Rather than viewing psychosocial and biological interventions as distinct therapeutic modalities, psychiatrists are exceptionally trained to conceptualize patients’ care on the psychosocial-biological continuum and to shift flexibly across various parts of this spectrum among patients and treatment junctions. Thus, wide-ranging involvement of psychiatrists will invigorate essential elements of evaluation and treatment armamentarium that may be underutilized by their medical colleagues. This is a timely effort because majority of neuropathic pain is only partially responsive to opioids 27, 165
so innovative approaches are essential for the pain field.
Psychiatrists are understandably suited to recognize and manage subtle psychological processes including expression of feelings via somatic pain complaints 166
, defense mechanisms e.g., denial and repression vs. lie and malingering along with conscious and unconscious motivations 167
such as self reported pain in the face of adequate analgesia due to unwarranted anxiety about the opioid dose reduction (i.e., pseudo-opioid resistance; 168
) or drug craving vs. pseudo-addiction 84
or therapeutic dependence 85
. Additional pertinent function is the motivational enhancement 169
fostering compliance and active participation in pain treatment plans 80
While multiple cognitive and behavioral strategies (e.g., cognitive restructuring, stress management and systemic desensitization) were reportedly helpful for chronic pain 164, 170
, National Institute of Health Technology Panel assigned the highest score (i.e., strong) to the evidence regarding the effectiveness muscle relaxation 171
. Psychiatrists can become strong advocates for the utilization of cognitive and behavioral techniques by the pain field as they routinely apply them to the care of psychiatric patients. Moreover, being undisputed experts in psychopharmacology, psychiatrists can promulgate viable and non-addictive alternatives to opioids with substantial analgesic properties such as antidepressant, anticonvulsant and neuroleptic agents (49
, however see 172
suggesting only minor pain effect of neuroleptics). Also, psychiatrists are the most logical physicians to diagnose and treat suicidal tendencies 1, 173
as well as mood, anxiety, psychotic and personality disorders exerting pivotal impacts on pain intensity and treatment outcomes 16
The psychiatrists’ dialectical perspective 174
on pain alleviation while preventing, diagnosing and treating addiction to prescription opioid pain killers is addressed in the preceding sections. Additional contribution from the addiction psychiatry field may involve empirically driven treatment matching algorithms allowing provision of individualized level care according to patients needs with regard to their medical status, employment/support, drug addiction, family situation and psychiatric condition. Patient Placement Criteria by American Society of Addiction Medicine 175
, may be adapted to pain patients 176, 177
since they provide multidimensional assessment of severity of illness and level of function and treatment assignment based on needs for service and level of care determination within the available treatment options.
Hence, outweighing any personal benefits for psychiatric trainees per se
, this may be of a broader public health interest to engage psychiatrists in the care for the pain patients. Such an addendum will not only generate additional clinical expertise to evaluate and treat a large spectrum of pain-related problems, but will also help expanding the spectrum of psychiatric field to include pain as an entity rooted in numerous other specialties (to name a few: neurology, medicine, surgery and anesthesiology) and will thus advance the integration psychiatry into the mainstream medical care 178
and underscore the significance of attending in concert to mental and physical problems notwithstanding physicians’ specialties and patients’ presenting problems.