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Old 01-08-2013, 03:21 PM   #1
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PAIN MEDICATION: For trauma or depression?

Hello all, especially fellow pain sufferers. This is a posting that I felt compelled to share since I cannot find a similar post on HealthBoards. In a nutshell, I have been experiencing chronic pain as a result of 3 surgeries - neck fusions (acd&f procedures)from 2008 until October, 2012. Each surgery was to prevent the loss of functions caused by nerve root damage, not to reduce existing pain. The pain has been chronic, persistent etc (my other posts can be read elsewhere in "Pain Management". I had been asked if I had taken certain drugs that are primarily used for treating depression. (We have all seen the ads on TV) Which, for me, brings me to this important question. A question that perhaps should more appropriately be asked of our doctor(s). And before anyone responds, please hear me out. Why are doctors prescribing antidepressants willy-nilly? Especially when narcotics / opiates work for pain suppression, at least in the short term! Firstly, let me affirm that I do not doubt that much pain is felt by many people because they are clinically depressed. This would be where there is necessarily no other reason for feeling pain. However, for the readers and posters of this wonderful health message board, I would think that anyone suffering from depression - as I do - are suffering because of their trauma, whether sustained as a result of an accident or surgery. And as a result of there being no cures on the horizon! So yes, myself and no doubt you, the reader, is depressed. And no doubt, like guinea pigs and not wanting to be AMA "against medical advice", we try these newly discovered anti-depressant medications. I suppose my point is this: our attending medical specialists should look further than their pharmacopoeia - books of drugs - when prescribing meds. Yes! Cimbalta, effexor, trazadone, amitryptiline, and nortriptyline ad nauseum do, at times, work for pain but only where the patient is suffering from clinical depression rather than depression resulting from chronic pain. Myself, and likely along with most of the other readers at this site have done our duties and tried these meds. All I ever experienced were the negative side-effects! Not one came close to relieving any pain. I would be most interested in feedback, pros and cons, regarding my opinion as expressed here. Which is, for all pain sufferers, think twice before taking anti-depressant medication where there was little or no depression before the trauma. And for our GP's and PM doctors: think twice before prescribing anti-depression medication for pain which commences post surgery or post accident!

 
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Old 01-08-2013, 08:30 PM   #2
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Re: PAIN MEDICATION: For trauma or depression?

Here's my opinion: I disagree with the statement that for these types of adjunct meds to work for someone's pain they need to be depressed at all...there is plenty of data that has shown this to the contrary. Anti depressants can have pain relieving properties. Yes much of their response is unexplained (not much info on why they work for pain in those which they do).

Yes often depression is co-morbid with chronic pain, but that hasn't been shown to have any relationship to the effectiveness of these meds. Yes they have a potential for side effects and its a balance of benefit vs. risk. Yes their use is often off label (except some for fibro for example).

I agree it can take a lot of trial and error to find a helpful adjunct med, and there are cases where a patient may go through even dozens of these meds without anything working (I have), but these are the more rare cases. The fact that a lot of us on forums report these meds not working is not so much a truth as it is an anomaly, as folks who go to their doctor, get a medication, and have it treat their pain aren't typically going to be posting on message boards.

The fact that pain medications are more likely to work isn't a very appropriate reason to use them more often or sooner in treatment. Although I suffered for years before I achieved any amount of pain relief, I'm glad that my doctor didn't initially hand me opiates without exploring other options. I have enough trouble currently trying to get relief due to my tolerance.

In fact, I wish it could have been delayed even more. Now that I have some pain relief I will keep wanting to chase it, and couldn't fathom going back to the full pain all the time. I'd suggest some reading on the pain relieving properties that medications such as certain anti depressants can have, separate from depression.

There are also many adjunct meds that aren't anti depressants (muscle relaxers, nerve pain meds, etc), if the patient was personally opposed to them. A good doctor would try to explain the potential benefits, but nonetheless respect the patient's wishes to try something else. Also, most of these are by no means new meds (Cymbalta is the newest you listed, and that has been out since 2004, about 8 years). Anything generic for example has been on the market for 10 years (when patents expire), and spent many years in testing before that. I'll admit though that I typically avoid meds the first couple years they are out though. Best wishes.
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Old 01-10-2013, 09:22 AM   #3
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Re: PAIN MEDICATION: For trauma or depression?

Hi Lanser, They have been using antidepressants to treat chronic pain longer than they have used opiates to treat chronic pain. Back in the 90's nobody prescribed pain meds for chronic pain or very very few docs did. Most of the meds available for pain now weren't even available back then, They didn't have all the long acting or the high strength short acting. Every surgery I have ever had, I was given 5 mg percs for the imediate post op pain and quickly reduced to hydrocodone. They didn't make 10mg or even 7.5 mg percs back then.

The theory behind using antidepressants is that they reduce the formation of a neuro transmitter known as substance P, you can google it, The studies they used back then showed that people with chronic pain have a higher level of this neurotransmitter in their spinal fluid than non pain patients, Antidepressants from any of the classes, have a similar effect in reducing the level of substance P. It wasn't untill Cymbalta actually did a clinical trial on the effects of antidepresants on pain did it obtain FDA approval which allows them to advertise the use of these meds for speific pain conditions. AntiD's have been used by PM docs for welll over 20 years. I know this because Ive been in PM for 20 years, On their own I didn't find them particularly effective but I recently added cymbalta to the cocktail of meds I take and I find it does help. I dont have depression, I have learned many coping skills over the last 2 decades and have certainly heard the argumant of what came first, depression of reactive depression, The botom line is that it doesn't matter. If it reduces one of the neurotrnasmitters involved in the transmission of pain than anyone should benefit from an anti D, It's just a matter of finding the one the helps the most and has the least side efects. Just becuase cymbalta did the clinical trial doesn't mean it's the only one that works, It's extremely expensive and time consuming to run a trial and not neccessary since any med can been used for any off label use.

One of the more relevant examples of an off label use would be Viagra, It was developed as a BP medication, however during the trials they kept getting reports of it's other effects to the point they lost all interest in it's BP effects, ran a trial to treat ED and we had the first working FDA aproved method for treating impedence or ED. Many meds have multiple uses and it's not always the use it was given FDA aproval for. Opiates are and should be the last line of defense when treating chronic pain, Bio feedback, relaxation techniques like self hypnosis, guided imagry and meds like anti depressants and antiseizure meds are front line meds for Chronic pain. Expect to try more than one and I wouldn't feel obliged to only try the ones that bothered to get FDA aproval like cymbalta unless you like the name brand prices, They never would have run the trials on cymbalta had they not had success with it's predecessors. Ellivill, prozac, zoloft, effexor etc etc etc. PM is trial and error, not gaurenteed relief with a potent opiate.
Good luck, Dave

 
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Old 01-13-2013, 12:06 PM   #4
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Re: PAIN MEDICATION: For trauma or depression?

Hi Shoreline, I don't know who 'Dave' is, but, re: your statement "Opiates are and should be the last line of defense when treating chronic pain" I believe this is and always will be the case. It certainly is for me, until I am shown viable alternatives. Regarding antidepressant medication for pain, I still believe it works only for those whose depression is not wholly rooted in their constant and chronic pain. Perhaps that too should be included in the last line of defense. Especially considering the nasty side effects that Cymbalta (et al.) can give (as it did me and everyone in my PM therapy group)!

 
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Old 01-13-2013, 12:51 PM   #5
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Re: PAIN MEDICATION: For trauma or depression?

Quote:
Originally Posted by lansur View Post
Hi Shoreline, I don't know who 'Dave' is, but, re: your statement "Opiates are and should be the last line of defense when treating chronic pain" I believe this is and always will be the case. It certainly is for me, until I am shown viable alternatives. Regarding antidepressant medication for pain, I still believe it works only for those whose depression is not wholly rooted in their constant and chronic pain. Perhaps that too should be included in the last line of defense. Especially considering the nasty side effects that Cymbalta (et al.) can give (as it did me and everyone in my PM therapy group)!
Dear lansur, I am trying to get your point. I too have never been depressed even though i have been in severe, chronic pain since 1998. When I was given cymbalta it worked for nerve pain but was Dc'd b/c of intraocular pressure. I took zoloft, paxil, wellbutrin,effexor, prozac & the anti-depressants made me have depression that i didnt/dont have unless the pm/anes insisted on me taking an anti-depressant b/c he thought i had to have a depression component b/c i have such pain but i havent/didnt/dont have depression except when taking certain antidepressants. I take trazadone for sleep but this antidepressant doesnt make me depressed. So, i couuld concede your point but not all anti-depressants make me depressed, if i am understanding you right??

 
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Old 01-13-2013, 03:44 PM   #6
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Re: PAIN MEDICATION: For trauma or depression?

Pain and depression share the same brain receptors. Depression can make pain worse and pain can make depression worse. If depression was an issue before the pain depression need to be addressed. There are Psych drs that specialize in the pain depression circle.
I have had un resolved pain post surgery for 3 years. Did shots, meds...blah blah.....i couldnt live with what the drs told me..."learn to live with it".....out of frustration I went to a Chiropractor....my sacroiliac was way out of alignment causing the pain, which was also causing my hip to wear where it shouldnt have and i'm not lookng at hip surgery.
good luck!

 
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Old 01-13-2013, 11:53 PM   #7
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Re: PAIN MEDICATION: For trauma or depression?

Hi Lansur, My name is Dave, That's why I sign my post that way. Your statement about antidepressants only being used if there is truly underlying depression just isn't true when antiD's are known to inhibit one of the neurotransmitters only seen in CP patients. Did you look up substance P. All antidepressant have an effect to some degree at inhibitting this neurotransmitter, I get that some have side effects, but just because everyone in your group didn't respond positively or had the same negative side efcts dooesn't mean you give up on antidepressants, You try others, They dont all produce the same side efects, I'm not experiencing any negative side effetcs from cymbalta, But I also excercise and stay as active as possible, so weight gain isn't an issue, sexual performance hasn't been an issue, All it's dont is take the edge off and that's what I was looking for rather than increasing my dose of opiates, Ive had a pump for 9 years and usually go years between increases other than when they make a switch and have to titrate again. Im certainly not saying antiD's are something everyone needs to take, but they are worth trying for your pain weather you have true clinical depression or just reactive to the circumstances, Of course being in pain is depressing but it doesn't mean your need an antiD, but if anti D's can reduce the formation of substance P, why not try it all. I look at it as if you can fight pain at several different point of the whole cycle your pain management is going to be more effective. Opiates have their place, antiD's affect a different part of the pain process than opiates and antiseizure meds effect the formation of Gabba, another neurotransmitter involved in neuropathic pain.If you look at pain as a 4 lane oval track, the idea of pain management docs using adjunct and non opiates is that they block a different part of the neurochemical pain process or a different lane in that circut. Alternative meds and alternative therapies work on different lanes of that oval biochemical circuit called CP. If you can block all the lanes at different points using different methods the combined effect will be better than sticking to just one med like oxycodone at any dose.

If cymbalta causes a weight issue you can either excercise or try a different antiD' perhaps you may respond to a tricucylic or better to a SSRI , their are some unique antiD's like trazadone and remeron that kind of stand alone in their class, but wether it's an SSNRI, SSRI, Tricyclic or whatever, they have all shown positive reults in other patients by reducing the formation of aditional substance P. I really haven't met a PM doc that is looking to treat depression, that alone has it's own specialty in psychiatry and someones doc may be more comfortable having someone that's more adapt at treating depression than the PM doc may have time for. After all, people with true depression have shown to respond better to the combination of meds and talk therapy than they are by treating with one or the other alone. Same idea with pain manangement, attack multiple points of the neurochemical process rather than simply feeding opiate receptors.

Their are meds like nemanada that are potent NMDA receptor blockers, another NT that when kept in check can help reduce tolerance and increease ones tolerance to pain. Many docs have used Dextormathorphan for the same purpose and their were even LA meds on the market that contain DXM for it's NMDA blocking ability. It's often one of the elements used in compounding meds to make a med longer lasting. Treating chronic Pain is all about the neurochemicals involved, blocking the production or the ability to increase or decrease selective neurochemicals that are known to be part of the chronic pain experience is why I truly belive in the board certication process rather than any doc just writing scipts because of a reps influence or a very simple understanding of chronic pain when only opiates are used is such a pet peve of mine.
Good Luck, Dave

 
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Old 01-14-2013, 03:24 PM   #8
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Re: PAIN MEDICATION: For trauma or depression?

Hi gmak, Whether or not you understand me is, perhap, irrelevant. But I certainly think you do. We have similar paths. I wish I could say that I am not depressed, or was not, before my surgical procedures. All of us, I believe, suffer, at times, depression of sorts. But I doubt there can be anything more depressing than to suffer chronic and severe pain knowing that we will likely have to suffer it until we die. If only "the rest of the world" would understand. Until then, good luck, best wishes and 'stiff upper lip' - what my very British father would say.

 
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Old 01-14-2013, 03:52 PM   #9
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Re: PAIN MEDICATION: For trauma or depression?

Hi lansur, Yes, sir! Lol thank you.

 
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