CLINICAL
PAIN
CHRONIC PAIN, DEPRESSION LINK
Chronic pain can be lethal. Its unwelcome presence and debilitating impact can considerably increase
the risk of suicide among people living with it. Several large-scale epidemiological surveys have now
established that the presence of any pain condition doubles the risk of suicide in the general population.
Pain and depression commonly
co-exist. The presence of pain
negatively affects the ability to
recognise and treat depression. There is
a 2.5 to 10 times increase in anxiety or
major depression in patients with pain.
Depressed patients are more likely to
have pain symptoms than low mood.
Even when depression is recognised
in conjunction with pain, clinicians are
more likely to focus on treating the
pain and are less likely to consider
psychological treatments, leading to
poorer outcomes.
For patients with chronic pain,
depression often goes undetected.
Untreated depression may adversely
affect the ability to treat pain. The
argument is strong to include screening
for pain when assessing patients with
long-term conditions of depression.
The presence of chronic pain
appears to increase the resistance of
depression to treatment. A combined
diagnosis of both pain and depression
also accounts for greater healthcare
utilisation in primary and secondary
care. It is known that there are sets
of beliefs held by patients about pain,
its aetiology, severity, predictability
and interference in daily life. Negative
distortions of these conditions bear
resemblance to the cognitive triad of
depression: a negative sense of the
future and the environment.
There are also mental factors
involved in the development of these
cognitions, including memories,
expectations, attitudes and focus of
attention. Patients tend to predict
their pain to worsen or perceive worse
chances of attaining pain control.
MANAGING PAIN AND
DEPRESSION
In patients suffering from pain and
co-occurring depression, the depression
may be misdiagnosed due to shared
somatic symptoms between pain and
depression, such as sleep disturbance,
weight and appetite changes, and
changes in libido and/or energy. It
requires a whole-person perspective
to address physical, psychological and
social factors. Lifestyle measures,
psychological therapies and drug
treatment all have roles to play.
When selecting an antidepressant
drug, it is logical to choose one that
boosts the common neurotransmitters
that are involved in both pain and
depression pathways. Antidepressants
can be used in treatment of chronic
pain. Serotonergic-noradrenergic
antidepressants (SNRIs) appear to
be more effective than serotonergic
antidepressants (SSRIs).
SUICIDALITY IN PAIN
Although many people can self-manage
their pain conditions, a substantial
proportion require specialist help.
Approximately 25% of individuals who
attend MDT pain centres for treatment
report at least one suicide attempt or
self-harming incident in
the past.
A survey by Hitchcock found that
50% of chronic pain patients had
serious thoughts of committing suicide
Dr Anusha Lachman, Child and
Adolescent psychiatrist with
the University of Stellenbosch,
based at Tygerberg Hospital
due to their pain disorder.
Drug overdose is the most common
means for a suicide attempt and
self-harm among chronic pain patients.
References available on request.
Total Pain
Solution
Tramadol Hydrochloride
and Paracetamol
Moderate to moderately
severe pain in adults 1 Severe, chronic
intractable pain 3 Chronic intractable
pain 5
Rapid-acting, longer duration Once-daily, 24-hr pain control 4 Continuous 72-hour
analgesic • Chronic non-cancer pain analgesia
2
• Acute pain
• Sub-acute pain
• Chronic cancer pain
• Chronic cancer pain
• Chronic non-cancer pain 6
• Chronic pain
S5 TRAMACET ® tablets. Composition: Each tablet contains 37,5 mg tramadol hydrochloride and 325 mg paracetamol Reg. No. 35/2.9/0010. Full prescribing information refer to the package insert. (May 2008)
S6 JURNISTA ® 4 mg extended-release tablets. Each JURNISTA ® 4 mg extended-release tablet contains 4,36 mg and delivers 4 mg hydromorphone hydrochloride, equivalent to 3.56 mg hydromorphone base. Reg. No.
41/2.9/1136. S6 JURNISTA ® 8 mg extended-release tablets. Each JURNISTA ® 8 mg extended-release tablet contains 8,72 mg and delivers 8 mg hydromorphone hydrochloride, equivalent to 7,12 mg hydromorphone
base. Reg. No. 41/2.9/1130. S6 JURNISTA ® 16 mg extended-release tablets. Each JURNISTA ® 16 mg extended-release tablet contains 16,35 mg, and delivers 16 mg hydromorphone hydrochloride, equivalent to 14,24
mg hydromorphone base. Reg. No. 41/2.9/1131. Full prescribing information refer to the package insert. (October 2011)
S6 DUROGESIC ® 12 mcg/h transdermal patch. Each 5,25 cm 2 transdermal patch contains 2,1 mg fentanyl delivering 12.5 mcg fentanyl/h. Reg. No. A40/2.9/0203
S6 DUROGESIC ® 25 mcg/h transdermal patch. Each 10,5 cm 2 transdermal patch contains 4,2 mg fentanyl delivering 25 mcg fentanyl/h. Reg. No. 28/2.9/0288
S6 DUROGESIC ® 50 mcg/h transdermal patch. Each 21 cm 2 transdermal patch contains 8,4 mg fentanyl delivering 50 mcg fentanyl/h. Reg. No. 28/2.9/0289
S6 DUROGESIC ® 75 mcg/h transdermal patch. Each 31,5 cm 2 transdermal patch contains 12,6 mg fentanyl delivering 75 mcg fentanyl/h. Reg. No. 28/2.9/0290
S6 DUROGESIC ® 100 mcg/h transdermal patch. Each 42 cm 2 transdermal patch conta ins 16,8 mg fentanyl delivering 100 mcg fentanyl/h. Reg. No. 28/2.9/0291
For full prescribing information, refer to the latest package insert (March 2013).
References: 1.Tramacet ® package insert. July 2014. 2.Dhillon S. Tramadol/paracetamol fixed-dose combination. Clin Drug Investig 2010;30(10):711-738. 3.Jurnista ® package insert. October 2010. 4. Drover
DR, Angst MS, Valle M, et al. Input characteristics and bioavailability after administration of immediate and a new extended-release formulation of hydromorphone in healthy volunteers. Anesthesiology
2002; 97(4):827-836. 5.Durogesic ® package insert. March 2013. 6.Kornick CA, Santiago-Palma J, Moryl N, et al. Benefit-risk assessment of transdermal fentanyl for the treatment of chronic pain. Drug Safety
2003;26(13):951-973.
JANSSEN PHARMACEUTICA (PTY) LTD/(EDMS) BPK; (Reg. No./Regnr. 1980/011122/07); Building 6, Country Club Estate, 21 Woodlands Drive, Woodmead, 2191. www.janssen.co.za.
Medical Info Line: 0860 11 11 17. Cert. no.: PHZA/PAI/1015/0001
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