The biopsychosocial approach to a diagnosis

It is essential that all reasonable attempts are made to establish a cause for the patient's pain behavior, including nociceptive, neuropathic, and psychological contributions. Pain behavior itself can obviously be modified by many other factors involving social and environmental influences. A demonstration of pathology commensurate with the degree of pain behavior is desirable. However, patients often have pathology which is difficult to interpret, e.g. degenerative changes on spinal radiographs. In some cases, the treating physician can be confident that these changes are relevant to the patient's pain behavior, but in others they can be the least important contributor.

Certain conditions result in neuropathic pain, which is usually a clinical diagnosis and may not be reflected in investigations, such as radiographs or nerve conduction studies. Examples include postherpetic neuralgia, tri-geminal neuralgia, postlaminectomy syndrome, and painful peripheral small fiber neuropathies.

Investigations, such as the effects of local anesthetic blocks, must be taken into account along with other clinically relevant information to determine whether a nociceptive stimulus is the main cause of the patient's pain behavior.

There is increasing support for the use of opioids within a biopsychosocial perspective where opioids are used as one component of a pain management plan.92 However, opioids are not appropriate for patients whose main problem is loneliness, fear, anxiety, hypervigilance, or activity intolerance.

Patients for whom opioids are being considered should be psychologically stable, although it is recognized that this is difficult to define. It is not uncommon for patients to develop psychological problems, including depression and anxiety states, as a result of their chronic pain, and therein lies a dilemma for the physician. Will treating the pain reverse some of the psychological abnormalities? Or are the psychological abnormalities a significant contributor to the overall pain behavior? Studies would suggest the former in most cases.93

It is important, however, to avoid treating distress with opioids. Some patients' lives degenerate into chaos for reasons unrelated to their pain syndrome. Opioids may appear to help with their distress, but may make little impact on their pain behavior or level of function. Of course, it is not always easy to differentiate distress related to sociodomestic disintegration from that related to severe pain. In this situation, it is vital to limit initial opioid therapy to a clearly defined and limited trial period with the provision of informed consent and a plan to cease therapy if required. Otherwise, in our experience, well-intentioned but uncontrolled prescribing usually results in escalating doses with a negative overall outcome.

For certain groups of patients, a formal psychological/ psychiatric assessment is useful before prescribing opioids. This may include patients with poorly defined pathology, younger patients, those with high levels of distress, and those with previous or ongoing substance abuse. Such a formal assessment may lead to information related to personality disorders, identification of treatment-resistant depression, past history of sexual, physical or emotional abuse, and may be essential in designing alternative or complementary management plans. Specific treatment aimed at reducing anxiety, improving coping mechanisms and, where appropriate, cognitive behavioral therapy may potentiate the beneficial effects of opioid therapy. Screening tools to predict development of addictive behavior are being developed and might prove useful to the prescribing clinician.94'95 Consideration should be given to managing these more complex patients in a multidisciplinary pain center.

Having reached an appropriate diagnosis and identified significant psychological issues, it is important to determine that patients have had a thorough trial of previous conservative therapy before consideration is given to adding in the medium- to long-term use of opioids.9 This may mean combined and continued intervention with:

• active exercise programs;

• attention to improving coping mechanisms;

• a formalized multidisciplinary pain management program;

• attention to psychosocial stresses;

• the use of appropriate invasive physical treatments;

• drug therapy, which should include trials of:

- nonopioid analgesics;

- tricyclic antidepressants;

- anticonvulsant and membrane-stabilizing medications (e.g. sodium valproate, gabapentin, pregabalin, carbamazepine).

Opioids should be seen as a means to an end, not the end point of treatment. The analgesia obtained should ideally allow an increased participation in these therapies. As detailed already, the current evidence for opioid efficacy is limited to relatively low-dose and short-term use, consequently an expectation of a finite window to encourage involvement and compliance with these other therapies rather than an expectation of using opioids in the long term should be encouraged.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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