Components of Treatment—Psychiatric Pain Consultation Service
Chronic pain is one of the most difficult and least understood of all problems in primary care practice. According to the National Health and Nutrition Examination Survey, chronic regional pain was reported by 11.0% of Americans and widespread pain was reported by 3.6% of Americans. 12 months after traumatic injury, 63% of 3047 subjects still reported pain; most often pain in more than 1 body region.
Unfortunately, physicians often respond to pain complaints by starting patients on opioid hormones. Americans, constituting 4.6% of the world's population, consume 80% of the world's opioid supply and 99% of the world's hydrocodone supply. Prescription of opioids increased 2 ¼ times from 1997 – 2006. According to the National Ambulatory Medical Care Survey opioid prescribing for chronic pain doubled from 1980–2000 to 16% of all patients seen. Prescriptions for more potent opioids; hydrocodone, oxycodone and morphine, given for chronic musculoskeletal pain, increased from 2% of patients to 9% of patients from 1980–2002.
When a hormone is taken daily, the body's natural production of the hormone is suppressed. The brain responds to blanketing of its pain receptors by increasing the number and sensitivity of those receptors. The resulting condition is called "hyperalgesia." Chronic pain patients begin to feel more and more pain. They experience that every pain killer helps, but they often do not notice how pain sensitive they are becoming.
We diagnose hyperalgesia with the Cold Pressor Test; simply the time that a person can tolerate the discomfort of holding their forearm in icewater. 95% of our normal control subjects could hold their arm in the icewater for at least 34 seconds. We find most patients maintained on opioids for pain have times such as 5, 4 or 2 seconds – while on their "pain pills."
The staff of the Psychiatric Pain Consultation Service includes both Psychiatrists and Pain Fellows; physicians who have already completed their resident training in a specialty such as anesthesia or neurology, but who are taking an extra training year to learn how to address chronic pain. Patients who come for evaluation have a careful history, depression and cognitive screens, a physical examination, and a Cold Pressor Test. In many cases we detoxify patients from their opioid medications. Patients are amazed when a week later their pain is already reduced by half. We have a number of treatments for pain that are effective and not addictive. In many cases of patients who have been maintained on opioids for prolonged periods, we will treat persistent hyperalgesia with naltrexone at 1/10 of the usual dose to help their body's own natural opioid system return to normal, healthy functioning. In cases where pain patients have been addicted to opioid pills by their physicians, we will help this subpopulation of pain patients get into a process of recovery from addiction.