PTSD, insomnia, alcohol use and somatic symptom disorder in chronic pain

PTSD, insomnia, alcohol use and somatic symptom disorder change pain care: favor trauma-focused psychotherapy, CBT for insomnia, alcohol treatment that does not block opioids, and scheduled visits with limited testing for somatic symptom disorder.

1. PTSD: trauma-focused psychotherapy first. The 2023 VA/DoD guideline recommends manualized trauma-focused psychotherapy (prolonged exposure, cognitive processing therapy or EMDR) over drugs; if medication is used, paroxetine, sertraline or venlafaxine ¹.
2. No benzodiazepines or cannabis for PTSD. The guideline recommends against benzodiazepines and against cannabis or cannabis-derived products, and supports secure video delivery of recommended psychotherapy when validated or when other options are unavailable ¹.
3. CBT-I comes first for chronic insomnia. ACP strongly recommends cognitive behavioral therapy for insomnia as initial treatment for all adults with chronic insomnia disorder; medication is considered through shared decision making only if CBT-I alone fails ².
4. Hypnotics add opioid risk. Nonbenzodiazepine sedative hypnotics, like other central nervous system depressants, can potentiate opioid-induced respiratory depression, so clinicians should weigh whether the benefits of combining them outweigh the risks ³.
5. Naltrexone and opioid analgesics do not mix. Extended-release naltrexone is contraindicated with opioid analgesics, physiologic opioid dependence or withdrawal ⁴; acamprosate has no opioid contraindication but needs renal dosing ⁵.
6. Somatic symptom disorder: structure the care. Distressing symptoms with excessive thoughts, feelings or behaviors persist, typically over 6 months; schedule regular visits, build an alliance, legitimize symptoms, limit tests and referrals, and offer CBT or mindfulness ⁶.

Acamprosate is contraindicated at creatinine clearance 30 mL/min or less and needs a lower dose at 30–50 mL/min; monitor for depression and suicidality ⁵.

• DSM-5 adds a "with predominant pain" specifier to somatic symptom disorder ⁶.
• Severity is mild with one Criterion B feature, moderate with two or more, and severe with added multiple or very severe complaints ⁶.
• The PHQ-15 or Somatic Symptom Scale-8 can screen for somatic symptom burden ⁶.
• Amitriptyline and SSRIs are listed as effective drugs for somatic symptom disorder ⁶.
• The CBT-I recommendation is strong, based on moderate-quality evidence; medication is a weak recommendation ².
• Related disorders include conversion disorder, factitious disorder and illness anxiety disorder, a preoccupation with having or getting a serious illness ⁶.
• In a patient taking opioid analgesics, naltrexone would precipitate withdrawal and block analgesia ⁴.
• CBT-I comes before trazodone or other sedating drugs in patients on opioids ²³.

• Starting a hypnotic before CBT-I in a patient taking opioids ²³.
• Giving naltrexone for alcohol use to a patient taking opioid analgesics ⁴.
• Ordering more tests to reassure a patient with somatic symptom disorder ⁶.
• Prescribing a benzodiazepine or cannabis for PTSD symptoms in a patient with chronic pain ¹.