Antidepressants in Pain Treatment
by Joel Hochman, MD; A. V. Anderson, MD; and Forest Tennant MD, DrPH
 Depression is a virtually universal complication of intractable pain. When
pain prevents patients from doing the things that give them satisfaction and purpose in
life, depression is unavoidable. Antidepressants have become a routine adjunctive therapy
for most forms of chronic pain.1-6 Not only may they provide their primary mission of mood
elevation, they may also have other positive attributes including relief from neuropathic
pain, headache prophylaxis, sleep induction, and potentiation of opioid therapy. But how
does a practitioner select the “right” one considering that there are now over
20 antidepressants on the commercial market with more to come? At this point in time there
is insufficient clinical experience to establish reliable selection criteria. However,
some general guidelines are presented here that may be useful until controlled studies
provide more specific guidelines.
Select one with which you are familiar
Antidepressants may all produce profound side-effects including complications such as
cardiac arrhythmias, blurred vision, dystonia, psychosis, over-sedation, weight gain and
sexual dysfunction. Keep in mind that the terms “antidepressant” and “mood
elevator” are unfortunately vague. In fact “antidepressants” vary widely as
to their effect on neurotransmission and should scientifically be labeled according to
their selective effect on adrenergic receptors, serotonin reuptake, monoamine oxidase and
other neurotransmitters and receptors. Knowing the psychopharmacological consequences of
these effects provides a scientific basis for drug selection. Generally speaking, however,
there are four classes from which to choose:
1. Monoamine oxidase inhibitors. These very old drugs should be left to experienced
clinicians for special situations, as they are potentially fatally toxic.
2. Tricyclics. These include amitriptyline, imipramine, and desipramine and are also
very old and often most familiar to non-psychopharmacologists. They cause more adverse
effects and complications than newer agents, particularly weight gain, dry mouth,
sedation, sexual dysfunction, lethargy, and cardiotoxicity in overdoses. Other than
inexpensiveness, there is no reason to favor this group over other antidepressants.
Please refer to the Jan/Feb 2003 issue for the complete text. In the event you need to order a back issue, please click here.
— Jan/Feb 2003
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