Introduction

Current pain management guidelines advocate the use of tricyclic antidepressants as a first-line or adjunctive treatment for chronic, neuropathic pain. This practice may contribute to narcotic dependence and addiction in bipolar patients and requires reexamination.

Studies have demonstrated the efficacy of tricyclic antidepressants such as Amitriptyline or Imipramine in potentiating opioid analgesia (1,2,3). They appear to contain direct innate analgesic properties independent of their effect on mood. Because many bipolar patients with chronic pain may seem depressed, they can be misdiagnosed with unipolar depression, warranting a trial with antidepressants. The use of these antidepressants may precipitate an increase in anxiety which in turn can cause an increase in their pain level.

Prescription drug abuse is very common in people with bipolar disease and is often used, like alcohol or other illicit drugs, as a form of “self-medication” in order to counteract unpleasant psychological symptoms. Bipolar patients may demonstrate somatization and therefore seek out “pain management” doctors, because the analgesics, hypnotics and stimulants commonly prescribed in this context can help to relieve temporarily or control dysphoric symptoms experienced in part as physical pain. Therefore, we believe that antidepressants should be prescribed with caution given their potential to exacerbate an undiagnosed bipolar disorder which may worsen the patient's prognosis and perhaps even contribute to a narcotic dependence or addiction.

Effective care of patients with chronic pain should include a rigorous assessment for bipolar spectrum disease and, if appropriate, the use of a mood stabilizer or a combination of mood stabilizers in addition to or in place of an antidepressant. In our experience, psychological dependence on narcotics diminishes with appropriate treatment of the bipolar disorder. If an antidepressant has already been prescribed, the patient should be closely evaluated for a worsening of psychiatric and/or pain symptoms and discontinuing the antidepressant medication in this case may be warranted.