Vocational Rehabilitation

Patients with pain can experience significant losses, including the loss of work. Beyond the obvious resultant loss of income, and perhaps medical coverage, the loss of work can imply several other losses for the patient depending on the meaning of work for that person. For many persons, work is a source of self-identity, power, influence, and a social network. Loss of work, therefore, can mean the feared loss of control and a feared loss of usefulness. Psychiatrists can facilitate pursuit of...

Medication Diversion

The issues around medication diversion have acquired increasing media, public, and legal attention, especially as related to pain medications. Diversion refers to the misappropriation of prescribed medications, either by physicians or by other persons who acquire medications from treating sources. Opiate analgesics of all sorts and varieties can be diverted for their abuse appeal. In the past, agents such as butorphanol had abuse appeal lately, concerns about diversion have focused on...

Nonopiate Analgesics

Acetylsalicylic acid (aspirin), other salicylates, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors are useful for treating acute and chronic pain. These nonopioid agents act by interfering with prostaglandin synthesis and disrupting pain by reducing inflammation at peripheral sites. (However, the mechanism of the analgesia produced by acetaminophen is unclear.) Some of these are also useful as antipyretic agents. The efficacy of these agents...

Adjunctive Interventions

Adjunctive interventions are not forms of therapy but are nonetheless helpful techniques that can be undertaken with the pain patient. These techniques can complement other medical treatments and psychotherapies. Biofeedback refers to a procedure in which physical parameters (e.g., muscle tension) are continuously monitored and fed back to the patient, who then attempts to alter the physical parameter. For example, an individual attempting to regulate and modify the degree of muscle tension in...

Table 85 Common causes of back pain

Intervertebral disc rupture or herniation Meningeal irritation Infection Tumor Bleeding Arachnoiditis Trauma Spinal cord involvement (extremely dangerous) Cauda equina syndrome (extremely dangerous) ally. Without a doubt, back pain results in significant morbidity and constitutes the leading cause of long-term disability in the United States (Atlas and Deyo 2001). Clinicians treating patients with back pain often are confronted with a perplexing differential diagnosis. Common causes of back...

Benzodiazepines and Anxiolytics

Benzodiazepines have been employed acutely to mitigate pain arising from muscle spasm (e.g., after spinal cord injury). The presumption is that patients with marked anxiety are prone to heightened muscle tension, which may exacerbate musculoskeletal pain. Other uses for benzodiazepines have included treatment of restless legs syndrome, tension headache, and neuropathy (Bartusch et al. 1996 Bouckoms and Litman 1985 Dellemijn and Fields 1994). Clonazepam, a long-acting benzodiazepine, might be...

Muscle Antispasmodics

Muscle antispasmodics include true muscle relaxants (e.g., baclofen, dantro-lene) along with agents in which the mechanism of action is unclear (e.g., car-isoprodol, cyclobenzaprine, methocarbamol, orphenadrine). Some of these agents may suppress polysynaptic reflexes and thereby reduce pain, but they do not influence skeletal muscles per se. Generally, antispasmodic agents are to be used for acute pain arising from muscle strain or injury (see Table 5-14). Baclofen might be indicated for more...

Somatic Amplification and Its Function

In some patients with pain, like patients with other somatoform disorders, amplification of somatic symptoms (including pain) may be a manifestation of psychological distress. For some persons, this amplification might reflect a strategy to cope with or manage psychological distress (Lipowski 1988). For others, somatic amplification may result from the distress associated with unpleasant affective states such as depression or anxiety. These emotional states may lead to heightened...

Multiaxial Pain Classification

The International Association for the Study of Pain 1986 has advocated a multiaxial classification of chronic pain, comparable to that used in psychiatric diagnosis. The intention behind the classification system is to standardize diagnosis and facilitate research endeavors in pain treatment. Axis I refers to the body region that is the source of pain e.g., lower back Axis II refers to the systemic source whose abnormal functioning produces pain e.g., neurologic system Axis III characterizes...

Serotonin Norepinephrine Reuptake Inhibitors

The serotonin-norepinephrine reuptake inhibitors SNRIs i.e., venlafaxine and duloxetine have demonstrated utility as analgesic agents, and they bypass several of the untoward effects commonly associated with the TCAs. Both agents have been demonstrated to have pain-mitigating effects in randomized con- Table 5-5. Analgesic effects of antidepressants Table 5-5. Analgesic effects of antidepressants preventing further pain augmentation Decreased firing of neurons, reduced Note. 5-HT serotonin GABA...