Doctors are increasingly prescribing antidepressants to older adults for pain management, despite limited evidence supporting this practice, according to a new expert review from the University of Sydney. The review highlights potential risks, including increased falls, dizziness, and injury, associated with antidepressant use in seniors for pain relief. Published in the British Journal of Clinical Pharmacology, the findings raise concerns about the appropriateness of current prescribing trends.
Lack of Evidence for Pain Relief
The research team, led by Dr. Christina Abdel Shaheed, analyzed data from 15 trials conducted over the past 40 years, focusing on antidepressant use for physical pain in individuals over 65. The analysis revealed little evidence to support the efficacy of antidepressants in alleviating pain in this population. "These medicines are being prescribed to remedy patients' pain, despite the lack of evidence to adequately inform their use," Dr. Abdel Shaheed stated.
Risks Outweigh Benefits
The study emphasized the documented harms of antidepressant use in older individuals, noting a higher incidence of falls, dizziness, and injury compared to those using alternative pain management strategies. Furthermore, patients taking antidepressants for pain were more likely to discontinue their medication, which can lead to withdrawal symptoms comparable to those experienced with opioid cessation. "Withdrawal from antidepressants can be as bad as withdrawal from opioids," cautioned Dr. Sujita Narayan, recommending that patients consult with their clinician for a tapering plan before discontinuing antidepressant medication.
Guideline Limitations
While international guidelines generally support the use of antidepressants for chronic pain, these recommendations are primarily based on data from studies involving younger populations. This discrepancy can lead to misinformed decisions when applying these guidelines to older adults, whose bodies may respond differently to medications due to age-related physiological changes. Dr. Narayan explained, "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... This can lead to different effects in older people compared to younger people."
Duloxetine for Knee Osteoarthritis
An exception was noted with duloxetine (Cymbalta) for knee pain associated with osteoarthritis. Evidence suggested some efficacy when used for two to four months. However, benefits were not immediate (within two weeks) and no data supported 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 concluded.
Need for Further Research
The researchers highlighted the small sample sizes of most trials examining antidepressants for pain relief, averaging less than 100 participants. They emphasized the need for more research specifically focused on older adults to inform evidence-based prescribing practices.
