Summary: New research reveals limited evidence supporting the use of antidepressants for pain management in adults over 65, despite widespread prescribing practices.
Estimated reading time: 5 minutes
A University of Sydney study has uncovered a concerning gap between clinical practice and scientific evidence in the treatment of pain for older adults. The research, published in the British Journal of Clinical Pharmacology, shows that international guidelines recommending antidepressants for chronic pain management in people over 65 are based on limited data.
Limited Research, Widespread Practice
Dr. Sujita Narayan, lead author and Research Fellow at the University’s Institute for Musculoskeletal Health, found that in the past four decades, only 15 trials worldwide have focused on the benefits of antidepressants for pain in older people. This scarcity of targeted research raises questions about the efficacy and safety of these medications for this age group.
“If I am a busy clinician and want to look at the guidelines for quick reference, I will probably have time to look at only the key points regarding management of chronic pain, some of which advise the use of antidepressants,” said Dr. Narayan, from the Faculty of Medicine and Health.
The study reveals a critical issue: international guidelines that health professionals rely on when treating older patients with chronic pain conditions, such as osteoarthritis, are heavily based on studies that either exclude older adults or include only a small number of them.
Risks Outweigh Benefits
Associate Professor Christina Abdel Shaheed, senior author of the study, emphasized that no trials examined the growing use of antidepressants for acute pain, such as that experienced by those with shingles or muscular pain. “These medicines are being prescribed to remedy patients’ pain, despite the lack of evidence to adequately inform their use,” she stated.
The research found that people taking antidepressants experienced more negative effects, including falls, dizziness, and injuries, compared to control groups. These adverse effects led to higher discontinuation rates among those taking antidepressants than those in placebo groups or groups using other pain management drugs.
Dr. Narayan cautioned against abrupt cessation of antidepressants: “Withdrawal from antidepressants can be as bad as withdrawal from opioids. I would recommend that anyone considering discontinuing their medication to not stop taking their antidepressants immediately, but to consult with their clinician and devise a tapering plan, as necessary.”
A Glimmer of Hope for Osteoarthritis
The study did find one exception to the overall trend. The SNRI duloxetine showed some efficacy in relieving knee osteoarthritis pain in older adults during the intermediate term (2-4 months). However, its effects were not significant in the short term (up to 2 weeks), and no data was available for use beyond 12 months.
“For clinicians and patients who might be using or considering duloxetine for knee osteoarthritis, the message is clear: benefits may be seen with a little persistence, but the effects may be small and need to be weighed up against the risk,” Dr. Narayan explained.
Call for Updated Guidelines and Personalized Care
The research underscores the need to update guidelines and rethink the clinical practice of prescribing antidepressants for pain in older adults. It supports recommendations for a multidimensional approach to managing chronic non-cancer pain in older people, emphasizing non-pharmacological strategies such as physical exercise and cognitive behavior therapy.
Dr. Narayan stressed the importance of age-specific research: “The key point is that we shouldn’t rely on findings from studies with younger people and apply them to older adults because they are different. Older people’s bodies undergo changes that alter how they respond to medications. This can lead to different effects in older people compared to younger people.”
As the population ages and chronic pain remains a significant health issue, this study highlights the urgent need for more robust, targeted research to inform safe and effective pain management strategies for older adults.
Quiz:
- How many trials focusing on antidepressants for pain in older people were found in the last 40 years?
- What was the one exception found for antidepressant efficacy in older adults with pain?
- What non-pharmacological strategies are recommended for managing chronic non-cancer pain in older people?
Answers:
- 15 trials
- Duloxetine showed some efficacy for knee osteoarthritis pain in the intermediate term (2-4 months)
- Physical exercise and cognitive behavior therapy
Further Reading:
- National Institute on Aging: Pain: You Can Get Help
- American Geriatrics Society: Pharmacological Management of Persistent Pain in Older Persons
- Cochrane Library: Antidepressants for treating depression in dementia
Glossary of Terms:
- Antidepressants: Medications used to treat depression and, in some cases, chronic pain.
- Osteoarthritis: A type of joint disease caused by breakdown of joint cartilage and underlying bone.
- SNRI (Serotonin-Norepinephrine Reuptake Inhibitor): A class of antidepressant drugs that increase levels of serotonin and norepinephrine in the brain.
- Duloxetine: An SNRI medication used to treat depression and certain types of chronic pain.
- Cognitive Behavior Therapy: A type of psychotherapy that helps people identify and change destructive or disturbing thought patterns.
- Multidimensional approach: A treatment strategy that addresses multiple aspects of a condition, not just medication.
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