The Missing ‘P’ in Pain Management

The Missing ‘P’ in Pain Management

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:


bigstock-Dramatic-black-and-white-portr-35649329Co-authors Catherine Howe, MD, and Mark Sullivan, MD, are both professors of psychiatry at the University of Washington School of Medicine in Seattle.

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.”

Authored by: Pat Anson, Editor

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*poorly designed studies

Chronic pain causes depression, not the other way around. Statistics and purely designed studies are easy to manipulate. Antidepressants are helpful for treating depression in chronic pain patients, but they can only augment opioids, not replace them.

John Quintner, Physician in Pain Medicine

@ Dave. Thanks for your prompt response. I see that we are also in agreement on this question.


John- my dorosolateral prefrontal cortex isnt methylated enough to tackle the question of whether or not pain is a disease in its own right. As far as i am aware the major proponents of pain being designated as a disease are the pain specialists. The pain specialists in the U.S. have for the sake of their own power, prestige, and profits tried to present themselves as the only authoritative group with an opinion worth considering. And so having dealings with them as i have had, i can only vote no confidence in their schemes. Clearly, as we discussed earlier they do not have a balanced or thoroughgoing approach to pain. Their effort at designating pain as a disease would lead to the further biomedicalization of pain and worsen their parallax gap and the would be even further removed from people in pain and the public good than they already are. The biomedicalization of pain has engendered a sense of helplessnes in people in pain and we know that their current efforts at blaming are genes and brain signals for pain only adds to a growing sense of powerlessness that people in pain have. And it is not that i am against pain specialists per se, but rather it is people in pain that i am for.

John Quintner, Physician in Pain Medicine

@ Dave. Thank you for your most generous response to my deliberately provocative posts on the website.

May I be permitted to suggest that the well-intentioned initiative that calls for chronic pain to be recognized as “a disease in its own right” may not be in the best interests of pain sufferers? We have recently published a paper that argues a case for the negative.

Cohen ML, Quintner JL, Buchanan DA. Is chronic pain a disease? Pain Med 2013; 14: 1284-1288.

Although it is outside the topic under discussion, I would be interested to hear your opinion on this important and fundamental question.


John, I commend you for your engaging some of the deeper and more troubling philosophical aspects of pain care. You and Dr Giordano and Michael Schatman serve a very vital purpose in raising the most important questions in pain care. And I believe, in what Voltaire wrote that it you should judge a man not by his answers but by the questions he asks.
In your papers you have the makings of “critical pain studies” and as such can free people in pain in a fundamental way from limiting orientations to pain that is of great importance. Similarly, I have been contemplating creating a book called “The Further Reaches of Pain Care”, where I, also, attempt, to free people about what pain care could conceivably be like. As Einstein wrote imagination is more important than knowledge. And since knowledge is politicized in pain care it is important to create a space, a forum where people in pain and those who care about them can imagine what pain care can be like. In this way we may be allowing what the Chinese refer to as the shen ming- the inner brilliance- shine through. And who knows what possibilities these flights of imagination might take us.
And so you have a kindred spirit in the U.S. who recognizes the need for a new paradigm and a new vision for pain care beyond the limitations and einschrankung that established approaches are made of.

John Quintner, Physician in Pain Medicine

@ Dave. I take all your points and am broadly in agreement with you regarding the parlous state of contemporary pain management.

Early last year Professor John Loeser listed five crises in pain management: lack of evidence for treatment outcomes; inadequate education of primary health care providers; the largely unknown value of opioid treatment for patients with chronic non-malignant pain; funding availability for health care providers; and access to multidisciplinary pain centres. To these I would like to add the current state of diagnostic confusion.

In my opinion, we first need to rethink the theoretical models that underpin our practices, whether they be orthodox or heterodox. There is general agreement that the biomedical reductionist approach has been unhelpful, to say the least. Bio-psycho-social approaches all too often default to biomedical reductionism and, even so, lack a coherent theoretical foundation.

At long last a new paradigm for Pain Medicine is slowly emerging (i.e. one based upon evolutionary biology) but it is still far too early to know whether or not it will be useful. To date, the take-up has been minimal.

Here are some references that may be helpful (by the way, no sources of external funding were obtained for this project of textual research):

Quintner JL, Buchanan D, Cohen ML. Katz J, Williamson O. Pain medicine and its models: helping or hindering? Pain Medicine 2008; 9: 824-834.

Lyon P, Cohen ML, Quintner JL. An evolutionary stress-response hypothesis for chronic widespread pain (Fibromyalgia Syndrome). Pain Medicine 2011; 12: 1167-1178.

Cohen ML, Quintner JL, Buchanan D, Nielsen M, Guy L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain Medicine 2011; 12: 1637-1643.


John- Im sure you have more than a little understanding of the politics in medicine and medical research. Was it so long ago that we found out about problems with Vioxx- despite fda approval and seemingly good research? Is it John q Public at NIH deciding if advanced clearing energetics will receive RCTs? Was it so long ago the AMA lost in court to anticompetitive practices with chiropractors? Just a few months ago news articles appeared about doctors ignoring guidelines about chronic low back pain and wasn’t it less than a year ago when a British study indicated 40% of low back pain may be due to bacteria. So evidence based medicine is politically based on the same sort of “poisonous enthusiasm” to use the words of Hume as advanced clearing energetics.
You mention routine use of treatments. In 2008 Story Landis- who runs the NIH Pain Consortium indicated for pain are “woefully inadequate” and so routine treatments are “woefully inadequate” with an overall effectiveness of 25% according to Dennis Turk. So, in my point of view there is a need to go outside of woefully inadequate standard preparations for and make available politically nontested treatments because they may lead to more satisfactory pain relief.
As for decision making much more sophisticated algorithms for diagnosis and treatment are needed. Perhaps cumulative complexity model, adaptive interventions and combining politically tested and nontested methods is needed. But frankly, current methods in pain care are stale and boring super stare vias antiquarius and show lack of vision and terrible lack of imagination. Doctors and medicine is not educated for visionaries or dynamic treatment regimens.
By studying all available information related to pain and synthesizing such in a nonbiased manner can we begin to put pain care on a better foundation-and the current foundation is too wobbly to be of much good for people in pain. All stakeholders should be part of the process of deciding what research is done, by whom and how as well as what treatments will be publically paid for.

John Quintner, Physician in Pain Medicine

@ Dave. Doubtless there are some people who would swear to the efficacy of the specific treatments that you have listed.

I have not condemned them. Rather I have pointed out that they do not appear to have a scientific evidence base that could be assembled to support their routine use.

In my opinion, they are all subject to expectation and/or confirmation bias, which is perhaps why they do not appear on the Cochrane Database etc.

But even so, I am left to wonder just how they might, in whole or part, constitute integrative and personalized care. Who decides – therapist or patient? And on what basis can informed decisions possibly be made? Or is it all to be “hit or miss”?


Mr. Quintner- Meditations are not passive, there is more than a few studies on acupuncture. As for evidence, 85% of research is found to be mistaken and 50% of research studies are either so poor or didn’t find what the researchers were looking for that they are never published. There was lack of long term studies when the AAPM in 2010 published guidelines for opioid use for noncancer pain-yet your colleagues freely prescribed them. And John- isn’t research based on population studies anyway and isn’t the battle cry of personalized medicine a rebuke to such population studies on which pain care is practiced today? Neither you nor i should dictate to someone in pain whether they chose a passive or active strategy. As someone who has helped hundreds of people to obtain better pain care, I am forced to say many of them are very dependent on others advice. While I believe, as Milton Ericson did their is a unique treatment to each individual, my experience has been that people in pain or other problems tend to seek established treatment and advice.
As you should know research shows about 50% of “patients” let their doctor decide what treatment they want. Because a treatment hasn’t gotten the cochrane database seal of approval or the approval of the fda, nhs or AAPM doesn’t mean it may not be of value to the person in pain. Lastly, as Einstein wrote condemnation without investigation is the height of ignorance- the fact that medicine may be too prejudiced toward nonbiomedical approaches to pain shouldnt be reason enough for you or anyone else to condemn them. If you have conclusive evidence that any treatment i mentioned cannot help someone with some pain condition-please share such.

John Quintner, Rheumatologist

@ Dave. I agree with you that a bio-psycho-social approach all too often defaults to one that is biomedical. However, your concept of integrative care appears to consist of offering people in pain a multitude of passive modalities of treatment for which there is not a shred of evidence of benefit. The missing “P” in pain management is not “Passive”.


The biopsychosocial approach advocated by Gatchel and his colleagues in the AAPM, APS, etc is, in my opinion, not an integrative approach. I think what these people are referring to is to send someone for cbt, or hypnosis or coping skills training( as if a person in pain were a dog that needed training) if they “catastrophize” about their pain. And according to Gatchel and his colleagues- people in pain are “catastrophizers”. An integrative approach is more sophisticated than that and goes deeper into the connection between the body and the mind and personological/biographical aspects of pain. I dare say, that Dr. Gatchel and proponents of the biopsychosocial aspects of pain are mostly focused on the biological aspects of pain and do not have an interest in an integrative and comprehensive approach to pain -and that is why their approach is limiting and of limited effectiveness.


Integrative care involves strategic and truly “personalized” combination of nonpharmacological treatments- scrambler therapy, advanced clearing energetics, one or more of the 80,000 meditations, kayakalpa, pemf, frequency specific microcurrent, holotropic breathwork, nutriceuticals, infoceuticals, tenant biomodulator, Manaka acupuncture, posture correction, Alexander technique, spagyrics, neural prolotherapy, homeopuncure, dry needling, chinese dietary therapy, kanpo medicine,theta healing, noesitherapy, biomagnetic pair, marma therapy, sound therapy, bowentech, versendal kinesiology, potency simulator, ESWT, etc with conventional medical therapies to effect the most satisfactory outcome for the person in pain. Its not about the McDonalized medicine that most people in pain are subjugated to.

John Quintner, Physician in Pain Medicine

@ Dave. Could you please define “integrative pain care”? Dr Johnson asserts that with such care, patients go into remission without the overuse of psychotropic drugs. Trudy’s experience would fall into the category of such overuse. However, if she had been offered “integrative pain care” in the first place, would she have been thereby cured of her pain?


I agree with Dr. Johnson- we need an integrative approach to pain-and the current approaches are hit and miss and when they miss most providers are at a loss as to what the next step is. Reductionistic thinking is at the heart of poor pain care with providers unwilling to make efforts to substantively transform pain care and would consider my suggestion to do so grandiose. But being overconformed to the sorry state of affairs in pain care is much worse than grandiose efforts to make real changes in pain care.

Trudy McGee

I have been on over 35 psychotropic medications for pain, and all it has gotten me were side effects. I have recently lost over 80+ pounds, finishing the last of the psychotropics, Cymbalta, and all the side effects that go with it. This is a chicken and egg story. All of the sudden everyone has stop this opioid epidemic, and it is the pain patients who suffer. None of those psychotropics helped the pain. But the depression wasn’t there before the pain either!! Can’t they see that fighting debilitating pain day in and day out makes a person depressed, and all the psychotropic medicines that Big Pharma provides will NEVER make the condition that caused the pain go away?? How does an antidepressant make stenosis, osteoarthritis, herniated disks, scoliosis, and kyphosis go away?? Yet then they turn around and tell you that you eat too much, and you wouldn’t be in so much pain if you lost weight, when it is the medications causing the problem! This is a travesty to pain patients all over!

John Quintner, Physician in Pain Medicine

Without impugning the good intentions of Professors Howe and Sullivan, they appear to have begged the question – what does Psychiatry have to offer in the care of people experiencing chronic pain?

Has this discipline been able to transcend the body/mind dualistic thinking that has been so unhelpful (and even damaging) to so many patients?

For example, look at the above statement attributed to Dr Johnson – “[T]he body and mind are closely tied together.” The corollary might be – treating the mind also treats the body. Well, really!!

The elephants in the room are the social determinants of health – poverty, joblessness, homelessness, lack of support, helplessness, alienation, stigmatization etc.

Addressing these issues, which in my experience loom large in the life of many pain sufferers who have been prescribed opioid medication, is a task that is well beyond the capacity of psychiatrists in particular, and of Medicine in general.