Psychiatry - December 2008 - (Page 24)

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? 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 individuals [manifesting pseudoaddiction] may present with several of the aberrant drug-related behaviors18–20 that are red flags for drug dependence, but in fact represent inadequately controlled 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, 24 Psychiatry 2008 [ V O L U M E 5, NUMBER 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 wellrecognized ADRBs, which may, however, represent pseudoaddiction from inadequately controlled anxiety. It may be safest, as with the pain patient, to prescribe and maximize 12, DECEMBER] 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

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

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