Current Psychiatry Reports (2018) 20:12

https://doi.org/10.1007/s11920-018-0872-4

COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)

Psychiatry and Pain Management: at the Intersection of Chronic Pain

and Mental Health
Jenna Goesling 1 & Lewei A. Lin 2,3 & Daniel J. Clauw 4

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review Chronic pain impacts millions of people in the USA. At the heart of the problem of chronic pain remains the
complex psychosocial aspects associated with living with chronic pain. Given the overlap between chronic pain and mental
health, a promising treatment approach is to improve how we integrate psychiatry into pain management.
Recent Findings Treatment of chronic pain and comorbid mental health issues requires a multidisciplinary approach.
Advancements in how pain is understood, especially centralized pain, have helped inform both pharmacological and behavioral
interventions for pain. Given the growing concerns about the opioid epidemic and the lack of data supporting the use of opioids
for long-term pain management, new treatment approaches are needed. Psychiatrist may be uniquely suited to help address
comorbid mental health disorders and addiction in the context of chronic pain management.
Summary Addressing the psychiatric needs of chronic pain patients remains challenging and there is much room to improve how
we address the complex issues associated with living with chronic pain. We believe psychiatrists are an important piece of the
pain management puzzle.

Keywords Chronic pain . Psychiatry . Multidisciplinary . Centralized pain

This article is part of the Topical Collection on Complex Medical-
Psychiatric Issues
* Jenna Goesling
jennagoe@med.umich.edu
Lewei A. Lin
leweil@med.umich.edu
Daniel J. Clauw
dclauw@med.umich.edu
1
Department of Anesthesiology, Back & Pain Center, University of
Michigan, Burlington Building 1, Suite 100, 325 E. Eisenhower
Parkway, Ann Arbor, MI 48108, USA
2
Department of Psychiatry, North Campus Research Complex,
University of Michigan, 2800 Plymouth Road, Ann
Arbor, MI 48109, USA
3 pression in a psychiatric setting, comorbid pain conditions
Department of Veterans Affairs Healthcare System, North Campus
Research Complex, VA Center for Clinical Management Research
(CCMR), 2800 Plymouth Rd, Ann Arbor, MI 48109, USA
4
Department of Anesthesiology, University of Michigan Health
System, Domino’s Farms, Lobby M, 24 Frank Lloyd Wright Dr, PO
Box 385, Ann Arbor, MI 48106, USA
Introduction
Over the past several decades, the comorbidity of chronic
pain and psychiatric diagnoses has been well established
[1–3]. Numerous studies have investigated the causal nature
of this association and strongly suggest a bidirectional rela-
tionship [4•, 5]. That is, people may develop a mental
health issue, such as depression or anxiety, as a conse-
quence of living with chronic pain [6, 7], and a history of
a mental health diagnosis is considered a risk factor for
developing chronic pain [8, 9]. In studies of pain popula-
tions, 30–60% of patients report comorbid depression [2].
This comorbidity is not only associated with higher eco-
nomic and treatment costs [10], patients with pain and co-
morbid depression also report greater pain severity, worse
functioning, and more disability compared to non-depressed
pain patients [11–13]. Among patients being treated for de-
are also common. For instance, 50% of patients diagnosed
with depression report experiencing some physical pain
symptoms [14]. Additionally, having a psychiatric diagnosis
is a risk factor for being prescribed an opioid and develop-
ing persistent opioid use [15–17]. We have seen the
12 Page 2 of 8
consequences of the dramatic rise in opioid prescribing over
the past 20 years, including opioid addiction and overdose
[18, 19]. In part because of the opioid epidemic, unraveling
the complex relationship between physical and emotional
pain has never been more important.
Pain is influenced by both biological and psychosocial fac-
tors. Historically, the bio-medical treatment model for chronic
pain focused primarily on relieving the physical symptoms.
For example, a person with low back pain would be treated
with surgical interventions, injections, and/or medication. Yet
less than half of patients improve following most surgical
interventions, and medications, especially opioids, have very
limited long-term benefits, and high risks [20, 21]. Over the
last several decades, the pain field has evolved and has begun
to increasingly recognize the role of psychosocial factors in
how we conceptualize and treat chronic pain. This shift in how
we think about pain and pain management has helped to ad-
vance the role of psychology and psychiatry in the context of
chronic pain management. Optimal and comprehensive pain
management includes a team of providers that includes pain
specialists, psychologists, and psychiatrists [22•, 23]. Despite
taking steps in the right direction, addressing the psychiatric
needs of chronic pain patients remains challenging and there is
much room to improve how we address the complex issues
associated with living with chronic pain.
Given the overlap between chronic pain and mental
health, there is a need to consider how best to integrate
psychiatry into chronic pain management. This paper has
the following four broad aims: (1) provide an overview of
several important principles of pain management includ-
ing differentiating between acute versus chronic pain,
with a focus on peripheral versus centralized pain pro-
cesses, (2) review evidence-based treatment approaches
for chronic pain, (3) consider the role of psychiatrists in
the context of pain management, and (4) identify several
“next steps” towards developing a more integrative model
of pain management.
All Pain Is Not Created Equal: a Review
of the Different Types of Pain
One of the most frequent reasons people seek out medical
care is because of pain. Pain is often described as the
body’s alarm system that alerts us that something is
wrong. When people describe pain, they usually focus
on a localized sensation in a particular part of their body.
However, pain is a complex protective mechanism and
understanding the different types of pain processing sys-
tems is important for diagnosis and treatment. In this sec-
tion, we will review acute versus chronic pain and the
peripheral nervous system versus centralized pain pro-
cessing, and discuss treatment implications.
Curr Psychiatry Rep (2018) 20:12
Acute Versus Chronic Pain
Acute pain has a useful biological purpose. It is the body’s
normal reaction to damage such as an injury, surgery, or a
disease process. As time goes on, the injury heals and pain
improves. Acute pain typically lasts less than 3 months and
resolves on its own with little or no intervention. For example,
most people will experience acute low back pain in their life-
time and most will improve with minimal treatment. When
pain persists for longer than 3 to 6 months, it is considered
chronic. There are known risk factors associated with the tran-
sition from acute to chronic pain including modifiable psycho-
social factors. While a range of risk factors have been identi-
fied, there is no single factor that explains who will develop
chronic pain.
In contrast to acute pain, chronic pain exceeds the normal
healing time, has no clear biological purpose, and is much
more strongly associated with psychological factors. The
2011 Institute of Medicine (IOM) report, Relieving Pain in
America, emphasized the importance of addressing the costs
of chronic pain: 100 million Americans suffer from chronic
pain, 200 million days of work are lost, and the economic
costs are estimated to be upwards of 635 billion dollars [24].
The recovery from chronic pain is often long and the course
varies greatly from patient to patient. In the next section, we
will describe the different pain processing systems involved in
chronic pain with a focus primarily on the role of the central
nervous system.
Chronic Pain and the Central Nervous System
Until relatively recently, many pain researchers and most cli-
nicians considered the majority of chronic pain to be caused
by ongoing peripheral nociceptive (i.e., due to damage or
inflammation) in peripheral tissues. In a few instances, the
lack of concordance between damage/inflammation and pain
is well known. For example, clinicians understand that there is
a poor relationship between the results of MRI or CT scans of
the back, and the presence or absence of lumbar pain [25].
However, very few realize there is not a single chronic pain
state where any pathological or radiographic description of
peripheral nociceptive damage has been shown to predict
who will experience pain, or the severity of pain. The leading
hypothesis for why this is the case is that the peripheral and
central nervous system both play a role in determining which
nociceptive input detected by sensory nerves in the peripheral
tissues will lead to the perception of pain. Many individuals
with significant peripheral nociceptive input will not experi-
ence pain, and others without any identifiable peripheral no-
ciceptive input will experience severe pain.
The concept of “central pain” was first used to describe
individuals that subsequently developed pain following a
stroke or spinal cord lesion. In this instance, “central pain”
Curr Psychiatry Rep (2018) 20:12
referred to the fact that the lesion leading to pain occurred
within the CNS (i.e., either spinal cord or brain). More recent-
ly, the term “central” has expanded to describe any CNS pa-
thology or dysfunction that may contribute to the development
or maintenance of chronic pain. Initially, “centralized pain”
was predominately associated with idiopathic or functional
pain syndromes, such as fibromyalgia (FM), headache, irrita-
ble bowel syndrome (IBS), temporomandibular joint disorder
(TMJD), and interstitial cystitis (IC) [26, 27]. These pain syn-
dromes have been shown to be familial/genetic, and strongly
co-aggregate in families [28, 29]. The symptoms experienced
by individuals with central pain syndromes consist of multi-
focal pain, with a high current and lifetime history of pain in
many bodily regions, and the cluster of co-occurring somatic
symptoms (i.e., fatigue, sleep disturbances, memory difficul-
ties) [30, 31]. In cases when an individual has been identified
as having a new onset of a regional pain syndrome, closer
evaluation often reveals high rates of pain in other body re-
gions, and somatic symptoms other than pain [31].
Overwhelming evidence suggests that what is often labeled
as a single chronic regional pain syndrome is actually a chron-
ic multisymptom illness, where the pain merely occurs at dif-
ferent points of the body at different points in time. The re-
gional pain syndromes are given different names by different
sub-specialists according to “their region” of the body and as a
consequence of this, the bigger picture illness may be lost in
the diagnosis.
After decade’s worth of research, we are beginning to un-
derstand the neurobiology of these centralized pain states fair-
ly well. The physiological hallmark of FM, centralized pain,
or central sensitization is augmented central pain processing.
This was originally identified in FM patients by clinical exam
findings, specifically when an individual is diffusely tender to
palpation. In the absence of an identifiable diffuse “peripher-
al” inflammatory process involving the body tissues, this
strongly suggests that the central nervous system (CNS; i.e.,
spinal cord and brain) is causing augmented pain processing.
Subsequent experimental pain testing studies have identified
multiple potential mechanisms that may be responsible for
pain amplification in FM, including a decrease in the activity
of descending analgesic pathways, and an increase in facilita-
tory activity [32].
Harris and colleagues showed evidence of decreased mu
opioid receptor availability in FM, possibly due to increased
release of endogenous mu opioids [33]. This finding as well as
previous studies showing increases in endogenous opioids in
the cerebrospinal fluid (CSF) of FM patients has been hypoth-
esized as evidence of why opioid analgesics appear to not be
efficacious in FM. Several groups have shown there are in-
creases in brain concentrations of the body’s major excitatory
neurotransmitter, glutamate, in pain processing regions such
as the insula in FM [34]. Drugs such as pregabalin and
gabapentin are likely working in part in FM by reducing
Page 3 of 8 12
glutamatergic activity. This has been demonstrated in another
study by Harris and colleagues who showed that individuals
with FM that had the highest pre-treatment levels of glutamate
in the posterior insula were those most likely to respond to
pregabalin [35]. An even more important finding from this
study was the fact that individuals with FM with normal or
low baseline levels of glutamate in their posterior insula did
not respond to pregabalin, even though this drug further
lowered glutamate levels in these individuals as well. This
helps us understand why no single class of CNS analgesic is
likely to work in every patient with pain of CNS origin.
Functional imaging studies have advanced our understand-
ing of how comorbid mood disorders or cognitions may be
influencing pain processing in centralized pain. Functional
MRI undertaken on 30 FM patients with variable levels of
depression investigated how the presence or absence of de-
pression influenced pain reports following experimental pain
testing [36]. This study found that the level of depressive
symptomatology did not influence the degree of neuronal ac-
tivation in brain regions responsible for coding for the sensory
intensity of pain, the primary and secondary somatosensory
cortices. As expected, the depressed individuals did display
greater activations in brain regions known to be responsible
for the affective or cognitive processing of pain, such as the
amygdala and insula. Another study with similar methodolo-
gy examined how the presence or absence of catastrophizing
might influence pain report in FM [37]. In contrast to the
results above, the presence of catastrophizing was associated
with increased neuronal activations in the sensory coding re-
gions. Taken together, these studies thus provide preliminary
empirical evidence for the value of treatments such as cogni-
tive behavioral therapy.
Evidence-Based Treatment for Chronic Pain
Fibromyalgia is the poster child for a fundamentally different
type of pain that needs fundamentally different treatments. It
follows that the optimal treatment approach for chronic pain
must address peripheral pain versus centralized pain and the
overlapping physical and emotional pain systems. Over the
last several decades, advances in our understanding of chronic
pain have led to novel treatments that target the underlying
biological and psychological causes. In most cases, patients
with chronic pain benefit from a combination of pharmaco-
therapy and behavioral interventions. The following section is
an overview of the current “gold standard” treatment recom-
mendations for managing chronic pain.
Non-opioid Pharmacotherapy
Pharmacological treatments for chronic pain are not all created
equal. Importantly, current treatment guidelines by the Center
for Disease Control (CDC) recommend against the use of
12 Page 4 of 8
opioids for chronic pain and state that opioids should only be
used as a last resort after all other treatment options have been
exhausted. Numerous review articles and meta-analyses have
concluded that certain antidepressants have at least a moderate
analgesic effect and are recommended as a first line of treat-
ment in some pain conditions [38–40]. Pain processing and
mood are controlled by common neurotransmitters such as
serotonin, norepinephrine, glutamate, and GABA. If pain
and depression share neurotransmitters that are part of an
overlapping pain system, it follows that they should respond
to similar pharmacological treatments. Non-opioid pharmaco-
therapy options for chronic pain include the following: tricy-
clic antidepressants (TCAs) [38, 41], selective norepinephrine
reuptake inhibitors (SNRIs) [42, 43], anticonvulsants (mainly
gabapentinoids), and NSAIDs. Several recent meta-analyses
on SSRIs have concluded there is limited evidence for their
use to treat pain specifically but they are recommended for
comorbid symptoms of depression.
It is more accurate to think of these medications according
to their mechanism of action versus class of drug. For exam-
ple, both TCAs and SNRI’s are thought to be improving pain
mainly via augmenting activity down descending
antinociceptive pathways that use norepinephrine and seroto-
nin as key neurotransmitters [44, 45]. Individuals with chronic
pain without depression are just as likely to respond to these
two classes of drugs as analgesics as individuals with depres-
sion. That is, these drugs are not making pain better by making
depression better, but rather because the same neurotransmit-
ter serves different functions in different brain regions. In con-
trast, gabapentinoids such as gabapentin and pregabalin are
thought to work in the CNS at least in part by reducing gluta-
matergic activity in ascending pain pathways [35]. NSAIDs
would be expected to be more effective for pain of
nociceptive/inflammatory action, as this is thought to provide
the primary analgesic efficacy of this class of drugs.
Given that patients with mental health disorders often have
worse pain and functioning, it is even more important to op-
timize mental health treatment in this patient population. As
pain specialists increasingly use non-opioid medications to
treat chronic pain, patients with comorbid psychiatric diagno-
ses are at risk of being treated with one-size fits all when it
comes to medication management for their mood. For in-
stance, it often takes some trial and error to find the right
antidepressants to manage depression. When an SNRI is being
used for pain in a patient with comorbid psychiatric issues, the
individual prescribing this medication (where it be a specialist
or PCP) needs to consider the medications effect on both pain
and mood. This may be particularly important in individuals
with less common psychiatric conditions such as bipolar dis-
order, or on multiple psychiatric medications, who can often
be made worse by simply adding one of these classes of drugs.
Even in cases when psychiatrists are not the providers pre-
scribing these medications for pain management, they can be
Curr Psychiatry Rep (2018) 20:12
important partners to observe for effects on functioning, men-
tal health symptoms, and for any side effects.
Non-pharmacological Psychotherapy Interventions: Cognitive
Behavioral Therapy
One of the most extensively researched non-pharmacological
treatments for chronic pain is cognitive behavioral therapy
(CBT). CBT has evolved over the last 30 years with many
variants of CBT-based interventions emerging. CBT was orig-
inally developed as a treatment for depression but has been
adapted to address a range of psychiatric and chronic health
conditions, including chronic pain. Traditional CBT for
chronic pain focuses on the relationship between cognitions
(i.e., thoughts), emotions, and behaviors and how these inter-
act with pain and functioning. CBT for pain typically focuses
on symptom relief and increasing physical functioning. The
goal of CBT interventions for chronic pain is to provide
psychoeducation about managing chronic pain and target
key psychological and behavioral factors. For instance, pa-
tients are taught how to (1) alter unhelpful thoughts and beliefs
in a manner that is better aligned with the management of pain,
(2) use new behavioral skills (e.g., time-based pacing, relaxa-
tion) to decrease pain and increase functioning, and (3) in-
crease use of adaptive coping strategies [46]. Although the
focus of CBT in the context of chronic pain management does
not necessarily address depression per se, alleviation of pain-
ful symptoms or increasing physical activity may subsequent-
ly improve mood.
The efficacy of CBT as a treatment for chronic pain has
been well established with numerous meta-analyses and re-
views on this topic [47]. Although treatment effect sizes are
small to moderate, CBT poses minimal risk compared to most
pharmacological options. CBT may also be promising for pa-
tients with comorbid substance use disorders, with results
from a recent trial showing both improved pain and function-
ing and decreased substance use in patients with comorbid
pain and substance abuse [48]. One possibility is that CBT
should be recommended as a “first line” of treatment for
chronic pain patients, especially patients who are at higher
risk because of substance abuse or comorbid mental health
issues.
CBT is not without its fair share of criticism and there are
several challenges associated with translating CBT into clini-
cal practice. Access to evidence-based CBT treatment, not
enough trained psychologists, and reimbursement are a few
of the critical barriers. One major obstacle is that dissemina-
tion of evidence-based CBT programs into real-world clinic
settings is challenging. Lack of access to what works and not
enough trained providers means many patients do not receive
much needed evidence-based care. Another barrier is that pa-
tients in medical settings often do not follow up on referrals to
CBT. A recent study found that CBT is the most frequently
Curr Psychiatry Rep (2018) 20:12
declined service by patients in multidisciplinary care. To ad-
dress this, researchers are exploring how to incorporate
technology-assisted interventions into pain management.
Psychiatrists and Chronic Pain: the Missing Piece
of the Puzzle
Assessment, Diagnosis, and Treatment of Mental Health
Comorbidities
In primary care settings, when a patient presents with a phys-
ical pain complaint, mental health diagnoses often go undiag-
nosed. One pivotal study of primary care patients found that
60% of all patients who initially presented with a pain com-
plaint would have been diagnosed with depression had they
been evaluated for depression [49]. It follows that the presence
of pain is negatively impacting the recognition and conse-
quently the treatment of depression. Similarly, providers
working in psychiatric treatment settings will frequently see
patients with comorbid pain. Because primary care physicians
and pain providers receive little to no training in psychiatry
and psychiatrists receive little to no training in pain manage-
ment, clinical decision-making for patients with comorbid
pain and psychiatric disorders is challenging for all providers
involved.
In many ways, psychiatrists are in a unique position to help
address the complex interface between chronic pain and men-
tal health. Psychiatrists have been trained using the
biopsychosocial model to assess and treat patients and thus
recognize the importance of addressing not just medical symp-
toms but also the psychological, behavioral, and social dimen-
sions of illness. In recent years, guidelines for chronic pain
management have begun to emphasize the biopsychosocial
model and the importance of targeting functional improve-
ment and quality of life rather than symptom elimination
(i.e., pain). The gaps in recognizing and diagnosing depres-
sion and other mental health disorders demonstrate a clear
problem: Not addressing psychological comorbidities will
likely impede progress in pain management. We believe psy-
chiatrists are an important part of the solution.
Psychiatrists have the depth of knowledge to assess, diag-
nose, and treat psychiatric comorbidities in the context of
chronic pain. There are several diagnoses in the Diagnostic
and Statistical Manual of Mental Disorders, fifth addition
(DSM-5) specific to pain. These include psychogenic pain,
pain from both physical and psychological etiologies, and
pain with minimal to no psychological basis. Many psychia-
trists may not be familiar or trained on the use of these diag-
nostic codes. Psychiatrists are however trained to assess and
diagnose comorbid mental health disorders including Axis I
and Axis II diagnoses. This is a critical skill set in the context
of pain because differentiating disorders and optimizing treat-
ment in general for mental health conditions may improve
Page 5 of 8 12
pain, and more importantly, overall functioning and quality
of life for the patient. Additionally, psychiatrists are familiar
with CBT and other behavioral treatments for depression.
The Opioid Epidemic and the Role of Psychiatrists
One of the most important public health issues in the USA
right now is the opioid epidemic [50]. Given the growing
concerns about the risks associated with opioids and lack of
data supporting long-term use for pain, physicians must now
reconsider the role of opioids in chronic pain management
[21, 51–53]. Pain patients with comorbid mental health diag-
noses are more likely to be prescribed opioids [54, 55], be
prescribed a higher dose [56], and two times as likely to report
chronic opioid use [17]. A recent study found that 43% of
chronic pain patients taking opioids had symptoms suggestive
of depression compared to 26% of chronic patients not taking
opioids [13]. Taken together, these studies suggest that comor-
bid psychiatric factors (e.g., depression) are not being properly
diagnosed and treated. Importantly, it has been posited that
some patients may be using opioids to treat an undifferentiated
state of emotional pain. As we attempt to reduce opioid use
among patients with chronic pain, we must simultaneously
address the psychological factors that maintain opioid use.
Howe and Sullivan’s formative article “The missing ‘P’ in
pain management: how the current opioid epidemic highlights
the need for psychiatric services in chronic pain care” high-
lights the role psychiatric disorders play in opioid use and
abuse and posits that psychiatrists should play a critical role
in curbing the harms associated with opioid use [57•].
Another important clinical need is to properly identify
and treat co-occurring addiction in pain patients. As de-
scribed above, patients with psychiatric disorders are not
only more likely to receive opioids but also more likely to
develop problems with opioid misuse and addiction [58,
59]. Psychiatrists with addiction treatment experience are
uniquely suited to help address addiction within the con-
text of chronic pain for a number of specific reasons.
First, it can be difficult at times to clinically assess addic-
tion in patients with pain and chronic use of opioids.
Physical dependence and tolerance to opioids, which oc-
curs commonly due to chronic opioid use, can often pro-
duce behaviors and symptoms in patients that can be mis-
taken for an opioid use disorder, which develops for a
smaller percentage of patients exposed to opioids and re-
flects an underlying addictive disorder [60]. Second, as
health systems work towards safer use of opioids, which
may involve reducing new prescriptions and reducing
doses for patients on chronic high dosage opioids, it
may reveal patients who experience significant challenges
with pain and opioids. These patients may require addi-
tional assessment and treatment, particularly if untreated
co-occurring addiction and mental health disorders are
12 Page 6 of 8
present. Third, at the same time, psychiatrists can also
help patients advocate for appropriate pain treatment,
which is often limited in psychiatric and addiction treat-
ment settings. And fear of inadequate pain control, for
patients vulnerable to addiction, may be a significant fac-
tor in the pathway to developing an opioid use disorder
[61]. Finally, use of evidence-based treatments, especially
with the opioid agonist medications buprenorphine and
methadone, can be very effective in treating patients
who have developed an opioid use disorder, and in some
patients, can also improve pain outcomes [62–64]. Thus,
psychiatrists are key partners both in identifying and
treating addiction in complex patients experiencing the
trifecta of pain, addiction, and other mental health illness.
Conclusions
Building a Bridge: an Integrative Approach to Chronic
Pain
There is a clear demand to better address the biopsychosocial
aspects of chronic pain and psychiatrists are well positioned to
play a key role in this process. While the need is evident, how
best to expand the role of psychiatrists in pain management is
not as clear. This lack of clarity is a barrier to facilitating a
strategy for integrating psychiatrists into chronic pain man-
agement. Next, we will discuss critical issues and identify
possible solutions.
Education and Training Gaps
Given the comorbidity of pain and mental health diagno-
ses, psychiatrists will inevitably encounter patients in psy-
chiatric treatment settings with a range of comorbid
chronic pain issues. Gaps in opportunities for psychiatrists
to receive education and training in pain management may
leave psychiatrists outside of their competency when it
comes to addressing chronic pain. There are several un-
answered questions when it comes to identifying educa-
tional and training needs including: (1) What amount of
training should be required in pain management, (2)
should psychiatrist become proficient in evaluating and
treating chronic pain, (3) how to diagnose and treat psy-
chiatric disorders that are likely contributing to pain pre-
sentation, and (4) who will provide the training in pain
management. Although there is a considerable need for a
greater number of specialists who can address pain, psy-
chiatric care, and addiction, there may be an even greater
need for generalists including primary care physicians and
general psychiatrists to be better equipped with basic
knowledge base to address chronic pain.
Curr Psychiatry Rep (2018) 20:12
A New Clinical Paradigm
There is not one clear superior clinical model for how to
best utilize psychiatrists in the context of chronic pain man-
agement. Current clinical care models typically involve a
psychiatrist in a consultative role as part of a multidisciplin-
ary pain clinic. One of the challenges with this model is that
often the demand exceeds the availability. Another possible
model includes integrating psychiatrists into primary care or
specialty pain clinics. Collaborative care models have begun
to incorporate psychiatrists into a primary care clinic. This
type of model has proven successful for depression manage-
ment. Given that most patients with pain first present to their
primary care provider, a collaborative care model may help
optimize early treatment for chronic pain and comorbid
mental health disorders. This is especially important when
patients have comorbid mental health diagnoses that often
go undiagnosed and untreated. Another possible model
would be specializing in pain management within a psychi-
atric treatment setting.
Commentary and Future Directions
Chronic pain impacts millions of people in the USA. It is
challenging to treat and unfortunately, there is no “magic
bullet” or single strategy that will solve this problem. As
described in this review, treatment of chronic pain is com-
plicated by a lack of understanding of centralized pain
states, decades of overprescribing opioid medication, and
limitations associated with evidence-based behavioral in-
terventions. At the heart of the problem of chronic pain
remains the complex psychosocial aspects associated with
living with chronic pain. Psychiatrists are an important
piece of the pain management puzzle and are well suited
to consider novel approaches for treating the whole per-
son. There are several clinical models to consider as we
work towards a more collaborative and interdisciplinary
approach to pain management. Changes to medical school
training, residencies, and fellowships are critical next
steps and will open up more opportunities for psychia-
trists with an interest in pain management. Chronic pain
is certainly a challenging field; however, the rewards as-
sociated with helping a person get back to living a happy
and healthy life in spite of pain are intangible.
Compliance with Ethical Standards
Conflict of Interest Jenna Goesling and Lewei A. Lin declare that they
have no conflict of interest. Daniel J. Clauw has received grants and
personal fees from Aptinyx, Cerephex, and Pfizer, Inc., and personal fees
from Abbott Pharmaceutical, Astellas Pharmaceutical, Daiichi Sankyo,
Pierre Fabre, Samumed, Theravance, Tonix, Williams & Connolly LLP,
and Zynerba.
Curr Psychiatry Rep (2018) 20:12
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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