Readers of this column are well aware that I am a vociferous advocate of more involvement by psychiatrists in the field of pain management. But I often feel that I am swimming against a tide of organized psychiatry.
There is continuing research that makes me still believe that I am right—and that those who view pain management as fitting far better under the purview of other specialties, most notably anesthesiology, are mistaken.
One of the things that makes me believe my view is correct is the growing literature on the association between pain and suicide. With increases in prescriptions for opioid analgesics, the rise in lethal overdoses and in suicides is probably not coincidental. The FDA reported that from 2000 to 2009, the number of prescriptions for opioids filled at outpatient pharmacies went from 175 million to over 250 million.1According to the CDC, from 1999 to 2010, the number of people dying from overdoses of opioid analgesics in the United States annually jumped from a little over 4000 to more than 16,500.2 (During this period, the deaths related to cocaine overdose declined and those related to heroin overdose remained about the same.) In the same period, the suicide rate of American adults aged 35 to 64 rose by almost 30%—the increase in availability of prescription opioids may be one of the factors involved in this increase.3
Drug overdose is the most common method of suicide attempts and of completed suicide in women (in men, firearms and suffocation/hanging are more common). In most cases of overdose deaths, we have no way of knowing with any degree of certainty whether they were accidental deaths or intentional suicides. Many who survive after taking overdoses are unable to aid us in elucidating reasons for the overdose. Patients may be so frustrated that they are willing to take potentially lethal doses to relieve their pain; some may feel that they would be better off dead unless the pain is alleviated. Opioids have sedative effects and can impair thought processes, so individuals who overdose may not be clear about why they overdosed.
Adding to this mix is the well-known association between chronic pain and depression and between both of these and suicide.4 That depression is a major risk factor for suicide is no surprise. However, chronic pain, is also associated with an increase in suicidal thoughts and attempts. At least one study has found that severe pain is a predictor for suicide.5 A history of substance abuse also increases the risk for future abuse of prescription opioids and for suicide.
Opioid analgesics are well recognized as depressants, so while their use can provide marked relief of pain and thereby reduce comorbid depression, they can also exacerbate or even precipitate depression. Weighing the mental health risks and benefits of these drugs can be, to say the least, quite difficult and requires trained caregivers. Physicians who prescribe opioids for chronic pain but fail to evaluate the mental health of their patients are not providing anything close to optimal care.
SNRIs and antiepileptic drugs (AEDs) are excellent analgesics for many forms of pain. These often provide far more analgesia than opioids, NSAIDs, or acetaminophen—all considered to be the primary analgesics—for neuropathic pain and fibromyalgia. Antidepressants have a black box warning because of increased risk of suicidal ideation and behavior in children, adolescents, and young adults.
A recent review of suicidality highlighted that AEDs, too, can carry a risk for suicidal ideation and suicidal attempts. Although the literature on this effect among patients with chronic pain who are taking these medications is limited, the researchers conclude that “in deciding whether to initiate or continue AED treatment in chronic pain patients, especially those with risk factors for suicidality (beyond the increase risk conferred by having chronic pain), careful evaluation is necessary to determine whether treatment benefits outweigh risks.”6(p348)
To be practical, many, if not most, non-psychiatrists (apart perhaps from primary care physicians, especially those who practice where there is a dearth of mental health professionals) feel that evaluating patients for suicide risk is beyond them. All of this leaves us with a significant patient population with a mixture of pain, depression, use of medications with abuse potential, and/or increased risk of suicide attempts and suicidal ideation. Other than treating pain, most non-psychiatrists do not have the training or the interest in evaluating and treating patients who have these problems—psychiatrists are best able to address these problems.
We can either train non-psychiatrists to be experts in recognizing and evaluating mental health problems or train psychiatrists to be experts in managing pain. Because psychiatrists are already experienced in using many of the most common analgesic medications and psychotherapeutic interventions that have been demonstrated to be effective for the management of pain, I think that the answer is obvious.
Dr King is in private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at the New York University School of Medicine, New York.
1. Governale L. Outpatient prescription opioid utilization in the US, years 2000-2009. July 22, 2010. http://www.fda.gov/downloads/AdvisoryCommitteesMeetingMaterials/Drugs/AnestheticandLifeSupportDrugsAdvisoryCommittee/ucm220950.pdf. Accessed May 20, 2013.
2. Centers for Disease Control and Prevention. Primary Care and Public Health Initiative. Balancing pain management and prescription opioid abuse: educational module. October 24, 2012. http://www.cdc.gov/primarycare/materials/opoidabuse. Accessed May 20, 2013.
3. Centers for Disease Control and Prevention. Suicide among adults aged 35-64—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:321-325.
4. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163:2433-2445.
5. Ilgen MA, Zivin K, Austin KL, et al. Severe pain predicts greater likelihood of subsequent suicide. Suicide Life Threat Behav. 2010;40:597-608.
6. Pereira A, Gitlin MJ, Gross RA, et al. Suicidality associated with antiepileptic drugs: implications for the treatment of neuropathic pain and fibromyalgia. Pain. 2013;154:345-349.