Neurology Clinic - Clinical Website

Other article on my website explain the 4 modalities for treating symptoms, when surgery is not involved and no specific treatment is available.

The fourth group after physical treatments, injection treatments, and talking therapies is drug therapy.

Medications other than pain killing tablets and anti-inflammatories, form a fundamental part not just of pain management, but also rehabilitation after many injuries and in particular brain injury.

The main medications are borrowed from other fields of endeavour. These include antidepressant drugs, anti-epilepsy drugs and heart drugs.

Often people with pain and in need of rehabilitation do not have depression, epilepsy, or heart disease, but they still need these medications.

If there is, for instance, a lowness of mood or anxiety associated with the primary problem being helped, then antidepressant medications would be even more beneficial. If added to this is any degree of sleep disturbance, then these treatments can be even more effective.

Sleep, for instance, is a fundamental part of recovery and pain control. If sleep is broken because of pain or the distress of injury or illness, then recovery will be delayed or at times even impossible. The correction of that disordered sleep pattern by whatever means, be they physical treatments, talking therapies or drugs therapies, essential.

As this article deals with drug therapies, all focus will be on those medications.

SLEEP DISTURBANCE

Having mentioned disorders of sleep, I will emphasise again, that correcting the abnormal sleep pattern, fundamental to improvement.

The sleep pattern may be disrupted by an inability to get to sleep, waking repeatedly during the night, or waking much earlier than is necessary. Nightmares may also cause problems and there are so called parasomnias that can be a challenge. For most people, however, it is the actual mechanism of sleep itself that is so challenging.

If pain is an issue, then management of the pain is crucial. The same applies of anxiety or depression or any other reason for disrupted sleep.

What must be apparent from what I have said already, is that the triad of pain, sleep disturbance and disorders of mood are all intimately linked. If all three are not approached at the same time, then treatment will often fail.

Sleep itself can be helped by simple hypnotic drugs. These have fallen into disrepute over many years because they do cause dependency. What is meant by dependency, is that they are so successful that when an individual uses them for many weeks, they find sleep so easy to achieve, that there is no reason to actually try any other techniques and hence dependency occurs. Sometimes this just does not matter, but it should be avoided if possible.

To balance that comment, 7 days of a so-called Z drug hypnotic can be remarkably effective in getting a disordered sleep pattern back under some degree of control, particularly if other measures are also introduced at the same time. The dose can either then be reduced slowly over another week, or the medication just stopped, as dependency will not have formed so acutely.

Melatonin can be a remarkably effective agent as well. In the UK, the controlled release preparation of Melatonin 2mg is available on prescription. Its license is for sleep disorder over the age of 50. Many travellers will know of its benefits and effectiveness at any age when used for long distance air travel, and normalising jet-lag.

Melatonin 1mg can be bought on the internet. Why it is not readily available in the UK, I do not understand. Melatonin itself can be a remarkably effective agent in helping disordered sleep, or in coming off of a Z drug hypnotic as a go between before completely stopping all sleep-inducing medication. It can then be introduced at any time if the sleep pattern is disturbed. The careful and judicious use of a Z drug hypnotic in low dose with melatonin can then be adopted so that a return or relapse of sleep disorder can be managed very quickly.

Some people will find herbal preparations such as chamomile beneficial as well.

Disordered sleep can also be helped greatly by the antidepressant medications available and these are discussed next.

ANTIDEPRESSANTS

Antidepressant drugs have carried with them bad press in recent years. This in the opinion of the author, ridiculous and more in the mind of holier than thou journalists.

Regrettably, the stresses of life lead many people to become anxious with depression. In an ideal world that would not happen, but it does, and genetics plays a major part. If there was the ready availability of counselling services throughout the country allowing at least 20 sessions of counselling, then the need for antidepressants drugs would be far less. My experience in the NHS is that something between 3 and 6 sessions are offered usually in groups as over a telephone and equally often ineffective.

Perhaps drugs should not be used alone as opposed to counselling, but again in my opinion, there should be a combination of both. As I am not a psychiatrist, I do not deal with pure depression and anxiety in isolation. If I perceive this is the case, then I will refer to either a psychologist or a consultant psychiatrist for opinion and advice.

Where lowness of mood, depression and anxiety do arise in neurology practice, it is associated with chronic pain including chronic headache, chronic back pain and chronic neck pain, or even pain in the limbs for neurological causes. Depression and anxiety may also arise in people who are needing rehabilitation after serious injury, illness or surgery.

In my experience a low dose of a tricyclic drug called dosulepin (it used to be called prothiaden and then dothioden) can be remarkably effective. I always start at a dose of 25mg at night, and the dose then needs to be tailored to each individual. A full dose would be 225mg at night. Although the science tells us that these medications work, it is an art to find the dose that works in each individual. It is very much a team effort between the suffering individual and the specialist to work out the right treatment. There are other tricyclic medications that can also be tried.

So many times, I have heard people say that for a few days they had some muzzy or drowsy side effects, and then the benefit kicked in thereafter if they deal with the side effect for those few days.

A much more well-known tricyclic antidepressant drug is amitriptyline. This agent is in fact the one that is usually recommended at general practitioner level. In my experience, amitriptyline just causes far too many side effects even at the lowest dose. It probably is a much more powerful antidepressant drug in itself, but this is not the role that is the need in neurology practice. In my opinion dosulepin and perhaps nortriptyline, much better as pain relieving and sleep-inducing agents when used at night, as well as having fewer side effects.

Every medication has side effects. My usual rule is that any drug, any person, any side effect, any time applies.

With the tricyclics such as dosulepin, a dry mouth is not a side effect, it is an effect. It is a useful effect, because if an individual does not have a dry mouth, then they are not taking a big enough dose of the treatment. This means that the dose can be increased. If there is a dry mouth and there is no other benefit or side effect, then the dose should still be increased with the individual reassured, that their mouth on the whole will not get any drier than dry and they should just carry a bottle of water with them. I cannot recall an individual stopping the medication for that effect or side effect alone.

There are other side effects of this type of medication including a blurring of vision, urinary hesitancy, and constipation. None of these side effects tend to lead to cessation of treatment. Nightmares can occur but again usually can be tolerated, but it is the side effect of palpitation that will lead to the drug being stopped. In low doses, a rare problem. A full side effect list can be obtained by looking on the internet.

It is vital in this type of treatment that the doctor and the patient work on the same team, as I have said elsewhere on the website. By so doing, the right dose of the right medication can usually be found, giving great benefit.

In my experience between 60% and 80% of people will get benefit, when using the right antidepressant drug for the appropriate reason. If the tricyclics cannot be tolerated or do not work, then there are a range of more modern antidepressant medications such as the SSRis and other treatments that may also give benefit. It is literally a matter of working through them. There is no test that says that one drug will be more effective than the other, it is absolutely, and regrettably trial and error.

The treatment of all of these disorders is not a revolution, it is an evolution. Others have rightly said it is a marathon, not a sprint, which is in a way saying much the same thing.

The more effort, however, that is put into a proper multidisciplinary regime including drugs, the better the individual will get.

In my opinion, such treatment regimes need to be supervised at consultant level, because of the greater experience of these treatments. Some GPs are more than able to supervise if interested and have the time available.

ANTI-EPILEPSY DRUGS

In the same way as individuals may not necessarily have depression, they certainly do not have epilepsy and yet anti-epilepsy drugs block pain pathways. These drugs are now known effectively as the neuropathic pain blocking drugs, and gabapentin and pregabalin would be the 2 major agents that are used. Other anti-epilepsy drugs can have the same effect. Different neurologists will have their own pet treatments besides gabapentin and pregabalin, which are nearly always used first.

Finding the right dose once again paramount. Gabapentin usually starts now at 100mg twice daily, pregabalin 25mg twice daily. Gabapentin can be used up to 4800mg. pregabalin up to 600, even 900mg daily. The right dose again is the dose that works without side effects.

I have found over the years that combining a low dose of a tricyclic antidepressant drug with one of the neuropathic pain blocking drugs, perhaps the most effective treatment of all. The side effect profile is very similar to that of the antidepressants and there is a great deal of information on the internet to assist.

CARDIAC DRUGS

There are a range of what I call cardiac medications that can help pain. For instance, beta blocking drugs can be very helpful in people with migraine or chronic migraine. The drug is not licensed for chronic migraine, but often used as are the other medications. Intriguingly the only medication that is licensed for chronic migraine, is Botox injected into the scalp, which is another drug treatment, but administered by the injection route.

There are other cardiac drugs such as orally active local anaesthetic agents that can be used for the chronic pain syndrome.

A local anaesthetic patch placed over the painful area may also be beneficial.

THE USE OF OPIATES

You will note that almost nowhere on the website or in this discussion, have I mentioned opiates as a treatment for pain.

I do not get involved in the management of malignant pain. This is a separate subject and opiates have an absolute role in the management of such unfortunate people. Again finding the right dose through an expert and a GP is essential.

In my world of neurology practice, I personally do not perceive that opiates have any role in the management of chronic pain or rehabilitation. I do acknowledge that there are 2 camps at the moment, whereby some pain specialists and neurologists perceive that the opiates do have a role and other who feel the opposite. It will be fair to say that the opinions are quite rigid. My own view is that people who get on to opiates, will become very rapidly not just dependent, but addicted to them. This means that if you do not take the drug then you get more pain. Opiates desensitise such that higher doses are needed and they also cause central sensitisation, whereby individuals will actually get more pain at the same dose. These side effects, I think, are too great a price to pay and getting people off the opiates, one of the greatest challenges of pain management. If it is possible to avoid going on to opiates, then the future is much brighter than if large doses of morphine are being administered at the time of first assessment.

PROGNOSIS

Drug therapies may need to be taken for a very long time. People often ask me how long they will need to take any medication. My usual answer, I hope not thought inappropriate “you should be so lucky that they work”. What I mean by this, is that the only reason an individual would remain on any medication, is that the drugs are working. When they work, then the medications are your friend, not your enemy and they should not be discarded too rapidly. This means that the treatment will continue over at least 6-12 months. If everything is going well, physical rehabilitation successful leading to marked improvement, then a slow withdrawal can be effected, but the emphasis must be on the word slow. There is no reason to reduce any medication quickly, if it has been successful. If it takes 6 months to come off a beneficial treatment, then so be it. The only exception to this would be say in a young woman who is trying to get pregnant when there would need to be a consideration of stopping the medication sooner. That is, however, for very specialist consideration.

The key to all of these conditions is moving the individual forward on multiple fronts, that is a multidisciplinary program. The greatest reason for failure in all the patients that I see, and many are second, third and nth opinions, is that the treatments are all tried individually. Not enough explanation is given to people to understand why the treatments are given. People are suspicious and cynical about say antidepressant drugs. They have read in the Daily Mail, Woman’s Own and Readers Digest, that the drugs are the devil reincarnate or Satan in disguise and hence must never be taken. I find those comments tend to be written by people who have never experienced the same.

I have a wonderful example for my own clinical experience. Many decades ago, when I was working at the National Hospital, Queens Square, an individual who was a major figure in the natural childbirth trust came in as a patient. They had been an advocate over years for mothers not receiving any pain relief of any kind in pregnancy. It would certainly suggest all those years ago that if any mother needed pain relief, then she was a lesser human being and was only trying to damage her child and there was enormous guilt and misery that was generated. How often did one hear or read in those days and even now, much the same thinking.

To cut a long story short, this individual who was such an advocate of pain free delivery, did in fact “suffer” from the condition known as congenital indifference to pain. This meant that they were unable to feel pain. They never knew what pain was. They had never had a painful period, for instance. Injury was an irrelevance as they never suffered pain from it. It is not surprising that they thought that everyone should be the same and they of course had painless childbirth, because they did not know what pain was in the first place.

Always beware people who have very fixed views, because often it is because of their own experience. People, in my opinion, should always declare their hand and where they are coming from, whenever an opinion is given that is likely to have a huge impact on other people.

As a doctor, I have to declare very carefully any conflict of interest I have with regard to treating an individual or providing treatment. In the medicolegal world I would not take on a matter for opinion if I had the slightest conflict at all. Individuals who, for instance, could not feel pain should not be giving opinion on pain as there is a massive conflict of opinion.

If you are reading this because you are in chronic pain, or because you have suffered serious injury, disease or in the post-operative state, then do not despair. Make sure you get the appropriate multidisciplinary treatment program. As Churchill said “never give up”.