Are antidepressants also pain relievers? – . Health Blog

Did you know that antidepressants are often prescribed for people without depression?

It's true. Antidepressants are often prescribed for chronic pain, especially pain related to nervous disorders (known as neuropathic pain), chronic lower back or neck pain, and certain types of arthritis.

In fact, some guidelines for treating chronic lower back pain and osteoarthritis (the most common type of arthritis) include antidepressants. One antidepressant in particular, duloxetine (Cymbalta), has been approved by the FDA for these conditions.

Exactly how antidepressants relieve pain is not known. One possibility is that they affect chemicals in the brain that are involved in the perception of pain, a mechanism that is different from fighting depression.

Usually not the first choice for pain relief

For people with chronic lower back or neck pain or osteoarthritis of the hip or knee, an antidepressant is usually not the first recommended treatment. Other approaches such as physical therapy, exercise, weight loss, nonsteroidal anti-inflammatory drugs (NSAIDs), or cortisone injections are usually tried first. However, if these don't help, antidepressants like duloxetine or amitriptyline might be a sensible next step.

When the starting dose for pain is prescribed, it is typically low (often lower than the starting dose for depression). It is increased gradually if necessary. Ideally, people will notice a benefit within weeks of starting the drug, and the drug can be continued at the lowest effective dose. Switching to a different antidepressant may be recommended if pain is not well controlled, side effects occur, or there is an interaction with another drug.

A new study suggests that antidepressants don't work well for common types of pain

Previous research on antidepressants for chronic pain, such as duloxetine for osteoarthritis of the knee, amitriptyline or duloxetine for chronic lower back pain, and amitriptyline for chronic neck pain, showed modest short-term benefits. The studies were limited, however: most of the studies were small and lasted only a few months or less. In particular, drug side effects such as nausea, constipation, and erectile dysfunction were common in these studies.

Now, a 2021 study has combined data from previous research to get a better sense of how safe and effective antidepressants are for these conditions. The news is not good:

• On average, antidepressant treatment reduced pain and disability minimally compared to placebo. The improvement in pain – about 4 points on a scale of 0 to 100 – was considered too little to be noticed.
• People treated with certain antidepressants for chronic pain often stopped taking the drug because it didn't work, caused unacceptable side effects, or both.
• People with chronic pain and depression showed no greater improvement than people with chronic pain alone.

Sciatica can be an exception: antidepressants can be less painful for up to a year. However, the quality of the previous research was poor, so the study's authors were not convinced by these conclusions.

These results cast doubt on the usefulness of antidepressant treatment for these common causes of chronic pain. However, they do not rule out the possibility that some people will get more relief from these drugs than others.

The final result

The available data suggest that the benefits of antidepressants for osteoarthritis or chronic lower back and neck pain are modest and more transient at best. This is disappointing because there are no reliably effective treatments for many pain patients (shortly before joint replacement for osteoarthritis).

So, if you are taking an antidepressant for pain and you are not sure if it is working, speak to your doctor about whether you should consider stopping it. But don't stop doing it alone. There may be other reasons your doctor recommends this drug, and many antidepressants should be reduced gradually, rather than stopped all at once, to avoid withdrawal symptoms.

If you are taking an antidepressant for pain, double-check that it is really doing something for you and that it may be time to shorten your medication list. Not only could you simplify your medical regime, but you could also reduce the cost of your medication and the risk of drug-related side effects.

Follow me on Twitter @RobShmerling