Your pain doctor handed you a referral to psychiatry at the end of a fifteen-minute visit.
You already have a theory. Somebody decided the pain is not real enough, and this is the polite version.
Both answers first. No, seeing a psychiatrist for chronic pain does not mean anyone decided the pain is imaginary. And no, we are not touching your prescriptions: we do not adjust another physician’s pain plan, and we do not prescribe opioids for pain under any circumstances.
That is a fixed policy, not a judgment about you. There is no pain prescription here to ask for, and none to take away.
If you are in crisis or thinking about harming yourself right now, call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or go to your nearest emergency room. Our office line, 817-659-7344, is answered during business hours, not as a crisis line.
Will you prescribe opioids for my pain?
No. Our chronic pain page says it in one line: we do not prescribe opioid medications for pain under any circumstances.
Not usually, not in certain cases, not once we know you better. Same answer on the first visit and the hundredth, so nobody walks into our Fort Worth office braced for a fight.
That page is equally direct about the other half: this is not a general pain clinic.
We will ask what you take, and the reason is safety. The duloxetine label warns that combining it with other serotonergic drugs, tricyclic antidepressants and tramadol, fentanyl, methadone and triptans among them, can raise the risk of serotonin syndrome. If a combination worried us, we would raise it with you and, with your permission, with the prescriber.
“Do you think the pain is in my head?”
No. The field’s own definitions are explicit. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Notice that emotional sits inside the definition of all pain, a broken ankle included, and that pain need not match visible damage.
IASP’s notes add that biological, psychological and social factors all influence pain, that pain and nociception (the nerve signaling itself) are distinct, and that a person’s report of pain should be respected.
Central sensitization, described carefully
IASP defines central sensitization as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.”
Plainly: the volume setting on a real signal can change.
What is a psychiatrist for chronic pain actually evaluating?
Four things, mostly: depression, anxiety, insomnia and trauma.
The National Center for Complementary and Integrative Health, part of NIH, describes chronic pain as lasting more than several months, variously defined as three to six months, and notes it may bring disturbed sleep, anxiety and depression.
We treat insomnia and anxiety as conditions in their own right, not as side effects of the pain. Both can improve whether or not the pain itself changes.
A 2021 study by Roughan and colleagues in Frontiers in Psychiatry describes the relationship as bidirectional, since having either condition raises the risk of developing the other, and reports that having both leads to poorer treatment outcomes and overall functioning than either alone.
Trauma belongs in this conversation
The VA’s National Center for PTSD states that “if you have chronic pain and PTSD, it can make each condition worse.” Pain acts as a trauma reminder, hypervigilance sharpens awareness of bodily sensations, and both disrupt sleep. The page is veteran-focused, but the pattern reaches further. If trauma is part of your history, PTSD care may be the more useful frame.
How does psychiatric care work alongside a pain specialist?
The CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain calls “a multimodal and multidisciplinary approach to pain management” critical and prefers nonopioid therapies for chronic pain. We are one corner of that picture; your pain physician, physical therapist and primary care doctor keep theirs.
What can psychiatric treatment realistically do for chronic pain?
A 2020 Cochrane review by Williams and colleagues compared cognitive behavioral therapy with no treatment in adults with chronic pain. People receiving CBT “probably experience slightly less pain and distress” at the end of treatment and six to 12 months later, and “may also experience slightly less disability,” at moderate and low certainty respectively.
The review says slightly twice, and that is as far as the evidence goes.
What treatment realistically aims at is room around the pain: sleeping, working, showing up for people, feeling something besides it. Even there the evidence is modest and the certainty low.
NCCIH calls CBT the prevailing psychological intervention here, and a therapist delivers it. What we provide directly is psychiatric evaluation and medication management for the conditions traveling with your pain; if CBT is the right addition, we will help you find it.
The CDC guideline also notes that patients with co-occurring pain and depression “might be especially likely to benefit from antidepressant medication,” a reason to have depression evaluated and treated properly instead of left running as background noise.
One reason that evaluation matters: the diagnosis changes the medication. Years of pain, broken sleep and a short fuse blur the line between unipolar depression and bipolar disorder, and the two are not treated the same way. Prescribed with no mood stabilizer to someone whose depression turns out to be bipolar, an antidepressant can flip the picture into mania or hypomania.
Which medications cross between pain medicine and psychiatry?
Several do, and their FDA labels differ more than people expect. Here is what the labels say for adults, no doses.
| Medication | FDA-approved pain indications in adults |
| Duloxetine (Cymbalta) | Diabetic peripheral neuropathic pain, fibromyalgia, chronic musculoskeletal pain. Also approved for depression and generalized anxiety disorder. |
| Milnacipran (Savella) | Fibromyalgia only. The label states it is not approved for major depressive disorder. |
| Pregabalin (Lyrica) | Diabetic peripheral neuropathic pain, postherpetic neuralgia, fibromyalgia, and neuropathic pain from spinal cord injury. |
| Gabapentin (Neurontin) | Postherpetic neuralgia only. Diabetic neuropathy, fibromyalgia and low back pain are off-label. |
| Amitriptyline | None. A depression label, so every pain use is off-label. |
| Nortriptyline (Pamelor) | None. Also a depression label, off-label for pain. |
That list is here so the words on your bottle make sense, not as an offer.
All four antidepressants above, duloxetine, milnacipran, amitriptyline and nortriptyline, carry the FDA’s antidepressant class boxed warning about suicidal thinking and behavior in children, adolescents and young adults. It applies to the class, not one product.
The gabapentin and pregabalin labels both warn of serious, life-threatening or fatal respiratory depression when combined with opioids or other central nervous system depressants. Pregabalin is also a Schedule V controlled substance. If you take an opioid, whoever prescribes a gabapentinoid needs to know, and the reverse.
Off-label does not mean improper or unstudied. It means the manufacturer has not obtained FDA approval for that particular use, which is a fact about the label rather than about the strength of the evidence. Your prescriber can tell you which uses are well studied. None of it is a reason to change anything on your own.
Do you prescribe buprenorphine for chronic pain?
No. Dr. Ghelber is certified to prescribe buprenorphine for opioid use disorder, a different condition entirely. The FDA lists three medications approved for it: buprenorphine, methadone and naltrexone. The Suboxone label gives its indication as treatment of opioid dependence. That creates no exception to anything above.
What about ketamine and TMS?
We offer both for psychiatric indications. For ketamine that means treatment-resistant depression, a use that is off-label and considered investigational by the FDA. Neither is offered here as a primary treatment for pain. Ketamine’s label covers anesthesia only, so any use aimed at pain is off-label as well. TMS devices are FDA-cleared rather than FDA-approved, and BrainsWay lists chronic pain among indications not cleared for commercial use in the United States.
Our own chronic pain page describes TMS being used off-label to target pain-related brain regions, and describes ketamine improving the experience of pain by treating the depression that travels with it. Both of those are off-label uses resting on thinner evidence than the psychiatric indications, and that is the honest frame for this visit: the route to your pain here runs through treating the psychiatric condition, not around it.
Both carry screening requirements. TMS is not appropriate for everyone with an implanted device, such as a spinal cord stimulator or a pump, or with certain metal in or near the head, and seizure history is reviewed. Ketamine is not appropriate when a temporary rise in blood pressure would be hazardous, the first contraindication on its label.
Chronic pain and suicide risk: why we ask about it
The CDC guideline also states that patients with chronic pain are at increased risk for suicidal ideation and behaviors, meaning higher than in people without it, one group set against another. It is why we ask directly, and why we ask everyone. Being asked is not an accusation.
If today is a hard day, call or text 988.
Frequently asked questions
Will a psychiatrist take away my pain medication?
Not here. We do not prescribe opioids for pain under any circumstances, and we do not manage, adjust or discontinue another physician’s pain prescriptions. We will ask what you take, because psychiatric medications interact with other medications. If something worried us, we would raise it with you and the prescriber.
Does being referred to psychiatry for pain mean my doctor thinks I am imagining it?
It should not. IASP’s notes state that pain is influenced by biological, psychological and social factors, and that a person’s report of pain should be respected. More often, a referral means someone noticed the depression, anxiety, insomnia or trauma that travels with long-standing pain.
Is depression and chronic pain treatment different from treating depression alone?
Somewhat. The CDC guideline notes that patients with co-occurring pain and depression might be especially likely to benefit from antidepressant medication. In the cohort Roughan and colleagues studied in 2021, participants with both chronic pain and depression reported significantly lower benefit from particular SSRI and SNRI antidepressants than participants with depression and no chronic pain.
What actually happens at the visit?
A conversation covering mood, sleep, anxiety, trauma history, what the pain has cost you, and everything you take. Expect a discussion rather than a physical workup: generally no imaging and no second opinion on your pain diagnosis. You should leave with a psychiatric assessment and a plan.
The bottom line
A referral to psychiatry means someone took the whole picture seriously enough to send you further into it. The visit exists because low mood, broken sleep, dread and old trauma frequently ride along with long-standing pain, and many people do improve on that side even when the pain stays stubborn. What we offer is care alongside your pain physician, honest expectations, and one fixed thing: no opioid prescriptions for pain, ever.
Talk with us
If you are in Fort Worth or the surrounding North Texas area and what you have read here sounds familiar, we would be glad to talk it through with you. The Institute for Advanced Psychiatry is an outpatient practice at 6800 Harris Parkway, Suite 100, treating adults 18 and older. You can request an appointment or call 817-659-7344.
If you are in crisis or thinking about harming yourself, please do not wait for an appointment. Call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or go to your nearest emergency room.
Sources
- International Association for the Study of Pain. “IASP Terminology.” Accessed 2026. https://www.iasp-pain.org/resources/terminology/
- Centers for Disease Control and Prevention. “CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022.” MMWR Recommendations and Reports. 2022. https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
- National Center for Complementary and Integrative Health, National Institutes of Health. “Chronic Pain: What You Need To Know.” 2023. https://www.nccih.nih.gov/health/chronic-pain-what-you-need-to-know
- Williams AC de C, Fisher E, Hearn L, Eccleston C. “Psychological therapies for the management of chronic pain (excluding headache) in adults.” Cochrane Database of Systematic Reviews. 2020;8:CD007407. https://www.cochrane.org/CD007407/SYMPT_what-are-benefits-and-risks-psychological-therapies-adults-persistent-and-distressing-pain-neither
- Roughan WH, Campos AI, Garcia-Marin LM, et al. “Comorbid Chronic Pain and Depression: Shared Risk Factors and Differential Antidepressant Effectiveness.” Frontiers in Psychiatry. 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8072020/
- U.S. Department of Veterans Affairs, National Center for PTSD. “Chronic Pain and PTSD.” 2026. https://www.ptsd.va.gov/understand/related/chronic_pain.asp
- DailyMed, U.S. National Library of Medicine. “CYMBALTA (duloxetine hydrochloride) Delayed-Release Capsules – Prescribing Information.” 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2f7d4d67-10c1-4bf4-a7f2-c185fbad64ba
- DailyMed, U.S. National Library of Medicine. “SAVELLA (milnacipran HCl) Tablets – Prescribing Information.” 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=16a4a314-f97e-4e91-95e9-576a3773d284
- DailyMed, U.S. National Library of Medicine. “LYRICA (pregabalin) Capsules and Oral Solution – Prescribing Information.” 2020. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=60185c88-ecfd-46f9-adb9-b97c6b00a553
- DailyMed, U.S. National Library of Medicine. “NEURONTIN (gabapentin) Capsules, Tablets and Oral Solution – Prescribing Information.” 2022. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee9ad9ed-6d9f-4ee1-9d7f-cfad438df388
- DailyMed, U.S. National Library of Medicine. “AMITRIPTYLINE HYDROCHLORIDE Tablets – Prescribing Information.” 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9110367c-4104-4836-8af3-649f86b0b3ea
- DailyMed, U.S. National Library of Medicine. “PAMELOR (nortriptyline hydrochloride) Capsules – Prescribing Information.” 2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e17dc299-f52d-414d-ab6e-e809bd6f8acb
- U.S. Food and Drug Administration. “Information about Medications for Opioid Use Disorder (MOUD).” 2024. https://www.fda.gov/drugs/food-and-drug-administration-overdose-prevention-framework/information-about-medications-opioid-use-disorder-moud
- DailyMed, U.S. National Library of Medicine. “SUBOXONE (buprenorphine and naloxone) Sublingual Film – Prescribing Information.” 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8a5edcf9-828c-4f97-b671-268ab13a8ecd
- DailyMed, U.S. National Library of Medicine. “KETALAR (ketamine hydrochloride) Injection – Prescribing Information.” 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=14e8f864-8b8a-4e7e-8439-e510d3107063
- BrainsWay. “Treatments – FDA-Cleared Indications for Deep TMS.” Accessed 2026. https://www.brainsway.com/treatments/
- Institute for Advanced Psychiatry. “Chronic Pain.” Accessed 2026. https://www.psychiatryfortworth.com/services/chronic-pain/
Medical disclaimer
This article is for general education and is not medical advice, a diagnosis, or a treatment recommendation for any individual. Reading it does not create a physician-patient relationship. Treatment decisions, including whether any medication or procedure is appropriate for you, should be made with a qualified clinician who knows your history. Do not start, stop, or change a psychiatric medication without talking to your prescriber. If you are experiencing a medical or mental health emergency, call 911 or 988.