This article is one in a series on Medications for Pain… what are your choices? how do various medications work? what are the pros and cons? how about side effects? (Discuss these ideas with your doctor. Don’t make any changes to your treatment by yourself.)
The class of medication we’ll look at today is Antidepressants, which are medications originally used to treat depression, but are good for anxiety as well as pain. Within this class, there are:
- Tricyclic antidepressants (TCA’s), which include Amitriptyline (Elavil) and Nortriptyline.
- SNRI’s (Serotonin-Norepinephrine Reuptake Inhibitors), which include Cymbalta, and Effexor (Effexor at higher doses).
- SSRI’s (Selective Serotonin Reuptake Inhibitors), which include Zoloft, Prozac, Lexapro, etc.
An important issue to address is that antidepressants work for pain even if you’re not depressed or anxious. They have an independent pain-reducing effect. So if your physician recommends an antidepressant, it’s not implying that your pain is all in your head, or that you’re just anxious or depressed.
That being said, anxiety and depression often go along with chronic pain, unfortunately. So if that’s your case, a good thing about these medications is that they also help depression, anxiety and PTSD (Post Traumatic Stress Disorder - PTSD can occur if there was a traumatic cause to your pain, such as a car or work accident). As well, because sedation is a common side effect of antidepressants, many of them can help the sleep disturbance that accompanies pain.
Effect of Antidepressants: All antidepressants work to change neurotransmitters in the brain. Neurotransmitters are those chemicals by which nerves communicate with one another. TCA’s and SNRI’s increase both serotonin and norepinephrine, while SSRI’s only increase serotonin. TCA’s also affect many other chemical systems, including the anticholinergic system (causing drying of your mouth, constipation and sedation), histamine (drying, sedating), and systems causing cardiac and blood pressure effects.
It seems that the combination of serotonin and norepinephrine effect is what’s crucial in decreasing pain.
Medical Studies:
- TCA’s: Out of 126 studies of TCA’s for pain, 95% of the studies showed that TCA’s were effective for reducing pain.
- SNRI’s: Out of 10 studies, 100% showed that SNRI’s were effective.
- SSRI’s: Of 39 studies, 33% showed that SSRI’s were effective.
So again, this demonstrates that the medications which effect both serotonin and norepinephrine work best at helping with pain.
Uses of Antidepressants: Let’s look at some examples of these medications for specific pain disorders. Cymbalta is FDA-approved for the pain that accompanies diabetes, called Diabetic Peripheral Neuropathy. Paxil is helpful for chronic daily headache and migraines. We do know that SSRI’s are generally not helpful for neuropathic pain.
Common Side Effects:
- TCA’s: sedation, constipation, weight gain; less often heart arrhythmia, decreased blood pressure
- SNRI’s: nausea, sedation
- SSRI’s: headache, nausea, anxiety
In 2 Mondays, we’ll review Anesthetics. Other articles in this series:
6 responses so far ↓
Heidi // Nov 16, 2007 at 9:37 pm
I’ve seen a couple of problems with antidepressants as pain treatment.
The first is simple: many doctors, looking at a meds list that includes antidepressants, stop looking right there. All pain, fatigue, headache, and related symptoms are simply part of depression then, and they look no further.
The second issue I’ve seen is that doctors often don’t realize how many drugs work in the same systems. Migraine? Bring on the triptans! It’s debatable which is worse, the migraine, or the feeling your head is going to explode from the overdose of serotonin and resultant high blood pressure. Same problem with tramadol.
Of course, once a patient says they can’t use those ‘non-narcotic’ offerings, they’re labeled as drug-seeking.
It’s enough to make a person give up and sit at home in pain.
How to Cope with Pain // Nov 17, 2007 at 4:48 am
Heidi, thanks for these points. I review with patients that antidepressants work in chronic pain even if you’re not depressed. Pain and depression are 2 different things, with regards to what antidepressants treat.
I do ask patients to sometimes tolerate some side effects, as with many of these drugs, there is a trade off unfortunately. But only you can decide if the trade off is worth it, and your physician should respect that. Keep talking to your doc!
Jeff J (USA Retired) // Aug 7, 2008 at 12:07 pm
My 84 year-old father is suffering from a great deal of back pain from a WWII injury; as well as blood passing with his urine and stool that was caused by radiation treatment to fight prostrate cancer. He and his doctor are reluctant to use pain medications because the side effects may lead to heart problems. He also takes a blood thinner due to a stroke he suffered 40 years ago.
How do I coach him to speak with his doctor about using an antidepressant therapy?
How to Cope with Pain // Aug 7, 2008 at 1:16 pm
Jeff, thanks for your question. I’d recommend asking directly. Some of the TCA’s can have heart side effects, but they are used at low doses for pain and these side effects can be carefully monitored. Some of the newer antidepressants for pain do not have this side effect, so might be an option.
Starting the conversation with “Can we take a look at all my options for pain management, and decide what might be best to try first?” can get the ball rolling. Some doctors are prickly when a patient requests what exact medication they want (”Start me on Demerol!”), so a more general opening might be better. But keep working on this! Almost always benefits can be balanced with side effects, and there are many medication options to try.
Sara // Aug 28, 2008 at 11:00 pm
My concern is that a pain disorder that can be treated with anti-depressants seems to bias doctors against offering other forms of medication management, particularly analegics.
The thought that seems to be going on is this: If a patient doesn’t need something to control degeneration or inflammation, then it’s not a “real” disease or “as painful” of a disease and therefore “doesn’t need” or it “isn’t appropriate” to give the patient pain medications, particularly opiates, if the patient doesn’t respond to anti-depressant therapy.
I know in my experience, and in the experience of others who I have talked to, we have been told we have “severe” cases of fibromyalgia or “the worst cases of fibromyalgia” simply because TCA’s and SNRI’s didn’t restore functioning to a managable level. I also know when my doctors thought RA was an issue they had no problem prescribing me pain medication but as soon as RA was ruled out and fibro was definitively diagnosed they gave me a hassle about it each and every visit until I finally switched to another doctor.
The thing is too, even if we the patient don’t have a problem with A-D’s being used for pain, it does seem that there is a doctor-related bias once you are on an A-D; that you must have depression or anxiety, especially with disorders like fibro, CFIDS, CMP, or others that don’t have clinical pathology to fall back on.
How to Cope with Pain // Aug 29, 2008 at 7:45 am
Sara, thanks for your insightful comments. 2 important points you raise are 1) it’s often multiple medications all used together that offer the best result. And 2) finding a doctor who really understands pain management is so important.
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