I taught in the Department of Orthopedic Surgery at the University of California, San Francisco, School of Medicine for 15 years as an Assistant Clinical Professor of Orthopedics in my specialty of Psychiatry. My interest and focus of teaching was the emotional impact of chronic pain on patients. At the Back Clinic, I worked with medical students, interns, and residents in evaluating many hundreds of patients to help the treaters understand the effect chronic pain has on an individual. We also looked at the impact of psychopathology on the perception of pain. My instruction was directed at a clinical level, although some of the patients reevaluated were involved in medical-legal controversy.
In 1973, Dr. William Collins, Professor of Neurosurgery at Yale, described the salutary effect of Elavil and Prolixin on the perception and experience of pain. This was an empirical observation on his part, although later research revealed there is an overlap between the chemical mediators of pain and the chemical mediators of depression, the dopamine system. The use of antidepressant medication for the treatment of chronic pain gradually became accepted more widely, not as a treatment of depression arising out of pain but rather as a treatment of the neurotransmitters associated with pain. Researchers examining the relationship between the existence of preexisting depression and the subsequent development of chronic pain found a positive correlation between the two. This psychobiological nexus also became more widely accepted once specialists in different fields began to appreciate the contributions other specialists could provide.
It is difficult to quantify pain, although certain clinical assessment tools provide some differentiation between the physical component and the emotional component of pain. I use these tools frequently in my practice as a forensic psychiatrist and they help establish the basis of my opinion regarding the extent, duration, and internal clinical consistency of complaints made by individuals who claimed to be suffering from chronic pain.
Recent research indicates that individuals who do not have their lingering pain adequately treated develop certain feedback loops at a subcortical level, which cause the persistence of pain to develop. These feedback loops are biologic in origin, not psychologic, and often are difficult to treat. Individuals with chronic pain are prone to physical and psychological dependencies on analgesics such as OxyContin, and as a result are challenging to treat. A part of my forensic practice has been to assess the nature of such dependency and/or abuse and whether or not it was iatrogenic(caused by the diagnosis, manner, or treatment of a physician). There have been occasions when the patients taking medication in excess of that prescribed by their treating doctor later blame the doctor for causing a dependency that they themselves brought on. There are other times, however, when individuals become dependent because the treating physician has not been judicious enough in monitoring the amount of medication prescribed. Instances have also occurred in which an individual has more severe pathology than the doctor had diagnosed, causing the person to become susceptible to developing the chronic pain syndrome. In such cases the doctor did not prescribe an aggressive enough therapy regimen to control the pain, leading to the development of the feedback loop that is a component of a chronic pain syndrome.
Chronic pain itself is a complicated topic to assess, but with care, the various components can usually be examined for their contribution to the development of the syndrome.
See Dr. Raffle’s related commentary: “Pain and the Mind”