It goes without saying that pain management is not an exact science. People have different pain experiences. They have different levels of tolerance for pain. Patients also react to pain treatments differently. For pain clinics, the goal is to find what works best for each patient. Unfortunately, a new study shows that antidepressants may not be a reliable option.
Antidepressants are sometimes prescribed in lieu of prescription painkillers, physical interventions (like physical therapy, for example), and invasive procedures. But it would now appear as though antidepressants do not help much, if at all.
A study recently published in the BMJ not only suggests antidepressants are not appropriate for pain management, but it also goes on to explain why that might be. It's a fascinating study that deserves attention from pain management physicians and the clinics that employ them.
As we have mentioned in other blog posts, pain is generally a response to some other condition. It has been described by some pain management doctors as an experience rather than a symptom. Pain signals are sent to the brain for interpretation. A person's perception of those signals constitutes their pain experience.
In many chronic pain cases, doctors are content to prescribe medications designed to either block pain signals or at least take the edge off. These prescription painkillers vary in their efficacy and potency. Some are considered pretty risky because of a high propensity for addiction.
When medications are preferred but painkillers are to be avoided, doctors may prescribe antidepressants instead. This is considered an off-label practice. In other words, doctors are prescribing medications for purposes other than originally intended.
Antidepressants were introduced as an alternative for managing chronic pain based on their effects on brain signals. Drugs like amitriptyline and sertraline alter some of the brain chemicals known to contribute to the pain experience. As the thinking goes, alter these chemicals in the right way and it is possible to either block pain signals or reduce their intensity.
Unfortunately, the previously mentioned study found otherwise. Researchers from Australia conducted systematic reviews of 26 previous studies involving 156 trials with a combined 25,000 patients. The study considered 8 different classes of antidepressants being used to treat nearly two-dozen pain conditions.
To make a long story short, so to speak, in nearly every instance in which antidepressants seemed to help alleviate pain, they did no better than placebo. Researchers were left to conclude that what chronic pain patients believe about their pain has a greater influence on the pain experience than antidepressant medications.
The one bright spot is the use of SNRIs to treat neuropathic pain, fibromyalgia, and a couple of other specific types of pain. The medications proved effective 26% of the time for those particular conditions. But other than that, the researchers didn't turn up very much evidence in support of prescribing antidepressants for chronic pian management.
On one hand, it is a relief to know that patients are not imagining things when they report antidepressants aren't helping their pain. On the other hand, it's disappointing to learn that a long trusted therapy probably isn't helping. Underscoring the whole discussion is the reality that patients still need options. They need as many options as possible.
It's back to the drawing board for pain management physicians who tend to rely on antidepressants rather than prescription painkillers. Hopefully, future research will give us access to more tools. The more choices we can offer our patients, the more effective we can be as pain management physicians trying to bring much needed relief.