Many know the benefits of some drugs with an anti-depressant effect in the treatment of the chronic pain of fibromyalgia. Well, now it would seem that there is no overwhelming evidence supporting the use of anti-depressants in the treatment of chronic low back pain. Although, the authors of a recent review (in the "Cochrane Database of Systematic Reviews") of the subject are quick to point out that this does not mean that depressed patients with back pain should not receive medical treatment for their depression.

The hypotheses for even considering anti-depressant drugs for chronic low back pain does, nonetheless, make sense:  First, patients with chronic low back pain often also suffer from depression, and improving the mood with medication may improve in turn pain tolerance.  Second, many anti-depressant drugs have actual pain-relieving activity which often occurs at lower doses than those utilized for the treatment of depression.  Finally, many anti-depressant drugs have a sedating effect, and perhaps the improvement of sleep in those who experience insomnia may improve pain tolerance.

Well, the conclusion of the Cochrane review included the finding that there was no difference in pain relief between different types of anti-depressants and placebo. And, it appears that patients with chronic low back pain do not experience a reduction in depression with the use of anti-depressants.

However, many pain experts are wondering how this can be.  Because there are fairly good studies which show that Effexor or Cymbalta have an effect on pain reduction.

The divergent conclusions could result from different measures of improvement in different types of patients—in different studies.

And primary care doctors continue to prescribe anti-depressants to their chronic low back pain patients; some studies showing at a rate of about 25%.

I use a variety of anti-depressants for the treatment of chronic pain, whether it be due to low back pain or neuropathy or fibromyalgia.  Sometimes there is no rhyme or reason as to why one drugs works for a particular patient with chronic pain; and so it is the duty of the doctor to be patient and use different drugs in succession if need be until the "winner" is stumbled upon.  This becomes the art of medicine, as opposed to the sometimes quirky science of medicine.

I have too many patients with chronic pain who obtain at least some relief with an anti-depressant drug, no matter that the scientific conclusions today might be against me. Tomorrow will likely bring another study and a different conclusion.

A toast to art!

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