by Linda J. Griffith, MD

Dr. Griffith is Board Certified, American Board of Psychiatry and Neurology, American Board of Family Medicine, American Board of Hospice and Palliative Medicine, Certificate of Added Qualifications in Geriatrics; Chief Medical Officer, Consolidated Care, Inc., Champaign and Logan Counties, Ohio; and Clinical Assistant Professor, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Psychiatry (Edgemont) 2008;5(12):20–27

Editor’s Note

All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment.

Abstract

Psychiatrists frequently see patients in their practices who struggle with issues of chronic physical pain. This can present diagnostic and therapeutic dilemmas. These patients require an approach that allows them to talk about their pain and feel supported while simultaneously being nudged to develop a meaningful life alongside their pain. This article addresses an approach to accomplish this difficult balancing act over the course of time and includes case examples.

Key Words: pain, chronic pain, addiction, pseudoaddiction, dependence, tolerance, psychotherapy, aberrant drug-related behaviors, aberrant drug-taking behaviors

INTRODUCTION

Individuals with chronic pain are common in psychiatric practice. It has been reported that 38 percent of psychiatric inpatients and 18 percent of psychiatric outpatients report pain as a significant concern.[1] Physicians, including psychiatrists, have numerous reactions to such individuals, often negative, if not openly pejorative and hostile. Faced with a patient complaining of pain that has not responded to the usual interventions, or for which no clear etiology has been determined, we often internally sigh and bow our heads in weariness. If the individual remains in our practice and continues to complain, this feeling can border on despair. How can I possibly help this person? Why don’t they listen to my sage advice? Why won’t they focus on something other than their pain? Are they trying to get out of work? Are they trying to dupe me into providing controlled substances? Will the Bureau of Worker’s Compensation and other agencies ever stop sending forms to complete?

This article seeks to answer some of these questions to assist you in developing a therapeutic stance in a difficult scenario. Working with patients who are in chronic pain has its challenges and rewards, and is similar, in that regard, to other compelling conditions by which we earn our living and for which other providers welcome our assistance.

It is natural for personal experiences to trigger one’s life interests. When contemplating patients in pain, I recall injuring my back when I was a nurse’s aide while attempting to prevent a large patient from falling. In the face of daily pain that interfered with restful sleep, I became whiny and irritable. Then, while I was a family doctor, prior to journeying into psychiatry, I witnessed a very ordinary, fairly content mother who worked full time as a janitor evolve into a whiny, irritable, and easily overwhelmed woman following a work injury. She developed what was then called reflex sympathetic dystrophy (now complex regional pain syndrome-I or CRPS-I).[2] It confirmed for me the answer to the question about whether miserable people handle their pain poorly or whether unremitting pain causes normative individuals to become miserable wrecks: Most certainly, it is the latter.

WHAT IS PAIN?

The brain is attuned to notice pain. Pain causes the individual to stop other activities and attend to the pain. This demand to stop and pay attention does not go away when the pain loop, due to plasticity in the nervous system, continues to send pain messages after the initial trigger has resolved.[3,4] Unfortunately, in some cases, pain messages continue for months or years after their utility has gone, as in CRPS-I. Researchers are beginning to clarify how it is that peripheral nociceptors sometimes fail to shut off, or how RNA in the cell body at the dorsal root ganglion begins to produce proteins and fashion them into additional receptors that travel back to the periphery.[5] While these and other neurological tidbits make for a great afternoon of continuing medical education, they are not the focus of this article. The important issue is that these and many other processes occur in the peripheral and central nervous system in some individuals, and, in some contexts, keep the patient’s mind focused unwaveringly on the pain, despite the absence of ongoing tissue injury. It is our job to help the patient redevelop a meaningful life in spite of this phenomenon.

PRACTICE POINT: The patient’s support network quickly grows weary of hearing about pain

An individual patient’s attention can be glued to his or her pain. This is not so with acquaintances, loved ones, and doctors. Most pain patients report that no one will listen to them regarding their pain. In general, there is a large discrepancy between a patient’s need to tell his or her story and the social support network’s capacity to hear it. The first and biggest therapeutic goal can be to ensure that we hear and acknowledge a patient’s ongoing struggle with pain. It is likely that he or she will need to be told numerous times over the course of therapy that you “get it” in regard to his or her ongoing burden. This can be a tremendous relief for our patients and allow them to reengage their sense of self respect in the face of their ongoing personal battle with pain.

CASE EXAMPLE: Discussing the patient’s pain.

Psychiatrist: Tell me about your pain.

Patient: (dubious) You really want to hear?

Psychiatrist: Yes. Hearing your story is the main way I can determine how I might be helpful to you.

Patient: Well, doc, no one really wants to hear about it.

Psychiatrist: Hmm. It sounds like, in addition to feeling the physical pain, you are feeling isolated from people around you who don’t want to listen.

Patient: That’s for sure.

Psychiatrist: You know, there is something about other people’s pain that seems to turn most people off…and yet you need to talk with someone to help deal with it. It makes your burden even harder to bear.

Patient: (visibly relaxing) That’s so true. You can’t believe what it’s like to be in pain day after day… and my wife… well I know she is tired of hearing about it. She just wants to know why I can’t mow the lawn. I can’t even carry in the groceries.

Psychiatrist: So you’ve got pain, isolation, and the struggle of not being able to be the man-about-the-house you once were.

Patient: You can’t believe how terrible it is, doc.

Psychiatrist: I want to try to understand.

Why is there such an intense need to keep talking about pain?

All of us have a story. Patients in pain are no exception. Life-altering events, such as the development of a terminal illness, the death of a loved one, or being exposed to severe trauma, are expected to reverberate in memory and to benefit from being voiced aloud. This is not as obvious with someone who, though in constant physical pain, may bear no visible stigmata to alert others to this fact. Patients in pain nevertheless continuously confront an assault on their previously established sense of self and need to talk through the impact of their pain on everything they previously “knew” about themselves. They must answer anew nagging questions, often previously resolved, about their personal worth and what gives their life meaning when they can no longer respond to life in a way that was once comfortable and routine.

What about pain medications?

Although there are definitely individuals who try to manipulate a physician into providing inappropriate prescriptions for pain medication, in most practice settings this is an exception. A recent meta-analysis of chronic opioid analgesic therapy demonstrated that the overall incidence of opioid addiction in this group was 3.27 percent, and in a subset preselected for having no history of substance abuse or addiction, the incidence was 0.19 percent.[6] Most pain patients are merely seeking relief.

In recent years there has been increasing understanding and collaboration between physicians advocating for relief of pain and relevant oversight/enforcement agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency (DEA).[7] This collaboration has led to the development of guidelines for appropriate use of opioids in chronic pain. One such guide is called “Universal Precautions for the Prescription of Opioids.”[8,9] It should be noted that physicians in pain medicine and hospice/palliative medicine usually take care to use the terms opioid or opiate rather than narcotic, which is considered to be pejorative and ill focused. The physical condition of pain is treated to preserve function, and narcosis, a condition of deep stupor or unconsciousness, will hopefully be avoided.

See Table 1 for a list of universal precautions in pain medicine.

How is talking about medication integrated into psychotherapy with the chronic pain patient?

Psychiatrists are well versed in utilizing a combination of medications and therapy to help the patient meet their goals.[10,11] With many of our pain patients, however, the psychiatrist is not prescribing one or more of the potentially psychoactive medications the patient is taking, such as opioids, benzodiazepines, or antiepileptic drugs. Issues related to medication misuse or to side effects often arise in psychotherapy with the pain patient who may be experiencing a negative impact from polypharmacy. Frequently this will create an issue by diminishing the patient’s ability to meet his or her stated objectives. Managing this can require some finessing with the individual and his or her other doctor(s).

CASE EXAMPLE: Medication interference with daily function

Psychiatrist: How have things gone for you at home this week?

Patient: I know I said I wanted to spend more time helping my wife, but I just don’t have any energy.

Psychiatrist: You do appear to be pretty lethargic.

Patient: (with apparent indignation) My wife said to the doctor, “Just look at him! He can’t even keep his eyes open!”

Psychiatrist: Do you realize that your eyelids droop as if you are just about to fall asleep?

Patient: No…I feel pretty awake.

Psychiatrist: There is something I have been concerned about regarding one of the prescriptions you receive from Dr. N. I know that you have a lot of anxiety along with your pain, but did you know that many pain specialists feel that benzodiazepines, such as the clonazepam you are taking, can actually be counter-productive for chronic pain?12

Patient: Well, no…do I really look like I’m half asleep?

Psychiatrist: You find that disturbing.

Patient: I sure do! I feel bad enough to be useless around the house, and now it seems I even look useless! I don’t want to be on anything that makes me look like a drug addict!

Psychiatrist: I can talk with Dr. N about my concerns if you like. What I would recommend is very slowly decreasing the clonazepam so that you don’t have significant withdrawal symptoms, and then see if you are functioning better or worse. The trade-off may be between being more alert but a bit more anxious.

Patient: I am going to see her next week. I will tell her I want off.

Psychiatrist: Remember that Dr. N started those pills for you in order to be helpful with your anxiety. Any time a medicine doesn’t work the way we hope it will, or has ill effects that make the medicine not worth the trouble, then we need to rethink the plan. Doctors need to get feedback to know if their prescriptions are helping or not.

Patient: Yeah, she’s really helped me.

Psychiatrist: I think that decreasing clonazepam will be a move that will help you reach your goal of being a support to your family again. Just remember you will need to decrease it slowly over time. If Dr. N prefers, I’d be glad to write out a schedule for you on how to do it. I’d be glad to talk with her again. Just let me know.

PRACTICE POINT: Make clinical decisions based on improving function

With the use of benzodiazepines or opioids, or any prescribed medication for that matter, the driving issue must be function. Is this intervention making it easier or more difficult for this patient to manage and enjoy life? It is surprising that many patients and their pain specialists come to the conclusion that recommended drugs, even opioids, are not worth the side effects. Then, the disappointing medications are discontinued, and a new tactic must be tried.

What is the Difference Between Physiologic Dependence/Tolerance, Drug Addiction, and Psychological Dependence?

Patients often fear addiction even more than the prescribing physicians do. Even more than dependence and tolerance, per se, is the fear of being thought of as an addict.[13]

Physiologic dependence is the term used to describe the phenomenon of a withdrawal syndrome that most individuals will experience if they take opiates for a long enough time in high enough doses and then abruptly reduce the dose. Physiologic tolerance is the associated term that describes the phenomenon of needing to take more of a medication to achieve the same effect that many individuals will experience if they take an opiate for a long enough duration. These are effects that can happen to any of us if we are prescribed opiates for more than a few days, and although they do not represent true addiction, the terms are often used in a way that suggests they do. It may be necessary to clarify to a pain patient that the development of physiologic dependence on an opioid does not indicate that the patient has become an addict. Addiction, or the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis of opioid dependence involves issues far beyond that of physiologic dependence, including the classic “four Cs” (Table 2).[14–16] If opiates are appropriately prescribed and monitored, this is unlikely.

CASE EXAMPLE: Evaluating and interpreting surreptitious opiate use.

Ms. M was given an appointment by an alcohol and drug program for the express purpose of being evaluated for buprenorphine (Suboxone®) treatment for opioid dependence due to overuse of hydrocodone with acetaminophen (Vicodin®). One might have expected that the type of motivation that would be needed in a case like this would be for sobriety.

Psychiatrist: Your drug counselor has told me you are interested in treatment for dependence on Vicodin.

Patient: Well actually, it’s my husband who wants me to quit.

Psychiatrist: Tell me more about that.

Patient: Well, I was seeing Dr. X for the pain in my back. I was told I should have surgery, but I have to work. I can’t take that kind of time off! The trouble all started when I ran out of my medicines and I couldn’t get any more. The doctor prescribed Vicodin every eight hours, but I can’t get out of bed unless I take two about an hour before I have to get out of bed. Then I need two more to be able to go to work. I was in pain and I just couldn’t hack it! My mother gave me hers so that I could at least function. Trouble is my husband found out about it and it has been hell ever since.

Psychiatrist: So your use of Vicodin was helping you to do what you needed to around the house as well as to work, but you didn’t have enough, so you took your mother’s which has gotten you into some marital strain. Are there any other problems you have run into with your using Vicodin?

Patient: Well, I feel really guilty about using more than I was prescribed… I know it’s not a good example for my children…and it doesn’t fit in with my concept of myself as a good Christian.

Psychiatrist: So other than the guilty feelings relating to your doctor, your husband, your children and your church, has your use of Vicodin presented any other problems?

Patient: I’ll tell you what. Vicodin practically saved my life. I was going crazy with the pain and could barely drag myself to work. I couldn’t even play with my children. My husband calls me an addict, but I don’t know how I will manage without Vicodin. The idea of Suboxone gave me some hope.

Psychiatrist: It sounds like you had a definite improvement in the way you were functioning, aside from lots of guilt.

Patient: No one likes being an addict.

Psychiatrist: Do you want to try to change your view of yourself as an addict and get some real help for your pain?

PRACTICE POINT: Reframing the need for pain medication can help the pain patient

Ms. M seemed to be manifesting pseudoaddiction, a term used to describe a phenomenon seen in individuals with inadequately controlled pain.[12] Such individuals may present with several of the aberrant drug-related behaviors (ADRBs)[18–20] that are red flags for drug dependence, but in fact represent inadequately controlled pain. Both Ms. M and her husband will need psychoeducation. Her family physician may or may not be open to prescribing Ms. M an adequate amount of Vicodin to control her pain and allow adequate function. Many primary care physicians (PCPs) in the community, such as family medicine or internal medicine specialists, will do so. They utilize a treatment agreement, sometimes referred to as a medication contract, that requires the patient to, among other things, only obtain his or her controlled medication from one physician and one pharmacy; forgo illicit drug use, including getting extra pills from family members; and submit to periodic urine toxicology screens.[12] A call from the psychiatrist can do much to reassure the PCP regarding the absence of a substance use disorder, as opposed to the expectable physiological dependence and tolerance. This will require honesty and advanced planning by Ms. M, for example, to not “run out” of pain medication on a Friday night and expect to receive some at the emergency room. This in and of itself can be the subject of motivational interviewing,21 exploring what might prevent Ms. M from cooperating with a medication program that provides huge functional benefits for her. The issue of her guilt might be more amenable to other types of therapy such as psychodynamic, interpersonal, or cognitive.[22–24]

The case of Ms. M bears some similarities to a patient with alcohol dependence and generalized anxiety disorder who has achieved a sustained full remission from the former but continues to experience dysfunction from the latter despite several adequate antidepressant trials, including various augmentation strategies. These individuals may present with a strong desire for benzodiazepines to control their anxiety; they may accept donations of alprazolam (Xanax) from kind and generous friends and family members; and they may use various means to try to persuade a variety of providers to give them a prescription. These are all well-recognized ADRBs, which may, however, represent pseudoaddiction from inadequately controlled anxiety. It may be safest, as with the pain patient, to prescribe and maximize use of nonscheduled medicines, such as antidepressants and antiepileptic drugs. If a cautious and time-limited trial of benzodiazepines is started however, with contractual agreements such as those noted previously, the patient should be observed for functional improvement and the reduction of such ADRBs. If this is not the outcome, the trial should be ended. This patient may similarly benefit from motivational interviewing, this time around the topic of maintaining abstinence from alcohol and reducing contacts with friends and family members who abuse drugs, prescription or otherwise. It should also be emphasized that, as exemplified in the second case example, unless there is a specific comorbidity with an anxiety disorder, benzodiazepines have generally not been found to be helpful in chronic pain.[12]

All of these factors are important to know and clarify for patients and their family doctors when you are part of the patient’s pain treatment team. Ultimately, if issues relating to dependence, tolerance, addiction, and pseudoaddiction are not addressed in therapy, they can strain the psychotherapeutic relationship. This can then move us farther from the desired goal of remaining compassionate psychiatrists in the face of a heavy burden of countertransference and possible mistrust with pain patients.

PRACTICE POINT: Helping the patient regain a sense of value in spite of the pain

Patients with chronic pain have often lost a lot: their livelihood, their pastimes, and their sense of themselves as friends or parents or lovers. It is not intuitively obvious how to put their lives back together, and it is hard for these patients to accept that things will not go back to the way they were. Their premorbid functioning may be idealized, creating an even wider gap between what was and what is to come. It is important to work with the chronic pain patient in such a way that they can regain a sense of self respect and acknowledge what they still have to offer.

CASE EXAMPLE: knitting together a good-enough life

Ms. D, a 27-year-old woman, was not of the generation of women who identified themselves with keeping the home fires burning, but rather had established a strong sense of herself through her work. Now, she was not only unable to work outside the home, but not even able to do basic household tasks. Folding laundry would send shooting pain down her legs. Giving her son a hug brought tears to her eyes, and they were not those of joy. In her recovery, she had learned to knit, and the irony was not lost on her that an injury sustained at a job which entailed hard physical labor had caused her to turn to a traditional domestic task to obtain relief.

Psychiatrist: How have you been functioning lately?

Patient: (with a bitter tone and tears evident) I can’t do a damn thing!

Psychiatrist: (meeting her stare directly) Not being able to do anything is very hard for a go-getter such as yourself.

Patient: I used to be a goddamn welder! I used to lift weights! I used to carry my son up hills in a backpack!

Psychiatrist: Your injury has brought about a lot of losses.

Patient: (tearful…nodding)

Psychiatrist: (silent)

Patient: I just can’t deal with this…I was so proud of my work…now I can’t do anything…I’m useless.

Psychiatrist: I understand that you’re feeling angry, overwhelmed, and useless, not to mention that you’re in pain, but I have to respectfully disagree with you about the useless part.

Patient: (looking dubious)

Psychiatrist: In our last session you told me you went to your son’s school play.

Patient: (rolling her eyes) I was hurting the whole time.

Psychiatrist: But you went! You are very important to your son…I’m guessing he was very glad to have you there.

Patient: (reluctantly) He was…I know he was sad when I missed his last soccer match.

Psychiatrist: But then you made the decision that even if you were in pain, you were going to try to be there for him, and you have been.

Patient: Big deal…I can’t afford to buy him an MP3 player.

Psychiatrist: It is a big deal! Your physical presence for him is one of the best gifts you can offer him. It’s an expensive gift too, because you have to save up your energy all day to give him that gift.

Patient: Tell him that when he’s pressuring me for the MP3.

Psychiatrist: Some things you’ll just have to know within yourself. He might not get it until he is a parent himself.

Patient: (nodding but somewhat dismissively)

Psychiatrist: You’re also doing a lot for him when you acknowledge his disappointment and just allow him to feel the way he’s feeling.

Patient: He does get past things pretty quick when I just sit with him.

Psychiatrist: He gets the double message that you support him and that you are bigger than his feelings and you are okay with those feelings.

Patient: Yeah, maybe, but even so…I can’t go roller-skating with him anymore…I won’t get in tickle fights…

Psychiatrist: Do you remember the session we had in which you realized how you’ve always felt you weren’t good enough, even before the accident? How you’ve always felt a need to do more…

Patient: (nodding tentatively)

Psychiatrist: Do you think that could be happening now with your son? That you’re not giving yourself permission to just be a “good-enough” mother?

Patient: What I’m doing seems so inadequate.

Psychiatrist: (looking at her quizzically)

Patient: Oh my gosh…

Psychiatrist: A bit like the example we came up with before about how the knitting you’ve taken up again is never fancy enough or soft enough or beautiful enough?

Patient: And how my Dad always thought sitting and doing hand work was so useless…

Psychiatrist: How else could you look at it?

Patient: It’s something I’m working on—to be able to provide gifts and things for my family in a way I can do now, even with the pain…

Psychiatrist: (smiling) By George, I think she’s got it!

Patient: (returning smile and appearing much less distraught)

PRACTICE POINT: Being practical and helping the patient return to a “new normal”

In working with pain patients, often the therapy will need to be very pragmatic, including elements of both supportive therapy and cognitive therapy.[25,24] No matter what therapeutic model is employed, chronic pain patients frequently get derailed back into a relatively dependent state and exhibit a compulsion to voice their pain story again, seeking reassurance and acknowledgment of their struggle. While it is important to do so, over time you will be able to decrease the amount of time spent reiterating and reassuring, and spend more time recognizing the strides they are making toward a meaningful life in the face of pain.

Often simple advice is called for, such as recommending individuals learn to balance activity and rest. They will need to learn that doing too little physical exertion or stretching can sometimes be almost as uncomfortable as doing too much, and they should be encouraged to build up to 30 minutes daily of aerobic activity of a tolerable type. If walking is too painful, then exercise bicycling or water exercise can be encouraged. They can stretch even if chair bound. They can be taught to “save up” their energy for meaningful activities, such as outings with family or friends. Any of these recommendations can be broken down into small steps. Cognitive techniques can be utilized such as first predicting how uncomfortable or difficult a particular bit of exertion will be, then doing it, and finally observing how difficult it actually was as well as how it made them feel. This practice of breaking activities into manageable steps and realizing they can accomplish more than they thought they could allows them to gradually re-engage in life alongside their pain.

CASE EXAMPLE: Taking things one step at a time

Psychiatrist: How did your homework go?

Patient: It was challenging.

Psychiatrist: Tell me about it.

Patient: Well, like we talked about, I made a schedule for what I needed to do before I could go to the party.

Psychiatrist: Let’s look at it together.

Patient: (bringing out a notebook) Well, first I had to shower. I thought it would be exhausting, an 8 out of 10.

Psychiatrist: How exhausting was it?

Patient: I decided to not wash my hair since I had done that the day before, so it didn’t take nearly as much energy as I thought it would. I actually felt a little bit better afterward, even though I was tired.

Psychiatrist: Those were important things to do and to notice: First you let yourself off the hook and gave yourself permission to do a little less than you usually do. Then you took note of the fact that you handled the shower without being so worn out.

Patient: I guess I did.

Psychiatrist: Both are really important. So what came next?

Patient: I laid down flat on my back for awhile. I was afraid I would get up all stiff, so I only rested for 20 minutes.

Psychiatrist: How did that work?

Patient: I was really tempted to lie there longer and just forget about going out, but I reminded myself of my promise to my husband, and I got up.

Psychiatrist: (nodding) Nice! How did you feel?

Patient: Oh man, I was in so much pain… (Initially, she appeared weary. Then, she spoke with apparent anger) I thought this homework was no good, that you were pushing me too hard!

Psychiatrist: (nodding again, waiting)

Patient: Then I remembered I was the one who chose it…

Psychiatrist: (still waiting)

Patient: (sheepishly) Then I felt angry at myself and the whole situation again…I was getting worked up into a major pity party.

Psychiatrist: But something changed?

Patient: I got the idea, “I’ll show her…I’ll go through with it and be so much worse…I’ll be in pain for a week after this.”

Psychiatrist: So you used your anger to motivate yourself.

Patient: You could say that I guess. Anyway, I did the schedule like we worked out. I just put on my underwear, and then I sat until I was ready. That wasn’t so bad. Then I put on my shirt and just sat there again…then the anger came back…I felt like a child, like a dope doing it this way.

Psychiatrist: Were you able to respond to that automatic thought?

Patient: (looking quizzically)

Psychiatrist: Remember how sometimes we make ourselves feel even worse than the situation already is, by criticizing ourselves harshly?

Patient: I do that all the time.

Psychiatrist: What could you have said to yourself instead?

Patient: (tentatively) That even though I really hate this, I’m an intelligent woman and I can do this?

Psychiatrist: You certainly are and you certainly can! This situation is very difficult and you suffer a lot, but you still keep on going.

PRACTICE POINT: Never give up

Working with patients who are always in pain is challenging and can be draining at times, almost as if by sharing a space with them, you affectively register the heaviness of their burden. They feel demoralized and hopeless, and you as their psychiatrist must recognize the shared affect and move past it. This recognition allows you to be truly empathic in your responses to them, and helps you not to feel demoralized and helpless yourself. The patient needs to know you are strong enough to handle his or her pain, his or her anger and frustration, and not be submerged by it nor abandon him or her.[26] By accepting the challenge of therapy with a chronic pain patient, you too become more flexible and more capable.

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