CHPR: Dr. Lin, please tell us a little about yourself.

Dr. Lin: I’m an addiction psychiatrist at the University of Michigan, and I direct our addiction psychiatry fellowship program. I also work as a research scientist in the Veterans Healthcare System, and my research focuses on understanding how to improve care for patients with complex substance use disorders (SUDs), including those with comorbid pain.

CHPR: Can you start by telling us where psychiatrists fit in the pain management plan?

Dr. Lin: We might not be the clinicians prescribing pain treatments, but we can educate our patients about the relationship between pain and mental health. We can treat the depression and anxiety that often accompany pain, help diagnose an underlying opioid use disorder (OUD), and advocate for our patients to their other medical professionals, helping those clinicians understand that the patients’ pain and suffering are very real. Close collaboration and communication with pain specialists is essential, because many of our medications help alleviate pain and because mental health symptoms and psychosocial stressors directly contribute to pain.

CHPR: How frequently are pain patients referred to psychiatrists?

Dr. Lin: It’s hard to say because access to psychiatric care is limited in many parts of the country. However, some studies have shown that patients with psychiatric conditions are more likely to have chronic pain conditions, and patients with mental health disorders receive about half of the total opioid prescriptions prescribed in the US (Davis MA et al, J Am Board Fam Med 2017;30(4):407–417).

CHPR: Wow, that’s concerning. When you refer to chronic pain, can you explain how it’s different from acute pain?

Dr. Lin: Acute pain is often defined as pain that lasts three months or less, and chronic pain is pain that persists for three months or longer. With acute pain, we think about injuries, surgery, or even appendicitis—pain you can localize to damage to a specific part of the body. In contrast, with chronic pain, the body’s response to that initial damage has become persistent, and the contributors of the pain can shift from that specific part of the body to things going on in the central nervous system. For example, chronic back pain might arise from degenerative disc disease. But often when pain has become chronic, it’s because many factors have contributed to the pain persisting, including psychosocial factors, depression, and anxiety. In other chronic pain conditions—like fibromyalgia, peripheral neuropathy, chronic headaches—it essentially becomes a multisystem illness, where a person might feel pain but then they also have fatigue, trouble sleeping, and memory difficulties. We’re thinking about chronic pain in a more holistic way than we used to, and that’s why, of all the folks in the health care field, psychiatrists have the skill set to understand such a myriad of causes.

CHPR: With patients who have chronic pain, how do you assess their level of pain?

Dr. Lin: The most important thing to remember is to assess not just the pain severity and location, but really the broad impacts for the patient. Patients are often asked, “What’s your level of pain on a scale of 0 to 10?” But we really need to go beyond that because you can end up with an arbitrary number that’s not very meaningful. There are various standardized instruments for assessing pain, but it can often be helpful to ask patients about their level of functioning. For example, “Tell me about your pain. How does it affect your life, your ability to do the things you want to do?” For clinicians who want to incorporate screening tools into their evaluations, the American Academy of Family Practitioners has a helpful website that lists pain assessment kits: www.tinyurl.com/3xpfu86n.

CHPR: And how do you define effective or successful management of pain? Do you set specific goals with a patient?

Dr. Lin: The key thing is to discuss expectations with the patient. Particularly with chronic pain, the goal is to help patients learn how to live a better life with their pain; the expectation and focus is not that the pain will completely go away, but that we will partner with the patient to help them find ways to reduce the negative impacts of pain and help them regain their lives.

CHPR: What interventions do you start out with?

Dr. Lin: First, I ask, “What are things you do that help the pain?” The goal is to put the ball back in the patient’s court and support them to feel empowered to manage their pain, rather than feeling like they are a victim of the pain. There’s good evidence that several nonpharmacologic approaches help manage chronic pain, such as exercise and physical therapy for back pain; yoga, acupuncture, massage, and mindfulness practices are also helpful (Chou R et al, Ann Intern Med 2017;166(7):493–505) (Editor’s note: See “Non-Opioid Interventions for Chronic Pain” table). Some of the most effective treatments for chronic pain are psychotherapies, like cognitive behavioral therapy for pain (Williams AC et al, Cochrane Database Syst Rev 2020;8(8):CD007407). These treatments help people learn skills and tools to manage their pain long term. And don’t overlook commonsense interventions, like weight loss for certain types of back and knee pain.

CHPR: What about pharmacologic treatments?

Dr. Lin: There are several medications that can be helpful, including in combination with the options I mentioned earlier. These medications include different formulations of nonsteroidal anti-inflammatory drugs (NSAIDs, like topical diclofenac), acetaminophen, SNRIs (like duloxetine), and others (Editor’s note: Cannabinoid-based medications are increasingly used for pain management, but since few high-quality research studies have examined their long-term efficacy and safety, we do not generally recommend them as first-line options; see “Non-Opioid Interventions for Chronic Pain” table). With all medications, make sure to prescribe them at the lowest effective doses and for the shortest duration needed, especially in specific patient populations. For example, be careful with NSAIDs in older patients and in individuals with kidney disease or a history of gastrointestinal bleeding. For neuropathic pain, capsaicin and lidocaine patches can help, or antidepressants, like SNRIs or tricyclic antidepressants (TCAs), or certain anticonvulsants, like gabapentin or pregabalin (Asmar A et al, Current Psychiatry 2022;21(11):47–48). It’s important to individualize treatment for each patient, balancing benefits, potential side effects, and risks such as TCAs increasing the fall risk in older adults.

CHPR: Do antidepressants work for chronic pain for someone who is not depressed?

Dr. Lin: Antidepressants like SNRIs and TCAs can help with pain, even among individuals who do not meet criteria for depression, but they are a particularly good option for individuals with depression or anxiety as well as pain. We know that depression and other mental health conditions affect a patient’s experience of pain—and, vice versa, we also know that pain can exacerbate mental health symptoms (Bair MJ et al, Psychosom Med 2004;66(1):17–22).

CHPR: Do you always start with non-opioid interventions first and only switch to opioids if all other treatment options have been exhausted?

Dr. Lin: For some patients with severe acute pain, such as after a traumatic injury, opioids can be helpful. For patients with chronic pain, the risks of opioids outweigh the benefits. A large randomized controlled trial has shown that opioids are no more effective than acetaminophen or NSAIDs for chronic pain (Krebs EE et al, JAMA 2018;319(9):872–882). Psychiatrists must be particularly vigilant because patients with mental health conditions are more likely to be prescribed opioids and to be given higher doses of opioids (Goesling J et al, Curr Psychiatry Rep 2018;20(2):12).

“Close collaboration and communication with pain specialists is essential, because many of our medications help alleviate pain and because mental health symptoms and psychosocial stressors directly contribute to pain." -Lewei (Allison) Lin, MD, MS

CHPR: Can you give us more details about when you consider opioids for chronic pain?

Dr. Lin: I would reference the updated guidelines the CDC released in November 2022 for opioid and pain management (Dowell D et al, MMWR Recomm Rep 2022;71(3):1–95). They cover how to determine whether to initiate opioids; how to select opioids and decide on the dosages; how to determine the duration of the initial opioid prescription; how to taper opioids when warranted; and how to address the risk and potential harms from opioid use. Although most psychiatrists rarely prescribe opioids, it’s helpful to be aware of these guidelines as we coordinate care with other providers. The guidelines also include recommendations for non-opioid medications, like NSAIDs and acetaminophen, and nonpharmacologic treatments (Editor’s note: For the full guidelines, see www.tinyurl.com/4ekmd4ub).

CHPR: It’s good to hear the guidelines include such a broad range of treatments, considering that opioid treatments are associated with so many risks and side effects.

Dr. Lin: Yes, although on the other hand, in the last 10 years there’s been so much concern about opioids that a lot of clinicians are afraid to treat patients who have chronic pain that does not respond to other interventions. So, one of the key points in the new guidelines is that management of pain needs to be patient-centered, and the benefits and risks of each treatment are individualized to each patient. The lowest effective dose of medications should be used with the goal of helping patients improve functioning. Most importantly, we should avoid mandating rapid tapers of opioids, and we must address the needs of our patients with pain, including patients who are taking opioids.

CHPR: How do you handle psychiatric patients admitted on opioids for chronic pain who report pain exacerbation and request escalating doses?

Dr. Lin: These are some of the patients we should be most concerned about. This group has been impacted by the increased exposure to prescription opioids in our country, and they are at higher risk for overdose. They often report anxiety and depression and may not be aware of an underlying addiction. It’s important to do a thorough assessment to see if the patient has an underlying OUD. I explore DSM-5 symptoms for OUD—how do opioids affect their lives and their relationships? How often do they think about or experience urges to take opioids, and how hard is it to ignore those thoughts or feelings? What happens when they try to cut down their use? Have family members expressed concern about the impact of opioids on the patient’s life? For patients who have been taking prescribed opioids consistently, symptoms of withdrawal and tolerance are often the norm and do not contribute to a diagnosis of an OUD. These questions help differentiate whether the patient is somebody with primarily chronic pain or somebody with an OUD who also has chronic pain. It’s not always easy to differentiate.

CHPR: If a patient is found to meet criteria for an OUD and is switched to buprenorphine or methadone, will these medications also work for the chronic pain?

Dr. Lin: Yes, buprenorphine and methadone can also be used to treat chronic pain.

CHPR: Do you recommend any resources for mental health clinicians who want to learn how to work with complex pain patients?

Dr. Lin: The Provider Clinical Support System (PCSS) is a helpful national resource. It is funded by the Substance Abuse and Mental Health Services Administration and made up of a coalition that is led by the American Academy of Addiction Psychiatry. You can find trainings, webinars, mentoring, and other sources of support (www.pcssnow.org).

CHPR: Thank you for your time, Dr. Lin.

Table
Non-Opioid Interventions for Chronic Pain