What are the effects of antidepressants on pain?

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Australian study published in BMJMore After a systematic review summary found evidence of efficacy in only 11 of 42 comparisons, it advocated a “subtle” approach to prescribing antidepressants for chronic pain.


According to this study, duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is effective in most pain conditions, including back pain, fibromyalgia, neuropathic pain, and knee osteoarthritis. It turns out that there is.


But researchers at the University of Sydney say evidence is lacking for other cotricyclic antidepressants, such as amitriptyline, which are most commonly used in clinical practice for chronic pain.


NHMRC-sponsored studies have found no or even inconclusive evidence for fluoxetine, venlafaxine, and mirtazapine for a variety of conditions, including irritable bowel syndrome, functional dyspepsia, fibromyalgia, and phantom limb pain. was shown.


This follows the UK’s National Institutes of Health (NICE). 2021 guidelines For chronic pain management in primary care, we discourage the use of analgesics but favor antidepressants.


Giovanni Ferreira, PhD, School of Medicine and Health, Sydney School of Public Health, lead author of the Australian study, said: News GP Making such a recommendation without sufficient evidence is misleading.


“Our research shows that prescribing antidepressants for chronic pain requires careful consideration of the evidence for each antidepressant and pain condition individually.


“Recommending a list of antidepressants without careful consideration of the evidence for each of them for different pain conditions is a way to remind clinicians and patients that all antidepressants are the same for pain conditions. It may mislead you to believe that it is effective.


“I showed you otherwise.”


Meanwhile, Dr. Milana Votrubec, Chair of RACGP Area of ​​Special Interest Pain Management, said: News GP She has concerns about conflicts of interest related to industry-funded research in this area. BMJMore paper.


‘[There is] There is not enough research done in this area that is not biased by conflicts of interest,” she said.


“The most important aspect of this paper, under the heading ‘Impact on clinicians and future research’, is that ‘45% of the trials forming the evidence for this review are industry ties’.”


She says this point is particularly relevant to the evidence on SNRIs. SNRIs accounted for 68% of trials identified as having industry links and potential sources of bias.


Dr. Votrubec believes it is important to do research that is independent of industry influence, but she says it is difficult to achieve.


‘[It’s] Without funding, research is impossible,” she said.


“However, the Australian NHMRC independent funding body has some fairly narrow criteria for inclusion. is funded by industry.


This review examined 26 systematic reviews from 2012 to 2022 and included over 25,000 participants. Data included 8 antidepressant classes and 22 pain conditions, including back pain, fibromyalgia, headache, postoperative pain, and irritable bowel syndrome.


Since antidepressants are commonly prescribed for comorbid pain symptoms such as brain fog, fatigue, and muscle aches, Dr. Ferreira emphasized that there is evidence of low levels of duloxetine in this area. said to be important.


“We believe that SNRI [such as] Duloxetine and SSRIs [such as] Paroxetine was effective in people with depression and comorbid pain.


“Given the high prevalence of pain and comorbid depression, and vice versa, this is an area worth investigating.”


Co-author Dr Christina Abdel Shaheed also said: News GP Just because some antidepressants don’t have enough evidence of their effectiveness for pain doesn’t mean they’re useless.


“‘Proof of no benefit’ is a very different proposition than ‘evidence of no benefit,'” she said.


“This review finds an alarming paucity of evidence in this area. Given the increasing prescribing of antidepressants for chronic pain worldwide, more research is needed.” is.”


Dr. Ferreira agrees that more data is needed.


“There is no doubt that more research is needed in this area,” he said.


“One condition that could benefit from more research is sciatica. Pharmacological treatments are a central component of the clinical management of sciatica, but the most commonly used has no effect and is of unknown value.


“Antidepressants may be effective in chronic sciatica, but the evidence is inconclusive.”


Dr. Ferreira says his team’s research provides an up-to-date review of antidepressants as part of a holistic approach to pain management.


“This review brings together, for the first time, all the existing evidence on the effectiveness of antidepressants in treating chronic pain into one comprehensive document,” he said.


“Treatment of chronic pain requires an interdisciplinary approach, with both pharmacological and non-pharmacological treatments playing a role.”


Antidepressants can be started sooner and are cheaper than other treatments such as physical therapy, exercise physiology, and psychology, but Dr. Ferreira says whether they are considered “first aid” or not, they are fundamentally effective. states that what is needed is pain relief.


“We need to focus on finding and implementing effective treatments that will improve the lives of millions of people with chronic pain in Australia.


“Some analgesics may help manage pain, but they should be considered only part of the solution.


“Exercise, physical therapy, and lifestyle changes may also help, depending on your pain condition. [Patients can] Talk to your healthcare professional to learn more about suitable alternatives.



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