When a patient is medicated for any condition, but especially when medicated for pain, anxiety or depression, it is important to understand the patient’s level of intellectual functioning, the reading ability, history of compliance, history or propensity for addiction/abuse and the potential difference between the goals of the prescription and the goals of this particular patient.

In the above example, my grandfather understood the goals of the medication. He understood the seriousness of his infection. He understood the purpose of taking all the prescribed medication. He did not understand the action of the medication, the side effect of the medication, the risks inherent in misuse of the medication or the importance of discussing any of the aspects of his care with his treating physician. Quite simply, he and the physician felt he “knew all he needed to know.” However, the outcome was certainly undesirable.

There is the frequently made statement that we under-treat acute pain (e.g. pain following injury or surgery) and then over-treat chronic pain (e.g. that which is likely to last indefinitely). When these problems become seemingly unmanageable, the patient is referred to a pain treatment center since pain management may appear bewildering.

One of the core problems is that patients are not psychologically prepared for pain, whether acute or chronic. They are most often told that “you may initially be a little uncomfortable.” I seriously doubt that many patients are told “you will be in screaming agony, and I really hate to get you started on pain medication.” However, when the patient complains of what he/she feels is intolerable pain, he/she is most often told that “we can give you something, but we do not want you to depend upon it.”

Now the patient is in pain for which he was not prepared and suddenly realizing that he is going to have to bargain for relief. When that relief is obtained, he is going to over-value its benefits and most often minimize its risk potential. As one patient told me: “well they wouldn’t make narcotics if we weren’t supposed to take them...and I’ll do whatever it takes to block this pain.”

A patient unprepared for pain, then reminded that relief from pain is something for which one needs to bargain, soon becomes a frightened patient. It also becomes a patient who feels that he/she must clearly demonstrate the degree of distress. One way to demonstrate distress is emergency calls to the prescribing physician and/or frequent trips to emergency rooms, often cycling through a collection of emergency rooms to avoid wearing out one’s welcome.

Interestingly, both pain and depression have not only common neurological pathways, but they also have common physiological impact: both pain and depression interfere with sleep. With sleep deprivation, that patient becomes less competent to deal with the pain.

Greater than 80% of antidepressants are prescribed by primary care physicians. Some orthopedic and neurosurgeons prescribe antidepressants while others prefer not to be involved in that aspect of care.

Among the benefits of antidepressants in patients with pain is that many of the newer SSRI antidepressants are also anti-obsessional. That is, the patient on these medications is less likely to ruminate (worry) about the same topics endlessly. Additionally, at proper dosage levels, the antidepressants result in less agitation, less irritability, less irrational thought and less variability of mood. And, as stated, when effective, many of the antidepressants result in improved sleep architecture (normal stages of sleep) so that the individual is better rested and more capable of coping with pain the following day.

A clear advantage of antidepressant therapies is that these agents are not addictive or habituating. They are most often well tolerated and often work at comparatively low dosages.

Anxiety is free-floating fear. It is a sense of disquiet accompanied by agitation, apprehension and worry. Patients in pain learn to be anxious as their medication is depleted, when they are in conflict regarding who more accurately sees their pain, their physician or themselves. While antidepressants also have the capacity to lower agitation, the anxiolytics (anti-anxiety agents) can be quite effective. There is the persistent concern that the patient will become dependent upon anti-anxiety agents. Once again, however, for short term and aggressive treatment, with a well informed patient, anti-anxiety agents can be a very effective means of calming the patient who is, at this point, fearful of their own pain experience.

Global Approach to the Problem

The most effective approach for managing pain, depression and anxiety in patients is to insure that they feel their complaints are adequately understood and treatment thoroughly explained.

Since pain is subjective, we often do not know without extensive investigation into the patient’s thoughts, mood and daily activities to what extent the pain is disruptive. These data can be reliably obtained, but they cannot be obtained during the course of a routine office visit. Often they cannot be obtained by the person prescribing the medication since the patient feels he/she must titrate-the-truth to insure that future access to the medication is not blocked.

Among the data that we need is:

How limiting is the pain?

What is the patient’s concept of managing pain?

What options is the patient willing to explore?

How much assistance can we expect from the family?

Does the patient have daily activities in which to invest or is he/she merely waiting for the next medication dosage?

Simply, we need to know more about the patient before we can determine what will be effective intervention and realistic precautions.