Antidepressant and Anticonvulsant Medication for Chronic Pain

Chronic pain has been one of the most important public health problems of the 21st century. Due to the impact of the opioid prescribing epidemic and the challenges of helping those affected, the interest in non-opioid analgesics has been growing over the past decade. Hence non-opioid medications use is increasing, despite a weak evidence base and, at times, known harms of some drugs on these categories. The present chapter will focus on the role of antidepressants, antiepileptics, antipsychotics, cannabinoids, anesthetics, muscle relaxants, and other atypical analgesics in the treatment of chronic pain. We will review the evidence supporting the use of each class of drug and discuss its hypothesized or theorized mechanisms of action in chronic pain conditions. The use of typical analgesics such as opioids, non-steroid anti-inflammatory drugs, corticosteroids, and acetaminophen will not be discussed.

Gender discrimination is a serious social issue that has been shown to increase negative consequences, especially in females when accompanied by acute or chronic pain. Experiencing social pain through discrimination can increase an individual's evaluation of evoked physical pain. However, few studies have explored the mechanism underlying how gender discrimination modulates brain responses when individuals experience physical pain evoked by noxious stimuli. In this study, we addressed this issue using a gender discrimination fMRI paradigm with thermal pain stimulation. We found that discrimination indeed affected participants’ own behavioral self-evaluation of noxious stimuli. Discrimination-encoded brain activations were identified in the temporopolar cortex, while brain activations to thermal stimuli after viewing pictures of discrimination were found in the dorsal anterior cingulate cortex (dACC). Brain activations in the temporopolar cortex and the dACC were correlated. Furthermore, pain perception-specific functional connectivity of the dACC-SII in the cue stage and the dACC-frontal in the pain stage were identified, suggesting a facilitative effect of gender discrimination on females’ experience of physical pain. Our results indicate that the dACC may play a central role in mediating the affective aspect of physical pain after experiencing discrimination. These findings provide novel insights into the underlying mechanism of how gender discrimination facilitates females’ experience of physical pain.

A number of chronic dermatologic conditions may necessitate long-term adjunctive pain management in addition to treatment of the primary skin disease, such as hidradenitis suppurativa, lichen planus, and other systemic diseases associated with significant pain. Adequate management of chronic pain can represent a unique challenge, but remains an integral component of clinical treatment in relevant contexts. For nociceptive pain of moderate to severe intensity, opioid analgesics can be beneficial when other pain management strategies have failed to produce adequate relief. The decision to initiate long-term opioid therapy must be carefully weighed, and individualized treatment plans are often necessary to effectively treat pain while minimizing adverse effects. Part II of this 2-part continuing medical education article will describe the appropriate settings for initiation of opioid analgesia for dermatology patients and detail therapeutic strategies and patient monitoring guidelines.

Pain is a central component of illness and suffering, yet unfortunately it is frequently undertreated. In dermatology, many acute and chronic conditions are characterized by pain that may require therapeutic intervention in addition to medical treatment aimed at treating the primary disease. To date, however, there are limited recommendations or evidence in the published literature on pain and pain management strategies for patients with skin disease. In an effort to enable providers to more comprehensively and effectively treat chronic pain in the primary and multidisciplinary dermatologic context, these topics will be discussed in this 2-part continuing medical education article. Part I of this series will describe important mechanisms of pain and detail individualized chronic pain assessment and treatment strategies using nonopioid analgesia.