• Home
  • Store
    • Newsletter Subscriptions
    • Multimedia Subscriptions
    • Books
    • eBooks
    • ABPN SA Courses
  • CME Center
  • Multimedia
    • Podcast
    • Webinars
    • Blog
  • Newsletters
    • General Psychiatry
    • Child Psychiatry
    • Addiction Treatment
    • Hospital Psychiatry
    • Geriatric Psychiatry
  • Log In
  • Register
  • Welcome
  • Sign Out
  • Subscribe
Home » Using Psychiatric Meds for Pain

Using Psychiatric Meds for Pain

July 1, 2004
Daniel Carlat, MD
From The Carlat Psychiatry Report
Issue Links: Editorial Information | PDF of Issue
Daniel Carlat, MD Dr. Carlat has disclosed that he has no significant relationships with or financial interests in any commercial companies pertaining to this educational activity.
Where does it hurt?

These are the “four little words” that Eli Lilly (in ubiquitous ads) is encouraging us to ask our depressed patients. The idea, evidently, is that if we psychiatrists get into the habit of evaluating somatic pain symptoms, we will discover them in many of our patients, and we will adjust our treatment plans accordingly. Lilly, of course, is hoping that our plan will include a prescription for duloxetine, but any drug company would be foolish not to jump on such a bandwagon: there are a lot of people out there who hurt.

The proper use of antidepressants (ADs) for pain in psychiatric patients is both complex and controversial, and Dr. Scott Fishman weighs in with his own views in this month's interview. In this article, we'll cover some of the relevant research and end with some common sense recommendations. We'll also touch, somewhat lightly, on the use of anticonvulsants for pain, focusing on those meds psychiatrists are most likely to use.

To begin with, how good is the evidence that ADs work for "straight" pain-that is, pain in the absence of depression? Well, the evidence is surprisingly strong. Hundreds of studies have been published, along with several metaanalyses. Fishbain, for example, did a meta-analysis of 93 placebo-controlled trials of various ADs for various pain syndromes. A majority of studies found tricyclics more effective than placebo for headache, fibromyalgia, chronic low back pain, arthritis pain, and miscellaneous acute pain syndromes. SSRIs largely flunked in this analysis, however (Ann Med 2000; 32:305-316).

Other reviews have also concluded that SSRIs are only marginally effective pain meds, but what about SNRIs, such as Effexor (venlafaxine) and the soonto- be-released Cymbalta (duloxetine)? Of these two, Effexor is the only one with published efficacy data for pain without depression; it was shown to be as effective as imipramine for painful polyneuropathy (Neurology 2003; 60:1284-1289), and showed promise in uncontrolled trials for migraine and tension headaches (Headache 2000; 40:572- 80), and for fibromyalgia (Ann Pharmacother 2003; 37:1561-5).

When it comes to comorbid depression and pain, however, Cymbalta has plenty of controlled data to recommend it (see TCR Jan 2004 for a review). As mentioned in that review, the methodology used in the Cymbalta studies included an outcome measure--the Visual Analog Scale for pain (VAS)--that has rarely been used in trials of other ADs. Thus, whether Cymbalta is actually more effective for "achy depression" than other ADs is still an open question.

Indeed, Effexor has recently entered the VAS fray with an uncontrolled study in which patients with depression and chronic pain showed improvement in both Ham D and VAS scores over the course of a year (Am J Ther 2003; 10:318-23). And we would guess that most TCR readers would have little trouble recalling depressed, somatizing patients in their practices in whom standard SSRIs have apparently quelled both physical and emotional anguish.

What about the anticonvulsants for psychiatric patients in pain? Of course, the only approved psychiatric indication for anticonvulsants is the treatment of bipolar disorder, an approval shared by Depakote (valproic acid) and Lamictal (lamotrigine). In addition, Tegretol (carbamazepine) is widely considered effective for bipolar disorder. All three of these medications are decent analgesics, and are approved for some painful conditions.

Depakote ER is FDA-approved for migraine prophylaxis, and is started at 500 mg QD for the first week, then increased to 1000 mg QD. As you can see, these doses are somewhat lower than what we are accustomed to prescribing for our bipolar patients. It's irksome and odd that Depakote ER is approved for migraine but not bipolar disorder, whereas standard Depakote is approved for bipolar but not migraine, but experienced clinicians won't let these relics of corporate marketing strategies get in the way of good patient care.

Tegretol is approved for one pain condition (trigeminal neuralgia), and considered effective for most types of neuropathic pain. Lamictal is not quite as well studied as Tegretol, but is also considered effective for neuropathic pain (Drugs 2000; 60:1029-52). Of these two, most psychiatrists would prefer to prescribe Lamictal, given the lack of drug interactions or need for blood monitoring. True, it may rarely cause Stevens-Johnson syndrome, but so can Tegretol (see TCR 1:9).

One of the most effective anticonvulsants for pain is Neurontin (gabapentin), which unfortunately is almost useless psychiatrically other than as a very expensive hypnotic (see TCR 1:3 for a review of these studies). But if you feel moved to treat your patients's neuropathic pain, Neurontin is a good bet because it's so safe and widely effective (Clin Ther 2003; 25:81-104). Just be forewarned that it has to be dosed fairly high for analgesic efficacy, in the range of 1800-3600 mg QD.

Of course, the list of novel anticonvulsants hardly ends here. The newer darlings, all of which have been used in psychiatry, are Topamax (topiramate), Trileptal (oxcarbazepine), Gabitril (tiagabine), Zonegram (zonisamide), Keppra (levetiracetam), and the soonto- be-approved pregabilin. See TCR 1:9 for coverage of Topamax and Trileptal, and stay tuned--we’ll get to all of them eventually!

TCR VERDICT
Pain: There’s plenty we can do with the meds we know.
General Psychiatry
Carlat 150x150
Daniel Carlat, MD

20 Years of The Carlat Report

More from this author
www.thecarlatreport.com
Issue Date: July 1, 2004
SUBSCRIBE NOW
Table Of Contents
Heroin for All
Dr. Scott Fishman on Psychiatric Approaches to Pain
Fibromyalgia: What Should We Make Of It?
Pain Treatment Update: The Opiates and NSAIDs
Using Psychiatric Meds for Pain
DOWNLOAD NOW
Featured Book
  • MFB6eCover.jpg

    Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)

    Guidance, clinical pearls, and bottom-line assessments covering the medications you use in your...
    READ MORE
Featured Video
  • therapist_canstockphoto9201097.jpg
    General Psychiatry

    Using SAMe In Clinical Practice with Garrett Rossi, MD

    Read More
Featured Podcast
  • canstockphoto11543850.jpg
    General Psychiatry

    Elvis, Adderall, and a Broken Heart - Part 1

    A new medical investigation changes our understanding of Elvis Presley’s untimely death and offer some pearls for modern psychiatric practice.

    Listen now
Recommended
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Newsletters
  • Multimedia Subscriptions
  • Books
  • eBooks
  • ABPN Self-Assessment Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Child Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Hospital Psychiatry Report
  • The Carlat Geriatric Psychiatry Report

Contact

info@thecarlatreport.com

866-348-9279

PO Box 626, Newburyport MA 01950

Follow Us

Please see our Terms and Conditions, Privacy Policy, Subscription Agreement, Use of Cookies, and Hardware/Software Requirements to view our website.

© 2023 Carlat Publishing, LLC and Affiliates, All Rights Reserved.