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Off-label Antidepressant Use for Treatment and Management of Chronic Pain: Evolving Understanding and Comprehensive Review

  • Other Pain (A Kaye and N Vadivelu, Section Editors)
  • Published:
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Abstract

Purpose of Review

While clinicians have been using antidepressants for off-label indications in the treatment of chronic pain in recent years, newer studies have proven effectiveness and provided additional mechanistic understanding and defined potential adverse effects. As depression and chronic pain are frequently comorbid conditions, the use of antidepressants has allowed for treatment of both conditions concomitantly in the same patient population.

Recent Findings

The most commonly used antidepressants for chronic pain are tricyclic antidepressants (TCAs), though selective serotonin or noradrenaline reuptake inhibitors and other atypical antidepressants have been shown to be effective at treating chronic pain. In addition to neuropathic pain, bupropion has also demonstrated effectiveness in treating chronic pain caused by inflammatory bowel disease. Selective norepinephrine receptor inhibitors (SNRIs), including duloxetine, serve to suppress neuropathic pain by altering recovery of the noradrenergic descending inhibitory system in the spinal cord. While the direct mechanism of action is largely unknown, TCAs may suppress the noradrenergic descending inhibitory system to produce an antihyperalgesic effect.

Summary

The use of antidepressants offers alternative and adjunctive therapy options for patients suffering from chronic pain from various modalities. TCAs, mono-amine oxidase inhibitors, selective serotonin receptor inhibitors, SNRIs, and atypical antidepressants have been shown to have analgesic and sometimes antiinflammatory capabilities that are independent of their mood-stabilizing effects. Further studies are warranted to establish better safety profiles and efficacy of antidepressant use in chronic pain.

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Authors and Affiliations

  1. Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA

    Ivan Urits & Vwaire Orhurhu

  2. Department of Anesthesiology, Mt. Sinai Medical Center of Florida, Miami Beach, FL, USA

    Jacquelin Peck

  3. Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Mariam Salisu Orhurhu

  4. School of Medicine - Phoenix Regional Campus, Creighton University, Phoenix, AZ, USA

    John Wolf & Riki Patel

  5. Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA

    Alan D. Kaye

  6. Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA

    Omar Viswanath

  7. Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA

    Omar Viswanath

  8. Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA

    Omar Viswanath

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  1. Ivan Urits
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  2. Jacquelin Peck
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Correspondence to Ivan Urits.

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Conflict of Interest

Ivan Urits, Jacquelin Peck, Mariam Salisu Orhurhu, John Wolf, Riki Patel, Vwaire Orhurhu, and Omar Viswanath declare no conflict of interest. Alan D. Kaye discloses that he is on the Speakers Bureau for Depomed, Inc. and Merck.

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Urits, I., Peck, J., Orhurhu, M.S. et al. Off-label Antidepressant Use for Treatment and Management of Chronic Pain: Evolving Understanding and Comprehensive Review. Curr Pain Headache Rep 23, 66 (2019). https://doi.org/10.1007/s11916-019-0803-z

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