Handbook of Consultation-Liaison Psychiatry

11. Chronic Pain

Jon Streltzer

CONTENTS

11.1 Vignettes

11.2 Background

11.3 Consultation with the Opioid-Dependent Chronic Pain Patient

11.4 Chronic Pain and Opioids

11.5 Principles of Consultation Intervention

11.5.1 Case Examples

11.5.2 Treatment

11.5.3 Detoxification

11.5.4 Psychological Support

11.6 Conclusion

The consultation-liaison (CL) psychiatrist is consulted fairly often for problems related to pain. This may vary substantially, however, depending on the presence of pain specialists from other disciplines, typically anesthesiology, and the CL psychiatrist's interest in and comfort with pain problems. If the CL psychiatrist accepts these consults, however, and is considered knowledgeable, requests for help will be frequent.

In the past, consultations often involved undertreatment of acute pain (Marks and Sachar, 1973; Streltzer and Wade, 1981). In recent years, however, most pain-related consultation requests involve chronic pain patients, particularly those using opioids. This is because acute pain is more effectively treated, often allowing the patient to determine the dose of pain medication through patient-controlled analgesia (PCA). This more liberal prescribing policy has carried over to the treatment of chronic pain in some centers, but because of substantial differences in the body's physiologic response to chronic opioid intake versus short-term intake, chronic pain patients are now much more prone to medical and psychological complications.

The following vignettes are examples of typical pain-related consult requests.

11.1 Vignettes

A 42-year-old woman is 6 days postoperative from back surgery. She insists she is in excruciating pain, but the surgeon thinks that she should be having minimal pain by now. This case may involve more than simple undertreatment of acute pain. Since there has been preoperative back pain, possibly for some time, she may have been using opioid pain medications and become tolerant. If so, more than the usual acute pain medications may be required. Even more importantly, it may become difficult to reduce the opioid dose even if surgery is successful. Consideration might be given to switching to a long-acting opioid, such as methadone, or extended-release morphine, and systematically tapering the dose, often on an outpatient basis.

A 68-year-old woman with cancer pain is fearful of taking pain medications, but she appears to be very anxious and uncomfortable. This case may well involve more than just encouraging her to take her pain medications. The meaning of the cancer in the context of her life should be explored. She may need to grieve the loss of her health. Psychological support should also help her to consider the options for pain control.

A 50-year-old homeless man with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis constantly demands pain medications, but sleeps most of the day. The assessment should consider the likelihood that subjective desire for pain medications is not consistent with objective indicators of pain, such as the nature of the medical condition, sleep, appetite, and activity levels. There may be an addiction problem associated with this man's diminished ability to care for himself.

A 70-year-old man, whose pain is treated with fentanyl and lorazepam, becomes delirious. Delirium can be a complication of pain medication, especially if the dose is too high or there is a preexisting cognitive disturbance. The geriatric population is particularly vulnerable. Lorazepam is especially likely to cause cognitive disturbances (O'Neill et al., 2000).

A 48-year-old woman claims that she suffers from fibromyalgia. She has nonphysiologic findings on examinations. Patients may carry a diagnosis in which the signs and symptoms are suspect with regard to reliability and validity. Common diagnoses in which this is the case include fibromyalgia, myofasciitis, reflex sympathetic dystrophy, and temporomandibular joint syndrome. Consults are often appropriately requested to assess for psychological issues.

Some pain consults are addiction related: A 36-year-old woman heroin addict has an acute medical condition causing pain. The referring physician wonders whether the pain should be treated. It is not helpful to "punish" an addict by not treating pain. Because she is likely tolerant to opioids, she will need higher than usual doses of opioid pain medications. As the acute pain abates, however, opioid doses must be carefully reduced so that she is not discharged with a bigger habit than she had on admission. Of course, the hospitalization presents an opportunity to motivate her toward treatment.

A 45-year-old man in a methadone maintenance program is hospitalized with acute pain. Physicians are often uncertain how to manage such patients, and psychiatric consultation is requested. There are generally two options. The easiest is to maintain the patient on the daily dose of methadone, and add shortacting opioids, such as morphine, as needed for control of the acute pain. Doses will need to be higher than usual because of tolerance. The other option is to raise the methadone dose sufficiently to produce analgesia. This requires that the consultant be familiar and comfortable with methadone dosing. It is important that permission be obtained from the patient to contact the methadone program so the patient's maintenance dose can be verified. If the patient has lied, and is not tolerant to the dose of methadone claimed, serious respiratory depression to the point of death can occur.

A 40-year-old man has used daily opioids for back and leg pain for 8 years, and doses have reached very high levels. Patients taking megadoses of opioids often have medical admissions to rule out various medical conditions when they may be having complications from their opioid use. The complications can include abdominal pain from severe constipation, withdrawal symptoms from using up their pain pills too quickly, and altered mental status. The problem must be recognized to devise a treatment plan, which necessarily requires coordination with the prescribing physicians.

11.2 Background

The treatment of chronic pain has changed significantly in the United States in recent years. It is far more complex than it used to be, because the CL psychiatrist is now more likely to see pain patients being maintained on opioids. This was relatively rare in 1980 and has now become commonplace (von Korff and Deyo, 2004). In the 1980s, the literature began to appear that suggested that some chronic benign pain patients benefited from treatment with long-term opioids (Portenoy and Foley, 1986). Anecdotal cases were minimally described, and improvement in functioning was generally not claimed. Patients who previously had been described as "pain-prone" (Engel, 1959) or hypochondriacal, with the treatment being primarily psychological, were now being prescribed opioids with increasing frequency and, in the 1990s, ever higher doses.

11.3 Consultation with the Opioid-Dependent Chronic Pain Patient

In conjunction with this dramatic increase of opioid prescription, emergency department data indicates that problems with prescription narcotic drugs have mushroomed in recent years (Drug Abuse Warning Network, 2004). Evidence is emerging that death rates associated with unintentional overdoses of prescription pain medications are rapidly increasing also (Morbidity and Mortality Weekly Report, 2005). Psychiatric consultations for such cases have also dramatically increased. Whereas at one time CL psychiatrists tended to see patients who were being undertreated for acute pain, now overtreated chronic pain patients predominate (Streltzer, 1994).

A typical case involves a middle-aged man or woman with chronic musculoskeletal pain who had been prescribed opioid drugs, such as codeine, hydrocodone, or oxycodone, and whose dose escalated over time from a few tablets per day to higher and higher doses, eventually reaching a relatively stable plateau. Such a patient is likely to receive a prescription for a fixed daily dose of an opioid, usually with the availability of additional "breakthrough" opioids, as needed for pain not controlled by the fixed dose. The patient will report that this additional medication is taken only as needed, but if the CL psychiatrist persists in determining how often it is actually taken, he or she will discover that it is the roughly the same amount each day, and the amount prescribed monthly remains the same from month to month.

The pain complaints tend to be continuous all day long, and they often have spread beyond their original location and increased in subjective intensity. The patient reports that narcotic pain medications are the only effective method of temporary relief, as other modalities such as physical therapy do not affect the overall course of the chronic pain.

The patient's history includes hospitalizations for additional testing, complications of the medication regimen, or a concurrent condition, and during these admissions a psychiatric consult may be requested. In some settings, the patient is referred for consultation as an outpatient. The referring physician suspects that psychological issues are maintaining the pain, or is concerned about the possibility of addiction, or is simply at a loss as to how to help the patient and hopes the CL psychiatrist will come up with something useful.

To provide effective consultation, the CL psychiatrist needs to consider not only the patient's subjective report but also what condition might be causing pain and to what degree objective findings are present. Also, the CL psychiatrist should know the limitations of common controversial pain diagnoses that are likely to entail psychological factors. Such diagnoses include fibromyalgia, reflex sympathetic dystrophy (also known as complex regional pain syndrome), temporomandibular joint syndrome, and others. In addition, there are diagnoses that are not controversial but can be questionable as far as the degree of pain being caused, or even the relationship to the pain. Examples include carpal tunnel syndrome, degenerative disk disease, and chronic migraine headaches.

11.4 Chronic Pain and Opioids

The CL psychiatrist also needs to know the effect of chronic opioid intake on pain. Nerve cells involved in pain pathways adapt to chronic opioid intake through a number of chemical mechanisms. These processes seem to overlap in a redundant fashion. For example, administration of chronic opioids suppresses the function of intracellular cyclic adenosine monophosphate (cAMP). This leads to an adaptive response, an upregulation of adenylyl cyclase and the system responsible for synthesizing cAMP. This upregulation of the cAMP system leads to an increase in cAMP response element binding protein, an intracellular peptide that stimulates RNA to make dynorphin in those cells capable of responding, including the pain transmitting cells of the dorsal horn of the spinal cord (Nestler, 2001). Dynorphin is associated with an abnormal pain sensitivity or hyperalgesia (Vanderah et al., 2000). It is present under conditions of painful stimulation, is associated with pain behaviors when is injected into animals, and it is increased by the chronic administration of opioids in a manner similar to that induced by painful stimulation.

Another chemical mechanism has to do with the upregulation of NK1 receptors and substance P (King et al., 2005), which are involved in the transmission of pain impulses and are induced by chronic opioid administration. An increasing number of intracellular compounds are found to be associated with pain induced by chronic opioids, including cholecystokinin (Xie et al., 2005), and orphanin/FQ (Stinus et al., 1995). Thus, cellular responses to stimulation by long-term exogenous opioids are multiple and overlapping, and they counteract, and ultimately reverse, the acute analgesic effects.

Animal studies consistently show a vigorous acute analgesic response to morphine in the opioid-naive animal. In contrast, pretreatment with morphine results in a much less robust response to morphine treatment of a painful stimulus. Furthermore, after a period of time, morphine administration causes increased pain sensitivity, the opposite of acutely administered morphine (Ibuki et al., 1997).

The evidence is convincing that the same phenomena occur in humans. Several studies have confirmed that methadone maintenance patients are more sensitive to experimental pain than controls who do not take daily opioids (Doverty et al., 2001; Jamison et al., 2000). Furthermore, Rosenblum et al. (2003) found that methadone maintenance patients reported much more chronic severe pain than a control group of non-opioid-using drug abusers in treatment programs. In addition, the longer the patient had been on methadone maintenance, the more chronic pain was reported.

The belief that chronic opioids maintain their analgesic effectiveness is belied by the fact that methadone maintenance patients on very high doses of the powerful analgesic are not protected from pain at all. Despite being maintained on doses of this powerful analgesic that would be lethal in other patients, if these patients need surgery, or have an acute painful condition, they do not need less pain medication, they need more than do opioid-naive individuals to effectively combat acute pain (Compton et al., 2000).

There is also evidence that patients with somatoform pain disorder are more likely to become dependent on daily opioids. Patients with serious injuries rarely take daily opioids in the long term. Patients with a somatoform pain disorder are more likely to have pain that spreads to new sites from the original injury, to have more diagnostic tests, to have nonphysiologic findings on examination, and to have received more treatments, such as physical therapy, than those with more serious injuries (Streltzer et al., 2000). Thus, when a consultation is called for a chronic pain patient, careful consideration must be given to the possibility of a somatoform pain disorder being present.

Treatment of opioid dependence for chronic pain can be effective. We followed 100 consecutive patients referred to a pain consultation clinic from a primary care clinic. In the majority of cases, daily opioid dependence was present. Almost all of these cases were detoxified from opioids. Nonopioids were substituted for pain management and, given in the context of psychological support, resulted in a beneficial outcome. This mirrors studies from the 1970s when multidisciplinary pain clinics were first being formed (Newman et al., 1978).

As summed up by Ballantyne and Mao (2003), the use of chronic high doses of opioids for the management of pain is neither safe nor effective. It is likely to contribute to morbidity and mortality in a vicious cycle of pain leading to the prescription of higher doses of opioid analgesics, which will induce greater pain sensitivity. Doses that appear to be stable over months, or even a few years, are likely to escalate when viewed from a longer-term perspective, unless something happens to disrupt this process (Streltzer and Johansen, 2006). Disruptions tend to occur because of medical complications, or loss of the prescribing doctor.

When chronic pain is associated with objective findings explaining the pain, it can most often be treated with nonopioid analgesics, and various coping strategies can be effective. In some cases chronic pain patients who are not dependent on opioids are somatizers, and they may have a somatoform disorder, or hypochondriacal traits, and can be treated according to the principles for treating somatoform disorders. Opioids are not a good treatment for psychological issues, although the patient's energy may be displaced to focus on opioid intake, and the other psychological issues are masked.

11.5 Principles of Consultation Intervention

The referring physician usually feels a responsibility for the overall well-being of the patient. In the inpatient setting, however, there can be pressure to make the difficult, chronic pain patient content by whatever means possible, leaving longterm goals and limit setting for outpatient care after discharge. This approach can make such outpatient management all the more unlikely to occur. The CL psychiatrist will naturally focus on the immediate problem when requested, but is well advised not forget the long-term needs of the chronic pain patient.

11.5.1 Case Examples

A 70-year-old woman with a history of multiple hospitalizations for chronic pain and chronic obstructive pulmonary disease (COPD) was well known by nursing staff for constantly demanding more pain medications, whatever her comfort level appeared to be. The hospital has a pain management team that had been consulted and recommended a higher dose of long-acting opioids plus "breakthrough" short-acting opioids. This had been done in prior admissions, with patient satisfaction. After discharge, however, the patient would soon be readmitted with similar complaints. A psychiatric consultation was requested because the patient intermittently would not make sense in her verbalizations. It became clear that opioid intake was influencing the mental status, and that the patient was consuming opioids in a manner unrelated to objective findings. The primary physician agreed to let the psychiatric consultant manage the pain medications. As the patient was detoxified, she became lucid, and her complaints were well managed by nonopioid analgesics and daily visits. At discharge, the nurses reported that she had never looked so good.

A 36-year-old man was hospitalized because of an excruciating headache unrelieved by extended release oxycodone, 240 mg, three to four times per day. The headache partially improved on intravenous morphine, given via a PCA pump, with the total dose averaging an astonishing 95 mg/hour. At that dose he could sleep and he could also converse with staff members without demonstrating any apparent cognitive impairment. The referring physician had consulted various specialists in the past and tried many different treatments. He was at a loss at this point, and just wanted help. The patient gave a history of suffering migraine headaches since age 22. His sister and mother had similar headaches. Originally, his headaches had been only occasional, and they were well controlled with medication. The headaches got progressively worse in severity, however, and by the time he was 29, he was using opioid analgesics daily. His opioid doses gradually rose, with temporary benefit whenever he raised the dose, but then the headaches would become worse again. He had been hospitalized with increasing frequency because of intractable pain, or complications from high-dose opioids. He was now on his highest dose yet, and his internist was at a loss where to go from here.

The CL psychiatrist recognized that the patient's headaches were probably due to a combination of rebound headaches associated with opioids and the enhanced pain sensitivity produced by them. He discussed this assessment with the patient, who was simultaneously intrigued by the potential of not living with constant pain but also fearful of changing his habits, having several times in the past experienced severe withdrawal discomfort and pain. He stated he would think about reducing his pain medications, but for now he was beginning to feel a little better and would prefer going back to his oxycodone, but at a higher dose.

The consultant pointed out that the patient had been through this many times before, and the recommendation was going to have to be what the consultant thought was best. Moreover, he was sure that the referring physician would agree, since he had discussed it with him already. The consultant assured the patient that he would visit him every day and monitor his comfort closely.

The patient-controlled morphine was changed to a fixed dose of intravenous morphine, initially at 70 mg per hour. Each day this was reduced by 10 mg, until it reached 40 mg, when it was reduced by 5 mg per day. The patient was assured that should he feel severe pain coming on, he could ask for something. He wanted to know what, and was told it would be haloperidol, a major tranquilizer with analgesic effects that would not interfere with his other medications or the changes in narcotic dose. It would be given intramuscularly for more rapid effect. If it did not help, it would be changed.

The patient asked for the injection several times the next day, and once or twice each day for the remainder of his hospitalization. The dose was 0.5 mg, low enough to minimize the possibility of side effects. More importantly, he was visited daily by the psychiatric consultant, who listened carefully to his concerns. Minor adjustments were made to his treatment as a result, but the narcotic dose consistently came down. He was praised for how well he was doing, and after a few days, he would greet the consultant with a smile.

When his dose was down to 25 mg/hour, there was pressure to discharge him, since he looked so comfortable. He was then switched to oral methadone 15 mg three times a day for the first day, being reduced to 10 mg three times a day in three more days, at which time he was discharged. He was then placed on an outpatient tapering schedule over 2 weeks, and was seen twice as an outpatient. He was put on an anticonvulsant by a neurology consultant for headache prophylaxis. Otherwise he was taking only acetaminophen and a rare haloperidol tablet. He gratefully stated that his life had been restored to him. Three months later he phoned the consultant, reported he was doing well, and talked about his sister who had migraine headaches also and was dependent on prescription narcotics.

This case example is consistent with the rapidly accumulating evidence that daily opioids, at least in high doses, enhances pain sensitivity in general, and clinically, dependency issues are a major problem. It was necessary for the patient's primary physician to allow the detoxification. Perhaps most importantly, the patient had to see that the consultant had his best interests in mind, and would stick with him through the psychologically stressful change in habits.

The detoxification went surprisingly smoothly considering the huge dose of opioid to which the patient was tolerant. Reducing a continuous intravenous dose is not difficult in the hospital because the dose is constant without the fluctuations that occur with oral dosing or if the patient controls the dose.

11.5.2 Treatment

A treatment model (Streltzer, 2001) for which there is evidence of effectiveness (Anooshian et al., 1999) proved successful in these patients (Table 11.1).

Once the assessment has been made that opioid dependence is adversely influencing the patient's condition, the CL psychiatrist will do well to undertake or guide treatment utilizing as many of the following steps as feasible: Explain to the patient the role of opioids in maintaining chronic pain and enhancing pain sensitivity. The patient should be told of the changes to the pain regimen and should be given a rationale for doing this. An appropriate message might be, "It is only natural that you are seeking to relieve your pain. You have been unsuccessful, however, despite very high doses of pain medications. In fact, these medications (opioids) have contributed to your chronic painful condition. Your body needs to recover from the changes induced by the constant intake of opioids, and it is likely that you will become stronger and feel better as a result."

Despite the anxiety engendered by modifying habitual ways of medicating pain, this approach, when given confidently, often inspires hope. For many patients, this makes sense because they have suspected that the medication is a problem and they have become dependent on it.

Other patients are convinced that they need opioids and cannot live without them. This is similar to the cigarette smokers who believe that smoking is something they cannot stop, despite all the warnings about the health consequences. These patients will argue that opioids are not the problem but the solution. Such a patient may resist change but still do well if the physician is supportive but strict in eliminating opioids. The physician does best by not focusing on addiction as an issue, but rather insisting that the best long-term solution for the pain is not the use of (high-dose) opioids that will enhance pain sensitivity.

11.5.3 Detoxification

Once the level of opioid dependence is estimated, the dose can be fixed and steadily reduced. Opioid substitution with methadone works particularly well. Methadone is a useful opioid with which to switch for detoxification, not just because of its excellent and reliable absorption, but because a relatively small dose can cover large doses of other opioids, when the patient has been taking the other opioids chronically. There appears to be less cross-tolerance to methadone, perhaps because of its N-methyl-D-aspartate (NMDA) blocking activity (Gorman et al., 1997). This is true only temporarily, however, and tolerance and opioid-induced hyperalgesia develop readily with methadone with steady use. Tables in textbooks tend to be based on single-dose studies, but clinical situations often involve patients who have had chronic dosing, and this influences the equivalent dose of another opioid, particularly if the duration of action is different.

Methadone is remarkably powerful in a patient naive to this drug, so care must be taken not to start with too high a dose.

Methadone metabolism changes with use and the duration of action lengthens each day (Gourlay et al., 1986; Mercadante et al., 1996). A technique that works well for inpatients recovering from acute pain on top of a chronic opioid dependence (other than methadone) is to give methadone every 4 hours for three doses, then every 6 hours for three doses, and then every 8 hours, which allows the patient to sleep through the night. For outpatients, three times daily dosing is satisfactory. Mild constriction of the pupils (Verebely, 1975) indicates an appropriate methadone effect.

Compared to methadone, short-acting opioids are less comfortable for the patient during detoxification because of fluctuating blood levels, and they do not allow a comfortable sleep through the night. Extended-release morphine does not have a buildup effect and may be immediately given every 12 hours, but it is much less reliably absorbed and dosing is more difficult to predict (Gourlay et al., 1986). Detoxification with extended-release morphine can work with the motivated patient, but it is less comfortable than proper dosing with methadone. Extended-release oxycodone has less flexibility in dosing schedules, and if the patient uses up the prescription too rapidly, withdrawal symptoms are intense, stimulating substantial pain behaviors. If the patient is on high doses to start with, detoxification with this drug is exquisitely difficult.

Detoxification using sublingual buprenorphine, a partial mu-opioid receptor agonist, is the easiest, safest, and most comfortable, but the patient must have a base average of only 30 mg or so of methadone or its equivalent. Because buprenorphine binds so tightly to the receptor, it displaces other opioids. Since the other opioids will be full agonists, their displacement at high doses will stimulate withdrawal. A useful technique is to detoxify with methadone down to 30 mg, and then switch to sublingual buprenorphine. Once this is accomplished, the patient could be discharged from the hospital, or leave against medical advice, which may occur with chronic pain patients, and even if no further buprenorphine is taken, minimal to no withdrawal symptoms will occur.

The psychiatric consultant should manage pain with nonopioid medications simultaneously with the detoxification process. Most of the time, the psychiatric consultant will be dealing with patients whose chronic pain is related to a stable condition. The objective medical findings will be those found for most patients who are not dependent on opioid pain medications. The primary need of the patient for opioid medications, then, is psychological, related to conditioning factors and the opioid dependence itself. The patient should be told that the opioids used for detoxification are not actually treating his pain but are eliminating the enhanced pain sensitivity caused by the opioids. Pain treatment will be with other medications. Most often, acetaminophen is satisfactory. The next choice would be nonsteroidal antiinflammatory medications. The long-term opioid dependent patient will often reject these choices saying that they don't work. The patient can be told that, of course, they don't work while he or she is dependent on high-dose opioids, but as the pain sensitivity improves, they may once again work as they should.

In addition, the patient will do best if told that an as-needed pain medication will be available on request. Psychologically, this is most effective if the medication is given intramuscularly. The medication should be one that will not cause adverse side effects. This can be an antihistamine, such as hydroxyzine, 25 mg IM, or a neuroleptic, such as haloperidol, 0.5 mg IM. These medications can be introduced as adjunctive pain medications that potentiate the opioid effect (Breivik and Rennemo, 1982; Schreiber et al., 1997). The patient should be told not to ask for this medication unless absolutely necessary and to try to take as little as possible. Psychologically, patients who are most dependent will then be more likely to think that this is a powerful medication, and it will satisfy them for at least 2 or 3 days, during which time detoxification is occurring and the patients are getting better. Tricyclic antidepressant and anticonvulsant drugs can be used also. These will not solve the pain problem, however, and are best used in small doses to avoid adverse effects.

11.5.4 Psychological Support

Perhaps the most important element of detoxification is the psychological support that can be provided to the patient. The patient must be supported through that critical stage where long established drug-taking habits are changing (Streltzer, 1980). The chronic patient will be quite anxious and often dubious of this new approach. The frequent visits, listening to the patients' concerns, and providing confident explanations, often repeatedly, goes a long way. When patients realize that the consultant is very interested in their well-being and not simply leaving orders that will make them suffer and then disappearing, patients begin to develop some trust in the consultant. Because these patients are often demanding, it is tempting not to see them very often, or not until specifically called. It works out much better, however, and in the long run more efficiently, to make frequent visits even when things are quiet.

The psychiatric consultant should coordinate care with other providers and with key family members. Coordinating care with the staff and the referring physician is critical so that they understand the treatment and do not inadvertently sabotage it. A house officer covering at night, unfamiliar with the case, may order opioids when the patient complains of pain, rather than utilizing the prn medications available. For outpatients, the physician who had been prescribing the opioids must be contacted to prevent a return to the former medications that were causing the problem.

Spouses or other family members can be extremely helpful unless they are opioid dependent themselves, or abusing and diverting the drugs. Family members frequently recognize opioid-related problems when the patient does not. They can help the patient comply with his alternative medications, and they can encourage increased functionality. The encouragement and appreciation of family members can help solidify and sustain the patient's improvement.

The psychiatric consultant should reinforce good health behaviors in general. Many if not most of these patients smoke. It is a good idea to talk to them about their smoking and to encourage their considering quitting. Patients can be given advice about stopping smoking if any interest is expressed. Some patients will indicate that with all their other problems and a medication dependency, smoking is the last thing to worry about. It is still useful to recommend stopping smoking simultaneously with the detoxification process, as it is part of good health behavior, and in general you are concerned with the patient's overall health status. Even if patients do not show interest in stopping smoking, the underlying message to them is that they are not just being considered addicted to medications, but that their health is the primary consideration. This helps with rapport and trust over the whole process.

Similarly to discussing smoking, other health behaviors should be brought up. There should be some questions and encouragement with regard to diet and exercise. Finally, it is helpful to talk about attitude, encouraging a positive attitude about the patients' willingness to go through this process and to develop a healthier lifestyle. In fact, they can be told that the most difficult part of all of this is the psychological part of breaking old habits. Many patients want to see themselves as psychologically strong, and this approach may spur them on to have a more positive attitude toward getting better.

11.6 Conclusion

The psychiatric consultant may receive frequent requests for help with chronic pain patients, especially if they are opioid dependent. Successful consultation requires knowledge about pain syndromes, particularly somatoform pain disorders, pain medications, and treatment approaches. Treatment involving detoxification and nonopioid pain medications with psychological support can be quite effective.

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