Pain, Anxiety, Addiction

September 18, 2013

pain & stressI recently attended a scientific meeting in Boston on Acute Pain Management.  Doctors in Massachusetts and many other states are required, for renewal of their license, to spend some hours of continuing medical education (CME) on a topic known euphemistically as “risk management”.  The “risk” referred to is medical malpractice.  The topic of pain management (either acute or chronic) is relevant because of the widespread use of narcotics (opiates) to treat pain, and the current epidemic of narcotic addiction in this country.  Doctors who over-prescribe narcotics to addicts are at risk of being sued for medical malpractice if their patients die of overdose or commit crimes to obtain narcotics.

I do not prescribe opiates myself, but do prescribe several classes of restricted drugs which can be habit-forming, namely, stimulants (Concerta, Adderall) for ADHD, and benzodiazepines (Ativan, Klonopin) for anxiety.  I also prescribe non-restricted psychotropic medications that help reduce pain (Cymbalta, Effexor, Remeron, amitriptyline, nortriptyline, Neurontin).

The topics of pain, anxiety, and addiction are all highly relevant to my primary interest in post-traumatic stress disorder (PTSD).  Stress of any kind, including post-tramatic stress, is physically painful.  Mental anguish can feel like actual pain (especially in the stomach, chest, and neck).  PTSD is associated with high levels of anxiety, particularly in relation to flashbacks and nightmares.  People suffering from PTSD may try to self-medicate with alcohol, marijuana (cannabis), opiates (Percocet, Demerol, Morphine, Heroin), or stimulants (cocaine, methamphetamine).  Self-medication with habit-forming substances can lead to addiction.

In treating PTSD with medication, I try to avoid prescribing potentially habit-forming drugs like stimulants or benzodiazepines, and try to assist people in recovering from addictions to alcohol, cannabis, opiates, or stimulants by using medications like trazodone (to induce sleep), prazosin (to reduce nightmares), and serotonergic antidepressants like Prozac, Zoloft, Celexa, and Lexapro (to reduce anxiety).  Antidepressants that increase noradrenaline (Wellbutrin, high dose Effexor) can make PTSD worse.  Prazosin, guanfacine, clonidine, and propranolol can reduce PTSD symptoms by blocking noradrenaline.

Antidepressants that reduce pain (high-dose Effexor, amitriptyline, nortriptyline) can increase anxiety, so one must be careful about treating pain in the presence of PTSD.  Stimulants can increase anxiety, so one must be cautious about treating ADHD in the presence of PTSD.  Neurontin, an anti-seizure drug, is useful in treating PTSD with pain, as it reduces both pain and anxiety.  Remeron, an anti-depressant, also reduces both pain and anxiety, and can be useful in treating PTSD with pain.  Remeron helps induce sleep, but can cause weight gain.

The most important treatment for PTSD is psychotherapy that involves exposure to the original trauma.  I like dream revision therapy, also called imagery rehearsal therapy (IRT), because it usually requires less exposure to the trauma than other forms of therapy.  Pre-treatment with trazodone and prazosin can help reduce nightmares so they can be addressed with dream revision therapy.  Management of sleep is crucial in PTSD treatment.  Getting a good night’s sleep is the first step toward recovery.