Advances in Comprehensive Pain Management

Pain has been defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 106 Pain is the most common reason a patient presents to a physician for evaluation. 80 , 81 As expected, this physician is rarely a psychiatrist. If the patient suffers from chronic pain, defined by Bonica 12 as pain persisting on a daily basis for a month beyond what would be considered the usual time for healing of underlying pathology, then many specialists are commonly involved in the care of the patient. The psychiatrist offers special skills in the care of patients with chronic pain. First, the psychiatrist is the examiner of mental life composed of thoughts, feelings, and actions. Patients with chronic pain suffer from depression, anxiety, and other psychiatric conditions often not recognized or, when recognized, undertreated. The psychiatrist possesses the expertise in making these diagnoses and providing treatment for them. When a complete evaluation of the individual patient is not performed, the opportunity for making a diagnosis is lost, and the patient's suffering cannot be optimally treated. Second, as a result of caring for patients with mental disorders, the psychiatrist is the keeper of a specialized fund of knowledge. It is this specialized fund of knowledge about the conditions psychiatrists treat and not the fundamental methods they use in clinical practice that distinguishes psychiatrists from other medical specialists. Psychiatrists follow the same process of evaluating a patient as other physicians. Psychiatrists then offer the opportunity of innovative applications of their psychiatric knowledge, especially to the treatment-resistant chronic pain syndromes. This application helps to reintegrate psychiatry with the other specialties of medicine. These two skills define the role of psychiatrists in the treatment of patients, and subsequently how they can make a substantial contribution to the management of chronic pain. Chronic pain as a field of study has grown considerably. Many individuals now are attempting to define pain management as a separate medical specialty. Although it is impossible to review this entire literature, several advances are especially relevant to psychiatry. Psychiatrists need to understand that in addition to providing treatment for the psychiatric disorders accompanying chronic pain, they can apply psychological and pharmacologic methods to the primary treatment of chronic pain. The multidisciplinary, integrated treatment model of chronic pain is particularly suited to use by the psychiatrist who examines the entire person and not just a particular organ system. As a result, psychiatrists offer the opportunity to provide assistance to other health care providers who are managing patients with this difficult problem.