Page 374 Guide to Pain Management in Low-Resource Settings

362 Andreas Kopf

Several antidepressants are used in the treat- of physical symptoms of arousal. Fears in correlation
ment of neuropathic pain. Th ey include the clas- with pain are often understandable, for example, anxi-
sic tricyclic compounds—divided into nonselective ety about increasing physical impairment and anxiety
norepinephrine/5-HT reuptake inhibitors (e.g., ami- about losing one’s employment. In consequence, dis-
triptyline, imipramine, and clomipramine) and pref- orders of anxiety can be the result of chronic pain, but
erential norepinephrine reuptake inhibitors (e.g., de- they can also be the cause of physical symptoms. For
sipramine and maprotiline), selective 5-HT reuptake example, severe chest and heart pain as well as breath-
(serotonergic) inhibitors (e.g., citalopram, paroxetine, lessness are some of the symptoms of a panic attack.
and fl uoxetine) and 5-HT antagonists (nefazodone). One consequence of chronic pain can be agoraphobia,
2
Th e reuptake inhibition leads to a stimulation of en- for example, if the patient is afraid to leave the house
dogenous monoaminergic pain inhibition in the spinal because the pain attack might occur on the street, and
cord and brain. In addition, tricyclics have NMDA- nobody would be there to help. In consequence, the pa-
receptor antagonist, sodium-channel-blocking, and tient tends more and more to avoid leaving the house.
potassium-channel-opening eff ects that can suppress Th e most common screening instruments for anxi-
peripheral and central sensitization. Block of cardiac ety disorders are the Hospital Anxiety and Depression
potassium and sodium channels by tricyclics can lead Scale (HADS-D), State-Trait-Anxiety Inventory (STAI),
to life-threatening arrhythmias. Th e selective 5-HT and Profi le of Mood States (POMS).
transporter inhibitors lack postsynaptic receptor block-
Anxiolytics
ing and membrane stabilization eff ects (and the result-
ing side eff ects) and therefore have only a limited role in Anxiolytics are medications used to treat anxiety. Short-
neuropathic pain treatment. acting anxiolytics, especially from the class of benzo-
diazepines, maybe benefi cial for panic attacks, while
Anxiety
long-acting anxiolytics, also mostly from the class of
Anxiety is a feeling of apprehension and fear charac- benzodiazepines, play a role in palliative medicine when
terized by physical symptoms such as palpitations, trait anxiety is uncontrolled by psychological interven-
sweating, and feelings of stress. Anxiety disorders tions. Th e antiepileptic drug pregabalin also has some
are serious medical illnesses that aff ect pain patients anxiolytic eff ect without the risk of addiction of ben-
more frequently than the average population. Th ese zodiazepines and may be benefi cial, therefore, in pain
disorders fi ll people’s lives with overwhelming anxiety patients with a mild anxiety disorder. Although recom-
and fear. Unlike the brief anxiety caused by a stressful mended in a number of textbooks, there is no indication
event such as a business presentation or waiting for for anxiolytics as pain killers.
surgery (state anxiety), anxiety disorders are chron-
ic, relentless, and can grow progressively worse if not Arthritis
treated (trait anxiety). Arthritis is the infl ammation of a joint, with typical
In the case of chronic pain, both in developing symptoms including stiff ness (especially in the morn-
and developed countries there is an increased preva- ing), warmth, swelling, redness, and pain. It can be di-
lence of anxiety disorders such as generalized anxiety vided into osteoarthritis (with a degenerative etiology)
disorder, panic disorder, social phobia, and post-trau- and rheumatoid arthritis (with an infl ammatory etiol-
matic stress disorder (PTSD) in comparison to people ogy). If the cause of arthritis is rheumatic, infl amma-
without pain. Th e prevalence increases when pain oc- tion control comes before pain management to avoid
curs at multiple sites. It is often not possible to de- ongoing tissue destruction in the joint. NSAIDs and
termine the direction of causality between pain and a opioids—sometimes given locally into the joint—are
psychiatric disorder. In biopsychosocial models of ex- among the drugs of fi rst choice for severe arthritis.
plaining the emotions, anxiety is seen as reaction of
Bereavement
the organism to external experience (for example, an
experience of violence) and to internal stimuli (for ex- Th e act of grieving someone’s death. Bereavement is in-
ample increased heart rate). Within the experience of tegrated into palliative care by off ering relatives support
anxiety there is an unspecifi c feeling of excitement and after the death of the patient. Th erefore, palliative care
tension as well as unpleasantness and the experience does not stop with the death of the patient.