Psychotropic Drugs
The important influence of psychological factors in modifying the pain
experience has led to increased use of psychotropic medication.
Unfortunately, the use of psychotropics in cancer patients has not been
well studied. Most of the time, inadequate doses of psychotropics have
been given, denying patients maximum benefit from them.
Hypnotic Sedatives
Anxiety is too often inappropriately treated with benzodiazepines rather
than with discussion and support. The routine use of hypnotic sedatives is
not encouraged, although assured, adequate sleep is important. One of the
goals of using these medications is the diminishing of anxiety, but it is
important to recognize that drugs should be combined with adequate
psychotherapeutic intervention.
Major Tranquilizers
Within the group of major tranquilizers, the phenothiazines
(chlorpromazine, thioridazine, and trifluoperazine hydrochloride) and
haloperidol are most frequently used. Haloperidol seems to be preferred
because it has a less sedating effect and fewer anticholinergic adverse
effects. The phenothiazines have an antinausea effect that is frequently
beneficial to cancer patients.
Antidepressants
Although depression and anxiety are commonly present in patients who
suffer pain; not all depressions require the use of antidepressant
medication. Anticipatory grief is a normal reaction and an integral
component of a life-threatening illness. When antidepressants are
necessary, the tricyclic antidepressants or newer antidepressants may be
chosen. Special consideration must be given to patients who have cardiac
conduction disturbances, prostatic hypertrophy, or glaucoma because
tricyclic antidepressants could complicate these conditions.
The drugs most commonly used are amitriptyline hydrochloride (Elavil),
nortriptyline hydrochloride (Pamelor), imipramine hydrochloride
(Tofranil), doxepin (Sinequan) and desipramine hydrochloride (Norpramin).
Generally, they should initially be given as single daily doses of 10-75
mg, preferably at bedtime, with increases according to tolerance. Doses of
150-200 mg may be needed, but doses above these are required only in
exceptional cases. The use of a single evening dose minimizes the
awareness of unpleasant anticholinergic secondary effects and diminishes
daytime sedation; in addition, a single evening dose is equally as
effective as divided doses. Unfortunately, the antidepressants need to be
used for 1-3 weeks before the total therapeutic effect can be observed.
Failure in the treatment of depression because of low doses is common, and
the medications should be adjusted according to clinical responses. In
elderly and/or debilitated patients, smaller doses, e.g., an initial total
daily dose of 10 mg, are indicated. Escalation of the dose should proceed
according to the patient's ability to tolerate it. Although depression may
not be fully relieved in lower dose ranges, patients may benefit
significantly from the pain-relieving properties of these drugs,
especially for neuropathic pain.
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