This article is one in a series on Medications for Pain. What are your choices? How do various medications work? What are the pros and cons? How about side effects?

Antidepressants are medications originally used to treat depression or anxiety, and which are also good for pain. Within this class, there are:

• Tricyclic antidepressants (TCAs), which include Amitriptyline (Elavil) and Nortriptyline.
• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors), which include Cymbalta, Effexor (specifically at higher doses), and Savella.
• SSRIs (Selective Serotonin Reuptake Inhibitors), which include Zoloft, Prozac, Lexapro, etc.

It’s important to know that antidepressants work for pain even if you’re not depressed or anxious. They have an independent pain-reducing effect. So if your physician recommends an antidepressant, that doesn’t mean that your pain is all in your head, or that you’re just anxious or depressed.

That being said, anxiety and depression often go along with chronic pain, unfortunately. So if that’s true for you, a good thing about these medications is that they also help depression, anxiety and PTSD (Post Traumatic Stress Disorder; PTSD can occur if there was a traumatic cause to your pain, such as a car or work accident). As well, because sedation is a common side effect of some antidepressants, they can help the sleep disturbance that accompanies pain.

Effect of Antidepressants: All antidepressants work to change neurotransmitters in the brain. Neurotransmitters are those chemicals by which nerves communicate with one another. TCAs and SNRIs increase both serotonin and norepinephrine, while SSRIs only increase serotonin. TCAs also affect many other chemical systems, so can cause many other side effects such as dry mouth, constipation, sedation, and cardiac and blood pressure effects.

It seems that the combination of serotonin and norepinephrine effect is what’s crucial in decreasing pain.

Medical Studies:

• TCAs: Out of 126 studies of TCAs for pain, 95% of the studies showed that TCAs were effective for reducing pain.
• SNRIs: Out of 10 studies, 100% showed that SNRIs were effective.
• SSRIs: Of 39 studies, 33% showed that SSRIs were effective.

So again, this demonstrates that the medications which affect both serotonin and norepinephrine work best at helping with pain.

Uses of Antidepressants: Let’s look at some examples of these medications for specific pain disorders. Cymbalta is FDA-approved to treat the pain that can accompany diabetes, called Diabetic Peripheral Neuropathy. Savella is approved for Fibromyalgia. Paxil is helpful for chronic daily headache and migraines. We do know that SSRIs are generally not helpful for neuropathic (nerve) pain.

Common Side Effects:

• TCAs: sedation, constipation, weight gain; less often heart arrhythmia, decreased blood pressure
• SNRIs: nausea, sedation
• SSRIs: headache, nausea

This article is in our series on Medications for Pain. What are your choices? how do various medications work? what are the pros and cons? how about side effects?

Anticonvulsants are medications originally used to treat seizure disorders. Within this class, there are:

1. 1st generation anticonvulsants, which are simply older medications. Tegretol and Dilantin are in this group.
2. 2nd generation anticonvulsants, which are simply newer medications. Medications such as Neurontin, Lyrica, and Topamax are in this group.

Effect of Anticonvulsants: Anticonvulsants work by decreasing the hyper-excitability of nerves, and so decrease how easily pain signals are transmitted.

Uses of Anticonvulsants: Because anticonvulsants work by slowing down nerve signals, they’re helpful in disorders that have overly-excited nerves. So they work best in nerve pain, which is called neuropathic pain. They don’t work as well in other pain disorders, for example pain caused by inflammation.

Neuropathic pain is pain caused by problems in the nerves running through the body (peripheral nerves), or in the brain or spinal cord. Some examples would be:

• Pain after amputation (nerves are cut and damaged with surgery)
• Spinal problems, such as herniated disks (pieces of spine are pushing on nerves as they leave the spinal cord)
• Microscopic damage to nerves in the body, such as occurs in diabetes (diabetic peripheral neuropathy) or shingles (post-herpetic neuralgia)

What’s most interesting about anticonvulsants is that they work in disorders where we might not expect them to work. An example is fibromyalgia, which used to be thought of as an inflammatory disorder or even a psychological disorder. Because anticonvulsants work, we now understand that fibromyalgia is, at least partly, neuropathic pain. This is an important advance, not just in treating fibro, but in understanding other pain disorders.

We now also know that there are changes in the brains of patients with fibromyalgia that make them more likely to experience pain. So recent brain studies confirm what responding to anticonvulsants suggests – this disorder is partly neuropathic.

What medications work? Some examples of FDA-approved medications:

• Lyrica in diabetic neuropathy and fibromyalgia
• Neurontin in shingles (post-herpetic neuralgia)
• Tegretol in trigeminal neuralgia

Medical Studies: Anticonvulsants are pretty well studied in various pain disorders, and they help in a wide range of disorders. What’s important to remember is that only some medications have been studied in some disorders, and have been FDA-approved. But that doesn’t mean that a medication won’t be helpful for a disorder it’s not formally approved for.  For example, Lyrica may help in shingles. It just may not have been studied yet. Your doctor should tell you if a medication she’s recommending is FDA-approved or not, and if not, how much it’s been studied for your disorder.

Side Effects:

• sedation (which can be helpful for sleep)
• tissue swelling
• weight gain
• cognitive interference (some patients call this “Neurontin head”)
• 1st generation anticonvulsants can have more serious side effects, including effects on blood cells.

Anticonvulsants should not be stopped quickly, as this can cause seizures.

Chronic illness is hard for patients to come to terms with. Something that will not get better with a quick diagnosis and easy treatment. As well, chronic illness is hard for people in our society to understand if they haven’t been there. “The fact that you’re just not going to get better seems unbelievable to most people. There must be something you can do that you aren’t doing! Eating raw foods, forcing yourself to exercise, thinking your way out of it, trying the latest drugs…. If you’re not better, then you’re not working hard enough.”

Laurie Edwards‘ new book, In the Kingdom of the Sick, explores many facets of chronic illness. It’s a book full of facts and insightful analysis, as well as patient stories which are interesting, heartbreaking and hopeful.

Chapters include:

• how chronic illness fits into the history of disease and medical advancement
• how disability rights and civil rights have affected the treatment of chronic illness
• gender and illness, focusing on diseases affecting women, such as pain
• the (mostly) good benefits of patient advocacy and “participatory medicine’

The book has a significant focus on pain. I would highly recommend it as an informative, interesting read. Many of the people quoted in the book are my online friends and colleagues, as well as people I’ve met at pain conferences. I respect them so much for their wisdom, personal sharing and patient advocacy. As I finished the book, I had the image of Laurie as a master orchestra conductor. Laurie was able to lead all of us in creating a beautiful whole. A few notes of piano are nice, as are a violin melody. But taken together, a symphony can be moving and inspiring. That’s what Laurie’s work is too! For more, see Laurie Edwards’ website.

We all have the occasional headache – maybe we’re tense and stressed, maybe we’re too tired, maybe we had a bit too much wine. But for some, headaches are more complex and painful. This book is for you if you’re beyond the “every once in a while” stage.

This book is written by a general medicine doctor, and this shows in the well-rounded treatment headaches receive in the book. This is an excellent overview of the types of headache and treatments for each. However, it goes beyond being just information you can read. It is an interactive workbook to help you gather information about your headaches and work with your doctor to get better treatment.

Dr. Ruoff provides a comprehensive list of treatments for headaches. This is crucial as there are many ways to help get headaches under control. Sections on diet, posture, relaxation, yoga, meditation, vitamins, etc, are included. As well, it includes logs and charts to gather and evaluate your own personal history, and then be able to see what is helping and what isn’t. Dr. Ruoff also includes sections on working with your physician to get the best treatment – by working together.

Knocking Out Headaches is an excellent workbook for those with headaches.

Carla Valentino developed a severe neurological pain condition, CRPS (also called RSD), after spraining her ankle. When her young daughter asked Carla when they’d be able to play again, this book was born. It’s a lovely, gentle, positive story.

We all know that pain diseases affect not just the person with the illness, but their family and friends too. Kids sometimes have a hard time understanding the facts about significant medical illness as well as why their family member isn’t their normal self. This book helps address these issues in several ways:

1. It normalizes a family’s experience with illness.
2. It specifically states that it’s not the child’s fault.
3. It lets children know that their family member is trying to get better, and wants to play with them again.
4. It suggests other ways for a family to be close and have fun, even with illness.

I would strongly recommend this book as a way of starting a dialogue with young children when there’s an illness in a family. An added bonus is that 20% of the proceeds from the book go to support CRPS research.

Doctor, Why Does My Face Still Ache?  is an informative, thorough book. I thought it was great!

Written by 2 dentist, the book offers information and help to patients with ongoing facial pain. Chapters include the biology of the face and neck, reasons for chronic facial pain, and treatment options. It is well written, friendly and easy to understand. Here’s what I especially liked about the book:

1. The authors understand that your brain is involved in chronic pain conditions.

Many things can go wrong in our bodies and cause pain, but chronic pain can also be an illness in the pain system itself. You can have no “underlying” cause, or have an underlying cause that has really healed, and still have pain symptoms. For those with  no underlying cause, your brain can generate pain signals all by itself. If an area has healed, your brain can be sensitized to keep generating pain signals. Recognition of this is crucial, because otherwise more and more time is given to trying to find what’s still wrong, which can expose patients to unneeded procedures.

2. A wide range of treatment options

Although the book is written by dentists, the treatment options include more than just dental-related treatments. The authors look at relaxation training, physical exercises, posture, medications, complimentary treatments including natural supplements, PT, sleep, and more. This provides options for patients. As well, if 1 thing doesn’t work, there are many alternatives.

3. The authors are dedicated and compassionate

A genuine concern and care for patients come through in the authors’ writing. They make an effort to communicate that your pain isn’t minor and that you aren’t imagining pain. They make an effort to get to know their patients and what’s going on in their lives. They recognize that their patients are people first. Understanding their patients’ lives also helps them to provide better care.

Overall, I think the book is excellent. It would be a wonderful resource for any patients with facial pain. As well, it’s a useful book for professionals in any discipline who see patients with facial pain. Great job, Drs. Tanenbaum and Roistacher!

We know that comprehensive pain treatment gives patients the best results. Less pain and better functioning. Unfortunately there are few integrative pain centers available, and few doctors practice truly bio-psycho-social care on their own. Dr. Stephen Colameco’s book Chronic Pain: A Way Out, is a wonderful example of a complete pain care program.

In the first half of the book, there is a thorough and state-of-the-art description of chronic pain. In particular Dr. Colameco explains our new understanding of pain – that chronic pain is located not just where you hurt, e.g. your back in chronic back pain or down your leg in sciatic pain, but is also imprinted in your brain. Colameco then describes what comprehensive care can include:

• medication
• surgery or procedures
• physical therapy
• psychological skills
• alternative and complementary treatment

As he is an addiction specialist, Dr. Colameco’s section on opiates and addiction is excellent.

The second half of the book is “the way out.” Rather than getting rid of pain, he describes  how to decrease suffering. This approach is modeled on a 12-step program. Included in this approach is:

• changing our attitudes to acceptance
• focusing on living rather than eliminating pain
• acknowledging that anxiety and depression increase pain
• focusing on spirituality

The approach Colameco presents is spiritually based, and this will appeal to some and not to others. Overall this book is very strong. It is one of the few patient-oriented books that describes a truly comprehensive treatment program. The sections on psychological skills and an attitude of acceptance are particularly helpful, especially given the book isn’t written by a mental health practitioner. It would be appropriate for those who would welcome a spiritual approach. It can offer a way out of suffering and a way back into your life.

This review is written by Jeisea, the excellent blogger at CRPS-RSD A Better Life.

What I’d like to share with you is the new NOI Group book The Graded Motor Imagery Handbook. This follows on from their really helpful Explain Pain book. Dr. Lorimer Moseley, one of the 4 authors says, “people in pain do better if they are given the resources to master their situation”. This new book provides a great resource.

A persistent theme is that treatment requires patience and persistence, courage and commitment. From my own experience I have to agree with that. There are five sections: knowledge, background, treatment, stories and tool boxes. Dr. David Butler explains that “graded motor imagery” (GMI) is a series of novel treatment strategies which remind us that representation of body in the brain should be considered in all patients. Importantly he says that patients cannot be just passive recipients of treatment. They need to self manage and understand that gaining knowledge is part of treatment – knowledge is power – knowledge can be therapy. “If you have knowledge of GMI, you have skills to know why it hurts so much today and how to deal with it.” Again, I couldn’t agree more. Not knowing what was happening to me and feeling like I had no control were the most frightening things about being diagnosed with complex regional pain syndrome (CRPS).

Dr. Moseley explains the science behind GMI which helps us understand the important message that, beyond doubt, pain can be reduced by brain retraining methods. Tim Beames goes much further into the practical aspects of treatment, the stages, adaptive techniques, how to use Recognise, implicit and explicit motor imagery and on to mirror therapy. There are also photos of mirror therapy in practice with a great “how to do mirror therapy” table on page 89. It’s refreshing to see the depth of information and practical support that Tom Giles gives in the last section. From system requirements and connecting to Recognize to making your own resources, Tom explains it all simply and logically.

I believe The Graded Motor Imagery Handbook  is a great resource for patients, but I consider it a must for those who treat people in pain. I got mine from NOI Group, but it’s also on Amazon. I know many clinicians loan Explain Pain to patients and hope that The Graded Motor Imagery Handbook is also shared in this way.

Thanks to Jeisea for sharing this resource and about NOI in general!