Psychosomatics 40:226-232, June 1999
© 1999 The Academy of Psychosomatic Medine
Effectiveness of a Psychiatric Pain Clinic
John Anooshian, M.D.,
Jon Streltzer, M.D., and
Deborah Goebert, M.S.
Received May 16, 1998; revised September 8, 1998; accepted August 28, 1998. From the Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu. Address correspondence and reprint requests to Dr. Streltzer, Department of Psychiatry, 1356 Lusitana Street, 4th Floor, Honolulu, HI 96813; e-mail: StreltzerJ{at}JABSOM.Biomed.Hawaii.Edu
|
ABSTRACT
|
Medical charts were reviewed for 101 consecutive outpatients seen between January 1, 1993 and July 1, 1996 at a unidisciplinary, psychiatric pain clinic, which exists within a hospital-based, university-run, outpatient service with primary and specialty care clinics. Mean duration of pain was 7 years. Multiple sites of pain were present in 69% of patients. Eighty-eight percent fulfilled DSM-IV criteria for pain disorder. The patients had significantly fewer medical visits and diagnostic tests 6 months after attending the pain clinic, compared with 6 months before (P<0.0001). Interventions frequently included detoxification and reduction and substitution of medication, and always included psychotherapeutic approaches, particularly support and suggestions.
Key Words: Pain • Chronic Pain • Pain Clinics
|
INTRODUCTION
|
Chronic pain is one of the most burdensome medical conditions in terms of social and economic costs.1 It is the most common reason for inability to work in adults between 25 and 64 years of age.2 Chronic pain frequently outlasts the recognized natural pain stimulus, so that the pain becomes dissociated from many of the physiological evidences of nociception.3–5 The patient with chronic pain commonly presents symptoms grossly disproportionate to objective findings from the history, physical examination, and diagnostic tests. Psychobehavioral symptomatology may be prominent with personality, mood, and functional capacity substantially altered.4–6 Because chronic pain is notoriously difficult to manage, specialized pain treatment centers have arisen to address this problem.7,8
Currently, there are about 2,000 pain treatment facilities in the United States. These centers differ in their staff makeup, size, philosophy, and treatment approach to chronic pain patients.8 The majority of these facilities are multidisciplinary pain centers (MPCs), consisting of physicians in various specialties such as anesthesiology, neurology, neurosurgery, physical medicine, and orthopedic surgery, as well as psychiatry. Other health professionals, such as dentists, nurses, psychologists, social workers, physical and occupational therapists, and vocational and rehabilitation counselors, are often included. These MPCs are purported to have the advantage of being comprehensive in nature.7,9–11
In general, most reports support the efficacy of MPCs and pain clinic programs. Concerns have been raised, however, about issues such as referral patterns to pain clinics, failure to enter treatment, attrition rates, and cost-effectiveness.11–13
In contrast to MPCs, pain clinics run by individual departments such as anesthesiology, neurology, internal medicine, and rehabilitation medicine may not be interdisciplinary, or only minimally so. Pain clinics are not often run by psychiatry departments, despite the fact that pain clinics have been criticized for their tendency to minimize the physiological origins of the pain and their emphasis upon psychiatric disorders.7 However, the literature overwhelmingly supports the notion that patients with chronic pain also have a wide range of comorbid psychiatric conditions, including depression, drug dependence, anxiety, somatization, and others.3,14–17 These psychological factors clearly influence pain perception, making the diagnosis of the cause of the pain particularly problematic.
Typically, in pain clinic populations the prevalence of depression and other psychiatric disorders ranges from 40% to 100%.18–20 Estimates of prescription drug dependency range from 3.2% to 37%.14,21,22 Psychiatric comorbidity is likely to be higher for pain clinic samples, in contrast to untreated community samples of people with pain.23–27 Neither medical factors (e.g., duration and location of pain) nor socioeconomic factors distinguish clinic from community pain samples; the difference has to do with impairment in functioning and psychological difficulties.21,25,28 This finding suggests that psychological factors are, indeed, critical in pain clinic populations.
Since it has been demonstrated that psychological factors distinguish pain clinic patients from community samples, a psychiatry pain clinic may offer significant advantages in the evaluation and treatment of these patients. This report evaluates the experience of a unidisciplinary, psychiatric pain clinic in a primary care setting.
|
METHODS
|
Setting
Medical charts were reviewed for 101 consecutive outpatients seen between January 1, 1993 and July 1, 1996 at a unidisciplinary, psychiatric pain clinic, which exists within a hospital-based, university-run, outpatient service with primary and specialty care clinics.
The outpatient service treats a multiethnic, indigent population, most of whom receive public assistance. The population tends to be stable; it is difficult for a patient to switch to another medical provider unless he/she moves or obtains private medical insurance.
All patients are required to attend a primary care clinic, from which they may be referred to specialty clinics. Criteria for referral to the pain clinic included suspicion of psychological factors or difficulty in medication management. The pain clinic served a consultation function to the primary care clinic, but also followed up with patients when deemed clinically necessary.
The pain clinic met once weekly and was staffed by one board-certified psychiatrist (JS) and one rotating psychiatry resident, as well as nurses from the primary care clinic. The background of the psychiatrist included extensive experience in consultation-liaison and an interest in pain disorders. Evaluation visits were scheduled for 1 hour and follow-up visits for 30 minutes. Interviews focused upon the patients' complaint of pain and the accompanying issues, emphasizing psychosocial factors and medication usage.
Procedures
Demographic, intervention, and outcome data were gathered through a systematic review of the patient's entire medical record. Outcome measures included frequency of medical visits and tests, medication use, and subjective outcome reports. Pain was qualified into three categories (improvement, no change, and worsening) at follow-up, based on comments in the charts that included patient report and physician observations. Pain disorder diagnoses were verified by using DSM-III-R and DSM-IV criteria.
Analyses
Descriptive statistics were used to determine frequency, distribution, and variances. Cross-classified, categorical data analyses, such as relative risk and chi-squared tests, were used to compare groups. Paired t-tests were used to assess changes in outcomes.
|
RESULTS
|
Sample Characteristics
The demographic characteristics of the 101 subjects are presented in Table 1. Ethnic distribution varied from the general clinic population, with an overrepresentation of Caucasians. Men and middle-aged patients were also overrepresented.
Reasons for referral and findings of the pain clinic are presented in Table 2. The referring physician was more than twice as likely to identify intractable pain as the major problem, whereas the pain clinic psychiatrist was three times more likely to identify medication dependence and nearly 1.5 times more likely to identify comorbid psychiatric conditions.
The pain characteristics are presented in Table 3. The duration of pain lasted an average of 7 years (range: 1 month–35 years).
DSM Criteria for Pain Disorder
As seen in Figure 1, half the subjects met DSM-III-R criteria for a somatoform pain disorder diagnosis, and 88% met DSM-IV criteria for pain disorder associated with psychological factors.
Interventions
All patients referred had some type or another of prior treatment. Forty-six (45.5%) had surgery, 26 (25.7%) had physical therapy, 9 (8.9%) had been to a chiropractor, 10 (9.9%) had used a TENS (transcutaneous electrical nerve stimulation) unit, 3 (3.0%) had psychotherapy, and 3 (3.0%) had massage. The most common prior treatment was with medications. All 101 (100%) patients had been treated with some type of medication for pain. Seventy-four (73.3%) had been on NSAIDs (nonsteroidal anti-inflammatory drugs); 77 (76.2%) had been on narcotics; 62 (61.4%) had been treated with antidepressants; 31 (30.7%) had been on benzodiazepines; 22 (21.8%) were on muscle relaxants (cyclobenzaprine, carisoprodol); 12 (11.9%) were on antihistamines; 11 (10.9%) were on tramadol; 9 (8.9%) were on anticonvulsants (carbamazepine, valproate, phenytoin); and 4 (4.0%) were on neuroleptics.
Sixty-six patients were seen for only one consultation in the pain clinic. The rest had from 2 to 20 visits. Only seven patients did not keep their follow-up appointments. New referrals from pain clinic to other specialty clinics included 13 (12.9%) to psychiatry, 5 (5.0%) to orthopedics, 2 (2.0%) to neurology, and 1 (1.0%) to physical therapy.
For 55 (54.5%) patients, narcotics and/or benzodiazepines were discontinued either immediately or gradually by detoxification. For five patients, ongoing narcotic usage was allowed since they did not use daily. One patient who had cancer with poor prognosis was maintained on narcotics daily.
There was no difference in the prescribing frequency of NSAIDs or antidepressants upon comparison of the primary care clinic/orthopedic clinic to the pain clinic psychiatrists. However, the types, doses, and schedules of the medications frequently changed.
Outcomes
As shown in Figure 2, there was highly significant reduction in the number of medical tests ordered and medical visits after the final visit to the pain clinic, compared with 6 months prior to the initial pain clinic consultation.
Forty-five (44.6%) patients reported that their pain had decreased after pain clinic intervention, 38 (37.6%) described their pain as the same, 9 (8.9%) stated it was worse, and 8 (7.9%) had no report. Physicians documented improvement in 56 (55.4%) patients, no change in 34 (33.7%) patients, worsening in 1 (1.0%) patient, and no report for 9 (8.9%) patients.
|
Case Examples
|
Case 1: Mr. A was a 52-year-old, divorced, Caucasian, unemployed, wheelchair-bound fisherman and construction worker, who was referred for chronic pain complaints from bilateral hip avascular necrosis. He also had a past history of low back surgery on two occasions, four-vessel coronary artery bypass surgery, and a substantial substance abuse history, including alcohol and heroin. For many years, he had been treated with multiple medications, including morphine, hydromorphone, methadone, diazepam, and corticosteroids, for constant complaints of severe pain and the desire for even more medications. Pain clinic interventions included tapering off narcotics via methadone; tapering off benzodiazepines; and using NSAIDs, acetaminophen, perphenazine, and other nondependency-producing medications prn for pain complaints, as well as providing psychological support. The patient always asked for stronger medication at each visit. Instead, he was given reassurance and support and given a new, benign medication in doses unlikely to produce adverse effects. Narcotics were successfully eliminated, and the patient received his second hip operation. He was vigorously treated postoperatively with narcotics but was referred back to the pain clinic because of ongoing demands for more narcotics as an outpatient. He was again firmly managed and successfully weaned off all narcotics. He became able to walk and returned to independent living, drug free.
Case 2: Mr. B was a 42-year-old, married, Caucasian tile-setter. Two years before, he sustained an ankle injury, followed by chronic pain, although he remained physically active. He controlled his pain with 5–6 oxycodone-plus-acetaminophen tablets per day. He denied any history of illicit substance use other than marijuana. His primary care physician became concerned about the chronicity of the pain requiring continuing narcotics, and the doctor referred the patient to the pain clinic.
Mr. B was told that the narcotics were probably maintaining or enhancing his pain sensitivity.22,29–31 He was given codeine in a fixed, tapering dose over 2 weeks and placed on acetaminophen and ibuprofen as needed for pain. At follow-up, Mr. B acknowledged that his pain had lessened since stopping narcotics, but he was experiencing some craving for the feeling the narcotics would give him. He remained active and resumed employment.
|
DISCUSSION
|
A striking finding was the disproportionate number of Caucasians seen in the pain clinic, compared with the primary care clinic. This finding may be related to cultural differences, in which Caucasians have been reported to be more expressive and perhaps less stoic about symptoms than Asians and Pacific Islanders.32 Prior studies in a similar ethnic population also demonstrated that Caucasians received more medication for acute pain,33 and also had a higher frequency of treatment for heroin abuse.34
Only 25% of the patients had reported receiving physical therapy, a striking contrast with a study of injured workers seeking compensation, in which 80% had been so treated.35
This finding may be attributable to the lack of availability of physical therapy to these unemployed patients on public assistance. It is unclear, however, whether physical therapy would have been beneficial to these patients.
The most common reason for referral was for intractable pain unresponsive to treatment. In contrast, pain clinic psychiatrists found 9 out of every 10 patients had psychological factors involved in their pain to a clinically significant degree, thus allowing for new treatment options focusing on these issues for those patients. Medication dependence was frequently noted by the referring physician, and was even more frequently found by the pain clinic. On occasion the pain clinic found no particular psychological issues influencing the pain problem, but this was rare. These findings support the conclusion that psychological factors contribute in a major way to difficult chronic pain problems.
The mean duration of pain of 7 years documents the chronicity of the population studied. These patients often experienced many different medication trials, but their pain never ceased. Some had prior surgery that either did not help or left them with more severe pain that did not resolve. Pain sites tended to be multiple and frequently spread beyond the original site of pain. However, compared with a study of injured workers seeking compensation, this indigent population had fewer pain sites and less spreading of pain.35
Only 50% of the patients met criteria of a pain disorder, according to DSM-III-R criteria, whereas 88% had psychological factors involved in their pain, according to DSM-IV criteria. This finding demonstrates that the DSM-IV criteria are substantially broader than DSM-III-R.
Most interventions could be categorized into two areas: 1) medication management and 2) psychological support and suggestion. Medication management frequently involved the elimination of narcotics and other dependency-producing drugs. Although some have suggested that narcotics are useful for chronic benign pain,36–37 our experience is to the contrary, and furthermore, patients seem to develop increasing pain sensitivity as a result of chronic narcotic use.22,31 Also, many such patients have prominent psychological factors contributing to their pain, and narcotics exacerbate these factors. Patients were not counseled about potential addiction, but rather about the ineffectiveness of narcotics, and the probable worsening of their chronic pain. Other medications, such as antidepressants or neuroleptics, were used in low doses, primarily for lack of harmful effects, and secondarily to help with sleep or anxiety.
Most patients showed improvement when dependency-producing drugs were eliminated, according to self-report, and even greater improvement was recorded by their physicians. The reduction in visits and tests provide further evidence for improvement. Some patients were extremely resistant to reducing narcotics at all, but this was usually accomplished by firm management, and these patients' then diminished their dependency on the outpatient clinic for medical care. They could not easily obtain prescriptions from other sources, although in a few cases this did occur.
While the majority received medication management, all patients received psychological interventions. These consisted of listening to the patient, attempting to understand his/her pain experience in the larger context of his/her life situation, giving positive or paradoxical suggestions (depending on the patient's personality), encouragement, simple instructions for exercise, and, at times, brief cognitive–behavioral therapies aimed at restructuring the patients' view of his/her situation and pain. Only a few patients were referred for other services.
Study Limitations
This descriptive study was limited by its naturalistic methodology and the information contained in the medical charts. There were many different referring physicians who varied in their approaches to the patient and in their documentation. No standardized measurement of pain was used, although this was not the focus of the study. Because the pain clinic was run by a psychiatrist, referrals consisted of patients likely to have psychological factors, rather than specific syndromes that might benefit from an anesthetic block or other such intervention. In many respects, however, these patients resembled the frustrating, unresponsive, chronic pain patients typically reported.
|
CONCLUSIONS
|
In a primary care setting, patients with chronic pain frequently have associated psychological factors influencing pain perception and behavior. Medication dependence, particularly on narcotics and benzodiazepines, is common and often causes or exacerbates the chronic pain problems. Managing the medication dependence and treating the psychological factors associated with chronic pain can be achieved in a cost-effective manner through a unidisciplinary, psychiatric pain consultation clinic.
|
ACKNOWLEDGMENTS
|
The work for this paper was done while Dr. Anooshian was a psychiatry resident, John A. Burns School of Medicine, University of Hawaii, Honolulu.
This paper was presented, in part, at the American Psychiatric Association Annual Meeting, San Diego, California, May 17–22, 1997.
|
REFERENCES
|
-
Bonica JJ: Introduction, in Evaluation and Treatment of Chronic Pain, 2nd Edition, edited by Aronoff G. Baltimore, MD, Williams & Wilkins, 1992, pp. xx–xxviii
-
Kelsey JI, White AA, Pastides H, et al: The impact of musculo-skeletal disorders on the population of the J Bone Joint Surg Am 1979; 61A:595–693
-
Fishbain DA, Goldberg M, Meagher BR, et al: Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain 1986; 26:181–197[Medline]
-
Bonica JJ: History of pain concepts and therapies, in Management of Pain, edited by Bonica JJ. Philadelphia, PA, Lea & Febiger, 1990, pp. 2–17
-
Mailis A, Papagapiou M: Profile of patients admitted to the Pain facility of a university-affiliated acute care hospital. The Pain Clinic 1993; 6:71–82
-
Kinney WW, Brin EN: Diagnostic evaluation and management of the patient with chronic pain, in Evaluation and Treatment of Chronic Pain, 2nd Edition, edited by Aronoff G. Baltimore, MD, Williams & Wilkins, 1992, pp. 26–55
-
Sullivan M: Psychosomatic clinic or pain clinic—which is more viable? Gen Hosp Psychiatry 1993; 5:375–380
-
Fishbain D, Rosomoff HL: Types of pain treatment facilities and referral selection criteria. Arch Fam Med 1995; 4:58–66[Abstract/Free Full Text]
-
Aronoff GM, McAlary PW: Pain centers: treatment for intractable suffering and disability resulting from chronic pain, in Evaluation and Treatment of Chronic Pain, 2nd Edition, edited by Aronoff G. Baltimore, MD, Williams & Wilkins, 1992, pp. 416–429
-
Cohen MJM: The pain center: centerpiece of comprehensive medicine, in Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal, Progress in Pain Research and Management, Vol 7, edited by Cohen MJM, Campbell JN. Seattle, WA, JASP Press, 1996, pp. 125–141
-
Turk DC: Efficacy of multidisciplinary pain centers in the treatment of chronic pain, in Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal, Progress in Pain Research and Management, Vol 7, edited by Cohen MJM, Campbell JN. Seattle, WA, JASP Press, 1996, pp. 257–273
-
Federico JV: The cost of pain centers: where is the return? in Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal, Progress in Pain Research and Management, Vol 7, edited by Cohen MJM, Campbell JN. Seattle, WA, JASP Press, 1996, pp. 249–256
-
Turk D, Rudy T: Neglected factors in chronic pain treatment outcome studies—referral patterns, failure to enter treatment, and attrition. Pain 1990:43:7–25
-
Fishbain DA, Steele-Rosomoff R: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 1992; 8:77–85[Medline]
-
Rafii A, Haller DL, Poklis A: Incidence of recreational drug use among chronic pain clinic patients (abstract A249). Published in Program and Abstracts of the Ninth Annual Scientific Meeting of the American Pain Society, St. Louis, MO, October 25–28, 1990
-
Berndt S, Maser C, Schiitz HW: Polymedication and medication compliance in patients with chronic non-malignant pain. Pain 1993; 52:331–339[Medline]
-
Jong AW: Ethical issues in pain management, in Evaluation and Treatment of Chronic Pain, 2nd Edition, edited by Aronoff G. Baltimore, MD, Williams & Wilkins, 1992, pp. 499–506
-
Turk DC: Pain and depression. Pain Management 1987; 1:17–26
-
Turkingron RW: Depression masquerading as diabetic neuropathy. JAMA 1980; 243:1147–1150
-
Reich J, Tupen JP: Psychiatric diagnosis of chronic pain patients. Am J Psychiatry 1983; 140:1495–1498
-
Portenoy RK, Kanner RM: Patterns of analgesic prescription and consumption in a university-affiliated community hospital. Arch Intern Med 1985; 145:439–441[Abstract/Free Full Text]
-
Turner JA, Calsyn DA, Fordyce WE, et al: Drug utilization patterns in chronic pain patients. Pain 1982; 12:357–363[Medline]
-
King SA, Strain JJ: The problem of psychiatric diagnosis for the pain patient in the general hospital. Clin J Pain 1989; 5:329–335[Medline]
-
Crook J: Epidemiologic comparison of persistent pain sufferers in a specialty pain clinic and in the community. Arch Phys Med Rehabilit 1986; 67:451–455
-
Crook J, Weir R, Tunks E: An epidemiological follow-up survey of persistent pain sufferers in a group family practice and specialty pain clinic. Pain 1989; 36:49–61[Medline]
-
Pilowsky I, Chapman CR: Pain, depression, and illness behavior in a pain clinic population. Pain 1977; 4:183–192[Medline]
-
Chapman CR: Illness behavior and depression in pain center and private pain practice patients. Pain 1986; 27:1–43[Medline]
-
Zitman FG: Chronic pain beyond patienthood. J Nerv Ment Dis 1992; 180:97–100[Medline]
-
Streltzer J: Chronic pain, in Biopsychosocial Approaches in Primary Care: State of the Art and Challenges for the 21st Century, edited by Leigh H. New York, Plenum, 1997, pp. 81–91
-
Stinus L, Allard M, Gold L, et al: Changes in CNS neuropeptide FF-like material, pain sensitivity, and opiate dependence following chronic morphine treatment. Peptides 1995; 16:1235–1241
-
Basbaum AI: Memories of pain. Science and Medicine 1996; 3:22–31
-
Streltzer J: Pain, in Culture and Psychopathology, edited by Tseng WS, Streltzer J. New York, Brunner/Mazel, 1997, pp. 87–100
-
Streltzer J, Wade TC: The influence of cultural group on the undertreatment of postoperative pain. Psychosom Med 1981; 43:397–403[Abstract/Free Full Text]
-
Streltzer J, Molarte A, Severson L: Heroin addiction and its treatment in Hawaii: a cross-cultural perspective. Hawaii Medical Journal 1980; 39:251–253[Medline]
-
Streltzer J, Eliashof BA, Kline AE: Associated features of somatoform pain disorder (abstract). Psychosom Med 1995; 57:92
-
Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986; 25:171–186 [Medline]
-
Brownlee S, Schrof J: The quality of mercy. U.S. News and World Report, March 17, 1997, pp. 54–60
This article has been cited by other articles:
|
|
|
|
 
J. STRELTZER, C.R. SULLIVAN, and B. JOHNSON
Addiction Versus Dependence in Pain Management
Am J Psychiatry,
November 1, 2006;
163(11):
2016 - 2016.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Streltzer and L. Johansen
Drs. Streltzer and Johansen Reply
Am J Psychiatry,
July 1, 2006;
163(7):
1299 - 1300.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Streltzer and L. Johansen
Prescription Drug Dependence and Evolving Beliefs About Chronic Pain Management
Am J Psychiatry,
April 1, 2006;
163(4):
594 - 598.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Leo, C. A. Pristach, and J. Streltzer
Incorporating Pain Management Training Into the Psychiatry Residency Curriculum
Acad Psychiatry,
March 1, 2003;
27(1):
1 - 11.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
The Psychiatric Pain Clinic: It Works!
Journal Watch Women's Health,
June 1, 1999;
1999(601):
4 - 4.
[Full Text]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 1999
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
