What Goes Up Must Come Down: The Complexity of Managing Chronic Pain and Bipolar Disorder
J.C. is a 40-year-old Caucasian woman who presented to the Kelly Family Medicine Clinic with multiple medical complaints, the most problematic being chronic myofacial pain, predominantly in her lower back, anxiety, and bipolar disorder. J.C. was well known to the military medical community owing to high utilization of primary and specialty medical care; however, a civilian, community-based psychiatrist was managing her psychiatric care.
J.C. is a high-school graduate with an unremarkable developmental history. Her psychosocial history was notable in that both of her parents were untreated alcoholics and prescription drug abusers. Her husband was discharged from active military service for diverting narcotics while working as a medical technician. Since J.C.’s husband was unemployable after leaving the military, J.C. became the primary income earner in her household, which caused both relational difficulties and personal maladjustment. J.C. held two jobs, both of which were physically demanding and both caused her bodily pain (back and legs). Within 2 months of her husband’s discharge, J.C. made her first appointment with the family medicine unit regarding her pain. Several subsequent appointments were made for complaints of diffuse lower-back and leg pain before she was referred to the pain management department at Wilford Hall Medical Center. She was treated by the Pain Management Department within Wilford Hall Medical Center for approximately 18 months. Although she had no documented mechanism of injury or skeletal pathophysiology, J.C. received deep muscle injections, facet injections, radiofrequency nerve ablation intervention, and nonsteroidal anti-inflammatory and narcotic pharmacotherapy over the course of her treatment by the pain management service. During this time period, she was also taking lorazepam (Ativan), although the exact dosages were unknown as she was initially getting this medication from both her psychiatrist and her primary care provider. The only interventions that J.C. reported being effective in the treatment of her pain were long- and short-acting opioid therapy. She was taking Oxycontin and Percoset for breakthrough pain. It should be mentioned that although J.C.’s physicians recommended physical activity, work modification, and nutritional behavior change, J.C. never initiated change of any kind. After 18 months of chronic early refills of narcotic analgesics, attempts at obtaining narcotics in other medical settings (urgent care, ambulatory primary care), and failed invasive interventions (injections/nerve blocks), J.C. was terminated from specialty care and referred back to her primary care provider. Given the fragmentation of her medical and psychiatric care, nothing was noted in her chart regarding her compliance with or response to her psychiatric medications for the bipolar or anxiety disorders.
KeywordsBipolar Disorder Behavioral Health Primary Care Provider Collaborative Care Behavioral Health Provider
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