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Antidepressants in Pain Treatment

General guidelines in the selection of an antidepressant as an adjunct to analgesia and physical therapy in treating pain.
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Summary of Commercially Available Antidepressants
Drug by Category Starting Dos (mg)
Tricyclics
Amitriplyline (Elavil®) 25 - 50
Clomipramine (Anafranil®) 25 - 50
Doxepin (Sinequan®) 25 - 50
Imipramine (Tofranil®) 25 - 50
Trimipramine (Surmontil®) 25 - 50
Desipramine (Norpramin®) 25 - 50
Nortriptyline (Pamelor®) 25 - 50
Protriptyline (Vavactil®) 25 - 50
Monoamin Oxidase Inhibitors
Phenelzine (Nardile®) 15 bid
Tranylcypromine (Parnate®) 10 bid
Isocarboxazid (Marplan®) 10
Serotonin Reuptake Inhibitors
Fluoxetine (Prozac®) 20
Paroxetine (Paxil®) 20
Sertraline (Zolofte®) 50
Fluvoxamine (Lovox®) 50
Citalopram (Celexa®) 20
Escitalopram (Lexapro®) 10
Multiple Action Agents
Bupropion (Wellbutrin®) 100
Venlafaxine (Effexor®) 37.5
Nefazodone (Serzone®) 100 bid
Mirtazapine (Remeron®) 15
Reboxetine (Vestra®) 4 bid
Amoxapine (Asendin®) 25 - 50
Maprotiline (Ludiomil®) 75
Trazodone (Desyrel®) 50

TABLE 1.

Although there have been traditional claims that tricyclics are particularly helpful in treating post-herpetic neuralgia and other peripheral neuropathies, no reliable scientific evidence exists to support a bias for this class over others.1-4 Most importantly, aside from prejudices, the antidepressant that works most effectively to relieve the patient’s symptoms is the drug that should ideally be used. The SRIs have been anecdotally reported to potentiate opioids and to relieve muscle pain in such common conditions as fibromyalgia.3,6 Despite this general observation, all the antidepressants, regardless of class, have the potential to be effective adjuncts to specific pain treatment approaches such as physical therapy and opioid analgesia.

Over-Promise and the Future

All antidepressants should be viewed as adjuncts to specific pain treatment approaches such as physical therapy and analgesia. While a great assist to intractable pain treatment, no antidepressant has yet demonstrated enough acute or chronic pain relief to warrant any promise of substitution for standard pain treatments such as opioids. Practitioners should educate pain patients that antidepressants, used as adjuncts to standard pain treatment, are used “off-label” or other than approved use by the U.S. Food and Drug Administration. Investigation with antidepressants is a fertile ground for pain research. For example, there are no controlled studies on the use of monoamine oxidase inhibitors in pain treatment. The unique neurochemical effects of some antidepressants will undoubtedly prove to have specific uses in pain treatment.

Summary

Even though antidepressants are used routinely in pain treatment, there is not yet enough scientific evidence to recommend one antidepressant over another. It is recommended that the practitioner initiate treatment with an agent with which he/she is most familiar, and proceed on the basis of clinical outcome. Table 2 presents a summary of guidelines for the adjunct use of antidepressants.

Guidelines for Antidepressant Use in Pain Treatment

Determine goals of treatment

Select a familiar antidepressant

Start at low dosage and titrate upward
over time

Inform patient about "off-label" use

Do not over-promise results

Switch to a different agent if current
one is ineffective or has side-effects

TABLE 2.

Last updated on: January 6, 2012
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