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Evaluating and Treating Pain in Psychiatric Patients
Michael Robert Clark, MD
Associate professor & director of the Chronic Pain Treatment Program at The Johns Hopkins Hospital in Baltimore, MD
Dr. Clark discloses that he has been a paid consultant to Collegium Pharmaceutical Inc. and Depomed, Inc. Dr. Carlat has reviewed this article and has found no evidence of bias in this educational activity.
TCPR: Dr. Clark, recently a local pain clinic asked me if I wanted to do some psychiatric consultation there. I ended up declining, partly because I really didn’t know what I was supposed to do as a psychiatrist working in a pain clinic. Can you provide some insight?
Dr. Clark: I think psychiatrists are being underutilized in chronic pain management, because many of the things that people with chronic pain are dealing with are psychiatric problems. Pain patients have tremendously high rates of major depressive disorder which is undertreated and underdiagnosed. Many clinicians assume that the depression is a reaction to living with chronic pain, but in fact it’s often the other way around. These people have high rates of family histories of affective disorders; they have prior episodes of depression themselves. And having depression puts you at about two to three times the risk of the general population of developing a chronic pain syndrome (Larson SL, Psychol Med 2004;34(2):211–219). In addition, most of the medicines that you would use to treat affective disorders, such as antidepressants, mood stabilizers, and neuroleptics for augmentation, are the same medicines and almost identical algorithms for managing chronic neuropathic pain.
TCPR: What sort of evaluation should a psychiatrist do if asked to evaluate a patient with chronic pain?
Dr. Clark: Well, in general, you should be doing the same kind of evaluation that you would do with any other patient. A couple of special areas of emphasis are the mood disorders and substance use disorders. To do a good evaluation, you have to understand something about the subjective experience of a patient with chronic pain. Chronic pain is poorly understood, difficult to cure, and frustrating to both patients and health care practitioners. As a result, patients with chronic pain find themselves in a world apart. They are isolated from family and friends and become trapped in the realm of the doctors, insurance companies, case managers, and even quacks. As patients struggle to find relief, they lose their lives.
TCPR: So it’s key to make sure that these patients feel you are on their side?
Dr. Clark: Absolutely. You have to have an alliance. You have to demonstrate that you’re thorough, that you know your field, and that you are interested in taking care of them. And then you have to begin a discussion with them about what you think might be contributing or causing their pain, such as depression or side effects of medications. For example, chronic opioid use often causes a host of problems in patients, including cognitive impairment and a hyperalgesic state.
TCPR: What is a hyperalgesic state?
Dr. Clark: The hyperalgesic state is a clinical phenomenon where you see somebody getting more severe and more generalized pain as the dosage of opioids is increased.
TCPR: Interesting, and do you have a hard time convincing patients that this is a problem that they have?
Dr. Clark: It depends on the person. Most people are skeptical, but now that they’re hearing more about opioids in the news and online, there’s a little bit more willingness to hear more about it. The biggest thing that we’re trying to overcome is somebody saying, “If I’m in this much pain on these medicines, how can I not be in more pain off these medicines?”
TCPR: I assume that many patients may not recognize cognitive impairment as a side effect of long-term opioid use. How do you address this?
Dr. Clark: It’s really helpful to have a family member with the patient when you’re discussing cognitive impairment. I usually say something like, “Often, after people have been on these medicines in these kind of combinations for a while, not only do they become tolerant to some of the side effects, but they don’t recognize how the medicines are affecting them. And you must have noticed that you’re not quite as attentive as you usually are; you’re more forgetful; you don’t have the same kind of motivation and interest in things; you tend to spend more time doing less, and your usual kind of get-up-and-go for projects is gone.” And usually it’s the family member who is sitting there—the partner or a son or daughter—who starts nodding their head and saying, “Oh, yeah, he’s not the person he used to be. He forgets all kinds of stuff. He’s always kind of nodding off even though he says he doesn’t sleep.” That’s where you can say, “Do you recognize any of these things?” and they’ll say, “Yeah, my wife has been telling me this for months, but what can I do?”
TCPR: So once you have that alliance going and the patient realizes you are both on the same side, you can begin talking to them about treatment?
Dr. Clark: Right. They have to be willing to make changes and accept a course of treatment that is focused on rehabilitation as opposed to comfort. And often that’s a paradigm shift for patients, when I tell them that we’re not going to be focused solely on making them comfortable, but that we are going to work on all the causes and contributors to their pain, whether it’s depression or another underlying pain problem. I’ll say something like, “There are a tremendous number of people who have these very same problems who are able to be more functional than you, and we will help you transform yourself into one of those people.”
TCPR: What do you mean by “rehabilitation” in the context of chronic pain?
Dr. Clark: Rehabilitation has to do with being productive and functional, with a higher quality of life: to move from a model that is a palliative care one—“Give me medicine until I’m comfortable; take my pain away; fix me, and if you can’t fix me, help me get disability.” And that’s where a lot of our patients are trapped. You want to say, “Look, you can actually do more despite what’s wrong, and there are better and more specific treatments than what you’re receiving. There are things that we can do that will ultimately decrease your pain and help you to have more motivation to do productive and functional things in your life.”
TCPR: Can you give us an example of a patient who’s responded to that message? I mean, it sounds great, but convince me that it actually works.
Dr. Clark: There have been quite a few studies over the years showing that multidisciplinary or interdisciplinary pain treatment is effective. One patient that comes to mind is a former military person who came to our program very depressed, intoxicated, and unable to function. He had sustained a horrendous injury while serving his country—very painful nerve damage that was being treated with intranasal ketamine and several different opioids as well as benzodiazepines. We gradually weaned him off all of those medications and treated him with a tricyclic antidepressant for his neuropathic pain as well as his mood. Ultimately, he was given a course of ECT because his depression was so severe. And he left our program pain free and on fewer medications. He went back to working full time in the family business and being a full partner with his wife in that endeavor.
TCPR: And that was due to a combination of the ECT for the depression and the tricyclic for both pain and depression. Any other medications?
Dr. Clark: He was also on a low-dose neuroleptic to augment the tricyclic and to facilitate sleep.
TCPR: Are there any specific medications that you find yourself turning to in these situations?
Dr. Clark: In my experience, the best medicines for neuropathic pain are the SNRIs and tricyclic antidepressants. So I use a lot of duloxetine, venlafaxine, and nortriptyline. If you’re going to use a tricyclic antidepressant, you really need to check serum blood levels, and you need to aim for the high end of the therapeutic range. If you’re using other medicines, you really should be willing to push beyond the usual dose—so 120 mg of duloxetine, 300–450 mg of venlafaxine. We also use a lot of anticonvulsants like Depakote and Lamictal—again, it’s necessary to treat to therapeutic blood levels—so you use the same range that you would use for treatment of mood disorders or for epilepsy. The downside is the possibility of drug interactions, so you really have to make sure that you’re tracking any over-the-counter medication use closely.
TCPR: We don’t normally think of Depakote and Lamictal as being helpful for pain. Are you prescribing these both for pain and for whatever mood issues there are?
Dr. Clark: Yes. There are some nice statistical analyses that have looked at some of these agents in randomized controlled trials and have been able to show that most of these drugs have independent effects on pain and mood (Martinez JM, Int Clin Psychopharmacol 2012;27(1):17–26). Clinically, I can tell you I’ve had patients receive benefit for pain but not mood, and vice versa, with any given agent. It’s very idiosyncratic who’s going to respond to what, and it’s challenging to know for certain whether it’s a direct or indirect effect when it seems to work for both.
TCPR: Anything else you’ve had success with?
Dr. Clark: As far as neuroleptic augmentation, the medicine that’s worked best for me and that I’ve seen the most dramatic results with is Zyprexa—2.5 mg to 5 mg at bedtime. There’s also Geodon—20 mg to 40 mg in the morning—or Latuda, Saphris, or Abilify. Any of these can be helpful as long as you’re monitoring the patient’s metabolic status and their weight.
TCPR: There’s also Lyrica (pregabalin) and Neurontin—are those helpful?
Dr. Clark: They can be in some people. They are a special class of anticonvulsants. They’re calcium channel modulators, which don’t really seem to provide any antidepressant or mood-stabilizing effects. They can sometimes be helpful with anxiety or insomnia, but are more limited in their use for neuropathic pain. Usually, by the time people come to see us, they’ve already tried those medicines.
TCPR: I imagine you must encounter resistance from some pain patients when you discourage opioids and suggest prescribing psychiatric meds. Some might think that you’re implying that their pain is “all in their head.” How do you address that concern?
Dr. Clark: You can say, “Look, it’s important to understand at this point that you’re not doing well: you’ve been trying things this way for years, if not decades, and it hasn’t helped you. In fact, we see this a lot and can tell you that people improve when they get off of narcotic medications—their mood gets better, their sleep gets better, their pain gets better, and their thinking gets clearer. We expect that that’s going to happen with you because we’ve seen it in thousands of patients. In addition to that, we think that your depression has taken on a life of its own. Of course, you’re unhappy about being in pain and demoralized and frustrated, but we think it’s gone to a new level, and that now you have a comorbid major depressive disorder because of the overlap in neurobiology of pain with the neurobiology of mood disorders. It makes perfect sense that these two things go hand in hand, and so both things have to be treated. And luckily a lot of the treatments are the same.”
TCPR: What do you tell them about their treatment?
Dr. Clark: Something along the lines of, “We’re not necessarily going to just double the medicines that you’re on because you have two disorders instead of one; we’re just going to find a more sophisticated and tailored regimen for you. And I think once you see things improve, you’ll find that you’re capable of doing more and you’ll have motivation to do more, and you’ll be able to participate in the physical therapy that you need to get your body back in shape in the same way that after you’ve been kicked by the flu for a week, your body hurts and doesn’t feel well and it has to kind of get going again. And you’ve had the flu for 10 years.”
TCPR: I like that very much. It’s a nice way to frame things so that patients understand the mind and body connection without feeling stigmatized. How do you handle the special circumstances surrounding disability insurance and litigation? Many practitioners are quite skeptical of patients seeking some form of compensation.
Dr. Clark: I think it’s important to approach patients with the assumption that they would rather be healthy than sick. And, while patients may be seeking disability, workman’s compensation, or pursuing other types of litigation, it’s more likely they have become trapped in a system that is reinforcing the illness rather than that they are simply faking one.
TCPR: Can you explain how that happens?
Dr. Clark: In these cases, the incentives are in conflict. While the patient may want to go back to work and to a productive life, they are actually being paid, or more accurately, being reinforced for remaining in the sick role and exhibiting the behavior of disability. The patient is at the center of a complex web of factors that make it more difficult to become functional and independent. Patients often feel the risk of returning to work is too high—if they fail, the benefits they were receiving for having been injured or unable to work are gone.
TCPR: So you’re saying that secondary gain can play an important part in maintaining the lifestyle of someone who has chronic pain.
Dr. Clark: Not exactly. It is true that illness behavior and disability can be reinforced by a system that does not necessarily have the patient’s best interests at heart. And it can sometimes be the case that the patient is taking advantage of that broken system. But, usually this is not at the level of manipulation or malingering so much as it is a way of life that emerges little by little. Think about it. If I said to you, “Think about how much money you’re making now and all the hassles that you have to put up with to make that money. Or, you could stay at home and get 60% of your income tax free as long as you continue to go to doctors’ appointments to confirm that you’re still sick.” What would you do?
TCPR: That’s a good question, and frankly, I’m not sure what I would do.
Dr. Clark: It comes down to what’s motivating you every day. And as doctors, it’s our job to help patients find a path toward being functional even in the presence of some pain, and even when some of the incentives are aligned against that outcome.
TCPR: I agree, and thanks very much for your time, Dr. Clark.
General PsychiatryDr. Clark: I think psychiatrists are being underutilized in chronic pain management, because many of the things that people with chronic pain are dealing with are psychiatric problems. Pain patients have tremendously high rates of major depressive disorder which is undertreated and underdiagnosed. Many clinicians assume that the depression is a reaction to living with chronic pain, but in fact it’s often the other way around. These people have high rates of family histories of affective disorders; they have prior episodes of depression themselves. And having depression puts you at about two to three times the risk of the general population of developing a chronic pain syndrome (Larson SL, Psychol Med 2004;34(2):211–219). In addition, most of the medicines that you would use to treat affective disorders, such as antidepressants, mood stabilizers, and neuroleptics for augmentation, are the same medicines and almost identical algorithms for managing chronic neuropathic pain.
TCPR: What sort of evaluation should a psychiatrist do if asked to evaluate a patient with chronic pain?
Dr. Clark: Well, in general, you should be doing the same kind of evaluation that you would do with any other patient. A couple of special areas of emphasis are the mood disorders and substance use disorders. To do a good evaluation, you have to understand something about the subjective experience of a patient with chronic pain. Chronic pain is poorly understood, difficult to cure, and frustrating to both patients and health care practitioners. As a result, patients with chronic pain find themselves in a world apart. They are isolated from family and friends and become trapped in the realm of the doctors, insurance companies, case managers, and even quacks. As patients struggle to find relief, they lose their lives.
TCPR: So it’s key to make sure that these patients feel you are on their side?
Dr. Clark: Absolutely. You have to have an alliance. You have to demonstrate that you’re thorough, that you know your field, and that you are interested in taking care of them. And then you have to begin a discussion with them about what you think might be contributing or causing their pain, such as depression or side effects of medications. For example, chronic opioid use often causes a host of problems in patients, including cognitive impairment and a hyperalgesic state.
TCPR: What is a hyperalgesic state?
Dr. Clark: The hyperalgesic state is a clinical phenomenon where you see somebody getting more severe and more generalized pain as the dosage of opioids is increased.
TCPR: Interesting, and do you have a hard time convincing patients that this is a problem that they have?
Dr. Clark: It depends on the person. Most people are skeptical, but now that they’re hearing more about opioids in the news and online, there’s a little bit more willingness to hear more about it. The biggest thing that we’re trying to overcome is somebody saying, “If I’m in this much pain on these medicines, how can I not be in more pain off these medicines?”
TCPR: I assume that many patients may not recognize cognitive impairment as a side effect of long-term opioid use. How do you address this?
Dr. Clark: It’s really helpful to have a family member with the patient when you’re discussing cognitive impairment. I usually say something like, “Often, after people have been on these medicines in these kind of combinations for a while, not only do they become tolerant to some of the side effects, but they don’t recognize how the medicines are affecting them. And you must have noticed that you’re not quite as attentive as you usually are; you’re more forgetful; you don’t have the same kind of motivation and interest in things; you tend to spend more time doing less, and your usual kind of get-up-and-go for projects is gone.” And usually it’s the family member who is sitting there—the partner or a son or daughter—who starts nodding their head and saying, “Oh, yeah, he’s not the person he used to be. He forgets all kinds of stuff. He’s always kind of nodding off even though he says he doesn’t sleep.” That’s where you can say, “Do you recognize any of these things?” and they’ll say, “Yeah, my wife has been telling me this for months, but what can I do?”
TCPR: So once you have that alliance going and the patient realizes you are both on the same side, you can begin talking to them about treatment?
Dr. Clark: Right. They have to be willing to make changes and accept a course of treatment that is focused on rehabilitation as opposed to comfort. And often that’s a paradigm shift for patients, when I tell them that we’re not going to be focused solely on making them comfortable, but that we are going to work on all the causes and contributors to their pain, whether it’s depression or another underlying pain problem. I’ll say something like, “There are a tremendous number of people who have these very same problems who are able to be more functional than you, and we will help you transform yourself into one of those people.”
TCPR: What do you mean by “rehabilitation” in the context of chronic pain?
Dr. Clark: Rehabilitation has to do with being productive and functional, with a higher quality of life: to move from a model that is a palliative care one—“Give me medicine until I’m comfortable; take my pain away; fix me, and if you can’t fix me, help me get disability.” And that’s where a lot of our patients are trapped. You want to say, “Look, you can actually do more despite what’s wrong, and there are better and more specific treatments than what you’re receiving. There are things that we can do that will ultimately decrease your pain and help you to have more motivation to do productive and functional things in your life.”
TCPR: Can you give us an example of a patient who’s responded to that message? I mean, it sounds great, but convince me that it actually works.
Dr. Clark: There have been quite a few studies over the years showing that multidisciplinary or interdisciplinary pain treatment is effective. One patient that comes to mind is a former military person who came to our program very depressed, intoxicated, and unable to function. He had sustained a horrendous injury while serving his country—very painful nerve damage that was being treated with intranasal ketamine and several different opioids as well as benzodiazepines. We gradually weaned him off all of those medications and treated him with a tricyclic antidepressant for his neuropathic pain as well as his mood. Ultimately, he was given a course of ECT because his depression was so severe. And he left our program pain free and on fewer medications. He went back to working full time in the family business and being a full partner with his wife in that endeavor.
TCPR: And that was due to a combination of the ECT for the depression and the tricyclic for both pain and depression. Any other medications?
Dr. Clark: He was also on a low-dose neuroleptic to augment the tricyclic and to facilitate sleep.
TCPR: Are there any specific medications that you find yourself turning to in these situations?
Dr. Clark: In my experience, the best medicines for neuropathic pain are the SNRIs and tricyclic antidepressants. So I use a lot of duloxetine, venlafaxine, and nortriptyline. If you’re going to use a tricyclic antidepressant, you really need to check serum blood levels, and you need to aim for the high end of the therapeutic range. If you’re using other medicines, you really should be willing to push beyond the usual dose—so 120 mg of duloxetine, 300–450 mg of venlafaxine. We also use a lot of anticonvulsants like Depakote and Lamictal—again, it’s necessary to treat to therapeutic blood levels—so you use the same range that you would use for treatment of mood disorders or for epilepsy. The downside is the possibility of drug interactions, so you really have to make sure that you’re tracking any over-the-counter medication use closely.
TCPR: We don’t normally think of Depakote and Lamictal as being helpful for pain. Are you prescribing these both for pain and for whatever mood issues there are?
Dr. Clark: Yes. There are some nice statistical analyses that have looked at some of these agents in randomized controlled trials and have been able to show that most of these drugs have independent effects on pain and mood (Martinez JM, Int Clin Psychopharmacol 2012;27(1):17–26). Clinically, I can tell you I’ve had patients receive benefit for pain but not mood, and vice versa, with any given agent. It’s very idiosyncratic who’s going to respond to what, and it’s challenging to know for certain whether it’s a direct or indirect effect when it seems to work for both.
TCPR: Anything else you’ve had success with?
Dr. Clark: As far as neuroleptic augmentation, the medicine that’s worked best for me and that I’ve seen the most dramatic results with is Zyprexa—2.5 mg to 5 mg at bedtime. There’s also Geodon—20 mg to 40 mg in the morning—or Latuda, Saphris, or Abilify. Any of these can be helpful as long as you’re monitoring the patient’s metabolic status and their weight.
TCPR: There’s also Lyrica (pregabalin) and Neurontin—are those helpful?
Dr. Clark: They can be in some people. They are a special class of anticonvulsants. They’re calcium channel modulators, which don’t really seem to provide any antidepressant or mood-stabilizing effects. They can sometimes be helpful with anxiety or insomnia, but are more limited in their use for neuropathic pain. Usually, by the time people come to see us, they’ve already tried those medicines.
TCPR: I imagine you must encounter resistance from some pain patients when you discourage opioids and suggest prescribing psychiatric meds. Some might think that you’re implying that their pain is “all in their head.” How do you address that concern?
Dr. Clark: You can say, “Look, it’s important to understand at this point that you’re not doing well: you’ve been trying things this way for years, if not decades, and it hasn’t helped you. In fact, we see this a lot and can tell you that people improve when they get off of narcotic medications—their mood gets better, their sleep gets better, their pain gets better, and their thinking gets clearer. We expect that that’s going to happen with you because we’ve seen it in thousands of patients. In addition to that, we think that your depression has taken on a life of its own. Of course, you’re unhappy about being in pain and demoralized and frustrated, but we think it’s gone to a new level, and that now you have a comorbid major depressive disorder because of the overlap in neurobiology of pain with the neurobiology of mood disorders. It makes perfect sense that these two things go hand in hand, and so both things have to be treated. And luckily a lot of the treatments are the same.”
TCPR: What do you tell them about their treatment?
Dr. Clark: Something along the lines of, “We’re not necessarily going to just double the medicines that you’re on because you have two disorders instead of one; we’re just going to find a more sophisticated and tailored regimen for you. And I think once you see things improve, you’ll find that you’re capable of doing more and you’ll have motivation to do more, and you’ll be able to participate in the physical therapy that you need to get your body back in shape in the same way that after you’ve been kicked by the flu for a week, your body hurts and doesn’t feel well and it has to kind of get going again. And you’ve had the flu for 10 years.”
TCPR: I like that very much. It’s a nice way to frame things so that patients understand the mind and body connection without feeling stigmatized. How do you handle the special circumstances surrounding disability insurance and litigation? Many practitioners are quite skeptical of patients seeking some form of compensation.
Dr. Clark: I think it’s important to approach patients with the assumption that they would rather be healthy than sick. And, while patients may be seeking disability, workman’s compensation, or pursuing other types of litigation, it’s more likely they have become trapped in a system that is reinforcing the illness rather than that they are simply faking one.
TCPR: Can you explain how that happens?
Dr. Clark: In these cases, the incentives are in conflict. While the patient may want to go back to work and to a productive life, they are actually being paid, or more accurately, being reinforced for remaining in the sick role and exhibiting the behavior of disability. The patient is at the center of a complex web of factors that make it more difficult to become functional and independent. Patients often feel the risk of returning to work is too high—if they fail, the benefits they were receiving for having been injured or unable to work are gone.
TCPR: So you’re saying that secondary gain can play an important part in maintaining the lifestyle of someone who has chronic pain.
Dr. Clark: Not exactly. It is true that illness behavior and disability can be reinforced by a system that does not necessarily have the patient’s best interests at heart. And it can sometimes be the case that the patient is taking advantage of that broken system. But, usually this is not at the level of manipulation or malingering so much as it is a way of life that emerges little by little. Think about it. If I said to you, “Think about how much money you’re making now and all the hassles that you have to put up with to make that money. Or, you could stay at home and get 60% of your income tax free as long as you continue to go to doctors’ appointments to confirm that you’re still sick.” What would you do?
TCPR: That’s a good question, and frankly, I’m not sure what I would do.
Dr. Clark: It comes down to what’s motivating you every day. And as doctors, it’s our job to help patients find a path toward being functional even in the presence of some pain, and even when some of the incentives are aligned against that outcome.
TCPR: I agree, and thanks very much for your time, Dr. Clark.
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