Treat the Pain First—Worry about Psyche Problems Later
There is no more agony for the practicing physician than the pain patient with concomitant psychiatric problems. Whether it is depression, manipulative behavior, addictive tendencies, or dementia, all are problematic. One thing is certain: Severe chronic pain will cause one or more psychiatric symptoms. It is unavoidable.
One of the biggest mistakes that I observe in clinical practice is the chronic pain patient who is given all kinds of anti-depressants, manic-depressive agents, and antipsychotics—but no opioids. This mistake sets up a vicious cycle. The pain keeps sending excess electricity to the brain which causes hormonal abnormalities, hyperplasticity (rearranging of neurons), receptor scarring, and loss of brain tissue—all of which just bolsters the psychiatric problems and the pain. Worse, loss of mental capacity and dementia may set in. Opioids and most psychiatric medications mix quite well, so they can be given together with a modicum of clinical supervision.
My message is simple and clear. Aggressively treat the pain first to prevent psychiatric deterioration, then attack the existing psychiatric problem. In this issue are two excellent articles on psyche problems in pain patients. They give you the basis of why you treat pain first then, after it is controlled, treat the psychiatric problems. Not the other way around. Above all, do not ignore either. Drs. Jim Mack and Roy Reeves from the Jackson Mississippi VA hospital and Dr. Thomas Sachy from Georgia give us, in this issue, the very best summaries of psyche problems in pain patients that I have personally encountered. They have attached a sterling list of scientific and clinic references to support their basic construct, which is that chronic pain and psychiatric illness are joined at the hip. One begets the other. Sometimes from birth and sometimes as a result of pain’s electrical insult to the central nervous system. Unfortunately, when a pain patient presents we may not know whether the chicken or egg came first. All we know is we’ve got a mighty big egg and chicken to treat.
In the Sachy article there is a “must read” and “must know” section about the history of using opioids to treat psychiatric illness. It has long been known that opioids often control many psychiatric problems including schizophrenia, manic depression, and major depression. In my practice, I commonly observe that depression, or other psychiatric problem, often lifts after enough opioids are given to control the patient’s pain. Drs. Mack, Reeves, and Sachy all point out the close biologic brain relationships between depression and pain. Although the tricycle antidepressants, such as amitriptyline and desipramine, have been used for over three decades to treat pain, there is a new generation of antidepressants that simultaneously treat pain and depression. These new agents are excellent first line treatments. They include duloxetine (Cymbalta®), venlafaxine (Effexor®), milnacipran (Savella®), and desmethylvenlafaxine (Pristiq®). To emphasize the importance of simultaneously treating pain and depression—and thanks to new science and drug development—we now also have our first opioid that simultaneously treats pain and depression, tapentadol (Nucynta®).
There is a critical point that needs to be understood by pain practitioners. There are corticoid receptors in the amygdala, and uncontrolled pain is known to raise serum cortisol levels. Coming into focus is the stark reality that uncontrolled pain may cause profound hormonal abnormalities, hyperplasicity (rearranging of neurons), and receptor scarring. The prevention of these complications demands aggressive pain treatment after a painful injury, illness, or post surgery. There are a growing number of physicians who now believe that the brain changes caused by peripheral pain is responsible for the intractable, constant pain state that is incurable and demands high dose opioid therapy.
It is quite clear. Treat pain first, and treat it very aggressively when it first starts, or you may soon have a pain patient with psychiatric problems. If you have a depressed patient with a little headache or backache, take these pains seriously and treat them lest you end up with an extremely depressed patient with intractable pain.