[Dubious]

So I was wondering, how many of you have been pushed by your whatever-MD into starting antidepressants for whatever reason?

Second question, did it help with for whatever it was you were prescribed?

[hope4thebest]

Hi Dubious,
The P.M. doc to whom I was assigned by my ortho doc who did my surgery (who by the way, after the surgery, administered shoddy post-op care and concern..don't get me started...) wanted me to try Cymbalta in conjunction with the neurontin which i still take..
I tried the Cymbalta for two and a half weeks and it made me feel hypo/hyper!
In other words it made me feel jittery while at the same time spacey..it didn't feel good at all...I stopped taking it and she sugested a couple of other meds, including methodone...
Apparently, the purpose of the Cymbalta is to keep seratonin at optimimum levels in order to decrease pain..
I thought of taking St. John's Wort, a supplement which does the same thing, but I have been told that it is contraindicated with Neurontin....hmmm..was that the A.P.A.?
I'm trying to find other ways to keep up the seratonin...

At this point I'm only taking the Neurontin but my new pain management doc is thinking about trying low dose naltrexone and switching me to Topomax in place of the Neurontin (I've gained ALOT of weight on the Neurontin!)
Not very beneficial to my RSD limbs!
Good luck with your quest!
Hope4thebest

[LIT LOVE]

Most docs will start with Antidepressants for pain relief.

I was a HUGE fan of Cymbalta. Then, it tore up my stomach after a few monthes. Everyone reacts differetly, you might have to try several before finding what works well for you.

RSD is life altering.

[mrsD]

Yes, most doctors will offer the chronic pain patient an antidepressant. This is because of a pain loop in the brain that is quite complex and contains an area of "perception" evaluation of pain, that involves serotonin.

http://www.medscape.com/viewarticle/568704_9

This article explains it somewhat. I've been to two medical conferences on chronic pain, where this was discussed at the beginning. But alas there is no illustration in my syllabus and I can't find it on the net! And I have to admit, it is very very complex anatomical neurological language and hard to remember.

What happens with time and chronic pain is that pathways become "cemented" and fixed and self sustaining. Blocking or retraining the brain to no longer "perceive" the noxious stimulus is one goal of chronic pain management. It is like learning to play an instrument, or ride a bike...only it involves pain pathways. This is why when a person has a limb amputated, they can still feel the phantom limb...often with pain, because the brain is using that learned loop still.

That said, the agents that exist for this, and which the drug companies taylor studies for, determines what you are offered.
Cymbalta is an example of this. IMO it is the only drug in its class that has liver toxicity and is quite flawed.

Other medications often work. The PNers here typically take TCAs in lower doses, to block this pain loop. The new drug Savella, targets fibro pain which is amplified normal impulses it is thought that are misperceived in the brain. Effexor is also a combo product like Cymbalta without the liver toxicity.
TCAs are Elavil and its cousins. Elavil (amitriptyline) has a new study out showing that it can enable regrowth of peripheral nerve fibers which may be damaged in PN. So it is often the #1 offered to PNers, for that reason.

Serotonin can be enabled without a drug by trying l-tryptophan.
This has returned to OTC shelves, and may work for some. It takes a bit of time, as it is slower acting, and needs the cofactors B6 and magnesium to be synthesized. L-tryptophan is much gentler, and often used to help people discontinue the more aggressive SSRI antidepressants.

Some people are naturally high in serotonin output. When these patients take an SSRI or one of the newer combo drugs that are SNRI + SSRI they report alot of side effects and in general don't do well on them. Serotonin is produced mostly in the GI tract and body (it is on platelets too) and about 90% of your total serotonin is in the body. So high serotonin producing people don't as a rule do well with these drugs.

The other problem with chronic pain, is that pain over time creates a depression of its own. It is similar to learned helplessness...which is a refractory type depression as well.
So this dual physiological issue with serotonin and the pain loop and the reactive depression potential makes the antidepressants a potential treatment. It is just finding the one agent for YOU that you can tolerate and afford. There is some trial and error involved, and it can be frustrating.

The pain conferences I attended did have some speakers targeting the psychological aspects of this pain problem. One year RSD was used as an example. They offer meditation, and neurofeedback training to young patients, to help them dissociate from the pain, and be able to go to school normally and socialize. There has even been a show on the science channels explaining visualization techniques they are trying now, to focus on using the brain to control its own pain, and not need drugs for this. The visual cue I saw was a campfire...and the patient was being trained with neurofeedback to turn the flames "down".

So Dubious, I hope this helps. If you decide on trying an antidepressant, do be patient, and expect some trial and error to find the one that may work for you.