Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA.
Postgrad Med. 2011 Sep;123(5):143-54. doi: 10.3810/pgm.2011.09.2470.
Many patients with chronic noncancer pain present with comorbid depression, which can greatly complicate the treatment of pain. Chronic pain and depression each increase the risk of licit and illicit substance abuse, including the abuse of opioids, and of suicide. Patients attempting suicide may overdose on opioids, which are commonly perceived as potentially harmful, or acetaminophen, an agent that is believed to be safe but is actually the leading cause of liver failure in the United States. Opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) have the potential to interact with antidepressants, and their adverse effects may be exacerbated by alcohol use, which is also common in patients with depression. Topical NSAIDs, capsaicin, and lidocaine provide effective analgesia for several pain conditions. These agents limit systemic drug exposure, reducing the risk of systemic adverse events without risk of accidental or deliberate overdose. However, use of topical agents is generally limited to localized pain syndromes and therefore does not substantially eliminate the need for systemic analgesics in those patients with diffuse persistent pain, central sensitization, and opioid-responsive pain. This review will discuss the challenges associated with treating chronic pain in depressed patients and will provide recommendations for optimizing treatment.
许多患有慢性非癌痛的患者伴有共病性抑郁，这会使疼痛治疗变得复杂。慢性疼痛和抑郁都会增加合法和非法物质滥用的风险，包括阿片类药物的滥用，以及自杀的风险。试图自杀的患者可能会过量服用阿片类药物，这些药物通常被认为是潜在有害的，或者服用对乙酰氨基酚，这是一种被认为是安全的药物，但实际上是美国导致肝衰竭的主要原因。阿片类药物、对乙酰氨基酚和非甾体抗炎药（NSAIDs）有可能与抗抑郁药相互作用，而酒精的使用会使它们的不良反应恶化，而酒精在抑郁症患者中也很常见。局部 NSAIDs、辣椒素和利多卡因可为几种疼痛病症提供有效镇痛。这些药物限制了全身药物暴露，降低了全身不良反应的风险，而不会有意外或故意过量用药的风险。然而，局部用药通常仅限于局部疼痛综合征，因此并不能实质性地消除那些患有弥漫性持续性疼痛、中枢敏化和阿片类药物反应性疼痛的患者对全身镇痛药的需求。这篇综述将讨论治疗抑郁患者慢性疼痛所面临的挑战，并为优化治疗提供建议。
