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Scientists urge doctors to be cautious while prescribing antidepressants for managing chronic pain


Chronic pain exerts a considerable burden among people across the world, affecting both men and women almost equally.According to a population-based 2021 study in India, among the rural populations, low-back pain was most prevalent (70%), followed by the knee (46%), leg or calf (39%) and mid back (39%)

The treatment of chronic pain is often suboptimal, with commonly used medicines having limited or unknown benefits and sometimes harmful side effects. In many cases, doctors prescribe antidepressants to help manage chronic pain, even when the person affected does not have a mood disorder like depression and the trend showing the use of such medications is increasing over time.

Now for the first time, an international review study tried to assess the efficacy of antidepressants in managing chronic pain has found that while some classes of antidepressants were effective in treating certain pain conditions in adults, others were either not effective or the effectiveness was unknown.

The study, published in The BMJ, reviewed the safety and effectiveness of antidepressants in treating chronic pain, and brought together all the existing evidence in one document for the first time.

The researchers say that their results show that doctors need to consider all the evidence before deciding to prescribe antidepressants for chronic pain management.

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Elaborating on their findings, professor Martin Underwood from the University of Warwick, a co-author of the study, said, “There is a role for antidepressants in helping people living with chronic pain; however, this is more limited than previously thought.”

Pointing out that antidepressants may have undesirable side effects that patients may wish to avoid, he added, “We need to work harder to help people manage their pain and live better without relying on the prescription pad.”

Researchers examined 26 systematic reviews from 2012 to 2022 involving over 25,000 participants for their study. They included data from eight antidepressant classes and 22 pain conditions, including back pain, fibromyalgia, headaches, postoperative pain, and irritable bowel syndrome.

While they found antidepressants belonging to the serotonin-norepinephrine reuptake inhibitors (SNRI) class, like duloxetine, to be effective for the most significant number of pain conditions, such as back pain, knee osteoarthritis, postoperative pain, fibromyalgia, and neuropathic pain (nerve pain), the tricyclic antidepressants, such as amitriptyline, which are the most commonly used antidepressant to treat pain in clinical practice, showed that it is unclear how well they work, or whether they work at all for most pain conditions.

However, in recent times more medics are relying on the use of antidepressants for managing chronic pains and a 2021 guideline for chronic primary pain management published by The National Institute for Health and Care Excellence (NICE), England, recommends against using pain medicines with the exception of antidepressants. The guideline recommends different types of antidepressants, such as amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline for adults suffering from chronic pain.

The study’s lead author Dr Giovanni Ferreira from The Institute for Musculoskeletal Health and Sydney Musculoskeletal Health at the University of Sydney said a more nuanced approach to prescribing antidepressants for pain is needed.

“Recommending a list of antidepressants without careful consideration of the evidence for each of those antidepressants for different pain conditions may mislead clinicians and patients into thinking that all antidepressants have the same effectiveness for pain conditions. We showed that is not the case.”

“The findings from this review will support both clinicians and patients to weigh up the benefits and harms of antidepressants for various pain conditions so that they can make informed decisions about whether and when to use them,” Dr Christina Abdel Shaheed from The School of Public Health and Sydney Musculoskeletal Health at the University of Sydney, Co-author of the study added.

Dr Ferreira said that there are multiple treatment options for pain, and people should not rely solely on pain medicines for pain relief.

“Some pain medicines may have a role in pain management, but they need to be considered only part of the solution. For some pain conditions, exercise, physiotherapy, and lifestyle changes may also help,” he added.

It may be noted that most antidepressant prescriptions for pain are ‘off label’, meaning they have not been approved to prescribe for pain. However, many antidepressants, including serotonin, are believed to help with pain by acting on chemicals that can help to relieve pain. However, it is still unknown exactly why some antidepressants improve pain.


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