Review Cochrane review: antidepressants used to treat chronic pain

https://www.cochrane.org/CD014682/S...ronic-pain-and-do-they-cause-unwanted-effects

Key messages

• We are only confident in the effectiveness of one antidepressant: duloxetine. We found that a standard dose (60 mg) was effective, and that there is no benefit to using a higher dose.

• We are uncertain about unwanted effects for any antidepressant as the data for this were very poor. Future research should address this.

• In clinical practice for chronic pain, a standard dose of duloxetine may be considered before trying other antidepressants.

• Adopting a person-centred approach is critical. Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable. Future studies should last longer and focus on unwanted effects of antidepressants.

 

Interesting for me that there’s little confidence in amitriptyline, which is what GPs tend to prescribe for chronic pain, at least in the UK.

I’ve been taking 15mg daily for two years. I have no real reason to believe it’s doing any good for pain, but vaguely suspect it contributes to regulating sleep, so will probably be taking it indefinitely. That does seem a little odd when scaled up to hundreds of thousands of patients.

 

BBC article on this review:

'Shocking' lack of evidence on antidepressants for chronic pain

People with chronic pain are being given antidepressants with very little scientific proof the medication helps, a major review has found.

In studies, with nearly 30,000 patients, there was "moderate" evidence for only one drug, duloxetine, and just for short-term pain relief.

And there was a "shocking" lack of long-term data, even though the pills are usually prescribed for many months.

But patients are advised to stay on medication if it works for them.

They must not suddenly stop taking tablets without talking it over with a doctor, experts say.

https://www.bbc.com/news/health-65532464

 

Of note:

“Of the 146 studies [out of 176] that reported where their funding came from, pharmaceutical companies funded 72 studies. The average study lasted 10 weeks.”

“For every 1000 people taking standard-dose duloxetine, 435 will experience 50% pain relief compared with 287 who will experience 50% pain relief taking placebo.”

The paragraph “What are the limitations of the evidence?” in the summary does not mention the absence of objective outcomes in the trials either (though they were placebo-controlled and blinded).

 

Little? None. EBM is not a scientific process. Without the absurdly low standards of EBM, none of this would have ever been recommended. But it is precisely because it's not scientific that it's used. It gives false positives. So many false positives. And false positives are A-grade hopium.

IMO the underlying belief with this is that they believe in placebo enough to think this is it, even though if it were it would literally work with anything.

 

Well, that fills me with confidence!