Summary: Doctors frequently use antidepressants to manage low back pain, especially if non-steroidal anti-inflammatory drugs fail to help. However, experts think that evidence in favor of antidepressant use for low back pain in men and women is weak, and most studies showing benefits were industry sponsored. The new systemic review combining data from 33 clinical studies found no sound evidence in favor of using antidepressants for chronic back pain.
Low back pain is among the leading causes of chronic pain and disability. Those with low back pain may not only have to live with pain for a long, but relapses are quite common even if such pain is treated successfully.
The primary way to manage low back pain in men and women is with non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy. However, these treatments do not work for many. In such cases, doctors have to consider various other treatment options.
Studies show that those experiencing low back pain are often living with many comorbidities. For example, mood and emotional disorders are pretty common among those living with low back pain. Therefore, no surprise that antidepressant use is pretty common in low back pain.
Additionally, it is worth noticing that most treatment guidelines also recommend using antidepressants as one of the treatment options for chronic back pain and even other joint pains. However, despite the recommendation, there is limited evidence that these medications work.
A new systemic review of 33 clinical trials concluded that there is little evidence in favor of antidepressant use in low back pain. Nonetheless, doctors continue to use these drugs widely. This is worrisome, considering that antidepressants have many side effects. Hence, it is quite likely that the harm from such a therapeutic approach may be greater than the benefit.
In the latest systemic review, researchers analyzed the benefit of antidepressants in low back pain and osteoarthritis in those who did not benefit from analgesic drugs. Systemic reviews are special kinds of studies that sum up the data from multiple clinical trials. Thus, systemic review conclusions have significant importance.
The researchers say that they did find some benefits from antidepressants. However, the chances of benefit were slim, and any benefit was low. Thus, for example, they found that antidepressants may help with osteoarthritis. However, only one in ten patients may expect to benefit from such a drug therapy after three or more months of prolonged use.
Here it is worth noting that many of those studies that demonstrated some benefit from antidepressants were industry-sponsored. Therefore, researchers say there is a need for more extensive clinical trials that are not funded by the industry.
Moreover, experts noted that many of these guidelines regarding the use of antidepressants are based on outdated data and studies. Hence, many of these studies have methodological flaws.
In the present systemic review, researchers included 33 clinical trials with a total sample size of 5000 adults living with low back pain, neck pain, sciatica pain, and hip or knee osteoarthritis2.
In the study, researchers used a 0–100-point scale to assess the benefit of antidepressants for back pain. Here zero means no pain at all. Researchers say that about a 10-point benefit on this scale may be accepted as clinically significant. However, in the study, researchers found that antidepressants had merely 5.3 points of benefit compared to placebo. This benefit is just too small to justify the regular use of antidepressants for chronic back pain. Even for osteoarthritis, this benefit was 9.7, which is barely acceptable.
Therefore, researchers concluded that there is insufficient evidence to justify the use of antidepressants for managing low back pain.
These are not the first findings of this kind. Many early studies have also expressed similar sentiments, saying that doctors should explore other treatment options for those living with chronic low back pain, including non-pharmacological means.
Experts have gone further, saying that most medications have a limited role in chronic back pain treatment, something that doctors must understand. The use of opioids, cannabis, gabapentinoids, and antidepressants is especially controversial, as harm from these drugs outweighs potential benefits.
By Gurpreet Singh Padda, MD, MBA