Chronic nonmalignant pain: How to ‘turn down’ its physiologic triggers
Ease suffering by managing psychiatric and social factors that heighten pain awareness.
Benzodiazepines have been used short-term to mitigate muscle spasm pain as in fibromyalgia, phantom limb pain, and restless legs syndrome.36,37 Long-term benzodiazepine use can lead to low activity levels, high use of ambulatory medical services, and high disability levels, however.38 if required for muscle spasm or restless legs syndrome, benzodiazepines may best be confined to short-term use.
Antipsychotics. Limited studies have evaluated antipsychotics’ efficacy for chronic pain.39,40 Some have been found to be useful in neuropathic pain.40 Antipsychotics are seldom used to treat pain because of limited efficacy data, potential side effects, and an abundance of alternate agents. Because risks—most notably extrapyramidal side effects and tardive dyskinesia—appear to outweigh analgesic efficacy, I would confine antipsychotics to pain patients with delirium or psychosis. Antipsychotics’ potential role in treating refractory pain might warrant further investigation.40
Stimulants may reduce sedation, dysphoria, and cognitive inefficiency that can accompany opioid use.
Table 4
Uses of psychotropics in patients with chronic pain
| Class/drug | Uses | Limitations |
|---|---|---|
| Antidepressants | Neuropathic pain, tension and migraine headache, FM, functional GI disorders, pain comorbid with depression/anxiety | NE/5-HT reuptake inhibitors are most effective for analgesia; side effects (TCAs may be least tolerable); drug interactions |
| Anticonvulsants | Neuropathic pain, migraine headache, central pain, phantom limb pain | Side effects (sedation, motor and GI effects, rash); drug interactions |
| Benzodiazepines | Muscle relaxation, restless legs syndrome, anxiety, insomnia | Abuse/dependence potential; sedation |
| Lithium | Cluster headache prophylaxis | Not effective for episodic cluster headache; risk of toxicity if dehydration occurs or with certain drug combinations |
| Stimulants | Opioid analgesia augmentation, opioid-induced fatigue and sedation | Abuse/dependence potential; overstimulation, anorexia, insomnia |
| Stimulants | Opioid analgesia augmentation, opioid-induced fatigue and sedation | Abuse/dependence potential; overstimulation, anorexia, insomnia |
| Antipsychotics | Neuropathic pain, migraine, cancer pain, delirium | Limited data; risks such as EPS and TD may outweigh benefi ts |
| EPS: extrapyramidal symptoms; FM: fibromyalgia; GI: gastrointestinal; NE: norepinephrine; 5-HT: serotonin; TCAs: tricyclic antidepressants; TD: tardive dyskinesia | ||
| Source: Adapted from reference 3 | ||
Table 5
Psychotropics approved for managing pain
| Drug | Indication |
|---|---|
| Carbamazepine | Trigeminal neuralgia |
| Divalproex | Migraine prophylaxis |
| Duloxetine | Diabetic neuropathy |
| Gabapentin | Postherpetic neuralgia |
| Pregabalin | Postherpetic neuralgia, diabetic neuropathy, fibromyalgia |
| Source: Adapted from reference 3 | |
- International Association for the Study of Pain. www.iasp-pain.org.
- Leo RJ. Clinical manual of pain management in psychiatry. Washington, DC: American Psychiatric Publishing; 2007.
- Loeser JD, Butler SH, Chapman CR, Turk DC. Bonica’s management of pain. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2001.
- Acetaminophen/hydrocodone • Lortab, others
- Amitriptyline • Elavil, Endep
- Carbamazepine • Tegretol
- Divalproex • Depakote
- Duloxetine • Cymbalta
- Fentanyl transdermal • Duragesic
- Gabapentin • Neurontin
- Lithium • Eskalith, Lithobid
- Pregabalin • Lyrica
Dr. Leo reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
