What I Wish I Knew: Pain Management in the Psychiatric Setting

Dr. Gasper spent the first half of his career at the San Francisco Department of Public Health (SFDPH) developing and implementing programs for the treatment of opioid addiction with office-based treatments such as buprenorphine in both mental health and primary care settings. Since leaving SFDPH he has continued to expand buprenorphine and methadone maintenance access into rural areas of California. In addition to statewide policy work for the Department of Health Care Services he is a consultant for the UCSF Substance Use Disorder Warmline which provides real time consultation for primary care providers throughout the country https://nccc.ucsf.edu/clinician-consultation/substance-use-management/.

How do you manage a patient’s pain in the psychiatric setting?

Early on in the opioid epidemic, when opioids were liberally prescribed, I would see psychiatric patients with poorly treated pain often using prescription opioids as blunt instruments to manage mood and anxiety symptoms. The result was ineffective pain management, untreated mental illness, and unsafe opioid use. It was evident to me that continuing to treat physical and emotional suffering separately was futile. Fortunately, in mental health settings, pharmacists already have well established relationships with patients so it was not out of place to ask about their pain concerns which were directly impacting their mental health. Additionally, I have found it is actually much easier on the mental health side because we are not typically involved in prescribing opioids. This allows us to advocate on behalf of our patients and monitor progress without struggling over refills and dose changes. In a supportive role we can often provide more frequent follow-up and closer monitoring for patients on high doses of opioids or risky drug combinations. Maybe most important of all, as pharmacists we can select psychiatric medications which benefit both the pain condition and mental illness at the same time. This reduces polypharmacy and overall medication burden.

What are some best practices for treating comorbid pain and opioid addiction?

Addressing chronic pain during active opioid use is challenging and can be dangerous if patients are given ongoing access to prescription opioids or worse yet if they are buying heroin/fentanyl or pills on the street. The immediate threat of opioid addiction has to be addressed. I often tell patients that my primary job is to keep them alive which is why we start with stabilizing their opioid use disorder with opioid agonist treatment before addressing their pain concerns. A common myth for patients being started on buprenorphine or methadone is that these medications will not address their pain. It is important for them to know that at least initially, our goal is not analgesia, but to treat withdrawal symptoms and decrease their cravings. Once these symptoms are stabilized a clearer picture of the pain condition emerges. Moving away from the cycle of intoxication and withdrawal often reduces the intensity of pain. Buprenorphine may uniquely reverse hyperalgesia from opioids (Silverman SM. Pain Physician 2009;12:679-684, Koppert W et al. Pain 2005;118:15-22). In almost all cases split dosing of these drugs should be used to capitalize on the shorter duration of pain relief. With time, patients’ concerns about opioid agonist treatment not working fade as they return to work, re-establish relationships, and increasingly focus outside their physical body.

What are some key steps in managing pain for patients with active substance use or a history of a substance use disorder?

Patients with pain and comorbid substance use disorders have been mistreated by our health care system and in many cases they have been outright fired by doctors and denied medications, surgeries, or other appropriate interventions simply because of their substance use. We must change this narrative and address their pain concerns with empathy and understanding. For patients with acute pain, the appropriate use of all forms of analgesia, including opioids, should be considered. For those on opioid agonist treatment, opioid antagonists, or with a high level of opioid tolerance, higher doses and non-opioid adjuncts such as regional anesthesia or ketamine may be needed.

For chronic pain, the repeated cycle of self-medication with drugs or alcohol makes it difficult to separate pain relief from intoxication. Patients may even be frustrated with medications or interventions which do not have sedative or euphoric properties. Explaining the relationship and concurrently treating the underlying substance use disorder can begin to erode the association. Appropriate evidenced based treatments for the pain condition can and should be employed regardless of substance use history.