Psychotropics Useful in Managing Chronic Pain; Practical Psychopharmacology: What Experts Do before Study Results Are in. (Psychopharmacology)

By Sherman, Carl | Clinical Psychiatry News, December 2001 | Go to article overview

Psychotropics Useful in Managing Chronic Pain; Practical Psychopharmacology: What Experts Do before Study Results Are in. (Psychopharmacology)


Sherman, Carl, Clinical Psychiatry News


Chronic pain is no stranger to the psychiatrist's office. In some patients, it is a secondary part of the clinical presentation; in others, it's the primary reason the patient has been referred.

Regardless of the pain's origin, antidepressants and anticonvulsants may play a role in its treatment: These drugs have analgesic properties independent of their psychotropic effects. They can be used alone or as an adjunct to opiates and other drugs when pain is moderate or severe.

When chronic pain is associated with psychiatric comorbidity, such as depression, anxiety or substance abuse, "the key is to treat the psychiatric comorbidity with an agent that also has proven efficacy for pain," said Dr. David A. Fishbain, professor of psychiatry at the University of Miami Comprehensive Pain and Rehabilitation Center.

When a patient is depressed, Dr. William Breitbart noted, "it's often very difficult to tease out whether pain is causing the depression or vice versa. I treat both simultaneously with antidepressants that have analgesic effects."

For Dr. Breitbart, this usually means a tricyclic, the class whose efficacy for pain is best supported by research. What is otherwise a vice--the impact of tricyclics on multiple neurotransmitter systems--appears to be a virtue here, and amitriptyline, the "dirtiest" among them, "is the standard against which other antidepressants have to be compared," said Dr. Breitbart, chief of the psychiatric service at Memorial Sloan-Kettering Cancer Center, New York.

When using tricyclics, blood levels should be monitored; there is evidence that the same concentrations that produce an antidepressant effect may be required for optimal analgesia, he said. Amitriptyline can help patients who have trouble sleeping or who have diarrhea or mouth sores as a result of treatment for diseases like cancer or HIV infection. But side effects from tricyclics are more often problematic, particularly for patients receiving opiates, which can cause adverse effects similar to those seen with tricyclics.

Tricyclics can increase blood levels of opiates, which may require a dosage adjustment. When tolerability is an issue, opt for a less-anticholinergic tricyclic, such as desipramine, or the selective serotonin reuptake inhibitor paroxetine, which appears to have some analgesic effects.

Dr. Fishbain also looks to tricyclics for an analgesic antidepressant, but his usual choice is clomipramine. Its efficacy is well supported by research, and its anti-obsessional properties are an additional benefit because rumination and preoccupation with pain are a problem for many patients.

If depression remains when the dose is as high as the patient can tolerate, he might augment clomipramine with venlafaxine, which also affects the neurotransmitter systems (serotonergic and adrenergic) that appear most important in pain modulation, and has some demonstrated efficacy as an analgesic. …

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