When treating patients with chronic pain, the authors of an editorial published in The BMJ encouraged physicians to consider antidepressants before dispensing potentially harmful prescription pain-relief drugs.

Osteoarthritis and chronic back and neck pain are the leading cause of disability worldwide. Although prescriptions of opioids have been decreasing in recent years in response to the rising opioid epidemic in the United States, evidence has indicated gabapentinoid prescriptions have been increasing despite little evidence of beneficial outcomes and established evidence of harm.

The authors of the editorial cited studies that may indicate some patients could be relieved from pain even though the studies’ observed effect sizes failed to reach the minimum threshold for clinical significance, which is 10 out of 100 points on pain or disability scales.

Although nearly the minimal effect size for clinical significance (-9.9-point change) was achieved by using tricyclic antidepressants among patients with chronic back pain, these findings are not considered sufficient to justify widespread guidance for using tricyclic therapy among patients with chronic back pain.


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The American College of Physicians guidance, however, suggests using duloxetine as a second-line treatment for low back pain. On the other hand, the United Kingdom National Institute for Health and Care Excellence guidance is opposed to using antidepressants for this kind of pain.

A similar pattern of change after antidepressant therapy with duloxetine (-9.72-point change) was observed among patients with osteoarthritis. These findings tend to agree with the Osteoarthritis Research Society International guidance, which advises the conditional use of antidepressants for patients with osteoarthritis and widespread pain comorbidities or depression.

Gleaning generalized recommendations about using antidepressants to treat chronic pain remains difficult due to inconsistent recommendations from governing bodies. A robust review is needed to clarify current recommendations and to determine how many patients gained a personal benefit from this therapy.

Nevertheless, some patients may choose to try antidepressant therapy for a short period if they have a 1 in 10 chance of reducing their pain symptoms with little risk for harmful side effects.

Few evidence-based studies have been conducted, and established drug treatments remain ineffective and pose a high risk for serious harm. The study authors, therefore, concluded that additional studies for the use of antidepressants for chronic pain therapy are needed.

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Underwood M, Tysall C. Antidepressants for musculoskeletal pain. BMJ. 2021;372:n80. doi:10.1136/bmj.n80