Innovative Management of Psychiatric Comorbidities and Chronic Pain

LAS VEGAS, NV—In a plenary session at PAINWeek 2012, three mental health experts described innovative programs that have been developed to help improve care for patients with chronic pain and psychiatric comorbidities.

Clinical psychologist Kevin Lancer, who treats veterans with chronic pain and psychiatric comorbidities at Malcolm Randall VA Medical Center in Gainesville, FL, outlined the biopsychosocial model he uses. He noted that every patient with chronic pain has at one time or another been told, “It's all in your head.”  One approach has been to provide a biopsychosocial model for treating comorbid psychiatric and physical pain. Pain perception can be affected and analgesia can be induced or learned. An anti-analgesic effect can also be induced by chronic pain.  There is no pain center in the brain, Dr. Lancer said, and patients with chronic pain become practiced and better at perceiving pain. It is a complicated matrix where chronic pain is chronic stress--unpredictable and uncontrollable. Psychological events can have physical results, he added.

Dr. Lancer also described the benefits of the Expert Patient Model, first introduced by Loring in 1993. The patient becomes the expert about his own pain, and is encouraged to take responsibility for his own care. There is also a relationship between the psychological and biological aspects of chronic pain– if the patient has pain, stress, sleep problems, and depression, one improvement can lead to the improvement of the other three areas.

VA patients being treated for chronic pain have two to three times the number of comorbidities as the general population, Dr. Lancer said. He added that an improved version of the VA Chronic Pain Management program has lessened the number of sessions from eight to four, and the time of sessions down to 90 minutes every other week. Such changes have improved patient compliance, and there is now an 80% completion rate.

Dr. Edward S. Lee, an expert in substance abuse and chronic pain at the University of Pittsburgh, Pittsburgh, PA, said that using an integrative approach to patients with chronic pain and comorbidities has improved the success of treatment. This integrative approach includes using substance abuse assessment, acupuncture, and interdisciplinary pain management. He also stressed the widespread use of pain control agents, noting that while Americans make up only 4% of the world population, they consume 80% of the opiates used worldwide.

He reminded the audience that substance abusers can be of any race, class, gender, or religion, and that there is a financial incentive for some to steal or misrepresent their needs for pain control, particularly in the case of drugs like oxycodone.

“If you do start patients on opiates, remember that it is not just a trial approach with using one tool in the patient's care,” he said. He further reminded audience members that sometimes patients get opiates from numerous sources because they don't know it is wrong to do so. Clinicians should be certain to stress to their patients that they should be the only source of the opiates.

To Ngo, PhD, MPH, Health Psychologist at Bedford VA Medical Center, Bedford, MA, outlined a step-care, collaborative program that integrates care of veterans with chronic pain and comorbid disease. Veterans are screened and placed into primary care unless they have a pain level that is >3. For those with greater needs and more serious comorbidities, secondary and tertiary levels of care are available. Using this approach, Dr. Ngo said, 90% of patients can be better served. The step-care approach stresses the importance of treating the whole person and coordinates well with integrative medicine.

Using a collaborative approach has also proved valuable, as has having the  designated care manager physically located in the primary care department. Dr. Ngo developed Bedford's Primary Care Behavioral Health program.

The plenary session was followed by a lively panel discussion with Drs. Lancer, Lee, and Ngo; Dr. Ilene Roebuck acted as moderator.