Efficacy, acceptability, and safety of antidepressants for low back pain: a systematic review and meta-analysis

Abstract

Background Antidepressant medicines are used to manage symptoms of low back pain. The efficacy, acceptability, and safety of antidepressant medicines for low back pain (LBP) are not clear. We aimed to evaluate the efficacy, acceptability, and safety of antidepressant medicines for LBP. Methods We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, the EU Clinical Trials Register, and the WHO International Clinical Trial Registry Platform from inception to May 2020. We included published and trial registry reports of RCTs that allocated adult participants with LBP to receive an antidepressant medicine or a placebo medicine. Pairs of authors independently extracted data in duplicate. We extracted participant characteristics, study sample size, outcome values, and measures of variance for each outcome. We data using random-effects meta-analysis models and calculated estimates of effects and heterogeneity for each outcome. We formed judgments of confidence in the evidence in accordance with GRADE. We report our findings in accordance with the PRISMA statement. We prespecified all outcomes in a prospectively registered protocol. The primary outcomes were pain intensity and acceptability. We measured pain intensity at end-of-treatment on a 0–100 point scale and considered 10 points the minimal clinically important difference. We defined acceptability as the odds of stopping treatment for any reason. Results We included 23 RCTs in this review. Data were available for pain in 17 trials and acceptability in 14 trials. Treatment with antidepressants decreased pain intensity by 4.33 points (95% CI − 6.15 to − 2.50) on a 0–100 scale, compared to placebo. Treatment with antidepressants increased the odds of stopping treatment for any reason (OR 1.27 [95% CI 1.03 to 1.56]), compared to placebo. Conclusions Treatment of LBP with antidepressants is associated with small reductions in pain intensity and increased odds of stopping treatment for any reason, compared to placebo. The effect on pain is not clinically important. The effect on acceptability warrants consideration. These findings provide Level I evidence to guide clinicians in their use of antidepressants to treat LBP. Trial registration We prospectively registered the protocol for this systematic review on PROSPERO (CRD42020149275).

Neural correlates of co-occurring pain and depression: an activation-likelihood estimation (ALE) meta-analysis and systematic review

“…The use of antidepressants in chronic pain is associated with moderate efficacy, e.g., ‘limited’ effect in fibromyalgia [ 5 ], ‘small and not clinically important’ effects for back pain [ 6 ], ‘low certainty evidence’ for an effect in osteoarthritis and sciatica [ 6 ]. Pain patients often do not respond well to antidepressants, resulting in higher odds of stopping treatment due to side effects [ 5 , 7 ], although antidepressants are overall tolerable in low doses [ 8 ], and have an increased risk of developing depression or addiction when treated with opioid analgesics [ 9 ], likely due to the dysregulation of the amygdala circuitry [ 10 ]. As such, better understanding of the depression-pain link is needed for a unified approach to treating comorbid pain and depression.…”

Self-Reported Pain and Emotional Reactivity in Bipolar Disorder: A Prospective FACE-BD Study

“…Medication intake was proportional to the pain level. The lack of effect of such medications has already been reported elsewhere [74][75][76].…”

Long-term and serious harms of medical cannabis and cannabinoids for chronic pain: a systematic review of non-randomised studies

“…We found very limited evidence comparing medical cannabis or cannabinoids with other pain management options. Other pharmacological treatments for chronic pain, such as gabapentinoids, antidepressants and opioids, may be associated with more (and more serious) adverse events 88–90. To guide patients’ and clinicians’ decisions on medical cannabis for chronic pain, future research should compare the harms of medical cannabis and cannabinoids with other pain management options, including opioids, ideally beyond 1 year of use, and adjust results for confounders.…”