Suicidal pt due to chronic pain

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Are there any good treatments for a lady on the inpatient unit that was admitted because of suicidal ideation due to chronic pain. She’s had many surgeries in the past and as a result has chronic pain all day only relieved by tons of opioids which were stopped by her pain medicine doc. She’s still on 7.5 mg Percocet 4x a day but that’s not enough she says. If her pain was manageable she would be able to move around the house and do stuff and be less depressed and suicidal but I can’t really give her pain relief so what do u guys typically do with these pt?

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CBT or ACT for chronic pain. Some evidence for biofeedback. CAMS first if SI is chronic.
 
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Not yet a psych resident, but maybe look into methadone TID dosing, it’s for pain. And perhaps she’s also developed a bit of opioid dependence so it can help cover that.

If she’s depressed and in pain you can try venlafaxine, anxious and in pain maybe try some good old fashioned gabapentin 300 TID
 
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I found these to be really tough cases on inpatient as we know pain and substance use both are substantial risk factors for suicide. SNRIs and psychotherapy are great long term, but probably aren’t going to help you get someone discharged in a timely manner who has significant abdominal surgery related pain and just got cold turkey cut off long term pain regimen.

Do you have consultants available or pain management in network this person will be able to follow up with?

Ultimately for this sort of hospitalization to go well, you probably need to coordinate with a new outpatient pain provider to determine if long term pain management is going to be traditional opioid based or not. If so, you can start inpatient. If not, then finishing her detox and suboxone is probably going to be a consideration.
 
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So she hasn’t been cut off from opioids she used to be on a lot more then pain management limited her to the 4x per day 7.5mg Percocet 2 yrs ago, she has been on that regimen for 2 years and it has been 2 years of hell she says that’s why she wants to end her life because the pain is never gonna get better. She’s tried many antidepressants, gabapentin, therapies and nothing seems to help like the opioids she used to get. I’m not sure if this is a person seeking drugs or if really nothing helps but the opioids.
 
You coordinate CBT for pain, try to set her up with a new pain management doctor if she wants, and discharge her. Her suicidality is not going to improve on an inpatient psych unit. She sounds like someone with suicidality that is contingent upon optimizing her pain regimen. A lot of times, these patients are chronically suicidal.
 
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Consider whether an opioid use disorder is present and if so consider methadone or Suboxone (I really prefer Suboxone because outpatient management with that is more compatible with living a normal life).
 
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Consider whether an opioid use disorder is present and if so consider methadone or Suboxone (I really prefer Suboxone because outpatient management with that is more compatible with living a normal life).

But she needs to be on the opioid I think or else she will be in such extreme pain she’ll def want to kill herself. It seems like an impossible situation tbh
 
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Are there any good treatments for a lady on the inpatient unit that was admitted because of suicidal ideation due to chronic pain. She’s had many surgeries in the past and as a result has chronic pain all day only relieved by tons of opioids which were stopped by her pain medicine doc. She’s still on 7.5 mg Percocet 4x a day but that’s not enough she says. If her pain was manageable she would be able to move around the house and do stuff and be less depressed and suicidal but I can’t really give her pain relief so what do u guys typically do with these pt?
It sounds like methadone or suboxone could be appropriate for this woman, but from a general inpatient psych unit you're going to be hard pressed to find someone on the outpatient side who is willing to continue them unfortunately.
 
You are aware that some literature indicates that preference for opioids has limited relation to actual pain. And that chronic opioids have been implicated in opioid-associated depression thought to be mediated through hypogonadotrophic hypogonadism.

Breckenridge, J. and J. D. Clark (2003). "Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain." J Pain 4(6): 344-350.

Daniell, H. W. (2008). "Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain." J Pain 9(1): 28-36.
 
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Need a lot more info—especially why she was tapered. Were there concerns for misuse? Running out early? Or clinic simply said ‘we now have a policy that people shouldn’t be on greater than X amount of opioids’.

For patients on LTOT without misuse you continue the original dose. Force tapering is inappropriate, dangerous, and may lead to suicide when there is not compelling evidence to taper. Providers have a duty to these legacy opioid patients. We put them on opioids—it’s wholly wrong to cut them off without a better alternative, explanation why a taper may be helpful, going very slow, and having the option of going back if the new plan fails. There are clear risks of LTOT, but there are risks, like you’ve seen, of also fast tapering someone without full buy in.

There are other things you can do—ketamine infusions, methadone instead of another full agonist(but often providers are reluctant to do this), suboxone or suboxone+butrans. I’ve transitioned high dose LTOT patients to partial agonist and they’ve done better, but it has to be a joint decision.

Gabapentin is useless, potentiates opioid and puts person at higher risk. SNRIs are often not helpful unless the pain is certain neuropathies. There is often a trauma history and ptsd and pain mutually maintain one another—seeing a trauma therapist can be helpful.
 
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You are aware that some literature indicates that preference for opioids has limited relation to actual pain. And that chronic opioids have been implicated in opioid-associated depression thought to be mediated through hypogonadotrophic hypogonadism.

Breckenridge, J. and J. D. Clark (2003). "Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain." J Pain 4(6): 344-350.

Daniell, H. W. (2008). "Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain." J Pain 9(1): 28-36.

No I didn’t know that thanks for your insight

Need a lot more info—especially why she was tapered. Were there concerns for misuse? Running out early? Or clinic simply said ‘we now have a policy that people shouldn’t be on greater than X amount of opioids’.

For patients on LTOT without misuse you continue the original dose. Force tapering is inappropriate, dangerous, and may lead to suicide when there is not compelling evidence to taper. Providers have a duty to these legacy opioid patients. We put them on opioids—it’s wholly wrong to cut them off without a better alternative, explanation why a taper may be helpful, going very slow, and having the option of going back if the new plan fails. There are clear risks of LTOT, but there are risks, like you’ve seen, of also fast tapering someone without full buy in.

There are other things you can do—ketamine infusions, methadone instead of another full agonist(but often providers are reluctant to do this), suboxone or suboxone+butrans. I’ve transitioned high dose LTOT patients to partial agonist and they’ve done better, but it has to be a joint decision.

Gabapentin is useless, potentiates opioid and puts person at higher risk. SNRIs are often not helpful unless the pain is certain neuropathies. There is often a trauma history and ptsd and pain mutually maintain one another—seeing a trauma therapist can be helpful.

Yeah it seems that pain management just decided that their policy was that she was on too much so they limited her to the 4x per day Percocet. It’s annoying because if they just continued what she was on for several years she was doing good and not having much problems but since they’ve cut her off now she becomes a psych problem and of course we cant prescribe her opioids so it’s a never ending cycle now. Thank you for your insights tho very appreciated
 
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Yeah it seems that pain management just decided that their policy was that she was on too much so they limited her to the 4x per day Percocet. It’s annoying because if they just continued what she was on for several years she was doing good and not having much problems but since they’ve cut her off now she becomes a psych problem and of course we cant prescribe her opioids so it’s a never ending cycle now. Thank you for your insights tho very appreciated

This is not a psych problem. This is a pain management problem. Unless she has a substance abuse problem, this is not a psychiatric issue.
 
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This is not a psych problem. This is a pain management problem. Unless she has a substance abuse problem, this is not a psychiatric issue.

Absolutely.

If someone said they were in extreme pain and wanted to kill themself to be rid of the pain because a urologist refused to remove their kidney stone, that’s not a psych problem that’s a urology problem.

This is pretty clearly based on the additional info a pain management problem. They cut her off too quickly without adequate buy in or a backup plan....now she’s on your unit for “SI”.

Agree with the above with seeing if she’d be willing to tough detox out while inpatient and start Suboxone (as long as she can get good follow up for this...). I’ve seen patients with opioid use disorder and chronic pain do fairly well on it. Otherwise I’d be trying to get into contact with her pain management outpatient person and letting them know what the situation is and your concerns about their rapid taper causing her symptoms...ask them what the game plan is now from their standpoint since this is pretty much a pain management issue.

Adjusting expectations is also super helpful...in the few patients I had like this I made it very clear to them that their pain would not be significantly improved by the time they left the hospital but we would try to get them good outpatient follow up (no pain management inpatient at our main psych hospital).
 
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I would have a talk with intake or whomever accepted this patient to your hospital. Anyone on a high OME should be taken to a hospital with pain management available.

BTW, opioid-induced hyperalgesia is very real
 
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Agree with the last few comments. It seems like her suicidal thoughts are secondary to poorly controlled pain, so this really isn’t the kind of patient who will gain much benefit from a psychiatric inpatient admission if you’ve excluded a substance use disorder.

The questions that need to be answered is why did her pain specialist change her dosage, what was their plan and what alternatives were being considered. As it appears to be completely arbitrary decision, I’d look at clearly documenting the onset of her depressive symptoms in relation to the medication changes. We know that chronic pain can negatively impact on mood, so if a causal relationship can be identified this would be one I’d hand back to the pain specialist who made the initial changes. If they are not comfortable with whatever dose she was on before, then perhaps they should be looking at getting a second opinion instead of blindly following a generalised policy and not taking individual patient factors into account.
 
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I do inpt psych for a hospital belonging to a large psych chain (not UHS). I sometimes get patients like this (of course, when I accept them, i don't know the cause of their SI). A difficult problem to deal with. In Tennessee, several months ago a pill mill chain of clinics was closed down by the feds, and their are a lot of patients out there having trouble getting their prior opioid prescription. Especially problematic is that they don't have access to their medical records from the pill mill.
 
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Are you in a state that certifies cannabis for chronic pain?
 
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Pain management consult +/- suboxone for opioid use/pain if appropriate. Unlikely to improve from inpatient admission, but you could certainly clarify diagnosis a bit and establish whether or not she has a substance use disorder vs. just chronic pain/opioid-induced hyperalgesia before sending her out.

You're not going to fix the problem this admission, but you can set up for regular treatment and therapy to manage pain.
 
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The cornerstone of treatment for these patients is CBT focused on adaptively coping with pain and functioning despite the presence of pain. Biofeedback can also be very helpful. Many of these patients have personality vulnerabilities that prime them to seek immediate resolution of negative emotions. Some of them will complain every day about how their pain is still there and you don't care about their pain but you just have to keep explaining that what they're doing now clearly isn't working, it's time to try a different approach, long term opiates may be counterproductive, etc.

Our mainstay psychopharmacological interventions were things like venlafaxine and duloxetine. We also use a lot of nortriptyline here, which seems to be effective for a lot of people. One of the above posters stated that SNRIs are not as effective for non-neuropathic pain. I'm not sure this is clearly the case but am open to correction. That being said, most forms of chronic pain probably have some neuropathic component. Anecdotally, we use a lot of these drugs and they do seem helpful. Carbamazepine can be helpful for those with bipolar disorder or whose pain is related to trigeminal neuralgia and a variety of anticonvulsants can help with migraines (doesn't seem like the case here).

As other posters have mentioned, ketamine infusions can be helpful in select patients. So can transition to methadone or Suboxone.

I have some disagreement with prior posters regarding the imperative to taper these patients. When you're seeing them on the inpatient unit, generally the clinical picture is one where long-term opiates have not worked. These are not stable outpatients who are benefiting from opiates without problems. These are people who are suicidal despite long-term opiate therapy. As mentioned before, every patient is different but many of these patients are temperamentally predisposed to seek an immediate solution. For many of them, use of opiates is an illness behavior that perpetuates and intensifies their chronic pain. Lots of these patients are at least ambivalent about tapering opiates, even if it's indicated.

We do all sorts of things on an inpatient unit that might make things worse before they make them better. This is part of the justification for hospitalization. When we cross-taper antipsychotics in people who are extremely sick, they might get worse. When we try to eliminate polypharmacy in geriatric patients with depression who are on a million meds, we might make them more suicidal in the process of getting them better.

I also disagree with those saying that you cannot do good work for these patients with an inpatient admission, though my perspective is probably biased from training at a place with a dedicated inpatient service and day hospital for chronic pain. These patients do require certain resources that aren't routinely available in every hospital. That said, you can get a lot of them better.
 
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This is not a psych problem. This is a pain management problem. Unless she has a substance abuse problem, this is not a psychiatric issue.

It is really unfortunate that this how physicians think. Pain is completely related to psych. When some has SI because of [fill in the reason] it is because there is also a mental health problem. Just like personality disorders deal with relationships when they don’t get their way. Granted, ACUTE pain can lead to severe discomfort, but CHRONIC pain is a completely different entity that does NOT relate to Acute pain (kidney stones), but rather perception of pain that is tied heavily to mental health.
When I see my patients, I build a connection, I train them to understand that pain can go down with less opioids, that some interventional procedures we do can help, that ultimately, people in third world countries use Tylenol. I train my PAs and NPs to focus on having empathy. Chronic pain is a complex field that shouldn’t be dismissed by psychiatry because patient had their opioids lowered so now it’s the pain physician’s fault.
 
It is really unfortunate that this how physicians think. Pain is completely related to psych. When some has SI because of [fill in the reason] it is because there is also a mental health problem. Just like personality disorders deal with relationships when they don’t get their way. Granted, ACUTE pain can lead to severe discomfort, but CHRONIC pain is a completely different entity that does NOT relate to Acute pain (kidney stones), but rather perception of pain that is tied heavily to mental health.
When I see my patients, I build a connection, I train them to understand that pain can go down with less opioids, that some interventional procedures we do can help, that ultimately, people in third world countries use Tylenol. I train my PAs and NPs to focus on having empathy. Chronic pain is a complex field that shouldn’t be dismissed by psychiatry because patient had their opioids lowered so now it’s the pain physician’s fault.
Do you perceive that all people who develop chronic pain that there is a component of poor mental health? I ask because I have a family member who seemed average as far as psychological health who after a kidney surgery now has developed chronic pain which has been debilitating. Previous to this I did see chronic pain related to below average psychological health but this experience has challenged that.
 
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It is really unfortunate that this how physicians think. Pain is completely related to psych. When some has SI because of [fill in the reason] it is because there is also a mental health problem. Just like personality disorders deal with relationships when they don’t get their way. Granted, ACUTE pain can lead to severe discomfort, but CHRONIC pain is a completely different entity that does NOT relate to Acute pain (kidney stones), but rather perception of pain that is tied heavily to mental health.
When I see my patients, I build a connection, I train them to understand that pain can go down with less opioids, that some interventional procedures we do can help, that ultimately, people in third world countries use Tylenol. I train my PAs and NPs to focus on having empathy. Chronic pain is a complex field that shouldn’t be dismissed by psychiatry because patient had their opioids lowered so now it’s the pain physician’s fault.

Chronic pain is not tied heavily to acute mental illness is the point and does not require inpatient psychiatric admission. This is not a psychiatric emergency. This is an outpatient pain management problem that can be helped by CBT augmentation, neither of which the patient will get on an inpatient psych unit.

Also, not sure it was a good idea to reference personality disorder to back up your point when you demonstrate a poor understanding (borderline offensive) of them.
 
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It is really unfortunate that this how physicians think. Pain is completely related to psych. When some has SI because of [fill in the reason] it is because there is also a mental health problem. Just like personality disorders deal with relationships when they don’t get their way. Granted, ACUTE pain can lead to severe discomfort, but CHRONIC pain is a completely different entity that does NOT relate to Acute pain (kidney stones), but rather perception of pain that is tied heavily to mental health.
When I see my patients, I build a connection, I train them to understand that pain can go down with less opioids, that some interventional procedures we do can help, that ultimately, people in third world countries use Tylenol. I train my PAs and NPs to focus on having empathy. Chronic pain is a complex field that shouldn’t be dismissed by psychiatry because patient had their opioids lowered so now it’s the pain physician’s fault.

This is incorrect.

There are a variety of situations in which someone may become suicidal or think that they would be better off not alive due to extremely adverse events in their life that have nothing to do with underlying psychiatric illness. This is actually a kind of amateur understanding of SI to make the blanket statement that when someone has SI because of (fill in the blank problem), they MUST also have a psychiatric disorder (unless that’s not what you’re saying by making the broad “mental health problem” statement which is rather overly broad). I mean this is almost a layperson understanding of suicidal ideation....

I would think that most, hopefully all, of us on here have encountered people who have suicidal ideation who don’t actually meet criteria for a diagnosable psychiatric disorder.

Of course, everyone on here is stating to make sure that the patient does not have an underlying psychiatric or substance use disorder to address but that doesn’t mean that there HAS to be one just because this person is reporting SI purely because of the terrible pain they have to endure every day.
 
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