Behavioral and Psychopharmacologic Pain Management
Pain has been defined as "an unpleasant experience which we primarily associate with tissue damage or describe in terms of such damage, or both."1 Recognition of its importance as an acute signal of impending physical danger led to pain’s being denoted as "the fifth vital sign."2 That physicians need to improve their management of both acute and chronic pain was a clear message of the recent Institute of Medicine (IOM) report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.3 This handbook offers a remedy to the knowledge deficits of physicians in all specialties by providing an understanding of the basis of the pain experience as well as offering data about pain management. For the psychiatric physician, it is essential reading!
Pain has both physical and psychological components, and psychiatrists, whatever their work setting, must have a working knowledge of pain management in order to properly diagnose and treat pain problems. Unfortunately, most psychiatric residency training programs provide minimal training in pain management, and only about 50 psychiatrists are formally board-certified in pain management.4 Therefore, as a specialty of medicine, Psychiatry, as well as other specialties, needs to improve in this area. This important volume will aid in closing the knowledge gap. The list of contributors is basically a "Who’s Who" of pain management, representing a variety of disciplines including anesthesia, gynecology, internal medicine, psychiatry, psychology, and neurology.
The book is divided into 5 sections. The initial section, The Basis of Pain Management, covers the process of pain management but also offers a biopsychosocial model that provides an excellent framework for understanding chronic pain. Both learning theory and sociocultural factors are discussed in a clear and succinct manner. The significance of negative belief systems in chronic pain patients is discussed. Such ideas can foster a sense of passivity and lack of self-efficacy and lead to cognitive errors and catastrophic thinking.
The second section reviews the assessment of pain from various perspectives. An excellent chapter considers comorbid psychiatric disorders such as substance abuse, depression and anxiety, posttraumatic stress disorder, and somatoform disorders that contribute to pain symptoms and make management more complex. The chapter on psychometric assessment of pain is very helpful in reviewing the role of pain in commonly used inventories that focus on depression, anxiety, and basic functioning. This chapter should be read and understood by all psychiatric residents, who certainly learn about such psychometric inventories but often do not utilize them in clinical practice.
Section 3 focuses on both biological and psychotherapeutic interventions. A chapter setting forth the principles for prescribing medication in chronic pain will enable the clinician to prioritize both the risks and benefits of various classes of medications. The clinical strategies for using such pharmacologic interventions are then outlined. The companion chapter is also essential reading for all physicians who prescribe opioid therapy or see patients who are using these medications. It includes samples of patient consent forms and agreement arrangements that pertain to opioid therapy. Other contributions in this section include chapters on various behavioral therapies including cognitive-behavioral strategies as well as couples and family paradigms. A review of combining medication and psychotherapy is the final chapter in this section and serves as an excellent summary.
Section 4 reviews specific diseases in which pain is a common and central issue, such as arthritis pain, neuropathic pain, and headache, and pain in oncologic, geriatric, and adolescent populations. The book concludes with a section discussing practice disparities, policy issues, and future research questions.
Tables and figures throughout the book enhance its value as a reference for any clinician, and it is reasonably priced for a large and comprehensive review of the area. This volume would be my choice to utilize as a text for a seminar on pain. Drs Ebert and Kerns have done our profession a great service by developing such a textbook, and it is my hope that pain seminars become more common in residencies both in psychiatry and in other fields. Improved education might eliminate the disparity noted in the IOM report between the need for pain management and the failure by the medical profession to provide it in an evidence-based, compassionate manner.
References
1. Merskey H. Psychiatry and chronic pain. Can J Psychiatry. 1989;34(4):329-336. PubMed
2. Casey G. Pain—the fifth vital sign. Nurs N Z. 2011;17(5):24-29. PubMed
3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies of Science; 2011.
4. Leo RJ, Pristach CA, Streltzer J. Incorporating pain management training into the psychiatry residency curriculum. Acad Psychiatry. 2003;27(1):1-11. PubMed doi:10.1176/appi.ap.27.1.1
Author affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland. Potential conflicts of interest: None reported.
doi:10.4088/JCP.12bk07701
© Copyright 2012 Physicians Postgraduate Press, Inc.
