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4 Articles in this Series
Introduction
Chronic Pain and Its Companions
Opioids & The Taper Talk
Painful Diabetic Neuropathy: Could SCS Replace Pharmacologic Management?
The Links Among Peripheral Arterial Disease, Lumbar Stenosis, and Claudication

Chronic Pain and Its Companions

with Gary W. Jay, MD, FAAPM and Charles E. Argoff, MD

Pain specialists know – they don’t just treat chronic pain; they also often deal with a list of other conditions in their patients that are inter-related to that pain, highlighted Gary W. Jay, MD, FAAPM, clinical professor of neurology at the University of North Carolina, Chapel Hill, whose talk at PAINWeek 2020 was titled "3 Doors, Lost Keys." Dr. Jay also serves on the editorial advisory board of PPM.

In a separate but related conference session, Charles Argoff, MD,  professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center, talked about how to manage patients with pain and cognitive impairment, including memory issues. His talk was titled "Go Ask Alice: Pain Management in Older Adults."

Here, some highlights from both sessions.

The co-occurrence rate for chronic pain and major depressive disorder (MDD) ranges from 30 to 60%. (Image: iStock)

 

Chronic Pain Doesn't Travel Alone

It's important for clinicians to remember that pain and psychiatric disorders often coexist. The co-occurrence rate for chronic pain and major depressive disorder (MDD), for example, ranges from 30 to 60%, noted Dr. Jay.  "Chronic pain and depression amplify each other, and make treatment harder," he said. There are other common threads with anxiety, mood disorders, fatigue, chronic stress, and cognitive impairment. These comorbidities complicate diagnosis, compromise treatment outcomes, and affect the patient’s functioning and quality of life.

What lies behind these connections? Dr. Jay called it “the heavy neurochemistry" of pain, which he pointed out, ''apparently it bores folks." However, this neurochemistry helps to explain what doctors need to know and why. "The effects of depression and sleep, for example, deal with the same anatomy, chemistry, and cells as chronic pain – and that has a bearing on treatment.”

MDD and chronic pain have a common pathophysiology as well. When the two coexist, they can make treatment of each other more difficult. On an anatomical level, structural and functional changes in the amygdala and hippocampus have been found in MDD, as well as in fibromyalgia and neuropathic pain, he added. Abnormalities in monoamine signaling in chronic pain and MDD can give rise to other  challenges, such as insomnia, anxiety, stress sensitivity, and poorer functioning of pain regulation.

Integrative Treatment Suggestions

When considering treatment for coexisting depression and pain, SNRIs and TCAs can help, said Dr. Jay. When pain is accompanied by anxiety and depression, clinicians may try prescribing duloxetine or venlafaxine. Depression, pain, and cognitive problems may benefit from SNRI and perhaps vortioxetine. For depression, pain, and sleep issues, TCA and adjunctive gabapentin or pregabalin may be beneficial. For depression, pain, and fatigue, try milnacipran, adjunctive bupropion or modafinil, he recommended.

Sleep disturbances, in particular, a pain patient can lead to greater irritability and other issues, something clinicians should be aware. Sleep hygiene instructions, as well as CBT, may help but "this does not mean you wouldn't [also] use medications," he clarified.

 

Older Adults and Pain Comorbidities

In Dr. Argoff’s session, the focus was on comorbidities in older adults, whom he noted, ''are found to have less tolerability of pain as they get older.”  Pain is particularly common in those aged 65 and above. ''As people get older, there are multiple medical comorbidities that can directly exacerbate the pain." Citing the American Geriatrics Society, he shared that 25 to 50% of community-dwelling older adults have substantial, persistent pain, as do 45 to 80% of nursing home residents.

Among the common sources of their pain are: arthritis, degenerative bone disease, nocturnal leg pain, as well as pain linked to various chronic illnesses such as cancer. 

Some of Dr. Argoff’s tips for managing pain in older adults include:

  • Use the same pain scale each time you talk with patients and with other providers. Whether numerical or verbal, using the same system maintains consistency.
  • When scale use is not possible, ask for a number or verbal description, or ask the patient to draw on a stick figure – where does it hurt?
  • The "start low, go slow" mantra for analgesic use is especially pertinent in older adults
  • Older patients may have legitimate concerns about opioids. Have a discussion; talk about use, misuse, and addiction. Teach patients (and caregivers) how to take medicine properly.
  • To evaluate pain in a cognitively impaired patient, turn to the caregivers for information.
  • Be aware of – and ready for – common pain behaviors in older adults with cognitive issues, such as verbal abuse, fidgeting, and rapid blinking.
  • Recommend CBT and regular physical activity when appropriate.

The Memory Connection

Of note, Dr. Argoff shared some recent research around pain and memory that may guide future treatment. Pain sensing neurons both in the central and peripheral nervous systems have been shown to have neuroplasticity after injury, he said, noting that pain and memory mechanisms may someday help us better understand chronic pain. While the concept of pain memory has been around for more than 40 years, more recently, molecular mechanisms underlying pain plasticity have been shown to bear a resemblance to those involved in learning and memory.

In addition, Dr. Argoff said, two major potential mechanisms for pain memory are changes in gene expression in the peripheral nociceptors that may permanently change the phenotype and changes in synaptic strength at key locations that play a role in chronic pain persisting.

 

Practical Takeaways

After their talks, Dr. Argoff further shared with PPM that providers – both generalists and specialists – should expect to see more and more older patients. "Pain in the older person is common and whether you are a primary care provider or a pain specialist unless you restrict your practice to a younger age group, you will see larger and larger numbers of older people coming in for help due to their chronic pain."

Accompanying that reality, he said, is the likelihood of seeing more older patients with cognitive challenges, ranging from minor memory issues to severe dementia.

Dr. Jay offered this final insight: ''Chronic pain is a biopsychosocial phenomenon.'' A provider must reflect on that and consider all of the effects, he said. "The main clinical implication is that a patient with chronic pain will [likely] feel depressed and will develop a sleep disorder.” Providers need to be aware of this, he said, and to keep in mind that chronic pain and depression are bidirectional.

 

Dr. Argoff reported no disclosures. Dr. Jay is the chief medical officer at Virtuous Pharma.

 

Next summary: Opioids & The Taper Talk
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