How to manage a patient with chronic abdominal pain, major depressive disorder, and domestic safety concerns due to daily alcohol consumption?

Management of Chronic Abdominal Pain with Major Depressive Disorder and Domestic Safety Concerns

This patient requires immediate assessment of domestic violence risk and safety planning before addressing chronic pain, followed by initiation of low-dose tricyclic antidepressants as neuromodulators while avoiding opioids entirely. 1

Immediate Priority: Address Safety Concerns

Screen explicitly for intimate partner violence using direct questions about physical harm, emotional abuse, and feeling unsafe at home. 1 The patient's statement about not feeling safe when her husband drinks daily is a critical red flag that supersedes pain management. Early-life adversity, trauma, and poor social support are established risk factors that accelerate the transition from acute to chronic pain and predict worse outcomes. 1

• Document her safety concerns in the medical record and provide resources for domestic violence support services, including hotline numbers and safety planning. 1
• Recognize that the presence of pain-reinforcing factors in the social environment, including lack of positive social support and substance misuse by household members, hastens conversion to chronic pain conditions. 1
• Consider that her worsening pain over the past two months may reflect increased stress from the unsafe home environment, as stress responsiveness amplifies pain through brain emotional arousal and central autonomic nervous system engagement. 1

Pharmacologic Management: Neuromodulators as Second-Line Treatment

Start amitriptyline 10 mg once daily at bedtime, titrating slowly to a maximum of 30-50 mg daily for pain management. 2 This low-dose tricyclic antidepressant (TCA) serves as a "gut-brain neuromodulator" with analgesic properties independent of mood effects. 1, 2

• Explain to the patient that TCAs modulate pain processing in the brain and spinal cord, not just treat depression, and that lower doses often suffice for pain relief. 1
• Anticipate that adverse effects (sedation, dry mouth, constipation) occur within days, but analgesic efficacy takes 1-3 weeks. 1
• TCAs are superior to SSRIs for abdominal pain based on meta-analysis data. 2

However, given her major depressive disorder, consider whether her current SSRI (sertraline/similar) adequately treats her mood symptoms. 1 If depression is poorly controlled, a serotonin-norepinephrine reuptake inhibitor (SNRI) like duloxetine 60 mg daily may address both pain and depression simultaneously, though evidence is stronger for TCAs in functional pain. 1, 3

• SNRIs show efficacy for both depression and chronic pain, with gradual improvement over 2-4 weeks. 1, 3
• Duloxetine demonstrated 56% reduction in abdominal pain severity and 64% response rate for depression in comorbid IBS-MDD. 3

Critical Medication Avoidance

Never prescribe opioids for this chronic functional abdominal pain. 1, 2 Opioids cause narcotic bowel syndrome (paradoxical pain amplification), dependence, gut dysmotility, serious infection risk, and increased mortality. 1, 2

• Narcotic bowel syndrome occurs in approximately 6% of chronic opioid users and is characterized by worsening abdominal pain despite escalating doses. 1
• Be direct with the patient that opioids and disability claims are associated with poorer long-term outcomes and do not reduce suffering. 1

Psychological and Behavioral Interventions

Refer to a psychologist experienced in chronic pain management for cognitive behavioral therapy (CBT) or gut-directed hypnotherapy. 1, 2 These brain-gut behavior therapies target cognitive-affective factors that amplify pain, including pain catastrophizing. 1

• CBT is most effective for patients who have insight into how thoughts, feelings, and behaviors relate to their pain. 1
• Gut-directed hypnotherapy works well for visceral hypersensitivity, provided she does not have severe post-traumatic stress disorder (which may be present given domestic violence concerns). 1
• Psychological flexibility and pain acceptance are associated with improved pain tolerance and better outcomes. 1

Assess for pain catastrophizing—the tendency to magnify pain's threat value coupled with feelings of helplessness. 1 This drives disability and unplanned care utilization. 1

• Patients at highest risk for chronic pain include those with pre-existing anxiety and depression, history of trauma, and poor coping styles like catastrophizing. 1
• Depression and anxiety independently predict pain reporting and correlate with pain burden, even in people without diagnosed IBS. 4

Non-Pharmacologic Self-Management Strategies

Initiate breathing techniques and relaxation training immediately, which can be taught by the gastroenterologist. 1 These address heightened autonomic arousal related to pain and stress. 1

• Regular exercise improves physical function and quality of life by offsetting the negative consequences of pain-related inactivity. 1, 2
• Mindfulness-based stress reduction teaches nonjudgmental observation of pain and has evidence in functional bowel disorders. 1

Dietary Considerations

Consider referral to a specialized gastroenterology dietitian if dietary triggers are suspected or if the patient is receptive to dietary modification. 1, 2

• A low FODMAP diet supervised by a trained dietitian may help moderate-to-severe gastrointestinal symptoms, but use caution in patients with moderate-to-severe depression or eating pathology. 1
• For psychological-predominant symptoms, a Mediterranean diet should be considered instead. 1

Monitoring and Follow-Up

Adjust visit duration and frequency to accommodate mental health needs and ongoing safety monitoring. 1 Elongate assessments over multiple visits if necessary to build trust, especially given her history suggesting abuse. 1

• Monitor for suicidal ideation, hopelessness, and deterioration in mental health at every visit. 1
• Inform her primary care physician or mental health provider about any changes in wellbeing, particularly risk of self-harm or harm to others. 1
• Recognize that depression is associated with repeat emergency department visits in patients with non-specific abdominal pain. 5

When to Refer to Specialists

Refer to a gastropsychologist or psychiatrist if she shows moderate-to-severe depression symptoms, suicidal ideation, low social support, impaired quality of life, or avoidance behavior. 1

• Severe psychiatric illness, concern about anxiety medication or opiate misuse, or eating disorders require specialist mental health referral. 1
• Integrated multidisciplinary care involving gastroenterology, pain management, and mental health services is essential for severe or refractory cases. 2

Common Pitfalls to Avoid

Do not perform repetitive testing once functional diagnosis is established, as this increases costs without benefit and reinforces illness behavior. 2 Limited investigations (such as celiac serology) are appropriate, but exhaustive workup should be avoided. 1

• Avoid language suggesting the patient "shouldn't be in so much pain" or continuing to order tests to find the "cause," as this engages in pain catastrophizing. 1
• Do not dismiss the reality of her pain—validate that both gastrointestinal and psychological symptoms are real and taken seriously. 1