Avoiding Illicit Use by Combining Opioids with Antidepressants Antiepileptics

Antidepressants and antiepileptics are both effective in treating neuropathic pain, but a combination performs best. Nearly 80% of patients who took a combination of antiepileptics and antidepressant medications had a greater than 50% Visual Analogue Scale (VAS) improvement, a statistically significant finding. Whereas clinical trials have shown clear evidence in favor of using antidepressants and antiepileptic medications alone in treating chronic pain, no studies have been designed to focus on the effect of combining antidepressants and antiepileptics for the treatment of neuropathic pain. Over a 2-year period Dr. Robinson and collegues of Beth Israel Deaconess School, Harward Medical at Boston reviewed 6,129 charts with an initial encounter and a diagnosis of neuropathic pain. They also analyzed VAS, medical procedures, and antidepressant and antiepileptic use and dosage at each visit. Patients who had a 50% or greater improvement in their VAS score were considered to have a favorable response. Of the charts reviewed, 3,370 patients had at least one antidepressant or antiepileptic prescribed. All of the antidepressant and antiepileptic drugs analyzed had favorable responses in more than 70% of patients. There was a statistically significant level of improvement among patients who were prescribed tertiary amines and among patients who were prescribed a combination of antiepileptic and antidepressant medication. A total of 939 patients received the combination, with 79.4% reporting a VAS score improvement of 50% or greater. About 19.4% of patients who received combination therapy had no response, and 1.2% had an unknown response.

The investigators stressed that addiction should be insured, treated, and evaluated like other chronic illnesses [11]. No single treatment is appropriate for everyone, and addicted individuals with co-morbid mental illness need to receive integrated treatment for both disorders. Recovery from addiction is a long-term process that often requires multiple treatment episodes. Unfortunately, many physicians that do see addiction as a medical problem tend to treat it as an acute, rather than chronic disorder. The concept of addiction as a medical disease has yet to gain acceptance with a large proportion of physicians. They, like many others in society, often regard abuse or alcohol as moral or behavioral problems.

The best addiction treatments teach patients the biologic origins of their disease while helping them understand how their behavior affects the individuals around them. Calling addiction a disease does not absolve personal responsibility [15] and it is noted that the different drugs also demonstrate a difference in addiction liability

Figure V-3. Relative ranking of the addictive potential inherent in different drugs

(Figure V-3). Experts were asked in regard to todays commonly used drugs and their addictiveness. Rating was done according to

- how easy it is to get hooked on the substance,

- how hard it is to stop using it,

- how much does the drug effect the persons health.

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