The evolution of contemporary clinical pain care dates back to the publication of Melzack and Wall?s gate control theory in
the journal Science in 1965. Opioid prescriptions written by primary care practitioners and pain specialists soared, diversion
became a very large problem, and deaths and emergency room visits ascribed to opioids esca?lated.
There are three basic reasons for considering antidepressant medications for patients with chronic pain. First, psychiatric
disorders are common in patients with severe or disabling chronic pain. Second, sleep disturbance is common, even in patients
who do not meet criteria for psychiatric disorders. Third, there is evidence that certain classes of antidepressants produce pain
relief separate from relief of depression or other psychiatric disorders. As a Pain Specialist I discuss the third reason. Antidepressant
analgesia has been well investigated over the past two decades.
Pain specialists typically discuss anticonvulsants primarily in relation to neuropathic pain, and the clearest evidence for their
efficacy comes from studies of patients with this type of pain. As a first approximation, one could say that anticonvulsants should
be used with enthusiasm in patients with neuropathic pain and with caution in patients with other types of pain; unfortunately,
this simple rule is beguiling because the boundaries around neuropathic pain are far from clear.
Although monotherapy for neuropathic pain has been reported to produce significant benefit for approximately 70% of
patients the responses are often partial. As a practical matter, one will commonly encounter patients who continue to complain of
significant pain despite trials on anticonvulsants, antidepressants, and other first-line agents. In this setting, combination therapy
is a reasonable strategy. Unfortunately, combination therapy involving anticonvulsants has received only minimal attention in research.
Foad Elahi is a graduate from New York Medical College. He has completed one year fellowship in pain medicine. He is currently working as
associate professor at the department of anesthesia pain medicine at the University Of Iowa Carver College Of Medicine. His practice fully dedicated
to acute and chronic pain management.
Peer Reviewed Journals
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals