Pain, Anxiety and Depression Drugs

Question: I have recently had a very bad flare up and have seen my GP regularly again. The first appointment, where admittedly I was at the end of my tether with the pain and worry of being off work (unpaid) etc etc, I was given Diazapam. I took these for 2 days cautiously as she had said they were muscle relaxants. I didn’t like the idea of them and so stopped as soon as I could. Yesterday I went for results of EMG (not arrived) and she spontaneously started talking about anti-depressants to dull my nerves instead, she has told me that they are too excited. Again, I expressed my concerns about taking anything now that I feel it is gradually improving again. We agreed that unless I felt I was going backwards into another flare up then it was sensible to avoid them too. (She also said that St. John’s Wort was the equivalent in herbal but is expensive and under research for the nasty side effects that the anti-depressants might have had). Also she is usually very good in general about sending me to specialists etc so is not ignoring the actual problem, despite still not having a firm diagnosis. I wondered afterwards if she had read about a bit and thought that the anxiety/muscle route was wrong and that the depression/nerve route was more appropriate – she said that if there is no depression it simply deals with the nerves. I had not gone along for more treatment – just for the results.
Admittedly my employment situation has been dire since October with me doing many short term part time research contracts alongside each other – no security – no single good workstation – began driving again out of necessity… Therefore the flare up was not wholly surprising.
My point is that even if any of these things worked, I am bothered that I would be coming to work today not knowing how I was really. Yesterday I had to stop all computer work and desperately scouted around looking for other things to do as it was too painful – if I don’t know this is happening and carry on then the damage could be worsening? However my GP said that dulling the nerve excitement is good for the injury too, not just the pain resulting from it. From experience in all of this I am not very confident in any aspect of medical care that I do not understand fully (besides all the surrounding issues of anti-depressants and anxiety pill popping) and would really appreciate any comments anyone may have on this?
As to normal pain killers, Ibuprofen isn’t working any more and Diclofenac gave me nasty side effects. I do wonder if a strong pain killer that I can tolerate and taken after work when I am resting may be the way to go? Basically, I would rather put up with pain as it is the only single thing that will make me slow down, but if the pain itself is making the injury worse too through worry, nerve excitement or muscle tension then maybe I should be more sensible about removing the pain?

Answer 1: I too have had a flare up since Friday. I get flare-ups regularly but this was OTT. I have not found painkillers to be helpful at all. I take Codeine based ones but they don’t help really. If you have localised RSI, ice might be better every few minutes for a couple of minutes or something like that. I have diffuse RSI or TOC or RDS and end up trying different places usually with no success. Last year I went on Prozac because my doc thought I was depressed but it did not help really. I finally realised that I am depressed when in pain, that is when I usually see the doctor and she thinks that the pills will stop me feeling down but nothing short of mental discipline (not very often that) stops the downward spiral when the pain is actually there. So she gave me another prescription for Prozac and it is still sitting in a drawer, unused. I had tried Amitryptiline for a few weeks and that was unhelpful too. So I am trying to just stop when the pain comes in because, like you, I think there is further injury and if I just stop, the pain does subside after a few days. My physio disagrees with me. She thinks it is merely chronic pain which does not cause damage and I should not stop.
I confess I am having a problem with professionals. My nutritionist is also the principal of a complementary college. She arranged for me to have a session free with a top osteopath during their teaching classes. He said I had TOC. She expected me to come in the next week and be miraculously cured. I feel like I have to perform. My physio won’t give me short term pain relief via massage or trigger points or stretching.
She thinks she is misleading me if she does that. My doctor wants to give me pills. Why don’t they ask ME what I think and work with me as much as I am working with them? Okay, that is my moan finished now.
I think there is a balance. It is important to get the pain down and not to irritate it further. A cousin from India once told me ‘Health comes before Work’. I wish someone had told me that when I got the RSI 3 long years ago!

Answer 2: There is growing evidence (from scientific research) that a herbal drug called “kava kava” in most cases performs nearly as well as modern anti-depressants. Why not try it! Please be careful with Diazepam. Search for Benzo-Diazepine on the net.

Answer 3: I’m sure others will have different views, but I personally do not think that any kind of drug therapy — painkillers which anyway don’t work for long, as you say, or anti-depressants or muscle relaxants — are a good idea. Yes your nerves are thoroughly jangled, whether they are excited I don’t know, but dulling them down chemically (can they really be dulled down without dulling other bits of you down?) seems to me to be over-riding them in a false and synthetic way. If you stop taking the fix (assuming it works in an acceptable way), they will probably start to scream again, so what will you have achieved over the long term? Perhaps nothing. Perhaps more damage.
I think the only way forward over the longer term is to start a long process of retraining or over-riding your dysfunctional jangling nerve pathways by exercise, stretching, changing work habits, postural change etc. The only really effective temporary fix in the context of work (keeping going) is not medical, but voice recognition. (Although I do accept that some treatments e.g. massage therapy can give some, usually temporary, relief.) Can you not get voice recognition and do your research projects from home? The workstation issue is real and your understandable anxiety must be making things a lot worse for you. I am full of sympathy but don’t despair. And don’t go down a drug path if you can avoid it because I don’t believe it will really help.

Answer 4: I’m sure that all of us really feel for you (in more ways than 1). I could not have survived without voice recognition software. This has been the case since I first scrounged enough money to buy DragonDictate for DOS. Having suffered with this infernal disability since April 1992 I know that resting, stretching, using voice recognition (sipping lots of water and resting my voice as well) are very important. Despite this, however, work, life in general still cause flareups all too often. For example, seeing a series of students with major problems (and themselves depressed) will often make my pain much worse than after a bit of typing. Filing is impossible, wiping myself in the loo can be that final straw in terms of pain.
I was put on Prozac in June 1998, which undoubtedly helped me to cope. I nevertheless dislike being on antidepressants and, like Sonal, left the last prescription in my drawer. I’ve been using St. John’s wort for a few weeks now (following advice from “the natural Prozac programme” by Dr Jonathan Zeuss) – Vermillion [Ebury Press, Random House UK] 1998, ISBN 0 09 181608 4].
Yes, it’s definitely more expensive than via the standard prescription route. Although I’m trying to give it a fair chance I don’t really feel much better.
I’ve responded before to this newsgroup regarding painkillers and the attendant problems. Using cold packs is still among the few things that have ever helped me. So far even the TENS machine has been fairly ineffective, and sometimes has seemed to increase the pain, even though I’ve tried to ensure that I move electrodes, don’t keep the machine on for too long, etc.
So although this may only serve to increase your depression (if such any of this can be called) I agree with Maggie. Voice recognition will definitely help, if you use it appropriately. A decent workstation, that you can depend on, must also be in place. Painkillers may cause as many problems as they help.

Answer 5: I tried “kava kava”, and it didn’t seem to have any effect. Which isn’t to say that it doesn’t work for anyone, only that it didn’t work for me. I agree that one should be careful with Diazepam. I was also prescribed Diazepam. It never helped at all and I couldn’t think clearly while I was taking it. I threw it away.

Answer 6: St. John’s Wort being an herbal substitute for antidepressants sounds very reassuring, but I’m not aware that there’s any scientific basis for such assurance. The effects of antidepressants are not very well understood at all, and the effects are different from one person to another.
You can also be in touch with a Disability Employment Advisor. PACT help is supposed to be available to someone in your position. Even though the difficulties are obvious, if you’re moving from one office to another, they might be able to help. Put it on their plate and *expect* them to do something — that’s what they’re there for. And they are often very helpful and understanding, which does tend to make you feel a bit better in any case.
If it’s the work situation that’s exacerbating the RSI, then case it’s hard to see how anti-depressants and tranquilizers can change it. The pain could well be a sign that the injury is being made worse. It wouldn’t be surprising under such difficult circumstances. I don’t think you should be trying to rely on the pain to make you slow down. I hope you can find a way to start using voice recognition instead of a keyboard.

Answer 7: “Kava kava” seems to work just like Prozac, i.e. it seems to need at least 2-8 weeks to start working…

Answer 8: You haven’t mentioned whether you’ve contacted AbilityNet for advice on alternative keyboards and mouse replacements – it’s probably a good idea, as a private individual their advice to you is free. You can 192 their number. You might be able to get help from the PACE scheme on the cost of hardware.
More even that, I’d recommend reading the *Pascarelli and Quilter* book. They give an excellent recipe for adapting a standard keyboard to make it less dangerous (negative tilt and a dvorak keymap, a pad of keystroke softening foam below.) You’ve got to read their stuff on correct hand position while typing. You can order from Amazon and have the book in 24 hours.
To deal with RSI you’ve got to have enough knowledge to make informed decisions – relying on doctors and news lists is close to suicidal; there’s good stuff to be had but you’ve got to be able to filter it – and this is the best place to get it.
And try to replace the mouse with something that can sit on your lap instead of being a reach, like a Glidepoint or a palm (not thumb) operated trackball. AbilityNet can help with a trial. Or find a keyboard with no numeric pad so that you don’t have to reach as far for the mouse at least, but make sure it’s otherwise a full-sized keyboard. I’m using a cherry ergo which can split and “tent.”
Alternative keyboards – including Pascarelli’s home brewed design -and mice can be carried around from job to job and quickly installed – just always switch off the PC while sticking the new cables in. Unlike VR software they don’t distract co-workers, so they don’t cost you jobs. (Telling your boss that this is “tough” isn’t really an option in most commercial environments, especially for contract hires, and is a very real problem, especially in intellectual property creation businesses where real thinking should be going on all the time.) But I’d say the most important thing of all is to learn to type in a safe manner, which I’ve only seen in Pascarelli.
Finally, consider some body work, like Alexander technique. I’ve just started and am please with the early results, but it’s a good several months of practice and tuition bills. It’s easy to take from office to office. But talk to a lot of teachers before choosing. Try to find someone who treats RSI in musician’s – they’ve had it for years. Speak to your local music college if you go this route. You need someone in the ATI or STAT.

Answer 9: I have jangled nerves too; and I wondered as mine are physical — my hands and wrists were bad anyway, I put out my right hand to steady myself, and have felt as if I could feel  every nerve in my right hand ever since! — what exactly your doctor meant by “nerves”. I coped with mine by resting my wrist on a can if iced coke while I was at work, and taking paracetamol this evening (I can’t take anti-inflammatories any more).
I think, unlike most people who have written, that you probably should find some way of killing the pain in the evenings, when you can rest. Ice is good but difficult to cope with. I suppose you could keep something like a can of Coke iced and never open it!
Diazapam are very good muscle relaxants; I was given them for 2 weeks ages and ages ago when I fell and slipped 2 disks. But as you know they are mainly used as tranquillisers and long term use is felt to be bad. The most important thing about them in your case is that *you* don’t want to take them, so, don’t! I don’t know enough about your form of RSI to know whether muscle relaxants would make sense, anyway.
Doctors in the US use anti-depressants, in small doses, for RSI. I read an explanation of how this works but I don’t know how convincing it would be to someone who knew about medicine! I imagine your doctor was thinking of a higher dose than that and of the kind that also acts as a sedative — some are more sedative than others, but I haven’t any names, as the sedative effect would begin right away. As another poster said, they take a while to work as an anti-depressant; ten days, three weeks, longer? During that time they have side effects of various kinds. (I’m not really up on this: I was once given Prozac and it made me feel sick, so I went back and said I wasn’t going to take it — rather than just stop taking it and not say anything.) Again if you don’t want to take them that seems to me important. St. John’s wort seems to fit with what I know about their sedative effects.
It is horrible to not have a single good workstation. Your hands will have no rest at all. I do think you should get voice software if at all possible; the problem I see about getting it provided for you is your part-time work, but I think it would be worth trying PACT, anyway. Even with voice software, on bad days filing papers was very painful. I often can’t sort papers, let alone file them. Marking essays is a problem too. And we have voice software. You have my sympathy. It is not surprising that you feel low.
Anti-depressants and anxiety pills have their uses. Not many people speak up for them these days, and I understand that. But they have helped a lot of people. What they don’t do as I understand it — but then I don’t really understand the point about nerves — is why they would help your RSI.
I had in mind more an evening break from the pain. There are techniques of controlling pain, mind-over-matter ones: I am trained in more than one. They are not, because of the way they work, that good for injured wrists – so I am taking the paracetamol too! For a long time, I took no painkillers; that was when my back was very bad but I wanted to know, so the pain could warn me. That may be why paracetamol works for me now. Why not ask your doctor? Mine knows a lot about painkillers.
There is a naturopathic treatment that isn’t for RSI but can be adapted for it: alternate warm and cold water. It helps me. I can’t swim, but loafing around in the shallow end of swimming pools, floating my hands and wrists in the water, also helps. Walking does too.  The problem is that continual pain is so miserable that it can be hard to get around to doing this stuff, and you must be having an exceptionally tiring time, too.
No-one’s mentioned the pain clinics. There might be one near you, and it might help. I know getting time off to go to one is a problem, and I’m afraid I just have no answer to that.

Answer 10: If you want to understand how the nerves work I suggest you get hold of the book below (from your local libary):
The Challenge of Pain
R. Melzack and P. Wall
Publ: Penguin
ISBN: 0140256709
Price: 10 ukp
This is a really good book on how the nerves work, pain etc.
Anti-depressants that are used as pain-killers can take up to eight weeks to gain their full effect. The dose is much smaller than that used for the anti-depressant effect. However like most of the comments I would be cautious about using them if you are continuing to work. If they reduce the pain but don’t mask it completely then use them, just stop working as soon as the pain starts, rather than waiting until you are in agony. Just learn to stop!
Maybe you should only do the same amount of ‘work’ every day, regardless of whether it causes you pain or not. This is what you do when you are ‘pacing’. Stop even when your pain has not started on a good day, continue until your time is up on a bad day. Within reason, of course. You have to find the ‘level’ that you can work at.
Having said that, I do wonder whether the ‘pacing’ should only really be done when you have stopped injuring yourselves. This raises the question: How do I know whether I am injuring myself or whether it is just chronic pain? I don’t know the answer. Maybe someone on the list who has been to the INPUT pain clinic at St. Thomas’s can answer this question?
If you have reached the point when over-the-counter pain killers don’t work enough, then isn’t it time to visit a pain clinic? I know this isn’t the usual up-beat advice you get on this list, and I will probably get flamed for it, but, shouldn’t you really consider stopping working or reducing the amount of work you do? Continuing to work and making your condition this bad is not really a good idea.

Answer 11: Two points (I have been on the pain management course at INPUT): (1) Pacing, as taught to me at INPUT, is a bit more complicated than described. You establish baselines – i.e. what you can do for any activity which is within a comfortable range — and then you use that and very gradually build up from there. To work well, it has to be done very systematically, with a timer, and with fall-back plans etc. for cases if you’re hurt. It is a more systematic and scientific technique than ‘time off, time on’. Caudill’s book on pain management has some stuff on it. Penny and I cover it in our forthcoming book. But best try and get to the course at INPUT. (2) I don’t think there is yet medical or scientific agreement about whether there are injuries or not, and at what point one leaves acute pain for chronic pain and sees chronic pain as the prevailing condition. (I’m not sure even INPUT staff are consistent on this.) My own view is that diffuse RSI is a chronic pain condition, and one in which nerves are thoroughly jangled and sending wrong messages, not one in which injuries are going on or continuing. This is just a personal view. If you believe this, then you will be less worried about injuring yourself, and more concerned to get the pain under control by reprogramming the nerves and seeing that as the route forward. There will be less fear about working from the point of view of injury, although pain is no less real. However, if you think you are being injured, you should obey your instincts. The key is to be able to hear your body properly and gauge your situation, which can be greatly aided by yoga relaxation, pilates and those sorts of things. Then you can sense much better what is going on and how to cope. I feel drugs will only get in the way of this, and their utility is bound to be short-term. INPUT is certainly unenthusiastic about drugs, except as occasional props during flare-ups.

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