Chronic Pain and the Psychiatrist

Since the first multidisciplinary pain management clinic in Seattle in the 1960s,1 mental health professionals have been key participants in pain clinic services. This involvement has been driven by several factors: the high prevalence and social cost of chronic pain; the influence of a growing number of pain societies internationally (especially the International Association for the Study of Pain) that have advocated for better pain treatment; the no-fault accident insurance and the workers' compensation systems for whom successful treatment of chronic pain disability was an obvious need; and basic science advances inspired at the outset by the gate control theory of pain in 1965,2 which moved away from a hardwired view of pain as a passive, subjective response to a noxious stimulus and instead conceptualized interactions among stimuli, sensory, and CNS processing systems, and supraspinal (psychological) influences. Psychological treatments in pain management have included hypnosis, relaxation training, operant behavioural, cognitivebehavioural approaches, psychopharmacological treatment, and multidisciplinary pain management programs. Many mental health professionals and psychiatrists developed a special interest in pain management, either as independent consultants or working within these interdisciplinary programs. As it developed from the mid-1980s, epidemiologic research demonstrated that chronic pain was a very prevalent condition, associated with a high burden of illness, personal financial and societal economic burden, and frequently with comorbid psychological and psychosocial and medical problems that augment the severity and chronicity. A Statistics Canada report estimated the prevalence of chronic pain at 20% for women and 15% for men.3 The prevalence of notable and continuous chronic pain (excluding intermittent or nonrecent pain) was estimated at 11% of the adult population, and increasing with age.4 Moulin et al5 reported that 7% of chronic pain patients were unemployed. Health care use and cost increases with higher levels of chronic pain.6 Contrary to the intuitive notion that when the original injury heals the pain ought to resolve, pain and disability both decrease rapidly within the first month and then tend to decrease gradually until about 3 months, after which time, pain levels and disability remain nearly constant for months to years. Settlement of a claim does not necessarily end the chronic or intermittent pain trajectory: between 68% and 86% of those initially off work return to work within a month but the cumulative risk of at least one recurrence within 12 months is 73%, and within 3 years is 84%. 7 Mental health workers have long recognized that adverse psychosocial problems, and especially abuse during childhood or lifelong abuse, have a noxious influence on future physical and emotional health. VanHoudenhove et al8 compared groups with chronic fatigue and chronic pain (fibromyalgia) and other medical diagnoses. The prevalence of some form of victimization was not uncommon in groups representing normal controls, those with arthritis or multiple sclerosis, or chronic fatigue and fibromyalgia; however, the groups representing chronic fatigue or fibromyalgia had about 4 times the prevalence of lifelong victimization, compared with the other patient groups and normal group. Emotional neglect and emotional or physical abuse by the family of origin was significantly more frequent than in the other groups. The popular notion that people with chronic pain need to learn to live with it also needs some modification. There is considerable evidence that persistent pain significantly increases the risk of future psychological problems,*"11 and likewise, the presence of depression increases the probability of future chronic pain.9'10'12 These problems and associations are not just in North American environments but are worldwide13,14-a truly global problem. What can mental health workers and psychiatrists do about such complex problems? …