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Antidepressants Use for Chronic Pain on the Rise, but Are They Effective?

Discussion in 'Other health news and research' started by Mij, Feb 2, 2023.

  1. Mij

    Mij Senior Member (Voting Rights)

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    Summary: SSRI antidepressants appear to be effective in the treatment of a range of pain conditions including neuropathic pain, fibromyalgia, and postoperative pain. Tricyclic antidepressants may not be effective in the treatment of pain.

    https://neurosciencenews.com/pain-antidepressants-22426/
     
    hibiscuswahine, RedFox, shak8 and 3 others like this.
  2. CRG

    CRG Senior Member (Voting Rights)

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    Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews, 2023, Ferreira et al

    Giovanni E Ferreira, Christina Abdel-Shaheed, Martin Underwood, Nanna B Finnerup, Richard O Day, Andrew McLachlan, Sam Eldabe, Joshua R Zadro

    Abstract


    Objective To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition.

    Design Overview of systematic reviews.

    Data sources PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022.

    Eligibility criteria for selecting studies Systematic reviews comparing any antidepressant with placebo for any pain condition in adults.

    Data extraction and synthesis Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework.

    Results 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference −5.3, 95% confidence interval −7.3 to −3.3), postoperative pain (−7.3, −12.9 to −1.7), neuropathic pain (−6.8, −8.7 to −4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons).

    Conclusions Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews—seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.

    Full paper: https://www.bmj.com/content/380/bmj-2022-072415
     
  3. rvallee

    rvallee Senior Member (Voting Rights)

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    A very odd reaction to facing the reality that commonly used medication, which millions of people use, have no evidence of efficacy. It's all pooled data from entire drug classes on a wide and heterogenous population. Who would ever take seriously a review of immune drugs for various issues? All bunched up together? No one, obviously. About anything, not just in medicine.

    And as they write, prescriptions are on the rise. Despite no evidence, and a very arbitrary process of trial-and-error that lacks any form of assessment, which basically maximizes the horrible side effects, which are denied and minimized reflexively to add even more harm. In most contexts this would be considered catastrophic. Imagine spending billions, trillions really, affecting hundreds of millions of lives and you find that it's basically not worth much, that you have to dig very hard to find even weak evidence of "efficacy", as long as efficacy is defined as not much. Imagine what kind of progress could have been made using those resources smartly.

    There are literally no problems that can be addressed the way they do this, comparing a huge range of various possible solutions for many varied problems and trying to find signal out of very limited data that include zero objective measurement and basically no interoperability or standardization of data. It's a generic approach using generic solutions to generic problems with generic assessments. That literally can't work anywhere about anything. Never has. Never will.

    But sure, let's frame this as needing a more "nuanced" approach. Because this is clearly not nebulous enough.
     
    alktipping and Creekside like this.
  4. Creekside

    Creekside Senior Member (Voting Rights)

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    Sometimes it's valid to say "We don't know why x works, but it's an effective treatment, so prescribing it will improve the patient's life." That's fine when you have clear clinical evidence of it working (makes a wart go away, heals wounds 50% faster, etc). It's not fine when the supporting evidence is from a bunch of numbers filtered and manipulated to look like supporting evidence, even more so when the numbers are from poorly done studies based on poorly designed questionnaires.

    Does "nuanced" mean "adjust the studies and the goals until you get something that lets you claim that it's effective"?
     
  5. cassava7

    cassava7 Senior Member (Voting Rights)

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    It seems to me that even if low dose antidepressants can be effective in the short term (up to a few weeks or months), tolerance gradually builds and renders them ineffective in the long term, unless the dose is increased. The same goes for pregabalin and gabapentin. Unfortunately, clinical trials of these drugs have only run for short durations.

    The accompanying editorial to this meta-review, written by the clinical lead of the NICE guideline on chronic pain and a layperson on the guideline committee, calls for “rethinking the use of medicines in chronic pain” and advocates for exercise and a psychosocial approach where the patient develops an empathic relationship with their doctor. I cannot understand why they do not ask for more biomedical research into chronic pain that would yield better treatments.
     
    Last edited: Feb 3, 2023
  6. Mij

    Mij Senior Member (Voting Rights)

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    Low dose trazadone is effective for insomnia. They don't know why it works for some but not others. It works well for me and it's non addictive.
     
  7. rvallee

    rvallee Senior Member (Voting Rights)

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    Which has even worse evidence and is frankly laughable, you can't build an empathetic relationship on the basis of lies and pseudoscience. Just great. It's really hard not to conclude that the profession has simply given up, strong echoes of people calling for the end of invention and science because everything had been discovered... in the late 19th century. Same inability to think that there are many things left to know.
     
    Peter Trewhitt and alktipping like this.
  8. shak8

    shak8 Senior Member (Voting Rights)

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    I read the BMJ article (referenced above) about their massive review of evidence.

    Then I found on PubMed, a fairly recent and adequately powered (enough subjects) Canadian, randomized, double-blind study on duloxetine (SNRI) for FM, FDA-approved for neuropathic and FM pain. The study participants had a drop-out rate of 37% due to the incidence of nausea (also at 37%), Other adverse effects included headache (about 12 %) and constipation.

    And not to mention the nasty tapering side effects of discontinuation syndrome when you want to stop taking duloxetine or any other anti-depressant.​

    As the most recent FM clinician-researchers point out in several more recent review reports: there is no effective treatment for FM.

    Everyone in the business would like there to be, but effectiveness of any drug lies far south of 15% of patients (in reducing pain at or above placebo levels, sleep, exhaustion, cognitive symptoms and no one drug works on all symptoms). Combinations of drugs? Only if you crave side effects because your pain levels are off planetary norms.

    I'll stick with my tried and true drugs plus pacing.
     
  9. Creekside

    Creekside Senior Member (Voting Rights)

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    That fits my definition of 'nuanced' (Does "nuanced" mean "adjust the studies and the goals <and study duration> until you get something that lets you claim that it's effective"?).
     
    Peter Trewhitt and alktipping like this.

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