Low and therapeutic doses of antidepressants are associated with similar response in the context of multimodal treatment of pain.

BACKGROUND: Antidepressants are prescribed in a wide range of doses to treat both depression and chronic pain, with optimal psychopharmacology individualized for each patient. In the past decade more antidepressants from different chemical classes have become available and are being used for the treatment of both chronic pain and depression. OBJECTIVE: To review the utilization pattern changes and compare response rates of different classes and doses of antidepressants for various pain conditions in the context of multimodal therapies. DESIGN: Chart review. METHODS: We reviewed 5,916 records at an outpatient multidisciplinary pain center. Of these, 379 records were for patients diagnosed with cancer pain. Because the mechanisms and treatment approaches to cancer pain can differ greatly from non-cancer chronic pain, these records were excluded from the analysis. We assessed 1,506 medical records for patients with chronic non-caner pain who had used at least one antidepressant, with the main outcome measure being the Numeric Rating Pain Scale, 0-10. RESULTS: Of the 5,916 charts reviewed, 1,506 (25.4%) chronic non-cancer pain charts recorded the prescription of at least one antidepressant. Most patients received a combination of medications and procedures. Of the 450 patients receiving secondary amines, favorable responses were recorded for 340 (76%) patients, while 103 (23%) did not respond and 7 had unknown responses. Of the 492 patients receiving tertiary amines, favorable responses were recorded for 375 (76%) patients, while 113 (23%) did not respond, and 4 had unknown responses. Of the 533 patients receiving SSRI/SNRIs, favorable responses were recorded for 382 (72%) patients, while 147 (28%) did not respond, and 4 had unknown responses. Of the 369 patients receiving atypical antidepressants, favorable responses were recorded for 272 (74%) patients, while 94 (25%) did not respond, and 3 had unknown responses. LIMITATIONS: A retrospective study design and the use of antidepressants as a part of multimodal treatment of pain. CONCLUSION: The data suggest that in the context of multimodal treatment for chronic pain, antidepressant therapy at both low and therapeutic doses demonstrates similar response rates. Tricyclic antidepressants (TCAs), which include secondary and tertiary amines, as well as SSRI/SNRIs and atypicals, all appear to show similar favorable response rates.

Radiofrequency lesioning of the L2 ramus communicans in managing discogenic low back pain.

BACKGROUND: Discogenic low back pain is a common cause of chronic low back pain that remains a treatment challenge. The innervation and transmission of nociceptive information from painful lumbar discs has only recently been better described. OBJECTIVE: To report initial experience of effectiveness of radiofrequency lesioning of L2 ramus communicans in managing discogenic pain. STUDY DESIGN: A prospective, case series. METHODS: A case series of 5 patients who had radiofrequency lesioning of the ramus communicans at the L2 level. All patients had discogenic low back pain and had diagnostic blocks with local anesthetic at the level of the L2 ramus communicans demonstrating significant pain relief. Continuous radiofrequency lesioning at 80 degrees C of the L2 ramus communicans for 60 seconds was performed. Standard outcome measures of reduction in the visual analogue scale (VAS), improvement in function, reduction in pain medication, and consistent improvement in low back pain with repeating of the procedure after its initial effect has worn off were recorded. RESULTS: All five patients had consistent pain relief after a minimum of 2 radiofrequency lesioning treatments approximately 4 months apart. Four of the five patients had a reduction in pain medication, and all reported improvement in sitting tolerance and functioning. There were no side effects or complications. CONCLUSION: Radiofrequency lesioning of the L2 ramus communicans seems to offer partial relief for patients suffering from discogenic pain. Further studies are needed to confirm our results.

Pain patterns in patients with polycystic kidney disease.

BACKGROUND: Pain is a common problem in patients with polycystic kidney disease (PKD), but patterns have not been characterized as to frequency and severity. Physicians should be aware of pain problems so an approach to chronic pain management can be pursued. METHODS: One hundred seventy-one completed questionnaires out of 300 distributed to PKD patients whose renal function ranged from normal to end-stage renal disease (ESRD) were analyzed. Age at diagnosis of PKD was documented, and patients noted how the diagnosis was made. Location, severity, and frequency of pain were characterized. The Visual Analogue Scale (VAS) was used to measure pain intensity. RESULTS: There were 94 females and 77 male respondents, with a mean age of 47.4 years. Initial diagnosis of PKD occurred at a mean age of 31.6 years. Caucasians comprised 92.2% of the respondents. Patients' symptoms, a family history of PKD, and discovery of PKD during evaluation for hypertension or hematuria were the most frequent factors that led to the diagnosis. Order of frequency of pain was: low back pain, abdominal pain, headache, chest pain, and leg pain. Severity of pain, documented by the VAS intensity, was 4 to 5/10 in the majority of patients. CONCLUSION: Pain, which can be diffuse, is the most frequent symptom that led to the diagnosis of PKD in patients who responded to this questionnaire, and occurs with greater frequency than generally appreciated. Physicians need to obtain a detailed history about pain in their PKD population so as to allow an approach to pain management.