Dr. Shaohua Lu - Addiction and Consultation Liason Psychiatry

It was a rainy dark night at the end of a long day of clinic.  While the Seasons is a very fine restaurant,   on such a night I'd gladly have been home.   Dr. Shaohua Lu, however. was the night's dinner speaker. His topic was Pain and Addiction, A Psychiatric Perspective.
Dr. Lu is extremely well educated in the field but more importantly he is one of the leading clinicians in hospital based psychiatry for the addicted and medically ill.  His contribution to psychiatry at Vancouver General Hospital is immense.  Personally I've always admired his knowledge and clinical acumen in the treatment of difficult and complex cases.
I've had the pleasure of treating people in the community who were seen by him in the hospital.  There had been no platitudes or stupidities, no missed diagnosis, or whacky medication regimens.  He'd given patients the straight goods and they'd returned to the community well aware of the seriousness of their illness and exactly what they needed to do to address it.
When the College of Physicians and Surgeons employed lesser qualified physicians in the field of addictions it was always a pleasure to listen to the greater experience, training and wisdom of Dr. Lu. Never a policeman, in the field of addiction where sometimes punitive controllers loved to act out their unresolved traumas of  potty training, Dr. Lu by contrast, was always a physician first, and always a gentleman.  He based his work on the latest in research and taught the basic foundations of medicine and psychiatry.
It was a packed room he spoke to that night. Two of my most seasoned addiction medicine colleagues had been at another talk sitting next to him.  Later they'd say they'd got more clinical 'pearls' from him than from the speaker. The people in this room were impressive.  Dr. Paul Sobey, a leader in the Canadian Society of Addiction Medicine, sat near Dr. Malomed from the excellent BC College of Physicians and Surgeons Methadone Committee.  Dr. Horvath and Dr. Tsung, well weathered clinicians from the DTES Docside Clinic. Dr. Durnin. with her vast clinical experience, from her practice at Pender and also in Surrey. Dr. Klajic, humorous and wise, spoke with the very bright Dr. Cohen who sat near a couple of the top East Indian clinicians whose long names I shamefully forget.  I actually asked one fellow twice and really should have written it down. There were several others too, a great turn out.  Mostly the over 40's crowd.  There might well have been another 60 year old but I fear my beard was whitest. The experience,  knowledge and collective wisdom was palpable.  The questions asked of Dr. Lu came from that depth of experience.
Dr. Lu spoke to the overlapping areas of Pain and Psychiatry, the appropriate use of antidepressant, anti anxiety, anti inflammatory medications and finally opiates. There's been much talk of abuse of prescription opiate medication.  Dr. Lu cited the appropriate use of opiates but distinguished his work with cancer patients and palliative care versus his work with 'chronic pain'.  There's clearly a different approach to dosage when a person's life expectancy is months not years.  Further he emphasized proper medical work up for pain and the importance of recognising co morbidity with psychiatric disorder.
"No chronic pain patient is without psychological consequences."
Nadine Sparks, the Senior Sales Representative for Eli Lilly Canada Inc had organized this meeting for the benefit of pain and addiction clinicians who were commonly prescribing a variety of medications to address the patients issues with complex pain.  Cymbalta, (duloxetine) is the new antidepressant the FDA has approved for pain treatment especially fibromyalgia.  No other antidepressant medication has received such approval to date though commonly the tricyclic antidepressant, elavil (amitriptylline) has been a mainstay of pain treatment.  My patients swear by Cymbalta,this breakthrough medication.
Dr. Lu never spoke to any drug or company by name, having no conflict of interest and clearly basing his discussion of the research data to date.  He discussed buprenorphine as well in the chronic pain patient and addressed the importance of exercise in the treatment of chronic pain.
Discussing the controversial topic of 'medical marijuana' in the treatment of chronic pain he cited the research that showed that the cannabinoids that help with pain are not the same that get people high. Essentially he said, "If a person is 'feeling' high on the marijuana the dosage is too high or its not the right cannabinoid medication."
He was especially helpful in his discussion of the early onset of hyperalgesia.  Most people think of opioid induced hyperalgesia as happening at high dosage whereas Dr. Lu cited low dose induction. He maintained that it was wise clinical course to be aware of this phenomena with all opioid usage but especially when the response is not what is anticipated.
It was a truly delightful presentation and I was thankful even driving home late in the rain that I'd made it out for the evening.  Yes the Season's was a very nice restaurant.  And yes, Nadine Sparks is extremely enthusiastic and convincing.  It was great too to see fellow front line workers, the clinicians who work with the patients who suffer from these ofttimes difficult but equally challenging illness.      

Somatization and Chronic Pain

People don't like to hear that their pain is 'all in their head'.  Rarely do people say this but those with issues almost invariably translate that 'some' of their pain is 'mental' as 'you don't validate' my pain.  This merely confirms that a lot of people with 'chronic pain' have a dual diagnosis a) they have pain b) they are crazy.
The fact is, without a head, a person would not have pain. The brain is the central processor of pain.  When I had the pleasure of assisting neurosurgeons with the skull cap off the patient anesthetized and awake I witnessed the surgeon touching various structures and the patient reporting pain in different parts of their body.
When I hypnotised patients who had pain or didn't have pain I could alter their perception of their pain by my hypnotic inductions and suggestions. I actually did surgery on people I hypnotised so not only could a person's pain be affected by their brain their perception of their pain could be greatly modified by their mental state.
A classic study done in the Vietnam era was a comparison of young men in the field who lost a leg by stepping on a grenade versus young men in New York who lost a leg by a sheering injury in a car accident. Theoretically if pain was external in the limb the grenade wound would require more pain medication to address it than the sheering car injury wound.  This was because grenade explosions creating 'dirty wounds' involving far more nerve endings and far greater trauma than the slicing injuries of motor vehicle accidents.  As it turned out the young men in New York required a quantum factor more  pain medication, for argument sake say 10 x more, than the Vietnam soldiers. It was highly significant and very dramatic and not what people expected and not because soldiers are tougher.
People experience dependent on a variety of factors and a major one is the psychiatry of the pain and the belief associated with the pain.
Further people who have difficulty expressing their feelings, those who have hidden trauma and a variety of other psychological constructs will often experience pain greater than those with less complicated lives.  Men who were physically abused as children taken much longer to heal following back injuries.
There's a matter of secondary gain. If a person is paid for being unwell they may in fact take the 'sick role' for a long time. This is overt secondary gain and may give rise to 'malingering' where a person will present with physical illness for the express purpose of getting financial advantage.
In factitious disorder the person presents with physical disease including pain and often dizziness not overtly for financial benefit but for some other secondary gain.  An example is a person who was cared for in childhood when they were sick and neglected when not. This person may 'milk the mercy' out of an injury or illness or pain as a means of getting attention later in life having unconsciously learned this was an acceptable way of emotional communication.
Some people can't express anger and instead have a 'pain in the neck' or a 'back ache'.  Historically most men have heard some joke about women not wanting to have sex because they have the 'proverbial headache'.
These are all aspects of 'somatization'.  Somatization simply suggests that psychological factors are experienced through the periphery nervous system. People have no difficulty accepting that the hands can feel and send feeling messages to the brain. However they have difficulty with the idea that brain messages can be transmitted to the hands in illness. Having treated patients with amputations I've had a man who when angry found his missing limb hurting him because he was 'clutching' his missing fist too hard.

Given the reality of this there's a tendency to treat chronic pain with psychiatric medication. The treatment of choice for fibromyalgia, a disorder originally called 'somatic depression' and originally described by psychiatrists not internists or surgeons, today still responds to the antidepressant medication amitriptylline.  The latest antidepressant medication which is actually 'labelled 'for pain therapy as well as depression and anxiety is 'cymbalta' or 'duloxetine.' This is today the treatment of choice for chronic pain of most kinds.

In addition individual and group therapies are used to address somatization and chronic pain with great success.  Exercise is also very beneficial.

Cymbalta (duloxetine)

Cymbalta (duloxetine) is a new serotonin norepinephrine re uptake inhibitor (SNRI) antidepressant medication developed by Lilly Pharmaceuticals.  After the Tricyclic medications which were the first truly effective antidepressant medications which came out in the early 50's, prozac became available as the first of the Serotonin Specific Reuptake Inhibitors (SSRI's)..  Subsequently antidepressants like Effexor were developped which worked on both the serotonin neurotransmitter pathways and the norepinephrine neurotransmitter pathways.  Cymbalta is not there fore the first SNRI.
What it is however is the first of this class of medications which has FDA approval for pain disorders.  Prior to this amitryptalline, a tricyclic antidepressant was the treatment of choice for fibromyalgia for instance.  However patients commonly complained that they only had limitted benefit and the tricyclics have alot of hard to tolerate side effects.  The side effects in general assocaited with all the new antidepressants are mostly annoying and not particularly dangerous. The tricyclics however could cause heart failure.
Cymbalta in contrast is a major breakthrough and relatively safe with much fewer side effects than those early antidepressants. Already it has given many patients improvement in pain which they did not have from any non narcotic agents. .
Naturally when a new medication is developed the pharmaceutical company would like everyone to switch to this medication. Medications are like cars in this regard.  Commonly family physicians and psychiatrists are given 'free samples' to help start patients on the latest medication.  This is a marketting strategy but it's also a very valuable clinical tool. Commonly in psychiatry a patient may have to try more than one medication before that which is most effective is found. Each time they fill a prescription they are charged the full amount even if they can't tolerate the medication or it's ineffective and they stop it aftera a few weeks. Free samples allow a patient to try a medication without cost to them and if it works without negative side effects then they can fill the prescription.
I have some patients who are still taking the original tricyclic medication prescribed to them 30 or more years ago. It worked then and it works now. Several other patients responded to later SSRI's called Paxil and Zoloft.  They benefited from these medications when they had their first bout of depression, recovered and stopped the medication only to have the depression occur 5 or 10 years later. I tend to try the medication that worked for them before in the hope that they will benefit from this once again. It's not disimiliar to antibiotics in that way.
Roughty 75% of patients with depression or generalized anxiety will respond to whichever antidepressant you choose first time.  Of the 25 % non responders, roughly 75% of them will respond to the second line choice.
When I worked in the states patients without plans would ask for the cheapest medications and I'd be able to know the oldest cheapest antidepressant would do the trick but the side effect profiles were a concern. Not unlike cars, the shocks on the old ones aren't what they are today.  Prozac was a break through in medication as compared to the tricyclics and MAOI inhibitors because it was hard to kill yourself with it.
The newer antidepressants collectively have a safer profile and overall improved side effect profile.  The antidepressants compared to most medications are very safe.
Cymbalta is effective for generalized anxiety disorder and depression.  So normally a specialist, especially a consulting specialist will see the 'non responders'.  There are patients in my practice who have simply not got better with any antidepressant medications and have been sent to me. This is where cymbalta is the 'first line choice of medication. I am truly happy to say that I have already seen Cymbalta work with non responders.
Further, people who had less than complete results with trials of several of the other classes of antidepressant medications have had excellent response to cymbalta.
Also benefitting are those people who have chronic depressions or anxiety disorders and whose medications seems to wear off after a year of two requiring higher dosage with increasing dose related side effects. These people tend to respond immedidately to the lowest dosage of an untried antidepressant medication, like Cymbalta.
What is offensive in psychiatry and why good universities demand that psychiatrists working for drug companies declare their bias is when these 'trend setters' make unreasonable claims for a new medication.  These colleagues get called 'drug company whores'as a result.  For instance they might say some new medications has a 95 % success rate with depression or suggest that patients already responding well to an earlier antidepressant medication should suddenly switch to the newest and more expensive medication.  For this sell out they get a trip to Hawaii or help getting up the academic ladder.
The fact is Cymbalta has something the other medications don't have and for that reason is my first line choice when I'm treating a combination of either a generalized anxiety disorder or depression with a pain disorder. My patients especially the older ones with traumatic athritis and those with fibromyalgia and even a patient with migraines have reported significant improvement in their pain as a result of starting cymbalta.
This happened when I gave wellbutrin, also marketted as zyban, to smokers with depression, a number of them found it easier to quit somking. Hence if I have a patient who wants to quit smoking and has depression I would consider well butrin as a first line treatment.  Wellbutrin is also called buproprion and has been used successfully extensively in addiction psychiatry.
Cymbalta now is the new drug of choice for that mixed state where pain and depression or anxiety prevail.  I love scientific advances in psychopharmacology and this truly is.  My fibromyalgia patients are especially pleased with it's benefit.
The side effect profile is roughly the same as effexor with some nausea and possibly tendency to make one sleepy.  The key is starting the medication at 30 mg and slowly titrating it upwards to the best dose for the patient, which so far in my practice has been in the 60 to 90 mg range though it's likely to be beneficial at double this dosage or it may turn out there's a window between 60 and 120. It's too early to tell but responses are being noted in the early weeks at as low as 30 mg which was what we saw when we started using prozac and 10 mg to 20 mg was sufficient.  Later we learned that obsessive compulsive patients often needed 60 to 80 mg and it's possible there will be a subcategory of patients who need higher dosages of Cymbalta. For now I'm just really thankful to Lilly for providing a product that is such a breakthrough.
Pharmaceutical companies spend millions and millions on research and development something the 'health food industry' is not in the habit of doing.  Consider the making of a new Hollywood movie with all the jobs and all the new ideas and compare that to late night 're runs'. That can be said for alot of 'alternative medicine'. Yes I know their are exceptions but I think people forget that these are 'big business' too and don't appreciate the contributions that are provided by the pharmaceutical industry.
Almost all my patients have tried 'everything' when they get to me.  I am thankful for all the help I can get. Cymbalta is just that kind of help. Lilly is a great pharmaceutical company that has done amazing research and provided great breakthrough in medications. Thank you, Lilly.