A common treatment for chronic back pain may not provide much rest after all. A new review released Wednesday suggests that antidepressants provide little to no back pain relief on average, although they may have modest benefit for osteoarthritis and sciatica.
Chronic pain can be an emotionally draining experience, which is why antidepressants are sometimes prescribed by doctors to help patients with their mental problems. But beyond their typical use, research has also suggested that antidepressants such as serotonin-norepinephrine reuptake inhibitors (SNRIs) have a added pain relief effect. Exactly how this happens is still being studied, but it is thought that the same neurotransmitters that regulate mood (and that antidepressants help balance) also play a role in regulating our feelings of pain, especially pain caused by damaged nerves or a dysfunctional nervous system.
There has been at least one antidepressant – the drug duloxetine, also known as Cymbalta approved in the US to treat chronic nerve pain and back pain. And organizations like the American College of Physicians now to advise duloxetine also for low back pain. But according to the authors of this new article, published in the BMJ on Wednesday, the overall effectiveness of antidepressants for the treatment of pain is still uncertain.
Their review looked at data from 33 randomized and controlled clinical trials examining the use of antidepressants for chronic back pain and osteoarthritis of the hip and knees, including studies that were not included in previous reviews of the evidence, they wrote. These trials in total there were more than 5,300 participants. The main outcome they looked at was a reduction in people’s reported score on a pain scale of 1 to 100, with any reduction of 10 points or more after three months of treatment considered a clinical improvement that patients would notice in their lifetime.
Overall, the review found that the mean pain relief for SNRIs in the treatment of low back pain after three months of treatment was only about five points. For osteoarthritis, the mean decrease in SNRIs was just under 10 points, so a meaningful improvement is more likely. Other evidence also suggested that tricyclic antidepressants, an older class of drugs, had little effect on back pain, but that both tricyclic antidepressants and SNRIs could have an effect on the treatment of pain from sciatica, a certain type of nerve pain that affects the legs and back. However, the researchers were much less confident about the latter two findings, due to the limited data available.
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“Our findings show that antidepressants are largely ineffective for back pain, but may be beneficial for osteoarthritis and sciatica,” wrote lead author Giovanni Ferreira, a researcher studying musculoskeletal health at the University of Sydney in Australia, in an email. .
The findings don’t necessarily mean that no one should use these drugs for back pain. Chronic back pain is notoriously difficult to treat, and for some patients, even the hope of a small benefit may be worth a try. But antidepressants have side effects, and both doctors and patients should know ahead of time that the chances of significant improvement from their use are likely to be small, Ferreira and his team noted. There are also other non-drug options that patients can still try, such as physical therapy programs and exercise.
“If people are currently taking antidepressants for their back pain or osteoarthritis and they think it is helping them, then we recommend that they continue with the treatment,” he said. Those who do not benefit from it should consult their doctor before making any changes as abruptly stopping its use withdrawal symptoms such as anxiety and insomnia.
Another important consideration the authors brought up is that much of the data they studied came from studies funded by the makers of the antidepressants being tested. Industry-funded studies are known to paint a brighter picture of the evidence, so it’s still possible that even the benefits they found here may not be as great as they look.
“This should be taken into account when interpreting the findings of our review, especially for osteoarthritis, where six of the eight studies were sponsored by pharmaceutical companies,” said Ferreira. “That’s why we need more studies, and ideally these should be conducted by independent researchers with no ties to the industry.”