Are Antidepressants Also Pain Relievers?

Were you aware that antidepressant medications are commonly recommended for individuals who do not have depression?

Indeed, it is a fact. Antidepressants are regularly prescribed to address chronic pain, particularly pain associated with nerve diseases (referred to as neuropathic pain), persistent discomfort in the lower back or neck, and specific types of arthritis.

Surprisingly, some medical guidelines for managing chronic low back pain and osteoarthritis, the most prevalent form of arthritis, advocate the use of antidepressants. Notably, one specific antidepressant, duloxetine (Cymbalta), has obtained FDA approval for addressing these conditions.

The precise mechanism by which antidepressants alleviate pain is not thoroughly comprehended. One hypothesis suggests that they may impact the brain’s chemical composition involved in pain perception, a process distinct from their role in treating depression. This underscores the multifaceted nature of antidepressant medications and their versatile applications in addressing various health conditions beyond their original intended purpose.

Not usually the first choice for pain relief

For individuals dealing with chronic low back or neck pain, or osteoarthritis of the hip or knee, antidepressant medications are generally not the foremost treatment option suggested. Initial strategies typically involve alternative approaches such as physical therapy, exercise, weight management, nonsteroidal anti-inflammatory drugs (NSAIDs), or cortisone injections. These interventions are usually explored before considering antidepressants like duloxetine or amitriptyline.

When prescribed for pain management, the initial dosage is typically conservative, often lower than the starting dose for addressing depression. If necessary, the dosage can be gradually increased. The optimal goal is for individuals to perceive a positive effect within a few weeks of commencing the medication, and the treatment is ideally maintained at the lowest effective dose. In cases where pain control is inadequate, side effects emerge, or there is an interaction with another medication, healthcare providers may recommend transitioning to a different antidepressant to enhance the therapeutic outcome. This nuanced approach underscores the tailored and evolving nature of prescribing antidepressants for pain management.

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

Previous research on the use of antidepressants for chronic pain, including medications like duloxetine for osteoarthritis of the knee, and amitriptyline or duloxetine for chronic low back pain, as well as amitriptyline for chronic neck pain, indicated modest, short-term benefits. However, these studies had limitations, with most trials being small-scale and of relatively short duration, often lasting only a few months. Furthermore, these trials highlighted common medication side effects, such as nausea, constipation, and erectile dysfunction.

• A more recent study conducted in 2021 aimed to aggregate and analyze the data from previous research to provide a more comprehensive understanding of the safety and efficacy of antidepressants for these specific conditions. The results, however, were not particularly encouraging:

• On average, the use of antidepressants showed only minimal reductions in pain and disability compared to a placebo. The observed improvement in pain, approximately 4 points on a 0 to 100 scale, was deemed too marginal to be perceptible.

• Individuals undergoing treatment with certain antidepressants for chronic pain often discontinued the medication due to its ineffectiveness, the onset of unacceptable side effects, or a combination of both factors.

• Those experiencing both chronic pain and depression did not witness more substantial improvement than individuals dealing with chronic pain alone.

• An exception to these general trends may be sciatica, where antidepressants potentially contributed to pain reduction for up to a year. However, the study authors expressed reservations about the reliability of these conclusions due to the poor quality of prior research on this specific aspect.

While these findings raise skepticism regarding the overall efficacy of antidepressant treatment for prevalent causes of chronic pain, it’s essential to acknowledge the potential variability in individual responses, suggesting that some individuals might derive more significant relief from these medications than others.

The bottom line

Based on the available evidence, the overall benefit of antidepressants for conditions such as osteoarthritis, chronic low back pain, and neck pain appears to be, on average, modest at best and tends to be of a temporary nature. This can be disheartening for individuals suffering from pain, especially given the limited availability of reliably effective treatments, with joint replacement often being the most substantial option for osteoarthritis.

If you are currently using an antidepressant for pain and are uncertain about its effectiveness, it is advisable to have a discussion with your doctor regarding the possibility of discontinuing it. However, it is crucial not to stop the medication independently. Your doctor may have specific reasons for recommending this medication, and in many cases, antidepressants should be gradually tapered rather than abruptly discontinued to prevent discontinuation symptoms.

For those taking antidepressants for pain, reassessing whether the medication is providing meaningful benefits and considering whether it’s time to streamline your medication list is a worthwhile endeavor. Beyond simplifying your medical regimen, this approach may also lead to a reduction in medication costs and a decreased risk of medication-related side effects.