Depression, anxiety and suicide risk in chronic pain

Screen for depression, anxiety and suicide risk in every chronic pain patient; treat mood with agents that also help pain, avoid adding benzodiazepines to opioids, and never stop long-term opioids abruptly in someone at risk.

1. Chronic pain raises suicide risk. People with chronic pain are 2 to 3 times as likely to report suicidal behaviors, and CDC notes about 9% of suicide decedents in 18 states had evidence of chronic pain ¹².
2. Mitigate risk on long-term opioids. Recommended strategies include opioid education with naloxone, lethal-means safety counseling, more frequent visits, individualized tapers, nonopioid and nonpharmacologic treatment, and addressing modifiable risk factors ¹.
3. Do not taper abruptly. CDC states opioids should not be stopped abruptly or rapidly reduced from higher doses unless there is a life-threatening issue; stopping long-term high-dose therapy has been associated with increased suicide risk ².
4. Pick a drug that treats both. Patients with co-occurring pain and depression might be especially likely to benefit from antidepressants ²; ACP lists duloxetine, with tramadol, as second-line for chronic low back pain after NSAIDs ³.
5. Treat anxiety without benzodiazepines. For anxiety in patients on opioids, CDC advises evidence-based psychotherapy such as CBT, specific antidepressants or other nonbenzodiazepine drugs approved for anxiety ².
6. Screen with brief validated tools. PHQ-9 scores of 10 or more had 88% sensitivity and specificity for major depression ⁴; GAD-7's cut point gave 89% sensitivity and 82% specificity for generalized anxiety ⁵.

If a benzodiazepine must stop, taper it gradually: abrupt withdrawal can cause rebound anxiety, hallucinations, seizures, delirium tremens and, rarely, death ².

• CDC urges particular caution prescribing opioids with benzodiazepines, and weighing risk with gabapentinoids, muscle relaxants and sedative hypnotics ².
• Buprenorphine or methadone for opioid use disorder should not be withheld because a patient takes benzodiazepines ².
• Overdose or suicide death rates rose right after starting or stopping opioids, decreasing over about 3–12 months ².
• Modifiable suicide risk factors in chronic pain include pain intensity, long-term opioid use, catastrophizing and perceived burdensomeness ¹.
• In older adults, tricyclic antidepressants require judicious case-by-case use because of confusion and falls ².
• CDC advises coordinating with other clinicians to weigh concurrent benzodiazepine and opioid risk and prioritize patient goals ².
• Physical activity can help prevent or reduce depressive symptoms as well as pain ².

• Treating new anxiety in a patient on opioids by adding a benzodiazepine ².
• Rapidly tapering long-term high-dose opioids as a "safety" step in a patient at suicide risk ².
• Stopping a long-standing benzodiazepine abruptly once the opioid risk is recognized ².
• Skipping depression screening in chronic pain; depression can exacerbate physical symptoms, including pain ².