Substance abuse complicates pain management. The comorbidity of substance abuse and pain is particularly problematic in the United States and Canada, substantially more than in most countries with advanced health care systems. Treatment of pain with long-term opioids, particularly in high doses, is known to be associated with substantial medical comorbidity, unintentional overdoses, and death. Treatment of opioid dependence in the chronic pain patient is necessary for effective pain management, whether or not the patient uses drugs illicitly. Opioids, particularly in high doses, produce central nervous system neuroadaptations that reduce or eliminate analgesic effectiveness and enhance sensitivity to pain in general. The neuroadaptations often result in opioid dependency and, in the long-term, craving. Weaning patients from chronic opioids can be exquisitely difficult if simple dose reduction is attempted. The process can be quite successful and gratifying, however, if certain principles are followed. These include education, comfortable detoxification using long-acting opioids, usually methadone or buprenorphine, nonopioid pain management, psychological support, and coordinated care.

opioid-dependent pain patient, while refilling the prescription would take only a few minutes of office time. Furthermore, simply gradually tapering the dose causes too much discomfort if the doses have been high [9]. Many practitioners do not have the time, skills, and patience to effectively manage the opioid-dependent chronic pain patient. It can be done successfully, however. I have instituted a six-point protocol that has proven successful over the years. (1) Explain to the patient that daily opioids maintain pain and enhance sensitivity to pain over the long run. (2) Switch to a slowly metabolized, long-acting opioid such as methadone or buprenorphine to allow a comfortable detoxification. (3) Manage pain complaints with non-dependency-producing medications. (4) Provide psychological support during the process. (5) Coordinate care with family and other providers. (6) Promote other positive health behaviors involving smoking, diet, exercise, and attitude [10]. The medical culture that fostered opioid overprescribing has begun to change in the last few years. Knowledge of the factors that led to the prescription opioid crisis in the United States may help practitioners in other countries avoid similar problems. A recent editorial by Fava and Rafanelli [1] reviewed commonly unrecognized iatrogenic factors in psychopathology. Such are also becoming abundantly clear in relation to the treatment of chronic pain in the United States and Canada. The opioid crisis that has developed has substantial roots in the overprescribing of opioids by presumably well-meaning practitioners. This began in the 1980s, after undertreatment of acute pain and cancer pain became increasingly recognized [2]. By the 1990s, American pain societies were calling for a liberalization of opioid prescribing not just for acute pain, but also for chronic pain, promoting non-evidence-based beliefs, including that pain prevented tolerance to opioids and allowed analgesic efficacy to be retained over the long term, and that opioid dependence naturally occurred with prescribed daily opioids but rarely resulted in addiction [3]. These myths were reinforced by pharmaceutical marketing with great success. The prescription of opioids for pain skyrocketed, and morbidity and mortality skyrocketed in kind [4]. Despite numerous research studies, no good evidence has developed that daily opioids are effective for chronic pain, nor are they safe [5]. In contrast, compelling evidence developed demonstrating lack of efficacy and safety. Basic science studies consistently show that daily opioid intake results in nervous system adaptations that actually enhance sensitivity to pain [6]. Studies of experimental pain, clinical pain, and epidemiological studies have all been consistent with the same results [7, 8]. For years, some pain specialists (typically supported by Pharma) resisted these findings and blamed patients if they developed addiction. The crisis steadily grew until finally the dangers of daily prescription opioid intake and lack of efficacy became more widely realized. The problem was compounded by the experience of patients, who discovered that if they tried to stop taking opioids, they felt even worse. Some took this as evidence that they required opioids because of their pain, but many recognized that it was withdrawal that was intolerable. They then often developed a mood disorder and/or a substance use disorder. Practitioners may not recognize that their management had caused psychopathology, and even if they did, they now had a dilemma: to reduce the dose of opioids would meet with resistance and take a long time to discuss with the Received: July 11, 2019 Accepted after revision: July 15, 2019 Published online: September 5, 2019

This is a history of the International College of Psychosomatic Medicine from 1970 to the present.

This is a history of the International College of Psychosomatic Medicine from 1970 to the present.

BACKGROUND AND OBJECTIVES:In some countries, particularly the United States and Canada, there has been a growing problem of opioid dependence associated with the treatment of chronic pain. Controversy exists regarding the efficacy and safety of opioid therapy, particularly in high doses for extended periods of time. This study reports on the outcome of chronic pain patients treated with buprenorphine in an outpatient psychiatric consultation clinic.METHODS:Forty three consecutive outpatient clinic chronic pain patients with a DSM-IV diagnosis of opioid dependence and treated with buprenorphine during a 3-year period were monitored for follow-up periods of up to 5 years. All subjects were dependent on drugs prescribed for pain and were divided into two groups: those who had a history of abuse of alcohol or drugs and those who did not Historical, physical, demographic, and outcome data were collected.RESULTS:The majority of patients were male, not working, and between the ages of 45-60. Follow-up revealed that treatment with buprenorphine was effective. Most patients had improved pain with treatment of the opioid dependence. There were no differences between those with or without a history of substance abuse.DISCUSSION AND CONCLUSIONS:Patients often improved with much less preoccupation with pain, expressing great satisfaction with buprenorphine treatment.SCIENTIFIC SIGNIFICANCE:Buprenorphine is an effective tool when treating the opioid-dependent chronic pain patient.

Article AbstractBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.Seminars in Liaison Psychiatry, Second Edition, published by the Royal College of Psychiatrists, is significantly expanded from the first edition that was published in 1996. It has 29 chapters and 2 appendices written by 47 contributors, all of whom were trained in the United Kingdom. It is intended for trainees or beginning psychiatrists and has questions at the end designed to help prepare for certification examinations. In the United States, consultation-liaison psychiatry is so called because it combines 2 clinical activities that, while closely related, have distinctly different meanings.

Pain management has received increased attention from the medical community, influenced by societal demands for more effective and comprehensive treatment. In fact, the Joint Commission on Accreditation of Health Care Organizations requires that physicians consider pain as “the fifth vital sign.” It requires that pain severity be documented by using a standardized pain scale. Unfortunately, the assessment and management of pain is difficult. Pain is more than a sensation; it is influenced by emotional, cognitive, and psychosocial factors. The role of the psychiatrist in managing patients with pain has received increasing attention. The American Board of Psychiatry and Neurology now offers a subspecialty certification in Pain Management. While certification is warranted for those who practice extensively in this area, the general psychiatrist should also have familiarity with those issues that are likely to arise in treating patients with pain. Toward this end, the following guidelines are proposed for pain management training to be incorporated into the residency training curriculum.