Depression, anxiety, and substance use disorder in chronic pain

Depression, anxiety, and substance use disorder are frequently seen in patients with chronic pain. Depression and anxiety are common in substance use disorder. It may be difficult to determine when the conditions are a primary problem or secondary to the treatment of the pain itself. A variety of pharmacologic interventions are reviewed. Antidepressants with a dual-mechanism action (serotonin and norepinephrine) tend to be most effective. Various psychological treatments may be indicated, such as cognitive behavioral therapy, couples therapy, or electroconvulsive therapy (ECT). Anxiety models such as phobic avoidance of pain or Post Traumatic Stress Disorder may be relevant in understanding the patient with pain. A variety of pharmacologic approaches may address anxiety in patients with chronic pain. Various psychological interventions to address the anxiety are also discussed, including biofeedback training and Eye Movement Desensitization Reprocessing.