Treating Pain and Depression Without Getting Depressed Joseph P, Arpaia, MD www.jparpaiamd.com More than 50% of patients with chronic pain also have clinically significant depression. Interestingly that means a lot of patients with chronic pain are not significantly depressed. When depression and pain co-occur they reinforce each other. Depression Pain Depression simplified State of being in which Perceived Stress >> Perceived Resources Mind elects to give up, to conserve energy I just can t do it anymore Sleep and rest not restorative. Pain exacerbates these. 1
Treating Depression Simplified Increase perceived resources. Reduce perceived stress (demand). Increase stress tolerance (Medications). Factors that increase the pressure on a patient with pain. Anxiety exacerbates depression and pain directly Fear of pain Fear of loss of function Finances Loss of relationships When the fear of pain is greater than the fear of loss of function, then the patient is in a trap. Their fear of pain will reduce their function and that will worsen other areas of life and increase the anxiety about finances and relationships. Factors that decrease the resources for a patient with pain. Exhaustion reduces resources and leads to mistakes which increase demand Lack of restorative sleep Lack of ability to recharge during day Loss of social support reduces resources Pain prevents them from engaging in activities with others If they are always talking about their pain they become a pain and others will shun them. 2
How do depression and pain reinforce each other Depression reduces motivation to engage in helpful behaviors Reduced adherence to medical treatment Reduced adherence to lifestyle recommendations Reduced social contact depressed people don t like to do things and are not fun to be around Depression and pain both exacerbate insomnia Depression increases subjective sense of pain, and pain is depressing Effect on Provider Chronic pain rarely goes away Provider feels pressure to help patient Stress of being required to help patient, with few resources provider burnout and eventual depression. What do we do? Reduce stress on patient and provider Increase resources available for patient and provider 3
Cognitive flow for this talk: Principles Methods Techniques Principles Focus on improving function more than reducing pain, or reducing sadness. When depression and pain co-occur, depression is more debilitating than pain. Principles Focus on improving function more than reducing pain, or reducing sadness. Improved function usually leads to less pain and less depression in the long run. Reducing pain without any improvement in function is palliative care. Function is more objective than pain or sadness. Improved function can mean increased ability or finding meaning in spite of limitations. 4
Principles When depression and pain co-occur, depression is more debilitating than pain. A significant number of patient with chronic pain are not depressed. These people tend to function fairly well compared with patients who have similar pain and are depressed. Suicidal ideation correlates more with the severity of depression than the severity of pain. Principles Function is more important than feeling. When depression and pain co-exist Depression is more important than pain. Methods Assessment Non-pharmacologic interventions Pharmacologic interventions Connections 5
Methods Assessment Use rating scales to assess function. It is not how severe the pain feels, but how severely the pain affects the ability to function. Similarly it is not how distressing the emotions are but how severely they impair the ability to function. Techniques Assessment focus on function Example: 0 no symptoms 1,2,3 symptoms present but ignorable 4,5,6 symptoms cannot be ignored but do not interfere with important tasks 7,8,9 symptoms interfere with important tasks 10 can only lie in bed and suffer Have patient rate best day, worst day, and average day over past month. Methods Non-pharmacologic interventions Setting expectations Behavioral experiments Challenging unhelpful thoughts Changing self-talk 6
Techniques Non-pharmacologic interventions Setting expectations Goal is to improve function and increase meaning Reducing pain is also important but not at the expense of reducing ability to engage with life Need to learn to engage in spite of how one feels Reinforce improvements in function by giving attention to those. Techniques Non-pharmacologic interventions Behavioral experiments Look for activities patient is avoiding that have potential to be meaningful. Encourage them to test their fears. Reinforce the attempt, even if it was not successful. Techniques Behavioral Experiments; example Planned activity: Anticipated enjoyment: -10 to 10 (Do Activity) Actual enjoyment: -10 to 10 Comments 7
Techniques Non-pharmacologic interventions Challenging unhelpful thoughts Just because a thought is true doesn t mean it is helpful Point this out to patients Thoughts that increase focus on improved function or increased meaning in spite of limitations are helpful. Techniques Challenging unhelpful thoughts Unhelpful: My pain is always going to be here Helpful Even if my pain does not improve, I can find things to enjoy I can help others and make their lives better even if I am in pain My pain may be bad today, but it was better yesterday and may be better tomorrow. Its OK for me to feel sad about my pain for the time being because later I will find something else to focus on. Techniques Non-pharmacologic interventions Changing self-talk Have patient keep a positive log, i.e. record anything that goes better than expected. Focusing on successes no matter how small teaches the patient to do the same. 8
Methods Pharmacologic interventions Reduce pain Reduce depression Reduce both Adjuncts Opioids Generally do NOT increase long term function in chronic pain Higher doses seem to make chronic pain WORSE Very helpful for those with acute pain, but in chronic pain they tend to reduce function because of sedation, constipation, interference with sleep, Can cause or exacerbate depression. If dose tied to subjective report of pain, then that reinforces the patient being in pain, NOT GOOD. If dose tied to increased function, then that reinforces the patient doing things to increase function, OK. Benzodiazpines Generally do NOT increase long term function (in anyone) Cognitive impairment Increase fall risk Interact with opioids and combination can be dangerous Tolerance and addiction are issues Can use for sleep or anxiety, but be cautious 9
Antipsychotics NOT helpful for reducing pain NOT first choice for treating depression or anxiety due to poor benefit/risk ratio when compared with antidepressants NOT first choice for treating insomnia Anticonvulsants Can help with pain and sleep Gabapentin and pregabalin in particular Sleep inducing properties can augment antidepressants Weight gain and sedation can be a problem Muscle relaxants NOT Carisoprodel (Soma) due to abuse potential cyclobenzeprine sedating; has some structural similarity with TCA s but I haven t seen it really help with depression other than by improving sleep tizanidine has some alpha-2 agonist properties so helps with nightmares and anxiety but doesn t lower blood pressure as often as clonidine metalaxone not sedating so better tolerated during day baclofen orally results seem equivocal; can have seizures if suddenly stopped; usually not as sedating as others 10
Antidepressants need serotonergic and noradrenergic activity to reduce pain TCA s Reduce pain and depression Can help with sleep Can start with very small doses and titrate gradually Can check blood levels Side effects are dose-related and can be problematic especially in elderly or in those on sedating medications Anti-cholinergic side effects Amitriptyline most anticholinergic; desipraminemost noradrenergic Cardiac side effects; cardiotoxicity; get ECG for elderly or if dose is high Weight gain No sexual side effects Tramadol Weak mu-opioid agonist, ~5000 times weaker than morphine Analgesic properties for acute pain ~acetaminophen or NSAIDS Abuse potential is low, but not zero Little risk of respiratory depression and low sedation Inhibits serotonin and norepinepherinereuptake which decreases pain transmission in the spinal cord and contributes significantly to the analgesic effect Serotonin syndrome can occur if tramadol given with SSRI or SNRI Withdrawal is related to serotonergic and noradrenergic effect and is similar to that seen in withdrawal from venlafaxine or duloxetine. Need to taper very slowly, or can use an SNRI to reduce withdrawal symptoms, but then have to withdraw person from SNRI. SNRI s Cymbalta and Effexor Better tolerated than TCA s Can cause hypertension (dose-related effect) Weight gain can occur GI distress Nausea, diarrhea Sexual side effects Severe withdrawal syndrome Pain relief not as strong as with TCA s in my experience 11
SSRI s Can help with depression and anxiety but not with pain Watch for increased bleeding if on SSRI and NSAID Can interfere with sleep (see trazodone) Low toxicity Various SSRI s have different CYP effects and need to watch interactions Trazodone Reasonably good antidepressant Off label use for early, middle and late insomnia AM sedation is the main difficulty Can cause priapism ~1/1000 Often used with an SSRI or SNRI Bupropion Couple of studies show effective in neuropathic pain Inhibits reuptake of norepinephrine and dopamine Often combined with an SSRI No sexual or weight gain side effects Can cause anxiety, restlessness, like too much caffeine Seizure risk increases rapidly if dosing >450 mg /day Mirtazapine Low doses can help with pain and insomnia Can relieve gastric distress Can increase liver enzymes and can cause neutropenia Sedation and weight gain are main effects Stimulants Can help with energy, increase activity and reduce depression Can reduce perceived pain High abuse potential; tolerance is a problem Watch for cardiac effects in elderly 12
Overview for using medications Use smallest dose if in capsule form, or ½ smallest tablet. Titrate dose slowly, increase every 1-4 weeks, not days. Chronic pain is chronic, and any rapid improvements are not related to a direct pharmacologic effect. The placebo effect is large and has no risks, and if it does not occur at one dose or with one medication it may well occur with the next. Medical Marijuana Pain relieving effect probably from cannabinoids other than THC Not beneficial for long-term treatment of anxiety or depression THC responsible for main psychotropic effects, which can include psychosis (~5% of population susceptible) Very long half-life so person may not get psychotic till after 2-3 months of use Honesty better than covert use, and drug-testing just tells you if they are using it, not the amount. So I don t fire people for using it. I document that we are working to reduce use. If its medicine, then it is not used recreationally, the amount and time of administration are carefully regulated to reduce risk. Patients I ve seen this work for (i.e. improved function) generally use only q HS and THC dose is 10-40 mg / day; so 1 ounce of typical strain would last 2-8 months. Low THC strains have a higher benefit/risk ratio. Cannabidiol(CBD) more likely to cause reduction of pain and muscle tension. Little euphoric experience if ratio of THC:CBD <1:1. Sativexis nasal spray 1:1 THC:CBD prescribed in UK. Daily dose around 30 mg of each. Keeping Your Spirits Up Focus on increasing function is key. If patient is improving in function, then can empathize with their pain without feeling useless. Placebo effect is huge in pain and if you keep trying things that have a low side-effect profile then you are likely to eventually find something that is helpful. While you are trying things you keep working on increasing function. Each med trial or dose change buys you more time. Connect patient with community resources. This can include alternative providers. If the patient finds them helpful then fine. If you are concerned about the patient using herbal remedies useful resource (subscription required) is The Natural Medicines Comprehensive Database. Encourage movement especially movement that helps get them engaged in meaningful activities. Encourage your staff to ask about others in the patient s life. You do that as well. Get them focused outside themselves. 13
The difficult or threatening patient. Patient who threatens suicide or self-harm if doesn t get opioids. Different from patient expressing idea that life not worth living without relief from pain. That is them expressing their depression. The issue is when a patient is clearly trying to obtain opioids by threatening suicide or self-harm. Remember, suicidal ideation is a symptom of depression. Opioids are NOT a treatment for depression, and they can worsen depression. So, make that clear to patient and refer to ED for suicidal ideation. You might consider stopping the opioids. The difficult or threatening patient. Patient threatens to complain or sue because you won t prescribe opioids. Message is that there is nothing the patient can do that will make you prescribe something that you think may be harmful or not in their best interest. If they want to find a doctor who has a different opinion than yours they are welcome to do so. Give patient time to cool off. Then contact them and see what they say. If patient still threatens call your malpractice carrier for advice on how to document encounter. The King, the Mice, and the Cheese These patients are usually on multiple medications, and no one can remember all the interactions. Use a reliable source of information to check these. Rather than continuing medications that might be helping, take them off medication that are not clearly helping. Replace medications rather than add them to the regimen. Or start one and then taper off another. Be cautious about drug interactions, especially with alcohol. You can t caution the person enough about alcohol. Alcohol is a major contributing factor in prescription drug overdose. 14
References I can email anyone who is interested ~40 abstracts of articles from the last year. If you want this please email me jparpaia@me.com and I will send this to you. 15