Antidepressants and Back Pain
One of the hot topics in treating chronic pain is that we doctors should prescribe antidepressants. Why? Well as I used to say, many doctors view patients with chronic low back pain as crazy or lazy. Let’s dig into how well antidepressants work for back pain and dig in a bit more about why your doctor might think you’re crazy.
Crazy or Lazy
When I was a young doctor with brown hair (now it’s mostly grey), there was an immense amount of pressure to call my low back patients crazy or lazy. What does that mean? Well, back then (and still today), most physicians had no idea how to diagnose or treat low back pain. Hence, if someone had chronic low back pain and wasn’t a surgical candidate, they must be crazy or lazy.
“Crazy” meant these patients didn’t really have pain, but instead they just thought they had pain. This concept is still alive and well today in physical therapy programs like Pain Neuroscience Education or Pain Reprocessing Therapy (PRT) “Lazy” meant that since physical therapy flared them up, they were just lazy and didn’t want to exercise.
On the crazy side, physicians began to think that chronic pain was caused by depression. Hence, why not give these patients anti-depressant medications? While this makes little sense to anybody who has chronic pain, who knows that depression is caused by the pain, it makes all sorts of sense to many poorly educated physicians.
Antidepressants and Back Pain
Two of the most common types of anti-depressants to pull this kind of double-duty are serotonin-norepinephrine reuptake inhibitors (SNRIs like Cymbalta and Effexor) and tricyclic antidepressants (TCAs like Elavil and Sinequan). However, to date, quality data on their effectiveness in pain management has been lacking. And impartial evidence not sponsored by the pharmaceutical industry is even rarer.
New Research
The latest meta-analysis (January 2021) in BMJ looked at 33 different studies with data from more than 5,000 participants with lower back or neck pain, sciatica, or hip or knee osteoarthritis (1). Their analysis found that SNRIs improved back pain by a lousy 5.3 points (out of a 100-point scale or 5.3%) compared to a placebo! So much for the crazy part!
The upshot? I guess low back pain patients aren’t crazy! However, I’m glad that the research is now catching up and showing that this whole crazy or lazy thing more accurately describes the physical therapists and physicians who believe this stuff!
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References
- Ferreira GE, McLachlan AJ, Lin CC, et al. Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ. 2021;372:m4825. Published 2021 Jan 20. doi:10.1136/bmj.m4825
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