Dr Penelope Ziegler's article was correct in the assertion that treating pain in a patient with a substance use disorder can be very difficult and requires consideration of multiple factors ("Safe Treatment of Pain in the Patient With a Substance Use Disorder," Psychiatric Times, January 2007, page 32); however, I believe several topics discussed require further clarification.
The table of possible nonopioid medications for use with chronic pain appears to indicate that atypical antipsychotics are—for the conditions listed (fibromyalgia, neuropathic pain, migraine, rheumatoid pain)—generally as effective as tricyclics (TCAs) and anticonvulsants. A few human and animal studies have been conducted on the possible analgesic effects of antipsychotics, but at present, these are not usually considered to be useful pain relievers.
In contrast, there have been multiple studies with TCAs and anticonvulsants and these are viewed as the most effective for treating fibromyalgia, migraine, and neuropathic pain syndromes.1-3 In fact, they are usually more effective for these conditions than opioids.
It also should be noted that the serotonin-norepinephrine reuptake inhibitors duloxetine(Drug information on duloxetine) (Cymbalta) and venlafaxine (Effexor) also appear to provide relief for these conditions and should be considered when TCAs are contraindicated.
NSAIDs and acetaminophen are effective analgesics. However, patients with substance use disorders are at especially high risk for experiencing the adverse effects associated with them. Alcohol(Drug information on alcohol) and injection drug abusers commonly have hepatic disease, which requires that acetaminophen be administered with caution. These patients may also be at risk for GI bleeding. Thus, the use of NSAIDs may precipitate a potentially lethal problem.
Methadone (Dolophine, Methadose) and buprenorphine(Drug information on buprenorphine) (Suboxone, Subutex) are employed as analgesics and for the treatment of substance abuse. Since there are different licensing requirements depending on the condition for which these agents are being prescribed, physicians must clearly document what it is they are treating.
Finally, the article mentioned the use of meperidine (Demerol) for postoperative pain. Because of adverse effects associated with this medication, all published pain guidelines of which I am aware recommend against its use for any type of pain. The most serious adverse effect is seizure. Since hospitalized patients who abuse or are dependent on alcohol are usually unable to obtain alcohol, they are at especially high risk for seizures, and clinicians should avoid prescribing medications that heighten this risk.
Steven A. King, MD, MS
Dr Ziegler responds:
I agree with all the points Dr King raises in his very thoughtful letter. Meperidine, alone and in combination with antinausea drugs, is very dangerous to use postoperatively or in an emergency situation, especially when dealing with an unknown patient. Unfortunately, many surgeons and trauma specialists still use it, and patients presenting to the emergency department often request it by name (ie, Demerol, Mepergan).
I also agree that acetaminophen should probably not be used at all, and NSAIDs should be used only with great caution in patients who abuse alcohol or drugs who are in active disease or early recovery. However, these medications are the workhorses of pain management for persons in sustained recovery who do not have persistent liver or GI impairment.
Regarding the off-label use of atypical antipsychotics in treating fibromyalgia, my clinical experience has reinforced the importance of establishing a relatively normal sleep pattern in these patients; using a sedating atypical agent is much safer than prescribing a benzodiazepine or benzodiazepine-like sedative such as zolpidem(Drug information on zolpidem) (Ambien) or eszopiclone (Lunesta) for patients with a co-occurring substance use disorder, since this will frequently complicate an already confusing picture.
Penelope Ziegler, MD