Psychiatry - December 2008 - (Page 22)

TABLE 1. Ten steps of universal precautions in pain medicine 1. 2. 3. 4. 5. 6. 7. 8. Make a diagnosis with appropriate differential. Perform a psychological assessment including risk of addictive disorders. Obtain informed consent Obtain a treatment agreement (also called a medication contract). Perform pre- and postintervention assessment of pain level and function. Initiate appropriate trial of opioid therapy ± adjunctive medication. Reassess pain score and level of function. Regularly assess the “four A’s” of pain medicine: a. Analgesia b. Activity c. Adverse effects d. Aberrant behavior (Affect was later proposed as a fifth “A”). 9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders. 10. Maintain complete documentation. Adapted from Gourley DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Medicine. 2005;6(2):107–112. 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 22 Psychiatry 2008 [ V O L U M E 5, NUMBER 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 12, DECEMBER] 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

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.