Most of the people who are referred to me for the treatment of chronic pain also suffer some form of phychiatric illness. In Understanding Chronic Pain, I explore this relationship because it helps us understand just what chronic pain really is. I also develop the thesis that aggressive treatment of the psychiatric disorder can diminish and sometimes even cure the pain. Thus, my enthusiam for the treatment of pain with psychiatric drugs. Only recently have I taken the opportunity to look at the issue the other way around. That is, what happens to psychiatric disease when I treat the pain? My hesitancy in pursing this has been my reluctance to use opiate therapy if it could be avoided. However, within the past year I have seen incredible, almost unbelievable results with opiate therapy in the treatment of bipolar (manic depressive) disorder.
Belinda was 42 years old and suffered that form of migraine known as cluster headaches. The pain would strike her about her eye and last for an hour or so. It would then abate spontaneously, only to recur several times during the day, especially at night. The name cluster headache derives from the fact that in most people the headaches cluster in time, appearing repetitively for a month or so. Then they go away only to return months later. Belinda wasn’t so lucky. She had that form of the affliction known as chronic cluster headaches, and for two years she had not known a day without several hours of pain. She had not responded to the usual drugs to arrest migraines, nor to any of the several drugs used to prevent migraine or cluster. She denied to me that she felt depressed, but acknowledged that ” this thing is getting me down.” Troubled not only by her headaches , she also had a teenaged son with unstable bipolar disease, and that was as much a stressor as her headaches.
I began my treatment with the drugs Nortriptyline and Clonazepam, neither of which she had taken before. They are, in my opinion, preeminent in the treatment of most forms of chronic pain, and she did respond, at least partially.She occasionally went a few days without a headache, and she and I considered that quite a positive.
Several weeks into her treatment, she told me something that alarmed me. She said for the first time that she felt depressed and sad, and that her emotions were on a roller coaster. I prescribed the antidepressant Lexapro. I took a call from her husband a few days later, telling me that she had become suicidal and was admitted to a psychiatric hospital. I saw her a few days following her discharge and she told me she had been diagnosed with bipolar disease and treated with the mood stabilizers Lamictal and Keppra. Nonetheless, her moods were still shifting and her headaches had returned full force. At least she wasn’t suicidal, she told me. I elected to prescribe the opiate Methadone, beginning at the rather low dose of 10 mg every 8 hours.
It’s still hard for me to believe what I saw when she returned two weeks later. She was smiling. She told me her moods were no longer shifting as they had before and that her headaches were much relieved. She still had one when she woke up each morning, but it was quite tolerable.
I was thrilled. I wrote her another prescription for the Methadone, telling her she could go up to 2 pills every 8 hours if she felt it was necessary. She returned at the appointed time to tell me that she had not increased her dose and she had attended her son’s graduation from high school. Sitting on the third row in the front, she realized that she had made a mistake, because the school band, but a few feet away, was about to perform. She expected the worst, knowing that bright lights and loud sounds would precipitate a headache. Astonishingly, it didn’t bother her at all.
We’ve been into it for several months now and Belinda continues to do well, suffering only a morning headache which soon abates. She remains on the Nortriptyline,Clonazepam, Lamictal and Keppra, doing vastly better than when we started.
I’ll explore the curious opiate Methadone as we go along. I will advise you that there are sound physiologic and pharmacologic reasons for her to have responded the way she did. Methadone, I believe, will turn out to be one of the best treatments there is for the painful bipolar.