Forensic and administrative challenges in psychiatric pain medicine

Patients with chronic pain and psychiatric comorbidities are more complicated and, thus, inherently more challenging than patients with either problem alone. There are also administrative challenges, which include dealing with workers’ compensation insurance carriers and their adjusters, the majority of whom lack a medical background. Fortunately, some adjusters are open to being educated about chronic pain and psychiatric problems, and our staff spends significant time educating them about these issues. Frequently, educating the adjuster about the biopsychosocial model of pain becomes extremely important. When primitive attitudes are overcome through education about the patient’s condition and related treatments and options, adjusters often take on a collaborative role and work to ensure the best outcome for the patient.

Case VignetteMr X is a 62-year-old former law enforcement official from a major city. During his career, he sustained injuries to his spine that required multiple fusions. He also incurred an inoperable fracture to the thoracic spine. He presented to the clinic in severe pain despite prescriptions for narcotic analgesics, was severely depressed with paranoid ideation, and seldom left his bed.

We aggressively treated his symptoms of psychotic depression with dual-channel antidepressant therapy (SSRI and a serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitor) and we prescribed a selective D2 blocker. We controlled the pain by progressively weaning him from the long-acting opiates. Once his depressive illness was in remission and his pain was under control, we began a series of trigger point injections and percutaneous neuromodulation therapy designed to minimize the need for opiates (which he strongly desired). With the help of the insurance adjuster, we were also able to get him a hot tub for hydrotherapy for muscle spasms.

The patient still has pain, especially during weather changes, but he only takes opiates at low doses on an occasional pain-rescue basis. He actively pursues hobbies, has an active life with his wife and grandchildren, and manages a small ranch as a hobby.

Some adjusters have extreme biases against patients with pain, and view them as malingerers, even those with catastrophic injuries. Worse, some adjusters have even more malignant biases toward patients with psychiatric illness, viewing them as either “crazy,” malingering, or just “weak.” In these cases, educating the adjuster about the biopsychosocial model of pain becomes extremely important. Unfortunately, we are not always able to change an adjuster’s attitude and sometimes the patient’s attorney has to intervene to ensure that needed medical care can be provided as required by law.

Case Vignette Mr Z is a 58-year-old Vietnam veteran who returned from the war relatively unscathed. He began work in a local factory where he was involved in a severe chemical explosion. In the accident, he was thrown over 50 feet and sustained burns over 60% of his body; several of his coworkers were killed. PTSD and spinal pain syndrome developed. He began having nightmares, ran through his house while asleep and at one point sustained further injury by running through a glass door. Afterward, he began sleeping outdoors in a lawn chair or would tie himself to his bed to prevent sleepwalking. He was treated for PTSD by multiple psychiatrists, which included an inpatient hospitalization with no improvement.

On referral to our clinic, we began simultaneous treatment of PTSD, sleep dysfunction, and chronic pain. He was found to be a rapid metabolizer on the cytochrome P-450 2D6 system (based on laboratory and clinical findings, along with medication blood levels) and required what appeared to be large doses of some medications. He was referred for psychotherapy with a psychology associate, and eventually he was stabilized on a regimen of anxiolytics, an SSRI, long-acting opiates for pain, and an anti-insomnia agent.

The PTSD has been in full remission for about 12 months. The patient sleeps 7 to 8 uninterrupted hours per night without nightmares and actively runs his home-based business. He recently began to exhibit deterioration, because his insurance adjuster is attempting to force him to “settle his medicals” (as a cost containment measure); and he is required to travel across the state for a medical examination with an insurance company-approved physiatrist who has no training in psychiatric disorders. His psychologist and our staff are extremely concerned about this conflict, and we are currently working with his attorney to intervene on the patient’s behalf.


More often than not, chronic pain is accompanied by anxiety- and depressive-spectrum disorders. By treating pain and psychiatric disorders simultaneously, we are able to maximize outcomes. Similarly, a biopsychosocial model of pain that optimizes patient-centered care can improve outcomes. Our group’s philosophy of pain medicine practice can be articulated by the 5 principles summarized in the Table.



Governing principles of the pain clinic

• Comorbid depressive disorders, anxiety disorders, and personality disorders must be detected and appropriately managed for the target pain disorder to be managed effectively
• The life issues and the life changes resulting from the injury and pain must be addressed, faced, and dealt with at each visit; this may include pharmacotherapy and/or brief psychotherapy
• Activity is encouraged: reentry into the workforce is a major goal; the work does not need to be similar to the work done before the injury
• Adjunctive non-narcotic pharmacological agents (eg, neuromodulators, anticonvulsants, and so forth) are used to target specific pain generators and pain-related problems (eg, insomnia); these serve to reduce the dose of opiate analgesic needed to control pain (thus, the concept of “opiate-sparing” agents)
• Pain should be managed with the lowest dose of opiate analgesic possible to both effectively control pain and maximize the patient’s ability to function and live life to the fullest


Although the management of psychiatric disorders and pain in the work injury setting can be challenging, the rewards of watching patients return to happy, healthy, and productive lives are significant. We encourage psychiatrists to make themselves available as consultants to the pain clinics in their communities and to work cooperatively with pain physicians. We likewise encourage interventional pain clinics to use the services of psychiatrists. Without doubt, patients will benefit from such collaboration.

[At the time of publication] Dr Workman is medical director of Neuro-psychiatric Pain Medicine Associates of Tennessee and president and CEO of Forensic Medicine Associates, Inc. He is board-certified in psychiatry (recertified in 2004) with “Added Qualifications in Forensic Psychiatry,” and board-certified in pain medicine. He is a clinical associate professor of medicine at the University of Tennessee Medical Center in Knoxville. Ms Hendrix is administrative director of Neuropsychiatric Pain Medicine Associates of Tennessee and executive vice president of Forensic Medicine Associates, Inc. She is a registered nurse, holds a BS in health care management, and is dually board-certified in forensic nursing and case management. The authors report that they have no conflicts of interest concerning the subject matter of this article.

1. Workman EA, Hubbard JR, Felker BL. Comorbid psychiatric disorders and predictors of pain management program success in patients with chronic pain. Prim Care Companion J Clin Psychiatry. 2002;4:137-140.
2. Wald J, Alvaro R. Psychological factors in work-related amputation. J Rehabil. 2004;October-December:10-12.
3. Bryant RA, Marosszeky JE, Crooks J, Gurka JA. Posttraumatic stress disorder after severe traumatic brain injury. Am J Psychiatry. 2000;157:629-631.
4. Stanos S. Pain and depression: pathology, prevalence, and treatment. Pain Med News. 2007;7/8:1-8.
5. von Knorring L, Perris F, Oreland L, et al. Pain as a symptom in depressive disorders and its relationship to platelet monoamine oxidase activity. J Neural Transm. 1984;60:1-9.
6. Arnold L, Rosen A, Pritchell Y. A randomized double blind placebo controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 2005;119:5-15.
7. Gallagher RM. Selective, tailored, biopsychosocial pain treatment: our past is our future. Pain Med. 2007;8:471-472.
8. Workman E. Computerized assessment in outpatient psychiatry practice. In: Miller M, ed. Clinical Mental Health Computing. New York: Springer-Verlag; 1996.
9. Workman E, Hubbard JR. Chronic pain. In: Hubbard JR, Short D, eds. Primary Care Medicine for Psychiatrists. New York: Plenum Medical Book Co; 1997.


This article originally appeared in:

Psychiatric Times

It is reprinted here with permission.