose may or may not be appropriate for all
patients, depending on syndrome and ability to use the
drug responsibly
– Rescue is 5%-15% of total daily dose; usually
prescribed “q2-3h prn” when oral
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Opioid Therapy: Drug Selection
Immediate-release preparations
Combination products, single-entity drugs,
and tramadol
Used mainly for acute pain, for dose
finding during initial treatment, and for
“rescue” dosing
Can be used for long-term management in
selected patients
Not preferred: meperidine, propoxyphene,
and agonist-antagonist drugs
Cancer Pain Model Does Not Fit
All Nonmalignant Pain Patients
Long-acting agents +/ short-acting
opioids? Differentially chosen for cause
Is there a true need for rescues?
– Are they being taken for psychological factors
(ie, when additional doses of the long-acting
drug do not eliminate the need for even some
of the rescues)
Evaluate the additional risk vs the
functional enhancement that the additional
dose will bring
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Pain perception
“Is it all in my
head?”
Emotional
aspects of pain
Biology of pain
perception
Cultural factors
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Assessment of chronic pain and depression
Clinical interview (Biopsychosocial factors) – Do not
avoid or overlook the Social context – It is the most
common indicator of substance abuse versus
legitimate pain control needs – Collateral information
from family or friends may be highly enlightening – but
can also be biased
Substance abuse evaluation (prescription and/or illicit)
Suicide assessment – Social context critical
Case management – Should responsible others be
engaged ?
Facts about depression
Affects about 10% of the U.S. population with nearly three out
of four in the workplace (Gemignani, 2001)
Prevalence among school age children and adolescents is
4.6% (Wagner, 2003)
Millions do not seek treatment due to inadequate benefits and
the stigma associated with depression (U.S. Surgeon General,
2000)
Effective pharmacotherapy combined with psychotherapy has
been shown to reduce healthcare costs and the rate of suicide
attempts (Ballenger, 1999)
Average disability length as well as disability relapse are
greater for depression than most comparison medical groups
(Conti and Burton, 1994)
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Types of depression:
Unipolar
Bipolar
Dysthymia
Seasonal Affective Disorder (SAD)
Symptoms of depression
Depressed mood, Occurring over a two
week period
Tearfulness
Irritability
Low energy level
Guilt
Helplessness/hopelessness
Anhedonia
Poor concentration
Sleep disturbance (initiating and/or
maintaining sleep)
Suicidal ideations
Appetite disturbance (typically weight
loss, but in a small subgroup, weight
gain).
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Psychological management of chronic pain:
Medication use (indications/contraindications)
Cognitive-behavioral approaches
Family systems approaches
Case Management
The role of attention focus and complaint
Treatment personnel
The faith factor
Accessing support systems
Lifestyle changes
Locus of control (internal vs. external)
Stress Management
Assertiveness Training
Exercise
Barriers to treatment:
Inadequate assessment/missed diagnoses
Co-morbid conditions (such as diabetes, stroke,
cancer etc)
Substance abuse
Lack of available resources
Poor continuity of care
Inappropriate medication dosing/titrating
Lack of behavioral health treatment providers in rural
areas
Chronic Pain Assessment
Collect the data
History
Pain characteristics
Pain impact
Known etiologies and treatments
Physical examination
Record review
Appropriate laboratory and radiological tests
Prior prescribed and nonprescribed treatments
Current therapies
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Chronic Pain Assessment
Medical history
Physical exam
Integrate the findings:
Pain diagnoses
Etiologies
Syndromes
Inferred pathophysiologies
Develop a therapeutic strategy for pain and its comorbidities
Comorbidities
Physical/medical
Psychiatric/psychosocial
Understand the severity and nature of disability
Ultimately - Single modality vs. Multimodality?
Chronic Pain Assessment
“PQRST”
– Provocative/palliative factors (eg, position,
activity, etc.)
– Quality (eg, aching, throbbing, stabbing, burning)
– Region (eg, focal, multifocal, generalized,
deep, superficial)
– Severity (eg, average, least, worst, and current)
– Temporal features (eg, onset, duration, course,
daily pattern)
Medical history
– Existing comorbidities
– Current medications
Inferred Pain Pathophysiology
Nociceptive pain
Neuropathic pain
Psychogenic pain
Idiopathic pain
Explained by ongoing
tissue injury
Believed to be
sustained
by abnormal
processing
in the PNS or CNS
Believed to be
sustained
by psychological
factors
Unclear mechanisms
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Common Chronic Pain Disorders
Headache
Back Pain
Nonarticular Pain Syndromes
Osteo and Rheumatoid Arthritis
Neuropathic Pain
Sympathetically Mediated Pain
Phantom Limb Pain
Cancer and HIV
Therapeutic Approaches for Chronic Pain
Pharmacotherapy
Rehabilitative approaches
Psychological approaches
Anesthesiologic approaches
Surgical approaches
Neurostimulatory approaches
Complementary and alternative
approaches
Lifestyle changes
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Pharmacotherapy for Pain
Categories of analgesic drugs
Opioid analgesics
Nonopioid analgesics
Adjuvant analgesics
Headache medications
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Non-Opioid Analgesics
Cyclooxygenase-2 Inhibitors
Anticonvulsant Drugs
Antihistamines
Mexilitine
Alpha 2-Adrenergic Agonists
Corticosteroids
Muscle Antispasmodics
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Psychotropic Adjunctive Agents
Antidepressants
– Tricyclic Antidepressants
– Monoamine Oxidase Inhibitors
– Selective Serotonergic Reuptake Inhibitors
– Other Categories
Benzodiazepines and Anxiolytics
Stimulants
Neuroleptics
Placebo Effects
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Duloxetine
Can be very effective in
mild to moderate
neuropathy, blends
reasonably well
Often a trial of gabapentin
or duloxetine required
prior to use of pregabalin
Use for depression not
much enhanced with
dose above 60 mg/d but
this is not true for
neuropathy
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Topical Agents
Capsaicin
Lidocaine Patch
Compounded Local Anesthetics
Pharmacology of Pain - Opiates
Opioid Analgesics, Tramadol
N-Methyl-D-Aspartate Antagonists
– Methadone
– Ketamine
– Dextromethorphan
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Tramadol
Synthetic Analog of Codeine, binds to mu receptors and inhibits
NE and 5HT3 reuptake
Analgesia is due to parent compound and the M1 metabolite
Well absorbed GI (bioavailability 75%), 20% bound
Metabolic Pathways – N and O demethylation/conjugation –
Formation of M1 metabolite is CYP 450 dependent – 30%
excreted unchanged
Peak plasma level at 2.3 hours and t1/2 is 6.7 hours – In
hepatic insufficiency 1.9 hours and 13.3 hours
Increased seizure risk with SSRI/TCA/MAOI or opioids use
50 – 100 mg q6h with a 400 mg limit on total daily dose
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Opioid Analgesics
Opioids relieve the subjective suffering
component of pain, without interfering with
basic sensations
(light touch, pinprick, temperature, position)
“The pain is still there,
but it doesn’t bother me”
Dissociation
Dissociation is when a person loses track of time and/or
person, and instead finds another representation of their
self in order to continue in the moment. A person who
dissociates often loses track of time or themselves and
their usual thought processes and memories. People
who have a history of any kind of childhood abuse often
suffer from some form of dissociation. People who use
dissociation often have a disconnected view of
themselves in their world. Time and their own self-image
may not flow continuously, as it does for most people. In
this manner, a person who dissociates can “disconnect”
from the real world for a time, and live in a different
world that is not cluttered with thoughts, feelings or
memories that are unbearable.
* A body can pretend to care, but they can’t pretend to be
there.
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Opioid Therapy: Professional
Obligations
Learn how to assess patients with pain and
make reasoned decisions about a trial of
opioid therapy
Learn prescribing principles
Learn principles of addiction medicine
sufficiently to monitor drug-related behavior
and address aberrant behaviors
Opioid Therapy: Prescribing
Principles
Prescribing principles
Drug selection
Dosing to optimize effects
Treating side effects
Managing the poorly responsive patient
Use the construct of “Therapeutic Nihilism”
Opioid Therapy: Drug Selection
Long-acting opioids
– Preferred because of improved treatment
adherence and the likelihood of reduced risk in
those with addictive disease
– Extended-release preparations
eg, morphine, oxycodone, fentanyl
– Methadone
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Opioid Dosing:
Evaluation of Opioid Responsiveness
Individualization of the dose is critical to
successful opioid therapy; there is no one
“correct” dose
Endpoint: Adequate pain relief or intolerable
and unmanageable side effects
Dose increments: 25%-150% depending on
circumstances, or equal to the daily “rescue”
during prior days
Pure opioid and mu agonists have no ceiling;
thus there is no maximal dose
Clinical Observations With Mu
Opioids
Patients respond differently, and unpredictably, to
different mu opioid analgesics, requiring individualization
of treatment
– Genetic issues are involved
Side effects from mu opioids vary among patients
– Are side effects mediated through the same
receptors as analgesia? Probably not
Clinically, patients show incomplete cross-tolerance
when switched from one “mu” analgesic to another
– Can incomplete cross-tolerance explain
the advantages of “Opioid Rotation”?
Opioid Rotation
Based on large intraindividual variation in the response to
different opioids
Reduce equianalgesic dose by ≥50% with provisos5,10:
– Reduce less if pain severe
– Reduce more if medically frail
– Reduce less if same drug by different route
– Reduce fentanyl less
– Reduce methadone more: 75-90%
5. Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International
Conference on Pain and Chemical Dependency; June 6-8, 2002: New York, NY.
10. Hewitt DJ. Principles of opioid therapy (dosing). Presented at: The International Conference on Pain and Chemical
Dependency; June 6-8, 2002; New York, NY.
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Opioid Therapy: Side Effects5,11
Common: Constipation and somnolence
Less common
– Nausea
– Myoclonus
– Itch
– Headache
– Sweating
– Amenorrhea
– Sexual dysfunction
– Urinary retention
Managing the Poorly
Responsive Patient
Better side-effect management
Pharmacological strategy to lower opioid
requirement
– Spinal route of administration
– Add non-opioid or adjuvant analgesic
Opioid rotation
Nonpharmacologic strategy added to lower
opioid requirement
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The Patient Who Refuses to Transition
to Long-acting Agents Might Be
Manifesting:
Addiction/chemical coping
Fear
Lack of additional coping strategies
Loss of perceived control
True physiologic effect of the drug on their pain
4. Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in
chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The
International Conference on Pain and Chemical Dependency; June 6-8, 2002; New York, NY.
What Influences the Risk of Addiction
and/or Aberrant Behavior?
Addiction and/or aberrant behavior results
from a combination of influences
– Chemical
– Psychiatric
– Social/Familial
– Genetic
– Spiritual
The “Four A’s” of Pain:
Treatment Outcomes
Analgesia (pain relief)
Activities of daily living (psychosocial
functioning)
Adverse effects (side effects)
Aberrant drug-related behavior
(addiction-related outcomes)
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Spectrum of Risk of Addiction
and/or Aberrant Behavior
~45%
<1%
HIGH
Long-term
exposure to
opioids in
addicts
LOW
Short-term
exposure to
opioids in
non-addicts
Dunbar and Katz
Porter and Jick
Where is your patient?
The “Four A’s”: Aberrant Drugrelated Behaviors—The Model
Probably more predictive
– Selling prescription drugs
– Prescription forgery
– Stealing or borrowing another patient’s drugs
– Injecting oral formulation
– Obtaining prescription drugs from non-medical
sources
– Concomitant abuse of related illicit drugs
– Multiple unsanctioned dose escalations
– Recurrent prescription losses
Probably less predictive
– Aggressive complaining about the need for
higher doses
– Drug hoarding during periods of reduced
symptoms
– Requesting specific drugs
– Acquisition of similar drugs from other medical
sources
– Unsanctioned dose escalation 1-2 times
– Unapproved use of the drug to treat another
symptom
– Reporting psychic effects not intended by the
clinician
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Differential Diagnosis of Aberrant
Drug-related Attitudes and Behavior
Addiction
Pseudoaddiction (inadequate analgesia)
Other psychiatric diagnosis
– Encephalopathy
– Borderline personality disorder
– Depression
– Anxiety
Criminal intent
Substance Use Disorder versus the
Typical Pain Patient on Opioids
A maladaptive pattern of substance use leading to significant impairment
or distress as manifested by 3 or more of the following 9 symptoms:
Need for markedly increased doses to achieve effect
Diminished effect with same dose
Withdrawal syndrome
Taking substance to relieve or avoid withdrawal symptoms
Dose escalation or prolonged use
Persistent desire or unsuccessful efforts to cut down or control
substance use
Excessive time spent obtaining, using, or recovering from
use of the substance
Activities abandoned because of substance use
Use despite harm
What is Addiction?
Medical Model
- Habituation with withdrawal symptoms
- Tolerance with dependency
- Dose escalation into tachyphylaxis
AA Model
- Dependence on psychoactive substances
for stabilization (more strictly constructed
in some groups than others)
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What Addiction Is Not:
Physical Dependence
Pharmacologic effect characteristic of opioids8
Withdrawal or abstinence syndrome manifests
upon abrupt discontinuation of medication or
administration of antagonist
Assumed to be present with regular opioid use
for days to weeks
Becomes a problem if :
– Opioids not tapered when pain resolves
– Opioids are inappropriately withheld
What Addiction Is Not: Tolerance
Pharmacologic effect characteristic of opioids
Need to increase dose to achieve the same effect or
diminished effect from same dose
Tolerance to various opioid effects occurs at differential
rates
Tolerance to non-analgesic effects often beneficial to
patients (sedation, respiratory depression)
Analgesic tolerance is rarely the dominant factor in the
need for opioid dose escalation
Patients requiring dose escalation most often have a
change in pain stimulus (disease progression, infection,
etc.)
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Consider the Risk of Not
Treating Pain
in Addicts
Study comparing addicts with AIDS to
cancer patients and the response to
undertreatment
– Aberrant behavior is set in motion by
undertreatment (Passik, et al. 2001)
“Pseudoaddiction”
Pattern of drug-seeking behavior of pain
patients
receiving inadequate pain management
that can
be mistaken for addiction
– Cravings and aberrant behavior
– Concerns about availability
– “Clock-watching”
– Unsanctioned dose escalation
Resolves with re-establishing analgesia
Opioid Therapy: Conclusions
An approach with extraordinary promise
and substantial risks
An approach with clear obligations on
prescribers
– Assessment and reassessment
– Skillful drug administration
– Knowledge of addiction medicine principles
– Documentation and communication
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Psychotherapy
Behavior Therapy
Cognitive-Behavioral Therapy
Supportive Therapy
Marital, Couples, Family Therapy
Group Therapy
Biofeedback
Relaxation and Imagery Training
Hypnosis
Vocational Rehabilitation
Specialized Procedures in Pain
Management
Transcutaneous Electical Nerve
Stimulation
Acupuncture
Regional Neural Blockade
– Spinal Anesthesia
– Peripheral Nerve Blockade
– Sympathetic Nerve Blockade
Neurosurgical Issues
– Ablation
– Neural Stimulators
– Psychosurgery
Populations with Special
Considerations
Geriatrics
Pediatrics
Pregnancy
Substance Dependent and Substance
Abusing Patients
Terminal Patients
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Forensic Issues in Pain
Management
Diversion
Confidentiality
Informed Consent, Capacity, Competency
Pain and Litigation
Disability Compensation
– Worker’s Compensation
– Social Security Disability
– Veteran’s Administration Benefits
– Disability and Doctor Patient Alliance
Things to do - Psychopharmacology
Treat Unipolar Depression to REMISSION !
Manage Bipolar D/O to stability
Avoid mixing SSRI’s – Central Serotonergic Syndrome,
anticholinergic synergy, side effects
Bupropion mixes well and is a good supplement
Mirtazepine is sedating and covers much like
amitriptyline does, but it produces much better mood
elevation, particularly better than trazodone
Stephen Stahl refers to SSRI (or SNRI) plus mirtazepine
and bupropion as “California Rocket Fuel”
Watch out for Psychotic Decompensation
Consider Benzodiazepines as a trade off for opiates ?
Step back and think the process through – Use common
sense !
Never be unwilling to say “NO” or just “No”
Psychopharmocology Don’ts
If mixing several psychiatric meds, look up interactions and
THINK them through
Usually more than one drug per category is a poor plan
Buspirone treats Generalized Anxiety but is ineffective in Phobic
Anxiety (unless it is Double Anxiety)
Don’t use meds off label without informed consent and
documentation
CSS, NMS, hyperpyrexia, muscular rigidity with elevated CPK
require accurate diagnosis and urgent treatment
Do not assume that the relative safety of newer meds means they
cannot be dangerous, especially in combination
Always consider orthostatic hypotension in combos
Don’t assume trazodone can’t worsen anxiety or produce a
substantial amount of headaches.
Don’t forget the PDR warns that mixing ALL tranquilizers with
opiates must be done with caution
Don’t forget, if it isn’t written down, it didn’t happen!
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Things To Do – General Supportive Care
Gabapentin, pregabalin and duloxetine can be very
helpful – Gabapentin can contribute to Vit D def.
Use a stepwise model and insist on an operational
demonstration that a simple plan cannot work
In assessing the outcomes of simple plans, assess
the veracity of the patient’s report
Use and assess the context of family collateral
information
Muscle Relaxers have a place, sometimes with
NSAIDS
Assess the use of and value of physicomechanical
interventions
Use Consultants and Communicate Plans in Writing
Insist on Standard Medical Care and Use Your Usual
Routines
Things Not To Do
The value for your services is your routine fee, don’t
cross boundaries !
Don’t be doggedly stubborn – Refer - if it is out of
your comfort zone or your area of expertise
Don’t be a Cowboy - Ask the opinion of valued and
experienced colleagues in difficult situations
Do not engage in Pain Management with patients in
which you have a dual role
Don’t tell patients that medications have actions
which they don’t
Don’t forget to document informed consents and
initial treatment agreements
Don’t overlook random UDS and Pill Counts
Don’t think tramadol cannot be addictive, but it does
have a much decreased liability for addiction
Clinical Conclusions
Chronic pain continues to affect the quality of life
of many patients
Healthcare providers need to appropriately assess, treat,
and reassess chronic pain
Opioid therapy is one effective treatment modality
for chronic pain
– Long-acting opioids help control chronic pain better
and increase compliance
All healthcare practitioners prescribing opioids should
be aware of potential aberrant behavior
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