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Psychological Skills to Help with Pain

September 15th, 2014 · No Comments

Welcome to the continuing series Why You Should See a Pain Management Psychiatrist.  This week we’ll look at what psychological skills you can learn to decrease and cope with pain.

There are many types of relaxation exercises you can learn.  Breathing, basic relaxation and visualization all help in several ways.  They:

  • help you relax and decrease anxiety
  • decrease the stress response associated with pain
  • help you get better sleep
  • may indirectly help decrease pain

Here are several from the How to Cope with Pain website:

Guided imagery and hypnosis, which use suggestions of decreasing pain paired with imagery, help in the same ways that relaxation exercises do.  In addition, these exercises can directly decrease pain through these suggestions.

Here are 2 examples of guided imagery exercises:

You can learn all of these skills and then practice them regularly on your own.  That regular practice is key!

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Using Antidepressants to Treat Pain

September 8th, 2014 · No Comments

Welcome to the continuing series Why You Should See a Pain Management Psychiatrist.  This week we’ll look at using psychiatric medication for pain.

Antidepressants are, obviously, best know for treating depression.  But there’s more!  Antidepressants can be used for chronic pain itself, separately from treating depression.  This means they are sometimes prescribed even if someone has no depression – just to treat pain itself.  Let’s look at 3 different categories of antidepressants used to treat pain.

1. SNRI (Serotonin-norepinephrine reuptake inhibitors) “Dual-action” antidepressants, those that work on both the serotonin and norepinephrine systems, help with pain.  An example is Cymbalta, which is helpful in both diabetic peripheral neuropathy and fibromyalgia, and Savella, which is approved for fibromyalgia.

2. Tricyclics (TCAs) These are older antidepressants which help in many different pain disorders.  In fact, they are the most-studied antidepressants for pain.  However, even though they work, they are not FDA-approved to treat pain.  Examples include Amitriptyline (Elavil) and Nortriptyline (Pamelor).

3. SSRIs (Selective serotonin reuptake inhibitors) There is some evidence, thought research has been mixed, that SSRI’s help with headaches, both migraines and chronic daily headache.

Overall, antidepressants are sometimes helpful in treating pain itself.  As we know, pain often exists along with depression and anxiety, so these medications can be a good choice when psychiatric symptoms are present along with pain.  Using 1 medication for multiple symptoms is a good idea.  An important point to remember is that if your doctor recommends an antidepressant, it doesn’t mean that your pain is “in your head” or that you’re simply imagining your pain.

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How Can You Imagine a New Life Despite Pain

September 2nd, 2014 · 3 Comments

I just finished reading Burnt Shadows, by Kamila Shamsie.  It’s an interesting story of relationships, loss and hope across generations, in the era of WWII.

One character experiences great losses when the atomic bomb was dropped in Japan.  Later, she says to another character,

You just gave me something valuable.  The belief that there are worthwhile things still to be found.  All I’ve been doing all this while is thinking of losses.  So much lost.

This conversation in the book made me think about how people with pain are able to move on.  Just as we can’t bring back a person who’s died, we can’t go back to a life with no pain.  So how do you go on?  How do you begin to look ahead instead of back?  How do you begin to imagine a new life, rather than focus on the one that’s lost?

How did you move from “thinking about losses” to believing there are worthwhile things ahead?

Please share in the comments.

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Treatment of Psychiatric Symptoms When You Have Pain

August 25th, 2014 · 1 Comment

Welcome to the series Why You Should See a Pain Management Psychiatrist.  Last week we learned that psychiatric symptoms – such as depression, anxiety, etc. – often come along with pain pain.  This week we’ll look at how to treat psychiatric diseases.

As we saw last week, depression (8-50% of patients with pain), anxiety (19-50%), PTSD (10%), sleep disturbance (50% or more), and drug and alcohol problems (3-19%) are common in patients with pain.  Let’s look at some important issues related to treating these problems.

1. Identifying symptoms

To be able to treat psychiatric symptoms, they first have to be identified.  Your medical doctor should be asking about these common symptoms and referring you for treatment if appropriate.  You should also report if you’re having such symptoms.  Don’t be embarrassed or feel like you’re complaining.  Getting help is important!

2. Taking symptoms seriously

If you’re having significant depression, anxiety or other symptoms, it’s important to report these to start to get treatment for them.  These symptoms should not be dismissed as, “of course you have depression – it’s because of your pain.”  Chronic pain does not automatically  mean depression, anxiety and disturbed sleep.  There’s treatment for these symptoms.!  And they should be treated!

3. Treat all the disorders that are present

We know that if psychiatric problems are present along with pain, it’s crucial to treat both.  Treating just 1 doesn’t make the other go away.  For example, if someone has depression and pain, treating just pain doesn’t necessarily mean the depression will go away.  And sometimes neither gets better unless you treat both.

4. Treatment

There are both therapies and medications to treat nearly all psychiatric diseases.  Medication should be used only along with therapy.  Unless symptoms are severe, I strongly recommend trying therapy first, before medication, to see if just therapy alone can work.  There are times, when psychiatric symptoms are severe, that both will be started together, but that’s less common.  Most people with pain disorders are already on several medications and have side effects, so trying non-medication treatment first makes sense.

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Benefits of a Psychiatric Evaluation

August 18th, 2014 · No Comments

Welcome to the series Why You Should See a Pain Management Psychiatrist.  This week we’ll look at what a psychiatric evaluation includes.

When I see someone for psychiatric pain management, I initially do a psychiatric evaluation which includes these areas:

1.  Prior psychiatric functioning and psychiatric diagnoses

This lets me understand if someone has had difficulty with anxiety, depression, sleep, etc, even before confronting a pain disorder.  If so, there’s a higher risk for these symptoms to recur.

2.  Current psychiatric symptoms

Unfortunately, psychiatric disorders often accompany pain.  Let’s look at some of the data:

  • Depression…  8-50% of patients with pain
  • Anxiety…  19-50%
  • PTSD…  10%
  • Sleep disturbance…  50% or more
  • Drug and alcohol problems…  3-19%

We know that if multiple disorders are present, it’s crucial to treat them all.  For example, if someone has depression and pain, treating just 1 doesn’t necessarily mean the other will go away.  And sometimes neither gets better unless you treat both.

3.  Psychiatric interactions with medications

Many drugs used for pain cause psychiatric symptoms, including sedation or depression.  It’s important for someone on your treatment team to figure out what’s causing what and make recommendations to minimize side effects.

Some pain medications cause unusual or serious side effects.  For example, medications which are “NMDA receptor antagonists” such as Dextromethorophan or Ketamine can cause anxiety, hallucinations, or cognitive problems.  Most doctors prescribing these require a prior psychiatric evaluation to be sure there aren’t underlying psychiatric disorders which might be worsened by these medications.

4.  Treatment of psychiatric disorders

If psychiatric symptoms or disorders are found, treatment is crucial.  Having an expert in this area is important.  Treatment might include therapy, medication or both.

It’s also helpful to know that a good pain management psychiatrist will know how to treat issues related to pain.  Your treatment shouldn’t be just talking about how bad things are.  It also shouldn’t be treating a medical pain disorder as if it’s psychiatric.

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Why Comprehensive Pain Treatment is Best

August 11th, 2014 · No Comments

This article is part of our series How You Can Benefit from Psychiatric Pain Management.

This week we’ll look at why comprehensive pain treatment – seeing several different types of health care providers – works best.  Why should you work with a health care team?

1.  Pain is complicated and takes a team of experts to help get you better

Pain is complicated and is caused by many different factors.  Unfortunately, there’s usually not 1 simple treatment that will cure you.  However, on the positive side, that means there are multiple ways to improve things.

Seeking different types of treatment – doctor, pain psychiatrist/psychologist, physical therapist, massage therapist, acupuncturist – lets each person add something to your treatment.  Hopefully, all the treatments together get you to a better place.

Many times treatments work in concert with each other.  For example, anesthetic injections work better is you’re not overly anxious or depressed.  So treating anxiety can help medication be more effective.

2. Working with a team lets each provider focus on what (s)he does best

In a sense, this is the flip-side of #1.  But to expand on this, it means that you utilize each person on your health care team to your best advantage.  Your appointment times are not unlimited, so focusing in on what each person does best means you’re taking advantage of the expertise of each person.

As a psychiatrist, I notice this issue most often related to anxiety or depression.  If you’re seeing a psychiatrist or psychologist, you can work on these issues in therapy.  This lets you spend your time with your medical pain management doctor (neurologist, anesthesiologist, rheumatologist, etc) talking about medications, injections and other procedures, instead of unloading your stress with them.  Often they don’t have time to do both.  So you get appropriate treatment, and they don’t get overwhelmed trying to treat problems they’re not equipped for.

Readers, have you found that working with a team helps you?

2 studies that look at comprehensive treatment are:

  • “Rational integration of pharmacologic, behavioral and rehabilitation strategies in the treatment of chronic pain,” Am J Phys Med Rehabil 2005, 84: S64-76
  • “Efficacy of multidisciplinary pain centers in the treatment of chronic pain,” Prog Pain Res Manage 1996, 7:257-74

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What is Psychiatric Pain Management?

August 4th, 2014 · 3 Comments

I’m back and refreshed after a July vacation.  I hope you’re enjoying your summer too!

Our next topic is psychiatric pain management.  We’ll learn what it is and figure out if you might you benefit from this treatment.

If your doctor has recommended that you considering seeing a pain management psychiatrist or psychologist, it might not be clear exactly why this might be helpful.  You might think, Does my doctor think my pain is all in my head?  or, Will I have to lie on a couch and talk about my dreams?

The answer is no.  No, it’s not all in your head.  And, no, you’ll do other things instead of talking about your childhood.

There are many ways some visits to a pain management psychiatrist might be helpful.  This is a psychiatrist who understands chronic pain, and who can teach you many ways to decrease and cope with pain.  You want to look for someone who specifically has expertise in treating pain.

Over the next several weeks, we’ll look at the benefits of this treatment.  So stay tuned to this series!  Readers, have you visited a pain management psychiatrist?  What was your experience?

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A Bit of Vacation…

July 7th, 2014 · No Comments

I’ll be on vacation for July.  I hope you can join me in relaxing for the month!

If you’d like some good books to read while relaxing, here are some recommendations:

Or, if you’d like to brush up on some skills that help with pain, here are some suggestions:

Happy Summer!!!

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Medications for Pain Series: Research Advances

June 30th, 2014 · No Comments

This article is one in a series on Medications for Pain… What are your choices? How do various medications work? What are the pros and cons? How about side effects?

Today is the last article in this series, and we’ll look at 2 promising advances in research for pain.

1. The first advance is studying multiple medications together.  As you might know all too well, it’s usually not a single medication alone which helps in chronic pain.  Patients often use 2, 3, or even more medications together.  However, most research looks at only 1 medication at a time.  While this practice is simpler, it doesn’t help us know how to best combine medications for pain management.

Studies looking at more than 1 medication at a time are beginning to be published. Yeah!! Here’s an example:

Lamotrigine in Combination with Other Medications for Neuropathic Pain. This study looked at adding lamotrigine (an anti-seizure medication) to either neurontin, a tricycle antidepressant, or another non-narcotic medication, in patients whose pain wasn’t well controlled with only 1 medication.  The results showed that the addition of Lamotrigine didn’t help with pain.

As more studies are done, we’ll know better:

  • what drugs to use together
  • in what order to prescribe them
  • what dosages to use together

(Study is: Silver M, Blum D, Grainger J, Hammer A, Quessy S, “Double-blind, placebo-controlled trial of lamotrigine in combination with other medications for neuropathic pain.” Journal of Pain and Symptom Management, Vol 34, 2007, 446-454.)

2. The second advance is studying medications for pain specifically and for particular pain disorders.  National research organizations (eg NIH) as well as pharmaceutical companies are directing more dollars towards the study of pain.  This will create advances in pain medicine – more options and quicker development of medication options.  As well, specific pain disorders are being researched.  For example, fibromyalgia has gone from being a questionable diagnosis to having multiple medications being approved to treat it.

This is the end of our series on Medications for Pain.  I hope you’ve enjoyed this series and that the information has been helpful to you.

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Medications for Pain Series: Medication Advances

June 23rd, 2014 · No Comments

This article is one in a series on Medications for Pain… What are your choices? How do various medications work? What are the pros and cons? How about side effects?

Today we’ll look at what medication advances are coming soon. How exciting!!

1. Improvements to opiates (narcotics)
While opiates or narcotics are sometimes helpful, they have more than their share of negatives.  Selective narcotics, which give pain control but have fewer side effects, are being developed.  Instead of working everywhere in the body, they’re being designed to work at pain sites, but not at so many other sites (for example, in your digestive tract) where they cause the problematic side effects.

Another improvement is medication that will decrease side effects, such as this medication for the side effect of constipation from opioids.

2. Different delivery systems for narcotics
Narcotics are being developed to be given either by inhalation (in inhalers, like asthma medication) or through the skin inside your mouth or nose (by rubbing a little gel there).  Why?  Medications used in these ways work faster and can last for a shorter time.  These delivery systems may be very helpful for people who have “break-through pain,” which are short-duration spikes of pain.  These short flares of pain can be hard to treat because medication didn’t work fast enough, or lasted too long.  And, because of other advantages of getting medication into your body in these ways, lower overall dosages can be used, which also mean fewer side effects.

3. Using medications more safely
Research is being done to see how to use the medications we have now more safely.  For narcotics, how do we avoid tolerance (tolerance = your body “gets used to” a dosage, so to get the same benefit, the dosage must increase).  We’re finding that another pain medication, Ketamine, may be helpful to prevent tolerance.

4. Using genetics to predict which medication is right for you
Depression research in studying how genetics can predict which antidepressant is right for you.  No guessing, no waiting… just a simple blood test which can be used to say, “This one should work the best.”  We’re not at this stage yet with pain medication, but my hope is that such tests will be available soon.  We could tell, Lyrica versus Neurontin? Cymbalta or Effexor?  This would save a lot of time – not using medications which won’t work – and prevent a lot of side effects.

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