Med/Psych Update

Managing chronic pain: Consider psychotropics and other non-opioids

Current Psychiatry. 2012 February;11(2):38-43

References

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Acetaminophen (APAP) is available in several dosage forms as a single ingredient and in combination with opioids in prescription products. For more information about APAP, see the Box below.

Atypical antipsychotics

Although atypical antipsychotics are not often used to treat pain, studies indicate that fibromyalgia patients may benefit from ziprasidone²⁶ and olanzapine,²⁷ most often as an adjunctive treatment rather than monotherapy. Randomized controlled studies indicate poor tolerability with several atypical antipsychotics. Weight gain, akathisia, and somnolence are side effects of some atypical antipsychotics. Additionally, ziprasidone has been associated with QTc prolongation. For chronic pain patients, atypical antipsychotics are most useful for treating psychiatric comorbidities.

Box

Acetaminophen: Safe and effective for treating pain

Although its mechanism of action is not well understood, acetaminophen (APAP) works by blocking prostaglandin syntheses via inhibition of cyclooxygenase-1 and cyclooxygenase-2 in the CNS.^a Therefore, in contrast to NSAIDs, APAP does not possess peripheral anti-inflammatory effects or affect platelet function and is effective for treating fever, headache, and acute and chronic mild pain. The American Geriatrics Society recommends APAP for minor and persistent pain in older patients^b and the American College of Rheumatology recommends it as first-line therapy for osteoarthritis of the hip or knee.^c

APAP has few clinically significant drug interactions, an excellent safety profile, and a long history of safe and effective use. When used within the recommended dosage range, APAP has few side effects. However, overuse of APAP is the leading cause of acute liver failure in the United States.^d APAP hepatotoxicity can be accompanied by nephrotoxicity, is dose-dependent, and can be caused by acute overdose or chronic ingestion at doses over the recommended maximum of 4 g/d. Patients have experienced elevated liver transaminases with coadministration of APAP with phenytoin and phenobarbital.^e,^f Alcohol and other potentially hepatotoxic drugs also can increase the risk of liver toxicity when combined with APAP.^d APAP is pregnancy category B and is considered the drug of choice for treating pain or fever during pregnancy and breast-feeding.^g

References

Amadio P Jr. Peripherally acting analgesics. Am J Med. 1984;77(3A):17-26.
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-1346.
Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43(9):1905-1915.
Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005;42(6):1364-1372.
Pirotte JH. Apparent potentiation of hepatotoxicity from small doses of acetaminophen by phenobarbital. Ann Intern Med. 1984;101(3):403.
Brackett CC, Bloch JD. Phenytoin as a possible cause of acetaminophen hepatotoxicity: case report and review of the literature. Pharmacotherapy. 2000;20(2):229-233.
Hersh EV, Moore PA, Ross GL. Over-the-counter analgesics and antipyretics: a critical assessment. Clin Ther. 2000; 22(5):500-548.

Related Resources

Leo RJ. Chronic nonmalignant pain: How to ‘turn down’ its physiologic triggers. Current Psychiatry. 2008;7(8):19-36.
Nikolaus T, Zeyfang A. Pharmacological treatments for persistent non-malignant pain in older persons. Drugs Aging. 2004;21(1):19-41.
World Health Organization. WHO’s pain ladder. www.who.int/cancer/palliative/painladder/en.

Drug Brand Names

Acetaminophen • Tylenol
Amitriptyline • Elavil, others
Amoxapine • Asendin
Carbamazepine • Tegretol, Carbatrol, others
Clomipramine • Anafranil
Desipramine • Norpramin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Gabapentin • Neurontin, Gralise
Imipramine • Tofranil
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Methotrexate • Rheumatrex, Trexall
Milnacipran • Savella
Nortriptyline • Aventyl, Pamelor
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Pregabalin • Lyrica
Topiramate • Topamax, Topiragen
Venlafaxine • Effexor
iprasidone • Geodon

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.