RSD Puzzle #033

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #33
"I Can't Antidepressant. Elavil Made Me Sad And Exhausted, Caused Dizziness And Fast Heart Beat".

As we have repeatedly discusses, the treatment of choice for chronic pain is antidepressant. This is independent of any depression. Antidepressant is the most effective medication for chronic pain.

However, there are actually different types of antidepressants.

1. The tricyclic antidepressants have been around for over 25 years, and there has been extensive medical literature regarding the efficacy of Elavil, Tofranil, Norpramine, etc., for pain control. However, these anticonvulsants have been recently labeled as "dirty" because they have multiple side effects. These consist of obesity, aggravation of fatigue, tendency for inactivity, low blood pressure, and excessive drowsiness. Obviously, the RSD patient cannot afford such side effects. However, until recently there was not much of an alternative.

2. Twelve years ago a non-tricyclic antidepressant became available, called Trazodone. This antidepressant has the side effects of pelvic genitalia congestion so it improved erection in men, Twelve years of use has showed no more than 3 or 4 serious erection complications.

On the other hand, Trazodone in judicious careful doses provides an excellent REM sleep. The best time to take the medication is at bedtime and with the help of adjustment of the dosage and blood level of Trazodone an accurate dosage can be figured for each patient. It is an excellent analgesic. However, it does have a tendency to mildly increase the appetite.

3. In the past 8 years, a new series of antidepressants called selective serotonin re-uptake inhibitors (SSRIs) have been available. The most commonly used of this group of medications that raise the concentration of serotonin in the central nervous system are Prozac, Paxil, and Zoloft. This group of antidepressants do not cause the serious complications of obesity, hypotension (low blood pressure), and fatigue. If anything, they are quite effective in counteracting fatigue.

Of the three, Prozac possesses the most analgesic effect. The Zoloft, on the other hand, has very little analgesic effect. Paxil, which is not as effective pain medication as Prozac, is better tolerated in the long run and causes less side effects. It is the treatment of choice for chronic fatigue.

Prozac has been the most widely used SSRI, and when used on a long term basis can cause significant complications. These consist of bouts of agitation, lack of sexual desire, and weight loss. The weight loss actually in many patients is a plus as such for some patients who have weight problems but in occasional patients the Prozac may be abused because of obsessive tendency for the patient to lose weight.

The main problem with Prozac is the problem with drug interaction. Paxil and Prozac should not be used along with Valium, Xanax, alcohol, Risperdal, or tricyclic antidepressants. Addition of Paxil or Prozac to tricyclic (such as Elavil or Tofranil, raises the tricyclic drug level by 400% and can cause serious complications).

Of the three SSRIs, Zoloft is the cleanest in regard to interaction with other medications but has the least analgesic value.

If the patient has any tendency for seizure disorder, then Prozac, Wellbutrin ,or Clozaril should not be used:

1. Prozac is reported in PDR (Physicians' Desk Reference), on page 946, to cause convulsion.

2. Wellbutrin is reported in PDR, on page 826, to cause seizures, myoclonus seizures, and abnormal EEG.

3. Clozaril is reported in PDR, on page 2152, 2nd column under "Central Nervous System", to cause myoclonus, status epilepticus (continous seizures), and abnormal EEG.

At times a combination of two antidepressants may become necessary. One example is the patient who has such severe pain and insomnia that Trazodone, Prozac, or Paxil alone do not control her pain. In such patients, a combination of a tricyclic such as Norpramine given at bedtime in small doses, and Prozac given in the morning in small doses can provide good pain control and a good night's sleep. This is because of the fact that Prozac inhibits the enzyme (P450) that breaks down the tricyclic antidepressant. As a result, giving 20mg Prozac in the morning and a minimum dose of Norpramine (25mg) at bedtime enhances the function of the Norpramine with good antidepressant and pain control affect without serious side effects without side effects of the large dose of the drug.

As is the case with any medication that influences the function of the brain, the patient should abstain from any alcohol intake while he is on antidepressant medication.

Finally, antidepressants are not addicting. The antidepressants provide three beneficial therapeutic effects.

1. Pain control.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.