By Steven Reinberg
"A lot of patients have depression and anxiety on top of their back pain," said lead researcher Dr. Ajay Wasan, a professor of anesthesiology and psychiatry at the University of Pittsburgh School of Medicine. Pain can make depression and anxiety worse and depression and anxiety can make pain worse, Wasan said. "It's a two-way street."
But, he added, people with depression or anxiety may get a lot less pain relief from narcotic painkillers and have a higher rate of misuse of their medications.
Wasan said misuse includes taking too many pills and running out of medication early, doctor shopping -- getting prescriptions for the same drug from several doctors -- and using marijuana or cocaine along with narcotic painkillers.
Doctors should know whether someone has depression or anxiety before prescribing a narcotic painkiller, Wasan said.
"That needs to be assessed and needs to be treated," he said. "Treating these conditions improves pain by itself," he added.
Wasan also thinks doctors should prescribe alternatives, such as non-narcotic pain medicines and physical rehabilitation.
The report was published July 9 online in the journal Anesthesiology.
The study included 55 people with chronic lower back pain and low to high levels of depression or anxiety. They were randomly assigned to receive morphine, oxycodone (Oxycontin) or a placebo for six months. Patients reported their pain levels and daily drug doses to the researchers.
People with high levels of depression and anxiety had less pain relief -- about 21 percent pain improvement compared to 39 percent for the group with less depression and anxiety, the study found.
In addition, patients who had high levels of depression or anxiety showed far more painkiller abuse than those with lower levels of depression or anxiety -- 39 percent versus 8 percent.
They also had more side effects from the narcotic medications, the study found. Side effects common to this class of medication include constipation, nausea, fatigue and confusion, according to the American Academy of Family Physicians.
Dr. Allyson Shrikhande, a physiatrist at Lenox Hill Hospital in New York City, said, "Using narcotics to treat chronic back pain in patients with a history of a psychiatric disorder may not be effective in decreasing the pain."
In addition, patients with a history of anxiety or depression can have an increased risk of addiction to pain medication versus a person without a psychiatric history, she said.
"This is due to the effect of narcotic medications on the neurohormonal balance. It is important for physicians treating back pain to inquire about a patient's psychiatric history prior to initiating treatment. A team approach is also vital, using experts such as psychiatrists and psychologists to assist in managing the patient," Shrikhande said.
Dr. Scott Krakower is the assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y. He said, "Narcotic painkillers are a temporary 'band-aid' and often exacerbate the problem."
With the rates of narcotic addiction on the rise, doctors should be mindful of other treatments available to patients for chronic back pain, he said. In addition, conditions such as depression and anxiety should themselves be treated, which in turn will make relieving back pain more effective, he added.
"This study reinforces the importance of screening for coexisting conditions and treating them effectively," Krakower said. "If the anxiety and mood symptoms diminish, then there is a better chance of relieving pain in the long run."