Osteoarthritis and back pain are two of the most common and difficult to treat conditions in the United States.
According to the Centers for Disease Control and Prevention, one in four Americans has experienced low back pain within the last three months. This makes it the most commonly reported type of pain.
Osteoarthritis, which is caused by the breakdown or damage to joint cartilage between bones and joints, is also tops of its class. It affects 32.5 million Americans.
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These drugs, which include SNRIs (serotonin reuptake inhibitors) and SNRIs (serotonin reuptake reuptake stimulators), are prescribed to treat these conditions. However, a meta-analysis has shown that these drugs may not be effective for many people.
The results suggest that antidepressants don’t help with back pain.
Giovanni Ferreira, PhD is a postdoctoral researcher at the University of Sydney. He was the main author of the research published in the journal BMJ on January 20th.
Antidepressant medication is often used to treat chronic pain
Major medical organizations like the American College of Physicians and the Osteoarthritis Society include antidepressants as part of their treatment guidelines.
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Antidepressant medication is the fourth most commonly prescribed medicine for low back discomfort in the United States. About one in four Americans seeking treatment for low-back pain are prescribed antidepressant medications within three months of being diagnosed. According to a BMJ study, February 2017, about 1 in 4 people are prescribed antidepressant medications.
Antidepressants used to treat pain are often prescribed at lower doses than those for depression. Scientists are still trying to understand the mechanism of antidepressants’ action. They work by increasing the levels of neurotransmitters and chemicals in the brain and spinal canal, which reduce the pain that people feel.
Investigators Examined 33 Studies and More Than 5,000 Patients
Researchers looked at 33 random controlled trials, which included 5,318 participants, to determine if antidepressant medication are safe and effective for people suffering from low back, neck, or sciatica pains. The funding for five of those trials was not clear, while 14 of the studies were funded in part by pharmaceutical companies.
The pain and disability scores from the various studies were converted into a common 0-100-point scale. 100 is for severe pain and disability.
These antidepressants were tested in the following classes:
- SNRIs are serotonin- and norepinephrine reuptake inhibiters. Duloxetine (Cymbalta), and venlafaxine, (Effexor and Effexor XR), are two examples of SNRIs.
- SSRIs are selective serotonin reuptake inhibitors. These SSRIs include citalopram, escitalopram and Lexapro.
- Tetracyclic antidepressants, (TCAs), Medications such amitriptyline(Elavil), desipramine/Norpramine and imipramine/Tofranil
- SARIs are serotonin antagonists and reuptake inhibits. These medications are also known by the name atypical antidepressants. They include trazodone, Desyrel, and nefazodone.
- NDRIs (norepinephrine/dopamine reuptake inhibits) are a group of antidepressants that include bupropion (Wellbutrin SR and Wellbutrin XL).
The following were the results of an investigation:
- SNRIs had a small impact on back pain. They reduced pain by 5.3 points of 100 on the pain scale compared to placebo after three months. This is a difference that most patients would not find meaningful, according to researchers.
- The SNRIs were slightly less effective in osteoarthritis pain than placebo and had a 9.7 point reduction in pain compared to placebo. This was just short of the 10-point mark that investigators considered clinically meaningful.
- Although TCAs and other SNRIs might help sciatica pain, the evidence isn’t conclusive. The sciatic nerve, which controls the muscles at the lower leg and back of your knee, is the largest nerve in our bodies. Sciatica is usually only one side of your body. It can cause weakness or pain in one side, as well as numbness and tingling.
- TCAs were not found to be effective in treating back pain.
Dr. Ferreira says that it is important to be cautious when interpreting our findings regarding OA and sciatica. He says that most of the trials in osteoarthritis patients were funded by pharmaceutical companies. The drug’s benefits could be substantial, but the trials in sciatica patients were smaller and less well-conducted, so the results are less certain.
Research Leaves Questions Unanswered About Pain Causes, Duration, And More
This paper provides some insight into the use of these medications in patients with back pain, sciatica and osteoarthritis. However, Brian Neuman MD, an assistant professor in orthopedic surgery at Johns Hopkins Medicine, Baltimore, points out that there are some limitations to using a meta analysis to determine their efficacy.
This analysis is useful because it examines many patients. However, Dr. Neuman says that this particular study includes several types of pain and different levels of severity. He also mentions that there are many types of medication and different dosages.
“There are many [unanswered] question. What is the cause of their pain? How long have they been suffering from the condition? He asks, “What are their other risk factors?” Neuman says that these factors cause him to view the results of this type of analysis with caution.
He adds that a multi-center randomized controlled study comparing the most commonly used antidepressant with placebo would be able to better assess its efficacy.
There is limited evidence to support the use of antidepressants for pain relief.
Ferreira says that antidepressants can be prescribed for back pain and OA for different reasons. He points out that most guidelines for osteoarthritis and back pain recommend their use.
Ferreira says that some patients may not respond to anti-inflammatories and paracetamol, and therefore were prescribed an antidepressant second-line therapy.
For pain relief, non-drug treatments such as massage, mind-body techniques, and physical therapy may be underutilized.
Ferreira says that many doctors and patients don’t know about the benefits of nondrug treatment for these conditions. However, the latest guidelines for osteoarthritis and back pain emphasize the importance of non-drug therapies over prescription drugs.
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According to the American College of Family Physicians, doctors should avoid prescribing opioids for low back pain. Instead, they should recommend non-pharmacological treatments such as massage, superficial heat and physical therapy.
Arthritis Foundation guidelines and American College of Rheumatology recommend that you use educational and behavioral strategies to treat osteoarthritis. These include exercise, weight loss and mind-body techniques.
Antidepressants are relatively safe and have a good risk vs. Benefit Profile
Neuman says that the study shows that antidepressants can be used safely and have few side effects. There is little risk and a potential benefit to taking a medication that isn’t an opioid medication. He says that there is not much to lose by at least trying an antidepressant medication for pain relief.
Neuman says, “If I were in pain backwards, I would prefer to take that route over any narcotics that put me at risk of addiction.”
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Are Antidepressants for pain worth stopping taking?
Your doctor should be consulted before you stop taking your medication. It is important to not abruptly stop taking antidepressant medications. Ferreira says that withdrawal symptoms can occur, which can cause distressing withdrawal symptoms and can sometimes lead to serious health problems.
He says, “If someone is currently taking antidepressants to treat their back pain or osteoarthritis, and they feel it is helping,” he suggests. Ferreira says that if you don’t see improvement after three months, it is a good idea for you to talk with your doctor.
He says that non-drug treatment and a healthy lifestyle are more important than prescription drugs in the long-term management of both diseases.
Despite this analysis, antidepressants may be a good option for some people with sciatica, OA or back pain
Neuman says that even though the study does not show any significant benefit in pain management, it did reveal some patients who do. “This study does not [account] for every patient’s pain or treatment plan. I recommend that people suffering from chronic pain in any of the treatment areas talk to their healthcare providers about the possibility to try an antidepressant medication before resorting to any narcotics.
