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Do we choose pain medication over anti-depressants?

The views expressed are those of the author and are not necessarily those of Scientific American.

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According to recent headlines, we might be poisoning ourselves and our kids with pain pills, yet we’re afraid to tell doctors we’re depressed.

Anti-depressants are the second most prescribed kind of medication in the U.S., and an estimated one in 10 Americans reports suffering from depression. This class of drugs has become about as common as table salt in American households, yet enough stigma (and fear of side effects) still exists to make patients feel uncomfortable telling their doctors if they’re experiencing symptoms of depression. In a recent study, 23 percent of people polled said they kept their symptoms of depression a secret because they feared their doctors would prescribe anti-depressants. And in fact, disclosing depression might be more of a societal than personal problem, with anxieties that insurance premiums will rise or colleagues at work will find out.1

Is this such a thing to be ashamed of? Funny how chronic pain is acceptable, eliciting the most sympathetic of nods from acquaintances and colleagues alike, yet the equally chronic debilitation of depression is taboo. It makes me wonder: do we avoid treatment for chronic depression and instead overuse and abuse supposedly sensible, necessary pain pills to self medicate?

Do we subconsciously favor physical over mental pain?

The Problem With Choosing Physical Pain Pills

An op-ed in the Archives of Internal Medicine (subscription required) noted that little research has been done on long-term effects of opioids (a common type of prescribed pain pill), including the drugs’ effects on patients with psychological disorders and depression. This is alarming when 30-50% of those taking opioids suffer from symptoms of depression and anxiety, and as seen above, many more are likely undiagnosed.2 Even when doctors flag a secondary problem, such as depression, in addition to chronic pain, the diagnosis can easily slip through the cracks, doctors tending to treat one disorder over the other. Plus, over time, those being treated for chronic pain need higher and higher doses of opioids to feel the same effects.

And do we need all these opioids? Accidental poisonings of children five years old and younger increased by 22% from 2001 to 2008, with most of these kids ingesting opiates like oxycodone and codeine.3 Researchers attributed this largely to higher amounts of prescription drugs in homes.

Though, regardless, we need to do a better job of locking up meds around kids, should doctors be more stringent on pain pill dissemination and more open to discussions on depression medication, where more treatment might be actually needed?

Or perhaps we’re our own worst enemies? Do we think we can conquer depression on our own? Do we simply think prescription pain meds are fine, non-problematic substances?

Someone certainly has her pills badly sorted.

1 Bell, Robert A., Franks, Peter, Duberstein, Paul R., Epstein, Ronald M., Feldman, Mitchell D., Garcia, Erik Fernandez y, Kravitz, Richard L. Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care. Ann Fam Med 2011 9: 439-446
2 Grady, Deborah, Berkowitz, Seth A., Katz, Michael H. Opioids for Chronic Pain. Arch Intern Med. 2011;171(16):1426-1427
3Bond, Randall G., Woodward, Randall W., Ho, Mona. The Growing Impact of Pediatric Pharmaceutical Poisoning. The Journal of Pediatrics 2011 07.042

Cassie Rodenberg About the Author: I write on culture, poverty, addiction, and mental illness: I explore things we like to ignore. I also teach public school in New York City's South Bronx. Follow on Twitter @cassierodenberg.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. loki525 1:40 pm 09/29/2011

    Another significant effect of the widespread use of narcotics is that people fairly rapidly become habituated to them with regular use. This can present a real challenge to anesthesia providers like myself while trying to provide pain relief during and after surgery or procedures. Some people’s tolerances are so high it’s very difficult to get them comfortable with the recommended doses of our drugs. We sometimes have to give very high doses or try a number of different types of narcotics to find the right combination and our patients can experience a great deal of discomfort while we try to come up with something that works. I am really astonished at the number of people out there who regularly take Vicodin, Percocet and other narcotics on a regular basis.

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  2. 2. 5:16 pm 09/29/2011

    It is very strange to hear that “chronic pain is acceptable, eliciting the most sympathetic of nods…” This is true of so-called organic pain [cancer, etc.] but if this pain is from a so-far unknown source, one is often accused of malingering, or worse. This despite the fact that fMRIs and other rarely available tests, show that the spectrum of organic, psycho-social, psychiatric syndromes demonstrate a large number of electro-chemical changes.

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  3. 3. Butterflyfred 6:38 am 09/30/2011

    My experience has been that patients with chronic pain are also treated for depression as it creates an interwoven viscous cycle. What is alarming is the number of drugs each interacts with and their ramifications. Chronic pain may always be a part of life, however, the additional illnesses created from a cornucopia of pharmaceuticals exacerbates the original condition, often requiring additional medication. IMHO, I believe that the pharmaceutical industry must step up to meet the needs of their ‘users’ by addressing the need for pain & depression in one. I also believe that it is quite a travesty that long term usage affects of opiods are unknown. Poison now, discuss later? Not very scientific and pretty shameful. An integrative approach with alternative medicine may be the only saving grace to one achieving a life with quality.

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  4. 4. focalist 8:00 am 09/30/2011

    I find it odd that the author doesn’t discuss the obvious- that depression in the chronically ill is often the RESULT of the chronic illness, and not the medication.

    I have Crohns Disease and Degenerative Spinal Disc disease. Due to perforation I’ve had to have sigmoid and transverse colon removed via emergency surgery (which caused a lot of scarring and nerve damage) and also have had laminectomy on L4 and L5.. spinal surgery. In addition, Crohns causes Kidney Stones. Fact is, I live in nearly continuous “moderate” pain with periods of what can only be described as agonizing pain. Later today I make appointments for cortisone injection into my spine to hopefully avert another spinal surgery- I can barely walk or stand for more than a few minutes right now, I’ve compressed the left sciatic nerve.. though the compression is actually in the back, the pain is felt in the leg.

    In short- I know pain. I also know painkillers.

    I also have struggled with depression and PTSD- lost both my parents at fifteen in a gas explosion.. and that was after already having depression issues as a child.

    In short- I know depression. I also know antidepressants.

    Here’s what I can tell you– being in nearly constant pain causes depression and exacerbates any other issue. Physical torture trumps emotional pain.. but being depressed also changes the PERCEPTION of pain, making dealing with it much harder.

    All patients of chronic disease should be on antidepressants. It doesn’t take a genius to make this common-sense link.

    Patients on antidepressants typically use less painkillers- because the synergy between perception and sensation of pain. If you cut down the pain, mood increases, or if you increase mood, pain perception decreases.

    Both are required.

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  5. 5. focalist 8:21 am 09/30/2011

    One more point: it seems very fashionable to demonize painkillers at the moment, mainly because of the rampant abuse of oxycodone for recreational “highs”.

    I take between 200 and 400mg of Tramadol (synthetic codeine) daily, and have for over a decade. Happily, my tolerance has increased very little over the years and this dosage range still is effective in managing pain. If I could not control my pain, I’ll assert that the pain very well could have driven me to suicide.

    Yes, I am addicted to an opiate- Tramadol. What seems odd to me is that is viewed by some as a negative thing, rather than a simple process of the body adapting to the medication. The author (along with some segments of society) seems to view addiction as a shortcoming, when it’s really just a consequence of managing a disease- a disturbing trend of late.

    Addiction among recreational users is another thing entirely- you can’t lump in people who are trying to manage depression by self-medicating with opiates (and likely alcohol also) with people who are medicating actual pain.. different animal.

    The societal view, as well as the huge recreational use problem (created and perpetuated by pill mills) has caused some doctors to now inadequately use painkillers in legitimate circumstances. The problem does not lie with the patients.. it lies with large scale recreational drug dealers with a prescription pad.

    Last but not least, how is it surprising that those addicted to opiates might be depressed about that situation?

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  6. 6. gmperkins 5:40 pm 10/1/2011

    Good comments.

    What I think is needed are different names and categories (same goes for “anxiety”). This is because “depression” in the minds of most people is completely about “sad feelings/emotions” yet doctors use “depression” to cover a wide gambit of symptoms and causes. A clear cut example is how “emotional depression” in men can actually formulate as “constant anger and irritability”. A first step would be to split emotional and physical depression, and seperate names/categories for men and women. The possible brain imbalances caused by internal and external factors would then segregate the categories further.

    Its like when I tell someone that so and so is schizophrenic… people seem to always goto movie case scenario of multiple personalities (which is really rare). So I stopped and I just say they have a brain chemical imbalance which makes it very difficult for them to function. Really need alot of new names for many (now way outdated yet still misunderstood/misrepresented by society) mental conditions.

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