With the exception of one drug, antidepressants (paroxetine, amitriptyline, etc.) prescribed to reduce chronic pain lack effectiveness in this type of prescription, warns a large study.
Except duloxetine (marketed as Cymbalta®) which would have “an undeniable interest in the treatment of pain“, most antidepressants prescribed to relieve chronic pain (mainly fibromyalgia, neuropathic pain and musculoskeletal disorders (TMS)) would lack efficacy and harmlessnessreport the authors of a meta-analysis published in the Cochrane review on May 10, 2023. They reviewed 176 randomized controlled trials involving nearly 30,000 participants with chronic pain. In total, 25 antidepressant molecules were analyzed by the researchers who have classified according to their effectiveness using several criteria including: pain relief, pain intensity, adverse events, physical function, sleep, quality of life, global impression of the patient, weaning.
Duloxetine, the only effective antidepressant
The result is clear: in this review, only Ia duloxetine seems to have “A moderate effect on reducing pain and improving physical function. It’s the antidepressant we trust the most“, detail the researchers. Indeed, for 1,000 people taking standard-dose duloxetine, 435 experienced 50% pain relief compared to 287 taking a placebo, they continue.
Another antidepressant, Milnacipran (Milnacipran Arrow®) “may reduce pain, but we are not as confident in this result as duloxetine because there have been fewer studies with fewer people involved“, say the researchers. Further research is needed to confirm these findings. For the other antidepressants analyzed (amitriptylinemirtazapine (Norset®), fluoxetine (Prozac®), citalopram (Seropram®)paroxetine (Deroxat®)sertraline (Zoloft®)…), “There was not not enough evidence For draw strong conclusions about efficacy and safety for chronic pain“.
“We don’t know the adverse effects of using antidepressants for chronic pain”
Also, researchers don’t know if antidepressants are effective. to treat long-term pain because the average duration of the studies was only 10 weeks. Finally, “we don’t know the adverse effects of using antidepressants for chronic pain; there’s not enough data” they warn. There duloxetine and Milnacipran are on the list of drugs to be ruled out according to the French medical journal Prescrire because of their undesirable effects (cardiac disorders, arterial hypertension, tachycardia, cardiac arrhythmias, etc.). “There duloxetine also exposes to hepatitis and hypersensitivity reactions with severe skin damage (including Stevens-Johnson syndromes).”
Do not stop treatment without medical advice
Antidepressants are prescribed in the treatment of pain because they would reduce the transmission of the painful message to the brain. They represent an alternative to opioidslong prescribed to treat pain but associated with a real risk of addiction and overdose. DIn the chronic pain patient population, approximately 1 in 5 would experience a depressive disorder or an anxiety disorder“which justifies taking a first-line antidepressant“, estimates Professor Eric Serra, psychiatrist and pain doctor, vice-president of the French Society for the study and treatment of pain, questioned by our colleagues from the Doctor’s Daily. However, it recalls the need to prescribe them to an effective dosewith a well-defined objective and duration of treatment. Moreover, the patient should not stop his treatment without medical advice : Sudden withdrawal can have dangerous effects. The authors of the study are in favor of non-drug alternatives in the treatment of pain the practice of an adapted physical activitymobility support and psychological approaches to social isolation.
Source: Antidepressants for pain management in adults with chronic pain: a network meta‐analysis, Cochrane Library, 10 May 2023