Summary: A new study by University of Sydney researchers found little proof that antidepressants help much with chronic pain in older adults. There are a few exceptions. Most guidelines rest on a small number of studies done in fairly young adults. One new study by the University of Sydney shows the gap. These drugs are widely used for chronic pain in older adults, yet the proof for them is thin. Chronic pain is hard to treat, and harder in older adults. It also gets more common with age. That is because most older adults, especially those over 65, live with one health problem or another. Pain doctors have often said older adults need pain care built for them. Many guidelines still advise these drugs for chronic pain, though the proof is thin. Very few strong studies back their use. This new study looked back over the last 40 years. Use of these drugs for pain rose. Yet only about 15 studies tested them for pain in older adults. So this study fills a long gap. It checks how good the proof really is. It looked closely at common drugs given for chronic pain, like amitriptyline and duloxetine.
Dr. Sujita Narayan is one of the lead researchers. She says most world guidelines on these drugs for chronic pain rest on studies that left out older adults or had very few of them. Yet doctors, including those in interventional pain management in St. Louis, often use these guidelines for common pain in older adults, like knee osteoarthritis. Most busy doctors lack time to dig into the proof. So they lean on guidelines. Older adults also face special risks. These drugs can make them dizzy. They can cause falls, injuries, or poor judgment. So it is no surprise that many older adults stop taking them. The guidelines also leave out withdrawal. Stopping these drugs after long use can be hard. It may cause withdrawal much like opioids do. So they must be stopped slowly, with a taper. The researchers did find some proof that the drugs may work in a few cases. For example, duloxetine may help older adults with knee pain from osteoarthritis. But most of that proof comes from short studies. They used duloxetine for about two to four months. No study ran for 12 months or more. So no one knows if the benefit lasts. Patients and doctors, including chronic pain specialists, need to know this before using duloxetine for knee osteoarthritis. The benefit may be small and may fade. The long-term risks may be greater. Most proof for these drugs also comes from small studies with fewer than 100 people. And the drug industry paid for most of the studies that showed a benefit. So the researchers say some guidelines need an update. They urge a broader plan for chronic pain. It should include drug-free options like exercise and cognitive behavior therapy. The researchers said it is unwise to base advice on small trials in younger adults. Older adults are different. Their bodies respond to drugs differently. Source: Narayan, S. W., Naganathan, V., Vizza, L., Underwood, M., Ivers, R., McLachlan, A. J., Zhou, L., Singh, R., Tao, S., Xi, X., & Abdel Shaheed, C. (n.d.). Efficacy and safety of antidepressants for pain in older adults: A systematic review and meta-analysis. British Journal of Clinical Pharmacology, n/a(n/a). https://doi.org/10.1111/bcp.16234
Dr. Gurpreet Singh Padda, MD, MBA, MHP
