Here's a case that illustrates the importance of factoring in the presence of pain when treating mental disorders in patients with seemingly intractable pain.
More and more frequently, I am getting the sense that as far as the rest of medicine is concerned, pretty much the only role psychiatrists have in the evaluation and care of patients with pain is to treat those who have opioid use disorder or who have another mental disorder that is considered to be unrelated to the pain.
Both are important roles for psychiatrists. Unfortunately, many of our physician colleagues-and even many of us-appear to believe that psychiatrists have little to contribute with regard to the pain itself or even to factoring in the pain to a treatment plan for a comorbid mental disorder. Many patients seem to think that psychiatrists are uninterested in physical pain and often fail to mention pain unless asked directly about it. Patients may even be concerned that the linking of pain and mental disorders in any way devalues the pain complaint by suggesting it isn’t “real.”
This case report illustrates the importance of factoring in the presence of pain when treating mental disorders in patients with seemingly intractable pain.
Mr. R is a 57-year-old attorney referred by his primary care physician (PCP) for treatment of depression. He has been depressed for approximately 8 months-since the death of his wife from breast cancer. He feels the depression is worsening, and he is having problems with decreased appetite, poor sleep, and anhedonia. His PCP prescribed paroxetine 3 months earlier, but Mr. R hasn’t noticed much improvement in his symptoms-even at a dose of 50 mg/d.
Mr. R reports that he takes tramadol regularly for low back pain. He has had chronic low back pain since an automobile accident 20 years earlier. He had taken ibuprofen or naproxen for the back pain with some relief, but he began having epigastric distress about 2 years ago when using these medications and his PCP recommended discontinuing them. Once he stopped taking the NSAIDs, the epigastric distress resolved.
1. When you ask about his back pain, Mr. R replies that he is willing to talk about it but doesn’t see how it’s relevant to the depression for which he was referred to you. What would your response be to Mr. R?
A. Explain that you are doing so just for the sake of completeness and that the depression will be the focus of your attention.
B. Explain that depression and chronic pain, including low back pain, often occur together and that when they do so this can influence treatment decisions for the depression.
C. Tell Mr. R that if pain and depression are occurring together, it means that the depression is secondary to the pain.
2. After examining the patient, you feel that a trial of a different antidepressant is indicated. Which would be the best choice?
3. With regard to Mr. R’s use of tramadol, what would you recommend?
A. Tell him to continue using it.
B. Tell him that with the addition of the antidepressant, it is doubtful continuing the tramadol will provide much additional benefit. Recommend tapering the dose and then discontinuing the tramadol after the antidepressant has had a chance to be effective.
C. Tell the patient that because tramadol contains an opioid, extended use would indicate he was becoming addicted to it.
D. Tell the patient that the opioid in tramadol is such a weak one that you will recommend his PCP prescribe a stronger one, such as oxycodone or hydrocodone.
4. The patient mentions he had taken diazepam that his wife had been prescribed during her terminal illness to help him sleep. He asked his PCP to prescribe diazepam for him, but she was hesitant and suggested he discuss this with you. How should you proceed?
A. Prescribe diazepam
B. Prescribe trazodone
C. Prescribe zolpidem
D. Discuss nonpharmacologic treatments
ANSWERS FROM PAIN MANAGEMENT QUIZ:
Answer: B. The association between pain and depression is often complex. While many people are depressed because of their pain, pain can also be a presenting symptom of depression. Even in patients with preexisting pain, the onset of depression can exacerbate the pain.
Answer: C. Duloxetine is the only antidepressant approved by the FDA for the management of back pain or any other form of pain. The SNRIs appear to provide the greatest analgesic effects of any of the antidepressants, and it is questionable whether duloxetine is more of an analgesic than the tricyclics and other SNRIs. In a younger person amitriptyline might be considered because of its sedating effects; however, because of the patient’s age-which increases the risk of adverse effects-it would generally be contraindicated, despite his poor sleep.
Answer: B. Tramadol contains a weak opioid combined with a weak SNRI. Studies indicate that most of its analgesic effect is due to the SNRI; thus, the addition of a separate SNRI is very likely to provide at least as much analgesia. Because of its opioid component, tramadol can be addictive and abused. Because studies have failed to find much benefit for chronic low back pain from opioids, the use of tramadol or a stronger opioid is not indicated.1
Answer: D. Current guidelines on the management of chronic insomnia recommend CBT as first-line treatment.2 CBT can also be beneficial for chronic pain. Not only are diazepam and other benzodiazepines not recommended for insomnia, but they should also usually be avoided in patients with chronic pain because their use can result in hyperalgesia.
Unfortunately, as yet, there are no clear guidelines for the use of other sleep medications for patients with chronic pain, so it is unclear how beneficial trazodone or other non-benzodiazepine medications such as zolpidem are for these patients. However, all of these medications are indicted only for brief use; thus, given the chronicity of Mr. R’s sleep problems, it is questionable how beneficial time-limited use will be.
1. Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med. May 23, 2016; [Epub ahead of print].
2. Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. May 3, 2016; [Epub ahead of print].