Mr Z is a 58-year-old Vietnam veteran who returned from the war relatively unscathed. He began work in a local factory where he was involved in a severe chemical explosion. In the accident, he was thrown over 50 feet and sustained burns over 60% of his body; several of his coworkers were killed. PTSD and spinal pain syndrome developed. He began having nightmares, ran through his house while asleep and at one point sustained further injury by running through a glass door. Afterward, he began sleeping outdoors in a lawn chair or would tie himself to his bed to prevent sleepwalking. He was treated for PTSD by multiple psychiatrists, which included an inpatient hospitalization with no improvement.
On referral to our clinic, we began simultaneous treatment of PTSD, sleep dysfunction, and chronic pain. He was found to be a rapid metabolizer on the cytochrome P-450 2D6 system (based on laboratory and clinical findings, along with medication blood levels) and required what appeared to be large doses of some medications. He was referred for psychotherapy with a psychology associate, and eventually he was stabilized on a regimen of anxiolytics, an SSRI, long-acting opiates for pain, and an anti-insomnia agent.
The PTSD has been in full remission for about 12 months. The patient sleeps 7 to 8 uninterrupted hours per night without nightmares and actively runs his home-based business. He recently began to exhibit deterioration, because his insurance adjuster is attempting to force him to "settle his medicals" (as a cost containment measure); and he is required to travel across the state for a medical examination with an insurance company-approved physiatrist who has no training in psychiatric disorders. His psychologist and our staff are extremely concerned about this conflict, and we are currently working with his attorney to intervene on the patient's behalf.Conclusions
More often than not, chronic pain is accompanied by anxiety- and depressive-spectrum disorders. By treating pain and psychiatric disorders simultaneously, we are able to maximize outcomes. Similarly, a biopsychosocial model of pain that optimizes patient-centered care can improve outcomes. Our group's philosophy of pain medicine practice can be articulated by the 5 principles summarized in the Table.
Governing principles of the pain clinic
|• Comorbid depressive disorders, anxiety disorders, and personality disorders must be detected and appropriately managed for the target pain disorder to be managed effectively|
|• The life issues and the life changes resulting from the injury and pain must be addressed, faced, and dealt with at each visit; this may include pharmacotherapy and/or brief psychotherapy|
|• Activity is encouraged: reentry into the workforce is a major goal; the work does not need to be similar to the work done before the injury|
|• Adjunctive non-narcotic pharmacological agents (eg, neuromodulators, anticonvulsants, and so forth) are used to target specific pain generators and pain-related problems (eg, insomnia); these serve to reduce the dose of opiate analgesic needed to control pain (thus, the concept of "opiate-sparing" agents)|
|• Pain should be managed with the lowest dose of opiate analgesic possible to both effectively control pain and maximize the patient's ability to function and live life to the fullest|