Pain medicine: Why and when to call for the addictionologist and/or psychiatrist

Substance abuse and psychopathology are frequently present in pain patients and often complicate pain treatment. Whereas the pain physician does not necessarily need to possess the tools needed to effectively treat these complicating conditions, it is incumbent on the pain physician to determine their presence and secure appropriate consultation. Aberrant drug behaviors may be present when patients manifest one or more of the following: continued use despite self harm, daily functionality deteriorates, impaired control over use (unable to take medications as prescribed), preoccupation with use of analgesics for non-analgesics purposes, inability to use non-opioid pain interventions, and/or preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). The most common psychopathology is depression and anxiety. The clinical presentation of depression is commonly: persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). Anxiety is somewhat different and the clinical signs are: personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression) or triggered by stressful situation (eg, chronic pain), worry out of proportion about negative results, kinesophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restlessness, and/or fatigue. Depression and anxiety (most commonly Generalized Anxiety Disorder) are most effectively treated by Cognitive Behavioral Therapies in combination with pharmacologic means. Practicing in an interdisciplinary manner, with appropriate specialty consultation, is indicative of a comprehensive pain management program which is associated with the best possible patient results when dealing with patients manifesting comorbid addiction and/or psychopathology conditions.