Antidepressants and Chronic Pain

Antidepressants: Another weapon against chronic pain
Antidepressants are a mainstay in the treatment of many chronic pain conditions — even when depression isn’t a factor.

And even though they haven’t been proven to work unless you actually suffer from Major Depression.

Antidepressants seem to work best for pain caused by:

  • Arthritis
  • Nerve damage from diabetes (diabetic neuropathy)
  • Nerve damage from shingles (postherpetic neuralgia)
  • Nerve pain from other causes (peripheral neuropathy, spinal cord injury, stroke, radiculopathy)
  • Tension headache
  • Migraine
  • Facial pain
  • Fibromyalgia
  • Low back pain
  • Pelvic pain

The painkilling mechanism of these drugs still isn’t fully understood…

Click to access antidepressantsforthetreatmentofchronicpain.pdf


In summary, evidence supports the use of tricyclic antidepressants in neuropathic pain, headaches, low back pain, fibromyalgia and IBS. The efficacy of the newer serotonin and norepinephrine reuptake inhibitors is less supported by evidence, but can be recommended in neuropathic pain, migraines and fibromyalgia. To date, evidence does not support an analgesic effect of serotonin reuptake inhibitors, but beneficial effects on well-being were reported in several chronic pain conditions…

Janice Lynch Schuster was the kind of person who never got sick, because she “didn’t have the time.” A writer for a health research institute, mom to six kids and a boxing hobbyist, Schuster considered herself a healthy 51-year-old. But in January 2013, she developed a sudden throbbing pain in her tongue. When topical treatments failed to relieve her swollen salivary glands, her dentist referred her to an oral surgeon who suggested a lingual frenectomy, a procedure to remove the band of tissue between the tongue and floor of the mouth. It was described as “just a snip,” but the result was so painful that even after the stitches healed, the pain remained unbearable, transforming into an entirely new injury. On bad days, Schuster can’t talk or eat…

SCHUSTER: One emergency room doctor asked if I was depressed, because he had never met a pain patient who wasn’t depressed. [ER doctors diagnosing depression?]  The experience of just constantly being in pain, it just saps your energy, saps your joy of experience in your life. It narrows the scope of what you’re able to do.

I have had a lifelong history of depression…

Why did my doctor give me an antidepressant for my pain? I’m in pain, not depressed! Can’t he see that the only problem is my pain? I need help now!
It is a little confusing, but a number of antidepressants have actually been found to help ease chronic pain. The effect these medicines have on pain is separate from their effect on mood. There are many things about chronic pain that we do not understand. However, it seems that imbalances in chemicals involved in pain perception and transmission may play a role. In low doses antidepressants seem to adjust these chemicals. As a result, they are a common and useful way to treat chronic pain…

Common?  Yes.  Useful?  Extremely doubtful, unless you suffer from Major Depressive Disorder.

Almost every drug used in psychiatry can also serve as a pain medication. Relieving anxiety, fatigue, depression, or insomnia with mood stabilizers, benzodiazepines, or anticonvulsants will also ease any related pain. The most versatile of all psychiatric drugs, the antidepressants have an analgesic effect that may be at least partly independent of their effect on depression since it seems to occur at a lower dose.

The two major types of antidepressants, tricyclics and selective serotonin reuptake inhibitors (SSRIs), may have different roles in the treatment of pain. Amitriptyline (Elavil), a tricyclic, is one of the antidepressants most often recommended as an analgesic, partly because its sedative qualities can be helpful for people in pain. SSRIs such as fluoxetine (Prozac) and sertraline (Zoloft) may not be quite so effective as pain relievers, but their side effects are usually better tolerated, and they are less risky than tricyclic drugs. Some physicians prescribe an SSRI during the day and amitriptyline at bedtime for pain patients.

Both drug classes act in brain pathways that regulate mood and the perception of pain. Tricyclics heighten the activity of the neurotransmitters norepinephrine and serotonin; SSRIs act more selectively on serotonin. Some researchers and clinicians believe that a newer antidepressant which acts strongly on both neurotransmitters, the so-called dual action drug venlafaxine (Effexor), is superior to both tricyclics and SSRIs for treating pain. So far, the evidence is inconclusive.

Physicians and psychiatrists are also considering the uncertain potential of the anticonvulsant drug gabapentin (Neurontin) and drugs that block the activity of substance P, another neurotransmitter involved in the regulation of both pain and depression. Electroconvulsive therapy, a standard treatment for severe depression, may have independent analgesic effects...

Patients with chronic diseases such as rheumatoid arthritis, lupus, and fibromyalgia
can experience depression — it’s not uncommon. For many patients, the depression is temporary or even brief, but others with recurring symptoms may benefit from a visit to a counselor, psychologist, or psychiatrist. Medication is often prescribed to help with the symptoms of depression, too…

Do not use Lexapro if you have taken an MAO inhibitor in the past 14 days. A dangerous drug interaction could occur. MAO inhibitors include isocarboxazid, linezolid, phenelzine, rasagiline, selegiline, and tranylcypromine. After you stop taking Lexapro, you must wait at least 14 days before you start taking an MAOI.

To make sure Lexapro is safe for you, tell your doctor if you have:

liver or kidney disease;
seizures or epilepsy;
narrow-angle glaucoma;
heart disease;
bipolar disorder (manic depression); or
a history of drug abuse or suicidal thoughts.

Ask your doctor before taking a nonsteroidal anti-inflammatory drug (NSAID) for pain, arthritis, fever, or swelling. This includes aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), celecoxib (Celebrex), diclofenac, indomethacin, meloxicam, and others. Using an NSAID with escitalopram may cause you to bruise or bleed easily.

Drinking alcohol can increase certain side effects of Lexapro.

Lexapro may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert…

Tell your doctor about all medicines you use, and those you start or stop using during your treatment with Lexapro, especially:

  • any other antidepressant;
  • buspirone;
  • lithium;
  • St. John’s wort;
  • tryptophan (sometimes called L-tryptophan);
  • a blood thinner such as warfarin, Coumadin;
  • migraine headache medication – sumatriptan, rizatriptan, and others; or
  • narcotic pain medication – fentanyl or tramadol.


Although Lyrica is listed as a Schedule V drug on the DEA’s drug scheduling list, I cannot find any other antidepressants which are included.  Antidepressants appear to be Schedule N drugs, meaning they’re not a controlled drug.  Yes, antidepressants must be prescribed by a doctor, but the DEA believes there’s no risk of abuse.  And when a prescription drug isn’t controlled by the DEA, doctors have no fear in prescribing it.  So, as a chronic pain patient, if your doctor keeps pushing you to take antidepressants, this is why.

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