Strengthening the Role of Psychiatrists in the Treatment of Chronic Pain

Dear Editor, Chronic pain is often accompanied by psychiatric illnesses and is one of the most common medical complaints reported in mental health clinics [1,2]. Chronic pain and mental health disorders are often treated separately. Currently, primary care clinicians are at the forefront of chronic pain management, and they have prescribed the highest number of the opioid prescriptions, which has led to the opioid crisis [3]. Psychiatrists are well versed in the use of psychotropic medications that are frequently utilized in the treatment of chronic pain and have specialized knowledge and training in the prevention and treatment of addiction [4]. By virtue of this knowledge, psychiatrists have an advantage over other professionals, especially primary care clinicians, in the treatment of chronic pain disorders. Psychiatrists trained in pain management during residency would be well suited to act as the care coordinator of a multidisciplinary team for patients with chronic pain and mental health issues. Chronic pain disorders are often associated with a variety of mental health illnesses such as substance use, mood disorders, anxiety, post-traumatic stress, personality disorders, and increased risk of suicide [5]. Individuals with a dual diagnosis of chronic pain and mental health disorders must overcome many social, financial, and clinical barriers to obtaining optimum care. These include access to health care systems because of limited mobility, reduced income from disabilities, poor compliance with multiple appointments, and more copayments, resulting in poor treatment outcomes [6]. To address these concerns, the American Psychiatry Association (APA) has issued a position statement encouraging psychiatrists to advocate for and engage in cotreatment or management of several common chronic medical conditions such as pain for these patients [7]. A psychiatrist-centered approach would be ideal for providing care in this challenging patient population. Currently, most psychiatrists are not treating chronic pain. Several subspecialties of psychiatry—such as psychosomatic medicine, geriatrics, addiction, and forensics—frequently deal with pain issues. Yet, pain education in graduate medical education (GME) for psychiatrists is fragmented and inadequate [8]. The guidelines of the Accreditation Council for Graduate Medical Education for psychiatry residency emphasize that residents should receive a thorough education in neurological disorders encountered in psychiatry, such as traumatic brain injury, headache, and pain [9]. In practice, education and training in these areas are practically nonexistent, and certainly inadequate in most training programs. Residents learn about addiction in detail, but usually the safe prescription of opiates or the use of several psychotropic medications for pain management is ignored. The American Board of Psychiatry and Neurology classifies knowledge about pain as “Other Areas of Psychiatric Endeavors” and seldom tests this knowledge in its exams. Psychiatry GME should adopt a comprehensive strategy to include pain prevention, education, training, and research during residency. Residents should learn more about pain management during primary care rotations, via didactics, consultation-liaison rotations, therapy classes, and psychopharmacology lectures. In 2014, an interprofessional executive committee of health professionals published a set of 21 core competencies for pain management that has been adopted by several professional bodies across many disciplines [10]. The APA and other professional bodies representing psychiatrists should also endorse and adopt these competencies. This will require a cultural shift in training, as well as in professional evaluations. These changes should be implemented from the top down by changing expertise requirements and exams and from the bottom up by upgrading curricula and training to teach pain management to all psychiatrists. In-training and board exams should include more questions regarding pain diagnosis and management. Psychiatrists should take a leading role in a holistic approach to treating chronic pain. This may initially strain mental health services, but in the long run, the coordination of care will save time, money, and resources for the entire health care system. Expanding the active participation of psychiatrists should bring a new perspective to the field of pain management, increase human capital to treat more patients, and also help patients by fostering compliance, decreasing stigma, and improving mental health while administering effective pain management services. Pain is a public health concern, and if psychiatrists take an active role in chronic pain management, the goal of effective pain treatment as a basic human right for everyone could be fulfilled [11].