Treatment of Pain in Bipolar Patients

Treatment of Pain in Bipolar Patients: Clinical Challenges

A number of researchers have linked bipolar disorder with chronic pain syndromes like fibromyalgia and migraine headaches. Pain management of these patients requires a multidisciplinary approach to improve their outcomes.

Incidence

Bipolar disorder is one of the 10 most debilitating illness worldwide, with a prevalence of 1.4%. The onset of bipolar disorder is usually between 15 and 30 years of age; the lifetime risk for bipolar is 5% to 10% for a first-degree relative. According to the National Institute of Mental Health, the lifetime prevalence of bipolar disorder is 3.9% of the US adult population (or approximately 9 million Americans). 

In comparison, up to 76.2 million American adults (26% of the adult population) experience chronic pain.

Pathophysiology

Bipolar type I is characterized by the presence of episodes of mania and depression, and in particular is associated with a poor clinical and functional outcomes and a high suicide rate. One reason for the poor prognosis is the frequent misdiagnosis or late diagnosis of the disorder, leading to delay in the initiation of appropriate treatment.

Bipolar type I has at least one manic episode, whereas type II has hypomania or subacute mania and at least one episode of major depression.

bipolar depression continues to be frequently misdiagnosed and inappropriately treated as unipolar depression in individuals without a clear previous history of manic episodes

Pain and Bipolar Disorder

Fibromyalgia

A number of researchers have linked bipolar disorder with chronic pain syndromes like fibromyalgia. University of Alabama researchers reported that 13% of fibromyalgia patients had bipolar disorder, a significant difference from the general population

Headache

The researchers found that the prevalence of migraine was 25.9% in the bipolar patients; 25% of bipolar men and 27% of bipolar women suffer from migraine.12 By contrast, the prevalence of migraine in the general population is 10.3%.

Suicide Risk Increases With Pain Level

Both patients with chronic pain as well as patients with bipolar disorder are at increased risk for suicide. Although the majority of people with chronic pain do not develop suicidal tendencies, according to the National Pain Foundation, people with chronic pain other than arthritis are four times likelier to have attempted suicide than other adults

In fact, in one survey,

  • 14% of respondents with three or more painful conditions said they had thought about suicide, and
  • almost 6% reported an actual suicide attempt.
  • Nearly 8% of people with frequent or severe headaches had thought about killing themselves.

This is four times the rate found among adults with no chronic head pain

In a review of bipolar patients, a Duke University researcher found that 20% have attempted suicide

According to the study, suicide rates for bipolar patients are among the highest for any psychiatric disorder, and improved identification of risk factors for attempted and completed suicide translates into improved clinical outcome.

Suicidal ideation should be considered a comorbid risk when treating either a bipolar patient or a patient with chronic pain. However, according to the Duke University study, the use of opioids or other analgesic medication is not in itself associated with increased incidence of suicide

An increase in emotional lability or deterioration of psychiatric stability of a patient during the course of pain treatment should warrant a renewed assessment of the pain treatment plan.

Treatment of Pain

Relief of pain improves depression and anxiety in the acute as well as chronic stages, and

“Pain management should be viewed as a fundamental human right.”

The right to life would be worth a lot more if there was a corresponding right to pain relief.

As is the case with all patients with complex pain, a multidisciplinary team of professionals and various modalities should be individualized for each patient. The team should include the physician, a psychiatrist, medical psychologist, physical and massage therapists, and an addiction specialist, if necessary. The team of professionals should have expertise in the treatment of soft tissue and chronic pain disorders.

Treatment of Bipolar Disorder

The challenge for the pain practitioner is how to manage the comorbid pain and bipolar symptoms. In general, lithium, valproic acid, lamotrigine (Lamictal), atypical antipsychotics, olanzapine, and carbamazepine are the mainstays of treatment of bipolar illness.

  • First-line mood stabilizing medications (eg, lithium, atypical antipsychotics) can be effective in reducing symptoms in patients with chronic pain and can be considered beneficial for treating both the affective and physical components of the bipolar patient’s pain
  • Tricyclic antidepressants (TCAs) have been well studied to show efficacy in treating chronic pain
  • Both selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have a proven role in intractable pain
  • In fact, the SNRI duloxetine (Cymbalta) has been FDA-approved for neuropathic pain, chronic musculoskeletal pain, and fibromyalgia, and
  • the SNRI milnacipan (Savella) is approved for fibromyalgia
  • The anticonvulsant gabapentin (Neurontin) is approved for postherpetic neuralgia (PHN), and
  • pregabalin (Lyrica) is FDA-approved for fibromyalgia and neuropathic pain (diabetic peripheral neuropathy and PHN).

One also has to be aware that some psychotropic medications can cause pain; lithium is an example

Agents that treat pain without interrupting the emotional state of a patient with an affective disorder include topical agents such as lidocaine (Lidoderm), diclofenac sodium (Voltaren), and injectable agents such as botulinum toxin A (Botox)

Opioids

Opioids have an established track record in the treatment of chronic pain26 but should be used judiciously in patients with bipolar disorder. Because of the risk for addiction in this patient population

According to the Balanced Pain Policy Initiative from the Federation of State Medical Boards, “pain management is at the core of the covenant between physicians and patients.”

According to the National Pain Educational Counsel, patients who have an addiction should not be treated without co-treatment by an addiction specialist. The counsel also recommends use of long-acting opioids with no rescue doses

Nonpharmaceutical Treatments

Recent studies suggest that structured psychotherapy, when combined with pharmacotherapy, may modify the course of bipolar disorder. Intervention with psychotherapy should not be ruled out when forming a treatment plan, as both bipolar disorder and pain are alleviated by psychotherapy.

Although exercise is beneficial for most people, in patients with chronic pain, traditional therapy or exercise rehabilitation may worsen symptoms

Clinicians need to treat exercise as a “therapy,” monitoring patients’ progress and providing dosing guidelines and instructions. Gradual, graded exercise is a necessity for this patient population

These patients need to start with small and limited exercise programs, making changes in the exercise program very slowly over time. Too much exercise tends to flare the patient’s condition and lead to poor exercise compliance

Manual massage, heat, and cold therapy have been widely recognized to have therapeutic benefits for more than a millennium. Other adjunct therapies, such as pet and music therapy, may be beneficial to patients and aid in soothing bipolar symptoms

Diet and nutrition also are integral to treatment. Omega-3 docosahexaenoic acid (DHA) is important for the development and maintenance of many central nervous system and peripheral nervous system functions, as DHA concentrates in nerve synapses.33 A systemic review investigating omega-3 fatty acids for bipolar disorder found some improvement in depression but not mania.

Summary

Chronic, intractable pain is a real disease, and its incidence is 10 to 150 times greater in patients with bipolar disorder than in the general population. For patients with both chronic pain and bipolar disorder, disability can be severe and pervasive; therefore, the pain medicine specialist’s approach to chronic pain should be guided to improve the patient’s function

Bipolar patients can present with pseudo-fibromyalgia, which does not respond to traditional fibromyalgia treatments. In fact, there is a risk that SSRI and SNRI medications may exacerbate mania in some bipolar patients. However, the atypical antidepressants have proven efficacy in both chronic pain control and bipolar treatment.

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