Highlights From the 2022 NEI Synapse: Pain in the Presence of Psychiatric Comorbidities
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Austin, TX & Virtual | Session Highlights |
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At the 2022 NEI Synapse, Andrew Cutler, MD presented a practical and comprehensive lecture on treating chronic and neuropathic pain in the presence of psychiatric comorbidities. Chronic pain is common and associated with psychiatric disorders, particularly mood and anxiety disorders, and suicidal ideation and attempt. |
Following a review of the factors associated with comorbid pain and psychiatric disorders, Dr. Cutler presented the neurobiology of neuropathic pain, including the potential mechanisms for pharmacological intervention with psychiatric medications. These mechanisms included 1) increased noradrenergic and serotonergic neurotransmission in the descending spinal pathway to the dorsal horn to inhibit pain with serotonin-norepinephrine reuptake inhibitors (SNRIs) and certain tricyclic antidepressants (TCAs); and 2) binding to voltage-sensitive calcium channels in the dorsal horn, thalamus, and cerebral cortex to reduce excitatory neurotransmission and alleviate pain with alpha-2-delta ligands. Table 1 shows the most commonly used medications for neuropathic pain and psychiatric conditions, as described by Dr. Cutler. A brief but important discussion on the overlap in use of cannabis, benzodiazepines, and opioids for chronic pain and mental health disorders wrapped up this useful presentation.
Table 1. Most Commonly Used Medications for Neuropathic Pain and Comorbid Psychiatric Disorders
| Drug Class |
Mechanism of Pain Inhibition |
Psychiatric Use |
TCAs
(amitriptyline, nortriptyline) |
↑ norepinephrine
↑ serotonin |
Depression
Anxiety
Insomnia |
SNRIs
(duloxetine, milnacipran, venlafaxine, desvenlafaxine) |
↑ norepinephrine
↑ serotonin |
Major depressive disorder
Generalized anxiety disorder
Other anxiety disorders
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Alpha-2-delta ligands
(gabapentin, pregabalin) |
↓ calcium influx and excessive stimulation of postsynaptic receptors |
Generalized anxiety disorder
Social anxiety disorder
Panic disorder
Substance use disorders
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Source: Andrew J Cutler, MD. Everything Hurts: Pain Management in the Context of Psychiatric Comorbidities. Presented April 24 at 2022 NEI Synapse, Austin, TX.
To Learn More: The recording of this presentation by Dr. Cutler, as well as all of the other presentations from the 2022 NEI Synapse, will be available as Encore Presentations for NEI Members.