Page 136 Acute Pain Management

Amitriptyline also provided good control of phantom limb pain and stump pain in amputees
(Wilder‐Smith et al, 2005 Level III‐1). There was no significant difference in pain or disability with
amitriptyline compared with placebo in spinal cord injury patients with chronic pain (Cardenas
et al, 2002 Level II), however amitriptyline improved below‐level neuropathic pain in patients
with depression (Rintala et al, 2007 Level II). There are no studies of SSRIs in the treatment of
central pain (Sindrup & Jensen, 1999 Level I).
Duloxetine is effective for the treatment of both painful diabetic neuropathy and fibromyalgia
(Sultan et al, 2008 Level I).
There are very limited data on the use of antidepressants in acute nociceptive pain.
Desipramine given prior to dental surgery increased and prolonged the analgesic effect of a
single dose of morphine but had no analgesic effect in the absence of morphine (Levine et al,
1986 Level II). However, when used in experimental pain, desipramine had no effect on pain or
hyperalgesia (Wallace et al, 2002 Level II). Amitriptyline given prior to dental surgery (Levine et al,
1986 Level II) or after orthopaedic surgery (Kerrick et al, 1993 Level II) did not improve morphine
analgesia.
There is no good evidence that antidepressants given to patients with chronic low back pain
improve pain relief (Urquhart et al, 2008 Level I).
CHAPTER 4 This reverses the Level 1 conclusion in the previous edition of this
Note: reversal of conclusions

document; an earlier meta‐analysis had reported improved pain
relief.

However, this and the earlier meta‐analysis did not differentiate between TCAs and SSRIs, and
the former have been shown to be effective compared with the latter (Staiger et al, 2003 Level I).
There is good evidence for antidepressants in the treatment and prophylaxis of chronic
headaches (Tomkins et al, 2001 Level I).
Clinical experience in chronic pain suggests that TCAs should be started at low doses
(eg amitriptyline 5 to 10 mg at night) and subsequent doses increased slowly if needed, in
order to minimise the incidence of adverse effects.

Key messages
1. In neuropathic pain, tricyclic antidepressants are more effective than selective
serotonergic re‐uptake inhibitors (S) (Level I [Cochrane Review]).
2. Duloxetine is effective in painful diabetic neuropathy and fibromyalgia (N) (Level I
[Cochrane Review]).
3. There is no good evidence that antidepressants are effective in the treatment of chronic
low back pain (R) (Level I [Cochrane Review]).
4. Tricyclic antidepressants are effective in the treatment of chronic headaches (U) and
fibromyalgia (N) (Level I).
5. Antidepressants reduce the incidence of chronic neuropathic pain after herpes zoster (U)
(Level II).
Note: withdrawal of previous key message:
Antidepressants reduce the incidence of chronic neuropathic pain after breast surgery
This has been deleted as the information and evidence supporting it has been
withdrawn.
88 Acute Pain Management: Scientific Evidence