Intro to Managing Chronic Pain: Practical Considerations to Improve Treatment Outcomes

In the first installment of the Managing Chronic Pain: Practical Considerations to Improve Treatment Outcomes video series, moderator Jeffrey A. Gudin, MD, Director of the Pain Management Center at Englewood Hospital and Medical Center in Englewood, NJ, weighs the pros and cons of various treatment options for chronic neuropathic pain with the panel, which consists of Charles E. Argoff, MD, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center; Christopher Gharibo, MD, Medical Director of Pain Medicine at the Hospital for Joint Diseases in NYU Langone Medical Center and Associate Professor of Anesthesiology & Orthopedics at the NYU School of Medicine; Vitaly Gordin, MD, Professor of Anesthesiology, Associate Vice-Chair of Chronic Pain, and Director of Pain Medicine Division at Penn State Hershey Pain Management; and Joseph Pergolizzi, MD, Adjunct Assistant Professor at Johns Hopkins University School of Medicine.

According to Pergolizzi, “a lot of times when a patient finally gets to see a pain management specialist, they’re looking for some more immediate gratification.” Consequently, one of his concerns with anticonvulsants, antidepressants, serotonin—norepinephrine reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) is their slow onset of action.

Among older patients with non-cancer-related neuropathic pain, another potential limiting factor may be tolerability, given the increased potential for comorbidities and “clinically relevant pharmacokinetic and pharmacodynamic drug-drug interactions (that) exist because of the rational polypharmacy they’re on,” Pergolizzi notes. Nevertheless, he believes antidepressants and anticonvulsants “do provide a decent opportunity for our patients once you get them to a titrated effect dose.”

But when Gordin informs a neuropathic pain patient that he is going to prescribe an antidepressant or anticonvulsant, the patient immediately responds with “I’m not necessarily depressed” or “I don’t have convulsions.” As a result, Gordin is obliged to educate patients on how the therapies suppress the excitatory neurons responsible for neuropathic pain.