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CHAPTER 76: Psychotropic Medications

Robert M. McCarron; Shannon Suo

INTRODUCTION

Chronic pain is frequently comorbid with both anxiety and mood disorders. Although many pain medicine practitioners may not manage psychiatric conditions, it is increasingly important to have at least a rudimentary familiarity with first-line psychiatric medications used to treat anxiety and mood disorders, a class of medications that is commonly encountered by pain specialists.

The mnemonic AMPS, or anxiety, mood, psychosis, and substance abuse, can be used to describe which psychiatric conditions are more commonly seen in the outpatient setting. In this chapter, we focus on the medication management of anxiety and mood (including major depressive disorder and bipolar spectrum disorders) because these disorders often influence the short- and long-term prognosis of those with chronic and unexplained pain. Antipsychotic medications are also discussed because there is much overlap with this class and the treatment of bipolar disorder. Tables 76-1 and 76-2 provide a practical overview of these medications.

TABLE 76-1

Overview of the First-Line Antidepressants

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TABLE 76-1

Overview of the First-Line Antidepressants

Class

Initial Dose (mg/day)

Therapeutic Dose (mg/day)

Clinical Highlights

Selective Serotonin Reuptake Inhibitors

Sertraline

50

50–200

Serotonin and dopamine reuptake inhibition

Possible early and temporary diarrhea and dyspepsia

Relatively low chance for drug interactions

Paroxetine

20

20–60

High anticholinergic and antihistamine side effect profile

Paroxetine CR

12.5–20

25–75

High risk for sedation, weight gain, and dry mouth

Short half-life with more risk for discontinuation syndrome

High chance for drug interactions

Unsafe during pregnancy (Category D)

Fluoxetine

20

20–60

Long half-life and ideal for intermittently compliant patients

Relatively inexpensive

High chance for drug interactions

Citalopram

20

20–40

Structurally similar to escitalopram

Decreased chance for drug interactions

Warning for QTc prolongation above 40 mg/day

Escitalopram

10

10–20

Structurally similar to citalopram

Decreased chance for drug interactions

Warning for QTc prolongation

Vilazodone

10

40

Increase dose every week by 10 mg, as tolerated and to effect

Must be taken with a meal in order to be fully bioavailable

Moderate-to-high potential for CYP 3A4 drug interactions

Serotonin–Norepinephrine Reuptake Inhibitors

Venlafaxine XR

37.5

75–225

Structurally similar to desvenlafaxine (do not use concurrently)

Dual action on serotonin and norepinephrine receptors

Not consistently “activating” but usually does not cause sedation

Sometimes used as an adjunct for chronic pain

Avoid in those with difficult-to-treat hypertension

Short half-life with more risk for discontinuation syndrome

Reduce dose with renal insufficiency

Desvenlafaxine

50

50–100

Structurally similar to venlafaxine (do not use concurrently)

Dual action on serotonin and norepinephrine receptors

Not consistently “activating” but usually does not cause sedation

Avoid in those with difficult-to-treat hypertension

Short half-life with more risk for discontinuation syndrome

Sometimes used to treat neuropathic pain syndromes

Reduce dose with renal insufficiency

Duloxetine

30

20–60

Dual action on serotonin and norepinephrine receptors

Not consistently “activating” but usually does not cause sedation

Approved for treatment of pain conditions

Short half-life with more risk for discontinuation syndrome

Increased risk for drug interactions

Atypical

Bupropion XL

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