“At that point, you have to say, 'Is this really helping your problem? If it was, you probably wouldn't be here. Could it be hurting you?' Well, yeah, probably it is, in terms of some cognitive impairment, and a whole host of effects on autoimmune and endocrine function. Like anything else, you have to look judiciously at the specific risks and benefits for an individual patient,” he said.
Dr. Aronoff advises “erring on the conservative side” when treating any chronic pain patient with opioids or any other medications, since he considers these patients to be at high-risk for self-harm.
“I can't overemphasize that it is very important to do a very thorough mental status examination before prescribing any of these medications that have toxicity at low doses,” he said.
Within the larger context of chronic pain, patients with generalized pain syndromes deserve special consideration, Dr. Clark said.
Central sensitization appears to be the common denominator among fibromyalgia, interstitial cystitis, diffuse low back pain, chronic fatigue syndrome, irritable bowel syndrome, and headache syndromes, with resulting amplified pain sensations.
Depression itself may be a problem of central sensitization, he added. Such patients describe vague symptoms with a lack of clearcut etiology and a seemingly disproportionate degree of disability.
“The most important thing is you don't want to give these patients a little bit of everything and think that's the answer: a little bit of occupational therapy, a little bit of physical therapy, a little bit of psychotherapy and psychopharmacology.
“Throwing ingredients into a soup without a recipe is not the answer. These patients need to have someone design a rational plan for their care,” Dr. Clark said.
Dr. Schatzberg and Dr. Streltzer reported no relevant financial conflicts with regard to this story. Dr. Aronoff and Dr. Clark have both served on the speakers bureau or as consultants for Lilly Pharmaceuticals, maker of Cymbalta, and Pfizer Inc., maker of Lyrica. Dr. Aronoff also has been a speaker and/or consultant for Cephalon Inc., maker of several pain medications, and Endo Pharmaceuticals, maker of several opioids.
'You don't want to give these patients a little bit of everything and think that's the answer.' DR. CLARK