Psychiatrists Have Multiple Roles in Treating Chronic Pain

The Institute of Medicine (IOM) recently released a report titled "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" that describes pain as "a national challenge" requiring "a cultural transformation ... to better prevent, assess, treat, and understand pain of all types." Jon Streltzer, M.D., a professor of psychiatry at the University of Hawaii's John A. Burns School of Medicine, describes the role of psychiatry in pain medicine as important, "especially with regard to chronic pain, where psychiatric issues are common in the maintenance and severity of the pain. Psychiatric complications of treatment are also a critical issue."

Pain treatment "has evolved into a biopsychosocial paradigm," according to Raphael Leo, M.D., an associate professor of psychiatry at the School of Medicine and Biomedical Sciences of the State University of New York at Buffalo, who served on the Accreditation Council for Graduate Medical Education's (ACGME) Working Group and Subcommittee on Pain Medicine. He noted that psychiatrists are often involved in several pain treatment approaches. They include identifying and treating psychiatric disorders that complicate recovery, refining and administering psychopharmacologic agents that can be useful co-analgesic agents, monitoring for opioid abuse and dependence, and developing strategies to more effectively manage them when they occur. Psychiatrists also assist in the management of the emotional and cognitive components of pain or its treatment, as well as other social factors that interfere with rehabilitative efforts.

Interested psychiatrists may opt to seek subspecialty training and certification in pain medicine, although that route has primarily been pursued by anesthesiologists. The one-year multidisciplinary programs, which follow completion of specialty training, are accredited by the ACGME. The ACGME's Web site lists 92 programs for the academic year 2011-2012 with 315 onduty residents. In the 2001-2002 academic year, there were 101 accredited programs with 208 on-duty residents. Thus, over the past decade, the number of fellowship programs has decreased slightly, but the number of on-duty residents has increased substantially.

Multiple member boards of the American Board of Medical Specialties (ABMS) are involved in the certification process. In March 1998, the ABMS approved a joint proposal from the American Board of Psychiatry and Neurology (ABPN) and the American Board of Physical Medicine and Rehabilitation (ABPMR) to join with the American Board of Anesthesiology (ABA) in offering subspecialty certification in pain management. (The name was changed to pain medicine in 2002.) The ABA serves as the administering board, and the examinations are developed by a multidisciplinary group of subject matter experts, including psychiatrists and neurologists representing the ABPN.

The first examination was administered in 1993 to anesthesiologists, and beginning in 2000, it was opened to ABPN diplomates—psychiatrists and adult and child neurologists—and ABPMR diplomates. In addition, diplomates of ABMS boards other than anesthesiology may apply for examination through the ABPN or the ABPMR.

The examination consists of 200 multiple-choice questions administered annually at Prometric testing centers, a nationwide network for administering computerized examinations. The test includes questions from four broad categories: general topics (for example, relevant basic sciences, evidence-based medicine, ethical standards), assessment and psychology of pain (including epidemiology), treatment of pain, and clinical states (for example, cancer pain; headache and facial pain; and pain in infants, children, and adolescents).

From 2000 through 2010, 49 psychiatrists and six double-boarded psychiatrists/neurologists were certified in pain medicine, as were 203 neurologists and six child neurologists. According to the ABMS, through August 2010, 3,378 anesthesiologists and 1,311 physiatrists also were certified in the subspecialty.

During the "grandfathering" period from 2000 through 2006, diplomates could qualify for examination in multiple ways. In addition to both specialty certification by an ABMS board and possession of an unrestricted medical license, one of the following was required: satisfactory completion of an ACGME-accredited training program in pain medicine, satisfactory completion of a formal training program in pain medicine (non-ACGME-accredited), completion of 24 months (full-time equivalent) of practice in pain medicine, or a combination of formal training and practice. After 2006, satisfactory completion of a pain medicine training program accredited by the ACGME was required.

As with all other ABPN specialties and subspecialties, individuals who meet the requirements and pass the certification examination receive 10-year (time-limited) certificates and must participate in the ABPN's Maintenance of Certification program to maintain their diplomate status. Of the 39 ABPN diplomates in pain medicine whose initial certificates lapsed (certified in 2000), 23 (59 percent) have maintained their certification.

Further highlighting the role of psychiatry in what the IOM report describes as a major public-health challenge, Dr. Streltzer, a former member of the multidisciplinary test committee, suggested, "Pain medicine demands multidisciplinary training, and with recent federal proposals to require physician education in pain management to maintain a license to prescribe narcotics, there will be even more demand for the inclusion of psychiatric specialists."

However, a recent survey of psychiatry residency program directors conducted by Dr. Leo, a current member of the test committee, and his colleagues indicated that general (adult) psychiatry trainees are given very limited exposure to pain medicine either in didactic instruction or in clinical experience. He expressed a concern that this will limit the interest that future psychiatrists have in pursuing pain medicine as a subspecialty and, more important, that it "may stifle efforts to inform and collaborate with nonpsychiatric pain practitioners regarding the biopsychosocial components and psychiatric approaches essential to pain medicine."