How would you treat mild to moderate cognitive impairment resulting from necessary opioid therapy after the opioid with the fewest side effects for the patient has been found?
Thank you for your interesting question.
I really don't believe that there is any specific treatment for medication-related confusional states or cognitive impairment other than reduction of the medication dosage or substitution with another agent that appears to be less toxic with respect to mental acuity.
I accept your point that the opiates you are prescribing are necessary, but I would still like to refer you to an excellent review of pain management in the psychiatric newsletter The Carlat Report Vol 2, No. 7, July 2004. (see www.thecarlatreport.com). In this article, Dr. Carlat reviews the entire range of pain management options, including various antidepressants and antiepileptic mood stabilizers with at least minor analgesic properties, as well as NSAIDS, Cox-2 inhibitors, and opiates of varying strengths and lengths of action. There is also an interview with Dr. Scott Fishman, Chief of Pain Medicine at the University of California, Davis, which might be relevant to your clinical situation. Dr. Fishman points out that whether or not antidepressants have major analgesic effects, reduction of depression, if present, may raise the pain threshold and permit the use of lower opiate doses. He also notes that when evaluating patients who are chronically on opiates, you should look carefully at functional outcomes, i.e., is the patient actually experiencing relief of pain? He says that to justify the prescription, "people's lives should get better, and there should be objective evidence of that. . . ."
