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Antidepressants and chronic pain -- McQuay and Moore 314 (7083): 763 -- BMJ

Tags: antidepressants, tricyclic, neuropathic, pain on 2008-05-09 -All Annotations (0) -About

in list: Neuropathic Chronic Pain

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The speed of onset of effectis much faster
(one to seven days) than that reported in depression,and the analgesic effect is distinct from any
effect on mood.⁷
Theprimary role is when pain
relief with conventional analgesics(from aspirin or paracetamol through to morphine) is
inadequateor when pain relief is combined with intolerable or unmanageableadverse effects
A secondary role of antidepressants in treating chronic painis their use in addition to
conventional analgesics.
The
common first choice is amitriptyline, with a startingdose of 25 mg (10 mg in frail patients) to
be taken as a singlenight time dose one hour before lights out. We advise patientsto increase the
dose by 25 mg at weekly intervals until theyeither achieve pain relief or adverse effects become
problematic.The maximum dose is 150 mg. Patients are warned to expect adry mouth and
drowsiness, which is why they should take thedrug at night. If they are still drowsy first thing
in the morningthey should take the drug earlier in the evening.
One obvious question is what happens in the long term. Mostevidence of efficacy comes
from short term trials (lasting weeksto months), and, although many patients continue to achieve
painrelief with antidepressants for months to years, this is nottrue for everybody. Another
puzzle is how antidepressants workas analgesics. The standard (but not compelling) explanation
isthat they act on descending tracts from the brain via noradrenalineand serotonin systems to
modulate signalling of pain in thespinal cord. This sounds, and is, an unsatisfactory explanation.
Butin the meantime it is clear that antidepressants have an importantrole to play in relieving
chronic pain.

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