Low and therapeutic doses of antidepressants are associated with similar response in the context of multimodal treatment of pain

BACKGROUND

Antidepressants are prescribed in a wide range of doses to treat both depression and chronic pain, with optimal psychopharmacology individualized for each patient. In the past decade more antidepressants from different chemical classes have become available and are being used for the treatment of both chronic pain and depression.

OBJECTIVE

To review the utilization pattern changes and compare response rates of different classes and doses of antidepressants for various pain conditions in the context of multimodal therapies.

DESIGN

Chart review.

METHODS

We reviewed 5,916 records at an outpatient multidisciplinary pain center. Of these, 379 records were for patients diagnosed with cancer pain. Because the mechanisms and treatment approaches to cancer pain can differ greatly from non-cancer chronic pain, these records were excluded from the analysis. We assessed 1,506 medical records for patients with chronic non-caner pain who had used at least one antidepressant, with the main outcome measure being the Numeric Rating Pain Scale, 0-10.

RESULTS

Of the 5,916 charts reviewed, 1,506 (25.4%) chronic non-cancer pain charts recorded the prescription of at least one antidepressant. Most patients received a combination of medications and procedures. Of the 450 patients receiving secondary amines, favorable responses were recorded for 340 (76%) patients, while 103 (23%) did not respond and 7 had unknown responses. Of the 492 patients receiving tertiary amines, favorable responses were recorded for 375 (76%) patients, while 113 (23%) did not respond, and 4 had unknown responses. Of the 533 patients receiving SSRI/SNRIs, favorable responses were recorded for 382 (72%) patients, while 147 (28%) did not respond, and 4 had unknown responses. Of the 369 patients receiving atypical antidepressants, favorable responses were recorded for 272 (74%) patients, while 94 (25%) did not respond, and 3 had unknown responses.

LIMITATIONS

A retrospective study design and the use of antidepressants as a part of multimodal treatment of pain.

CONCLUSION

The data suggest that in the context of multimodal treatment for chronic pain, antidepressant therapy at both low and therapeutic doses demonstrates similar response rates. Tricyclic antidepressants (TCAs), which include secondary and tertiary amines, as well as SSRI/SNRIs and atypicals, all appear to show similar favorable response rates.

Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar epidural steroid injection

BACKGROUND AND OBJECTIVE

Epidural steroid injections are commonly used to palliate the symptoms of spinal stenosis. Deep tissue infection is a known potential complication of these injections. There have been no previous published cases of osteomyelitis without epidural abscess after such injections. We present a case in an elderly patient who presented only with persistent axial low back pain following a lumbar epidural steroid injection (LESI). We emphasize early patient evaluation, consideration of infectious predisposing factors, sterile technique, and skin disinfectant.

DESIGN

Open-label case report.

CASE DESCRIPTION

A 77-year-old diabetic male with a history of radicular pain related to lumbar spinal stenosis was treated successfully several years prior with a series of lumbar epidural steroid injections (LESI) and was re-treated with LESIs for recurrent symptoms. Following his second epidural injection, he presented with back pain and induration at the injection site without fever or neurological deficits. Urgent magnetic resonance imaging (MRI) revealed a soft tissue abscess extending close to the epidural space around the corresponding L4/L5 vertebral level. The patient recovered after incision and drainage of the abscess which was associated with an osteomyelitis of the L4 and L5 vertebral spine. The causative organism was methicillin-resistant Staphylococcus Aureus.

CONCLUSION

This case demonstrates that even with proper aseptic techniques, immune-compromised patients who are colonized with an aggressive micro-organism may develop a potentially catastrophic infectious complication if subtle persistent symptomatic complaints are not promptly and carefully evaluated.

The use of opioids in the treatment of osteoarthritis: when, why, and how?

As life expectancy increases every decade, the incidence and prevalence of osteoarthritis (OA) also will increase. Despite progress in our knowledge of the pathophysiology of OA, the management of OA-mediated pain continues to challenge physicians. Concern regarding the cardiovascular effects of cyclooxygenase-2 inhibitors and the gastrointestinal and renal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in general has limited the use of these medications in the management of chronic non-cancer pain. Appropriately dosed and monitored use of opioids for OA pain, when more conservative methods have failed, has potentially fewer life-threatening complications associated with it than the more commonly and often less successfully employed pharmacotherapeutic approaches to care. When used as part of a multimodal approach to pain control, opioids are a safe and effective treatment for joint pain, including that of OA. Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. Patient education and informed consent, exercise, complementary medicine, and the use of a controlled substance agreement increases the likelihood of patient compliance with treatment guidelines, improving functional capacity and quality of life.