Mental Health Services Key to Effective Pain Management

Pauline Anderson

May 01, 2018

VANCOUVER, British Columbia — A growing body of evidence suggests that including mental health services in a pain care program significantly improves patient outcomes.

One study showed access to a pain psychologist improves pain outcomes and boosts function and mood.

The results provide concrete evidence of the importance of mental health treatment, lead author, Ajay Wasan, MD, professor of anesthesiology and psychiatry, and vice chair for pain medicine, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pennsylvania, told Medscape Medical News.

"No one has actually looked at real-world data to see if there are benefits of embedding a psychologist in a pain practice, so experts didn't know if there's some added effect on patients with the addition of psychological services," said Wasan.

"This study answers that question, and found that, indeed, there is a true real-world clinical effect of a pain psychologist."

The findings were presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

A "Clear Difference"

The University of Pittsburgh Medical Center Pain Medicine clinical network has two pain psychologists and a psychiatrist on staff who specialize in treating patients with chronic pain who have comorbid mental health issues. 

Physicians may refer patients to these specialists as part of a multimodal treatment plan, following a standardized comprehensive evaluation.

The new study used data from electronic health records and the Collaborative Health Outcomes Information Registry (CHOIR). This system allows clinicians and researchers to track a patient's self-reported pain, and mental and physical health status, over time using the National institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) program.

A total of 412 patients who had accessed a pain psychologist on at least three occasions were compared with 7658 controls matched for age, sex, pain condition, and pain duration who had at least three pain clinic visits but no mental health referral.

The psychologist specializes in pain-focused treatments. These include cognitive-behavioral therapy, acceptance and commitment therapy, relaxation training, coping skills training, and pain education, said Wasan.

Compared with the control group, those seen by a psychologist were more likely to be female, have Medicaid insurance, and to be black or another minority race. In addition, at baseline, they tended to have worse pain, function, and sleep symptoms and more depression and anxiety symptoms.

The data were collected over a 12-month period.

Patients receiving psychological treatment and the controls showed significant improvements in pain, function, and mental health.

"Even the patients who are the most severely impaired by their pain, who have higher pain levels, worse functioning, worse sleep, worse mood, can get better with the right treatments," said Wasan.

Patients were also asked to report how they felt overall on an impression-of-change scale. The psychologist-treated group came out on top (P = .03 vs controls). This was the only measure where patients in the treatment group showed significant improvement and control patients did not.

"There was a clear difference" between the two groups, said Wasan. "The patients who visited a psychologist reported much greater improvement than the control group."

Commenting on this study, Traci Speed, MD, PhD, assistant professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, Maryland, said it "makes an important contribution to the field of chronic pain literature."

Dr Traci Speed

The study is significant, she said, because it suggests chronic pain treatment that includes mental health services leads to better clinical outcomes than does chronic pain treatment alone.  

Speed's own institution has launched a perioperative pain program that includes psychiatrists as well as specialists in pain, physical medicine, and rehabilitation. The program, also highlighted at the AAPM meeting, aims to safely get surgery patients off opioids while effectively managing their pain.

Avoiding Opioid Dependence

Since its inception last June, the program has had more than 100 new patients. Most experience back pain and are scheduled for spine procedures.

Approximately 60% to 80% of back surgery candidates have been receiving opioids for at least a month, which puts them at increased risk for surgical complications, such as respiratory depression, said Speed.

Patients are also referred to the program from general surgery or an ear, nose, and throat specialist. Some have gastrointestinal disorders or had undergone cesarean delivery or plastic surgery.

The program targets patients who are opioid tolerant or are receiving opioid maintenance therapy, for example, methadone or combination buprenorphine and naloxone.

"We're capturing patients before surgery, weaning them off opioids a little bit before surgery, then again trying to work with them to get them off opioids completely," said Speed.

Program organizers also expect to see improved overall outcomes, including fewer hospital readmissions after surgery.

"One of the biggest challenges is patients who are already on chronic opioids whose pain tends to be under-managed both in-hospital after surgery and postoperatively in follow-up," said Speed.

"That's because a lot of specialty providers, including surgeons, don't necessarily know how to properly manage pain for patients who are already on high doses of opioids."

The program also aims to avoid opioid dependence in patients who, for example, have had a major trauma like a gunshot wound or motor vehicle accident, require surgery, and then receive opioid therapy.

While there's extensive literature on how to prevent these opioid-naive patients from becoming dependent, there's little guidance on how to effectively manage pain in patients who are already receiving long-term opioid therapy, said Speed.

The team uses multimodal techniques, she said. After surgery, this may involve alternatives to opioids (eg, acetaminophen, nonsteroidal anti-inflammatory drugs, or ketamine) and different routes of administration (intravenous, epidural, oral).

"We have been able to take patients who have been on chronic opioid therapy for 5 to 10 years and actually wean them off opioids completely, and they still say their pain is managed," said Speed.

The program offers help for patients who have comorbid psychiatric disorders, such as anxiety, depression, or substance use problems, who often have worse outcomes after surgery with regard to pain, said Speed.

A lot of this involves pain-related education, managing expectations, and easing anxiety before surgery, she said.

The investigators, Wasan, and Speed have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstracts 187  and 188. Presented April 27, 2018.

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