Nowadays, opiate medications are primarily used to treat pain states, but there is a storied history of using these drugs to treat depression and other mental illness. In the absence of pain, opiates can induce euphoria – a welcome relief from melancholia. Many of the opiate preparations were used for women in response to mood swings associated with menstruation and childbirth – long before it earned the moniker postpartum depression. But as early physicians began to better understand the risk factors associated with opium preparations (tolerance, dependence, addiction), they fell by the wayside in the medical world, leading to extensive regulation and even prohibition in the early 1900s. But this has changed big time.
Many of the issues that people with chronic pain are dealing with are psychiatric in nature. Pain patients have high incidences of depression that so often go undiagnosed and subsequently untreated. Also, many clinicians make the false assumption that depression is an outgrowth of living with chronic pain, when it fact it is the other way around. So much so that depression places someone at 2-3 times the risk as that of the general population for developing a chronic pain syndrome. In addition, most of the medications used to treat affective disorders, such as antidepressants, mood stabilizers and antipsychotics, are the very same drugs with almost identical decision trees for treating neuropathic pain.
When it comes to evaluation, you have to understand the subjective feelings of someone with chronic pain, because chronic pain is poorly understood, conceivably difficult to manage and a source of frustration for both patients and their service providers. Thus, as with any patient, an alliance is necessary such that the chronic pain sufferer feels and believes you are on their side and fully comprehend their plight. Then you can open a dialogue with them about what might be contributing to or even causing the pain – such as aforementioned depression or the side effects of the opiates they are using. For example, chronic opiate use can actually exacerbate generalized pain as the dosage increases, and lead to cognitive impairment.
Once you’ve got an alliance established, you can then initiate a discussion about treatment – the core of which is rehabilitative in nature. This can be troubling for some, because rehabilitation means not focusing exclusively on making them comfortable, but more so on the factors and contributors to their pain. Rehabilitation is concerned with becoming more functional and productive and that these patients can actually do more than they have been doing; and that there are more efficacious and specific treatments than continued opiate use from which they are no longer benefiting.
Psychotropics for Neuropathic Pain
The medications with the best track record for chronic pain are the SNRIs – Effexor and Cymbalta, and the older tricyclic antidepressant Pamelor. It’s also important to push the dosage range – so 300-450mg of Effexor and 120mg of Cymbalta would be appropriate. Also anticonvulsants like Depakote and Lamictal have independent effects on pain and mood. Some patients receive benefit for pain but not mood, and vice versa with any particular agent, so it’s important to understand that it’s very unpredictable as to who will respond to what agent. As for antipsychotic augmentation, Zyprexa at a dose of 2.5 – 5mg at bedtime can work very well. Positive results have also come from Geodon 20 – 40mg in the morning. Latuda and Abilify have also worked well.
Expect resistance from some patients who might think you’re implying that their pain is all in their head. Reinforce the notion that people do improve when they discontinue narcotic medications – they sleep better, think more clearly, their mood becomes more upbeat and their pain is lessened. They need to hear that such positive results have been observed in thousands of patients and that opiate use has enslaved them to pain and not liberated them from it.
It’s imperative to approach chronic patients from the perspective that they would rather be healthy and living a gratifying life, than sick and living in a demoralized way. So it’s our job to help them find their way to functionality – even if it means not being completely pain-free.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.