The headline above is the title of a provocative article appearing in General Hospital Psychiatry, a journal that takes a “biopsychosocial” approach to health by exploring “the role of emergency psychiatry in addressing personal, social, political, and forensic responses to stress and trauma.”
With that caveat, we can now reveal what the two authors of the article believe is the missing “P” in pain management:
They have come to the conclusion that, in many cases, chronic pain really is in your head – and you should see a psychiatrist.
“Psychiatric disorders, especially substance abuse, depression and PTSD (post-traumatic stress disorder) are highly prevalent in patients with CNCP (chronic non-cancer pain). Patients with these substance abuse and mental health diagnoses are more likely to receive long-term opioid therapy for their pain, at higher doses, and with concurrent sedatives,” Howe and Sullivan wrote, adding that there is “scant evidence” of any long-term benefit from opioid use and that mental health problems may actually make the drugs less effective.
“There is experimental evidence that common mental health conditions, such as depression and anxiety, may decrease opioid analgesia. Transient improvements in pain and psychological distress might be prompting opioid dose increases in patients with chronic pain and psychiatric disorders, thereby increasing the risk of opioid abuse and other adverse outcomes.”
Howe and Sullivan reached that conclusion after a retrospective study (a study of studies), in which they reviewed dozens of articles on chronic pain, psychiatric disorders and trends in long-term opioid therapy, as well as clinical trials that used opioids to treat chronic pain or mental health disorders.
They concluded that people in chronic pain frequently suffer from severe emotional distress, depression, anxiety and substance abuse; and that long term opioid use increases their risk of drug abuse, overdose and death.
“Patients with severe emotional issues are likely to receive high dose, high risk opioid regimen for chronic pain over a long period of time,” Howe told the Health Behavior News Service.
Howe says people with mental health disorders or who suffered from child abuse may be predisposed to develop chronic pain.
“What these patients really need is psychiatric care instead of the de facto treatment of opioids,” Howe explained. “When psychiatric services aren’t available, patients often end up on opioid therapy because the drugs numb the emotional pain as well as providing temporary relief for physical pain.”
“Clinicians must be vigilant about identifying and treating these problems in patients receiving, or being considered for, long-term opioid therapy. The current opioid epidemic has revealed the dire need for psychiatric services — the presently missing “P” — in chronic pain care. Psychosocial screening to identify possible depression and anxiety disorders as well as substance abuse problems should be part of the initial assessment for every patient who presents with chronic pain.”
Howe’s controversial views are finding support among other psychiatrists.
Bankole Johnson, MD, who is chairman of the department of psychiatry at the University of Maryland School of Medicine, agreed with the study’s findings but said the use of opioids was not so much an epidemic as an “overuse of psychotropic drugs.”
“It’s not clear what the alternatives are for patients when pain is not controlled. The crux is to provide integrative pain care so patients go into remission without the overuse of psychotropic drugs,” Johnson told the Health Behavior News Service.
“The mind and body are closely tied together. Doctors sometimes forget that — that pain is an emotional state, which is why people have different pain thresholds.”